Chapter 3: Pathophysiology

The hallmark pathophysiologic feature of dilated cardiomyopathy is systolic dysfunction. Several pathogenetic mechanisms appear to be operative. These include increased hemodynamic overload, ventricular remodeling, excessive neurohumoral stimulation, abnormal myocyte calcium cycling, excessive or inadequate proliferation of the extracellular matrix, accelerated apoptosis, and genetic mutations. Although beneficial in the early stages of heart failure, these compensatory mechanisms eventually lead to a vicious cycle of worsening heart failure. Genetic causes account for 30\u201340% of DCM and involve genes that encode a heterogeneous group of molecules that participate in force generation, force transmission, sarcomere integrity, cytoskeletal and nuclear architecture, electrolyte homeostasis, mitochondrial function, and transcription. Additional research will improve our understanding of the complex and longitudinal molecular changes that lead from gene mutation to clinical expressio

The prognostic value of dobutamine stress echocardiography amongst British Indian Asian and Afro-Caribbean patients: a comparison with European white patients

Background The incidence of cardiovascular disease is considerably disparate among different racial and ethnic populations. While dobutamine stress echocardiography (DSE) has been shown to be useful in Caucasian patients, its role among ethnic minority groups remains unclear. This study aimed to investigate the prognostic importance of DSE in three ethnic groups in the UK. Methods DSE was performed on 6231 consecutive patients. After exclusions, 5329 patients formed the study (2676 [50.2 %] Indian Asian, 2219 [41.6 %] European white and 434 [8.1 %] Afro-Caribbean). Study outcome measures were non-fatal cardiac events (NFCE) and all-cause mortality. Results There were 849 (15.9 %) NFCE and 1365 (25.6 %) deaths over a median follow-up period of 4.6 years. In total 1174 (22 %) patients had inducible myocardial ischaemia during DSE, 859 (16.1 %) had fixed wall motion abnormalities and 3645 (68.4 %) patients had a normal study. Ethnicity did not predict events. Among the three ethnic groups, ischaemia on DSE was associated with 2 to 2.5 times the risk of non-fatal cardiac events and 1.2 to 1.4 times the risk of all-cause mortality. Peak wall motion score index was the strongest independent predictor of non-fatal cardiac events and all-cause mortality in all groups. The C statistic for the prediction of NFCE and all-cause mortality were significantly higher when DSE parameters were added to the standard risk factors for all ethnic groups. Conclusions DSE is a strong predictor of NFCE and all-cause mortality and provides predictive information beyond that provided by standard risk factors in three major racial and ethnic groups. No major differences among racial and ethnic groups in the predictive value of DSE was detected

Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography

Purpose: A number of parameters recorded during dobutamine stress echocardiography (DSE) are associated with worse outcome. However, the relative importance of baseline mitral regurgitation (MR) is unknown. The aim of this study was to assess the prevalence and associated implications of functional MR with long-term mortality in a large cohort of patients referred for DSE. Methods: 6745 patients (mean age 64.9±12.2 years) were studied. Demographic, baseline and peak DSE data were collected. All-cause mortality was retrospectively analyzed. DSE was successfully completed in all patients with no adverse outcomes. Results: MR was present in 1019 (15.1%) patients. During a mean follow up of 5.1±1.8 years, 1642 (24.3%) patients died and MR was significantly associated with increased all-cause mortality (p<0.001). With Kaplan-Meier analysis, survival was significantly worse for patients with moderate and severe MR (p<0.001). With multivariate Cox regression analysis, moderate and severe MR (HR 2.78; 95% CI 2.17 - 3.57; and HR 3.62; 95% CI 2.89 - 4.53, respectively) were independently associated with all-cause mortality. The addition of MR to C statistic models significantly improved discrimination. Conclusions: MR is associated with all-cause mortality and adds incremental prognostic information among patients referred for DSE. The presence of MR should be taken into account when evaluating the prognostic significance of DSE results

New view in the mammary asymmetry treatments [Nuove prospettive nel trattamento delle asimmetrie mammarie]

Aim. Breast asymmetry is a huge chapter of breast abnormalities. Surgical therapy is the exclusive one. The breast of women can vary in shape, volume and position, thus creating esthetic, social and psychological problems. Methods. We classified breast asymmetry into 6 categories and then we treated them with different surgical techniques: reduction mammaplasty according to Planas; augmentation mammaplasty with prosthesis; grafts or both; ultimately mammaprosthesis (association of mastopessy and prosthesis). We obtained satisfactory esthetic results often with one surgery procedure. Rarely we performed 2 or more procedures of symmetry. We treated 77 patients suffering from breast asymmetry. We excluded in this study the gigantomastic asymmetry (anomaly determined by severe and asymmetric mammary hypertrophy). Results. We found a low number of complications at short and long term. These results are likely due to the ability of the surgeon in the appropriated preoperative evaluation of the patients and of their expectancy and correct surgical techniques. Conclusion. We tried to obtain 3 results: shape and position of the sick breast as same as possible to the contralateral breast and less evident scars located in hidden regions

New view in the mammary asymmetry treatments [Nuove prospettive nel trattamento delle asimmetrie mammarie]

Aim. Breast asymmetry is a huge chapter of breast abnormalities. Surgical therapy is the exclusive one. The breast of women can vary in shape, volume and position, thus creating esthetic, social and psychological problems. Methods. We classified breast asymmetry into 6 categories and then we treated them with different surgical techniques: reduction mammaplasty according to Planas; augmentation mammaplasty with prosthesis; grafts or both; ultimately mammaprosthesis (association of mastopessy and prosthesis). We obtained satisfactory esthetic results often with one surgery procedure. Rarely we performed 2 or more procedures of symmetry. We treated 77 patients suffering from breast asymmetry. We excluded in this study the gigantomastic asymmetry (anomaly determined by severe and asymmetric mammary hypertrophy). Results. We found a low number of complications at short and long term. These results are likely due to the ability of the surgeon in the appropriated preoperative evaluation of the patients and of their expectancy and correct surgical techniques. Conclusion. We tried to obtain 3 results: shape and position of the sick breast as same as possible to the contralateral breast and less evident scars located in hidden regions

Devastating methicillin resistant Staphylococcus aureus wound infection following abdominoplasty in a prior bariatric surgery patient

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks' She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty. We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach

Su un caso clinico di torsione uterina in gravidanza

The Authors report a case of classic cesarean section through the posterior uterine wall because of a uterine torsion with failure of restitution at 31st week of pregnancy, abruptio placentae, premature rupture of the membranes and partial septate uterus. The uterine torsion is a very rare complication in pregnancy, but it is associated with serious fetal and maternal consequences