Fulminant myocarditis with dramatic response to corticoids.

A 47-year-old healthy man developed acute fulminant coxsackie BI myocarditis with cardiogenic shock and extreme elevation of NT-pro-BNP (82585 pg/ml). He had a dramatic and rapid improvement within the following days after administration of corticoids on top of dobutamine and classic treatment.

Uncommon acquired Gerbode defect (left ventricular to right atrial communication) following a tricuspid annuloplasty without concomitant mitral surgery.

Left ventricular (LV) to right atrial (RA) communication, also known as Gerbode defect, is very rare, usually congenital but sometimes also acquired. Cases of Gerbode defect have been reported after left valve surgery, usually valve replacement. We describe the first case of LV-RA communication following a tricuspid annuloplasty not combined to a left valve surgery. The case we report concerns a 73-year-old woman who underwent a double-valve surgery (pulmonary valve replacement and tricuspid annuloplasty) for symptomatic severe right heart failure due to post-endocarditis pulmonary valve regurgitation. A LV-RA shunt was discovered 1 year after surgery. This case report confirms the responsibility of a tricuspid annuloplasty in an acquired LV-RA shunt.

Bosentan decreases pulmonary vascular resistance and improves exercise capacity in acute hypoxia.

BACKGROUND: Altitude exposure is associated with mild pulmonary hypertension and decreased exercise capacity. We tested the hypothesis that pulmonary vascular resistance (PVR) contributes to decreased exercise capacity in hypoxic healthy subjects. METHODS: An incremental cycle ergometer cardiopulmonary exercise test and echocardiographic estimation of pulmonary artery pressure (Ppa) and cardiac output to calculate total PVR were performed in 11 healthy volunteers in normoxia and after 1 h of hypoxic breathing (12% O(2)). The measurements were performed in a random order at 1-week intervals after the receiving either a placebo or bosentan, following a double-blind randomized crossover design. Bosentan was administered twice a day for 3 days, 62.5 mg on the first day and 125 mg on the next 2 days. RESULTS: Hypoxic breathing decreased the mean (+/- SE) pulse oximetric saturation (Spo(2)) from 99 +/- 1% to 3 +/- 1% and increased the mean PVR from 5.6 +/- 0.3 to 7.2 +/- 0.5 mm Hg/L/min/m(2), together with a decrease in mean maximum O(2) uptake (Vo(2)max) from 47 +/- 2 to 35 +/- 2 mL/kg/min. Bosentan had no effect on normoxic measurements and did not affect hypoxic Spo(2), but decreased PVR to 5.6 +/- 0.3 mm Hg/L/min/m(2) (p < 0.01) and increased Vo(2)max to 39 +/- 2 mL/kg/min (p < 0.01) in hypoxia. Bosentan therapy, on average, restored 30% of the hypoxia-induced decrease in Vo(2)max. Bosentan-induced changes in Ppa and Vo(2)max were correlated (p = 0.01). CONCLUSIONS: We conclude that hypoxic pulmonary hypertension partially limits exercise capacity in healthy subjects, and that bosentan therapy can prevent it.

Acquired coronary fistula after left ventricular de-airing by apical needle aspiration.

Acquired coronary fistula is uncommon, but has been reported to occur after several surgical procedures, acute myocardial infarction, endomyocardial biopsy, coronary angioplasty, and thoracic trauma. We describe the occurrence of a left coronary to left ventricular cavity fistula following resection of a left atrial myxoma, with spontaneous closure in the following weeks. The fistula was likely caused by a needle inserted into the left ventricular apex, a procedure routinely used to ensure left ventricular de-airing.

Prognosis of patients with systemic rheumatic diseases admitted to the intensive care unit.

OBJECTIVE: To determine prognostic factors in patients with systemic rheumatic diseases admitted to the intensive care unit (ICU) and to examine whether the observed mortality rate is predicted using the Acute Physiology And Chronic Health Assessment II (APACHE II) score. DESIGN AND SETTING: Retrospective study with historical controls in a 31-bed medicosurgical ICU at a university hospital. PATIENTS AND PARTICIPANTS: Seventy-one patients admitted to the ICU for an acute illness related to a systemic rheumatic disease and/or its treatment and 353 ICU control patients. RESULTS: Systemic rheumatic diseases were mainly rheumatoid arthritis and vasculitides. In-hospital mortality rate was 28/71 (39%), including 23 patients who died in the ICU. Multivariable logistic regression showed that poor prior health status (Berdit's classification), APACHE II score, and admission for infection were associated with mortality, whereas prior use of immunosuppressive agents was not. APACHE II score at admission was higher in nonsurvivors (22+/-9) than in survivors (17+/-5) (p<0.01). The standard mortality ratio, i.e., the ratio between observed and predicted mortality, was 1.7 in the 71 study patients and 1.0 in the 353 control patients (p<0.0001). CONCLUSIONS: In patients with systemic rheumatic diseases admitted to the ICU for at least 48 h, poor prior chronic health status, APACHE II score, and infection were prognostic factors for in-hospital mortality. SMR was higher than in a control ICU population.