Coping, Mood, Quality of Life, and Outcomes in Recipients of Left Ventricular Assist Devices: A Cluster Analysis.

OBJECTIVE: Left ventricular assist devices (LVADs) are increasingly used for temporary circulatory support until transplant or as destination therapy for patients with end-stage heart failure. Understanding patients' attitudes and resources is crucial to support them. METHODS: Sixty-one LVAD recipients (55 [10] years, 10% women, 15% destination therapy) participating in cardiac rehabilitation (CR) postimplant underwent assessment of coping styles (Coping Orientation for Problem Experiences), quality of life (Medical Outcomes Study Short-Form 36, Minnesota Living with Heart Failure Questionnaire), and mood (Hospital Anxiety and Depression Scale). RESULTS: Cluster analysis identified two homogeneous groups: C1 (n = 18) patients had higher anxiety (9.6 [5.0] versus 4.0 [2.7], p < .001), depression (10 [3.0] versus 4 [2.7], p < .001), and avoidant coping (29 [5.2] versus 21.2 [3.8], p < .001) scores and worse quality of life (Short-Form 36 of the Medical Outcomes Study Physical Component Scale 31 [5.3] versus 35.6 [6.9], p < .001; Mental Component Scale 34.3 [6.8] versus 50.3 [8], p < .001; MLHFQ physical 26 [7.2] versus 13.9 [8.2], p < .001; emotional 17.7 [3.4] versus 3.86 [3.2], p < .001) than C2 participants (n = 43). During 31 (15-54) months, 20 patients (33%) died. By Cox multivariable analysis, after adjustment for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support level at surgery, and meters walked during 6 minutes at CR discharge, C1 was associated with mortality (hazard ratio = 2.858; 95% confidence interval = 1.102-7.408, p = .031; model χ = 7.286, df = 5, p = .20). Survival was 44% in C1 and 77% in C2 (log-rank p = .033). CONCLUSIONS: Among patients discharged from CR after LVAD implant, one third show a profile characterized by worse perceived quality of life, mood disorders, and dysfunctional coping that is associated with long-term mortality, and these factors are potential targets for post-LVAD intensive support.

Pilot Test of a New Personal Health System Integrating Environmental and Wearable Sensors for Telemonitoring and Care of Elderly People at Home (SMARTA Project).

BACKGROUND: The increase in life expectancy is accompanied by a growing number of elderly subjects affected by chronic comorbidities, a health issue which also implies important socioeconomic consequences. Shifting from hospital or community dwelling care towards a home personalized healthcare paradigm would promote active aging with a better quality of life, along with a reduction in healthcare-related costs. OBJECTIVE: The aim of the SMARTA project was to develop and test an innovative personal health system integrating standard sensors as well as innovative wearable and environmental sensors to allow home telemonitoring of vital parameters and detection of anomalies in daily activities, thus supporting active aging through remote healthcare. METHODS: A first phase of the project consisted in the definition of the health and environmental parameters to be monitored (electrocardiography and actigraphy, blood pressure and oxygen saturation, weight, ear temperature, glycemia, home interaction monitoring - water tap, refrigerator, and dishwasher), the feedbacks for the clinicians, and the reminders for the patients. It was followed by a technical feasibility analysis leading to an iterative process of prototype development, sensor integration, and testing. Once the prototype had reached an advanced stage of development, a group of 32 volunteers - including 15 healthy adult subjects, 13 elderly people with cardiac diseases, and 4 clinical operators - was recruited to test the system in a real home setting, in order to evaluate both technical reliability and user perception of the system in terms of effectiveness, usability, acceptance, and attractiveness. RESULTS: The testing in a real home setting showed a good perception of the SMARTA system and its functionalities both by the patients and by the clinicians, who appreciated the user interface and the clinical governance system. The moderate system reliability of 65-70% evidenced some technical issues, mainly related to sensor integration, while the patient's user interface showed excellent reliability (100%). CONCLUSIONS: Both elderly people and clinical operators considered the SMARTA system a promising and attractive tool for improving patients' healthcare while reducing related costs and preserving quality of life. However, the moderate reliability of the system should prompt further technical developments in terms of sensor integration and usability of the clinical operator's user interface.

Fingolimod effects on left ventricular function in multiple sclerosis.

BACKGROUND: Cardiovascular side effects such as bradycardia and atrioventricular block were observed during the early clinical trials of fingolimod in multiple sclerosis, and one cardiovascular- linked death has been reported in the post-marketing period. OBJECTIVE: To investigate the medium-term effects of fingolimod on heart function in order to obtain further insights into its cardiac safety profile. METHODS: The study involved 53 patients starting treatment with fingolimod 0.5 mg daily and 25 patients treated with natalizumab 300 mg monthly. Cardiac function was assessed by means of echocardiography at baseline (T0), and after one (T1), six (T6), and (in the case of the fingolimod group) 12 months (T12). RESULTS: Mean left ventricular ejection fraction significantly decreased and end-systolic volume increased from T0 to T1 (p=0.005) and T6 (p=0.0001) in the fingolimod but not the natalizumab group, although a slight increase was observed at T12. A similar decrease in ejection fraction was also observed after six months in nine patients switched from natalizumab to fingolimod. CONCLUSION: Fingolimod significantly reduces left ventricular systolic function in MS patients. This effect has no clinical consequences in subjects without previous cardiac disorders, but suggests that more caution is required in patients with current or previous heart failure.

Quality of life and emotional distress early after left ventricular assist device implant: a mixed-method study.

Patients who temporarily or permanently rely on left ventricular assist devices (LVADs) for end-stage heart failure face complex psychological, emotional, and relational problems. We conducted a mixed-method study to investigate quality of life, psychological symptoms, and emotional and cognitive reactions after LVAD implant. Twenty-six patients admitted to cardiac rehabilitation were administered quality of life questionnaires (Short Form 36 of the Medical Outcomes Study and Minnesota Living with Heart Failure Questionnaire), the Hospital Anxiety and Depression Scale, and the Coping Orientation for Problem Experiences inventory, and underwent three in-depth unstructured interviews within 2 months after LVAD implant. Quality of life assessment (Short Form 36) documented persistently low physical scores whereas mental component scores almost achieved normative values. Clinically relevant depression and anxiety were observed in 18 and 18% of patients, respectively; avoidant coping scores correlated significantly with both depression and anxiety (Pearson correlation coefficients 0.732, P < 0.001 and 0.764, P < 0.001, respectively). From qualitative interviews, factors that impacted on LVAD acceptance included: device type, disease experience during transplant waiting, nature of the assisted organ, quality of patient-doctor communication, the opportunity of sharing the experience, and recipient's psychological characteristics. Quality of life improves early after LVAD implant, but emotional distress may remain high. A multidimensional approach that takes into account patients' psychological characteristics should be pursued to enhance LVAD acceptance.

Evaluation of a textile-based wearable system for the electrocardiogram monitoring in cardiac patients.

AIMS: We developed a textile-based wearable system, named MagIC, for the unobtrusive monitoring of one electrocardiogram (ECG) lead, respiratory frequency and motion. In the present study, we investigated the ability of this system to monitor cardiac rhythm and arrhythmic events in cardiac patients. METHODS AND RESULTS: The study was carried out by comparing ECG tracings simultaneously recorded by MagIC and traditional ECG devices (Trad-ECG) in 40 cardiac patients at rest and during physical exercise. Data were manually scored by two cardiologists. At rest the artefact rates observed with MagIC and Trad-ECG were virtually identical (1.4% of the registered signal); while during physical exercise the artefact rate observed with MagIC was much lower than with Trad-ECG (4.07 vs. 17.31%). Recordings from MagIC allowed a correct identification of the type of rhythm in the vast majority of patients (92.5%) and an estimation of PQ interval and QRS duration similar to Trad-ECG (<0.016 s). MagIC displayed a good performance in detecting arrhythmias, with only 14 misclassified events out of 3618, and both specificity and sensitivity being above 99%. No practical difference was observed in the estimation of the beat-by-beat RR interval by the two methods. CONCLUSION: This study indicates that in static condition MagIC has a capability of monitoring cardiac rhythm and arrhythmic events which is comparable with what obtainable by a traditional one-lead ECG recorder. During movement MagIC provides an ECG signal of better quality.

Psychological profiles derived by cluster analysis of Minnesota Multiphasic Personality Inventory and long term clinical outcome after coronary artery by pass grafting.

BACKGROUND: To evaluate the psychological characteristics of coronary heart disease (CHD) patients after coronary artery bypass grafting (CABG) by cluster analysis of Minnesota Multiphasic Personality Inventory (MMPI-2) questionnaires and to assess the impact of the profiles obtained on long-term outcome. METHODS: 229 CHD patients admitted to cardiac rehabilitation filled in self-administered MMPI-2 questionnaires early after CABG. We assessed the relation between MMPI-2 profiles derived by cluster analysis, clinical characteristics and outcome at 3-year follow-up. RESULTS: Among the 215 patients (76% men, median age 66 years) with valid criteria in control scales, we identified 3 clusters (G) with homogenous psychological characteristics: G1 patients (N = 75) presented somatoform complaints but overall minimal psychological distress. G2 patients (N=72) presented type D personality traits. G3 subjects (N=68) showed a trend to cynicism, mild increases in anger, social introversion and hostility. Clusters overlapped for clinical characteristics such as smoking (G1 21%, G2 24%, G3 24%, p ns), previous myocardial infarction (G1 43%, G2 47%, G3 49% p ns), LV ejection fraction (G1 60 [51-60]; G2 58 [49-60]; G3 60 [55-60], p ns), 3-vessel-disease prevalence (G1 69%, G2 65%, G3 71%, p ns). Three-year event rates were comparable (G1 15%; G2 18%; G3 15%) and Kaplan-Meier curves overlapped among clusters (p ns). CONCLUSIONS: After CABG, the interpretation of MMPI-2 by cluster analysis is useful for the psychological and personological diagnosis to direct psychological assistance. Conversely, results from cluster analysis of MMPI-2 do not seem helpful to the clinician to predict long term outcome.

Cardiac deatH prevention by aUtomated defibrillatoRs in ChurcHes: rationale and design of the CHURCH trial.

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

Psychological disorders after coronary artery by-pass surgery: a one-year prospective study.

BACKGROUND: Coronary artery by-pass surgery (CABG) is often followed by anxiety and depression that require early identification in order to provide adequate psychological support. The predictive role of tests administered soon after CABG on long-term psychological outcomes has been only incompletely explored. AIM, DESIGN AND METHODS: Aim of this study was to assess post-operative and 12-month persistence of psychological disorders by means of the Minnesota Multiphasic Personality Inventory (MMPI-2) and the depression and state and trait anxiety scales of the Cognitive Behavioural Assessment (CBA-2.0) in 118 male patients admitted to cardiac rehabilitation after CABG. RESULTS: Early after CABG we observed a high prevalence of depression (11.8% by MMPI-2 and 12.7% by CBA) and state anxiety (23.5%). At 1-year the MMPI-2 scale D indicated stable mean score and high scores at entry were predictive of persistent depression. Conversely the CBA-2.0 scale QD score significantly decreased (from 3.86 +/- 3.19 to 2.91 +/- 3.45, p = 0.017). Also ST1 state anxiety significantly decreased (from 35.17 +/- 6.95 to 32.55 +/- 6.72, p = 0.003) whereas ST2 trait anxiety was stable. We found no association between psychometric results and ventricular function, number of grafts or time since diagnosis of coronary artery disease. CONCLUSIONS: State anxiety and depression by CBA significantly decreased 1-year after CABG; conversely trait anxiety and depression, investigated by MMPI-2, a more specific personality questionnaire, were stable. High scores for the depression in the scale D of MMPI-2 early after CABG seem to be predictive of the persistence of the disorder at 1-year.

Psychological Profile in Coronary Artery By-Pass Graft Patients vs. Valve Replacement Patients Entering Cardiac Rehabilitation after Surgery.

Anxiety and depression are thought to influence the genesis of ischemic diseases and not of valvular diseases, but little is known on the psychological profile of cardiac patients after surgery. Aim of this study was to investigate differences in disease experience and mood between patients undergoing cardiac rehabilitation after coronary artery by-pass graft (CABG) or after valve replacement (VR). We studied 1,179 CABG and 737 VR patients who completed the Illness Behaviour Questionnaire and the Hospital Anxiety and Depression Scale after surgery. We tested the independent effect of the type of surgery by multivariate analysis and between-group differences in prevalence of clinically relevant scores. Relevant scores in the psychosomatic concern scale were more frequent in CABG than in VR patients. After correction by age, sex, education and marital status, scores of disease conviction and psychosomatic concern were higher in CABG patients, scores of denial were higher in VR patients. Unexpectedly, anxiety and depression scores did not differ between groups. Results suggest providing psychological support for anxiety and depression to both VR and CABG patients during cardiac rehabilitation, and planning differentiated interventions of cardiac rehabilitation and secondary prevention tailored to the specific psychological reactions of CABG and VR patients.

Promotion of Home-Based Exercise Training as Secondary Prevention of Coronary Heart Disease: A PILOT WEB-BASED INTERVENTION.

BACKGROUND: Although cardiac rehabilitation (CR) is cost- effective in improving the health of patients with coronary heart disease (CHD), less than half of eligible CHD patients attend a CR program. Innovative web-based technologies might improve CR delivery and utilization. We assessed the feasibility and impact on functional capacity and secondary prevention targets of a long-term web-monitored exercise-based CR maintenance program. METHODS: Low- to moderate-risk CHD patients were recruited at discharge from inpatient CR after a coronary event or revascularization. We developed an interactive web-based platform for secure home individual access control, monitoring, and validation of exercise training. Of 86 eligible patients, 26 consented to participate in the study intervention (IG). Using a quasi-experimental design, we recruited in parallel 27 eligible patients, unavailable for regular web monitoring, who consented to a follow-up visit as usual care (UC). RESULTS: Among IG, active daily data transmission was 100% during month 1, 88% at month 3, and 81% at 6 months, with sustained improvement in self-reported physical activity beginning with the first week after discharge from inpatient CR (2467 [1854-3554] MET-min/wk) to month 3 (3411 [1981-5347] MET-min/wk, P = .019). Both groups showed favorable changes over time in lipid profile, ventricular function, distance walked in 6 min, and quality of life. At 6 mo, IG achieved a significantly higher proportion of cardiovascular risk factor targets than UC (75 ± 20% vs 59 ± 30%, P = .029). CONCLUSIONS: Our web-based home CR maintenance program was feasible, well-accepted, and effective in improving physical activity during 6 mo and achieved higher overall adherence to cardiovascular risk targets than UC.

Differences in biochemical markers between Heart-transplanted and Left Ventricular Assist Device implanted patients, during cardiac rehabilitation.

Heart transplant (HTx) and left ventricular assist device (LVAD) implant are the best options for symptomatic end stage heart failure, but LVAD patients show lower rehabilitative outcome than HTx patients. To investigate the causes, we compared biomarkers levels and their association with rehabilitative outcome in 51 HTx and in 46 LVAD patients entering the same cardiac rehabilitation program. In both groups, routine biomarkers were measured at start (T1) and end (T2) of cardiac rehabilitation while homocysteine, leptine and IGF-1 were measured at T1 only. HTx patients had lower lymphocyte, platelets, glucose, total proteins and albumin at T1; differences with LVAD patients vanished during rehabilitation when new cases of diabetes were observed in HTx. By contrast, total cholesterol, LDL and HDL fractions, leptin and IGF-1 were higher in HTx patients. The increase from T1 to T2 in six-minute walking test distance, measure of functional rehabilitation outcome, was positively associated with homocysteine and IGF-1 levels in HTx patients. In conclusion, during rehabilitation care should be paid to the early occurrence of dyslipidemia and hyperglycemia in HTx patients, which also require a proper protein dietary support. IGF-1, dangerously low in LVAD patients, might contribute to their lower rehabilitative outcome.

End-stage heart failure: Two surgical approaches with different rehabilitative outcomes.

BACKGROUND: A rising number of patients are surgically treated for heart failure at the more advanced stage, thanks to the increasing use of left ventricular assist device (LVAD) as a reliable alternative to heart transplantation (HTx). However, it is still unknown whether differences exist between the two surgical approaches in the efficacy of rehabilitation programmes. Therefore, aim of this study was to evaluate whether functional capacity and rehabilitative outcomes differ between HTx and implantation of LVAD. METHODS AND RESULTS: We enrolled 51 patients with HTx and 46 with LVAD upon admission to our rehabilitation-unit. We evaluated six-minute walking test (6MWT), resting oxygen saturation (SaO2) and nutritional assessment before and after a standardised cardiovascular rehabilitation programme. HTx and LVAD groups differed in age, anthropometric variables, gender distribution. Upon enrolment, 6MWT distance was similar in the two groups, whereas malnutrition was less frequent and the waist circumference/height ratio (WHtR) was greater in LVAD patients. SaO2 was greater in HTx patients. Rehabilitation improved SaO2, 6MWT distance and nutritional status. The difference in malnutrition disappeared, but WHtR remained higher in the LVAD and SaO2 higher in the HTx patients; the 6MWT distance improved more in the HTx patients. Multivariate linear regression analysis confirmed that the type of intervention was independent predictor of 6MWT distance after rehabilitation. CONCLUSIONS: HTx patients improve more rapidly and perform better after rehabilitation, suggesting the need for more tailored rehabilitation training for LVAD patients.

Osteopathic Manipulative Treatment Improves Heart Surgery Outcomes: A Randomized Controlled Trial.

BACKGROUND: Controlling sternal pain after heart surgery is important to reduce the risk of postoperative complications, but pain is often undertreated because of contraindications and side effects of analgesic drugs. Recently, osteopathic manipulative treatment (OMT) was demonstrated to reduce pain in different clinical contexts, suggesting its potential utility after cardiac surgery. The aim of this open-label, controlled study is to assess whether OMT contributes to sternal pain relief and improves postoperative outcomes. METHODS: Eighty post-sternotomy adult inpatients were randomly allocated one to one to receive a standardized cardiorespiratory rehabilitation program alone (control group) or combined with OMT. Pain intensity and respiratory functional capacity were quantified by the Visual Analogue Scale score and by a standardized breathing test, at the start and end of rehabilitation. RESULTS: At the start of rehabilitation, the control group and the OMT group had similar Visual Analogue Scale median scores (controls 4, interquartile range [IQR]: 2 to 5; OMT 4, IQR: 3 to 5; p = not significant) and mean inspiratory volumes (controls 825 ± 381 mL; OMT 744 ± 291 mL; p = not significant). At the end of rehabilitation, the OMT group had a lower Visual Analogue Scale median score (controls 3, IQR: 2 to 4; OMT 1, IQR: 1 to 2; p < 0.01) and higher mean inspiratory volume (controls 1,400 ± 588 mL; OMT 1,781 ± 633 mL; p < 0.01). The analgesic drug intake was similar in the two groups. The hospitalization was shorter in the OMT group than in the control group (19.1 ± 4.8 versus 21.7 ± 6.3 days; p < 0.05). CONCLUSIONS: The combination of standard care with OMT is effective in inducing pain relief and functional recovery, and significantly improves the management of patients after heart surgery with sternotomy.

Angiotensin-converting enzyme inhibitors slow recovery from anemia following cardiac surgery.

OBJECTIVES: Angiotensin-converting enzyme (ACE) inhibitors, which are frequently administered in patients with heart disease, have a known inhibitory effect on erythropoiesis. The aim of this study was to detect whether early ACE inhibitor administration slows recovery from anemia following recent cardiac surgery. METHODS AND RESULTS: Forty male patients with anemia (hemoglobin < 12 g/dL) an average of 9 days after cardiac surgery were randomized to receive enalapril (ACE inhibitor group) or not. All of the patients received ferrous sulfate, 525 mg, in addition to standard therapy. Patients with anemia due to other causes were excluded. Blood samples were obtained at baseline, and after 8 days, 16 days, and 60 days. A 6-min walking test and echocardioscan were performed at baseline, and after 16 days and 60 days of treatment, and a chest radiograph was obtained at baseline and after 60 days. The ACE inhibitor group showed a statistically significant lower increase in hemoglobin and RBC values. The peak between-group differences of 1 g/dL of hemoglobin (p = 0.012) and 444 RBCs per milliliter (p = 0.017) were observed on day 16. CONCLUSIONS: Early enalapril maleate administration in anemic patients after heart surgery significantly inhibits erythropoiesis. This unfavorable effect on anemia should be considered when prescribing ACE inhibitors for such patients.

[Referral to cardiac rehabilitation of patients with left ventricular assist devices in Italy]. / Ricoveri in riabilitazione cardiologica dei pazienti sottoposti ad impianto di assistenza ventricolare sinistra in Italia.

In recent years, the lack of heart donors caused an increase in the proportion of patients undergoing left ventricular assist device (LVAD) implantation. The clinical complexity of these devices requires a multidisciplinary approach to be extended after hospital discharge. The lack of shared care pathways for these patients may result in an impairment of both of short- and long-term results. Available data show that cardiac rehabilitation (CR) improves physical performance and quality of life. Notwithstanding this, there is a lack of information about its effects on mortality, hospitalizations and major complications. This article is a survey focus on the referral to CR facilities and the number and types of LVAD implanted in Italy. Among the 24 Italian cardiac surgery centers that have been contacted, 22 provided their data: from 2012 to 2014, 260 patients underwent LVAD implantation with an in-hospital post-surgical mortality of 10%, and 77% of patients were admitted to CR facilities. For patients with LVAD, a referral to an inpatient rehabilitation unit may be considered appropriate.

The negative prognostic synergism of anemia and heart disease in female nursing home residents.

This study assessed functional and cognitive status, hemoglobin, serum creatinine, and heart disease from chart reviews in 441 female nursing home residents (mean age 86.8 +/- 7.5 years) and correlated the findings with 1-year survival. Independent predictors of outcome were older age (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.13 to 2.73), Barthel index (HR 0.31, 95% CI 0.15 to 0.62), and the combined presence of anemia (hemoglobin < or =11 g/dl) and heart disease (HR 3.50, 95% CI 1.50 to 7.47). Survival rates were 92% in the reference group with neither anemia nor heart disease, 91% in anemic subjects without heart disease, 87% in nonanemic patients with heart disease, and 72% in women with the 2 conditions (p <0.001). Anemia is highly prevalent in this population and when present in subjects with heart disease determines a threefold increase in mortality risk.

[Coronary flow reserve assessment by transthoracic color Doppler echocardiography after primary angioplasty: relationship with recovery of left ventricular function]. / Valutazione della riserva di flusso coronarico mediante ecocardiografia color Doppler transtoracica in pazienti sottoposti ad angioplastica primaria: relazioni con il recupero della funzione ventricolare sinistra.

BACKGROUND: The aim of this study was to determine the relationship between coronary flow reserve measurement by transthoracic Doppler echocardiography in recent acute myocardial infarction treated with primary coronary angioplasty (PTCA) and recovery of left ventricular function. METHODS: Forty-one consecutive patients (3 patients excluded for not good quality of the Doppler signal) have been studied with: (1) recent first acute myocardial infarction treated with primary PTCA within 6 hours of pain onset; (2) optimal angioplasty result with stent deployment, anti-IIb/IIIa infusion and TIMI 3 flow; (3) lack of type 1 diabetes and/or hypertension; (4) good tolerance to adenosine. Transthoracic Doppler echocardiography was used to record coronary flow velocities in the distal left anterior descending and posterior descending coronary arteries at rest and after infusion of adenosine. Coronary flow reserve was measured after 11 +/- 1 days from the acute event. The wall motion score index (WMSI) was calculated at baseline, 1 month and 3 months from myocardial infarction. RESULTS: Patients of group A (n = 29 with coronary flow reserve > or = 1.6) showed a progressive and significant recovery of left ventricular function at follow-up. Patients of group B (n = 9 with coronary flow reserve < 1.6) had persistent left ventricular dysfunction at 3 months (ANOVA, p < 0.0001). WMSI was 1.64 +/- 0.26 in group A and 1.81 +/- 0.16 in group B (p = 0.09) at baseline; 1.30 +/- 0.26 in group A and 1.75 +/- 0.16 in group B (p < 0.0001) at 1 month; and 1.20 +/- 0.25 in group A and 1.73 +/- 0.17 in group B at 3 months. There was an inverse correlation between coronary flow reserve and WMSI at 1 month (r = -0.564, p < 0.0001), and at 3 months (r = -0.583, p < 0.0001). On multivariate analysis baseline WMSI and coronary flow reserve were the only predictors of 1-month WMSI recovery and of WMSI recovery at 3 months. CONCLUSIONS: Coronary flow reserve by transthoracic color Doppler echocardiography is a useful method for predicting left ventricular function recovery in patients after primary PTCA.

[Complexity of observable psychological distress after surgical myocardial revascularization in male subjects]. / Complessità dei disturbi psicologici osservabili dopo rivascolarizzazione miocardica chirurgica in soggetti di sesso maschile.

BACKGROUND: Psychological disturbances like anxiety, depression, post-traumatic stress disorder are often associated with coronary artery disease and, in some studies, play a prognostic role after a coronary event. Despite some psychological disturbances following coronary artery bypass graft (CABG) have an impact on outcomes of both the surgical intervention and the rehabilitation program, their complexity as well as their clinical and instrumental determinants are still not fully understood. The aim of this study was to determine in male subjects with coronary artery disease the prevalence and complexity of psychological disturbances occurring after CABG as well as their predictors. METHODS: One hundred eighteen males without history of psychological disturbances consecutively admitted to our rehabilitation inpatient service between September 2002 and September 2003 underwent 11 +/- 2 days after CABG extensive psychometric testing including the Minnesota Multiphasic Personality Inventory-2, the Cognitive Behavioral Assessment.2, and the Hamilton test. Cardiac evaluation included coronary risk factors, NYHA class, coronary heart disease history, medical therapy, CABG number, and echocardiography. RESULTS: Mean age 63.7 +/- 8.1 years; ejection fraction 54.6 +/- 10.3%; NYHA class I 92.4%, NYHA class II and III 7.6%; CABG number 1 (11%), 2 (23.7%), 3 (39.8%), 4 (21.8%), 5 (4.2%); coronary artery disease length 64 +/- 85 months, hospital stay 31.3 +/- 8 days. The score was above clinical cut-off on scale for depression in 16-39.8% of the patients, state anxiety in 27.1%, trauma in 16.1%, type A personality in 16.1%. Subjects above clinical cut-off for depression, anxiety and trauma did not differ from subjects below in terms of clinical and instrumental characteristics. Age, ejection fraction, coronary risk factors, coronary heart disease duration, and CABG number did not predict the development of depression, anxiety and trauma. Psychological disturbances often clustered in the same subjects. CONCLUSIONS: In males following CABG, psychological disturbances are extremely frequent, often clustered, and independent of subjects' characteristics and coronary heart disease severity.

[Resection of unusual atrial mass complicated with fungal endocarditis in a patient undergoing immunosuppressive treatment]. / Resezione di una neoformazione atriale rara complicata da endocardite fungina in paziente in terapia immunosoppressiva.

Nodules of mesothelial and monocytic cells (Mesothelial/Monocytic Incidental Cardiac Excresences; MICE) are rare cardiac lesions, non neoplastic, possibly reactive and in part derived from mesothelium. A 76 years old woman, treated with low dose of steroid and methotrexate for rheumatoid arthritis, underwent surgical excision of cardiac "MICE". Postoperative period was complicated with early and severe fungal endocarditis requiring reintervention. Two aspects are of interest: rarity of both cardiac pathologies and the possible relation to immunosuppressive therapy. Treatment of fungal endocarditis should be aggressive, overall survival is rather poor. Possibility to discontinue immunosuppressive treatment should be considered before cardiac surgery.