A rare case of Ebstein's anomaly with left ventricular noncompaction.

Ebstein's anomaly is a rare congenital cardiac disease characterized by apical displacement of the tricuspid valve with decreased right ventricular function. Left ventricular noncompaction is a cardiomyopathy characterized by the presence of numerous and prominent trabeculations together with deep intertrabecular recesses in a portion of the ventricular wall, principally at the lateral and apical level. We describe the very rare case of a patient living for 78 years with a benign form of Ebstein's anomaly and left ventricular noncompaction cardiomyopathy with slightly reduced systolic function.

Simultaneous implantation of MitraClip devices in a patient with severe mitral and tricuspid valve regurgitation.

We present a case of an 84-year old patient with severe mitral and tricuspid regurgitation with a lot of cormobidities who underwent a simultaneous transfemoral (one approach) mitral and tricuspid valve repair using the MitraClip system.

An Unusual Case of Arterial Embolism in an Adolescent With a Mitral Valve Repair With a Ring.

We report a case of an adolescent young man who presented with embolism of both lower legs. The patient had undergone mitral valve repair with a Kalangos biodegradable ring (Bioring SA, Lonay, Switzerland) 9 months earlier. Bilateral embolectomy was performed. Histopathologic examination revealed minute fragments of synthetic material within the embolus, which otherwise consisted of recent thrombus.

Effects of central sympathetic activation on repolarization-dispersion during short-term myocardial ischemia in anesthetized rats.

AIMS: Sympathetic activation during myocardial ischemia enhances arrhythmogenesis, but the underlying pathophysiologic mechanisms remain unclear. We investigated the central sympathetic effects on ventricular repolarization during the early-period post-coronary artery occlusion. MAIN METHODS: We studied 12 Wistar rats (254±2 g) for 30 min following left coronary artery ligation, with (n=6) or without (n=6) pretreatment with the central sympatholytic agent clonidine. Mapping of left and right ventricular epicardial electrograms was performed with a 32-electrode array. As an index of sympathetic activation, heart rate variability in the frequency domain was calculated. Heart rate and repolarization duration were measured with a custom-made recording and analysis software, followed by calculation of intra- and inter-ventricular dispersion of repolarization. KEY FINDINGS: Heart rate and heart rate variability indicated lower sympathetic activation in clonidine-treated rats during ischemia. Repolarization duration in the left ventricle prolonged after clonidine at baseline, independently of heart rate, but no differences were present 30 min post-ligation. Dispersion of repolarization in the right ventricle remained stable during ischemia, whereas it increased in the left ventricle, equally in both groups. A similar trend was observed for inter-ventricular dispersion, without differences between groups. SIGNIFICANCE: In addition to intra-ventricular repolarization-dispersion, anterior-wall myocardial ischemia may also increase inter-ventricular repolarization-dispersion. Progressive central sympathetic activation occurs during myocardial ischemia, but it does not affect intra- or inter-ventricular dispersion of ventricular repolarization during the early phase. Further research is warranted on the potential effects during subsequent time-periods.

Central Sympathetic Activation and Arrhythmogenesis during Acute Myocardial Infarction: Modulating Effects of Endothelin-B Receptors.

Sympathetic activation during acute myocardial infarction (MI) is an important arrhythmogenic mechanism, but the role of central autonomic inputs and their modulating factors remain unclear. Using the in vivo rat-model, we examined the effects of clonidine, a centrally acting sympatholytic agent, in the presence or absence of myocardial endothelin-B (ETB) receptors. We studied wild-type (n = 20) and ETB-deficient rats (n = 20) after permanent coronary ligation, with or without pretreatment with clonidine. Cardiac rhythm was continuously recorded for 24 h by implantable telemetry devices, coupled by the assessment of autonomic and heart failure indices. Sympathetic activation and arrhythmogenesis were more prominent in ETB-deficient rats during the early phase post-ligation. Clonidine improved these outcomes throughout the observation period in ETB-deficient rats, but only during the delayed phase in wild-type rats. However, this benefit was counterbalanced by atrioventricular conduction abnormalities and by higher incidence of heart failure, the latter particularly evident in ETB-deficient rats. Myocardial ETB-receptors attenuate the arrhythmogenic effects of central sympathetic activation during acute MI. ETB-receptor deficiency potentiates the sympatholytic effects of clonidine and aggravates heart failure. The interaction between endothelin and sympathetic responses during myocardial ischemia/infarction and its impact on arrhythmogenesis and left ventricular dysfunction merits further investigation.

Attenuation of post-infarction remodeling in rats by sustained myocardial growth hormone administration.

Prevention of left ventricular remodeling is an important therapeutic target post-myocardial infarction. Experimentally, treatment with growth hormone (GH) is beneficial, but sustained local administration has not been thoroughly investigated. We studied 58 rats (322 ± 4 g). GH was administered via a biomaterial-scaffold, following in vitro and in vivo evaluation of degradation and drug-release curves. Treatment consisted of intra-myocardial injection of saline or alginate-hydrogel, with or without GH, 10 min after permanent coronary artery ligation. Echocardiographic and histologic remodeling-indices were examined 3 weeks post-ligation, followed by immunohistochemical evaluation of angiogenesis, collagen, macrophages and myofibroblasts. GH-release completed at 3 days and alginate-degradation at ∼7 days. Alginate + GH consistently improved left ventricular end-diastolic and end-systolic diameters, ventricular sphericity, wall tension index and infarct-thickness. Microvascular-density and myofibroblast-count in the infarct and peri-infarct areas were higher after alginate + GH. Macrophage-count and collagen-content did not differ between groups. Early, sustained GH-administration enhances angiogenesis and myofibroblast-activation and ameliorates post-infarction remodeling.

What is the best approach in a patient with a failed aortic bioprosthetic valve: transcatheter aortic valve replacement or redo aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether transcatheter aortic valve-in-valve replacement (viv-TAVR) or redo aortic valve replacement (rAVR) is the best strategy in a patient with a degenerative bioprosthetic aortic valve. Altogether, 162 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The results of the studies provided interesting results. All the studies are retrospective. Four papers reported the results of redo aortic valve replacement in patients with failed aortic bioprosthetic valve, six papers demonstrated their results with transcatheter aortic valve-in-valve replacement for the same indication and two papers reported their propensity-matched analysis of outcomes between viv-TAVR and rAVR in patients with previous cardiac surgery. Thirty-day mortality for rAVR was 2.3-15.5% and 0-17% for viv-TAVR. For rAVR, survival rate at 30 days was 83.6%, 76.1% at 1 year, 70.8% at 3 years, at 51.3-66% at 5 years, 61% at 8 years and 61.5% at 10 years. For viv-TAVR, the overall Kaplan-Meier survival rate at 1 year was 83.2%. After viv-TAVR at 1 year, 86.2% of surviving patients were at New York Heart Association (NYHA) class I/II. The complications after rAVR were stroke (4.6-5.8%), reoperation for bleeding (6.9-9.7%), low-cardiac output syndrome (9.9%) whereas complications after viv-TAVR at 30 days were major stroke (1.7%), aortic regurgitation of at least moderate degree (25%), new permanent pacemaker implantation rate (0-11%), ostial coronary obstruction (2%), need for implantation of a second device (5.7%) and major vascular complications (9.2%). It is noteworthy to mention that there is a valve-in-valve application that provides information to surgeons for choosing the correct size of the TAVR valve. Transcatheter aortic valve-in-valve procedures are clinically effective, at least in the short term, and could be an acceptable approach in selected high-risk patients with degenerative bioprosthetic valves. Redo AVR achieves acceptable medium and long-term results. Both techniques could be seen as complementary approaches for high-risk patients.

Coil embolization of traumatic pseudoaneurysm of right internal thoracic artery.

Traumatic injury to the chest and internal thoracic artery is a perplexing problem that is difficult to diagnose and open to different treatment options. Internal thoracic artery pseudoaneurysms are an extremely rare vascular abnormality. We report the case of a patient with a pseudoaneurysm of the musculophrenic artery, a branch of right internal thoracic artery, caused by a penetrating injury of the chest.