Thyroid hormones regulate cardiac repolarization and QT-interval related gene expression in hiPSC cardiomyocytes.

Prolongation of cardiac repolarization (QT interval) represents a dangerous and potentially life-threatening electrical event affecting the heart. Thyroid hormones (THs) are critical for cardiac development and heart function. However, little is known about THs influence on ventricular repolarization and controversial effects on QT prolongation are reported. Human iPSC-derived cardiomyocytes (hiPSC-CMs) and multielectrode array (MEA) systems were used to investigate the influence of 3,3',5-triiodo-L-Thyronine (T3) and 3,3',5,5'-tetraiodo-L-Thyronine (T4) on corrected Field Potential Duration (FPDc), the in vitro analog of QT interval, and on local extracellular Action Potential Duration (APD). Treatment with high THs doses induces a significant prolongation of both FPDc and APD, with the strongest increase reached after 24 h exposure. Preincubation with reverse T3 (rT3), a specific antagonist for nuclear TH receptor binding, significantly reduces T3 effects on FPDc, suggesting a TRs-mediated transcriptional mechanism. RNA-seq analysis showed significant deregulation in genes involved in cardiac repolarization pathways, including several QT-interval related genes. In conclusion, long-time administration of high THs doses induces FPDc prolongation in hiPSC-CMs probably through the modulation of genes linked to QT-interval regulation. These results open the way to investigate new potential diagnostic biomarkers and specific targeted therapies for cardiac repolarization dysfunctions.

Generation and characterization of the human induced pluripotent stem cell (hiPSC) line NCUFi001-A from a patient carrying KCNQ1 G314S mutation.

In this study we describe the generation and characterization of an human induced pluripotent stem cell (hiPSC) line from a long QT syndrome type 1 (LQT1) patient carrying the KCNQ1 c.940 G > A (p.Gly314Ser) mutation. This patient-specific iPSC line has been obtained by using non-integrational Sendai reprogramming method, expresses pluripotency markers and has the capacity to differentiate into the three germ layers and into spontaneously beating cardiomyocytes (iPSC-CMs).

Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation. METHODS: Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29). RESULTS: No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33). CONCLUSIONS: The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

Prokineticin system modulation as a new target to counteract the amyloid beta toxicity induced by glutamatergic alterations in an in vitro model of Alzheimer's disease.

The accumulation of ß-amyloid (Aß) is one of the hallmarks of Alzheimer disease (AD). Beyond the inflammatory reactions promoted by Aß, it has been demonstrated that the prokineticin (PK) system, composed of the chemokine prokineticin 2 (PK2) and its receptors, is involved in Aß toxicity. In this study we have analyzed how the Aß chronic treatment affects the glutamatergic transmission on neurons from primary cortical cultures, clearly demonstrating the PK system involvement on its action mechanism. In fact, we have observed a significant increase of the ionic current through the AMPA receptors in primary cortical neurons and an up-regulation of the PK system in cultures chronically treated with Aß. All effects were nullified by the prokineticin antagonist PC-1. Moreover, we have herein firstly demonstrated that the incubation of primary cortical culture with Bv8, the amphibian homologue of PK2, was able to increase in neurons the AMPA currents at specific doses and exposure times, measured both as evoked and as spontaneous currents. This effect was not due to a modification of the AMPA receptor subunit expression. In contrast, the up-modulation of AMPA currents were blocked by PC-1 and were mediated by the activation of the intracellular protein kinase C (PKC) transduction pathways because Gö6983, the PKC inhibitor added in the medium, nullified the effect. Finally, cellular death induced by kainate was also reduced following treatment with PC1. In conclusion, our results show that the prokineticin system may be a key mediator in the Aß-induced neuronal damage, suggesting PK antagonists as new therapeutic compounds to ameliorate the AD progression.

Undifferentiated metastatic renal cell carcinoma presenting as a cutaneous nodular lesion.

Cutaneous metastases may be the first sign of clinically silent visceral cancer. Approximately 30% of patients with primary renal cell carcinoma present with metastatic disease, and only 8% of them have skin metastases. We present the case of a 59-year-old male patient with a subcutaneous nodular on the upper chest extending to the jugular region. The lesion appeared skin colored and was not painful and 5 cm × 3.5 cm in diameter. The histological examination of the cutaneous biopsy showed an infiltration of undifferentiated epithelial cells positive to cytokeratins AE1/AE3, whereas they were negative to CK-20, CK5/6, cluster of differentiation 10, vimentin, thyroid transcription factor-1, S-100, human melanoma black-45, hepatocyte-specific antigen, carcinoembryonic antigen, and chromogranin A. A total-body computed tomography (CT) showed the presence of a tumoral lesion in the left kidney with multiple metastases in the lung, brain, and bones. According to the cutaneous biopsy and total-body CT, a final diagnosis of an undifferentiated renal carcinoma presenting as a subcutaneous metastasis was made. A chemotherapeutic treatment with gemcitabine and cisplatin resulted in the stabilization of the renal and metastatic lesions with an improvement in the quality of life of the patient. Considering that the prognosis of patients with cutaneous metastases is very poor, it is necessary to obtain an appropriate diagnosis in order to identify patients with treatable disease with the purpose of starting a therapeutic protocol.

Cutaneous metastasis of unknown primary presenting as massive and invasive abdominal lesion: an elective approach

Abstract: We describe herein what is to our knowledge the first reported case of an invasive cutaneous metastasis with unknown primary, electively treated solely with electrochemotherapy. We describe a female patient with a large, invasive and painful lesion in her hypogastric region, extending up to the pubic area. The cutaneous biopsy and instrumental and laboratory analyses, all failed to reveal the primary site. A final diagnosis of cutaneous metastasis with unknown primary was made and treatment was performed with electrochemotherapy. Our case highlights the importance of interdisciplinary choices in clinical practice to cope with the lack of a primary site and to improve quality of life, since no standardized therapy exists for these classes of patients.

Cutaneous metastasis of unknown primary presenting as massive and invasive abdominal lesion: an elective approach with electrochemotherapy.

We describe herein what is to our knowledge the first reported case of an invasive cutaneous metastasis with unknown primary, electively treated solely with electrochemotherapy. We describe a female patient with a large, invasive and painful lesion in her hypogastric region, extending up to the pubic area. The cutaneous biopsy and instrumental and laboratory analyses, all failed to reveal the primary site. A final diagnosis of cutaneous metastasis with unknown primary was made and treatment was performed with electrochemotherapy. Our case highlights the importance of interdisciplinary choices in clinical practice to cope with the lack of a primary site and to improve quality of life, since no standardized therapy exists for these classes of patients.

Low-grade fibromyxoid sarcoma: an unusual cardiac location.

We report the unusual cardiac localization of a primary low-grade fibromyxoid sarcoma of the right ventricle in a 57-year-old woman. Histological examination revealed a prevalent myxoid appearance with whorling growth pattern of small or spindle cells with bland features alternating with rare more collagenous hypocellular areas with rare atypical cells. Genomic polymerase chain reaction of genomic DNA revealed the typical FUS/Creb3L2 fusion gene products typical of low-grade fibromyxoid sarcoma. The tumor was surgically removed and recurred after 7 years as high-grade pleomorphic sarcoma. The patient died 6 months after the clinical manifestation of recurrence. Low-grade fibromyxoid sarcoma of soft tissues is a rare, distinctive variant of fibrosarcoma-typically arising in deep soft tissue of lower extremities and trunk-that rarely metastasizes. Clinically, low-grade fibromyxoid sarcoma is characterized by a longer survival rate compared to other sarcomas, suggesting its consideration in the differential diagnosis of cardiac tumors with a myxoid appearance.

Left atrial radiofrequency ablation associated with valve surgery: midterm outcomes.

BACKGROUND: Left atrial ablation is a surgical standard technique for the treatment of persistent or chronic atrial fibrillation (p-AF and c-AF, respectively).Objective The aim of the study is to evaluate midterm results of left atrial ablation according to modified Maze procedure in patients affected by p-AF or c-AF and concomitant mitral or aortic valve disease requiring surgical treatment. METHODS: A total of 108 patients (age, mean ± standard deviation [SD]: 66 ± 8.5 years) underwent left atrial ablation by means of unipolar (n = 62) or bipolar (n = 66) radiofrequency for p-AF (n = 28) or c-AF (n = 100) in association with mitral (n = 93) or mitral and aortic valve (n = 35) surgery. RESULTS: In-hospital mortality was 0.8%. Patients with preoperative c-AF had preoperative greater value of left atrial diameter (56.7 ± 7.4 vs. 52 ± 9 mm, p = 0.05) than those with p-AF. At 9 years after Maze procedure, 86% (n = 24/28) of patients with preoperative p-AF were in sinus rhythm versus 28% (n = 27/95) with c-AF (p < 0.0001). Preoperative c-AF and left atrial diameter of 75 mm or more predicted atrial fibrillation recurrence. In patients in sinus rhythm compared with those in residual atrial fibrillation, survival was 100 versus 86% ± 6.4%, New York Heart Association class was 1.3 ± 0.5 versus 1.7 ± 0.6, and need of lifelong anticoagulation therapy was 43 versus 91% (p < 0.05, for all comparisons). CONCLUSIONS: Left atrial Maze procedure for p-AF offers better chances to conversion in sinus rhythm as compared with long-standing c-AF. Survival, functional status, and quality of life are superior in patients who benefit from sinus rhythm.

Aortic root surgery in Marfan syndrome: Bentall procedure with the composite mechanical valved conduit versus aortic valve reimplantation with Valsalva graft.

OBJECTIVES: The aim of the study is to compare mid-term results of Bentall aortic root replacement with composite mechanical valved conduit and aortic valve reimplantation procedure using the Valsalva graft for the treatment of aortic root aneurysm in patients with Marfan syndrome. METHODS: We retrospectively compared data of 23 patients (mean age 38 + or - 14 years) who had undergone the Bentall procedure (group B) to those of 24 patients (mean age 36 + or - 12 years) who had undergone aortic valve reimplantation (group R) during a 14-year period. Follow-up (mean duration 65 + or - 44 months) was 100% complete. RESULTS: There were no operative deaths in either group. In group B, as compared with group R, preoperative aortic insufficiency (3.2 + or - 1.1/4 vs. 1.7 + or - 1.4/4, P < 0.001), ascending aorta diameter (55.8 + or - 4.9 vs. 44.1 + or - 8.7 mm, P = 0.001) were prevailing; cardiopulmonary bypass (107 + or - 51 vs. 145 + or - 32 min, P < 0.05) and aortic cross-clamp (77 + or - 17 vs. 116 + or - 30 min, P = 0.005) times were shorter. Eight-year survival and freedom from cardiac death and reoperation were 91 + or - 6, 96 + or - 4 and 100% in group B and 100, 100 and 91 + or - 6% in group R, respectively (P = NS for all comparisons). At follow-up, echocardiography showed significant improvement of left ventricular ejection fraction (0.60 + or - 0.10 vs. 0.52 + or - 0.09 preoperatively, P = 0.01) and end-systolic diameter (34 + or - 5 vs. 47 + or - 14 mm, P = 0.001) in group B and significant reduction of preoperative aortic insufficiency (0.7 + or - 1.0/4 vs. 1.7 + or - 1.4/4, P = 0.01) and aortic annulus (24 + or - 2.4 vs. 33 + or - 5 mm, P = 0.01) in group R. CONCLUSION: In Marfan patients, the Bentall procedure is associated with excellent mid-term outcome. The reimplantation technique, adopted for less dilated aortas, provides similarly satisfactory results. The Valsalva graft seems, with time, to allow a stable aortic valve function.

Long-term outcomes after surgical ventricular restoration and coronary artery bypass grafting in patients with postinfarction left ventricular anterior aneurysm.

OBJECTIVE: Surgical ventricular restoration (SVR) for postinfarction left ventricular anterior aneurysm improves left ventricular function. The aim of this study was to evaluate whether concomitant multivessel coronary artery disease (MVCAD) can affect long-term outcome. Thus, long-term results of SVR associated with multiple coronary artery bypass grafting (CABG) for MVCAD (group 1) were compared with SVR with or without CABG to left anterior descending artery and/or its diagonal branch for single-vessel coronary artery disease (group 2). METHODS: Data from 104 consecutive patients (age 64 +/- 8 years) with left ventricular anterior aneurysm, subjected to SVR from January 1994 to December 2004 and divided into group 1 (n = 79) and group 2 (n = 25), were analyzed. RESULTS: In group 1 vs. group 2, number of grafts/patient (2.7 +/- 0.9 vs. 0.6 +/- 0.6, P < 0.0001) was higher, cardiopulmonary bypass (109 +/- 30 vs. 65 +/- 28 min, P < 0.0001) and aortic cross-clamp times (65 +/- 18 vs. 44 +/- 23 min, P < 0.0001) were longer, resected aneurysmatic area (12 +/- 8 vs. 17 +/- 11 cm2, P < 0.05) was smaller. Operative mortality was 3.7 vs. 4% (P = not significant). At 12 years, survival (85 +/- 5 vs. 80 +/- 16%) and freedom from cardiac events (70 +/- 7 vs. 75 +/- 16%) were not statistically different in both groups. Follow-up echocardiography showed significant left ventricular ejection fraction improvement in group 1 (0.45 +/- 0.07 vs. 0.34 +/- 0.10 preoperatively, P < 0.0001) and group 2 (0.47 +/- 0.09 vs. 0.36 +/- 0.12, P = 0.001). Independent predictors of late death were preoperative history of ventricular arrhythmias (P < 0.001) and hypo/akinesia of proximal myocardial anterior wall (P < 0.05). CONCLUSION: Late survival and freedom from cardiac events are excellent after SVR, also when concomitant MVCAD requires complete revascularization. Ventricular arrhythmias and impaired left ventricular anterior wall function are predictors of worse outcome.

Permanent pacemaker implantation after isolated aortic valve replacement: incidence, risk factors and surgical technical aspects.

OBJECTIVES: Conducting system defects are common in patients with aortic valve disease. Aortic valve replacement may result in further conduction abnormalities requiring permanent pacemaker implantation. The aim of our study was to identify the incidence and predictors for postoperative 30-day permanent pacemaker implantation in patients undergoing isolated aortic valve replacement, and the effect of an accurate surgical technique in order to prevent permanent pacemaker implantation. METHODS: Data from 261 consecutive patients (mean age 69 +/- 12 years, 136 men) undergoing isolated aortic valve replacement from January 2004 to January 2008 were analyzed retrospectively. Indications for aortic valve replacement were aortic valve stenosis (n = 156), stenoinsufficiency (n = 63), regurgitation (n = 42). Aortic bicuspid valve was present in 25% of cases (n = 64), redo operation was the indication in 7% (n = 18). Preoperative conducting system disease, defined as first-degree atrioventricular block, left or right bundle-branch block or left anterior hemiblock, was present in 25.6% (n = 67) of patients. An accurate surgical technique for debridement of calcific material was performed. RESULTS: In-hospital mortality was 0.8% (2 out of 261 patients). Postoperatively, 8 out of 261 patients (3%) required permanent pacemaker implantation, for second-degree (n = 1) or complete atrioventricular block (n = 7). Incidence of permanent pacemaker implantation was similar for patients either with or without preoperative conducting system disease (25 vs. 25.7%, P = NS). Independent predictors of permanent pacemaker implantation were greater preoperative end-systolic diameter (P = 0.026) and left ventricular septum hypertrophy (P = 0.041). CONCLUSIONS: Need of permanent pacemaker implantation after aortic valve replacement seems to be related more to preoperative advanced aortic valve disease rather than pre-existing conducting system abnormalities. An accurate surgical technique for aortic valve replacement probably helps to prevent further impairment of conducting system function requiring early postoperative permanent pacemaker implantation.

Long-term outcome of coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: Coronary artery bypass grafting (CABG) is a well-accepted therapeutic strategy for patients with multivessel coronary artery disease and left ventricular dysfunction. The aim of the study was to evaluate long-term results after CABG in patients with preoperative left ventricular ejection fraction (LVEF) of 0.35 or less. METHODS: Data from 302 consecutive patients (mean age, 62 +/- 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome. RESULTS: Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% +/- 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% +/- 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 +/- 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 +/- 0.09 versus 0.28 +/- 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% +/- 3%. CONCLUSIONS: Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.

Thrombosis of the left anterior descending artery due to compression from giant pseudoaneurysm late after a bentall operation.

BACKGROUND: A postoperative pseudoaneurysm may develop and gradually expand in the mediastinal space even late following Bentall operation for aortic root replacement, particularly in patients with dissection of the aorta. METHODS: A very large (148 mm) pseudoaneurysm originating of the right coronary ostium suture line was observed in a patient admitted with unstable angina 6 years after Bentall procedure for type A aortic dissection. Angiograms showed reduced flow in the right coronary and thrombotic subocclusion of the left anterior descending (LAD) coronary artery due to extrinsic compression from the expanding mediastinal mass. RESULTS: Reoperation was performed during femoro-femoral cardiopulmonary bypass and brief period of circulatory arrest to clamp the tubular graft. After closure of the detected right coronary ostium in the tubular graft double bypass, grafting to the right coronary and LAD arteries was required. Postoperative course was uneventful. CONCLUSIONS: Close long-term follow-up after a Bentall procedure is required to minimize the risk of developing a large pseudoaneurysmal mass, in particular, after dissection of the aorta.

Conversion to sinus rhythm by ablation improves quality of life in patients submitted to mitral valve surgery.

BACKGROUND: Atrial fibrillation can be successfully treated with surgical ablation, but the effect of restoring sinus rhythm on the quality of life has yet to be established. We evaluate the effects of left atrial ablation combined with mitral valve surgery on health-related quality of life in patients with permanent atrial fibrillation. METHODS: Ninety-one consecutive patients with permanent atrial fibrillation underwent mitral valve surgery at our division. The last 53 also received left atrial ablation by means of monopolar radiofrequency and excision of the left appendage. The patients were divided into two groups according to the median total score obtained at the Short Form 36 Health Survey used to evaluate their quality of life (ie, the good quality of life group [n = 54] and the poor quality of life group [n = 37]). RESULTS: Preoperative and intraoperative data of the two groups were similar. In-hospital mortality and morbidity were similar in both groups. Sinus rhythm was obtained in 68% of patients (36 of 53) treated with left atrial ablation and it occurred spontaneously in 10% of patients (4 of 38) treated for the mitral pathology only. At follow-up, there was no difference between the groups in ejection fraction, left atrial diameter, mitral dysfunction, tricuspidal regurgitation, and New York Heart Association functional class. Using stepwise logistic regression, only the presence of sinus rhythm was associated with better quality of life. CONCLUSIONS: In patients submitted to mitral surgery, conversion to sinus rhythm by left atrial ablation can significantly improve the health-related quality of life.

Small "functional" size after mechanical aortic valve replacement: no risk in young to middle-age patients.

BACKGROUND: The impact of a valve prosthesis-patient size mismatch is still controversial. In most studies, the inclusion of a large proportion of poorly active old patients with low cardiac output requirements may be misleading, due to the close correlation between trans-prosthetic gradients and cardiac output. The aim of this study was to assess the impact of small "functional" prosthesis sizes in active young to middle-age patients. METHODS: Eighty-three active patients with a mean age of 46 +/- 8 years and a high health survey questionnaire score were followed for 80 +/- 34 months after isolated aortic valve replacement with a mechanical prosthesis. RESULTS: Patients with an indexed, Doppler derived, effective orifice area index less than 0.85 cm2/m2 (0.77 +/- 0.1 cm2/m2) showed higher early trans-prosthetic gradients (peak, 34 +/- 11 vs 26 +/- 8 mm Hg; P = 0.001) than patients with a larger effective orifice area index. However, significant regression of the left ventricular mass index and improvement of the left ventricular ejection fraction were observed in both groups at follow-up (119.8 +/- 26 vs 165.2 +/- 38 g/m2 and 128.5 +/- 25 vs 181.8 +/- 50 g/m2; P < 0.001; 58 +/- 6 vs 52 +/- 11% and 58 +/- 7 vs 53 +/- 10%; P < 0.001), with no differences between groups (P = 0.4 and P = 0.7, respectively). At multiple linear regression, the final left ventricular mass index was positively related to the preoperative left ventricular mass index (P = 0.004) and was unaffected by the effective orifice area index (P = 0.4). Symptomatic improvement (New York Heart Association class 1.3 +/- 0.4 vs 2.4 +/- 0.8 and 1.2 +/- 0.4 vs 2.2 +/- 0.8; P < 0.001) and freedom from late cardiac death (93 +/- 3% and 95 +/- 6%) were comparable between groups (P = 0.6 and P = 0.7, respectively). CONCLUSIONS: Our findings indicate that small "functional" prosthesis sizes with modern mechanical valves may not adversely affect outcomes of aortic valve replacement in young patients with high cardiac output requirements.

Mechanisms and predictors of transient left ventricular dysfunction early after successful percutaneous balloon mitral valvuloplasty.

BACKGROUND: The immediate effects of balloon mitral valvuloplasty (BMV) on left ventricular (LV) function in patients with mitral stenosis are still controversial. The aim of this study was to investigate the mechanisms and potential clinical, echocardiographic and hemodynamic predictors of transient LV dysfunction occurring in patients with mitral stenosis early after successful percutaneous BMV. METHODS: Sixty patients without residual mitral regurgitation were divided into two groups according to the changes in the left atrial (LA) pressure 15 min after successful BMV: 18 patients (group A) did not present with any reduction in LA pressure, and underwent nitroglycerin administration (0.4 mg, sublingually). The remaining 42 patients (group B) presented with a decrease in LA pressure. RESULTS: At baseline, both the mitral valve gradient and area assessed at echocardiography and during cardiac catheterization were similar in groups A and B. Group A patients presented with, however, higher LV early- and end-diastolic pressures and peak V waves during cardiac catheterization both prior to and 15 min after BMV than group B patients (all p values < 0.05). In group A, nitroglycerin administration was associated with a decrease in LV end-diastolic pressure (p = 0.049), LA pressure (p < 0.001), and peak V wave (p < 0.001) that was still persistent 30 min after its administration, reaching values similar to those observed in group B early after BMV. At multivariate analysis, the only independent predictors of LV dysfunction early after BMV were found to be LV early- (p = 0.015) and end-diastolic (p = 0.023) pressures at baseline and the Wilkins' score (p = 0.004). CONCLUSIONS: After successful BMV a transient lack of LV adaptation to the increased LV preload resulting in a persistently elevated LA pressure is predicted by higher baseline LV diastolic filling pressures and higher Wilkins' scores. It is promptly and steadily reversed by nitroglycerin administration through a transient LV unloading, thus allowing a correct hemodynamic evaluation of the immediate results of the procedure.

Acute left ventricular failure after transcatheter closure of a secundum atrial septal defect in a patient with coronary artery disease: a critical reappraisal.

We report a case of acute left ventricular failure after transcatheter closure of a single secundum atrial septal defect in a 68-year-old man with coronary artery disease. Just before the procedure, two coronary lesions had been treated with direct stenting. Transcatheter closure of atrial septal defects should always be deferred in ischemic heart disease patients who need percutaneous myocardial revascularization.