[Perimyocarditis as a complication of a multiple drug therapy in the treatment of a severe ulcerative colitis episode]. / Perimyokarditis als Komplikation einer medikamentösen Mehrfachtherapie bei Colitis ulcerosa.

HISTORY AND CLINICAL FINDINGS: A 19-year-old patient presented as an inpatient with an acute flare-up of ulcerative colitis for about six weeks and symptom progression for one and a half weeks. The patient was treated with topical and oral 5-aminosalicylic acid (5-ASA) preparations and oral prednisolone. With an intensification of the prednisolone dose, administration of a monoclonal antibody (Vedolizumab) and antibiotic therapy, inpatient discharge against medical advice. Oral administration of ciprofloxacin due to continued elevated infection parameters. The 5-ASA administration was continued. In the following two weeks, recurrent episodes of fever and renewed inpatient admission. INVESTIGATIONS AND DIAGNOSIS: Microbiological detection of Acinetobacter ursingii in blood cultures. Echocardiographic evidence of pericardial effusion. Transesophageal echocardiography revealed no evidence of infective endocarditis. Serological evidence of elevated cardiac enzyme levels. An MRI scan of the heart confirmed the diagnosis of perimyocarditis. TREATMENT AND COURSE: Intensive medical care and resistogram-based antibiotic therapy with meropenem, stopping the topical and oral 5-ASA doses and not continuing the integrin antagonist therapy. In addition, start of guideline-based cardiac insufficiency therapy and change of therapy to a tumor necrosis factor alpha blocker. Under the accelerated application scheme, stabilization and improvement of the general condition protracted. After two months of hospitalization, the patient was discharged to outpatient care. DISCUSSION: Perimyocarditis may occur after long-term administration of 5-ASA. The integrin antagonist as a new therapy can also be a causal factor. Therapeutic management when the cause of the complaint is unclear depends on the symptoms and the most likely cause of the disease. If there is no response to therapy, carry out early re-evaluations.

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus.

Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure.

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.

The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations.

End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.

Interventricular mechanical dyssynchrony: quantification with velocity-encoded MR imaging.

PURPOSE: To evaluate the performance of velocity-encoded (VENC) magnetic resonance (MR) imaging, as compared with pulsed-wave echocardiography (PW-ECHO), in the quantification of interventricular mechanical dyssynchrony (IVMD) as a predictor of response to cardiac resynchronization therapy (CRT). MATERIALS AND METHODS: The study was approved by the local ethics committee, and all patients provided written informed consent. The study involved the examination of 45 patients (nine women, 36 men; median age, 60 years; interquartile age range, 47-69 years) with New York Heart Association class 2.0-3.0 heart failure and a reduced left ventricular ejection fraction (median, 25%; interquartile range, 21%-32%), with (n = 25) or without (n = 20) left bundle branch block. Aortic and pulmonary flow curves were constructed by using VENC MR imaging and PW-ECHO. IVMD was defined as the difference between the onset of aortic flow and the onset of pulmonary flow. Intraclass correlation coefficient, Spearman correlation coefficient, Bland-Altman, and Cohen kappa analyses were used to assess agreement between observers and methods. RESULTS: Inter- and intraobserver agreement regarding VENC MR imaging IVMD measurements was very good (intraclass r = 0.96, P < .001; mean bias, -3 msec +/- 11 [standard deviation] and 0 msec +/- 10, respectively). A strong correlation (Spearman r = 0.92, P < .001) and strong agreement (mean difference, -6 msec +/- 16) were found between VENC MR imaging and PW-ECHO in the quantification of IVMD. Agreement between VENC MR imaging and PW-ECHO in the identification of potential responders to CRT was excellent (Cohen kappa = 0.94). CONCLUSION: VENC MR measurements of IVMD are equivalent to PW-ECHO measurements and can be used to identify potential responders to CRT.

Detection of mechanical ventricular asynchrony by high temporal resolution cine MRI.

The purpose was to assess the feasibility of high temporal resolution cine MRI (HTRC-MRI) to detect and to quantify mechanical ventricular asynchrony in patients with left bundle branch block (LBBB). Inter- and intraventricular delays were quantified by HTRC-MRI in 32 patients with (n=17) and without (n=15) LBBB. In patients with LBBB, delays by HTRC-MRI were correlated with echocardiographic parameters using pulsed wave Doppler echocardiography (PW-Echo) and tissue Doppler imaging (TDI-Echo). The interventricular delay by HTRC-MRI was 110+/-50 ms in patients with and -1+/-18 ms in patients without LBBB (P<0.0001). The intraventricular delay was 336+/-86 ms in patients with compared to 40+/-49 ms in patients without LBBB (P<0.0001). A strong correlation (r=0.78, P=0.0002) and good agreement (mean difference: 39+/-36 ms) was found for the interventricular delay between HTRC-MRI and PW-Echo. A good correlation (r=0.66, P=0.0042), but a large discrepancy (mean difference: 257+/-64 ms) was found for the intraventricular delay between HTRC-MRI and TDI-Echo. Detection and quantification of mechanical ventricular asynchrony using HTRC-MRI is feasible. However, further comparison with other imaging modalities is required.