Takotsubo cardiomyopathy associated with rupture of the left ventricular apex: assessment of histopathological features of a fatal case and literature review.

Takotsubo cardiomyopathy, also known as "broken heart syndrome," is a cardiac entity characterized by transient left ventricular dysfunction without obstructive atherosclerotic coronary artery disease. An episode of emotional stress is believed to act as a trigger in the development of this syndrome, which typically occurs in female patients. We report a fatal case of a previously healthy 70-year-old woman who suffered an out-of-hospital cardiac arrest and cardiac rupture during emotional distress, due to Takotsubo cardiomyopathy. Ventricular rupture with Takotsubo cardiomyopathy is rare, but our case emphasizes the importance of dealing with this serious and potentially life-threatening disease. Takotsubo cardiomyopathy should be considered as a differential diagnosis in cases of early-developing heart failure, and clinicians should subsequently use adequate diagnostic and therapeutic options.

Incidence, management, and prevention of right ventricular perforation by pacemaker and implantable cardioverter defibrillator leads.

BACKGROUND: Cardiac perforation of the right ventricle (RV) is a rare but potentially life-threatening complication of both pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant. Appropriate management is still uncertain. We assessed the incidence of subacute (24 hours-1 month) or delayed (>1 month) cardiac perforation by RV lead and the results of percutaneous lead extraction. METHOD: The study population included all patients diagnosed with subacute or delayed RV-lead perforation during the period 2007-2013. The incidence of perforation according to device type and fixation mechanism was calculated. The outcome of the percutaneous approach, consisting of lead extraction by simple traction, was assessed. RESULTS: Cardiac perforation was diagnosed in 14 (eight females, mean age 71 [range 47-83] years) patients out of 3,815 who received an RV-lead implant (0.4%). The overall incidence of RV-lead perforation was similar between ICD (0.3%) and PM (0.4%) implants (P = 1.0) and between active (0.5%) and passive (0.3%) fixation leads (P = 0.3). All perforating leads were originally placed at the RV apex. Five patients were asymptomatic, but all presented altered lead electrical parameters. Surgical removal of the lead was performed in one patient while in the remaining the leads were successfully extracted by direct manual traction in the absence of any complications. In all patients, new active fixation leads were positioned in the RV septum and the follow-up (42 ± 27 months) was uneventful. CONCLUSIONS: RV perforation is a rare complication of both PM and ICD implants, regardless of the lead fixation mechanism. In most patients, percutaneous lead extraction is a safe and effective management approach.

First-in-man assessment of a dedicated guidewire for transcatheter aortic valve implantation.

AIMS: The aim of this study was to evaluate the safety and performance of a specifically designed, dedicated TAVI guidewire. METHODS AND RESULTS: From May 2011 to August 2012, 39 consecutive patients referred for TAVI were prospectively enrolled in a first-in-man, open label, non-randomised feasibility study to evaluate the safety and performance of a specifically designed, dedicated TAVI guidewire in our institution (mean age 80.4±5.1 years, mean logistic EuroSCORE 26.8±11.7%, n=29 CoreValve transfemoral, n=8 CoreValve direct aortic, n=1 Edwards SAPIEN valve direct aortic, n=1 CoreValve subclavian). The primary safety endpoint was reached successfully with the dedicated TAVI guidewire in all 39 cases with no cases of guidewire displacement from the left ventricle during the procedure. In three cases the wire was repositioned to optimise loop position using a pigtail catheter prior to valve implantation. There were no cases of guidewire-related procedural complications. The mean delivery system tracking time using the guidewire was 1.4±0.6 minutes and the mean deployment time for TAVI was 13.8±7.8 minutes. CONCLUSIONS: This represents the first recorded use of a dedicated TAVI guidewire to treat patients with a transcatheter aortic valve. The wire is easy to place, safe to adjust within the ventricle, and the stiffness of the wire facilitates valve tracking through tortuous anatomy. In this study there were no pericardial complications with the use of this dedicated TAVI guidewire.

[Penetrating cardiac injuries: assessment of 21 patients]. / Penetran kardiyak yaralanmalar: 21 olgunun degerlendirilmesi.

BACKGROUND: Penetrating cardiac injuries carry high mortality rates due to serious clinical outcomes. This study was planned to investigate patients treated surgically in our hospital for penetrating cardiac injury. METHODS: In this article, we reviewed retrospectively 21 patients (18 male, 3 female) suffering from penetrating heart injuries who admitted to our hospital between February 2006 and January 2011. Patients were evaluated with respect to clinical findings, treatment methods and clinical outcomes. RESULTS Among the patients, 19 cases were due to stab injury and 2 cases to gunshot injury. Emergent surgical interventions were performed in all patients. Cardiac injuries involved the right ventricle in 13 patients, left ventricle in 5 patients and right atrium in 3 patients. There was no left atrial injury. Cardiac injuries were repaired by primary suturing method. Mortality was determined in 6 patients (28.6%). CONCLUSION: Penetrating cardiac injuries are seen generally in young people. Early transport, proper resuscitation and emergent surgery treatment improved survival in patients who sustained penetrating cardiac injuries.

Percutaneous transatrial mitral commissurotomy by modified technique using a JOMIVA balloon catheter: a cost-effective alternative to the Inoue balloon.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transatrial mitral commissurotomy (PTMC) is an established non-surgical treatment of rheumatic mitral stenosis. The study aim was to assess the safety and efficacy of PTMC using the Joseph mitral valvuloplasty (JOMIVA) balloon catheter, with a modified technique. METHODS: PTMC was performed in 252 patients (88 males, 164 females; mean age 39.2 +/- 13.8 years; range: 10-76 years) with symptomatic mitral stenosis. Among patients, 52 (20.6%), 182 (72.2%) and 18 (7.2%) were in NYHA classes II, III and IV, respectively. Atrial fibrillation was present in 52 patients (20.6%), and mild mitral regurgitation (MR) in 26 (10.3%); 92 patients (36.5%) had a mitral valve echo score > 8. Patients were followed up with detailed clinical and echocardiography studies at three-month intervals during the first year, and at six-month intervals thereafter. RESULTS: The procedure was technically successful in 247 patients (98%), and an optimal result was achieved in 228 (90.5%), with mean mitral valve area increased from 0.81 +/- 0.32 to 1.92 +/- 0.39 cm2 (p < 0.001). NYHA class was improved in most patients. Seven patients (2.8%) had cardiac tamponade during the procedure; one of these (0.4%) died from left ventricular tear. MR appeared (n = 10) or worsened (n = 20) in 30 patients (11.9%), among whom three (1.2%) developed severe MR. Each JOMIVA balloon catheter was used 10 to 20 times without being damaged. In total, 220 patients were followed up for between six and 54 months (mean 30 months). At follow up, 140 (63.6%) and 67 (30.5%) patients were in NYHA classes I and II, respectively. Seventeen patients (7.7%) developed mitral restenosis. CONCLUSION: PTMC using the JOMIVA balloon catheter is a cost-effective and safe alternative to the Inoue balloon when treating symptomatic severe mitral stenosis. The hemodynamic benefits were sustained long term in a majority of patients. In particular, cost is important factor in a less wealthy country such as India.

Transesophageal three-dimensional echocardiographic assessment of left ventricular pseudoaneurysm.

We report an adult patient with a left ventricular pseudoaneurysm following an acute myocardial infarction in whom three-dimensional (3-D) transesophageal echocardiography (TEE) delineated clearly not only the location but also the size and shape of the rupture site. The size of the rupture site measured by 3-D TEE correlated well with the surgical measurements. Three-dimensional images also showed a localized superior distortion of the lateral aspect of the mitral annulus and left atrial wall produced by the pseudoaneurysm. The resulting severe mitral regurgitation practically disappeared after repair and decompression of the pseudoaneurysm.