Postoperative Takotsubo cardiomyopathy triggered by intraoperative fluid overload and acute hypertensive crisis.

The Takotsubo cardiomyopathy is a rare haemodynamic dysfunction, only recently reported perioperatively. While the diagnostic criteria have been established and the outcome is known as favorable, the pathophysiological mechanisms are not entirely understood. Here we present the case of a patient scheduled for laparoscopic hysterectomy and adnexectomy, who early postoperatively developed a Takotsubo cardiomyopathy supposedly triggered by an acute hypertensive crisis due to intraoperative fluid overload.

Placement Of A Coronary Sinus Pacing Lead From A Sub-occluded Left Subclavian Vein Using A Collateral Vein To The Right Subclavian Vein.

Upgrading of a pacing system in the presence of a subclavian occlusion is technically challenging. We describe the case of a patient who underwent a successful upgrading procedure of an implantable cardioverter-defibrillator (ICD) to a biventricular defibrillator (ICD-CRT) in the presence of a suboccluded left subclavian vein, using a collateral vein that drained into the contralateral subclavian vein.

Effects of n-3 polyunsaturated fatty acids on malignant ventricular arrhythmias in patients with chronic heart failure and implantable cardioverter-defibrillators: A substudy of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza Cardiaca (GISSI-HF) trial.

BACKGROUND: The antiarrhythmic effects of n-3 polyunsaturated fatty acids (n-3PUFA) in ischemic heart disease have been demonstrated; however, studies in patients surviving malignant ventricular arrhythmias of different etiologies treated with an implantable cardioverter-defibrillator (ICD) have given conflicting results. The purpose of this study was to assess the antiarrhythmic effect of n-3PUFA versus placebo in 566 patients with heart failure enrolled in the GISSI-HF trial who received an ICD for secondary or primary prevention of ventricular fibrillation (VF) or tachycardia (VT). METHODS: Clinical data and arrhythmic event recordings extracted from the device memory were obtained. We tested the treatment effect by a multivariate Cox model adjusting for all clinical parameters associated with the primary end point defined as time to first appropriate ICD discharge for VT/VF. RESULTS: In the 566 patients with at least one recorded follow-up visit, 1363 VT and 316 VF episodes were terminated by ICD pacing or shock over a median follow-up of 928 days. The incidence of the primary end point event was 27.3% in the n-3PUFA group and 34.0% in the placebo group (adjusted hazard rate = 0.80, 95% CI 0.59-1.09, P = .152). Patients who received 1, 2 to 3, or >3 ICD discharges were 8.9%, 7.1%, and 11.1% in the n-3PUFA group, compared with slightly higher rates of 11.1%, 10.7%, and 12.1% in the placebo group (overall P = .30). Patients with the highest 3-month increase in plasma n-3PUFA had a somewhat lower incidence of arrhythmic events. CONCLUSIONS: The results of this study, though not statistically significant, support prior evidences of an antiarrhythmic effect of n-3PUFA in patients with ICD, although they leave open the issue of whether this effect leads to a survival benefit.

Homologous in vitro fertilization in Turner syndrome: insights from a case report.

OBJECTIVE: To describe a bigeminal pregnancy obtained with a homologous intracytoplasmic sperm injection cycle in a patient with high-grade mosaic Turner syndrome (45,XO/47,XXX 97.5%/2.5%) with bicuspid aortic valve. DESIGN: Case report. SETTING: Unit of Pathophysiology of Human Reproduction in a general hospital. PATIENT(S): Patient with mosaic Turner syndrome with bicuspid aortic valve. INTERVENTION(S): Homologous intracytoplasmic sperm injection cycle after controlled ovarian hyperstimulation with a GnRH agonist flare-up depot protocol and menotropins. MAIN OUTCOME MEASURE(S): Pregnancy development, echocardiographic monitoring of aortic root, karyotypes of progeny. RESULT(S): Ongoing bigeminal pregnancy with the delivery of two healthy infants (46,XX and 46,XY, respectively) by cesarean section without any cardiovascular complication or aortic root echocardiographic modification in the mother. CONCLUSION(S): Even in patients with Turner syndrome with high-grade 45,XO mosaicism and reduced ovarian reserve, a trial of homologous reproduction should be offered after a thorough cardiologic evaluation to avoid pregnancy-related cardiovascular complications.

Coffee consumption and risk of cardiovascular events after acute myocardial infarction: results from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico)-Prevenzione trial.

BACKGROUND: The relation between coffee consumption and cardiovascular disease has been studied extensively, but results are still debated. In addition, little evidence is available on patients with established coronary heart disease. METHODS AND RESULTS: Prospectively ascertained information among 11,231 Italian patients (9584 males and 1647 females) with recent (< or = 3 months) myocardial infarction enrolled in the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico)-Prevenzione trial was used. Usual dietary habits were assessed at baseline and updated at 0.5 and 1.5 years. Coffee consumption was categorized as never/almost never, < 2 cups per day, 2 to 4 cups per day, and > 4 cups per day. Medication use and fasting glucose were assessed at 0.5, 1, 1.5, 2.5, and 3.5 years. Risk was evaluated with Cox proportional hazards with time-varying covariates. The main outcome measure was the cumulative incidence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke). A total of 1167 cardiovascular events occurred during 36,961 person-years of follow-up. After multivariable adjustment for potential confounders in the time-dependent analysis, the relative risk of cardiovascular events across categories of coffee consumption was 1.02 (95% CI 0.87 to 1.20) for < 2 cups per day, 0.91 (95% CI 0.75 to 1.09) for 2 to 4 cups per day, and 0.88 (95% CI 0.64 to 1.20) for > 4 cups per day compared with abstainers (P for trend=0.18). Ultimately, coffee consumption did not change the risk of coronary heart disease events, stroke, and sudden death. CONCLUSIONS: No association between moderate coffee intake and cardiovascular events was observed in post-myocardial infarction patients.

Dynamic Left Ventricular Outflow Tract Obstruction During Myocardial Ischemia in Mitral Valve Prolapse Syndrome.

Systolic anterior motion of the mitral valve (MV) with dynamic left ventricular (LV) outflow tract obstruction is a well known phenomenon in hypertrophic cardiomyopathy, or other forms of hyperdynamic LV function associated with hypovolemic states, or LV hypertrophy. We report three patients with MV prolapse in the absence of the above predisposing factors, who developed an LV outflow dynamic gradient during acute transient myocardial ischemia. An interaction between structural abnormalities of the mitral apparatus and ischemia-dependent LV shape deformity most likely accounted for the outflow gradient.

Modifications of Oxygen Saturation During Transesophageal Echocardiography.

The present study was designed: (1) to establish the effects of transesophageal echocardiography (TEE) on arterial oxygen saturation (SAO(2)%); (2) to verify the possible clinical consequences of this phenomenon; and (3) to study the possibility of predicting modifications of SAO(2)% by clinical or hemodynamic variables or by specific factors related to the TEE procedure. We prospectively studied 116 unselected patients, aged 61 +/- 12 years, who underwent diagnostic TEE for various clinical indications. Thirty-seven patients had mitral valve disease, 19 aortic valve disease, 14 combined mitroaortic disease, 8 congenital heart disease, and 38 other cardiovascular diseases. Eight patients were affected by chronic obstructive pulmonary disease. Ninety-seven patients were sedated by 4 +/- 2 mg of diazepam IV SAO(2)% (5-min average) (Ohmeda Biox 3700 pulse oxymeter finger probe), heart rate (HR), and blood pressure (BP) were considered during baseline transthoracic examination, after pharmacological sedation but before the introduction of the probe, and finally during TEE. Neither clinical complications nor major arrhythmias were observed. Baseline SAO(2)%, HR and BP were, respectively, 93.6 +/- 3.3%, 76 +/- 14 beats/min, and 129 +/- 20/75 +/- 10 mmHg. Pharmacological sedation did not modify SAO(2)%, HR, and BP (P > 0.1). During TEE a small but significant reduction in SAO(2)% by an average of 1.2 +/- 3.2% was observed (P < 0.005), as well as a small and significant increase in HR by an average of 3 +/- 10 beats/min (P < 0.01). BP did not change significantly (P > 0.1 for both systolic and diastolic). The changes of SAO(2)% and HR were not interrelated and were not related to the duration of the procedure and to any of the clinical and hemodynamic variables taken into consideration. TEE can induce a small but significant drop in SAO(2)% and a small increase in HR even without any clinical relevance. No clinical or hemodynamic variable or specific factors related to the TEE procedure were related to these changes.