The added value of three-dimensional transthoracic echocardiography in mitral annular disjunction: a case report

BackgroundMitral annular disjunction (MAD) refers to the arrhythmic mitral valve prolapse (MVP) syndrome associated with ventricular arrhythmias and sudden cardiac death. Although the pathophysiology of this disease is still under investigation, specific imaging criteria that establish the diagnosis have been recognized. In this article, we demonstrate most of these criteria using three-dimensional transthoracic echocardiography (3D-TTE) and provide added value in the management of MAD syndrome.Case presentationA 50-year-old male patient with recent syncope and a history of mitral regurgitation (MR) and MAD was admitted to our clinic for further investigation. According to our protocol, the patient underwent a complete 3D-TTE, laboratory blood exams, and 24 h ambulatory electrocardiogram (ECG). Our investigation confirmed the presence of MAD syndrome with bileaflet prolapse, severe MR, and non-sustained ventricular tachycardia, necessitating an implantable cardioverter defibrillator (ICD) and surgical mitral valve repair. The 3D-TTE analysis of the mitral valve demonstrated mitral annular systolic expansion and systolic flattening of the saddle-shaped annulus and quantified the extent of the disjunction arc. Additionally, four-dimensional (4D) strain analysis of the left ventricle revealed the presence of fibrosis of the posteromedial papillary muscle and basal inferolateral wall, which are variables that are required for the diagnosis and therapeutic management of MAD syndrome.Conclusions3D-TTE and 4D strain offer valuable insights for diagnosing and managing patients with MAD syndrome. This method seems to correlate well with the other imaging modalities and could be included in the management protocol of MAD syndrome

1119-99 Immunoglobulin A anticardiolipin antibodies are markers of the extent of daily life ischemia in patients with stable angina

Rising population numbers place ever increasing demands on energy resources. A large percentage of the worldwide energy production is reserved for the generation of electricity and a significant portion of the electrical energy generation is used for illumination purposes. At the same time, people demand brighter light sources that provide better light quality. The luminaire of today is not just a simple lamp, but a complex, intelligent piece of technology designed for a specific purpose. This doctoral dissertation aims to provide a link between the theoretical universe surrounding the physics of electromagnetic radiation and the practical illumination world. A theoretical framework presents the physical properties of light and connects, through the human visual system, to a number of perceptual models. Based on these perceptual models, the colourimetric qualities of an illumination spectrum are analysed and a theoretical framework that aims to optimise the balance between colour fidelity and energy efficiency is proposed. The result of this optimisation is a spectrum that needs to be implemented into a light source. Recent advancements in semiconductor technology led to the development of highly efficient light emitting diodes. The monochromatic nature of these light sources offers the possibility of creating a spectrally tuneable luminaire that is able to reproduce these optimised illumination spectra. A fully integrated spectrally tuneable light engine combines knowledge on characterising and driving LEDs, optical design and thermal management. Each group of monochromatic LEDs needs a variable current source that ensures predictable behaviour regardless of their dimming level or temperature. An advanced optical solution enables efficient light extraction from the LEDs, provides excellent luminance and chroma homogenisation and, finally, delivers a suitable beam pattern for the intended illumination application. Proper thermal management establishes sufficient heat extraction to guarantee low semiconductor temperatures. Finally, the LED light engines created during this doctoral research are incorporated into three spectrally tuneable illumination devices, each designed for a specific purpose. A set of spectrally tuneable downlights installed in the laboratories of the lighting group of the Catalonia Institute for Energy Research (IREC) in Barcelona, Spain and the department of neuroscience of the University of Newcastle in the United Kingdom serves as a valuable tool for experiments that evaluate both physical and psychovisual properties of selected illumination spectra. A compact spotlight, used during the "Making Colour" exhibition of the National Gallery in London, is optimised to provide a set of specific illumination spectra to illuminate art reproductions. Lastly, a high power luminaire was designed to generate specialised spectra to irradiate greenhouse plants, steering their morphology and the production of plant-specific compounds.El incremento de población mundial en los últimos años implica necesariamente un incremento en la demanda energética global. Un alto porcentaje de la energía producida globalmente es utilizada para iluminar los diferentes espacios. Al mismo tiempo, los usuarios reclaman cada vez fuentes de luz más potentes y entornos más iluminados y con mayor calidad de luz. Las luminarias actuales no son simplemente lámparas, sino sistemas complejos e inteligentes diseñados con propósitos específicos. Esta tesis doctoral pretende unir dos espacios que normalmente son abordados de manera separada: por un lado, el entorno teórico de la radiación visible y sus propiedades colorimétricas, y por otro lado la luminotecnia aplicada. En el ámbito teórico, se han tratado con las propiedades físicas de la luz, estableciendo un puente a través de la visión humana con diferentes modelos de percepción visual. En base a estos modelos, se han analizado las propiedades colorimétricas de los espectros de iluminación estudiados y se propone un marco teórico de optimización entre fidelidad de color y eficiencia energética. Los resultados de esta optimización se han implementado también en una fuente de luz de espectro modulable real. Recientemente, el mercado LED está alcanzando valores altísimos en cuanto a eficacias lumínicas. Sin embargo, el crecimiento del mercado pasa por mejorar otros aspectos que garanticen el progreso de la tecnología. La naturaleza esencialmente monocromática de los LEDs de estado sólido ofrece la posibilidad de crear fuentes de luz de espectro sintonizable mediante la composición espectral o adición cromática de varios tipos diferentes de LED. Para el diseño de una de estas fuentes de luz se requieren conocimientos en cuanto a la caracterización y energizado de los LEDs, diseño óptico y diseño térmico. Cada clúster de LEDs de características espectrales similares necesita una fuente de corriente variable que garantice unos valores estables y que no dependan de otros parámetros como la potencia de entrada o la temperatura. Se necesitan también soluciones ópticas avanzadas para conseguir no solo una alta eficiencia de extracción de la radiación sino también una mezcla homogénea de los colores a la salida así como una distribución angular específicamente diseñada para cada aplicación. Por otro lado, se precisa de un manejo térmico óptimo que permita la extracción de calor hacia elementos activos o pasivos para que así la temperatura de la unión de los LEDs sea óptima. Finalmente, los módulos LED creados durante esta tesis doctoral se han incorporado en tres luminarias distintas representativas de tres campos de aplicación independientes. La primera aplicación implicó el diseño y la incorporación de los módulos LED a un grupo de downlights que se instalaron en una habitación del Instituto de Investigación en Energía de Cataluña y en el Instituto de Neurociencia de la Universidad de Newcastle (UK), constituyendo dos instalaciones únicas para la investigación de los aspectos físicos y físico-visuales de diferentes espectros de iluminación. Para la segunda aplicación, se diseñaron un conjunto de luminarias tipo spotlight que fueron instaladas y demostradas en la exhibición "Making Colour" que tuvo lugar en la National Gallery (Londres). En la misma, se mostraron las propiedades de distintos espectros de iluminación. Finalmente, se ha realizado también una luminaria de alta potencia optimizada para la generación de espectros de interés en horticultura, habiéndose demostrado que es posible cambiar la morfología de los cultivos estudiados e incentivar la producción de ciertas vitaminas y compuesto

Inotropes in Acute Heart Failure: From Guidelines to Practical Use: Therapeutic Options and Clinical Practice

Inotropes are pharmacological agents that are indicated for the treatment of patients presenting with acute heart failure (AHF) with concomitant hypoperfusion due to decreased cardiac output. They are usually administered for a short period during the initial management of AHF until haemodynamic stabilisation and restoration of peripheral perfusion occur. They can be used for longer periods to support patients as a bridge to a more definite treatment, such as transplant of left ventricular assist devices, or as part of a palliative care regimen. The currently available inotropic agents in clinical practice fall into three main categories: beta-agonists, phosphodiesterase III inhibitors and calcium sensitisers. However, due to the well-documented potential for adverse events and their association with increased long-term mortality, physicians should be aware of the indications and dosing strategies suitable for different types of patients. Novel inotropes that use alternative intracellular pathways are under investigation, in an effort to minimise the drawbacks that conventional inotropes exhibit

Telemedicine in Congenital Heart Disease

BACKGROUND: The primary rationale for the development of telemedicine has been to serve populations that have limited access to traditional, high quality medical services. These include those living in rural areas or other underserved areas, like islands, or even urban areas when a rare medical subspecialty, such as pediatric cardiology is not available. OBJECTIVE: The aim of the present study was to present our results with use of telemedicine during the European project TELEREMEDY over a period of 26 months when adult cardiologists and pediatricians of our hospital communicated with pediatric cardiologists at the tertiary Children’s Hospital “Agia Sofia” in Athens and at the Royal Brompton Hospital in London, as well as with physicians at the “Venizelio” Hospital in Crete. METHODS AND RESULTS: Over 26 months, 31 teleconference sessions were organized. During this period, 155 children with suspected congenital heart disease (CHD) underwent echocardiographic examination, which confirmed CHD in 83 (54%), acquired heart disease in 13 (8%) and normal anatomy in 59 (38%). Ventricular septal defect was diagnosed in 26/83 (31%), complex CHD in 20 (24%), atrial septal defect in 12 (14%) and patent ductus arteriosus in 8 (10%) children. Our hospital with the adult electrophysiology team was the expertise center for diagnosis and treatment of 30 children with arrhythmia. During 23 sessions with the tertiary Children’s Hospital “Agia Sofia” in Athens, an immediate transfer to the pediatric intensive care unit of the tertiary center was decided for 27 cases (17%). During 3 sessions with one participating hospital we provided consultation for 10 cases with arrhythmias. During 6 sessions with the Royal Brompton Hospital in London, rare cases of CHD, both adult and pediatric, were discussed. Two multilane conferences were organized among all participants and the systems capabilities in each hospital were discussed. CONCLUSION: Telemedicine systems, like the one used herein in the context of the TELEREMEDY program, facilitate a timely diagnosis and management of children with CHD in hospitals lacking pediatric cardiology service. In the present series, use of this program obviated unnecessary and costly transfers in 83% of cases. Thus, immediate access to specialists can guide patient management and may potentially alter the morbidity and mortality in this patient population

Interrelated modulation of endothelial function in Behcet's disease by clinical activity and corticosteroid treatment

Corticosteroids are commonly used in empirical treatment of Behçet's disease (BD), a systemic inflammatory condition associated with reversible endothelial dysfunction. In the present study we aimed to dissect the effects of clinical disease activity and chronic or short-term corticosteroid treatment on endothelial function in patients with BD. In a case-control, cross-sectional study, we assessed endothelial function by endothelium dependent flow mediated dilatation (FMD) at the brachial artery of 87 patients, who either were or were not receiving chronic corticosteroid treatment, and exhibiting variable clinical disease activity. Healthy individuals matched for age and sex served as controls. Endothelial function was also assessed in a prospective study of 11 patients before and after 7 days of treatment with prednisolone given at disease relapse (20 mg/day). In the cross-sectional component of the study, FMD was lower in patients than in control individuals (mean ± standard error: 4.1 ± 0.4% versus 5.7 ± 0.2%, P = 0.003), whereas there was a significant interaction between the effects of corticosteroids and disease activity on endothelial function (P = 0.014, two-factor analysis of variance). Among patients with inactive BD, those who were not treated with corticosteroids (n = 33) had FMD comparable to that in healthy control individuals, whereas those treated with corticosteroids (n = 15) had impaired endothelial function (P = 0.023 versus the respective control subgroup). In contrast, among patients with active BD, those who were not treated with corticosteroids (n = 20) had lower FMD than control individuals (P = 0.007), but in those who were receiving corticosteroids (n = 19) the FMD values were comparable to those in control individuals. Moreover, FMD was significantly improved after 7 days of prednisolone administration (3.7 ± 0.9% versus 7.6 ± 1.4%, P = 0.027). Taken together, these results imply that although corticosteroid treatment may impair endothelial function per se during the remission phase of the inflammatory process, it restores endothelial dysfunction during active BD by counteracting the harmful effects of relapsing inflammation