Coronary artery fistulas as a rare cause of heart failure and ventricular arrhythmia, associated with multiple large vessel fistulas

Coronary artery fistulas are abnormal connections between the coronary arteries with a heart chamber or any of the major blood vessels. Fistulous connections between systemic arteries and pulmonary vessels are even less frequent. We present a case of a 71-year-old man with symptoms of dyspnea, exercise intolerance, and ventricular arrhythmia who attended the emergency department. Coronary angiography revealed bilateral coronary fistulas drained into the pulmonary circulation. Computed tomography angiography revealed the presence of fistulas arising from the descending aorta, right internal mammary artery, and subclavian arteries, all these drained into the pulmonary circulation. Due to the rarity of the disease, there are no international guidelines for the management of coronary fistulas and the treatment is controversial. Coronary artery fistula is a rare pathology that should be included in the differential diagnosis of heart failure and ventricular arrhythmia.

Diagnosis and Management of Cirrhotic Cardiomyopathy

BACKGROUND

Cirrhotic cardiomyopathy refers to the structural and functional changes in the heart leading to either impaired systolic, diastolic, electrocardiographic, and neurohormonal changes associated with cirrhosis and portal hypertension. Cirrhotic cardiomyopathy is present in 50% of patients with cirrhosis and is clinically seen as impaired contractility, diastolic dysfunction, hyperdynamic circulation, and electromechanical desynchrony such as QT prolongation. In this review, we will discuss the cardiac physiology principles underlying cirrhotic cardiomyopathy, imaging techniques such as cardiac magnetic resonance imaging and scintigraphy, cardiac biomarkers, and newer echocardiographic techniques such as tissue Doppler imaging and speckle tracking, and emerging treatments to improve outcomes.

METHODS

We reviewed available literature from MEDLINE for randomized controlled trials, cohort studies, cross-sectional studies, and real-world outcomes using the search terms "cirrhotic cardiomyopathy," "left ventricular diastolic dysfunction," "heart failure in cirrhosis," "liver transplantation," and "coronary artery disease".

RESULTS

Cirrhotic cardiomyopathy is associated with increased risk of complications such as hepatorenal syndrome, refractory ascites, impaired response to stressors including sepsis, bleeding or transplantation, poor health-related quality of life and increased morbidity and mortality. The evaluation of cirrhotic cardiomyopathy should also guide the feasibility of procedures such as transjugular intrahepatic portosystemic shunt, dose titration protocol of betablockers, and liver transplantation. The use of targeted heart rate reduction is of interest to improve cardiac filling and improve the cardiac output using repurposed heart failure drugs such as ivabradine. Liver transplantation may also reverse the cirrhotic cardiomyopathy; however, careful cardiac evaluation is necessary to rule out coronary artery disease and improve cardiac outcomes in the perioperative period.

CONCLUSION

More data are needed on the new diagnostic criteria, molecular and biochemical changes, and repurposed drugs in cirrhotic cardiomyopathy. The use of advanced imaging techniques should be incorporated in clinical practice.

Adipose-derived mesenchymal stem cells preserve cardiac function via ANT-1 in dilated cardiomyopathy hamster model

Introduction

Idiopathic dilated cardiomyopathy (DCM) is associated with abnormalities in cytoskeletal proteins, mitochondrial ATP transporter, microvasculature, and fibrosis. Mesenchymal stem cells (MSCs) can ameliorate distressed mitochondrial and structural proteins, as well as fibrosis, via the paracrine effect of cytokines. This study aimed to investigate whether the transplantation of adipose tissue-derived MSCs (ADSCs) reverses histological and functional abnormalities in the distressed myocardium of DCM-like hamsters by modulating the expression of adenine nucleotide translocase 1 (ANT-1).

Methods

Eighteen weeks after birth, ADSCs were implanted onto the cardiac surface of δ-sarcoglycan (SG)-deficient hamsters or sham surgery was performed.

Results

Left ventricular ejection fraction and end-systolic diameter were maintained in ADSC-treated animals for four weeks, ATP concentration was considerably elevated in the cardiomyocytes of these animals, and ANT-1 expression was significantly upregulated as well. The expression of extracellular matrix and myocardial cytoskeletal proteins, such as collagen, SG, and α-dystroglycan, did not differ between groups. However, significant improvements in myosin and Smad4 expression, cardiomyocyte hypertrophy, and capillary density occurred in the ADSC-treated group.

Conclusions

We demonstrated that ADSCs might maintain cardiac function in the DCM hamster model by enhancing ATP concentration, as well as mitochondrial transporter and myosin expression, indicating their potential for DCM treatment.

Transradial artery approach in STEMI patients reperfused early and late by either primary PCI or pharmaco-invasive approach

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There was a non-significant difference regarding LVEF and TIMI flow between both PPCI and PI.

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Myocardium wall preservation was significant in early PI (P = 0.023)

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Mean procedural and fluoroscopic time were 35.1 ± 6.1 and 6.3 ± 0.9 min.

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No reported entry site complications also no difference in primary end point (P = 0.326).

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It is safe and effective to use TRA in STEMI patients who reperfused by either early or late PPCI or PI.

The purpose of the study was to investigate the safety and efficacy of transradial artery approach (TRA) in STEMI patients who reperfused early (≤3 h from symptoms onset) or late (>3 h from symptoms onset) by either PPCI or pharmaco-invasive strategy (PI), thrombolysis followed by CA. Therefore, a total 143 STEMI patients (who were presented within 12 h from symptoms onset or 12–24 h with an evidence of ongoing ischemia or suffered from an acute STEMI were randomized for either PI or PPCI. Eighty-two patients were assigned to PI arm while the rest assigned were to PPCI arm. Patients who were taken to a non-PCI capable hospital received streptokinase and were then transferred to our Hospital for CA. TRA was used in the catheterization laboratory for all patients. Each arm was divided according to reperfusion time into early and late subgroups. A primary endpoint was death, shock, congestive heart failure, or reinfarction up to 30 days. There was a non-significant difference regarding LVEF in both arms. Myocardium wall preservation was significant in the early PI arm (P = 0.023). TIMI flow had no discrepancy between both arms (P = 0.569). Mean procedural and fluoroscopic time were 35.1 ± 6.1 and 6.3 ± 0.9 min. There were no reported entry site complications. There was no difference in primary endpoint complications (P = 0.326) considering the different times of patients’ reperfusion (early; P = 0.696 vs. late; P = 0.424). In conclusion, it is safe and effective to use TRA in STEMI patients who reperfused by either early or late PPCI or PI. We recommend PI for STEMI patients with delay presentation if PPCI is not available.

Cardiac magnetic resonance imaging characteristics and pregnancy outcomes in women with Mustard palliation for complete transposition of the great arteries

BACKGROUND

Women with transposition of the great arteries (TGA) following atrial redirection surgery are at risk of pregnancy-associated arrhythmia and heart failure. The cardiovascular magnetic resonance imaging (CMR) characteristics of these women and the relationship of CMR findings to pregnancy outcomes have not been described.

METHODS

We included 17 women with atrial redirection surgery and CMR within 2 years of delivery.

RESULTS

All women were asymptomatic at baseline (New York Heart Association Class 1). CMR studies were completed pre-pregnancy in 3, antepartum/peripartum in 2, and postpartum in 12 women. Three women (3/17, 18%) experienced major cardiovascular events related to pregnancy: cardiac arrest (n = 1) and symptomatic atrial arrhythmia (n = 2). Median gestational age at delivery was 38 weeks (24-39 weeks) and birth weight was 2770 g (2195-3720 g). Complications were seen in 3 offspring (3/17, 18%): death (n = 1) and prematurity (n = 2). CMR characteristics included median right ventricular end diastolic volume 119 mL/m2 (range 85-214 mL/m2) and median right ventricular ejection fraction (RVEF) 37% (range 30-51%). All women with cardiovascular complications had an RVEF < 35% (range 32-34%). The association between RVEF < 35% and cardiovascular complications trended towards statistical significance (p = 0.05). No statistically significant differences in CMR measurements were found between those with and without neonatal complications.

CONCLUSIONS

While the majority of women in this cohort had successful outcomes following pregnancy, important cardiovascular complications were seen in a significant minority, all of whom had an RVEF < 35%. The preliminary findings of our study provide impetus for a larger prospective study to evaluate the prognostic role of CMR in pregnant women with atrial redirection surgery.

Enzymatic replacement therapy for Hunter disease: Up to 9 years experience with 17 patients

Hunter disease is an X-linked lysosomal storage disorder characterized by progressive storage of glycosaminoglycans (GAGs) and multi-organ impairment. The central nervous system (CNS) is involved in at least 50% of cases. Since 2006, the enzymatic replacement therapy (ERT) is available but with no effect on the cognitive impairment, as the present formulation does not cross the blood-brain barrier. Here we report the outcome of 17 Hunter patients treated in a single center. Most of them (11) started ERT in 2006, 3 had started it earlier in 2004, enrolled in the phase III trial, and 3 after 2006, as soon as the diagnosis was made. The liver and spleen sizes and urinary GAGs significantly decreased and normalized throughout the treatment. Heart parameters improved, in particular the left ventricular mass index/m(2) decreased significantly. Amelioration of hearing was seen in many patients. Joint range of motion improved in all patients. However, no improvement on respiratory function, eye, skeletal and CNS disease was found. The developmental quotient of patients with a CNS involvement showed a fast decline. These patients were no more testable after 6 years of age and, albeit the benefits drawn from ERT, their quality of life worsened throughout the years. The whole group of patients showed a consistent residual disease burden mainly represented by persistent skeletal disease and frequent need of surgery. This study suggests that early diagnosis and treatment and other different therapies which are able to cross the blood-brain barrier, might in the future improve the MPS II outcome.