Blood Transfusion Components Inducing Severe Allergic Reactions: The First Case of Kounis Syndrome Induced by Platelet Transfusion

Kounis syndrome is a multisystem and multidisciplinary disease affecting the circulatory system that can be manifested as spasm and thrombosis. It can occur as allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions associated with the release of inflammatory mediators from mast cells and from other interrelated and interacting inflammatory cells, including macrophages and lymphocytes. A platelet subset with high- and low-affinity IgE surface receptors is also involved in this process. Whereas the heart, and particularly the coronary arteries, constitute the primary targets of inflammatory mediators, the mesenteric, cerebral, and peripheral arteries are also vulnerable. Kounis syndrome is caused by a variety of factors, including drugs, foods, environmental exposure, clinical conditions, stent implantation, and vaccines. We report a unique case of a 60-year-old male with a past medical history of allergy to human albumin, alcoholic cirrhosis, and esophageal varices, who was admitted due to multiple episodes of hematemesis. Due to low hemoglobin levels, he was transfused with 3 units of red blood cells and fresh frozen plasma without any adverse reactions. On the third day of hospitalization, severe thrombocytopenia was observed and transfusion of platelets was initiated. Immediately following platelet infusion, the patient developed chest discomfort, skin signs of severe allergic reaction, and hemodynamic instability. The electrocardiogram revealed ST segment elevation in the inferior leads. Given the strong suspicion of Kounis syndrome/allergic coronary spasm, the patient was treated with anti-allergic treatment only, without any anti-platelet therapy. The clinical status of the patient gradually improved and the electrocardiographic changes reverted to normal. Based on these findings, Kounis hypersensitivity-associated acute coronary syndrome, specifically, type I Kounis syndrome, was diagnosed. Although platelet transfusion can be a life-saving therapy, each blood transfusion carries a substantial risk of adverse reactions. The aims of this report are to expand the existing knowledge of patient responses to blood transfusion and provide information on the incidence of various severe transfusion reactions to all blood components and especially to platelets. To the best of our knowledge, Kounis syndrome induced by platelet transfusionhas never been previously reported. Hypersensitivity to platelet external membrane glycoproteins in an atopic patient seems to be the possible etiology. Despite that Kounis syndrome remains an under-diagnosed clinical entity in everyday practice, it should always be considered in the differential diagnosis of acute coronary syndromes.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Use of a novel handheld ultrasound device with continuous-wave doppler capability for the assessment of valvular heart disease

Background/Introduction

Echocardiography is the primary non-invasive imaging method for the diagnosis and evaluation of valvular heart disease. Doppler echocardiography provides accurate non-invasive evaluation of valve hemodynamics. Recent technological advancements have enabled the acquisition of echocardiographic images at the point-of-care by using small handheld ultrasound devices (HUDs); their availability and relatively low cost compared to the high-end systems have made these devices attractive to use for rapid medical decision making. However, the inability to quantify flow velocity has been a major limitation for HUDs; the lack of spectral Doppler capability has so far hindered the comprehensive assessment of haemodynamic data and valve function.

Purpose

To evaluate for the first time the accuracy of a novel HUD with continuous-wave (CW) Doppler capability to measure flow velocity in valvular heart disease.

Methods

We prospectively included 56 consecutive patients who were referred to the echocardiography laboratory of a tertiary hospital. All patients were scanned with both the Kosmos HUD and the standard echocardiography cart-based system (reference standard) in a randomized order. CW Doppler measurements of maximum velocities (Vmax) were obtained from the apical five-chamber view for the aortic ejection and regurgitation and from the apical four-chamber view for the mitral and tricuspid regurgitation (presence assessed by colour Doppler), maintaining a parallel orientation between the ultrasound beam and the blood flow. All measurements were compared to assess inter-method agreement using linear regression and Bland-Altman analysis.

Results

The acquisition of CW Doppler signal using the HUD was feasible in 55 out of 56 patients (mean age 66±16 years old, 40% female). Among them, there were 31 cases of (at least mild) aortic stenosis and 23 cases of valvular regurgitation (4 aortic, 6 mitral and 13 tricuspid regurgitations). There was excellent correlation between the HUD and the cart-based system CW Doppler for the aortic Vmax measurements (r=0.99, p<0.001) and for the valvular regurgitation Vmax measurements (r=0.98, p<0.001). The corresponding Bland-Altman plots showed a small underestimation bias of −0.13 m/sec (p<0.001), with limits of agreement ±0.41 m/sec for the aortic Vmax and −0.21 m/sec (p=0.003), with limits of agreement ±0.57 m/sec for the valvular regurgitation Vmax measurements.

Conclusion

A novel HUD with CW Doppler spectral analysis was able to provide peak jet velocity measurements comparable to the standard cart-based echocardiography systems, in patients with valvular stenosis and regurgitation. Such expanded capabilities of HUDs show clinical potential and may lead to the improvement of the assessment of valvular pathology at the point-of-care.

Funding Acknowledgement

Type of funding sources: None.

A Novel Handheld Echocardiography Device with Continuous-Wave Doppler Capability: Implications for the Evaluation of Aortic Stenosis Severity

BACKGROUND

The aim of this study was to evaluate the ability of a novel handheld echocardiography (HHE) device with continuous-wave Doppler (CWD) capability to measure peak aortic valve jet velocity (Vmax) and facilitate aortic stenosis (AS) severity grading.

METHODS

We prospectively included 121 consecutive patients with known or suspected AS. All patients were scanned with the HHE and the high-end echocardiography system (reference standard) in order to obtain CWD signal across the aortic valve. The aortic Vmax measurements were acquired from the apical 5-chamber view by both methods and were compared to assess method agreement using intra-class correlation coefficient (ICC), linear regression analysis and Bland-Altman analysis. The diagnostic accuracy for the detection of at least moderate AS (Vmax≥3 m/s) was calculated. Also, the utility of HHE with CWD to reclassify patients compared to the visual estimation of AS severity was assessed.

RESULTS

The acquisition of CWD signal using HHE was feasible in 118 out of 121 patients (mean age 68±17years old, 57% male). There was excellent agreement between the HHE CWD and the cart-based measurements (ICC=0.97; 95%CI 0.83-0.99 and r=0.98; 95%CI 0.91-0.99, p<0.001 for both). The Bland-Altman plot showed a small underestimation bias of -0.2 m/s (p<0.001), with limits of agreement ±0.44 m/s for the Vmax. Detection of at least moderate AS using the HHE with CWD was feasible with sensitivity 93% (95%CI 83%-98%), specificity 98% (95%CI 91%-100%), PPV 98% (95%CI 88%-100%), NPV 94% (95%CI 85%-97%) and a total diagnostic accuracy of 96%.The patients visually assessed as mild AS cases were reclassified as no stenosis (17%), mild (72%) and moderate (11%) AS with the addition of CWD imaging.

CONCLUSION

Use of a novel HHE device with CWD spectral analysis by experienced operators can reliably detect clinically significant AS and facilitate AS grading. This technology may improve screening and diagnostic workup of AS compared to current practice.

Left Distal Radial Artery Access for Coronary Angiography and Interventions: A 12-Month All-Comers Study

BACKGROUND

Interventional cardiologists prefer the right radial artery (RA) approach for coronary angiography and interventions, mainly for ergonomic reasons. However, the use of the left RA presents certain advantages, and the snuffbox approach has further potential advantages, including lower probability for RA occlusion, avoidance of direct puncture of the RA (thus maintaining its suitability for use as a graft), as well as easier and faster hemostasis.

METHODS

Consecutive patients scheduled for coronary catheterization were included, using the left distal RA (ldRA) in the anatomical snuffbox as the default vascular access site.

RESULTS

Out of 2034 consecutive cases, the ldRA was used as initial vascular access in 1977 patients (97.2%). The procedural failure rate was 9.9% (21.9% inability to puncture the artery, 75.0% inability to advance the wire, 3.1% other reasons). There was a sharp decrease in failure rate after about the first 200 cases (20.8% in the first decile vs 8.7% throughout the rest of the caseload; P<.001). No or very weak palpable pulse was the most important predictor of failure (odds ratio, 16.0; 95% confidence interval, 11.2-23.1; P<.001), in addition to older age, small stature, and female gender (although, after adjustment for height, the latter was no longer significant).

CONCLUSION

In a large series of consecutive patients scheduled for left heart catheterization, through a period of 12 months, with virtually no exclusions except those few imposed by anatomy or compelling clinical needs, the ldRA arterial access approach was shown to be highly effective, feasible, and safe.

Association between excessive supraventricular ectopic activity and future diagnosis of atrial fibrillation in patients with cryptogenic stroke

Funding Acknowledgements

Type of funding sources: None.

Background

The relationship between the excessive supraventricular ectopic activity (ESVEA) and the subclinical atrial fibrillation (AF) in patients with cryptogenic stroke is yet not fully understood.

Purpose

The aim of this study is to examine the prognostic significance of ESVEA for the development of AF in those patients.

Methods

The study retrospectively included 124patients, hospitalized for a cryptogenic stroke between 2014 and 2015. Twenty-four hour inpatient Holter monitoring, was used to define ESVEA as the presence of ≥20 premature atrial complexes per hour (PACs/h), along with a duration of the longest run of supraventricular tachycardia (LSVR) ≥5 seconds. After approximately 5 years of follow-up, the patients were examined for AF.

Results

The remaining 111 patients(12 died and 1 was lost during follow-up) had a median age of 56 and 13 (11.71%) of them were diagnosed with AF (AF patients). The median value of CHA2DS2-VASc score was 3 and was similar for the two groups (p=0.252). Patients with AF had a significantly higher number of PACs/h and a longer duration of LSVR compared to nonAF patients (16.67 vs. 0.21, p&lt;0.001 and 3 vs. 0 seconds, p&lt;0.001, respectively). The existence of ESVEA was also significantly more prevalent among the AF patients (46.15%, 95% CI: 17.78% - 74.22%) compared to non-AF ones (6.1%, 95% CI: 1.3% - 10.7%, p&lt;0.001). ROC analysis revealed the high diagnostic test accuracy of both PACs/h and LSVR for AF. The area under the curve was 97.2% (p&lt;0.001) for PACs/h and 81.1% (p&lt;0.001) for LSVR.

Conclusions

Excessive atrial ectopy, detected with 24h inpatient Holter monitoring, is a significant indicator of future development of AF, in patients presenting originally with a cryptogenic stroke.

Use of artificial intelligence for real-time automatic quantification of left ventricular ejection fraction by a novel handheld ultrasound device

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Hellenic Society of Cardiology

Background/Introduction: Transthoracic echocardiography is the most widely used imaging modality for the assessment of left ventricular ejection fraction (LVEF), which is crucial for patient care and management. Most recently, artificial intelligence (AI) has been employed to automatically identify LV endocardial boundaries and calculate LVEF. Technological advancements have enabled the development of small handheld ultrasound devices (HUDs) that can provide echocardiographic images at the point of care; however until now the HUDs have presented limited quantification capabilities. The application of AI algorithms to point-of-care echocardiography may facilitate the acquisition and accurate interpretation of a high volume of imaging data in real-time.

Purpose

To evaluate the accuracy of a novel HUD with AI-assisted algorithm (autoEF) to automatically calculate LVEF.

Methods

 We prospectively included consecutive patients who were referred to a tertiary hospital echocardiography laboratory for a standard echocardiography examination. The modified biplane Simpson’s method was used to determine LV volumes and function from the apical four-chamber and apical two-chamber views. All patients were subsequently scanned with the Kosmos HUD and a fully automated estimation of the LVEF was possible after acquisition of the same two apical views within seconds by the device itself with the use of the AI-assisted autoEF algorithm. The image quality for each examination was assessed and classified as good, moderate and poor. The autoEF measurements were compared head-to-head with the manually traced biplane Simpson’s rule measurements on cart-based systems as the reference standard, using linear regression and Bland-Altman analysis.

Results

The study comprised 100 consecutive patients (57 ± 15 years old, 61% male), including 38 patients with abnormal LVEF &lt; 50%. The image quality for the cart-based systems acquisition was assessed as good in 45%, moderate in 50% and poor in 5% of patients and for the HUD acquisition as good in 31%, moderate in 57% and poor in 12% of patients. AutoEF measurement by AI-assisted algorithm was feasible in all patients with LVEF measurements on cart-based systems. There was good agreement between the reference standard and Kosmos autoEF algorithm with a correlation coefficient r = 0.87, 95%CI 0.81-0.91, (p &lt; 0.0001). The corresponding Bland-Altman plot showed a small non-significant bias of -1.42% (p = 0.058), with limits of agreement ±14.5% for the auto-EF. The paired comparison of the LVEF calculation by the 2 methods did not reveal a significant difference between reference standard and HUD autoEF [56% (IQR 40% - 62%) vs 53% (IQR 43% - 59%) respectively, p = 0.106].

Conclusion

The AI-assisted autoEF algorithm in a novel HUD can accurately calculate LVEF in real-time as compared to the recommended manual biplane Simpson’s method on cart-based systems in an "all-comers" patient population. Abstract Figure. Correlation plot for LVEF measurements  Abstract Figure. Bland-Altman plot

Handheld ultrasound device with continuous-wave doppler capability: is it feasible?

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Hellenic Society of Cardiology

Background/Introduction: Echocardiography is the key tool for the diagnosis and evaluation of valve disease, and has been the primary non-invasive imaging method for valve stenosis assessment. The antegrade systolic velocity across the aortic valve, or aortic jet velocity, is measured using continuous-wave (CW) Doppler ultrasound and is of paramount importance for diagnosis and prognosis of such patients. Recent technological advancements have enabled the acquisition of echocardiographic images at the point of care by using small handheld ultrasound devices (HUDs); their availability and relatively low cost compared to the high-end, fully equipped systems have made these devices attractive to use for rapid medical decision making. However, the inability to quantify flow velocity has been a major drawback for HUDs, since the lack of spectral Doppler capability makes assessment of valvular pathology difficult.

Purpose

 To evaluate the feasibility and accuracy of a novel HUD with CW Doppler capability to measure aortic jet velocity.

Methods

 We prospectively included 43 consecutive patients who were referred to the outpatient specialist valve clinic of a tertiary hospital. All patients were scanned with both the Kosmos HUD and the standard echocardiography cart-based system (reference standard) in order to obtain CW Doppler signal across the aortic valve. The peak aortic jet velocity measurements used for the analysis were acquired from the apical five-chamber view by both techniques and were compared to assess inter-method agreement using linear regression and Bland-Altman analysis.

Results

The acquisition of CW Doppler signal using the Kosmos HUD was feasible in 42 out of 43 patients (mean age 65 ± 15 years old, 58% male). Among them, there were 12 patients (29%) with peak aortic jet velocity &gt;3 m/s (which is the cut-off to define at least moderate aortic valve stenosis). The peak aortic jet velocity was measured as 2.15 ± 1.16 m/s with the HUD CW Doppler and 2.28 ± 1.16 m/s using the cart-based system CW Doppler. There was excellent correlation between the HUD CW Doppler and the reference standard with a correlation coefficient r = 0.98, 95%CI 0.97-0.99, (p &lt; 0.001). The corresponding Bland-Altman plot showed a small underestimation bias of -0.13 m/s (p &lt; 0.001), with limits of agreement ±0.42 m/s for the peak aortic jet velocity. Of importance, for the subgroup of patients with aortic jet velocity &gt;3 m/s the correlation remained excellent (r = 0.92, p &lt; 0.001).

Conclusion

A novel HUD with CW Doppler spectral analysis was able to provide aortic jet velocity measurements similar to the standard cart-based echocardiography systems, including patients with high aortic jet velocities. Such expanded capabilities of HUDs show clinical potential and may lead to the improvement of the assessment of valvular pathology at the point of care. Abstract Figure. Correlation plot  Abstract Figure. Bland-Altman plot

Clinical validation of an artificial intelligence-assisted algorithm for automated quantification of left ventricular ejection fraction in real time by a novel handheld ultrasound device

Aims

We sought to evaluate the reliability and diagnostic accuracy of a novel handheld ultrasound device (HUD) with artificial intelligence (AI) assisted algorithm to automatically calculate ejection fraction (autoEF) in a real-world patient population.

Methods and results

We studied 100 consecutive patients (57 ± 15 years old, 61% male), including 38 with abnormal left ventricular (LV) function [LV ejection fraction (LVEF) < 50%]. The autoEF results acquired using the HUD were independently compared with manually traced biplane Simpson's rule measurements on cart-based systems to assess method agreement using intra-class correlation coefficient (ICC), linear regression analysis, and Bland-Altman analysis. The diagnostic accuracy for the detection of LVEF <50% was also calculated. Test-retest reliability of measured EF by the HUD was assessed by calculating the ICC and the minimal detectable change (MDC). The ICC, linear regression analysis, and Bland-Altman analysis revealed good agreement between autoEF and reference manual EF (ICC = 0.85; r = 0.87, P < 0.001; mean bias -1.42% with limits of agreement 14.5%, respectively). Detection of abnormal LV function (EF < 50%) by autoEF algorithm was feasible with sensitivity 90% (95% CI 75-97%), specificity 87% (95% CI 76-94%), PPV 81% (95% CI 66-91%), NPV 93% (95% CI 83-98%), and a total diagnostic accuracy of 88%. Test-retest reliability was excellent (ICC = 0.91, P < 0.001; r = 0.91, P < 0.001; mean difference ± SD: 0.54% ± 5.27%, P = 0.308) and MDC for LVEF measurement by autoEF was calculated at 4.38%.

Conclusion

Use of a novel HUD with AI-enabled capabilities provided similar LVEF results with those derived by manual biplane Simpson's method on cart-based systems and shows clinical potential.

A case series of skin manifestations of infective endocarditis in contemporary era: just another book finding or a useful clinical sign?

Background

Infective endocarditis (IE) is a disease of high morbidity and mortality. Infective endocarditis rarely involves skin manifestations in the contemporary era. The identification of typical skin lesions could be helpful in establishing early diagnosis of IE.

Case summary

We present four cases of IE hospitalized in our institution within a 12-month period. All patients were young and had skin manifestations on initial presentation (petechiae, splinter haemorrhages, Janeway lesions, and Osler’s nodes), which led to a high clinical suspicion of IE confirmed by echocardiography and positive blood cultures. All cases had a complicated course. One patient died and the other three had prolonged hospital stay due to variable complications.

Discussion

Clinicians should always assess for skin manifestations in patients with fever especially when suspicion of IE is high. Occurrence of skin lesions in the course of IE may be associated with higher rate of complications and worse prognosis.

A tricky case of cardiogenic shock: Diagnostic challenges in the COVID-19 era

Myocardial wall rupture should be considered in patients presenting with hypotension and STEMI especially of delayed onset. Diagnosing this entity in the COVID‐19 era can be challenging—handheld echocardiography may aid toward this end.

Embolization after percutaneous coronary intervention in acute coronary syndrome. Saphenous vein grafts versus native coronary arteries

AIMS

The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured during stent implantation in native coronary arteries, as compared with saphenous vein grafts (SVG) in patients at different time periods after an acute coronary syndrome.

PATIENTS AND METHODS

In all, 104 patients presenting with unstable or stable angina underwent percutaneous coronary intervention (PCI) in 107 vessels and stent implantation in 112 lesions, 53 % of which were in SVG.

RESULTS

Device deployment and retrieval was successful in 111 lesions. Embolic material was detected in 74 % of the protection devices. Early PCI, during a 2-week period after the last ischemic episode, was associated with larger embolic load, especially in the right coronary artery. The length of the lesion was the only preprocedural independent variable that was found to be a significant predictor for the presence of emboli (p = 0.002). The stent diameter and the maximum dilatation pressure were the two procedural variables found to be significant predictors for the presence of emboli (p = 0.025 and p = 0.008, respectively). The irregularity of the lesion and the number of stents deployed were found to have a predictive correlation to the total area of the embolic particles (p = 0.04 and p = 0.005, respectively).

CONCLUSION

Distal embolization of atherosclerotic debris is a frequent phenomenon after PCI not only in SVG but also in native vessels. The amount of embolic material seems to be related to the atherosclerotic burden of the vessel and to the early timing of the procedure as related to acute coronary syndrome.

Transulnar compared with transradial artery approach as a default strategy for coronary procedures: a randomized trial. The Transulnar or Transradial Instead of Coronary Transfemoral Angiographies Study (the AURA of ARTEMIS Study)

BACKGROUND

The ulnar artery is rarely selected for coronary angiography or percutaneous coronary intervention despite the expanding use of the transradial approach. We aimed to establish noninferiority of a default transulnar relative to transradial approach in terms of feasibility and safety.

METHODS AND RESULTS

This was a prospective, randomized, multicenter, parallel-group study involving 902 patients at 5 sites eligible to undergo diagnostic coronary angiography and percutaneous coronary intervention. Patients were randomized in a 1:1 ratio to either transradial approach (reference intervention) or transulnar approach (experimental intervention) regardless of the Allen test results. The primary end point was a composite of cross-over to another arterial access, major adverse cardiovascular events, and major vascular events of the arm at 60 days. The study was prematurely terminated after the first interim analysis because of inferiority of the transulnar approach. Although the difference in the primary end point became inconclusive after adjustment for operator clustering (24.30%; 99.99% confidence interval [CI], -7.98% to 56.58%; P=0.03 at α=0.0001), need for cross-over in the transulnar group remained inferior to transradial access site with a difference of 26.34% (95% CI, 11.96%-40.69%; P=0.004).

CONCLUSIONS

As a result of higher cross-over rates, a first-line transulnar strategy was proven inferior to the transradial approach for coronary procedures. At present, the transulnar route should not be regarded as an acceptable alternative to the transradial access site.

Serial measurements of acute phase proteins in patients with acute coronary syndrome

INTRODUCTION

Levels of inflammatory markers increase in patients with acute coronary syndromes (ACS) and the magnitude of the inflammatory response has been related to clinical outcomes. The release patterns and, thereby, the time point of maximal increase for multiple inflammatory markers following an ACS are not fully defined. Our purpose was to serially measure three acute phase proteins (APPs) in patients with ACS.

METHODS

We prospectively enrolled 74 consecutive patients (54 men, age 62.2 ± 9.8 years) with ACS: 38 with ST-elevation acute myocardial infarction (STEMI), and 36 with non-ST-elevation acute myocardial infarction (NSTEMI) or unstable angina (UA). Peripheral levels of alpha-1 antitrypsin (A1AT), alpha-1 acid glycoprotein (A1GP) and haptoglobin (HPT) were measured on admission, and 6, 12, 24, 48, 72 hours, 7 days and 6 months after the initial evaluation.

RESULTS

Baseline levels of the APPs did not differ between the two groups. A1AT, A1GP and HPT all exhibited a similar time course among NSTEMI/UA patients, all reaching maximal values at 7 days. The markers showed an earlier increase and A1AT showed earlier peaking (at 72 hours) in STEMI patients. Peak levels were higher in patients with STEMI vs. NSTEMI/UA for all three APPs (p<0.01 for A1AT and HPT, p<0.05 for A1GP).

CONCLUSIONS

A1AT, A1GP and HPT levels increase significantly in patients with ACS and display different release curves in those with STEMI versus NSTEMI or UA. Knowledge of the release patterns of APPs may determine the optimal time point of measurement and thereby enhance their potential prognostic value in the setting of ACS.

The factors contributing to the risk of sudden infant death syndrome

Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene and review of the clinical history. SIDS is one of the leading causes of infant mortality and occurs from the first month, until the first year of life for newborns and infants.The aim of this review was to identify and examine risk factors responsible for causing the sudden infant death and to propose certain measures in order to protect newborns and infants from sudden death. The potential factors that contribute to the occurrence of SIDS include inadequate prenatal care, low birth weight (<2499gr), premature infants, intrauterine growth delay, short interval between pregnancies and maternal substance use (tobacco, alcohol, opiates). Moreover, factors related to infant's sleep environment such as the prone or side sleeping position and thick coverlet increase the risk of sudden death in infants. Also, the combination of risk factors such as that of prone sleeping position and soft bed mattress are linked to a 20-fold increased risk of death. Finally, polymorphisms in the serotonin transporter gene (5-HTT), viral respiratory infections, long Q-T (responsible for the presence of fatal arrhythmia) are related to the SIDS.Literature review indicates that each individual risk factor contributes to the appearance of SIDS and the establishment of certain protective measures for parents and health professionals has reduced its prevalence. But the precise identification of the SIDS causes and how these contribute to the occurrence of sudden death in neonates and infants, remains a challenge for health professionals.

Brugada syndrome associated with supraventricular tachycardia: diagnostic and therapeutic strategies

We report the case of a patient with Brugada syndrome and a history of palpitations who presented with an episode of syncope and developed supraventricular tachycardia in the electrophysiological study. The patient was treated with radiofrequency ablation for the supraventricular tachycardia and an implantable cardioverter defibrillator for the Brugada syndrome. At 18 months following implantation of the defibrillator an electrical storm with ventricular fibrillation episodes occurred followed by appropriate discharges of the defibrillator.

Acute myocardial infarction manifested with headache

We report a very rare case of a patient who presented with headache as the sole symptom of an acute myocardial infarction (AMI). The patient underwent primary percutaneous coronary angioplasty followed by drug-eluting stent implantation and the headache was immediately relieved. The pathophysiologic explanation of the occurrence of headache as a sole manifestation of an AMI is discussed.

Left atrial volume and N-terminal pro-B type natriuretic peptide are associated with elevated pulmonary artery pressure in patients with systemic sclerosis

Early detection of pulmonary hypertension (PH) in patients with systemic sclerosis (SSc) is essential as it leads to substantial morbidity and mortality irrespective of its etiology. The aim of our study was to determine whether noninvasive biochemical and/or echocardiographic indices can predict the presence of PH in these patients. We prospectively studied 66 patients (mean age of 57.7 +/- 12.1 years, 63 women) with SSc without clinical manifestations of heart failure. All patients underwent standard and tissue Doppler echocardiography. Plasma N-terminal pro-B type natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) levels were also measured. In 24 (36%) patients, the diagnosis of PH was established by echocardiography (systolic pulmonary artery pressure value > or =40 mmHg). Left atrial (LA) volume, NT-proBNP, ADMA, ratio of early transmitral filling velocity to early diastolic velocity of the mitral annulus (mitral E/E (m)), and right ventricular myocardial performance index (MPI) were univariate predictors of PH. In multivariate analysis, NT-proBNP, LA volume, and right ventricular MPI were independent predictors of PH in SSc patients. LA volume and NT-proBNP may be useful noninvasive markers for the prediction of elevated pulmonary artery pressure in patients with SSc. These parameters should be considered when assessing this population for risk stratification and for identification of patients demanding further investigation and institution of specific therapy for the disease at the time when it is most likely to be effective.

Differences in echocardiographic characteristics of functional mitral regurgitation in ischaemic versus idiopathic dilated cardiomyopathy: a pilot study

INTRODUCTION

Functional mitral regurgitation (FMR) is a common complication in patients with ischaemic (ICM) or idiopathic dilated cardiomyopathy (DCM), as a consequence of left ventricular (LV) remodelling. The aim of this study was to elucidate the differences in FMR between patients with ICM and DCM utilising conventional and tissue Doppler echocardiography.

METHODS

We studied 21 patients with ICM and 17 with DCM using conventional and tissue Doppler echocardiography. The severity of FMR was assessed quantitatively and by the PISA method. The 2 groups were similar in terms of NYHA class, LV ejection fraction and pharmacological treatment.

RESULTS

Patients with ICM had higher pulmonary artery systolic pressures (48 +/- 16 vs. 38 +/- 10 mmHg, p=0.04), more severe FMR as assessed by colour Doppler (1.9 +/- 0.9 vs. 1.1 +/- 0.5, p=0.006), and a larger effective regurgitant orifice (0.17 +/- 0.07 vs. 0.1 +/- 0.05 cm(2), p=0.003) and tenting area (2.3 +/- 0.8 vs. 1.7 +/- 0.7 cm(2), p=0.02). In addition, ICM subjects had lower mitral annular systolic (Sm 2.3 +/- 0.8 vs. 3.4 +/- 0.9 cm/s, p<0.001) and diastolic (Em 2.5 +/- 1 vs. 3.8 +/- 1.5 cm/s, p=0.005; Am 3.1 +/- 1.4 vs. 4.3 +/- 1.7 cm/s, p=0.02) myocardial velocities, and a higher ratio of early transmitral filling velocity to early mitral annular diastolic velocity (LV E/Em 42 +/- 29 vs. 22.7 +/- 7.6, p=0.008) compared to DCM patients. Systolic and diastolic mitral annular velocities were significantly correlated with effective regurgitant orifice. Tenting area >1.27 cm(2) exhibited the highest sensitivity and regurgitant volume >24 ml the highest specificity for predicting ischaemic aetiology of LV dysfunction. However, only age and Sm were independent predictors of the diagnosis of ICM rather than DCM.

CONCLUSIONS

Mitral apparatus deformity, incomplete closure of mitral leaflets and global remodelling are more prominent in patients with ICM and lead to more severe FMR than in patients with DCM.

Arrhythmias, sudden cardiac death and incapacitation of pilots

Inflight medical emergencies occur at a rate of 20 to 100 per million passengers, with a death rate of 0.1 to 1 per million. Cardiac, neurologic, and respiratory complaints comprise the more serious emergencies, as defined by aircraft diversion or use of ground-based medical assistance. In this paper, we review changes seen in the resting electrocardiogram in normal individuals exposed to high altitude, alongside important implications for patients with heart diseases in high altitude exposures and the possible effects of high altitude to permanent cardiac pacemakers. Arrhythmias in pilots and public safety are revisited together with the guidelines of the Joint Aviation Requirements (JAR) in Europe. The situation of Military flights is also discussed. Physicians ought to become knowledgeable about the specific medical job standards for their patients when asked to render opinions regarding fitness to fly. A database must be established to obtain prospective data that defines the risk of accidents in patients who are or were being treated for arrhythmias. Current guidelines could then be updated and revised as appropriate.

Hypertrophic cardiomyopathy with late enhancement of the non-hypertrophied left ventricular segments

A 56-year-old asymptomatic man was referred for further evaluation because he displayed a rapid T-wave change on the ECG, from positive T waves to giant negative T waves in the anterolateral precordial leads, within 2 years. Transthoracic echocardiography revealed mild left ventricular apical hypertrophy without obstruction. Cardiac magnetic resonance imaging showed apical hypertrophic cardiomyopathy with focal hyperenhancement of the non-hypertrophic basal lateral segment of the left ventricle and absence of hyperenhancement of the hypertrophied apical segments.

The utility of the standard 12-lead electrocardiogram in the prediction of proximal right coronary artery occlusion in acute inferior myocardial infarction

Prior studies have proposed several electrocardiogram criteria for identifying patients with acute inferior ST-segment elevation myocardial infarction (iSTEMI) caused by obstruction of the proximal part of the right coronary artery (RCA). We applied 11 of these criteria and three new ones to the admission electrocardiograms of 80 patients admitted with an acute iSTEMI in order to evaluate their utility. All patients received thrombolytic treatment and underwent coronary angiography during the hospitalization. Four previously described criteria (ST-segment depression in lead V1, ST-segment depression in leads V1-V3, maximum ST-segment depression in the precordial leads, and ST-segment depression in lead V3 of <or= 50% of the magnitude of ST-segment elevation in lead III) and two new used criteria (the absence of ST-segment depression in lead V1 in combination with ST-segment depression in lead V2 and the arithmetic sum of the ST-segment: III + V3 > 1) were useful in identifying patients with obstruction of the proximal part of the RCA. Among the six criteria, ST depression in V1-V3 had the highest specificity (77.2%) and positive predictive value (56.5%), and a new criterion-the arithmetic sum of the ST-elevation in V3/ST-elevation in III < 0.5--had the highest sensitivity (80.9%) and negative predictive value (86.7%). Six criteria were helpful in identifying patients with acute iSTEMI caused by obstruction of the proximal part of the RCA. One of these has not been previously reported and has the higher specificity and negative predictive value.

Clinical significance of N-terminal-probrain natriuretic peptide in hypertrophic cardiomyopathy

N-Terminal-probrain natriuretic peptide (NT-proBNP) plasma levels are elevated in patients with congestive heart failure. Published data concerning the utility of NT-proBNP in hypertrophic cardiomyopathy (HCM) are lacking. Our aim was to evaluate the clinical significance of NT-proBNP in patients with HCM. A blood sample was collected for plasma NT-proBNP measurement from 43 consecutive patients with documented HCM. NT-proBNP was measured using a chemiluminescent immunoassay kit (Roche Diagnostics) on an Elecsys 2010 analyzer. Median value of NT-proBNP was 219 pg/ml (range 8-3 045 pg/ml) in NYHA class I patients, 698 pg/ml (125-2 463 pg/ml) in NYHA class II patients, and 2 683 pg/ml (131-11 542 pg/ml) in NYHA class III and IV patients. NT-proBNP plasma levels were significantly higher across the severity of functional limitation (i.e., NYHA class classification) (P = 0.002). NT-proBNP levels were significantly higher in female than male (P = 0.034), in referral vs nonreferral patients (P = 0.004), in symptomatic vs asymptomatic patients (P = 0.020), in patients with basal subaortic gradient >or=30 mmHg (P = 0.001) and in the patients who were on cardioactive medication (P = 0.010). In univariate analysis NT-proBNP was significantly correlated with age (P < 0.001), left ventricular maximum wall thickness (P = 0.001), left atrial size (P = 0.019), and subaortic gradient >or=30 mmHg (P < 0.001). In multivariate regression analysis, age (P < 0.001), maximum wall thickness (P = 0.007), and gradient >or=30 mmHg (P = 0.027) were independently associated with NT-proBNP levels. Our data support the idea that measurement of plasma NT-proBNP levels in HCM patients is useful to assess their clinical status, especially the severity of hypertrophy and the presence of obstruction, although age must be taken into account.

Totally endoscopic microwave ablation for lone atrial fibrillation: an alternative method of treatment

Recent studies suggest that pulmonary vein isolation can be an effective method of treatment for atrial fibrillation. This procedure can be performed with minimally invasive, totally endoscopic cardiac surgical techniques. We report our first successful endoscopic isolation of the pulmonary veins in a patient with paroxysmal atrial fibrillation. The procedure consisted of making a box lesion around the pulmonary veins, using a flexible microwave energy delivery probe which was placed endoscopically (video assisted thoracoscopy) through three ports, bilaterally. During a six-month follow up there was no recurrence of atrial fibrillation and the patient's quality of life improved significantly.