Impact of cardiac resynchronization therapy on the severity of mitral regurgitation.

AIMS: Functional mitral regurgitation (MR) could be managed by both cardiac resynchronization therapy (CRT) and mitral-valve surgery. Clinical decision making regarding the appropriateness of mitral-valve surgery vs. CRT is a challenging task. This study assessed the prevalence and prognosis of various degrees of functional MR in CRT candidates. Additionally, we sought to identify functional MR patients who either can be adequately managed by CRT only or will need surgery. METHODS AND RESULTS: Cardiac resynchronization therapy recipients (n= 794) were followed-up for 26 ± 18 months. Mitral regurgitation severity was quantified on scale 0-4. Cardiac resynchronization therapy responders were identified based on improvement in the New York Heart Association class and left-ventricular ejection fraction. Severity of MR and LV reverse remodelling were assessed at 3 and 12 months. Predictors of long-term MR change and CRT response were explored with multivariable models. Mitral regurgitation was present in 86%, with 35% prevalence of advanced MR (grade 3-4). Improvement of MR ≥ 1° after 12 months occurred in 46% of patients. It was relatively more frequent in patients with advanced MR at baseline (63%, P< 0.01). Baseline MR severity and change in MR at 3-month follow-up predicted response to CRT. Patients with ≥ 1° MR improvement at 12 months had more reverse remodelling compared with those with no change or worsening of MR. CONCLUSIONS: Mitral regurgitation improvement at 3 months predicts CRT response and MR improvement at 12-month follow-up. This finding could have implications for subsequent MR surgical therapies.

ß-blockade with nebivolol for prevention of acute ischaemic events in elderly patients with heart failure.

OBJECTIVES: This subanalysis of the Study of the Effects of Nebivolol Intervention on Outcomes and Hospitalisation in Seniors with Heart Failure (SENIORS) investigates whether treatment with nebivolol, a ß-blocker with nitric oxide-releasing properties, can provide additional benefits besides its effects on heart failure (HF), by reducing cardiac ischaemic events in patients with HF of ischaemic aetiology. DESIGN: A double-blind, randomised, placebo-controlled, multicentre trial of nebivolol in 2128 elderly patients. PATIENTS AND INTERVENTIONS: For this analysis, data were extracted for 2128 elderly (≥ 70 years) HF patients in whom coronary artery disease (CAD) was the underlying aetiology (68.2%; 717 placebo-treated patients and 735 assigned to nebivolol). MAIN OUTCOME MEASURES: The main endpoint was the composite of cardiac ischaemic events at 2 year follow-up: death/hospitalisation for myocardial infarction, unstable angina or sudden death, as originally identified in the case report form. RESULTS: At follow-up, nebivolol treatment was associated with a one-third reduction in the risk of ischaemic events, the composite endpoint occurring in 15.9% of placebo and 10.7% of nebivolol-treated patients (HR 0.68; 95% CI 0.51 to 0.90; p=0.008). This effect was independent of age, gender and ejection fraction. No difference in this composite endpoint was observed in the subgroup of patients of non-ischaemic aetiology. CONCLUSIONS: Nebivolol was effective in reducing cardiac ischaemic events in patients with HF of ischaemic aetiology. The prevention of ischaemic events can be an additional beneficial effect of ß-blockade in HF patients with underlying CAD.

Accuracy and usefulness of fusion imaging between three-dimensional coronary sinus and coronary veins computed tomographic images with projection images obtained using fluoroscopy.

AIMS: Coronary sinus (CS) and coronary veins are not delineated by fluoroscopy. The study evaluates the feasibility and accuracy of cardiac tomography (CT) image registration of CS anatomy on fluoroscopic image. METHODS AND RESULTS: Eighteen consecutive patients underwent contrast-enhanced, ECG-gated CT scanning. Coronary sinus, coronary veins, superior vena cava, the distal portion of the trachea, and of the two main bronchi were reconstructed. These images were then fused over the CS fluoroscopic angiogram. Registration accuracy was verified by assessing the overlap of CS borders both in the CT- and in the fluoroscopy-derived images. The mean distance between the centrelines of the CS was 0.73 mm, with a maximum distance of 2.22 mm. For the first-order branches, mean distance was 0.80 mm with a maximum distance of 2.64 mm. High Lin concordance correlation coefficients were computed (>0.95) for the CS and first-order branch diameters, although the Bland and Altman limits were large. The agreement between the number of vessels identified was moderate with kappa = 0.43. CONCLUSION: Fusion imaging processing of two different imaging modalities (CT and fluoroscopy) may be feasible and accurate for guiding CRT implantation as it allows constant comprehensive display of CS body and branches. Prospective studies are needed for assessing clinical implications.

Endogenous ethanol production in a patient with chronic intestinal pseudo-obstruction and small intestinal bacterial overgrowth.

The case of the gastrointestinal production of ethanol from Candida albicans and Saccharomyces cerevisiae in a Caucasian man with chronic intestinal pseudo-obstruction is reported. The patient, who declared to have always abstained from alcohol, was hospitalized for abdominal pain, belching and mental confusion. The laboratory findings showed the presence of ethanol in the blood. Gastric juice and faecal microbiological cultures were positive for C. albicans and S. cerevisiae. At home, he was on oral antibiotic therapy with amoxicillin plus clavulanic acid for a small bowel bacterial overgrowth, associated with a simple sugar-rich diet. Twenty-four hours after stopping both the antibiotic therapy and the simple sugar-rich diet, the blood ethanol disappeared. A provocative test, performed by giving amoxicillin plus clavulanic acid associated with the simple sugar-rich diet was followed by the reappearance of ethanol in the blood. A review of the literature is reported.

Efficacy of lamivudine therapy for advanced liver disease in patients with precore mutant hepatitis B virus infection awaiting liver transplantation.

BACKGROUND: Orthotopic liver transplantation (OLT) for end-stage liver disease resulting from hepatitis B virus (HBV) infection is associated with a high rate of recurrence and reduced survival. Lamivudine is effective in inhibiting HBV replication in patients with chronic hepatitis. This study evaluated the impact of lamivudine on viral suppression, liver function, and disease severity in patients awaiting OLT with HBV e-minus strain infection. METHODS: Twenty-five patients received lamivudine (100 mg per day) from the day of listing for OLT. All patients were positive for serum HBV-DNA by polymerase chain reaction and all had a Child-Pugh score of 7 or higher. RESULTS: Patients were followed for 12+/-9 months (mean +/- SD). Eleven underwent OLT within 13 months of treatment initiation, one died after 10 months, and one dropped out after 3 months. After 3, 6, and 9 months, HBV-DNA by polymerase chain reaction was undetectable in 14 of 25, 14 of 20, and 13 of 15 patients, respectively. Two patients developed lamivudine resistance after 9 and 18 months of treatment, respectively, without liver decompensation. Comparing baseline to last visit data, a significant improvement in prothrombin activity (43+/-15% vs. 52+/-19%; P=0.0014), serum bilirubin (3.4+/-1.9 vs. 2.5+/-2.2 mg/dL; P=0.0007), serum albumin (3.3+/-0.3 vs. 3.6+/-0.5 g/dL; P=0.0278), presence of ascites (15/25 vs. 7/25; P=0.0047), and Child-Pugh score (9 vs. 8; P=0.0003) was observed. Because of liver function improvement, four patients were placed on low priority status for OLT (United Network of Organ Sharing 3) and 9 on inactive status (United Network of Organ Sharing 7). The overall probability of survival at 6 and 12 months was 100% and 90.9%, respectively. CONCLUSIONS: Lamivudine has an important role in patients with end-stage liver disease caused by HBV precore mutant strain. Not only does HBV-DNA suppression allow patients to be eligible for OLT, but the improvement of the patients' clinical status may delay the need for OLT in an era of organ shortage.