Role of plaque calcification regulators osteoprotegerin and matrix Gla-proteins in stable angina and acute myocardial infarction.

AIM: To assess serum levels of the plaque calcification regulators osteoprotegerin (OPG) and Matrix Gla-proteins (MGP) in individuals with stable angina and acute myocardial infarction submitted to coronary angiography and their relation to coronary artery disease burden. METHODS: The study included 40 individuals affected by ST-elevation myocardial infarction (STEMI) and 40 individuals with stable angina who all underwent coronary angiography, with evaluation of the extent of coronary artery disease by Syntax Score calculation and measurement of serum OPG and MGP levels. Osteoporosis was excluded by femoral and vertebral computerized bone mineralometry. RESULTS: Serum OPG and MGP levels were respectively 3.87 ±â€Š1.07 pmol/l and 6.80 ±â€Š2.43 nmol/l in the stable angina group, 7.57 ±â€Š1.5 pmol/l and 7.18 ±â€Š1.93 nmol/l in the STEMI group (P < 0.01 and P = 0.33, respectively). Pearson correlation coefficient for OPG and Syntax Score, MGP and Syntax score was respectively 0.79 (P < 0.01) and 0.18 (P = 0.22) in the stable angina group, -0.03 (P = 0.43) and 0.10 (P = 0.5) in the STEMI group.Serum OPG and MGP levels were respectively 5.52 ±â€Š1.02 pmol/l and 7.56 ±â€Š1.42 nmol/l in diabetics, 4.3 ±â€Š0.8 pmol/l and 6.52 ±â€Š1.14 nmol/l in nondiabetics (P < 0.05; P < 0.05). CONCLUSION: OPG, in a relatively small group of patients with stable angina, correlates proportionally with the extent of coronary artery disease (CAD), as evaluated by the Syntax Score. Higher serum OPG levels can be observed in individuals with STEMI regardless of CAD burden. As for MGP, a potential role as marker of plaque calcification remains unproven.

Comparison of incidence and predictors of left bundle branch block after transcatheter aortic valve implantation using the CoreValve versus the Edwards valve.

Conduction disorders and permanent pacemaker implantation are common complications in patients who undergo transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the incidence and clinical significance of new bundle branch block in patients who underwent TAVI with the Medtronic CoreValve Revalving System (MCRS) or the Edwards SAPIEN valve (ESV). Data from 238 patients with no previous pacemaker implantation, left bundle branch block (LBBB) or right bundle branch block at baseline electrocardiography who underwent TAVI with either MCRS (n = 87) or ESV (n = 151) bioprostheses from 2007 to 2011 were analyzed. New-onset LBBB occurred in 26.5% patients (n = 63): 13.5% with the ESV (n = 20) and 50.0% with the MCRS (n = 43) (p = 0.001). Permanent pacemaker implantation was required in 12.7% of patients (n = 8) because of complete atrioventricular block (ESV n = 2, MCRS n = 4), LBBB and first degree atrioventricular block (MCRS n = 1) and new-onset LBBB associated with sinus bradycardia (MCRS n = 1). At discharge, LBBB persisted in 8.6% of ESV patients (n = 13) and 32.2% of MCRS patients (n = 28) (p = 0.001). On multivariate analysis, the only predictor of LBBB was MCRS use (odds ratio 7.2, 95% confidence interval 2.9 to 17.4, p <0.001). Persistent new-onset LBBB at discharge was not associated with overall (log-rank p = 0.42) or cardiovascular (log-rank p = 0.46) mortality. New-onset right bundle branch block was documented in 4.6% of patients (n = 11), with no statistically significant differences between the ESV and MCRS. In conclusion, new-onset LBBB is a frequent intraventricular conduction disturbance after TAVI with a higher incidence with the MCRS compared with the ESV. LBBB persists in most patients, but in this cohort, it was not a predictor of overall or cardiovascular mortality or permanent pacemaker implantation.

A 'clover' coronary artery: role of coronary computed tomography to indicate optimal treatment in aneurysmal coronary artery disease.

We report the case of a 61-year-old man referred to our department for exertional angina with a history of tri-vessel aneurysmal coronary artery disease. Exercise stress echocardiography was positive for inferior wall hypokinesia. Coronary computed tomography (CT) provided a more accurate characterization of the coronary aneurysms. It detected a laminated thrombus of the proximal left anterior descending and a clover-like aneurysmal dissection of the proximal right coronary artery, which questioned the feasibility of coronary angioplasty. So, the patient was treated with medical therapy only. This case confirmed the importance of coronary CT as diagnostic tool for procedural risk assessment and definition of the most appropriate treatment in patients with coronary aneurysms.

Unrepaired tetralogy of fallot in an 85-year-old man.

Tetralogy of Fallot is the most common cyanotic congenital heart defect and accounts for about 5% of all congenital cardiopathies. The definitive treatment modality for tetralogy of Fallot is reparative surgery, which is recommended to be performed by the time of diagnosis. Without surgical repair, most patients would die during their childhood. In the past, survival data indicated that 66% of persons with tetralogy of Fallot not surgically treated lived until the age of 1, 49% lived until the age of 3, and 24% lived until the age of 10. We now present a rare case of a man with unrepaired tetralogy of Fallot who survived until the age of 85. He presented to our emergency room for dyspnea and palpitations due to a new-onset high-frequency atrial fibrillation and acute heart failure; transthoracic echocardiography showed the presence of tetralogy of Fallot. By consulting the scientific literature, we can say that this is the second patient who survived more than 80 years without surgical intervention.

An unusual case of acute coronary syndrome late after stent implantation.

We report a case of a 66-year-old Caucasian male who presented to our department with unstable angina in July 2011. He had a medical history of trivessel coronary artery disease and underwent several percutaneous coronary interventions (2003, 2004, and 2006). The latest coronary angiography, performed in January 2011, showed mild intimal hyperplasia within the proximal left anterior descending segment, treated with a sirolimus-eluting stent in 2003. On admission, electrocardiogram was positive for a recent acute coronary syndrome, so the patient underwent coronary angiography, which showed proximal left anterior descending stent thrombosis, occurred eight years after drug-eluting stent implantation. Intravascular ultrasound revealed a soft plaque rupture within the stented segment, which was the cause of stent thrombosis. So the lack of endothelialization over stent struts is not the only mechanism determining acute coronary syndromes late after stent implantation. In-stent neoatherosclerosis, frequently disregarded, is another possible actor especially of very late thrombotic events. However, the pathogenesis of this phenomenon has not been clearly established.