Partial Brain Tissue Oxygen Levels Predict Arrhythmia and Prognosis in Patients With Brain Injury.

The objective of this study was to examine the clinical determinants of incidence and prognosis of arrhythmias in the setting of acute brain injury. Acute brain injury is known to cause electrocardiographic abnormalities and cardiac arrhythmias. The relation between partial brain tissue oxygen (PBTO) and intracranial pressure (ICP) with arrhythmia incidence and prognosis remains unknown. Consecutive patients with acute brain injury and intracranial bleed admitted to the neurosurgical intensive care unit were enrolled in the study. Baseline characteristics [demographics, medical history, etiology of brain injury, Glasgow Coma Scale (GCS) score, blood pressure, and respiratory rate] were documented. Patient's telemetry recordings were reviewed for daily mean heart rates and arrhythmias. If arrhythmia was noted, PBTO levels at the beginning of arrhythmia, ICP, brain tissue temperature, and outcomes were recorded. A total of 106 subjects (53% men, age 39 ± 18 years, 65 traumatic and 41 nontraumatic brain injuries) were studied. Overall, 62% of subjects developed a total of 241 arrhythmia episodes. Ventricular arrhythmias were associated with significantly higher daily mean heart rates, low PBTO levels, and low GCS scores, whereas atrial arrhythmias were associated with lower daily mean heart rates, normal PBTO levels, and higher GCS and ICP. Three or more episodes of arrhythmia predicted worse outcomes, including mortality (P = 0.001). In patients with acute brain injury, poor PBTO levels are associated with higher incidence of ventricular tachyarrhythmias. In contrast, atrial tachyarrhythmias occur in patients with normal PBTO levels and higher ICP. Incidence of ventricular arrhythmia in those with poor PBTO is associated with increased mortality.

Thoracic aortic atheroma severity predicts high-risk coronary anatomy in patients undergoing transesophageal echocardiography.

INTRODUCTION: We hypothesized a relationship between severity of thoracic aortic atheroma (AA) and prevalence of high-risk coronary anatomy (HRCA). MATERIAL AND METHODS: We investigated AA diagnosed by transesophageal echocardiography and HRCA diagnosed by coronary angiography in 187 patients. HRCA was defined as ≥ 50% stenosis of the left main coronary artery or significant 3-vessel coronary artery disease (≥ 70% narrowing). RESULTS: HRCA was present in 45 of 187 patients (24%). AA severity was grade I in 55 patients (29%), grade II in 71 patients (38%), grade III in 52 patients (28%), grade IV in 5 patients (3%), and grade V in 4 patients (2%). The area under receiver operating characteristic curve for AA grade predicting HRCA was 0.83 (p = 0.0001). The cut-off points of AA to predict HRCA was > II grade. The sensitivity and specificity of AA > grade II to predict HRCA were 76% and 81%, respectively. After adjustment for 10 variables with significant differences by univariate regression, AA > grade II was related to HRCA by multivariate regression (odds ratio = 7.5, p< 0.0001). During 41-month follow-up, 15 of 61 patients (25%) with AA >grade II and 10 of 126 patients (8%) with AA grade ≤ 2 died (p= 0.004). Survival by Kaplan-Meier plot in patients with AA > grade II was significantly decreased compared to patients with AA ≤ grade II (p= 0.002). CONCLUSIONS: AA > grade II is associated with a 7.5 times increase in HRCA and with a significant reduction in all-cause mortality.

Effect of medical therapy on left ventricular ejection fraction in patients with systolic heart failure and narrow QRS duration with and without ischemic heart disease and left ventricular mechanical dyssynchrony.

We studied 99 consecutive patients with class III-IV systolic heart failure with a left ventricular ejection fraction (LVEF) < or =35% and a QRS duration <120 milliseconds. Patients with cardiac resynchronization therapy were excluded. Echocardiography was performed in all patients before and after optimal standard heart failure therapy. The septal-to-posterior wall motion delay (SPWMD) > or =130 milliseconds on echocardiogram was defined as left ventricular mechanical dyssynchrony (LVMD). Sixty-nine of 99 patients (70%) had ischemic heart disease. During follow-up of 15.2 +/- 9.8 months, LVEF improvement > or =15% was greater patients in nonischemic group (50%, 15/30) than in ischemic group (9%, 6/69; P < 0.001). After adjustment for age, gender, and clinical and echocardiographic characteristics, ischemic heart disease and grade of coronary disease were persistently related to LVEF improvement > or =15% (P = 0.03 and 0.02, respectively). Twenty of 99 patients (20%) had SPWMD > or =130 milliseconds (LVMD group), and 79 of 99 patients (80%) had SPWMD <130 milliseconds (non-LVMD group). LVEF increased in both groups (P = 0.005) during follow-up, but the percentage of patients with LVEF improvement > or =15% in LVMD was greater compared with patients without LVMD (40% versus 16%, respectively, P = 0.03). In conclusion, the improvement of LVEF in patients with systolic heart failure and narrow QRS was greater in patients with nonischemic heart disease and LVMD compared with patients with ischemic heart disease and absence of LVMD during medical therapy without cardiac resynchronization therapy.

Cardiac resynchronization therapy in patients with intrinsic and right ventricular pacing-induced left bundle branch block pattern.

We studied 95 consecutive patients, mean age 70 years, who received cardiac resynchronization therapy (CRT) for class III or IV heart failure with a left ventricular (LV) ejection fraction < or =35% and a QRS duration > or =120 ms. Sixty-seven patients had intrinsic left bundle branch block (LBBB) (group 1), and 28 patients had right ventricular pacing-induced LBBB (group 2). The time difference (TPW-TDI) between onset of QRS to the end of LV ejection by pulsed wave Doppler and onset of QRS to the end of systolic wave in the basal segment with greatest delay by tissue Doppler imaging was measured before CRT and at the last follow-up after CRT. TPW-TDI >50 ms was defined as left ventricular mechanical dyssynchrony. A positive response to CRT was defined as LV volume at end-systole decreasing > or =15% after CRT. The percentage of CRT responders in group 2 was significantly greater than that in group 1 (68% versus 42%, P = 0.04) during follow-up of 16 months. After adjusting for age, gender, and clinical features, this pattern of CRT response persisted (P = 0.008). Similarly, there was a greater reduction in QRS duration in group 2 (178 ms) after CRT versus 154 ms for group 1, P = 0.01. There was no significant difference in TPW-TDI between the 2 groups at baseline or at follow-up. There was no significant difference in mortality (15% versus 14%) and Kaplan-Meier survival plot during follow-up. Patients with heart failure and right ventricular pacing-induced LBBB have a better response rate to CRT than patients with intrinsic LBBB. The change in left ventricular mechanical dyssynchrony after CRT was similar in these 2 groups of patients.

Acute eosinophilic myocarditis mimicking myocardial infarction.

Eosinophilic myocarditis is characterized by progressive myocardial damage that results in heart failure and death. Herein, we present the case of a 54-year-old man who presented with symptoms of acute myocardial infarction. Normal coronary angiographic results and the presence of elevated levels of peripheral-blood eosinophilia prompted an endomyocardial biopsy that revealed acute eosinophilic myocarditis. The early initiation of steroid therapy resulted in the patient's substantial clinical improvement and survival. Early diagnosis of eosinophilic myocarditis and its treatment with steroid agents in some patients can lead to a favorable outcome. We discuss the challenge of diagnosing and identifying the characteristics of this variant of necrotizing eosinophilic myocarditis before the condition proves fatal.

Diagnostic and prognostic value of cardiac magnetic resonance imaging in assessing myocardial viability.

Assessment of viability is pivotal to the prognosis of patients with chronic coronary artery disease (CAD) and left ventricular dysfunction. Patients with viable myocardium have a better prognosis with revascularization; however, patients with nonviable myocardium have worse outcomes with higher perioperative morbidity and mortality subsequent to revascularization. Cardiac magnetic resonance (CMR) imaging not only is the current reference standard technique in measuring cardiac chamber size and function and myocardial mass and volume but also provides spatially registered 2- or 3-dimensional data sets in myocardial perfusion and myocardial contrast enhancement in the same imaging session. Late gadolinium enhancement by CMR is the best current technique in discriminating myocardial scar versus viable myocardium. An extensive body of preclinical evidence has validated the detection and characterization of the morphology of infarcted tissue. In clinical studies, infarct characteristics by CMR has demonstrated a strong clinical utility in the prediction of left ventricular functional recovery and patient prognosis. In this paper, we aim to review the current CMR techniques in characterizing the spectrum of myocardial changes because of CAD, in the prediction of myocardial viability, and the current evidence of CMR's role in patient prognosis. In addition, we will also review the current literature comparing the clinical utility of CMR with other established imaging modalities in the assessment of CAD.

Differences in treatment and in outcomes between idiopathic and secondary forms of organizing pneumonia.

Organizing pneumonia is a major reparative response of the lung tissue to an acute injury and is a pathological hallmark of an entity called bronchiolitis obliterans organizing pneumonia (BOOP). It can be idiopathic and called cryptogenic organizing pneumonia (COP) or be secondary to various conditions such as infections, drugs, connective tissue disorders, and radiation. Fifty-seven patients with pathologically confirmed BOOP were identified and were classified as having either COP or secondary BOOP on the basis of whether there was an identifiable cause. The two groups were compared for demographic, clinical, laboratory, radiological and treatment variables. Duration of treatment with corticosteroids was longer for patients with COP.

Pacemaker utilization during permanent atrial fibrillation in patients who received pacemaker implantation for sinus node dysfunction.

Patients who have pacemakers and sinus node dysfunction frequently have atrial fibrillation (AF). The need for continued pacemaker therapy after conversion to permanent AF remains uncertain. This study showed that, among 174 patients who received pacemaker implantation for sinus node dysfunction, 38% (n = 62) had the minimum intrinsic ventricular rate of >60 beats/min after conversion to AF. The pacemaker memory showed that 30 patients (18%) never used ventricular pacing during permanent AF. The study results suggest that patients who have a stable intrinsic ventricular rate during permanent AF by serial assessment may no longer need continued pacemaker therapy.

Prognostic value of the Duke Treadmill Score in diabetic patients.

BACKGROUND: The Duke Treadmill Score (DTS) is an established clinical tool for risk stratification of coronary artery disease. We sought to assess the prognostic value of the DTS in diabetics compared with nondiabetics in this study. METHODS: We studied 100 diabetics and 202 age- and sex-matched nondiabetic controls without known coronary artery disease risk stratified by DTS and followed for a median duration of 6.6 years. The association between DTS and primary, secondary outcomes, composite events, and rate of coronary angiography was tested. RESULTS: Survival free from cardiac death, nonfatal myocardial infarction, congestive heart failure, or early and late revascularization was 89%, 54%, and 13%, respectively, in the low-, intermediate-, and high-risk categories of diabetic group (P < .0001), and 91%, 57%, and 17%, respectively, in the low- to high-risk groups of nondiabetics (P < .0001). During follow-up, diabetics had more secondary events (P = .011) and coronary angiography (P < .001) compared with nondiabetics. The DTS was a strong independent predictor of composite events in both diabetics (P < .001) and nondiabetics (P < .001). A significant number of diabetics were classified as intermediate risk and had a significantly higher incidence of coronary angiography (87.5% vs 70.8%, P = .032) and late revascularizations (35.4% vs 15.3%, P = .011) within this risk group compared with nondiabetics. Survival free from major adverse cardiac events differed significantly across the 3 Duke risk groups for diabetics (P = .002) but not for controls (P = .07). Survival free from composite events differed significantly across the 3 Duke risk groups for both diabetics and nondiabetics (P < .0001). Overall, diabetics had higher rates of major adverse cardiac events, composite events (P = .011), and coronary angiography (P < .001) than nondiabetics. The DTS is a strong predictor of survival free of composite events in both groups by multivariate analysis. CONCLUSIONS: The DTS predicted survival free from MACE and composite events equally well in patients with and without diabetes.

Transient left ventricular apical ballooning: a novel heart syndrome.

A novel cardiac syndrome of left ventricular apical ballooning (Takotsubo cardiomyopathy-ampulla cardiomyopathy) involves reversible left ventricular apical ballooning (during systole) of acute onset with chest pain, electrocardiographic changes, and minimal elevation of cardiac enzymes resembling acute myocardial infarction, but without evidence of myocardial ischemia or injury. Patients have no angiographic evidence of coronary artery stenosis and there is almost always a complete recovery of left ventricular function in days to weeks. The precise etiologic basic of this syndrome is not clear but most likely it is a non-ischemic, metabolic syndrome caused by stress-induced activation of the cardiac adrenoceptors in absence of ischemia and reperfusion. Reported here is a case of stress-induced transient left ventricular apical ballooning syndrome in a young woman.

Internal mammary artery steal syndrome secondary to an anomalous lateral branch.

A 53-year-old male who underwent three-vessel coronary artery bypass grafting had a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and saphenous venous grafts to right coronary artery (RCA) and left circumflex coronary artery. Four years after surgery, he developed exertion angina associated with upper body exercises and even deep breathing at times. Angiographic evaluation revealed an anomalous lateral internal thoracic artery with steal phenomenon documented by adenosine cardiolyte. Patient was successfully treated with transcutaneous steel coil embolization by closing the anomalous vessel. Repeat stress electrocardiogram did not show any signs of ischemia. This case report emphasizes the variability in internal mammary artery (IMA) anatomy and the need to completely ligate all the branches of internal mammary artery intraoperatively.

Pseudo-pseudoaneurysm of the left ventricle: a rare complication of acute myocardial infarction--a case report and literature review.

Rupture of the cardiac wall is usually a fatal complication of acute myocardial infarction within the first 2 weeks. However, in certain cases a ruptured ventricular wall is contained by overlying adherent pericardium called pseudoaneurysm, whereas a true aneurysm is one that is caused by scar formation resulting in thinning of the myocardium. The patients with pseudoaneurysm may survive until the aneurysm ruptures. In exceedingly rare instance, the rupture of the myocardium is not transmural but remains circumscribed within the ventricular wall itself, but in communication with the ventricular cavity. This finding is defined as pseudo-pseudoaneurysm. The authors report a case of postinfarction posterobasal pseudo-pseudoaneurysm along with review of the literature on the subject.