Cardiogenic Shock in Obstructive Hypertrophic Cardiomyopathy Plus Apical Ballooning: Management With VA-ECMO and Myectomy.

A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.).

One more option in heart failure: correction of mitral regurgitation with MitraClip®.

Degenerative mitral regurgitation in elderly patients and functional mitral regurgitation secondary to severe left ventricular dysfunction are not easy options for conventional surgery. Recently, a new percutaneous approach has been proposed with the MitraClip®, based on the Alfieri edge-to-edge repair technique. The aim of the study is to report, compare and discuss the results of two multicenter randomized trials: MITRA.FR and COAPT in light of the current practice. In both trials patients with functional mitral regurgitation grade 3/4+ or 4/4+ were randomly assigned, in 1:1 ratio, to undergo percutaneous repair and optimal medical therapy or optimal medical therapy alone. Other baseline characteristics reflecting severity of mitral regurgitation and of left ventricular impairment were statistically different, such as the effective regurgitant orifice area (0.31 cm2 in MITRA.FR vs 0.41 cm2 in COAPT) and the indexed LVEDV (135 ± 37 ml/m2 in MITRA.FR vs 101 ± 34 ml/m2 in COAPT). A 24 months follow-up and a 12 months follow-up have been completed, respectively, in COAPT and MITRA.FR. Out of the 307 patients enrolled in the MITRA.FR, 152 were randomized to percutaneous treatment but only in 138 (95.8%) the MitraClip® was actually implanted. At the end of the follow-up a residual mitral regurgitation of at least grade 3+ has been observed in 17% of the patients. A composite of death from any cause or unplanned hospitalizations for heart failure at 12 months respectively occurred in 83 patients (54.6%) treated percutaneously and 78 patients (51.3%) treated with medical therapy only. A total of 614 patients have been enrolled in the COAPT and 293 underwent transcatheter treatment. A successful implantation of the MitraClip® was achieved in 287 patients (98.0%). Hospitalization for heart failure at 24 months occurred in 160 patients in the device group and in 283 in the control group, with an annualized ratio of 35.8% and 67.9%, respectively (p > 0.001). The conflicting results of the two trials may have many explanations, but probably the main cause is the most stringent inclusion criteria in COAPT. The effective reduction of mitral regurgitation and improvement in exercise capacity already observed in registries including more than 70,000 patients was confirmed in a randomized trial with improvement observed in hard end-points. This has already led to an extension of FDA approval to functional regurgitation and a more liberal use across the world.

[Patent foramen ovale closure: how to choose the right device for the right patient]. / Tips and tricks: come orientarsi tra i vari dispositivi per la chiusura del forame ovale pervio.

Percutaneous patent foramen ovale (PFO) closure is an intervention aimed to prevent cardioembolic stroke. It recently proved to be superior to antiplatelet therapy in preventing recurrent strokes in a well-selected population of patients with a previous cryptogenic cerebral ischemic event. A large part of the clinical advantage of PFO transcatheter therapy derives from the very high efficacy and safety of the maneuver. Various types of devices with different characteristics are currently available for the use of the interventionists. Recently, a direct PFO suture device has been added to the device list, allowing for PFO closure without implanting any prosthesis. This article describes the procedure of PFO closure with a particular focus on the main characteristics of the various devices available. A road-map of choice among the various prostheses is also provided, keeping in mind the patient's clinical features and the various PFO anatomies.

[Tips and tricks for using extracorporeal life support devices in the intensive cardiac care unit]. / "Tips and tricks" sulla gestione del supporto extracorporeo alle funzioni vitali in unità di terapia intensiva cardiologica.

In patients with severe cardiac dysfunction refractory to conventional therapies, extracorporeal membrane oxygenation used in veno-arterious modality can provide temporary circulatory assistance (extracorporeal life support, ECLS). Since it is an invasive and complex technique, its use is potentially burdened by severe complications, thus requiring careful nursing and medical care during intensive cardiac care unit stay. The use of ECLS requires specific skills such as knowledge of protective mechanical invasive ventilation, specific echocardiographic evaluation, accurate monitoring of hemodynamics and laboratory tests. A patient on ECLS is at high risk of thrombotic and hemorrhagic complications that could be fatal, hence specific pro- and anti-hemostatic therapy is needed. Moreover, the knowledge of some peculiar aspects of ECLS system and management can help doctors to avoid several complications such as limb ischemia, left ventricular overload and regional perfusion discrepancy. In conclusion, careful management by adequately trained personnel is required.

Safety and effectiveness of combined percutaneous coronary angioplasty and aortic valvuloplasty in an elderly patient with cardiogenic shock: effect on concomitant severe mitral regurgitation.

An 80-year-old diabetic man with severe aortic stenosis was admitted to our hospital for cardiogenic shock complicating non-ST-elevation myocardial infarction. Echocardiographic evaluation showed also a severe degree of both left ventricular dysfunction and mitral regurgitation. The patient was initially stabilized with inotropes and mechanical ventilation was necessary because of concurrent pulmonary edema. The day after, he was submitted to coronary angiography showing bivessel coronary disease. Given the high estimated operative risk, the patient was treated with angioplasty and bare metal stent implantation on both right coronary and circumflex artery; contemporarily, balloon aortic valvuloplasty (BAV) was performed with anterograde technique, obtaining a significant increase in planimetric valve area and reduction in transvalvular peak gradient. Few days after the procedure echocardiogram showed an increase in left ventricular ejection fraction, moderate aortic stenosis with mild regurgitation and moderate mitral regurgitation. Hemodynamic and clinical stabilization were also obtained, allowing amine support discontinuation and weaning from mechanical ventilation. At three months follow-up, the patient reported a further clinical improvement from discharge, and echocardiographic evaluation showed moderate aortic stenosis and an additional increase in left ventricular function and decrease in mitral regurgitation degree. In conclusion, combined BAV and coronary angioplasty were associated in our patient with hemodynamic and clinical stabilization as well as with a significant reduction in transvalvular aortic gradient and mitral regurgitation and an increase in left ventricular ejection fraction both in-hospital and at three month follow-up; this case suggests that these procedures are feasible even in hemodynamically unstable patients and are associated with a significant improvement in quality of life.

Permanent genetic resources added to molecular ecology resources database 1 April 2013-31 May 2013.

This article documents the addition of 234 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Acipenser sinensis, Aleochara bilineata, Aleochara bipustulata, Barbus meridionalis, Colossoma macropomum, Delia radicum, Drosophila nigrosparsa, Fontainea picrosperma, Helianthemum cinereum, Liomys pictus, Megabalanus azoricus, Pelteobagrus vachelli, Pleuragramma antarcticum, Podarcis hispanica type 1A, Sardinella brasiliensis and Sclerotinia homoeocarpa. These loci were cross-tested on the following species: Acipenser dabryanus, Barbus balcanicus, Barbus barbus, Barbus cyclolepis, Drosophila hydei, Drosophila melanogaster, Drosophila obscura, Drosophila subobscura, Fontainea australis, Fontainea fugax, Fontainea oraria, Fontainea rostrata, Fontainea venosa, Podarcis bocagei, Podarcis carbonelli, Podarcis liolepis, Podarcis muralis and Podarcis vaucheri.

Genome evolution in the cold: Antarctic icefish muscle transcriptome reveals selective duplications increasing mitochondrial function.

Antarctic notothenioids radiated over millions of years in subzero waters, evolving peculiar features, such as antifreeze glycoproteins and absence of heat shock response. Icefish, family Channichthyidae, also lack oxygen-binding proteins and display extreme modifications, including high mitochondrial densities in aerobic tissues. A genomic expansion accompanying the evolution of these fish was reported, but paucity of genomic information limits the understanding of notothenioid cold adaptation. We reconstructed and annotated the first skeletal muscle transcriptome of the icefish Chionodraco hamatus providing a new resource for icefish genomics (http://compgen.bio.unipd.it/chamatusbase/, last accessed December 12, 2012). We exploited deep sequencing of this energy-dependent tissue to test the hypothesis of selective duplication of genes involved in mitochondrial function. We developed a bioinformatic approach to univocally assign C. hamatus transcripts to orthology groups extracted from phylogenetic trees of five model species. Chionodraco hamatus duplicates were recorded for each orthology group allowing the identification of duplicated genes specific to the icefish lineage. Significantly more duplicates were found in the icefish when transcriptome data were compared with whole-genome data of model species. Indeed, duplicated genes were significantly enriched in proteins with mitochondrial localization, involved in mitochondrial function and biogenesis. In cold conditions and without oxygen-carrying proteins, energy production is challenging. The combination of high mitochondrial densities and the maintenance of duplicated genes involved in mitochondrial biogenesis and aerobic respiration might confer a selective advantage by improving oxygen diffusion and energy supply to aerobic tissues. Our results provide new insights into the genomic basis of icefish cold adaptation.

[Inferior vena cava filters: any indications anymore?]. / C'è ancora un'indicazione all'impianto del filtro cavale?

Inferior vena cava filters (IVCFs) are metal alloy devices that mechanically trap fragmented thromboemboli from the deep leg veins en route to the pulmonary circulation. Filters are introduced (and in the case of retrievable filters, removed) percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile are unclear because there are very few controlled and randomized data. IVCFs are most frequently used in patients with contraindications to anticoagulation and in anticoagulated patients with recurrent pulmonary embolism, but few data are available in the literature about their efficacy. The indications for filters are based largely on custom, historical practice patterns and physician preferences, and their use is increasing: more trials are needed to confirm their benefit and accurately assess their safety. The care of patients with or at risk of venous thromboembolism is as variable and challenging as the range of patients who suffer from venous thrombosis. Careful, individualized decision regarding IVCF placement will be required for many years as we strive to learn more about these devices.

Permanent genetic resources added to Molecular Ecology Resources Database 1 October 2010-30 November 2010.

This article documents the addition of 277 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Ascochyta rabiei, Cambarellus chapalanus, Chionodraco hamatus, Coptis omeiensis, Cynoscion nebulosus, Daphnia magna, Gerbillus nigeriae, Isurus oxyrinchus, Lates calcarifer, Metacarcinus magister, Oplegnathus fasciatus, Pachycondyla verenae, Phaethon lepturus, Pimelodus grosskopfii, Rotylenchulus reniformis, Scomberomorus niphonius, Sepia esculenta, Terapon jarbua, Teratosphaeria cryptica and Thunnus obesus. These loci were cross-tested on the following species: Austropotamobius italicus, Cambarellus montezumae, Cambarellus puer, Cambarellus shufeldtii, Cambarellus texanus, Chionodraco myersi, Chionodraco rastrospinosus, Coptis chinensis, Coptis chinensis var. brevisepala, Coptis deltoidea, Coptis teeta, Orconectes virilis, Pacifastacus leniusculus, Pimelodus bochii, Procambarus clarkii, Pseudopimelodus bufonius, Rhamdia quelen, Sepia andreana, Sepiella maindroni, Thunnus alalunga, Thunnus albacares, Thunnus maccoyii, Thunnus orientalis, Thunnus thynnus and Thunnus tonggol.