Of mixed vegetables and cardiac arrhythmias - Digitalis purpurea confused with Borago officinalis: A case series of accidental digitoxin intoxications.

We present the case series of two women aged 35 and 60 years who presented to our emergency department with severe vomiting, nausea, and malaise. Their symptoms started approximately 2 h after the ingestion of home-made mixed vegetables with freshly picked vegetables and leaves from the patients' garden, of which one was supposed to be borage. An electrocardiogram revealed diffuse ST-segment depression with down-up sloping in both patients. We supposed an accidental confusion of wild borage (Borago officinalis) with foxglove (Digitalis purpurea). Both patients were subsequently admitted to the intermediate-care-unit for close monitoring and continuous activated charcoal administration. Digitoxin serum concentrations were elevated in both patients (40.9 and >50 ng/ml, respectively - reference therapeutic range 8-18 ng/ml). The younger woman, despite the relatively lower serum digitoxin concentrations, presented a single episode of advanced atrioventricular block and long-lasting sinus bradycardia. Both showed a complete recovery. Although not uncommon, our case series reiterates the fact that such plant misclassifications are potentially life-threating and warrant the treating physicians' full attention. Learning objective: Plant poisoning is a frequent reason for consultation of poison information centers and may result in life-threatening cardiac arrhythmias. Confusion of foxglove leaves (Digitalis purpurea) with borage leaves (Borago officinalis L.), which is a popular food ingredient for mixed salads, is not uncommon. Without a dedicated medical history, such cases are difficult to diagnose and warrant the treating physicians' full attention and the involvement of a local poison information center.

Early but not late stent thrombosis is influenced by residual platelet aggregation in patients undergoing coronary interventions.

AIMS: Recent studies suggest a relevant association of post-interventional residual platelet aggregation (RPA) under therapy with oral platelet inhibitors and the occurrence of atherothrombotic events. The influence of post-interventional RPA on the incidence of stent thrombosis (ST) has not been sufficiently evaluated in consecutive unselected cohorts of percutaneous coronary intervention (PCI) patients. The aim of this observational study was to investigate the impact of RPA on the incidence of ST within 3 months in patients treated with dual antiplatelet therapy. METHODS AND RESULTS: The study population included a consecutive cohort of 1019 patients treated with PCI [n = 741 bare-metal stent (BMS) and n = 278 drug-eluting stent (DES)] due to symptomatic coronary artery disease. Residual platelet activity was assessed by adenosine disphosphate (20 micromol/L)-induced PA after 600 mg clopidogrel loading dose. Maximum RPA was measured as peak of aggregation, final RPA was measured 5 min after addition of agonist. The primary endpoint was the occurrence of ST within 3 months defined according to academic research consortium (ARC) criteria. Final and maximum RPA were independent predictors of ST after 3 months. In secondary analysis, the observed effects were independently associated with early ST (HR 1.05, 95% CI 1.01-1.08 and HR 1.05, 95% CI 1.01-1.09, P < 0.01, respectively). However, incidence of 3-month late stent thrombosis (LAT) was not influenced by post-interventional RPA in multivariable analysis. CONCLUSION: Post-interventional RPA is associated with the occurrence of early ST in patients treated with either BMS or DES; however, there is no predictive value of RPA for the incidence of 3-month LAT, suggesting the involvement of other possible mechanisms like discontinuation of antiplatelet therapy.

Statins do not adversely affect post-interventional residual platelet aggregation and outcomes in patients undergoing coronary stenting treated by dual antiplatelet therapy.

AIMS: There are growing data suggesting a clinical relevance of residual platelet aggregation (RPA) in patients undergoing PCI. Drug-drug interaction of statins and clopidogrel has been controversially discussed in ex vivo studies and clinical trials. The aim of the present study was to investigate the effects of peri-procedural statin medication on the metabolization of aspirin and clopidogrel with regard to platelet aggregation and clinical outcome in patients undergoing coronary intervention. METHODS AND RESULTS: Patients with coronary stenting for symptomatic coronary artery disease are routinely evaluated by platelet function analysis in a monocentre registry, and for the present study, a consecutive cohort of 1155 patients were analysed. About 87.7% of the patients were treated with statins at the time of platelet function analysis. Residual platelet activity assessed by adenosine diphosphate (20 micromol/L)-induced platelet aggregation was not significantly influenced by statin treatment. Nor the significant effects of CYP3A4-metabolization pathway on post-treatment aggregation were recorded, although there was even a trend to lower RPA values in patients treated with CYP3A4-metabolized statins. Further, in an inter-individual analysis comparing patients treated with CYP3A4- and non-CYP3A4-metabolized statins, no time-dependent difference of clopidogrels anti-aggregatory effects was observed. Clinical follow-up of major adverse events (myocardial infarction, ischaemic stroke, death) in 991 patients within 3 months revealed no significant adverse effects of statin treatment on clinical outcome. Instead, statin treatment was independently associated with lower incidence of composite events (HR 0.44, 95% confidence interval 0.23-0.83, P = 0.01). CONCLUSION: Peri-procedural co-administration of statins does not increase the post-interventional RPA in cardiovascular patients treated with dual antiplatelet therapy and does not worsen the clinical prognosis of these patients.

Local catheter-based delivery of antithrombotic or antiproliferative drugs: a new concept for prevention of restenosis.

BACKGROUND: Drug eluting stents have reduced the incidence of restenosis after percutaneous coronary interventions significantly, but cause concern about long term safety. Local drug delivery using special application catheters is an alternative approach for intracoronary pharmacotherapy. Besides the fact, that no problematic coating as drug carrier has to be used, a local delivery independent of the stent itself by using catheter techniques offers further advantages - such as the possibility to treat the whole vessel wall, stent edges and adjacent vessel segments and not only the area close to the stent struts. METHODS AND RESULTS: We have developed a new local catheter-based delivery system for local intracoronary pharmacotherapy. An antithrombotic as well as an antiproliferative therapy concept for prevention of restenosis are presented in the manuscript. Our data show that local drug delivery of platelet glycoprotein VI and paclitaxel were effective in the reduction of thrombus formation and neointima formation in experimental animal models. CONCLUSIONS: A combination of early antithrombotic and antiatherosclerotic mechanisms may be a realistic and effective approach to minimize postinterventional thromboischemic events and neointima formation. These results may contribute to an advanced and even combined local intracoronary pharmacotherapy in near future, independent of stent coatings.

Local paclitaxel delivery after coronary stenting in an experimental animal model.

The goal of this study was to test the safety and efficacy of local paclitaxel delivery via a newly designed application catheter in an experimental animal study. Drug-eluting stents reduce restenosis in comparison to bare-metal stents. The drug-eluting polymer, however, may exert potential thrombogenic and inflammatory effects. A catheter-based local paclitaxel delivery offers further advantages, particularly a homogenous drug transfer into the vessel wall and a pharmacotherapy of the stent edges. In 30 pigs, both bare-metal stent (3.0 x 13 mm) implantation and balloon angioplasty were performed. Ten pigs received subsequent local delivery of paclitaxel-solution via a newly designed catheter (Genie, ACROSTAK corp., Switzerland), 10 animals served as a sham group and received vehicle (0.9% NaCl solution) and 10 animals were used as a control group. All animals were treated with aspirin and clopidogrel to prevent stent thrombosis. After final angiography the vessels were excised 42 days after intervention and prepared for histological and histomorphometric analysis. All coronary arteries showed complete endothelialization 42 days following treatment. Paclitaxel treatment led to a marked reduction of neointimal proliferation either post stent implantation (neointimal area: 1.04 +/- 0.10 mm(2) vs. 2.37 +/- 0.23 mm(2), p < 0.001) or post balloon dilatation (neontimal area: 0.35 +/- 0.14 mm(2), vs. 0.68 +/- 0.24 mm(2), p < 0.01). There were no significant angiographic or histomorphometric differences between the control and the sham group. In both paclitaxel groups neither angiographic edge phenomena nor a significant histomorphometric inflammatory response were found in the treated vessel segments. In conclusion, the local application of paclitaxel via the Genie catheter is safe and effective to significantly reduce the proliferative response post-stent implantation or balloon dilatation in an experimental animal model.

Local delivery of soluble platelet collagen receptor glycoprotein VI inhibits thrombus formation in vivo.

Platelet-mediated thrombus formation at the site of vascular injury is a major trigger for thrombo-ischemic complications after coronary interventions. The platelet collagen receptor glycoprotein VI (GPVI) plays a critical role in the initiation of arterial thrombus formation. Endothelial denudation of the right carotid artery in rabbits was induced through balloon injury. Subsequently, local delivery of soluble, dimeric fusion protein of GPVI (GPVI-Fc) (n = 7) or control Fc (n = 7) at the site of vascular injury was performed with a modified double-balloon drug-delivery catheter. Thrombus area within the injured carotid artery was quantified using a computer-assisted image analysis and was used as index of thrombus formation. The extent of thrombus formation was significantly reduced in GPVI-Fc- compared with control Fc-treated carotid arteries (relative thrombus area, GPVI-Fc vs. Fc: 9.3 +/- 4.2 vs. 2.3 +/- 1.7, p < 0.001). Local delivery of soluble GPVI resulted in reduced thrombus formation after catheter-induced vascular injury. These data suggest a selective pharmacological modulation of GPVI-collagen interactions to be important for controlling onset and progression of pathological arterial thrombosis, predominantly or even exclusively at sites of injured carotid arteries in the absence of systemic platelet therapy.

Stent-based delivery of tissue inhibitor of metalloproteinase-3 adenovirus inhibits neointimal formation in porcine coronary arteries.

BACKGROUND: Stent-based antiproliferative therapy appears to decrease in-stent restenosis. However, alternative approaches might produce equivalent efficacy with better long-term safety. In previous work, an adenovirus capable of expressing the tissue inhibitor of metalloproteinase-3 (RAdTIMP-3) inhibited neointima formation in cell cultures and porcine saphenous vein grafts. RAdTIMP-3 decreased smooth muscle cell migration, stabilized the extracellular matrix, and uniquely promoted apoptosis. The current study developed eluting stent technology to deliver RAdTIMP-3 during stenting of pig coronary arteries. METHODS AND RESULTS: Binding of virus to and elution from stents and transduction of pig coronary arteries were confirmed using beta-galactosidase as a reporter gene in vitro and in vivo. Deployment of RAdTIMP-3-coated stents increased apoptosis and reduced neointimal cell density, but did not increase inflammation or proliferation compared with beta-galactosidase-expressing adenovirus (RAdlacZ). Neointimal area after 28 days was significantly reduced to 1.27+/-0.19 mm2 with RAdTIMP-3 versus 2.61+/-0.31 mm2 with RAdlacZ stents (P<0.001) and 2.12+/-0.20 mm2 with bare stents (P<0.005). CONCLUSIONS: Our results demonstrate for the first time to our knowledge the feasibility of adenovirus-coated stent technology and highlight the potential of TIMP-3 to produce significant inhibition of in-stent neointima formation.

Usefulness of noninvasive MSCT coronary angiography as first-line imaging technique in patients with chest pain: initial clinical experience.

PURPOSE: Comparative studies with invasive coronary angiography (ICA) indicated a good sensitivity and specificity in the noninvasive detection of coronary artery disease (CAD) using Multi-slice spiral computed tomography coronary angiography (MS-CTA). The aim was to investigate the usefulness of MS-CTA as first-line imaging technique in patients (pts) with known or suspected CAD and low to intermediate probability of a severe coronary lesion. We report on our initial clinical experience using MS-CTA without compelled ICA. MATERIAL AND METHODS: One hundred thirty six patients with chest pain underwent MS-CTA on an outpatient basis (age 60+/-10, suspicion of CAD: n=95, suspicion of restenosis: n=24, after CABG: n=17). Based on the MS-CTA results, a recommendation concerning further diagnostics and therapy was given to each pt. A telephone interview was performed after 455+/-166 days to evaluate the further clinical course. RESULTS: Per pt, 8.2+/-2.7 coronary segments could be evaluated. Based on the MSCT results, the presence of flow-limiting stenoses was excluded in n=77 (57%) pts (group I). An additional ICA was recommended in n=59 (43%) pts (group II). An ICA had been performed in meantime in 27/136 (20%) pts, and could be avoided in the majority of pts. Nevertheless, 58/136 (42%) pts reported on improved clinical symptoms and 42/136 (31%) pts of improved quality of life. CONCLUSIONS: MS-CTA was found to be useful to evaluate the need and to reduce the total number of ICA in pts with unclear chest pain. It appears to be the first noninvasive modality, which might be used on a clinical routine basis in selected groups of pts.

Effects of local all-trans-retinoic acid delivery on experimental atherosclerosis in the rabbit carotid artery.

BACKGROUND: Retinoids regulate a variety of biological processes and play an important role in cell differentiation and proliferation. All-trans retinoid acid (atRA) is known to inhibit smooth muscle cell growth and thus is supposed to have favorable effects on the incidence of restenosis after percutaneous coronary interventions. The broad biological spectrum, however, leads to numerous severe side effects which limit the clinical use of a systemic application of atRA. In order to avoid systemic side effects, local delivery of atRA is preferable. The aim of this study was to evaluate the effects of atRA on the response to injury in a second-injury model of experimental balloon angioplasty. METHODS: After induction of a fibromuscular plaque in the right carotid artery of 40 New Zealand rabbits, 35 animals underwent balloon angioplasty of the preformed plaque formation. Subsequent local atRA delivery (10 ml, 10 microM) with the double-balloon catheter was performed in 15 animals. Five animals received vehicle only as sham controls, and five animals were solely electrostimulated, 15 animals served as control group with balloon angioplasty only. Vessels were excised 7 days (n=15) and 28 days (n=30) after intervention. Immunocytochemistry with antibodies against smooth muscle alpha-actin and myosin, bromodeoxyuridine, macrophages, collagen I and III and von Willebrand factor was performed. Quantitative analysis was done by computerized morphometry. RESULTS: After local atRA delivery in vivo, the extent of stenosis was markedly reduced with 21.7+/-8.3% (mean+/-S.D.) 4 weeks after intervention compared to 31.8+/-13.4% in balloon-dilated animals (P=0.0937). Both a reduced early neointimal proliferation (P=0.0002) and an increase in overall vessel diameter (4 weeks after intervention, P=0.0264) contributed to a limitation of restenosis in atRA-treated animals. Immunocytochemistry revealed a more intense alpha-actin staining pattern after local atRA therapy indicating redifferentiating effects of atRA on vascular smooth muscle cells. CONCLUSIONS: Local delivery of atRA led to limitation of restenosis formation in this animal model. The concept of a local atRA therapy might be a promising way to exploit the potential of atRA for vascular indications while minimizing the severe side effects of systemic retinoid therapy.

Effects of atorvastatin on in-stent stenosis in normo- and hypercholesterolemic rabbits.

BACKGROUND: In-stent stenosis is characterized by a prolonged proliferation and inflammatory reactions around the stent struts. Potentially the antiproliferative and lipid-lowering effects of atorvastatin can synergistically limit neointima formation after stenting. METHODS: Palmaz-Schatz stents were placed in the iliac arteries of white New Zealand rabbits. One half of the animals was fed an 0.5% hypercholesterolemic diet, the other half was normocholesterolemic. Both groups received either atorvastatin (3 mg/kg bodyweight) daily or placebo (n=10 each in the four groups). After 28 days the segments were excised. RESULTS: Injury scores as a result of vessel trauma induced by stent-overstretch injury differed significantly between the four groups (median 1.0-1.9) and the stent-induced injury outweighed the beneficial effects of statin therapy on neointima formation by far. Smooth-muscle-cell proliferation was significantly increased in both hypercholesterolemic groups. Intimal and medial proliferation as well as inflammatory infiltrates around the stent strut were reduced by 20-40% in animals that received statin therapy although the injury score in both statin groups was 19 and 60% higher than in control animals. CONCLUSION: Thus, the data of this study indicate that smooth muscle cell proliferation and inflammation in stented vessels can be reduced by atorvastatin both in hypercholesterolemic rabbits and in animals with normal lipid levels.

Non-invasive evaluation of coronary artery bypass grafts using multi-slice computed tomography: initial clinical experience.

Recurrence of angina pectoris in patients with previous coronary artery bypass graft (CABG) surgery due to severe coronary artery disease (CAD) is a common problem. Non-invasive imaging of coronary artery bypass grafts by computed tomography was first described in the early 1980s. Meanwhile, multi-slice computed tomography (MSCT) is now available. This new technique allows detection of coronary lesions with good sensitivity and specificity due to continuous improvement and modification of this method. The aim of this study was to investigate whether stenosis or occlusion of CABG can be detected by MSCT. Ten consecutive male patients (mean age 61+/-9.1 years) with previous CABG surgery and 21 bypass grafts (14 venous grafts, seven arterial grafts) were included in this study. Conventional coronary angiography and MSCT angiography (MSCTA) were performed in all patients. MSCTA results were compared with coronary angiography in regard of visualization and lesion detection in CABG. The analysis of MSCTA was performed blinded to the angiographic results. It was found that 18 of 21 bypass grafts (86%) were analyzable by MSCTA: seven of 21 (33%) grafts showed a significant stenosis (>75%), while six of them were detected by MSCTA (sensitivity: 86%, positive predictive value: 0.75). Dissection of one arterial graft could not be evaluated by MSCTA. Twelve of 13 grafts without severe lesion showed no significant stenosis in MSCTA (negative predictive value: 0.86). All grafts without severe lesions by MSCT showed no significant lesion in X-ray angiography (specificity: 100%). MSCTA is a promising new method for the detection of lesions in coronary artery bypass grafts. However, these data based on a small number has to be reevaluated by larger studies.

Noninvasive evaluation of the prevalence of noncalcified atherosclerotic plaques by multi-slice detector computed tomography: results of a pilot study.

BACKGROUND: Multi-slice detector computed tomography (MDCT) not only allows for the determination of coronary calcifications, but also for the noninvasive visualization of noncalcified plaques. Thus, coronary artery disease (CAD) can be detected at a fairly early stage. Since data on the prevalence of potentially rupture prone noncalcified coronary lesions are still missing, it was aim of the present investigation to study this in patients with a distinct cardiovascular risk profile, but without known CAD. METHODS: 68 patients with clinical suspicion of CAD and multiple cardiovascular risk factors were included in this prospective study. Calcium scoring, as well as the detection of noncalcified plaques were performed using a Somatom VZ scanner (Siemens, Forchheim, Germany). RESULTS: Calcium scoring could be performed in all patients on native scans; 63/68 (96%) of contrast enhanced scans showed sufficient image quality to perform a screening for noncalcified plaques. The three scans without diagnostic image quality had been performed at heart rates of 95 +/- 18/min. Coronary calcifications were found in 36/65 (55%) patients (Agatston score: 247 +/- 358). Additional noncalcified plaques were detected in 16/36 (45%) of these patients; 29/65 (45%) patients had no coronary calcifications (Agatston score: 0), but noncalcified plaques could be detected in 3/29 (10%) of these patients. CONCLUSIONS: The prevalence of noncalcified plaques was 29% in the whole study group, and even in 10% of patients without coronary calcifications. Further prospective large scale studies are required to confirm these data, and to evaluate the clinical implication of this finding.

Influence of heart rate on vessel visibility in noninvasive coronary angiography using new multislice computed tomography: experience in 94 patients.

OBJECTIVES: Initial reports indicate that coronary artery lesions might be visualized with high sensitivity and specificity by the use of recently introduced multislice computed tomography (MSCT). Current CT technology offers a temporal resolution of 250 ms. In case of heart rates (HRs) >65 beats/min (bpm), however, the reconstruction software switches from a single-phase algorithm (using data from one heart cycle only) to a biphase algorithm using image data of two consecutive heart cycles, improving temporal resolution to down to 125 ms. Thus, it was the aim of the present study to evaluate the influence of the patients' (pts) HR on image quality expressed by vessel segment visibility. METHODS AND RESULTS: MSCT scans (Somatom VZ) were performed in 94 pts. Ten coronary segments were analyzed in each patient with regard to image quality (RCA: segments [sgts] 1-4, LMS: sgt 5, LAD: sgts 5-8, LCX: sgts 11, 12). A total of 697 of 940 (74.1%) sgts were accurately visualizable (RCA: 244/376 [64.9%], LMS: 94/94 [100%], LAD: 232/283 (82.3%), LCX: 146/188 [77.7%]). Beta-blocker therapy had a significant influence on mean HR (65 pts on beta-blocker, HR 65.1+/-10.7 bpm vs. 29 pts, HR 71.6+/-12.2 bpm, P=.01). A significant inverse correlation between HR and segmental visibility was found (r=-.48, P<.0001), with best visibility in pts with lower HRs (n=14 pts with 10 analyzable sgts, HR 60+/-10.1 vs. n=8 pts with 4 analyzable sgts, HR 79.9+/-6.9, P<.0001). CONCLUSIONS: Our results indicate that vessel visibility is highly dependent on the pts HR. Best vessel visibility was found in pts with HR <65 bpm with single-phase image reconstruction. Thus, it appears to be advisable to evaluate, and if needed, to lower the pts HRs before undergoing MSCT coronary angiography in order to achieve best image quality.

[Noninvasive detection of coronary stenosis using 16-slice detector computed tomography in carefully selected patients]. / Nichtinvasive Stenosedetektion unter Verwendung der 16-Zeilen-Computertomographie in einem streng selektionierten Patientenkollektiv.

BACKGROUND AND PURPOSE: Due to technical improvements, multislice spiral computed tomography (MSCT) has become available for the noninvasive visualization of human coronary arteries. The current scanner generation provides 16 detector slices. The aim of the present study was to evaluate the influence of a careful patient selection on the diagnostic accuracy of noninvasive angiography. PATIENTS AND METHODS: Out of a study population of 60 patients, 36 with mild coronary calcifications (Agatston score < 500) were selected for the present retrospective analysis. In addition to conventional coronary angiography (CCA), all patients underwent a noninvasive MSCT examination of the coronary arteries. All coronary segments were assessed with respect to image quality and presence of severe lesions with a diameter stenosis >or = 50%. The MSCT examinations were performed using a Sensation 16 scanner (Siemens Medical Systems, Forchheim, Germany). RESULTS: The Agatston score of the study population was 83.3 +/- 125.4 (0-491.3), calcium mass 14.7 +/- 21.4 (0-83) mg CaHA (calcium hydroxyapatite). Diagnostic image quality could be obtained in 391/455 coronary segments (86%). 26 lesions > or = 50% could be detected by MSCT, CCA confirmed the presence of 21 lesions. No false-negative results were obtained (sensitivity: 100%, specificity: 99%, positive predictive value: 0.81, negative predictive value: 1.0). CONCLUSION: The new MSCT generation with 16 detector slices permits a noninvasive visualization of the coronary arteries with good image quality. It could be shown that a careful patient selection is of major importance for the diagnostic accuracy of MSCT imaging. It appears to be useful to perform a stepwise imaging, starting with a native scan to rule out severe calcifications. Prospective multicenter trials with larger patient numbers are required to confirm these initial results.

[Stent-based local delivery of therapeutic adenovirus effectively reduces neointimal proliferation in porcine coronaries].

OBJECTIVE: To find an effective means for delivering therapeutic genes of Tissue inhibitor of metalloproteinase-3 (TIMP-3) to the target sites of the dilated coronary artery for the purpose of preventing restenosis of the injured artery. METHODS: A stainless steel stent coated with a high-molecular-mass polymer phosphorylocholine, after treatment with recombinant replication-defective adenovirus designated as RAD TIMP-3, was implanted into the coronary arteries of 7 pigs (therapy group). Another 7 pigs serving as the control group received implantation of uncoated stent. In both groups, coronary artery angiography was performed before withdrawal of intubation and 28 days after the implantation. For the purpose of planimetric analysis, the stented coronary arteries were isolated and fixed followed by resin embedding. Six sections were obtained for each stent for morphological assessment. RESULTS: The lumen diameter of the therapy group was 2.32+/-0.18 mm, significantly greater than that of the control group (1.79+/-0.31 mm, P=0.014). The neointimal thickness was smaller in the therapy group (0.34+/-0.17 mm vs 0.81+/-0.32 mm, P=0.0 059). CONCLUSIONS: The stent with biosynthetic coating effectively promotes TIMP3 AdV transduction and transcription, which effectively reduces neointimal proliferation, thus confirming its role in the prevention of in-stent restenosis. This maneuver may offer an alternative to conventional drug coatings for preventing restenosis.

Prognostic value of mild-to-moderate pulmonary hypertension in patients with severe aortic valve stenosis undergoing aortic valve replacement.

BACKGROUND: Optimal timing of elective aortic valve replacement (AVR) for severe aortic stenosis (AS) is challenging. Hence, a sensitive marker in AS patients indicating increasing risk after AVR would be of great clinical value. In the present study, we hypothesized that mild-to-moderate pulmonary hypertension (PH) assessed prior to AVR is a sensitive marker for adverse events in patients after successful AVR. METHODS: We enrolled 200 consecutive patients with severe AS undergoing AVR. Among them, 176 patients (88%) were symptomatic. Patients were divided according to systolic pulmonary artery pressure (PAP(sys)) into three groups: no PH (PAP(sys) <30 mmHg), mild-to-moderate PH (PAP(sys) ≥30 and PAP(sys) <60 mmHg) and severe PH (≥60 mmHg). Multivariable analyses were adjusted for age and gender and included PH, left ventricular ejection fraction ≤35%, renal insufficiency and logistic EuroSCORE ≥20%. Primary endpoint was death of any cause within 5 years after AVR. RESULTS: During follow-up, 23 patients died (cumulative 5-year mortality rate 14.6%). Patients without (n = 78), mild-to-moderate (n = 99) and severe PH (n = 23) had 5-year mortality rates of 2.6, 15.2 and 26.1% (p = 0.001). PAPsys ≥30 mmHg yielded an excellent level of sensitivity of 92.8%. On multivariable analysis, mild-to-moderate PH was the only independent risk factor (hazard ratio 4.9, 95% confidence interval 1.1-21.8). CONCLUSIONS: In patients with severe AS undergoing AVR, mild-to-moderate PH is a strong and independent predictor of late mortality. Conversely, patients with normal PAP(sys) have an extremely good prognosis.

Best way to revascularize patients with main stem and three vessel lesions: patients should undergo PCI!

The optimal revascularization strategy for multivessel disease is under controversial discussion for long time. Until now, technical innovations have been faster than performance of clinical trials, making results of randomized studies outdated at the time of appearance. Recently, the SYNTAX trial has been published, which compared drug elutings stents (DES) implantation with Coronary artery bypass graft (CABG) patients with multivessel or left main disease in a clinically stable population. Overall, CABG was superior with respect to the clinical endpoint of death, myocardial infarction, stroke, or revascularization. However, the difference is driven by the "weakest" end point, namely repeated revascularization, whereas combined "hard" events did not demonstrate a difference. More detailed analysis demonstrates that only patients with most complex coronary anatomy gain definite benefit from CABG. In addition, SYNTAX demonstrated that left main disease is no longer a domain of CABG, since DES implantation revealed comparable results, as long as there is no concomitant multivessel disease. Regardless the results of SYNTAX, one should not forget that SYNTAX represents only a minority of daily patients in a catheterization laboratory, excluding patients with one- or two-vessel disease and those with an acute coronary syndrome. Especially in the latter, percutaneous coronary intervention has demonstrated to improve prognosis.

Massive haemoptysis in an intravenous drug user with infective tricuspid valve endocarditis.

Major causes of morbidity in intravenous drug users are infections. In infective endocarditis, the tricuspid valve is mainly involved. Masses can cause septic embolisms and, in rare cases, they are associated with mycotic aneurysms of pulmonary arteries that lead to severe haemorrhage. We report the case of a young woman with a history of intravenous drug abuse and prolonged infective tricuspid valve endocarditis. Initially, echocardiography showed large masses on the anterior leaflet of the tricuspid valve and severe tricuspid regurgitation; blood cultures revealed staphylococcus and streptococcus species. Eight months after initial diagnosis, she presented with severe haemoptysis and fever. CT revealed a ruptured mycotic aneurysm of the right pulmonary artery. Lobectomy was performed immediately. Postoperatively, the patient fully recovered. After continued antibiotic treatment, follow-up examinations showed negative echocardiographic findings and blood cultures results.