Epilepsy in patients undergoing cardiac surgery with ExtraCorporeal Circulation: case series and description of a peculiar clinical phenotype.

BACKGROUND: Extracorporeal circulation (ECC) is now being increasingly used in critical care settings. Epileptic seizures are a recognized but under reported complication in patients receiving this care. Acute symptomatic post-operative seizures have been described, as well as remote seizure, mostly in the form of convulsive seizures. Epilepsy has also been reported, although with lower frequency and mainly with convulsive seizures, while different seizure semiology is rarely described. CASE PRESENTATION: We report a case series of four patients developing epilepsy with homogeneous features following heart surgery with ECC. We present neurophysiological and neuroradiological data and we describe the peculiar characteristics of epilepsies in terms of seizure semiology, frequency, and drug response. The main features are: an insulo-temporal or parieto-occipital semiology, often multifocal and without loss of consciousness or motor manifestations, a high frequency of seizures but with low impact on daily life, and a good response to anti-epileptic therapy. CONCLUSIONS: We hypothesize a pathogenetic mechanism and we discuss the clinical implications of identifying these forms of epilepsy which tend to be often under-recognized.

Mortality after cardioverter-defibrillator replacement: Results of the DECODE survival score index.

BACKGROUND: Device replacement is the ideal time to reassess health care goals regarding continuing implantable cardioverter-defibrillator (ICD) therapy. Only few data are available on the decision making at this time. OBJECTIVES: The goals of this study were to identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early. METHODS: DEtect long-term COmplications after implantable cardioverter-DEfibrillator replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/cardiac resynchronization therapy - defibrillator replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI). RESULTS: We included 983 consecutive patients (median age 71 years (63-78)); 750 (76%) were men, 537 (55%) had ischemic cardiomyopathy; 460 (47%) were implanted with cardiac resynchronization therapy - defibrillator. During a median follow-up period of 761 days (interquartile range 628-904 days), 114 patients (12%) died. In multivariate Cox regression analysis, New York Heart Association class III/IV, ischemic cardiomyopathy, body mass index < 26 kg/m2, insulin administration, age ≥ 75 years, history of atrial fibrillation, and hospitalization within 30 days before ICD replacement remained associated with death. The survival score index showed a good discriminatory power with a hazard ratio of 2.6 (95% confidence interval 2.2-3.1; P < .0001). The risk of death increased according to the severity of the risk profile ranging from 0% (low risk) to 47% (high risk). CONCLUSION: A simple score that includes a limited set of variables appears to be predictive of total mortality in an unselected real-world population undergoing ICD replacement. Evaluation of the patient's profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.

Right ventricular presystolic peak velocity represents right ventricular function in stable patients.

BACKGROUND: Right ventricular (RV) function is difficult to be measured but plays a role in morbility and mortality of patients with cardiopulmonary diseases, so many echocardiographic parameters have been developed from M-mode, B-mode and Doppler tissue imaging (DTI) evaluation. Right ventricular presystolic peak velocity (RVPrP) measured with DTI of the tricuspidal annulus and its changes in RV dysfunction have never been assessed in a patient's cohort of stable patients with cardiovascular risk factors. RVPrP velocity could have a role in RV function evaluation; this study addresses such issue. METHODS: Four hundred thirty-six consecutive patients were submitted to a complete echocardiographic examination with the contemporary evaluation of the following RV function indexes: Tricuspid Annulus Plane Systolic Excurtion (TAPSE), RV Systolic Peak (RVSyP) and RVPrP. Pulmonary artery systolic pressure (PASP), left ventricular and RV diastolic function were also evaluated. RESULTS: According to TAPSE and RVSyP taken alone or in combination, 113 patients had RV dysfunction, while 323 patients had normal RV function. RVPrP was reduced in patient's group with RV dysfunction with respect to patient's group with preserved RV function (16.48±7.3 cm/s vs. 23.98±8.4 cm/s, respectively, P<0.001). RVPrP was related with RVSyP (P<0.001) and with TAPSE (P=0.002). TAPSE and RVSyP revealed a poor concordance to define RV dysfunction. PASP was higher in patient's group with reduced RV function (P=0.033). CONCLUSIONS: The study showed RVPrP able to detect stable patients with RV dysfunction.

Cardiac device therapy in patients with left ventricular dysfunction and heart failure: 'real-world' data on long-term outcomes (mortality, hospitalizations, days alive and out of hospital).

BACKGROUND: The impact on long-term outcomes of implantable cardioverter defibrillators (ICDs) and biventricular defibrillators for cardiac resynchronization (CRT-D) devices in 'real world' patients with heart failure (HF) needs to be assessed in terms of clinical effectiveness. METHODS AND RESULTS: A registry including consecutive HF patients who underwent a first implant of an ICD (891 patients) or a CRT-D device (709 patients) in 2006-2010 was followed (median 1487 days and 1516 days, respectively), collecting administrative data on survival, all-cause hospitalizations, cardiovascular or HF hospitalizations, and days alive and out of hospital (DAOH). Survival free from death/cardiac transplant was 61.9% and 63.8% at 5 years for ICD and CRT-D patients, respectively. Associated comorbidities (Charlson Comorbidity Index) had a significant impact on death/cardiac transplant, as well as on hospitalizations. The median values of DAOH% were 97.4% for ICD and 97.7% for CRT-D patients, but data were highly skewed, with the lower quartile of DAOH% values including values ranging between 0% and 52.8% for ICD and between 0% and 56.1% for CRT-D patients. Charlson Comorbidity Index was a very strong predictor of DAOH%. CONCLUSIONS: Patients who were implanted in 'real world' clinical practice with an ICD or a CRT-D device have, on average, a relatively favourable outcome, with a survival of around 62-64% at 5 years, but with an important burden of hospitalizations. Comorbidities, as evaluated by means of the Charlson Comorbidity Index, have a significant impact on outcomes in terms of mortality/heart transplant, hospitalizations and days spent alive and out of hospital.

Heparin/PF4 antibodies formation after heparin treatment: temporal aspects and long-term follow-up.

BACKGROUND: Heparin-induced thrombocytopenia is characterized by the presence of heparin-induced antibodies against heparin/platelet factor-4 (PF4) complex and paradoxical thrombosis. Little is known on the persistence of antiheparin antibodies in blood. The aim of this study was to evaluate the time course of heparin/PF4 antibodies in patients exposed to heparin. METHODS: We initially enrolled 500 patients treated with unfractionated heparin as part of perioperative management of coronary artery bypass graft; those who developed serologically confirmed heparin/PF4 antibodies were selected for further follow-up. Over 3 years, we repeatedly assessed serum concentration of antibodies (by enzyme-linked immunosorbent assay) and occurrence of thrombotic events. RESULTS: One hundred thirty-one patients (26.2%) developed anti-PF4/heparin antibodies, which persisted for a median time of 90 days (Quartile 1-Quartile 3, 31-186). At 30 days, patients with antibodies had higher incidence of thrombotic events (28.2% vs 14.9%, P < .01) and death/myocardial infarction (14.5% vs 7.8%, P < .001). Of the 131 patients with antiheparin/PF4 antibodies, 78 had already developed antibodies before cardiac surgery; such patients became serologically negative more slowly than patients who developed antibodies after surgery. Over 3 years of follow-up, patients with anti-PF4/heparin antibodies developed 65 thrombotic events, 25 patients developed deep vein thrombosis and/or pulmonary embolism, and 20 patients myocardial infarction. CONCLUSIONS: Patients with heparin-induced antibodies are more likely to develop thrombosis after cardiac surgery. Patients in whom antibodies are present before surgery show longer persistence of antibodies and increased incidence of thrombotic events over time. Persistence of antibodies suggests that these patients may be at risk for developing thrombosis; and therefore, further exposure to heparin should be limited.

Effect of coffee consumption, lifestyle and acute life stress in the development of acute lone atrial fibrillation.

OBJECTIVE: The study evaluated the relationships between acute stress, lifestyle and coffee consumption, and acute lone atrial fibrillation (AF). METHODS: The study group included 400 patients with mean age of 54 +/- 11 years, 205 of whom were men. They all presented with a first episode of AF. Patients underwent a series of cognitive tests to evaluate acute psychological stress (mean life acute stress score). Lifestyle and nutritional parameters (diet, alcohol and espresso coffee consumption, smoking and obesity) were investigated. An age-matched and sex-matched control group was selected and compared. RESULTS: Recent stress, high intake of coffee, and obesity were associated with greater risk of AF. Acute stress induces an increase in coffee consumption and changes in lifestyle. The increase in coffee consumption was more marked in nonhabitual drinkers, leading to a higher risk of developing AF [odds ratio (OR) 4.1; 95% confidence interval (CI): 1.98-4.56; P < 0.001]. Spontaneous conversion of AF to sinus rhythm was observed in 191 patients (47%). Patients who experienced AF after an acute stress showed the highest probability of spontaneous conversion. High espresso coffee consumption (OR 0.86; 95% CI: 0.49-1.21; P < 0.01) and obesity (OR 0.88; 95% CI: 0.84-1.20; P < 0.01) were associated with a significantly greater risk of persistent AF. CONCLUSION: Acute stress induced changes in lifestyle, including an increase in coffee consumption, leading to a higher risk of AF. Patients who developed AF after an acute stress showed the highest probability of spontaneous conversion. High espresso coffee consumption and obesity were associated with an increased risk of persistent AF.

Influence of regression of left ventricular hypertrophy on left atrial size and function in patients with moderate hypertension.

OBJECTIVES: The aim of the study was to evaluate the effect of regression of left ventricular (LV) hypertrophy on left atrial (LA) size and function in patients treated with telmisartan, an angiotensin II receptor blocker. METHODS: Patients population included 80 patients with mild-moderate LV hypertrophy treated with telmisartan. Patients were followed over a period of 12 months from the start of telmisartan treatment. LA size was measured during systole from the parasternal long-axis view from M-mode. Atrial function was assessed by Doppler-echocardiography and the following parameters were measured: transmitral peak A velocity, atrial filling fraction, atrial ejection force (AEF), peak E velocity, deceleration time and isovolumic relaxation time, LA maximal and minimal volume, and LV cardiac mass index (LVMI). RESULTS: All patients had an increased LVMI and decrease during follow-up. LA dimensions were greater at baseline and reduced after 1 year of treatment. LA volume indexes maximal volume, minimal volume and P volume were reduced compared with baseline value (maximal volume from 35+/-5 to 32+/-5, p<0.05; minimal volumes from 14+/-2 to 10+/-4, p<0.05). AEF, a parameter of atrial systolic function, increased from 12+/-3 to 15+/-2.4 (p<0.01). The reduction of LA volumes correlate with reduction of LVMI (LA maximal volume and LVMI r = 0.45; p<0.01; LA minimal volume and LVMI r = 0.34; p<0.05). A positive correlation was also found between LV mass index and P volume (r = 0.41; p<0.01), LV mass index and LA active emptying volume (r = 0.39; p<0.01), and LV mass index and LA total emptying volume (r = 0.38; p<0.05). CONCLUSIONS: The present study suggests that regression of LV hypertrophy due to telmisartan is associated with reduction of LA volumes that expresses variation of LV end-diastolic pressure. The reduction of LV end-diastolic pressure is associated with an increase in diastolic filling and with a significant reduction of active and passive emptying contribution of left atrium to LV stroke volume.

Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation.

AIMS: The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn). METHODS AND RESULTS: Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95% CI=3.23-9.42; P<0.0001). CONCLUSION: After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.

The relationship between personality, socio-economic factors, acute life stress and the development, spontaneous conversion and recurrences of acute lone atrial fibrillation.

AIMS: The present study was designed to establish the relationship between personality factors, socio-economic factors and acute life stress with development, spontaneous cardioversion and recurrences of acute lone atrial fibrillation. METHODS: The study group consisted of 116 patients with lone atrial fibrillation cardioverted within 48h of the onset of arrhythmia; they underwent a series of cognitive tests to evaluate acute psychological stress and personality type. The socio-economic status and other covariates (alcohol consumption, smoking, and body mass index) were investigated. A control group, age- and sex-matched, was selected and compared. In the logistic regression analysis, the presence of spontaneous conversion to sinus rhythm was used as the dependent variable. Independent variables were indicator variables representing categories of stress, Type A behaviour pattern, coffee consumption and body mass index. Variables considered for logistic analysis were only those with independent prognostic value. RESULTS: Type A behaviour pattern was found in 23 (20%) patients with atrial fibrillation and in 11 (9%) controls (P<0.001). The mean score among patients with atrial fibrillation was 8+/-2.7, while in control subjects it was 5.5+/-2. The mean acute life stress score among patients with atrial fibrillation was 56+/-33, while in controls it was 34+/-27 (P<0.01). Spontaneous conversion of atrial fibrillation to sinus rhythm was observed in 72 patients (63%). In univariate analysis alcohol consumption, income, education and smoking habits did not affect spontaneous conversion. High coffee consumption (OR 0.3 95% CI 0.11-0.49; P<0.008) and high body mass index were associated with a significantly greater risk of atrial fibrillation (OR 1.5 95% CI 1.2-1.7). CONCLUSIONS: Type A behaviour pattern and acute life stress affect the development and spontaneous conversion of atrial fibrillation. Patients with acute stress showed the highest probability of spontaneous conversion followed by patients with Type A behaviour. Other socio-economic factors affect spontaneous conversion and recurrences of lone atrial fibrillation to a lesser extent.

Acute myocardial infarction in young patients: nutritional status and biochemical factors.

PURPOSE: The aim of this study was to establish whether nutritional status and biochemical factors, C-reactive protein (CRP), serum amyloid A (SAA) protein, serum iron (Fe) and fibrinogen at admission were different in patients with acute myocardial infarction (AMI) at a young age (<40 years) vs. those with AMI at an older age (>60 years). We also investigated whether during the stay in the hospital, the increase in acute-phase reactants was different in young vs. older subjects, and if dyslipidemic aspects were different between the two groups. METHODS: The study population consisted of 40 patients, all males with a mean age of 36.7+/-1.16 years, admitted to our facility with AMI. The control group included 40 patients, all males, mean age of 66.3+/-4.24 years, with AMI. CRP, SAA, Fe and fibrinogen were determined at admission to the hospital and daily for 7 days in the two groups of patients. RESULTS: In young patients the median value of the highest levels were 6.2 mg/l (range 0.7-27.30) for CRP, 13.22 mg/l (range 0.7-130) for SAA, 420 mg/dl (range 76-840) for fibrinogen and 49.1 gamma/ml (range 14-102) for Fe levels. In the older patients, the median value of the highest levels were 5.9 mg/l (range 0.6-28.30) for CRP, 12.12 mg/l (range 0.9-280) for SAA, 480 mg/dl (range 60-780) for fibrinogen and 47.1 gamma/ml (range 12-94) for Fe levels. CONCLUSIONS: In the present study, acute-phase reactants were quantitatively similar in young and old patients. On the contrary, nutritional status, homocysteine, LDL and triglycerides are significantly higher in young patients than in old patients.

Prognostic value of iron, nutritional status indexes and acute phase protein in acute coronary syndromes.

BACKGROUND: The relation between the inflammatory status during unstable angina and nutritional parameters has not been well described. We sought to investigate the relation between the acute inflammatory status, as evaluated on the basis of high C-reactive protein (CRP) and serum amyloid A levels and laboratory indexes of iron and nutritional status in patients with unstable angina, and whether the variations in iron levels have a prognostic significance. METHODS: The study population consisted of 98 patients admitted to our facility with unstable (group 1: 64 consecutive patients, 52 males, 12 females, mean age 66 +/- 10 years) or stable angina (group 2: 34 patients, 30 males, 4 females, mean age 65 +/- 9 years). The hemoglobin levels, the erythrocyte mean cell volume, serum iron levels, the increase in transferrin levels, the decrease in the percent transferrin saturation, ferritin levels, the nutritional status, and the CRP and serum amyloid A levels were measured. RESULTS: On the basis of a CRP value > 1 mg/dl, 47 patients with unstable angina and 4 patients with stable angina were identified as having active inflammatory disease. The presence of inflammation was associated with significantly lower mean values of hemoglobin, erythrocyte mean cell volume, serum iron and transferrin levels, and percent transferrin saturation in comparison with patients without inflammation. A significant inverse correlation coefficient between a CRP level > 1 mg/dl and hemoglobin, transferrin levels and percent transferrin saturation was observed: the strongest correlation was with serum iron levels. The relative risk of total cardiac events was significantly greater in patients with low serum iron levels than in those with high serum iron levels. CONCLUSIONS: Patients with acute inflammation present altered iron status indexes. Increased CRP levels and reduced serum iron levels are associated with a worse outcome in patients with unstable angina.