Markers of Cardiotoxicity in Early Breast Cancer Patients Treated With a Hypofractionated Schedule: A Prospective Study.

PURPOSE: To evaluate, in a series of early breast cancer (BC) patients treated with hypofractionated adjuvant radiotherapy (RT), whether N-terminal-pro hormone B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I assay measurements can predict acute clinical or preclinical cardiotoxicity. PATIENTS AND METHODS: The study comprised 44 consecutive patients, who underwent conservative surgery with or without (neo)adjuvant chemotherapy and hypofractionated adjuvant RT. The RT schedule consisted in a total dose of 42.4 Gy in 16 fractions administered 5 days per week. Twenty-one patients received a subsequent boost to the tumor bed consisting of a total dose of 10 Gy in 4 fractions delivered via a direct electron field. All patients underwent 12-lead electrocardiogram, echocardiogram, and cardiac clinical examinations before RT to assess cardiovascular risk factors; these examinations were repeated yearly for 5 consecutive years. High-sensitivity cardiac troponin I and NT-proBNP were analyzed from serum samples at baseline, after delivery of the fourth and 16th RT fractions, and 12 months after treatment completion. RESULTS: No increase in cardiac troponin I and B-type natriuretic peptide levels related to left breast irradiation was observed. No statistical difference in NT-proBNP and high-sensitivity troponin I levels between left- and right-sided BC was found. An increase was observed of B-type natriuretic peptide levels at baseline, during treatment, and until 12 months after RT related to hypertension, with the P value near to the .05 threshold for age and chemotherapy. CONCLUSION: Conformational hypofractionated RT in left-sided BC may not cause acute myocardial damage. Early cardiac screening may be used to identify patients with cardiologic risk factors, patients who are older than 60 years, and patients who received chemotherapy that could result in clinically relevant cardiac pathologies.

SARS-CoV2 RNA detection in a pancreatic pseudocyst sample.

The involvement of gastrointestinal system in SARS-CoV2 related disease, COVID-19, is increasingly recognized. COVID-19 associated pancreatic injury has been suggested, but its correlation with pancreatic disease is still unclear. In this case report, we describe the detection of SARS-CoV2 RNA in a pancreatic pseudocyst fluid sample collected from a patient with SARS-CoV2 associated pneumonia and a pancreatic pseudocyst developed as a complication of an acute edematous pancreatitis. The detection of SARS-CoV2 within the pancreatic collection arise the question of whether this virus has a tropism for pancreatic tissue and whether it plays a role in pancreatic diseases occurrence.

Recurrent episodes of syncope in a patient with cerebral arteriovenous malformation.

As there are a number of possible causes of syncope, differentiation between cardiovascular disease, neurogenic disease and other disorders is mandatory. Cerebral arteriovenous malformations (AVMs) are tangled anastomoses of blood vessels of varying calibre in which arteriovenous shunting occurs in a central nidus, which is the area towards which multiple feeding arteries converge and from which enlarged veins drain. We describe a clinical case of syncope caused by a large AVM discovered in a 66-year-old woman. The symptoms were probably related to an epileptogenic mechanism since the syncope disappeared following the administration of antiepileptic therapy. The anatomical, pathological and clinical aspects of AVMs are discussed.

Cumulative effect of complete left bundle-branch block and chronic atrial fibrillation on 1-year mortality and hospitalization in patients with congestive heart failure. A report from the Italian network on congestive heart failure (in-CHF database).

BACKGROUND: Many clinical variables have been proposed as prognostic factors in patients with congestive heart failure. Among these, complete left bundle-branch block and atrial fibrillation are known to impair significantly left ventricular performance in patients with congestive heart failure. However, their combined effect on mortality has been poorly investigated. The aim of this study was to determine whether left bundle-branch block associated with atrial fibrillation had an independent, cumulative effect on mortality for congestive heart failure. METHODS AND RESULTS: We analysed the Italian Network on congestive heart failure (IN-CHF) Registry that was established by the Italian Association of Hospital Cardiologists in 1995. One-year follow-up data were available for 5517 patients. Complete left bundle-branch block and atrial fibrillation were associated in 185 (3.3%) patients. In this population the cause of congestive heart failure was dilated cardiomyopathy (38.4%), ischaemic heart disease (35.1%), hypertensive heart disease (17.3%), and other aetiologies (9.2%). This combination of electrical defects was associated with an increased 1-year mortality from any cause (hazard ratio, HR: 1.88; 95% CI 1.37-2.57) and sudden death (HR: 1.89; 95% CI 1.17-3.03) and 1-year hospitalization rate (HR: 1.83; 95% CI 1.26-2.67). CONCLUSIONS: In patients with congestive heart failure, the contemporary presence of left bundle-branch block and atrial fibrillation was associated with a significant increase in mortality. This synergistic effect remained significant after adjusting for clinical variables usually associated with advanced heart failure. We can conclude that this combination of electrical disturbances identifies a congestive heart failure specific population with a high risk of mortality.

Idiopathic dilated cardiomyopathy associated with coeliac disease: the effect of a gluten-free diet on cardiac performance.

An increased incidence of coeliac disease has recently been reported in patients with idiopathic dilated cardiomyopathy. This report deals with three patients with idiopathic dilated cardiomyopathy and coeliac disease who underwent clinical and laboratory evaluation to establish the effect of a gluten-free diet on cardiac performance. Two patients observed the gluten-free diet regimen very strictly, and, after a 28-month follow-up period, showed an improvement in echocardiographic parameters as well as in cardiological features and quality of life, as evaluated by the Minnesota Living with Heart Failure questionnaire and the Gastrointestinal Symptom Rating Scale questionnaire. The third patient did not observe the gluten-free diet and presented a worsening in the echocardiographic parameters and cardiological symptoms which required supplementary drug therapy. These preliminary data appear to suggest that the gluten-free diet may have a beneficial effect on cardiac performance in patients with idiopathic dilated cardiomyopathy.

Endothelin-1 circulating levels increase in patients with orthotopic heart transplantation and in chronic therapy with cyclosporine.

BACKGROUND: The aim of the study was to investigate the behaviour of plasma levels of endothelin-1 (ET-1), an endothelial peptide with vasoconstrictive and proliferative actions, in patients with cardiac transplantation and in chronic treatment with cyclosporine A, some of whom became hypertensive after cardiac transplantation. METHODS: We studied: 1) 18 consecutive patients (15 M, 3F; mean age 53 +/- 7 yrs) who underwent cardiac transplantation about six months ago at least (range 6-108 months); 2) 15 patients with essential arterial hypertension (10 M, 5 F; mean age 42 +/- 15 yrs) without organ damage; 3) 21 normal subjects (15 M, 6 F; mean age 31 +/- 12 yrs). Plasma levels of ET-1 (RIA), haemodynamic and functional renal parameters were determined in all groups and plasma levels of cyclosporine were measured in patients with cardiac transplantation. RESULTS: ET-1 was higher in patients with cardiac transplantation than in the other two groups (p < 0.05); instead there was no difference between patients with essential arterial hypertension and controls (p>0.05). A statistical difference was found between circulating ET-1 in hypertensive transplanted patients. In heart transplanted patients a positive and significative correlation was found between plasma levels of ET-1 and systolic (r=0.525; p<0.037) blood pressure.

Prevalence of coeliac disease in idiopathic dilated cardiomyopathy.

We examined 52 patients with idiopathic cardiomyopathy (IDCM) for coeliac disease. Three of them had coeliac disease, suggesting that prevalence of coeliac disease in IDCM patients is increased.

[Left ventricular aneurysm in a patient with mildly dilated cardiomyopathy]. / Aneurisma ventricolare sinistro in un paziente con cardiomiopatia "mildly dilated".

We describe the case of a patient with mildly dilated idiopathic cardiomyopathy and left ventricular aneurysm, diagnosed in absence of a prior clinical history and anatomo-pathological features of myocardial infarction. To ascertain the diagnosis of idiopathic cardiomyopathy, the patient underwent cardiac catheterization with coronary angiography, that showed the lack of epicardial artery stenosis and a slow run-off of the contrast. An endomyocardial biopsy showed the presence of hypertrophic myocytes and interstitial fibrosis. Moreover, a thoracic high resolution computed tomography showed the features of pulmonary bilateral basal emphysema, interstitial thickening and bronchiectasis. Alfa1-anti-trypsin plasma levels were reduced. The patient, because of worsening of clinical and hemodynamic conditions, underwent at age of 36 a combined heart-lung transplantation. The pathological examination of the native organs confirmed the previous diagnosis. At the moment, this is the second report in the literature concerning the presence of left ventricular aneurysm in a patient with idiopathic cardiomyopathy without an underlying coronary artery disease or prior history of myocardial infarction.

Blood pressure circadian rhythm and variability in subjects with severe heart failure.

To explore whether a condition of severe heart failure results in alteration of the 24-h-blood pressure (BP) profile and BP circadian rhythm, 19 patients with severe heart failure (NYHA class III-IV, 17M, 2F, mean age 57+/-8 years) were considered and compared to a control group of age- and sex-matched normal subjects. All subjects were submitted to non-invasive 24-h ambulatory blood pressure monitoring using a SpaceLabs 90207 unit (recording interval 15 min). Both systolic and diastolic BP profiles were evaluated using the two-step method of analysis reported by Staessen: the existence of a BP circadian rhythm was first tested using Siegel's runs test, then a Fourier multiple harmonic analysis allowed us to obtain the BP profile parameters Acrophases (Acro, hh:mm) and Amplitudes (Ampl, mm Hg). The same methods were used for pulse rate. Our results showed the presence of a BP circadian rhythm in severe heart failure subjects, as well as in control subjects. Furthermore, no significant difference was found between the two groups when considering the BP profile parameters Acro and Ampl. In conclusion, in contrast with previous reports, our results show that both BP circadian rhythm and BP profile parameters are preserved in patients with severe heart failure.

Pathologic evidence of arrhythmogenic cardiomyopathy and myocarditis in two siblings.

This report describes the case of two siblings who underwent heart transplantation with a clinical diagnosis of mildly dilated cardiomyopathy. Pathological examination of the hearts revealed arrhythmogenic (right ventricular) cardiomyopathy, adipose type, associated with biventricular myocarditis in both the recipients' hearts. Family history revealed the occurrence of dilated cardiomyopathy and myocarditis in their father and his sister. To our knowledge, this is the first pathological demonstration of arrhythmogenic cardiomyopathy and myocarditis in siblings. We think this report substantiates a genetic ground for the relationship between these two heart conditions.

[The psychological evaluation of patients with severe heart failure awaiting a heart transplant]. / Valutazione psicologica in pazienti con insufficienza cardiaca grave in attesa di trapianto cardiaco.

Because of the limitations resulting from the severity of heart failure, patients in the waiting list for cardiac transplantation often show a worsening in their social life. They usually present with psychological problems caused by symptoms, medical or surgical therapies and consequences on their own work. We have devised and utilized an experimental psychodiagnostic protocol to study the psychological characteristics of a sample of patients with heart failure (NYHA functional class III and IV) candidate to heart transplantation. Our study was particularly aimed at investigating the quality of life and the psychological mechanisms of adaptation. Findings show a strong attempt of denying the discomfort deriving from the disease and the expectation for transplant. Patients seem to have an adequate reaction to the illness and, otherwise, they feel anxiety and trouble that make very fragile their psychological adaptation. This behaviour is probably correlated with symptoms and the clinical history of heart failure, and does not match with a visible state of well-being that can be detected with a superficial analysis. Nevertheless patients have a good availability in receiving a psychological support from the whole medical staff (physicians, nurses): this suggests that the benefits deriving from a contemporary medical and psychological therapy are able to prevent the appearance of clear psychiatric symptoms. Additional studies involving larger samples of selected populations are needed to confirm the results of the present investigation.

Inhaled nitric oxide in patients with severe heart failure: changes in lung perfusion and ventilation detected using scintigraphy.

Inhaled nitric oxide (NO) is a selective pulmonary vasodilator in patients with end-stage cardiac failure. Preoperative high pulmonary vascular resistance could modify early and late results after heart transplantation generally due to right-ventricular failure. Aim of this study was to assess pulmonary vascular resistance variability following inhalation of NO by using a scintigraphic method. Our preliminary results suggest that inhaled NO in patients with end-stage heart failure redistributes blood away from apical regions and towards more basal and posterior segments, probably dilating blood vessels in ventilated but nonperfused zones. NO may represent a simple and reliable method to evaluate dynamic response of pulmonary vasculature.

[The correlation between left ventricular segmental kinesis and a Selvester QRS analysis in stabilized myocardial infarct]. / Correlazione tra alterazioni della cinesi segmentale ventricolare sinistra e analisi del QRS secondo Selvester nell'infarto miocardico stabilizzato.

We have studied the relationship between left ventricular segmental wall motion evaluated by means of biplane left ventricular cineangiography and the myocardial infarct size estimated using Selvester's scoring system based on the QRS of the electrocardiogram. Seventy consecutive patients with old myocardial infarction were recruited. All patients underwent diagnostic retrograde left heart catheterization including left ventriculography and selective coronary arteriography. Nineteen patients were excluded from the study due to intraventricular conduction disturbances and left ventricular hypertrophy. Of the remaining 51 patients, aged 33-76 years (mean 56 years), 31 had inferior or postero-inferior myocardial infarction (Group 1); 7 patients had combined anterior and inferior myocardial infarction (Group 2); 13 patients had anterior or antero-septal myocardial infarction (Group 3). The analysis of left ventricular segmental wall motion was performed according to the Collaborative Studies in Coronary Artery Surgery assigning at hypokinesia, akinesia and dyskinesia 1, 2 and 3 points, respectively. The values of statistical correlations between QRS scoring system and ventricular scoring were: r = 0.85 (Group 1); r = 0.78 (Group 2); r = 0.70 (Group 3). Our data indicate that Selvester's scoring system may provide useful information on functional status and on the extent of left ventricular wall motion abnormalities in patients with previous myocardial infarction.

Herpes simplex pneumonia in a heart transplant recipient.

An unusual case of Herpes simplex virus (HSV) pneumonia in a heart transplant recipient receiving chronic immunosuppressive therapy is reported. This infection presented an indolent course manifested by a chronic left pulmonary infiltrate unresponsive to antibiotic therapy and mild hypoxemia. Death eventually occurred as a consequence of an other infectious complication of the postoperative period. The HSV etiology of the necrotizing pneumonia observed at autopsy was established on the basis of histologic findings.

Multisystem evaluation in one case of pure autonomic failure.

Pure autonomic failure (PAF) is a rare syndrome characterized by a primitive failure of the autonomic nervous system (ANS). We have studied a 53-year old woman suffering from PAF by using ANS provocative tests investigating the cardiovascular system (standing up test, controlled ventilation, Valsalva manoeuvre, handgrip test, cold pressor test, mental stress test, plasma catecholamine levels), tests investigating the intrinsic ocular innervation (pupil reactivity), and the bladder function (urodynamic tests). Our results have shown abnormalities of all the studied parameters and they have also confirmed that these patients need a multidisciplinary autonomic evaluation to correctly identify the syndrome.