Anesthetic Management of a Voluminous Left Atrial Myxoma Resection in a 19 Weeks Pregnant with Atypical Clinical Presentation.

We report the case of a semi-urgent cardiac surgery, in a 19 gestation age pregnant. Despite the fact that the patient was asymptomatic, except for some palpitations, a large left auricle (LA) myxoma was fortuitously diagnosed with transthoracic echocardiography (TEE). Considering the important embolic risk, the tumor was successfully removed during cardiac surgery under cardiopulmonary bypass (CPB). Fetal bradycardia following defibrillation under stable maternal and CPB conditions was successfully managed. The postoperative period and remainder of the pregnancy was smooth and the delivery uneventful.

Clinical Implications of Preserving Subvalvular Apparatus During Mitral Valve Replacement for Acute Ischemic Papillary Muscle Rupture.

We report the case of a patient who presented with sequential rupture of two papillary muscle bellies after emergent mitral valve replacement with subvalvular apparatus preservation for acute severe mitral regurgitation and cardiogenic shock during acute myocardial infarction. We discuss the possibility that the remaining chordae may have meanwhile contributed to muscle avulsion by exerting traction on ischemic myocardium and prevented embolization of the secondarily detached papillary muscle heads.

Cardiac calcified amorphous tumor: A systematic review of the literature.

BACKGROUND: Calcified amorphous tumor (CAT) of the heart is a rare non-neoplastic intracavitary cardiac mass. Several case reports have been published but large series are lacking. OBJECTIVE: To determine clinical features, current management and outcomes of this rare disease. DESIGN: A systematic review of all articles reporting cases of CAT in order to perform a pooled analysis of its clinical features, management and outcomes. DATA SOURCES: An electronic search of all English articles using PUBMED was performed. Further studies were identified by cross-referencing from relevant papers. INCLUSION CRITERIA: We restricted inclusion to articles reporting cases of CAT in the English language literature published up to July 2014. DATA EXTRACTION: One author performed data extraction using predefined data fields. RESULTS: A total of 27 articles, reporting 42 cases of CAT were found and included in this review. CONCLUSION: In this review, the most frequent presenting symptoms were dyspnea and embolic events. Mitral valve and annulus were the most frequent location of CAT. Surgery was most of the time required to confirm diagnosis, and was relatively safe. Overall outcome after surgical resection was good.

Chagas disease: don't forget it in Latin American patients with heart block!

Chagas disease is caused by the parasite Trypanosoma cruzi, and mostly affects poor rural populations of central and south America. It is mainly acquired by bugs (triatoma) but also by ingestion of the parasite (fresh fruit juices) or by foetal-maternal blood passing. Despite an important decrease in transmission during the last decades in several countries, millions of patients are still chronically infected and most of them are asymptomatic. In 2012-2013, two cases were admitted in our cardiac intensive care unit (ICU) with heart block due to Chagas cardiomyopathy. Diagnosis was established by echocardiography and positive serological results for Trypanosoma cruzi. This report underlines that in cases of heart failure and conduction abnormalities of unclear aetiology, Chagas disease should be taken into consideration, even in patients originating from non-endemic countries.

Continuous heart murmur in a 26-year-old woman.

In this report, we describe a continuous murmur heard in a young woman at the beginning of her lactation period, which illustrates a typical example of 'Mammary Souffle', described one century ago. Colour Doppler and pulsed-wave mode echocardiogram allowed to precise, for the first time, the arterial nature of increased systolic and diastolic blood flow in tortuous branches of internal mammary artery, most probably responsible of the murmur, after ruling out any other origin of continuous murmur.

An Aspergillus myocardial abscess diagnosed by echocardiography.

This is a rare case of Aspergillus myocardial abscess in 19-year-old woman with acute lymphoblastic leukemia treated by chemotherapy. During pancytopenia she developed invasive aspergillosis with myocardial abscess. The presence of specific antigen in the pericardial effusion was diagnostic. She died despite vigorous antifungal therapy.

Possible association between 3,4-methylenedioxymethamphetamine abuse and valvular heart disease.

Valvular heart disease, inducing valvular regurgitation, has been described in users of drugs such as anorectic agents and ergot derivates. 3,4-Methylenedioxymethamphetamine (MDMA; "ecstasy") also leads in vitro to the proliferation of cardiac valvular interstitial cells by activation of the 5-hydroxytryptamine 2B receptor. The aim of this study was to determine the occurrence of valvulopathy in young adults taking MDMA. Twenty-nine subjects using or having used MDMA and 29 gender- and age-matched controls were blindly evaluated with echocardiography. Eight subjects (28%) who took MDMA had abnormal echocardiographic results using the United States Food and Drug Administration's criteria for appetite suppressant-induced valvular heart disease, compared with none in the control group (p = 0.0045). Six (21%) subjects had mitral regurgitation of 1/4 and 4 (14%) of > or =2/4, compared with none in the control group (p = 0.002). The mean mitral regurgitant area ratios (jet/atrium) were 12 +/- 9.8% and 5 +/- 1.3%, respectively (p = 0.007). Tricuspid regurgitation > or =2/4 was present in 13 MDMA users (45%) and absent in controls (p <0.001). The mean tricuspid regurgitant area ratios were 19 +/- 9.5% and 9 +/- 4.5%, respectively (p <0.001). Four MDMA users (14%) had mild aortic regurgitation (p = 0.11). Valvular "strands" were present in 6 MDMA users (21%) and in none of the controls (p = 0.02). In conclusion, MDMA may lead to mild to moderate valvular heart disease and valvular strands.

Role of myocardial bridging in the apical localization of stress cardiomyopathy.

BACKGROUND: The apical ballooning syndrome is precipitated by emotional or physical stress but the underlying mechanism remains poorly understood. The contribution of myocardial bridging on the aetiology and the onset of the syndrome is not known. METHODS: We observed 8 patients with chest pain, T-wave inversion in several leads of the ECG, transient left ventricular apical ballooning and no significant angiographic stenosis. RESULTS: There were 7 women and I man. The median age was 67.5 years. Seven patients had an intense emotional or physical stress (87.5%). All patients presented with chest pain and aT-wave inversion in the precordial leads. The median elevation of creatine-kinase was 171 IU. In all patients, echocardiography showed an alteration of the left ventricular function with a very extensive apical akinesia. Left ventricular hypertrophy was observed in 7 patients. A myocardial bridging in the mid segment of the left anterior descending coronary artery was observed in 5 patients (62.5%). Recovery was complete in all patients. During follow-up, no patient showed recurrence. CONCLUSIONS: Our data suggest that myocardial bridging possibly enhanced by catecholamines during stress may contribute, in association with left ventricular hypertrophy, to the preferential apical localization of the apical ballooning syndrome. Further investigations are necessary to confirm

Sympathetic control after cardiac resynchronization therapy: responders versus nonresponders.

Cardiac resynchronization therapy (CRT) decreases muscle sympathetic nerve activity (MSNA) in patients with severe congestive heart failure (CHF) and cardiac asynchrony. Whether this affects equally patients who clinically respond or not to CRT is unknown. We tested the hypothesis that the favorable effects of CRT on MSNA disappear on CRT interruption only in those who respond to CRT. Twenty-three consecutive CHF patients participated in the study, among whom 16 presented a symptomatic improvement by one or more New York Heart Association (NYHA) functional classes 15 +/- 5 mo after CRT (responders), and seven had not improved after 12 +/- 4 mo of CRT (nonresponders). MSNA and echocardiographic recordings were obtained in random order during atrio-right ventricular pacing (ARV), without stimulation in patients who were not pacemaker dependent (OFF, n = 17), and during atrio-biventricular pacing (BIV). Responders had a longer 6-min walking distance, a lower NYHA class and brain natriuretic peptide levels, and a better quality of life than did nonresponders (all P < 0.05). MSNA increased by 25 +/- 7% in the responders, whereas it remained unchanged in the nonresponders, when shifting from the BIV mode to a nonsynchronous condition (ARV and OFF modes) (P < 0.01). Cardiac output decreased by 0.7 +/- 0.2 l/min in the responders but did not change when shifting from the BIV mode to the nonsynchronous pacing mode in the nonresponders (P < 0.01). In conclusion, reversible sympathoinhibition is a marker of the clinical response to CRT.

Study of antirestenosis with the BiodivYsio dexamethasone-eluting stent (STRIDE): a first-in-human multicenter pilot trial.

The aim of this multicenter pilot study was to evaluate the acute safety and efficacy of the dexamethasone-eluting stent (0.5 microg/mm(2) of stent) implanted in patients with de novo single-vessel disease. This study included 71 patients, 42% of whom had unstable angina pectoris. An appropriately sized BiodivYsio Matrix Lo stent loaded with a total dexamethasone dose of 0.5 microg/mm(2) of stent was used. Technical device success rate was 95%. Six-month MACE occurred in two patients (3.3%). Binary restenosis rate was 13.3%. Late loss was 0.45. Late loss and percent diameter stenosis were lower in the unstable angina pectoris patients compared to the stable patients (0.32 +/- 0.39 vs. 0.60 +/- 0.55 mm, P < 0.07, and 26.86 +/- 14 vs. 38.40 +/- 16%, P < 0.02). This study demonstrated the feasibility and safety of the implantation of a dexamethasone-eluting stent and its effect on in-stent neointimal hyperplasia.

High prevalence of fenfluramine-related aortic regurgitation in women with end-stage renal disease secondary to Chinese herb nephropathy.

BACKGROUND: Non-controlled studies have noted a high prevalence of valvular regurgitation in patients with Chinese herb nephropathy; most of these patients had taken appetite suppressants. We aimed to determine the prevalence of valvular regurgitation and the role of appetite suppressants in patients with Chinese herb nephropathy. METHODS: This case-controlled echocardiographic study included 40 patients with end-stage renal failure due to Chinese herb nephropathy and 37 age-matched controls with end-stage renal disease due to nephropathy of other origin. Quantification of cumulative doses of appetite suppressants was performed. RESULTS: Aortic regurgitation was detected in 52.5% of patients with Chinese herb nephropathy, 72+/-1 months after stopping appetite suppressants, and in 21.6% of controls (P=0.009). No difference was found in the incidence of mitral or tricuspid regurgitation. A history of slimming medication was the only significant determinant for aortic regurgitation (P=0.009). Higher cumulative doses of Chinese herbs, (dex)fenfluramine and diethylpropion were observed in patients with Chinese herb nephropathy with, when compared to those without, aortic regurgitation. The dose-response relationship between the cumulative dose of drugs and the presence of aortic regurgitation was significant for fenfluramine only (chi-square=5.16, P=0.024). CONCLUSIONS: Six years after stopping appetite suppressants, aortic regurgitation remains highly prevalent among patients with end-stage Chinese herb nephropathy. The dose-related association with fenfluramine intake strongly confirms a determinant pathogenic role of anorectic drugs.

Relationship between late potentials and myocardial viability assessed by dobutamine echocardiography in the early postinfarction period.

BACKGROUND: In the postmyocardial infarction period, late potentials (LPs) are a sensitive marker for the occurrence of sustained ventricular tachycardia and ventricular fibrillation. The relationship between positive signal-averaged electrocardiogram (SAECG) and myocardial viability remains controversial. The aim of the present study was to assess prospectively the possible relationship between LPs and myocardial viability detected by dobutamine stress echocardiography (DSE) in the early period after myocardial infarction (AMI), before hospital discharge. DESIGN: Ninety-nine patients with AMI were included prospectively in the study. The mean age was 58 +/- 11 years, 17 were women and 82 were men. All patients had SAEG and DSE, and 94 had coronary angiography before hospital discharge. RESULTS: In the overall population, presence of viability was demonstrated in fewer patients with LPs [37 of 70 (52%)] than absence of viability [18 of 29 (62%)] but the difference did not reach statistical significance. In the subgroup of patients with left ventricular ejection fraction (LVEF) lower than 40%, at higher risk of arrhythmias, the presence of viability was associated with the absence of LPs: 80% of the patients without LPs had viability by DSE (P < 0.01) and only 35% of patients with LPs had viability by DSE (not significant). CONCLUSIONS: In patients with an acute myocardial infarction and with low ejection fraction (<40%), the absence of LPs is related to the presence of viable myocardium as assessed by DSE early after the acute event. These data also suggest that myocardial viability is not the substrate for LPs in this population.