Cardiac tumors: the experience of a tertiary cardiology center.

UNLABELLED: Cardiac tumors represent a rare condition, often presenting with severe symptoms and having a poor outcome in the absence of early diagnosis and therapy. The aim of this study was to assess the prevalence and type of cardiac tumors, the techniques used for the diagnosis and the therapy used in a tertiary cardiology center. METHODS: During a 2-years period, among the 35004 patients (pts) hospitalized in our Cardiology Department, 24 pts were diagnosed with CTum (0.068% of all hospitalizations). A retrospective study of CTum cases was based on the patient files, with full clinical data, paraclinic investigations and therapy details. RESULTS: In the CTum group (49 +/- 16.2 years, similar between men and women), the main symptoms leading to patients referral were dyspnea (15 pts, 62.5%) and embolic events (coronary, cerebral, peripheral arteries: 7 pts, 29%), while in 4 asymptomatic pts the diagnosis was incidental. Transthoracic echocardiography (TTE) detected the presence of CTum in all cases. In 20 pts (83%), TTE and transesophageal echocardiography (TEE) provided all the data required for preoperative assessment (tumor size, extension, location, insertion site). In 4 pts, additional CT and MRI investigations were necessary, mainly for complex disease (malignant secondary CTum). The imaging techniques suggested a diagnosis of benign tumor in 15 pts (62.5%) and malignant tumor in 5 pts. In 4 pts the tumor type could not be established. Myxoma was the most frequent diagnosis (14 pts, 58% CTum). Among malignant CTum, secondary tumors (melanoma, lung and uterine cancer) were more frequent than primary CTum (4 vs 1 pt). The localization of CTum was intracavitary in 22 pts, 91% mainly in the left atrium (15 pts), intramyocardic in 1 pt and pericardic in 1 pt. Surgery was performed in 18 pts, confirming the preoperative diagnosis in 17 cases (94%). In one case, a myxochondrosarcoma was diagnosed at pathology in a patient with an echocardiography-based preoperative diagnosis of myxoma. CONCLUSIONS: CTum represent a rare condition, accounting for only 0.068% of hospitalizations in a tertiary cardiology center, but with severe clinical presentation. Echocardiography (TTE and TEE) is the essential imaging modality, allowing in most cases the diagnosis, classification and localization of CTum and their insertion site. CT and MRI are useful additional modalities in complex cases (mainly malignant primary and secondary CTum). In the case of benign tumors, surgery must be performed as soon as possible after the diagnosis has been established, whereas for malignant tumors there is still much controversy in what regards the benefits of surgery.

[Pulmonary embolism--complication of proximal deep venous thrombosis in colorectal cancer. Diagnosis and management]. / Tromboembolismul pulmonar--complicatie a tromboflebitei proximale paraneoplazice în cadrul neoplasmului colo-rectal. abordare diagnostica si terapeutica.

We present the case of a 57 years old male, without cardiovascular history, with colorectal cancer and proximal deep venous thrombosis, who develops a massive pulmonary embolism. The surgical treatment consists in embolectomy of right ventricle, pulmonary trunk, left and right pulmonary artery. The specifics of the case is discussed: etiology and prevention of pulmonary embolism (caval filter) and treatment: the contraindications of thrombolytic therapy and the indications and perspectives of surgical treatment.

Is interleukin-18 correlated with endothelial dysfunction and platelet activation in patients with unstable angina?

UNLABELLED: The aim of the study was to assess the interaction between interleukin-18 (IL-18, a cytokine with a central role in the inflammatory cascade) and the presence of endothelial dysfunction and prothrombotic profile in patients with unstable angina and proven coronary artery disease. MATERIAL AND METHODS: The study EDIT-ACS (Endothelial Dysfunction, Inflammation and Thrombosis in Acute Coronary Syndromes) was set in the Cardiology Department of our Institute, and inclusions were performed between June-November 2004. We included 40 consecutive patients with unstable angina hospitalized in our Department (mean age = 60.2 +/- 8.8 years, 57.5% male), as well as 20 normal pts as a control population,matched for age and sex (mean age = 61.9 +/- 8.6 years, 58.3% male). All pts had the following biological studies performed: interleukin-18 (IL-18), C-reactive protein (CRP), fibrinogen, leukocyte count, and Von Willebrand factor, as well as platelet activity parameters (mean platelet volume, MPV and platelet distribution width, PDW). All pts had echographic studies of flow mediated dilatation (FMD) and measurement of carotid intima-media thickness (C-IMT), and underwent coronary angiography as well. RESULTS: We found that patients in the highest quartile of IL-18 had higher levels of CRP (11.9 +/- 4.2 vs 6.8 +/- 3.4 mg/l, p<0.01), von Willebrand factor (166% vs 150%, p=0.08), PDW (14.5 vs 13.2, p=0.04), MPV (11.2 vs 10.2, p=0.02), as well as a higher number of coronary stenoses (mean no. of affected vessels 2.5 vs 1.1, p<0.001), trend towards higher carotid IMT (0.92 mm vs 0.81 mm, p=0.06). They also have significant endothelial dysfunction (FMD of 5 % vs 8.5% for 4th quartile and 1st quartile respectively). Pts with higher levels of IL-18 associated a worse short term (in hospital prognosis) with 60% of pts in the 4th quartile having adverse events, versus 22% in the lowest quartile. CONCLUSIONS: High levels of interkleukin-18 are associated with endothelial dysfunction (high von Willebrand factor and low brachial FMD) and platelet activation (high MPV and PDW values), in pts with a higher number of affected coronary arteries but similar global atherosclerotic burden. This could explain the association between high levels of IL-18 and worse short-term prognosis in pts with unstable angina.

C-reactive protein, prothrombotic imbalance and endothelial dysfunction in acute coronary syndromes without ST elevation.

UNLABELLED: Inflammation is considered a crucial step in the pathogenesis of acute coronary syndromes (ACS). C-reactive protein (CRP) is proposed to be included in risk stratification of ACS patients. However, it is not yet known if CRP is only a risk marker, or merely a risk factor in the development of ACS. Our study looked at the links between inflammation and the prothrombotic factors present in patients with ACS without ST elevation. MATERIAL AND METHODS: 86 patients (pts), 46 men (53.4%), mean age = 58.2+/-12.4 years-old, with acute coronary syndromes (unstable angina and NSTEMI). The following parameters were measured in all pts on admission: CRP, fibrinogen, blood white cell count, and coagulation parameters: coagulation factor V and VIII, von Willebrand factor (vWf), antithrombin III (AT III), D-dimers (DD), C and S proteins. RESULTS: Mean CRP in the study group was 22.42+/-19.81 mg/dl (limits 1.40-88.8 mg/dl). We worked with quartiles of CRP plasmatic levels, in order to see how magnitude of inflammation correlates with different coagulation and fibrinolysis parameters. When comparing the 1st with the 4th CRP quartiles, we noted that important inflammation (4th quartile) was associated with higher factor von Willebrand (141.3 vs 108.9%, p<0.05), factor 5 (127.5% vs 88%, p<0.01), factor 8 (121.5 vs 117.1%, p=0.04), lower AT III (101.6 vs 118.2%, p<0.05), lower protein C and S. The associations did not keep for PAI-I or D-dimers, which might be associated with the lack of sensibility of fibrinolysis markers in the early period after thrombosis. CONCLUSIONS: Inflammation, as quantified by CRP, appears to be associated with a significant prothrombotic status and endothelial dysfunction (as reflected by high von Willebrand factor).

New insights into the pathogenesis and prognosis of aortic sclerosis.

Aortic valve disease includes a wide spectrum of conditions, from leaflets thickening to hemodynamically significant aortic stenosis and is one of the most important causes of morbidity and mortality worldwide. Studies performed during the last years bring consistent evidence that these lesions of the aortic valves share remarkable similarities with atherosclerotic lesions. They also reveal new risk factors for its development, which are superposed in fact with the major risk factors for atherosclerosis. Moreover, large prospective studies reported an increased risk for cardiovascular events and for total and cardiovascular mortality in patients with aortic sclerosis. Hence, recent papers also propose therapeutic targets, using statins for delaying the progression of the disease.

Subclinical atherosclerosis, carotid intima-media thickness and the cardiovascular risk.

The refinement and the improvement of the cardiovascular risk factors assessment became one of the high priorities in the global approach of cardiovascular diseases. Recent studies showed that increased carotid intima media thickness (IMT) is a relatively simple noninvasive marker of the global atherosclerotic disease, even in the asymptomatic stage. There is a strong link between IMT and both traditional and emerging cardiovascular risk factors, and IMT also predicts the occurrence of major cardiovascular events. Thus, IMT, as a marker of subclinical atherosclerosis, might improve the risk assessment in asymptomatic patients at risk.

Assessment of hypertension levels control and management (hypertension "AUDIT" project). Study in a population of workers.

The hypertension AUDIT project (WHO) was used for the study of large populations of workers in two Romanian industrial centers, Slatina and Sibiu, constituted into two main groups. The objects of the study were: the detection of new cases of arterial hypertension (AH) and of their proportion as compared with older cases, the assessment of the quality of diagnosis control and treatment methodology as well as the estimation of the patient's attitude regarding the conditions of treatment and of the physician's knowledge and attitude regarding AH. Group I (Slatina) included 22,839 workers and the program was applied in 15,740 randomly chosen subjects. Group II (Sibiu) included 14,874 workers of whom 2,838 were randomly chosen for study. From a total of 606 (6.20%) subjects aged 35 to 64 years with AH in both groups, 494 (81.51%) were older cases and 112 (18.48%) were newly detected. The prevalence of AH was found to increase with age and to be higher in women aged 55 to 64 years. The treatment in older cases from both groups was considered effective in 232 cases (46.96%) (of which 26 (11.2%) with overtreatment) and insufficient in 262 (53%). The reasons alleged by the patients for the late detection of AH were the absence of symptoms and a casual interest for their state of health. The risk factors were systematically checked. Smoking was found in 30.36% of the subjects in group I and in 31% of those in group II. The use of diagnostic laboratory procedures was corresponding to the present recommendations. The nonpharmaceutic therapy was frequently recommended, especially reduction of salt consumption. Besides that, pharmaceutic treatment was indicated in most of the patients (63% in group I and 90% in group II). Diuretics (41.26% in group I and 75% in group II), and beta blocking drugs (35.3% in group I and 70% in group II) were the most frequently administered and in a lesser proportion vasodilators with central or peripheral action, calcium blockers, Rauwolfia and angiotensin conversion enzyme inhibitors. The consumer inquiry showed satisfactory compliance of patients, most of them took their tablets regularly, were satisfied with the medical assistance and preferred to consult the same physician. The data of the physician inquiry regarding diagnosis treatment of AH and professional training also proved satisfactory. The use of the AUDIT project has allowed a complex estimation of AH in the groups studied and will prove useful for a more efficient control of AH in the whole population.

[Infectious endocarditis in mitral valve prolapse]. / Endocardita infectioasa pe prolaps de valva mitrala.

The paper reports on 13 cases of infectious endocarditis in the patients with prolapse of the mitral valve admitted for a period of 10 years (1979-1989) into the Clinic of Cardiology of the Fundeni Hospital. These cases stand for 3.6% of the cases with prolapse of the mitral valve admitted during that period, and 5% of the patients with infectious endocarditis. Our study dealt only with the cases of the prolapse of the mitral valve, clinically and echographically documented before the appearance of the septic graft. The hemocultures were positive in all the patients (viridans streptococci in 84.61% cases). The symptomatology, the clinical objective data and the paraclinical results (phonocardiographic, echocardiographic, electrocardiographic, radiologic, investigations with isotopes), the response to the treatment (medical, surgical) and the evolution in time were analyzed. An increase was found during endocarditis in the number of patients with holosystolic murmurs (30.7% cases) versus those with click-telesystolic murmur, the appearance in 41.15% of the cases of valvular vegetations at the Echo examination, and in 15.38% cases of ruptures of cordages. Mitral insufficiency secondary to endocarditis became worse, in 30.76% cases. The treatment with antibiotics resulted in the healing of the infection in all the cases. The surgery was not necessary in any patient during the evolution of endocarditis. The surgery (valvular prosthesis) was made in 23.07% cases, which presented, after curing the septic graft, important mitral regurgitation with cardiac insufficiency refractory to the medical treatment. Prophylaxis of the infectious endocarditis in the prolapse of mitral valve with mitral regurgitation is necessary.

[Arrhythmias in patients with mitral valve prolapse]. / Aritmiile la bolnavii cu prolaps al valvei mitrale.

The object of the present investigation was the discovery of the arrhythmias in the patients with prolapse of the mitral valve (PMV), the types of arrhythmias, the factors favouring them, the therapy used. In a group of 126 patients suffering from PMV, 25 had mitral insufficiency, and 48% of the cases had arrhythmias too. The ventricular arrhythmias existed in 18 patients, in the most of them as ventricular extrasystoles. Only in 2 cases, ventricular paroxysmal tachycardia was noticed, and only one case of ventricular fibrillation was recorded. The following conclusions were drawn from the study: the increase of arrhythmias is low, their appearance is correlated with mitral insufficiency, ventricular arrhythmias are predominant, the majority are benign, they are more frequent than in the patients with neurovegetative dystonia (if considering the prolapse associated with systolic murmur), necessity of periodic control for discovering the cases with high risk of ventricular arrhythmias with malignant potential.

[Mitral valve prolapse. An echocardiographic study of 456 cases]. / Prolapsul valvei mitrale. Studiu ecocardiografic a 456 de cazuri.

The prolapse of the mitral valve is an affection arousing much interest from the clinical and echocardiographical viewpoints. The present paper reports on the analysis of 456 cases (322 women--70% and 134 men--29.39%), suffering from prolapse of the mitral valve, selected out of 15,714 echocardiographic examinations (2.93%). All the patients were examined echocardiographically--Echo) in the M mode and bidimensionally; 256 cases underwent an Echo-Doppler examination, too and in 90 cases the phonocardiogram was also used. 983 cases were diagnosed as clinically suffering from prolapse, confirmed by Echo in 291 cases (29.62%), and in 165 cases the diagnosis was established only clinically. Phonocardiographically, the most frequent were recorded the mesotelesystolic click (40%), followed by click + holosystolic murmur (31.11%), telesystolic murmur (19.70%), holosystolic murmur (6.66%). The prolapse of the mitral valve was evidenced in 394 cases, both by M-Echo and by 2D-Echo; in 28 (6.1%) cases it was evidenced only by M-Echo, and in 34 cases (7.4%) only by 2D-Echo. In 62 cases (13.4%) the prolapse was better evidenced when the patients stood. The most affected was the anterior mitral valve, 203 cases (44.5%). The conclusion was drawn that the prevalence of the prolapse of the mitral valve is of 2.93% according to the Echo examination. A correct diagnosis requires the use of a rigorous examination technique and the observance of the clinical and Echo diagnosis criteria.

Metabolic "responders" and "non-responders" to muscular exercise in diabetes.

The metabolic effects of muscular exercise (bicycle ergometer, 75 watts, 15 min) were studied in 16 healthy controls and 49 diabetics distributed into three groups. The first two groups included insulin-dependent diabetics three hours after administration of insulin (group A, 24 cases) or 12--18 hours after the last insulin dose (group B, 18 cases). Group C included 7 non insulin-dependent diabetics. According to the glycemia response, the patients were listed as: high responders (greater than 20% below the initial values), low responders (10-20% fall) and non-responders (increase or less than 10% decrease). The data obtained show that, in most cases, in the presence of insulin, exercise has a hypoglycemic effect and, in its absence, a hyperglycemic one. To a lesser extent, the fall in glycemia may be attributed to an apparently insulin-independent mechanism. Exercise can only be indicated (in high-responders) or contraindicated (in non-responders) after a routine tolerance test.