Percutaneous closure of an iatrogenic fistula from the left ventricle to the coronary sinus.

A patient with a history of rheumatic mitral valve disease and valve replacement in childhood presented with severe, persistent dyspnea. During an electrophyisiologic procedure, she was discovered to have a fistula from the left ventricle to the coronary sinus. She had severe pulmonary hypertension and elevated filling pressures, with a significant left-to-right shunt. Percutaneous closure of the fistula was performed using two vascular plugs. Subsequently the patient's hemodynamics improved and her symptoms subsided. Here, we describe the case and review the literature.

Left ventricular end diastolic pressure and serum brain natriuretic peptide levels in patients with abnormal impedance cardiography parameters.

BACKGROUND: Distinct hemodynamic patterns determined by impedance cardiography (ICG) have been found to be superior to clinical assessment for the identification of patients at risk for heart failure decompensation in the outpatient setting. Correlation of these hemodynamic patterns with serum brain natriuretic peptides (BNP) and left ventricular end diastolic pressure (LVEDP) has not been established. We evaluated the correlation of low-, intermediate- and high-risk groups for acute decompensation of heart failure (ADHF) as determined by ICG parameters with LVEDP and serum BNP. METHODS: Consecutive patients referred for cardiac catheterization with echocardiographic diagnosis of left ventricle dysfunction (systolic or diastolic) or history of congestive heart failure (CHF) underwent ICG evaluation, serum BNP measurement, and LVEDP by cardiac catheterization. Three groups at different levels of risk for ADHF were determined according to ICG parameters: thoracic fluid content (TFC) and stroke volume index (SVI); low risk (low TFC, high SVI), intermediate risk (low-low or high-high TFC and SVI, respectively), and high risk (high TFC and low SVI). RESULTS: Sixty three patients were included in the present study. Mean LVEDP and serum BNP levels were 20.2 +/- 8.2 mmHg and 814 +/- 1005 pg/mL, respectively, in the high-risk group in comparison to 12.3 +/- 6.2 mmHg and 53 +/- 38 pg/mL in the low-risk group (p = 0.01 and p = 0.009). CONCLUSIONS: Patients with ICG parameters that represent high risk for ADHF have higher levels of serum BNP and LVEDP in comparison with patients who have intermediate- or low-risk ICG parameters for ADHF.

Pioglitazone and the risk of myocardial infarction and other major adverse cardiac events: a meta-analysis of randomized, controlled trials.

A recent meta-analysis suggested that the use of rosiglitazone increases the risk of myocardial infarction (MI) in patients with type 2 diabetes mellitus. It is unclear whether this is a class effect of thiazolidinediones (TZD). We did a meta-analysis to evaluate cardiovascular outcomes with the use of pioglitazone. Randomized, controlled trials in which pioglitazone was compared with placebo or other hypoglycemic agents were considered for analysis. Studies were included if the data for MI were available. Studies were identified with use of relevant search words in Medline, Pubmed, EMBASE, CINAHL, and Cochrane databases. Data abstraction was done by 2 individual authors using a standardized protocol. The relative risk across all study groups was computed by the Mantel-Haenszel method, and interstudy heterogeneity was assessed by the chi method. All results were computed according to 95% confidence intervals. Five trials (N = 9965) met the inclusion criteria for analysis. The relative risk for MI was 0.86 (0.69-1.07; P = 0.17). The relative risks for stroke and revascularization were 0.79 (0.61-1.02; P = 0.07) and 0.40 (0.13-1.23; P = 0.11), respectively. Pioglitazone does not increase the risk for MI and may decrease the risk for stroke and revascularization.

Takayasu arteritis presenting as postpartum cardiomyopathy.

A case of Takayasu arteritis (TA) presenting as postpartum cardiomyopathy in a puerperal 26-year-old Hispanic female patient is presented. TA is a large-vessel vasculitis affecting young to middle-aged women. TA can result in cardiomyopathy as a direct result of myocardial involvement. The patient had classical clinical and radiographic findings of TA that were previously undiagnosed. She had rapid functional improvement with corticosteroids. The importance of a thorough physical examination of peripheral pulses is stressed in all patients, especially in those with cardiomyopathy.

Stress cardiomyopathy in a Caucasian man.

Stress cardiomyopathy is increasingly being described as a form of reversible left ventricular systolic dysfunction, with a characteristic shape on left ventriculography. The acute clinical, electrocardiographic and laboratory abnormalities are reminiscent of acute coronary syndrome, with nonobstructive coronary arteries on angiography. Wall motion abnormalities typical of this disease exhibit apical akinesis with compensatory basal hyperkinesis, resulting in the characteristic systolic apical ballooning. Stress cardiomyopathy is much more common in women than men, especially postmenopausal women, and it is typically triggered by intense medical, emotional or physical stress. The pathogenesis of the disease is not well understood, with current evidence favouring catecholamine myocardial injury. Until prospective distinction can be made between stress car-diomyopathy and acute coronary syndrome, the diagnosis should be that of exclusion. In addition to long-term beta-blockers, angiotensin-converting enzyme inhibitors and diuretics as needed, treatment is generally supportive, with recovery of baseline left ventricular function within a few weeks to a month.

Syncope from dynamic left ventricular outflow tract obstruction simulating hypertrophic cardiomyopathy in a patient with primary AL-type amyloid heart disease.

Dynamic left ventricular outflow tract (LVOT) obstruction is seen classically in hypertrophic cardiomyopathy. Cardiac amyloidosis can present with asymmetric hypertrophy that resembles hypertrophic cardiomyopathy, and, in some cases, with dynamic LVOT obstruction. The occurrence of syncope in such patients is not uncommon. The syncope is usually thought to be related to mechanisms other than LVOT obstruction, such as arrhythmias, conduction disturbances, orthostatic hypotension, or vasovagal effects associated with neuropathy.Herein, we report the case of a patient who had immunocyte-derived (primary AL-type) cardiac amyloidosis with the echocardiographic appearance of hypertrophic cardiomyopathy and evidence of LVOT obstruction that caused syncope. We were able to provoke and identify dynamic LVOT obstruction that produced presyncopal symptoms similar to those that typically occur in such patients spontaneously. Dynamic LVOT obstruction as a cause of syncope should be considered in patients who have cardiac amyloidosis and echocardiographic evidence of hypertrophic cardiomyopathy.