Transthoracic echocardiographic imaging of coronary arteries: tips, traps, and pitfalls

The aim of this paper is to highlight coronary investigation by transthoracic Doppler evaluation. This application has recently been introduced into clinical practice and has received enthusiastic feedback in terms of coronary flow reserve evaluation on left anterior coronary artery disease diagnosis. Such diagnosis represents the most important clinical application but has in itself some limitations regarding anatomical and technological knowledge. The purpose of this paper is to offer a didactic approach on how to investigate the different segments of left anterior and posterior descending coronary arteries by transthoracic ultrasound using different anatomical key structures .as marker

Apoptosis Induced by Piroxicam plus Cisplatin Combined Treatment Is Triggered by p21 in Mesothelioma

BACKGROUND: Malignant mesothelioma (MM) is a rare, highly aggressive tumor, associated to asbestos exposure. To date no chemotherapy regimen for MM has proven to be definitively curative, and new therapies for MM treatment need to be developed. We have previously shown in vivo that piroxicam/cisplatin combined treatment in MM, specifically acts on cell cycle regulation triggering apoptosis, with survival increase. METHODOLOGY/PRINCIPAL FINDINGS: We analyzed, at molecular level, the apoptotic increase caused by piroxicam/cisplatin treatment in MM cell lines. By means of genome wide analyses, we analyzed transcriptional gene deregulation both after the single piroxicam or cisplatin and the combined treatment. Here we show that apoptotic increase following combined treatment is mediated by p21, since apoptotic increase in piroxicam/cisplatin combined treatment is abolished upon p21 silencing. CONCLUSIONS/SIGNIFICANCE: Piroxicam/cisplatin combined treatment determines an apoptosis increase in MM cells, which is dependent on the p21 expression. The results provided suggest that piroxicam/cisplatin combination might be tested in clinical settings in tumor specimens that express p21

Effect and Role of Post-conditioning During Coronary Angioplasty in Patients Affected by ST-Elevation Acute Myocardial Infarction

Background Reperfusion is the mainstay treatment for patients presenting with ST-elevation myocardial infarction (STEMI). Nevertheless, reperfusion itself may exacerbate myocardial injury, a process termed “reperfusion injury”. Post-conditioning (PostC) has been suggested to reduce myocardial damage during primary percutaneous coronary intervention (PPCI), nevertheless clinical experience is limited. Objectives We aimed to review all the known strategies to limit the reperfusion injury; moreover we explored the cardioprotective effect of mechanical postconditioning conducting a randomized trial aimed to evalutate infarct size (IS) at cardiac magnetic resonance (CMR) in STEMI patients treated by PPCI. Methods A total of 78 patients with first STEMI (aged 59±12 years) referred for PPCI, were stratified for STEMI location and randomly assigned to conventional PPCI or PPCI with PostC. All patients, with occluded infarct related artery and no collateral circulation, received abciximab intravenously before PPCI. After reperfusion by effective direct stenting, control subjects underwent no further intervention, while in treated patients PostC was performed within 1 minute of reflow by 4 cycles of 1-minute inflation and 1-minute deflation of the angioplasty balloon. Primary end-point was IS reduction, expressed as percentage of left ventricle mass assessed by delayed enhancement on CMR at 30±10 days after index PPCI. Results All baseline characteristics but diabetes (p=0.06) were balanced between groups. Postconditioning patients trended towards a larger IS compared to those treated by standard PPCI (20±12% vs 14±10%, p=0.054). After exclusion of diabetics, PostC group still showed a trend to larger IS (p=0.116). Major adverse events seem to be more frequent in PostC group irrespective to diabetes status (p=0.053 and p=0.080, respectively). Conclusions This prospective, randomized trial suggests that PostC did not have the expected cardioprotective effect and, on the contrary, it might harm STEMI patients treated by PPCI plus abciximab. (Clinical Trial Registration-unique identifier: NCT01004289).Razionale dello studio La terapia riperfusiva è la via principale per il trattamento di pazienti che si presentino con infarto miocardico con sopraslivellamento del tratto ST (ST-elevation myocardial infarction, STEMI). Tuttavia, la riperfusione di per sé può esacerbare il danno miocardico, un processo denominato “danno da riperfusione”. Il post-conditioning (PostC) é un processo che sembra possa ridurre il danno miocardico da riperfusione durante angioplastica primaria (primary percutaneous coronary intervention, PPCI), ciò nonostante l’esperienza clinical è limitata. Scopo dello studio Presentare e discutere tutte le strategie note in grado di limitare il danno riperfusivo; inoltre, valutare gli effetti cardioprotettivi del postconditioning ischemico meccanico mediante un trial clinico controllato randomizzato arruolante pazienti con STEMI e inviati a PPCI, con endpoint primario le dimensioni dell’infarto (infarct size, IS) finale alla risonanza magnetica cardiaca (cardiac magnetic resonance, CMR). Metodi Un totale di 78 pazienti con primo STEMI (età 59±12 anni) inviati per PPCI, sono stati stratificati per sede dello STEMI e successivamente randomizzati a PPCI convenzionale o PPCI con PostC. Tutti i pazienti, con arteria responsabile dell’infarto occlusa e assenza di circolo collaterale, hanno ricevuto abciximab endovena prima della PPCI. Successivamente alla riperfusione, avvenuta con tecnica direct stenting, i soggetti di controllo non sono stati sottoposti ad ulteriori interventi, mentre i soggetti nel gruppo PostC hanno rivevuto, entro un minuto dalla riperfusione, 4 cicli di 1 minuto di rigonfiaggio e 1 minuto di sgonfiaggio del pallone usato per l’angioplastica. L’endpoint primario oggetto dello studio, la riduzione dell’IS finale, veniva espresso come percentuale della massa ventricolare sinistra affetta, come possibile riconoscere ad una CMR con mezzo di contrasto eseguita a 30±10 giorni di distanza dalla procedura di PPCI indice. Risultati Tutte le caratteristiche di base, ad eccezione del diabete (p=0.06), risultavano ben bilanciate tra i gruppi di trattamento. I pazienti nel gruppo postconditioning tendevano ad avere un IS maggiore quando paragonati a quelli sottoposti a PPCI convenzionale (20±12% vs 14±10%, p=0.054). Dopo esclusione dei pazienti diabetici, il gruppo di pazienti PostC sembrava ancora associato ad IS finali di maggiori dimensioni (p=0.116). Gli eventi avversi cardiovascolari maggiori sono risultati essere più frequenti nel gruppo PostC, indipendentemente dal loro status diabetico (p=0.053 e p=0.080, rispettivamente). Conclusioni Questo trial clinico randomizzato prospettico suggerisce che il PostC non ha l’effetto cardioprotettivo atteso e, invece, potrebbe pure nuocere a pazienti affetti da STEMI e sottoposti a PPCI ed infuzione di abciximab. (Numero identificativo unico di registrazione del trial al sito clinicaltrial.gov: NCT01004289)

Clinical images. Pulmonary edema without an obvious cause: handgrip-induced large dynamic changes in ischemic mitral regurgitation in the cath lab.

We report a case of pulmonary edema experienced in a patient with severe left ventricular dysfunction without an obvious cause. Thus, we tested the hypothesis of a dynamic increase in the severity of (ischemic) mitral regurgitation. Right-and left-heart cardiac catheterization was performed before and after 2 minutes of maximal handgrip. We observed an increase in the patient\u2019s left ventricular systolic and end-diastolic pressures, his pulmonary and wedge capillary pressures, his heart rate and severe mitral regurgitation

Acidic postconditioning in ST-elevation myocardial infarction patients.

Comment on Design and methodologies of the POSTconditioning during coronary angioplasty in acute myocardial infarction (POST-AMI) trial. [Cardiology. 2010] Ischemic postconditioning with lactate-enriched blood in patients with acute myocardial infarction. [Cardiology. 2013

Pulmonary Edema Without an Obvious Cause: Handgrip-induced Large Dynamic Changes in Ischemic Mitral Regurgitation in the Cath Lab

none2We report a case of pulmonary edema experienced in a patient with severe left ventricular dysfunction without an obvious cause. Thus, we tested the hypothesis of a dynamic increase in the severity of (ischemic) mitral regurgitation. Right- and left-heart cardiac catheterization was performed before and after 2 minutes of maximal handgrip. We observed an increase in the patient's left ventricular systolic and end-diastolic pressures, his pulmonary and wedge capillary pressures, his heart rate and severe mitral regurgitation.noneFavaretto, Enrico; Tarantini, GiuseppeFavaretto, Enrico; Tarantini, Giusepp