Left ventricular apical ballooning--a novel cardiac disease mimicking acute coronary syndrome: a case report in a Caucasian patient.

The syndrome of "apical ballooning" consists of an acute onset of transient extensive akinesia of the apical portion of the left ventricle, without significant stenosis on the coronary angiogram, accompanied by chest symptoms, ECG changes, and a limited release of cardiac markers disproportionate to the extent of akinesia. So far, the vast majority of cases with this syndrome have been reported from Japanese patients and only a few cases of Caucasian patients have been described. Emotional or physical stress or other preceding triggering factors might play a key role in this cardiomyopathy, but the precise etiology remains unknown. We describe a case of "apical ballooning" in a white patient, who presented at our institution with this novel heart syndrome. Despite severe initial presentation, conservative medical management leads to good long term outcome in most patients.

Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation.

BACKGROUND: Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR. METHODS: In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge. RESULTS: Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 microg/L (9.1-51.4 microg/L) versus 25.9 microg/L (10.2-57.5 microg/L); 6 hours after ROSC: 15.2 microg/L (9.7-30.8 microg/L) versus 25.6 microg/L (12.7-38.2 microg/L); 12 hours after ROSC: 14.0 microg/L (8.6-32.4 microg/L) versus 28.5 microg/L (11.0-50.7 microg/L); and 48 hours after ROSC: 13.1 microg/L (7.8-29.5 microg/L) versus 52.0 microg/L (29.1-254.0 microg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 microg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%-100%), and a level of 29 microg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%-100%). CONCLUSIONS: Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.

Arterial stiffness and arterial wave reflections are associated with systolic and diastolic function in patients with normal ejection fraction.

BACKGROUND: Increased arterial stiffness and early wave reflections have been observed in patients with heart failure and normal ejection fraction (HFNEF). We investigated, whether impaired arterial function is associated with impaired systolic and diastolic function and symptomatic status. METHODS: We prospectively enrolled 336 patients (mean age 63.5 years) undergoing coronary angiography, and assessed pulse wave velocity (PWV) invasively, arterial wave reflections (augmentation index (AIx); pressure augmentation (AP)) noninvasively using radial applanation tonometry and a validated transfer function, and characteristic impedance (Zc) using echocardiography with tonometry. In addition, echocardiography including tissue Doppler of the mitral annulus was performed. RESULTS: Peak systolic velocity (S') varied inversely with AIx (R = -0.38, P < 0.001), AP (R = -0.48, P < 0.0001), PWV (R = -0.39, P < 0.001), and Zc (R = -0.29, P < 0.01). Likewise, early diastolic velocity (E') showed a strong, negative correlation with AP (R = -0.32, P < 0.01), PWV (R = -0.64, P < 0.0001), and Zc (R = -0.50, P < 0.0001). Higher filling pressures were associated with increased wave reflections (AIx, AP) and arterial stiffness (PWV, Zc). All associations were independent of age and gender. Patients suffering from exertional dyspnea had increased AIx, AP, and PWV. CONCLUSIONS: In middle-aged and elderly patients, increased arterial stiffness and wave reflections are consistently and independently associated with impaired systolic and diastolic function and with functional limitations.

Intracoronary air embolism in open heart surgery--an uncommon source of myocardial ischaemia.

We report a case of air embolism detected by transesophageal echocardiography in a patient undergoing open heart surgery for acute mitral regurgitation. Intraoperative transesophageal echocardiography revealed an increased brightness of the apical wall and a severely compromised left ventricular myocardium with severe diffuse hypokinesis after removal of the aortic cross clamps and spontaneous resolution in the control echocardiography.

Transient left ventricular apical ballooning mimicking acute coronary syndrome in four patients from central Europe.

The syndrome of "apical ballooning" consists of an acute onset of transient extensive akinesia of the apical portion of the left ventricle, without significant stenosis on the coronary angiogram. The syndrome is accompanied by chest symptoms, electocardiographic changes, and limited release of cardiac markers disproportionate to the extent of akinesia. So far, the vast majority of cases with this syndrome have been reported among Japanese population and only a few cases among Caucasian population. We describe "apical ballooning" in four Caucasian patients, three women and one man, who presented at a tertiary referral center over a period of eight months. Their age ranged between 64 and 84 years. Three of them presented with chest symptoms. All four patients had electrocardiographic changes and increased concentration of troponin T. One patient developed hemodynamic instability, but none died or showed recurrence of symptoms during the follow-up of 1-8 months. In all patients, a preceding triggering factor was identified, such as emotional or physical stress. In all patients left ventriculography showed extensive akinesia of the apex of the left ventricle ("apical ballooning") in the absence of a significant coronary artery stenosis. Left ventricular systolic function recovered completely within three days to three weeks. Emotional or physical stress or other preceding triggering factors might play a key role in this cardiomyopathy, but the precise etiology remains unknown. Despite severe initial presentation, conservative medical management leads to good long term outcome.

Multiple complex coronary plaques in a patient with acute myocardial infarction.

This report describes the case of a patient who developed acute myocardial infarction with ST segment elevation in anterior and inferior leads, simultaneously. After treatment with systemic thrombolysis, and after an initial short-lasting symptomatic improvement, chest pain and ST segment elevation recurred. Coronary angiography revealed severe complex stenotic lesions at both the right coronary artery and the left anterior descending (LAD) coronary artery. Percutaneous coronary angioplasty and stent implantation were successfully performed at both lesions. This case supports the concept that, at least in some patients, acute coronary artery disease reflects a diffuse pathophysiologic process that may lead to multifocal plaque instability associated with clinical instability at multiple sites.

Clinical and angiographic outcome after cutting balloon angioplasty.

The cutting balloon is a new device for coronary angioplasty, that, by the combination of incision and dilatation of the plaque, is believed to be promising for treatment of in-stent restenosis. The purpose of the study was to evaluate the safety and efficacy of CBA. We reviewed the immediate and 6-month follow-up angiographic and clinical outcome of 147 patients (109 men and 38 women) with a mean age of 67.3 +/- 10 undergoing this procedure at eight interventional centers in Austria. The target lesions treated with CBA were in-stent restenosis in 61% of patients, stenosis after balloon angioplasty in 8% of patients, and native lesions in 33% of patients. Sixty-five percent of the patients included had multivessel disease. Lesion type was A in 18% of patients, B1 in 31% of patients, B2 in 39% of patients, and C in 12% of patients. The degree of stenosis was 87% +/- 9%, the length of the target lesion treated with CBA was 8.8 +/- 5.1 mm. Target vessel was left circumflex artery in 22 cases, right coronary artery in 36 cases, and left anterior descending artery in 89 cases. The overall procedural success rate was 90.5%. "Stand-alone" CBA was performed in 63% of patients, the procedure was combined with coronary stenting in 16% of patients, and with balloon angioplasty in 21% of patients. Coronary complications occurred in eight cases (5.4%) with coronary dissection in seven (total dissection rate of 4.7%) and urgent bypass surgery in one case (0.7%). No further complications such as death, occlusion, or perforation of coronary arteries, embolization, or thrombosis were observed. Six-month clinical follow-up revealed q-wave myocardial infarction in 2.7% of patients, aortocoronary bypass surgery in 8.5% of patients, and repeated percutaneous coronary intervention in 17% of patients (11.5% with stenting). Six-month angiographic follow-up of patients with recurrent angina showed target lesion restenosis (> 50% diameter stenosis) in 14% of patients, late lumen loss with < or = 50% diameter stenosis in 6% of patients and progression of "other than target" lesions with > 50% diameter stenosis in 14% of patients. This series demonstrates the safety and feasibility of cutting balloon angioplasty in patients with complex coronary artery disease and in-stent restenosis.

[Angiographic results of "atypical" chest pain]. / Ergebnisse koronarangiographischer Untersuchungen bei Patienten mit "atypischem" Thoraxschmerz.

BACKGROUND AND AIMS: Coronary angiography permits evaluation of coronary artery morphology and coronary pathology. It represents an accurate method of defining stenotic coronary lesions. Chest pain may be caused by coronary artery disease as well as by other cardiac and noncardiac disorders. However, sensitivity of clinical evaluation and noninvasive diagnostic assessment in detection of coronary artery disease is limited. Noninvasive diagnostic strategies give inconsistent results in about 10-30%. Here coronary angiography is regarded as an accurate method for appropriate diagnosis. Ist sophisticated apparatus, cost, and invasiveness necessitate well-considered application of this procedure. Therefore, it appears important to analyze coronary angiograms in patients with the referral diagnosis of "atypical" chest pain with inconsistent noninvasive testing or impossibility to perform noninvasive assessment. PATIENTS AND METHODS: We analyzed records of 1,000 consecutive patients (625 men, 375 women, mean age 63.1 years), who underwent coronary angiography at our institution from January 5, 1998 to May 5, 1998. RESULTS: 49 patients (17 women, 32 men; mean age 59 years) were referred due to "atypical" chest pain. 21 (42.9%, nine women, twelve men) of these 49 patients had normal coronary arteries at angiography. 21 (42.9%) patients showed coronary artery disease with a diameter stenosis > 50%. In seven (14.2%) patients, coronary sclerosis with a diameter stenosis < 50% could be observed. Only five (29.4%) of the 17 women but 16 of the 32 men (50%) had coronary artery disease with a diameter stenosis > 50% (p < 0.01). CONCLUSIONS: In unselected patients referred for coronary angiography due to "atypical" chest pain and inconsistent noninvasive testing or impossibility to perform noninvasive assessment. 42.9% had coronary artery disease with a diameter stenosis > 50%. Angiographic evaluation of symptomatic patients with "atypical" signs and symptoms and inconsistent noninvasive testing seems to be appropriate.