Massive mitral regurgitation secondary to acute ischemic papillary muscle rupture: The role of echocardiography

Papillary muscle rupture is an infrequent but often fatal mechanical complication of acute myocardial infarction (AMI). We report the case of an AMI complicated by the development of an abrupt cardiogenic shock due to the rupture of the head of the postero-medial papillary muscle with echocardiographic demonstration of severe mitral regurgitation due to flail posterior mitral valve leaflet. After initial stabilization with medical therapy and diagnostic coronary angiography, the patient was referred for urgent cardiac surgery and successfully underwent mitral valve replacement with implantation of a bioprosthesis. This case confirms the importance of transthoracic echocardiography in diagnosing mechanical acute complications during an AMI and in the decision making of patients with sudden onset of hemodynamic compromise. Transthoracic echogardiography should be immediately carried out in all patients in whom a mechanical complication during an AMI is suspected. (Cardiol J 2010; 17, 4: 397-400

Left atrial strain in patients with arterial hypertension

Background: Arterial hypertension (HTN) causes left ventricular (LV) cavity dysfunction even if ejection function (EF) remains preserved. Recent studies have shown that diastolic dysfunction and left atrial (LA) dilatation are also associated with myocardial dysfunction. The aim of the present study was to explore the nature of LA longitudinal function disturbances in hypertensive patients with normal LV and LA structure and conventional function parameters.Methods: Peak atrial longitudinal strain (PALS) was evaluated in 78 patients with systemic HTN and preserved EF (≥ 55%) divided in 41 patients with diastolic dysfunction but no hypertrophy (group HTNdd), and 37 patients with no diastolic dysfunction or hypertrophy (group eHTN). Results were compared with those from 38 age and gender-matched healthy controls.Results: Indexed LA area and indexed LA volume were within the normal range and not different between the two patient groups and controls. eHTN group had reduced global PALS (p &lt; 0.001) and four-and two-chamber average PALS (p &lt; 0.001 for both). Similar abnormalities were seen in HTNdd group but to a worse degree (P &lt; 0.01 for both). LV EF was not different between the eHTN and HTNdd groups compared to controls. LV E/e' ratio was the strongest predictor of reduced global PALS in both eHTN and HTNdd groups.Conclusion: Asymptomatic untreated HTN patients with preserved LVEF and normal diastolic function have compromised LA strain despite normal cavity size, consistent with preclinical LA myocardial dysfunction.</p

Wpływ lewosimendanu podawanego bez dawki nasycającej na skurczową i rozkurczową funkcję serca u pacjentów ze schyłkową niewydolnością serca

Wstęp: Lewosimendan (L) jest lekiem stosowanym w terapii ciężkiej niewydolności serca (HF). Działa inotropowo dodatnio oraz wazodylatacyjnie, nie zwiększając zapotrzebowania serca na tlen. W ostrej HF lewosimendan poprawia parametry hemodynamiczne. W dostępnych publikacjach wykazano, że pozytywnie wpływa na funkcję rozkurczową lewej komory (LV). Celem niniejszego badania była ocena wpływu lewosimendanu na zmiany długiej osi LV, która jest wczesnym markerem dysfunkcji rozkurczowej. Metody: Do badania włączono 41 pacjentów w średnim wieku 62 &#177; 12 lat przyjętych do kliniki autorów niniejszej pracy z powodu ostrej HF w klasie IV według NYHA z istotną dysfunkcją LV. Dwudziestu sześciu pacjentom podano lewosimendan w dawce 0,1 &#956;g/kg/min w ciągu 24 godzin bez dawki nasycającej (grupa L), zaś 15 chorych poddano standardowej terapii (grupa C). Wyniki: Grupy nie różniły się między sobą pod względem podstawowych danych demograficznych, klinicznych i wyników badań biochemicznych. Po tygodniu od leczenia lewosimendanem obserwowano istotną poprawę wydolności w klasie NYHA oraz obniżenie stężenia N-końcowego propeptydu natriuretycznego typu B (pro-BNP). W badaniu echokardiograficznym obserwowano poprawę funkcji skurczowej (p < 0,05) i frakcji wyrzutowej LV (p < 0,05) przy redukcji wskaźnika E/E&#8217; (p < 0,05) w grupie L. Grupę L podzielono na podgrupę z aktywnym niedokrwieniem i bez niedokrwienia oraz wykazano istotną poprawę funkcji skurczowej w pierwszej podgrupie. Nie wykazano różnic między podgrupami w odniesieniu do funkcji rozkurczowej LV. Wnioski: Stosowanie lewosimendanu bez dawki nasycającej poprawia funkcję LV i klasę NYHA u pacjentów z ostrą HF. Wydaje się, że przedłużony wpływ na parametry hemodynamiczne jest związany z działaniem aktywnych metabolitów leku. (Folia Cardiologica Excerpta 2012; 7, 2: 71-77

Takotsubo cardiomyopathy in a Caucasian Italian woman: Case report

BACKGROUND: Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levels CASE PRESENTATION: A 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities. CONCLUSION: Takotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman

Effects of levosimendan without loading dose on systolic and diastolic function in patients with end-stage heart failure

Background: Levosimendan (L) is used in clinical practice for the treatment of severe heart failure (HF); it has inotropic and vasodilatory effects, without increasing myocardial oxygen consumption. In acute HF, levosimendan improves hemodynamic parameters; previous studies have demonstrated that it has favorable effects on left ventricular (LV) diastolic function. The aim of our study was to evaluate the effect of on LV long-axis function that represents the earlier marker of diastolic dysfunction. Methods: We enrolled 41 patients (age 62 &#177; 12 years) admitted to our Department for acute HF, NYHA class IV and severe LV dysfunction. Twenty-six patients were treated with L (0.1 &#956;g/kg/min ev for 24 h without loading dose) and 15 patients were treated with standard therapy (C). We evaluated clinical, blood exams and echocardiographic parameters at baseline and one week after L or C treatment. Results: Baseline demographic, clinical and biochemical data were similar in both groups. After one week, the L group had shown a significant improvement in NYHA class and a reduction of pro-B-type natriuretic peptide (pro-BNP). In echocardiographic study, we observed an improvement in LV longitudinal function (p < 0.05) and LV ejection fraction (p < 0.05) with a reduction of E/E&#8217; (p < 0.05) in the L group. We divided the L group into ischemic and non- -ischemic patients and we demonstrated a significant increase in systolic function in the former. No differences were found between subgroups in diastolic function. Conclusions: L therapy, without loading dose, improves NYHA class and ventricular function in patients with acute HF; we believe that these prolonged hemodynamic effects are due to active metabolities of L. (Cardiol J 2011; 18, 5: 532&#8211;537

Effects of levosimendan on heart failure in normotensive patients: Does loading dose matter?

Background: Levosimendan is a calcium sensitizer and K+-ATP channel opener with inotropic and vasodilatatory effects irrespective of myocardial oxygen consumption, used for treatment of heart failure (HF). A loading dose is usually given by infusion for 12 h; however, profound lowering of blood pressure often disrupts or prolongs the infusion. The aim of this study was to assess clinical, biochemical and myocardial differences between different regimes of levosimendan therapy, with or without loading dose, and compared to standard therapy in heart failure. Methods: Fifty-seven patients (mean age ± SD: 60.9 ± 9.3 years, 45 males) with HF, New York Heart Association (NYHA) III-IV, reduced left ventricular ejection fraction (LVEF) were included. Twenty patients (NB group) were given levosimendan without loading dose, 14 patients (B group) were given levosimendan with loading dose, and 23 patients (C group) were given standard therapy. Clinical, biochemical and echocardiographic characteristics at baseline and one week after treatment were evaluated. Results: Groups were similar at baseline. After one week NHYA class (P < 0.001), NT pro-BNP (P < 0.001), LVEF (P = 0.045), E/A (P = 0.048) E/e (P < 0.001), and PAPs (P < 0.001) decreased. DT (P = 0.011) and TAPSE (P = 0.035) increased in all groups. Conclusions: Levosimendan, as well as standard therapy, improves myocardial function and symptoms of HF, irrespective of the loading dose administration. Treatment options for patients with end-stage heart failure refractory to conventional medical therapy are limited. Inotropic drugs play an important role in heart failure (HF) (1-3)

Neurohumoral improvement and torsional dynamics in patients with heart failure after treatment with levosimendan

Levosimendan improves clinical and hemodynamic parameters exerting an anti-inflammatory and antiapoptotic effect in decompensated heart failure. The aim of this study was to evaluate the effects of levosimendan on LV torsion, plasma levels of NT-proBNP and on the balance between pro-inflammatory (TNF-α, IL-6) and anti-inflammatory cytokines (IL-10). We enrolled 24 patients (age 62 ± 7 years) with acute HF, NYHA class IV and severe LV dysfunction. All patients underwent transthoracic echocardiography using two-dimensional speckle tracking analysis to detect LV twist angle (LVTA), at baseline and 1 week after treatment with levosimendan infusion. Biochemical parameters (pro-BNP, IL-6, IL-10, TNF-α) were determined by enzyme-linked immunosorbent (ELISA). After one week, we observed an improvement in LV function especially in LVTA (4.15 ± 2.54 vs 2.9 ± 2.1 p 20%) and BNP (Δ > 40%), LVEF (Δ > 10%) and LVTA (Δ > 20%) (O.R. 1.77, 95% C.I. 1.11–2.83, O.R. 1.49, 95% C.I. 1.08–2.67, O.R. 1.66, 95% C.I. 1.10–2.74, respectively, confirmed p, all < 0.01 by Hosmer–Lemeshov confirmation and the formal test for interaction). Levosimendan exerts a hemodynamic effect by improving EF and LV torsion in patients with acute HF in association with a positive effect on the balance between pro and anti-inflammatory cytokines

Neurohumoral improvement and torsional dynamics in patients with heart failure after treatment with levosimendan

Background: Levosimendan improves clinical and hemodynamic parameters exerting an anti-inflammatory and antiapoptotic effect in decompensated heart failure. The aim of this study was to evaluate the effects of levosimendan on LV torsion, plasma levels of NT-proBNP and on the balance between pro-inflammatory (TNF-α, IL-6) and anti-inflammatory cytokines (IL-10). Methods: We enrolled 24 patients (age 62 ± 7 years) with acute HF, NYHA class IV and severe LV dysfunction. All patients underwent transthoracic echocardiography using two-dimensional speckle tracking analysis to detect LV twist angle (LVTA), at baseline and 1 week after treatment with levosimendan infusion. Biochemical parameters (pro-BNP, IL-6, IL-10, TNF-α) were determined by enzyme-linked immunosorbent (ELISA). Results: After one week, we observed an improvement in LV function especially in LVTA (4.15 ± 2.54 vs 2.9 ± 2.1 p  20%) and BNP (Δ > 40%), LVEF (Δ > 10%) and LVTA (Δ > 20%) (O.R. 1.77, 95% C.I. 1.11–2.83; O.R. 1.49, 95% C.I. 1.08–2.67; O.R. 1.66, 95% C.I. 1.10–2.74, respectively, confirmed p, all <0.01 by Hosmer–Lemeshov confirmation and the formal test for interaction). Conclusions: Levosimendan exerts a hemodynamic effect by improving EF and LV torsion in patients with acute HF in association with a positive effect on the balance between pro and anti-inflammatory cytokines

Cardiac benefits after alcohol withdrawal

Numerous studies demonstrated that a chronic consumption of alcohol is directly related to alcoholic cardiomyopathy (ACM), which is a specific dilated cardiomyopathy