Coronary plaque instability assessed by positron emission tomography and optical coherence tomography.

BACKGROUND: Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) are caused often by destabilization of non-flow limiting inflamed coronary artery plaques. 18F-fluorodeoxyglucose (FDG) uptake with positron emission tomography/computed tomography (PET/CT) reveals plaque inflammation, while intracoronary optical coherence tomography (OCT) reliably identifies morphological features of coronary instability, such as plaque rupture or erosion. We aimed to prospectively compare these two innovative biotechnologies in the characterization of coronary artery inflammation, which has never been attempted before. METHODS: OCT and FDG PET/CT were performed in 18 patients with single vessel coronary artery disease, treated by percutaneous coronary intervention (PCI) with stent implantation, divided into 2 groups: NSTEMI/UA (n = 10) and stable angina (n = 8) patients. RESULTS: Plaque rupture/erosion recurred more frequently [100% vs 25%, p = 0.001] and FDG uptake was greater [TBR median 1.50 vs 0.87, p = 0.004] in NSTEMI/UA than stable angina patients. FDG uptake resulted greater in patients with than without plaque rupture/erosion [1.2 (0.86-1.96) vs 0.87 (0.66-1.07), p = 0.013]. Among NSTEMI/UA patients, no significant difference in FDG uptake was found between ruptured and eroded plaques. The highest FDG uptake values were found in ruptured plaques, belonging to patients with NSTEMI/UA. OCT and PET/CT agreed in 72% of patients [p = 0.018]: 100% of patients with plaque rupture/erosion and increased FDG uptake had NSTEMI/UA. CONCLUSION: For the first time, we demonstrated that the correspondence between increased FDG uptake with PET/CT and morphology of coronary plaque instability at OCT is high.

Duchenne muscular dystrophy: preliminary experience with sacubitril-valsartan in patients with asymptomatic left ventricular dysfunction.

OBJECTIVE: Duchenne muscular dystrophy (DMD) is an inherited X-linked recessive neuromuscular disease caused by mutations of the dystrophin gene, leading to early and progressive muscle deterioration and dilated cardiomyopathy. The aim of this investigation was to assess whether treatment with sacubitril/valsartan (S/V) is well tolerated and may have beneficial effects in DMD patients with left ventricle (LV) dysfunction. PATIENTS AND METHODS: We administered S/V to 3 DMD patients (19-29 yeard old) with LV ejection fraction <35% at echocardiography but no symptoms of heart failure. All patients were on optimal medical therapy. S/V was initiated at a very low dose of 12/13 mg/die, after withdrawal of angiotensin-converting enzyme inhibitor therapy, and slowly titrated to the dose of 49/51 mg twice daily or the maximally tolerated dose. Clinical and echocardiographic follow-up was performed after 3, 6 and 12 months. RESULTS: At baseline, the LV ejection fraction was 32±1%. A significant improvement of LV ejection fraction was observed at 3 months (44.0±6.0%; p<0.05), which was maintained at 6 (45.7±5.0%) and 12 (43.3±3.2%) months (p<0.05 for both). No relevant side effects were reported throughout the period of the study. CONCLUSIONS: Our preliminary data suggest that, in DMD patients with reduced LV ejection fraction, S/V is safe and may improve LV function.

Diagnostic role of echocardiography in patients admitted to the emergency room with suspect no-ST-segment elevation acute myocardial infarction.

OBJECTIVE: We investigated whether echocardiography may help identify, among patients admitted with a suspect of non-ST-segment elevation acute myocardial infarction (NSTEMI), those with athero-thrombotic coronary artery disease (CAD). PATIENTS AND METHODS: We studied consecutive patients admitted with a clinical suspect of first NSTEMI. Echocardiography was assessed within 24 hours from admission. Patients were divided into two groups, according to the results of coronary angiography: 1) patients with obstructive stenosis (≥ 50%) and/or images of thrombosis in one or more coronary arteries (CAD group); 2) patients with no evidence of obstructive coronary arteries (NOCAD group). RESULTS: Of 101 patients enrolled in the study, 53 (52.5%) showed obstructive CAD and 48 (47.5%) NOCAD. At echocardiographic examination, regional wall motion abnormalities were found in 52.8% of patients in the CAD group and 43.7% in the NOCAD group (p=0.43). Left ventricle ejection fraction was 56.4±6.8 vs. 54.7±9.8% (p=0.30) and wall motion score index was 1.16±0.26 vs. 1.21±0.32 (p=0.39) in the two groups, respectively. A multivariable logistic regression independent predictors of obstructive CAD included age, male gender, typical angina, diabetes and hypertension. CONCLUSIONS: Our data showed that, in patients with acute chest pain and increased serum troponin T concentration, routine standard echocardiography does not significantly improve the diagnostic accuracy for the presence of obstructive CAD.

Microvascular ischemia in patients with successful percutaneous coronary intervention: effects of ranolazine and isosorbide-5-mononitrate.

OBJECTIVE: About one-third of patients undergoing percutaneous coronary interventions (PCIs) for flow-limiting coronary stenosis continue to develop signs of myocardial ischemia (MI) during exercise stress test [EST], despite successful coronary revascularization. Coronary microvascular dysfunction is a likely major cause of the persistence of EST-induced MI in these patients. PATIENTS AND METHODS: We studied 15 patients (14 men, age 67±5 years) fulfilling the following strict inclusion criteria: (1) recent PCI (<6 months), with drug-eluting stent, of coronary artery stenoses for stable angina, with evidence of full success (no residual stenosis >20% in any vessel); (2) persistence of ST-segment depression induction during EST. After a basal investigation, patients received either ranolazine (375 mg bid) or isosorbide-5-mononitrate (ISMN, 20 mg bid) for 3 weeks in a single-blind, randomized crossover study. Clinical assessment, symptom-limited EST, echocardiographic color-Doppler, with tissue-Doppler examination, and coronary microvascular dilator response to adenosine (CFR-ADO) and cold pressor test (CFR-CPT), assessed by transthoracic echo-Doppler, were obtained at baseline and the end of the 3-week therapy with each drug. RESULTS: Compared to both baseline and ISMN, ranolazine showed a longer time to 1 mm ST-segment depression (404±116 s vs. 317±98 and 322±70 s, respectively; p<0.01). No differences were observed in coronary microvascular function and diastolic left ventricular function between the 2 drugs and compared to baseline. CONCLUSIONS: Our data show that ranolazine, but not ISMN, improved time to ischemia during EST. This effect, however, was independent of any effects on coronary microvascular and diastolic function.

[Plasma-cell granuloma of the mediastinum]. / Granuloma plasmacellulare del mediastino.

Plasma-cell granuloma of the mediastinum is an unusual non-neoplastic lesion; a case of rare mediastinal localization is reported. Only the histopathological examination leads to a correct diagnosis. Since the possibility of local recurrence has been described, total excision is requested. Video-assisted thoracic surgery technique may be difficult to use in the management of these mediastinal tumors due to adhesions between the mass and the surrounding tissues. Complete open resection is the treatment of choice.

Evaluation of the precision of dimensional measurements of the mandible on panoramic radiographs.

The purpose of this study was to evaluate the precision of dimensional measurements of the mandible on orthopantomographic images and thus to evaluate their dimensional reliability. Different distances denoted by metal markers were measured on 25 dry mandibles. The same mandibles were then positioned in an orthopantomographic machine, and radiographic images of them were made. Measurements of the same distances were made on the panoramic images and then compared with the results of the measurements on the dry mandibles. All results were statistically analyzed. The results showed significant difference between the magnification factor listed by the manufacturer and calculated magnification factors, the latter being closer to 1.00. The study also showed that linear measurements made on only one side of the panoramic image of a mandible were very close to the actual dimensions of the dry mandible, whereas measurements that extended across the midline of the mandible were greatly enlarged because of large magnification factors; therefore, such measurements should not be made.

[A case of volvulus of the gallbladder]. / Un caso di volvolo della colecisti.

A rare case of total volvulus of the gallbladder observed intraoperatively and treated by cleansing and cholecystectomy in a 96-year-old woman undergoing surgery for acute lithiasic cholecystitis is described. More than the clinical and laboratory data (insignificant considering the patient's anergic and debilitated condition) it was the results of hepatobiliary ultrasonography which revealed acute, rapidly progressing inflammation of the gallbladder that supplied the indication for immediate surgery.

[Prevention of gastroesophageal reflux. Validity of hemifundoplication according to Cor-Casolo (experimental study)]. / La prevenzione del reflusso gastro-esofageo. Validità dell'emifundoplicatio sec. Dor-Casolo (studio sperimentale).

After a short preface about the main antireflux techniques employed in the treatment and prevention of gastro-oesophageal reflux, the problems involved in the iatrogenous gastro-oesophageal reflux are stated. As no unanimous opinion exists till now in literature about the importance and incidence of reflux after the operation of extramucous cardiomyotomy according to Heller, used in the treatment of achalasia, and after the Parietal Cell Vagotomy, employed in the treatment of duodenal ulcer, an experimental protocol was set up. An experimental research was performed on 16 dogs, subdivided into 3 groups: in the first group (6 dogs) extramucous cardiomyotomy according to Heller and antireflux procedure (antero-lateral hemifundoplication according to Dor-Casolo) were performed; in the second group (6 dogs) Parietal Cell Vagotomy + extramucous cardiomyotomy according to Heller + antero-lateral hemifundoplication according to Dor-Casolo were performed; in the third group (control) the only extramucous cardiomyotomy according to Heller was performed. In the research, articulated in two stages (1st time - operation; 2nd time - remote checking) the following was effected: pressure gauge test; pH-metric test; gastro-oesophageal scintigraphic test with Tc99m; histopathologic test. The experimental results obtained, elaborated by computer, demonstrated: that extramucous cardiomyotomy according to Heller causes serious oesophagitic phenomena, and therefore it should be joined to antireflux procedure; that Parietal Cell Vagotomy (P.C.V.) causes a significant decrease in the tone of L.E.S. (Lower Oesophageal Sphincter); that antero-lateral hemifundoplication according to Dor-Casolo (210 degrees) is effective in its antireflux action even after long time.