Diastolic Mitral Regurgitation as a Rare Cause of Acute Respiratory Failure Following Complete Atrioventricular Block.

A 77-year-old male presented to the emergency department with dyspnea. A third-degree atrioventricular block was present in the electrocardiogram and an echocardiography showed a moderate mitral regurgitation with a diastolic functional insufficiency. Hemodynamic variations were assessed in the context of heart rhythm disturbances. (Level of Difficulty: Intermediate.).

Cardiogenic shock code 2023. Expert document for a multidisciplinary organization that allows quality care.

Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS.

Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study.

AIMS: The aim of the LAICA study was to evaluate the long-term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF). METHODS AND RESULTS: This was a multicentre, randomized, double-blind, placebo-controlled clinical trial of intermittent levosimendan 0.1 µg/kg/min as a continuous 24-h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre-specified time-to-event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32-1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed. CONCLUSIONS: In our study, intermittent levosimendan in patients with AdHF produced a statistically non-significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.

Long-Term Radiotherapy-Induced Cardiac Complications: A Case Report.

BACKGROUND Tumor disease has improved survival due to therapeutic advances and early diagnosis. However, anti-neoplastic treatment involves generating harmful side effects in the body, both in the short-term and in the long-term. One of the most important side effects is cardiovascular disease after radiotherapy, which in addition to being influenced by classic cardiovascular risk factors, can be also be influenced by anti-neoplastic therapy, and represents the main cause of death after a second cancer. We present a case that synthesizes the most relevant and determining aspects of radiotherapy-induced heart disease. CASE REPORT We present the case of a 48-year-old male with a personal history of mediastinal Hodgkin lymphoma who was treated with local radiotherapy 20 years ago, and who was admitted to hospital due to dyspnea and oppressive chest pain with efforts. He was diagnosed with severe aortic stenosis, and a coronary angiography confirmed the existence of coronary disease. Two years before, he had been admitted to hospital due to syncope and a pacemaker had been implanted. This patient experienced several cardiovascular complications that could be attributed to the radiotherapy treatment received in his past. CONCLUSIONS Radiotherapy shows multiple cardiological complications, especially when applied at the thoracic level. This fact is very relevant, and this report can help determine the aspects of radiotherapy-induced heart disease affecting the mortality and morbidity of these patients.

Repetitive use of levosimendan in advanced heart failure: need for stronger evidence in a field in dire need of a useful therapy.

Patients in the latest stages of heart failure are severely compromised, with poor quality of life and frequent hospitalizations. Heart transplantation and left ventricular assist device implantation are viable options only for a minority, and intermittent or continuous infusions of positive inotropes may be needed as a bridge therapy or as a symptomatic approach. In these settings, levosimendan has potential advantages over conventional inotropes (catecholamines and phosphodiesterase inhibitors), such as sustained effects after initial infusion, synergy with beta-blockers, and no increase in oxygen consumption. Levosimendan has been suggested as a treatment that reduces re-hospitalization and improves quality of life. However, previous clinical studies of intermittent infusions of levosimendan were not powered to show statistical significance on key outcome parameters. A panel of 45 expert clinicians from 12 European countries met in Rome on November 24-25, 2016 to review the literature and envision an appropriately designed clinical trial addressing these needs. In the earlier FIGHT trial (daily subcutaneous injection of liraglutide in heart failure patients with reduced ejection fraction) a composite Global Rank Score was used as primary end-point where death, re-hospitalization, and change in N-terminal-prohormone-brain natriuretic peptide level were considered in a hierarchical order. In the present study, we tested the same end-point post hoc in the PERSIST and LEVOREP trials on oral and repeated i.v. levosimendan, respectively, and demonstrated superiority of levosimendan treatment vs placebo. The use of the same composite end-point in a properly powered study on repetitive levosimendan in advanced heart failure is strongly advocated.

Síncopes en un paciente con antecedente de radioterapia: la importancia de una valoración global de la afección cardiaca. Respuesta / Syncopes in a patient with a history of radiotherapy: the importance of a comprehensive assessment of cardiac involvement. Response

No disponible

Síncope de repetición inducido por radioterapia / Radiotherapy-induced recurrent syncope

No disponible

Levosimendan improves hemodynamic status in critically ill patients with severe aortic stenosis and left ventricular dysfunction: an interventional study.

AIMS: To study the hemodynamic effect of levosimendan administration in acute heart failure patients with severe aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF). METHODS: Hemodynamic response to 24 h intravenous levosimendan infusion (0.1 µg/kg/min without a loading dose) in patients with severe AS (aortic valve area ≤1 cm(2) , time-velocity integral between left ventricular out-flow tract and aortic valve <0.25), reduced LVEF (≤40%), and a depressed cardiac index (CI) <2.2 L/min/m(2) was determined in a sequential group of nine patients aged 76 ± 10 years (5 men). RESULTS: Baseline mean ejection fraction was 33 ± 0.7%; mean aortic valve area was 0.37 ±0.11 cm(2) /m(2) ; peak and mean gradients of 63.6 ± 20.53 and 36.7 ± 12.62 mmHg, respectively; and mean CI was 1.65 ± 0.20 L/min/m(2) . At 6 and 12 h of levosimendan therapy, mean CI had increased to 2.00 ± 0.41 L/min/m(2) (P = 0.02) and 2.17 ± 0.40 L/min/m(2) (P = 0.01), respectively. At 24 h, mean CI had increased further to 2.37 ± 0.49 L/min/m(2) (P = 0.01). A significant beneficial effect was also observed in pulmonary capillary wedge pressure, pulmonary artery mean pressure, central venous pressure, systemic vascular resistances, pulmonary vascular resistances, stroke volume index, left ventricular stroke work index. NTproBNP levels decreased at 24 h of levosimendan treatment. Levosimendan infusion was also well tolerated. Five patients subsequently underwent aortic valve surgery replacement. One died (of postoperative multiorgan failure). At 30 days, overall survival was 75%. CONCLUSIONS: Levosimendan administration improves hemodynamic parameters in critically ill patients with severe AS and reduced LVEF. In our study, it provides a safe and effective bridge to aortic-valve replacement or oral vasodilator therapy in surgical contraindicated patients. A controlled study is needed to confirm these preliminary findings.

Rationale and design of a randomized, double-blind, placebo controlled multicenter trial to study efficacy, security, and long term effects of intermittent repeated levosimendan administration in patients with advanced heart failure: LAICA study.

BACKGROUND: Advanced heart failure (HF) is associated with high morbidity and mortality; it represents a major burden for the health system. Episodes of acute decompensation requiring frequent and prolonged hospitalizations account for most HF-related expenditure. Inotropic drugs are frequently used during hospitalization, but rarely in out-patients. The LAICA clinical trial aims to evaluate the effectiveness and safety of monthly levosimendan infusion in patients with advanced HF to reduce the incidence of hospital admissions for acute HF decompensation. METHODS: The LAICA study is a multicenter, prospective, randomized, double-blind, placebo-controlled, parallel group trial. It aims to recruit 213 out-patients, randomized to receive either a 24-h infusion of levosimendan at 0.1 µg/kg/min dose, without a loading dose, every 30 days, or placebo. RESULTS: The main objective is to assess the incidence of admission for acute HF worsening during 12 months. Secondarily, the trial will assess the effect of intermittent levosimendan on other variables, including the time in days from randomization to first admission for acute HF worsening, mortality and serious adverse events. CONCLUSIONS: The LAICA trial results could allow confirmation of the usefulness of intermittent levosimendan infusion in reducing the rate of hospitalization for HF worsening in advanced HF outpatients.

Diurnal variation of soluble CD40 ligand in patients with acute coronary syndrome. Soluble CD40 ligand and diurnal variation.

INTRODUCTION: We sought to investigate whether day-night variations occur in the concentration of circulating soluble CD40 ligand in patients with acute coronary syndrome, as this may have practical implications. MATERIALS AND METHODS: We assessed 70 consecutive ST-segment elevation myocardial infarction patients admitted into the Coronary Care Unit and 50 control subjects. Each subject was studied under strictly controlled light/dark conditions. Blood samples were drawn at 09:00 h (light phase) and 02:00 h (dark phase). Nocturnal blood samples were drawn by a trained nurse, with the help of a minute torch with a dim red light in order to avoid any direct lighting on the patient during sleep. The soluble CD40 ligand was measured using a commercially available ELISA. RESULTS: Soluble CD40 ligand levels showed no diurnal variations in control subjects. In the ST-segment elevation myocardial infarction group, however, soluble CD40 ligand concentration (pg/mL) in the light phase was significantly higher than that in the dark phase (167.3+/-63.2 vs 118.9+/-48.3 pg/mL, p<0.001). CONCLUSIONS: The study shows for the first time the existence of diurnal variations in soluble CD40 ligand levels in ST-segment elevation myocardial infarction patients, which indicates the need for standardizing the time of blood sampling for the assessment of this molecule, at least in studies involving ST-segment elevation myocardial infarction patients.

Light-dark variations in neopterin serum levels in patients with ST-segment elevation acute coronary syndrome undergoing primary angioplasty.

INTRODUCTION AND OBJECTIVES: Activation of the cell-mediated immune system plays an important role in atherogenesis and in triggering the development of acute coronary syndrome. Neopterin, a biomarker of cell-mediated immune system activity, is also a well-known biomarker of coronary artery disease. It is known that the occurrence of coronary heart disease events is not distributed evenly throughout the day but instead undergoes cyclical variation. In addition, both the number and activity level of immune system cells also vary throughout the 24-h circadian period. We studied how the serum concentration of neopterin varies during the light and dark phases of the day in patients with ST-segment elevation acute coronary syndrome who had undergone primary angioplasty and in a group of control subjects without evidence of atherosclerotic disease. METHODS: The serum concentration of neopterin was determined at 10:00 in the morning (i.e., in light) and at 03:00 at night (i.e., in darkness) in 96 patients and 84 control subjects under strictly controlled conditions of light and darkness. RESULTS: Significant light-dark variations were observed in the serum concentration of neopterin in both patients with ST-segment elevation acute coronary syndrome (i.e., 10.2+/-3.8 nmol/L in light vs. 8.84+/-2.22 nmol/L in darkness; P< .001) and control subjects (i.e., 6.98+/-1.96 nmol/L in light vs. 5.87+/-2 nmol/L in darkness; P< .001). Moreover, levels were significantly higher in patients (P< .001). CONCLUSIONS: Diurnal variations in cell-mediated immune system activity were observed in both patients with ST-segment elevation acute coronary syndrome who underwent primary angioplasty and in a control group. Moreover, activity was significantly higher in patients.

Variaciones luz/oscuridad de las concentraciones séricas de neopterina en pacientes con síndrome coronario agudo con elevación del segmento ST tratados con angioplastia primaria / Light-dark variations in neopterin serum levels in patients with ST-segment elevation acute coronary syndrome undergoing primary angioplasty

Introducción y objetivos. La activación del sistema inmunitario celular desempeña un importante papel en la aterogénesis y el inicio del síndrome coronario agudo. La neopterina, marcador biológico de activación del sistema inmunitario celular, también es un buen marcador biológico de enfermedad coronaria. Se sabe que la distribución de los accidentes isquémicos coronarios a lo largo del día no es uniforme, sino que experimenta variaciones rítmicas. Por otro lado, tanto el número como las funciones de las células del sistema inmunitario pueden variar con el correr del día. Estudiamos las concentraciones séricas de neopterina en pacientes con síndrome coronario agudo con elevación persistente del segmento ST tratados con agioplastia primaria y en un grupo control de sujetos sin evidencias de enfermedad aterosclerótica, en fase de luz y en fase de oscuridad durante el día. Métodos. Se determinó la concentración sérica de neopterina a las 10.00 (periodo de luz) y a las 3.00 (periodo de oscuridad) en 96 pacientes y 84 sujetos control en condiciones de luz y oscuridad estrictamente controladas. Resultados. Las concentraciones séricas de neopterina mostraron variaciones entre luz y oscuridad significativas tanto en el grupo de pacientes con síndrome coronario agudo con elevación persistente del segmento ST (luz frente a oscuridad, 10,2 ± 3,8 frente a 8,84 ± 2,22 nmol/l; p < 0,001) como en el grupo control (luz frente a oscuridad, 6,98 ± 1,96 frente a 5,87 ± 2 nmol/l; p < 0,001). Sin embargo, en los primeros era significativamente mayor (p < 0,001). Conclusiones. Se producen variaciones diurnas en la activación del sistema inmunitario celular, tanto en el grupo de pacientes con síndrome coronario agudo con elevación persistente del segmento ST tratados con angioplastia primaria como en el grupo control, pero en el primero son significativamente mayores (AU)

Introduction and objectives. Activation of the cell-mediated immune system plays an important role in atherogenesis and in triggering the development of acute coronary syndrome. Neopterin, a biomarker of cell-mediated immune system activity, is also a well-known biomarker of coronary artery disease. It is known that the occurrence of coronary heart disease events is not distributed evenly throughout the day but instead undergoes cyclical variation. In addition, both the number and activity level of immune system cells also vary throughout the 24-h circadian period. We studied how the serum concentration of neopterin varies during the light and dark phases of the day in patients with ST-segment elevation acute coronary syndrome who had undergone primary angioplasty and in a group of control subjects without evidence of atherosclerotic disease. Methods. The serum concentration of neopterin was determined at 10:00 in the morning (i.e., in light) and at 03:00 at night (i.e., in darkness) in 96 patients and 84 control subjects under strictly controlled conditions of light and darkness. Results. Significant light-dark variations were observed in the serum concentration of neopterin in both patients with ST-segment elevation acute coronary syndrome (i.e., 10.2±3.8 nmol/L in light vs. 8.84±2.22 nmol/L in darkness; P<.001) and control subjects (i.e., 6.98±1.96 nmol/L in light vs. 5.87±2 nmol/L in darkness; P<.001). Moreover, levels were significantly higher in patients (P<.001). Conclusions. Diurnal variations in cell-mediated immune system activity were observed in both patients with ST-segment elevation acute coronary syndrome who underwent primary angioplasty and in a control group. Moreover, activity was significantly higher in patients (AU)

Prognostic value of admission myeloperoxidase levels in patients with ST-segment elevation myocardial infarction and cardiogenic shock.

Inflammation plays a critical role in acute myocardial infarction. One inflammatory marker is myeloperoxidase (MPO). Its role as a predictor of in-hospital death in patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) is unclear. Therefore, the aim of this study was to investigate the role of MPO as a predictor of in-hospital death in patients with STEMIs presenting with CS and treated with primary percutaneous coronary intervention. In 38 consecutive patients with CS complicating STEMIs who were treated with primary percutaneous coronary intervention, serum MPO levels were measured at coronary care unit admission using a commercially available enzyme-linked immunosorbent assay. The primary study end point was in-hospital cardiac death. Among the 38 patients included in the study, 20 died during their coronary care unit stays, whereas 18 survived. Compared with patients who survived, patients who died showed, at coronary care unit admission, higher serum MPO levels (81 +/- 28 vs 56 +/- 23 ng/ml, p <0.006). After controlling for different baseline clinical, laboratory, and angiographic variables, baseline serum MPO level was an independent predictor of in-hospital mortality on multivariate analysis (odds ratio 3.9, 95% confidence interval 1.8 to 7.5, p <0.001). In conclusion, admission MPO concentration is an independent predictor of in-hospital mortality in patients with STEMIs presenting with CS.