Acute Left Ventricular Dysfunction Research Articles

Associations of epicardial adipose tissue thickness and cardiometabolic risk factors in STEMI patients treated with percutaneous coronary intervention

Aim: To evaluate EAT thickness in STEMI patients treated with percutaneous coronary intervention (PCI) and its associations with body mass index (BMI), blood lipids and acute left ventricular dysfunction. Introduction: Epicardial adipose tissue (EAT), located between the myocardium and visceral layer of pericardium is an emerging risk factor for cardiometabolic diseases. Methods: The retrospective study consisted of patients hospitalised for STEMI treated with PCI from 2014 to 2016. EAT thickness was measured from the parasternal long-axis view at end-diastole. Cholesterol levels were determined in a blood sample. According to median patients were divided in two groups: thin EAT group (<2.27mm, n=270) and thick EAT group (≥2.27mm, n=223). Statistical analysis was performed with SPSS using Mann–Whitney test, T-test, logistic regression analysis. Values of cholesterol levels were evaluated by ROC curves. p<0.05 was significant. Results: Total 492 patients (332 males, 66.62±12.24 year-old) were enrolled. Groups did not differ by age, gender, morbidity of diabetes mellitus and triglyceride levels. Patients had higher BMI (29.41±4.97 vs. 28.13±4.67kg/m2, p=0.009), total cholesterol (>4.82mmol/l: 35.2 vs. 26.4%, p=0.024), low density lipoprotein cholesterol (>2.5mmol/l: 45.8 vs. 33.3%, p=0.004) and reduced high density lipoprotein cholesterol (HDL-C) levels (≤1mmol/l: 24.4 vs. 10.4%, p=0.009) in thick EAT group. Logistic regression analysis revealed that higher BMI (OR=1.532, 95% CI 1.008–2.328, p=0.002) and HDL-C ≤1mmol/l (OR=1.777, 95% CI 1.159–2.724, p=0.008) were associated with thicker EAT. Killip class ≥III was more frequent (17.6 vs. 10.3%, p=0.02) in thick than thin EAT group. Conclusion: Increased EAT thickness was associated with obesity, cardiometabolic risk factors and influenced severity of left ventricular dysfunction.

Catecholamine-Dependent β-Adrenergic Signaling in a Pluripotent Stem Cell Model of Takotsubo Cardiomyopathy

BackgroundTakotsubo syndrome (TTS) is characterized by an acute left ventricular dysfunction and is associated with life-threating complications in the acute phase. The underlying disease mechanism in TTS is still unknown. A genetic basis has been suggested to be involved in the pathogenesis. ObjectivesThe aims of the study were to establish an in vitro induced pluripotent stem cell (iPSC) model of TTS, to test the hypothesis of altered β-adrenergic signaling in TTS iPSC-cardiomyocytes (CMs), and to explore whether genetic susceptibility underlies the pathophysiology of TTS. MethodsSomatic cells of patients with TTS and control subjects were reprogrammed to iPSCs and differentiated into CMs. Three-month-old CMs were subjected to catecholamine stimulation to simulate neurohumoral overstimulation. We investigated β-adrenergic signaling and TTS cardiomyocyte function. ResultsEnhanced β-adrenergic signaling in TTS-iPSC-CMs under catecholamine-induced stress increased expression of the cardiac stress marker NR4A1; cyclic adenosine monophosphate levels; and cyclic adenosine monophosphate–dependent protein kinase A–mediated hyperphosphorylation of RYR2-S2808, PLN-S16, TNI-S23/24, and Cav1.2-S1928, and leads to a reduced calcium time to transient 50% decay. These cellular catecholamine-dependent responses were mainly mediated by β1-adrenoceptor signaling in TTS. Engineered heart muscles from TTS-iPSC-CMs showed an impaired force of contraction and a higher sensitivity to isoprenaline-stimulated inotropy compared with control subjects. In addition, altered electrical activity and increased lipid accumulation were detected in catecholamine-treated TTS-iPSC-CMs, and were confirmed by differentially expressed lipid transporters CD36 and CPT1C. Furthermore, we uncovered genetic variants in different key regulators of cardiac function. ConclusionsEnhanced β-adrenergic signaling and higher sensitivity to catecholamine-induced toxicity were identified as mechanisms associated with the TTS phenotype. (International Takotsubo Registry [InterTAK Registry] [InterTAK]; NCT01947621)

Journey from Bonsai Dependent Marginal Donor to a Happy Ending

Introduction As the prevelance of end stage heart failure increases clinicians are left without enough allografts to meet the growing need for heart transplantation.[1] This incompatible difference between the number of heart failure patients and the supply of suitable organs for transplant has increased the use of marginal donor hearts.[2][3] Reduced left ventricular ejection fraction in the donor heart has traditionally been a significant predictor of graft non utilization. However, there is enough evidence to accept that some donor hearts that do not initially meet optimum transplant criteria may be utilized with good results.[4] Case Presentation In February 2017 while we hospitalized a 44 year old male patient with end stage heart failure we have been informed about a 26 year old male patient who was previously using a synthetic Cannabinoid (Bonsai)[6][7] with no other known medical history. We learned that he had fallen from a balcony after taking the drug and sustained critical head injuries. After a brief period in the ICU he becomes haemodynamically unstable with no response to inotropic agents.[5] After brain death testing confirmed an echocardiogram is performed and reported as normal. In the course of harvesting mild left ventricular hypokinesia was noted. But as the final decision was given: the heart was arrested, preserved and was transplanted to the recipient. After the completion of the anastomoses of the allograft; heart started to beat spontaneously. However, the transesophageal echocardiography performed during the transplantation showed a bilateral ventricular dysfunction. The patient was supported by inotropes and central venoarterial extracorporeal membrane oxygenation (ECMO) when leaving the operating room. Patient was extubated and weaned from ECMO and decanulated on postoperative day 4. After extubation, a resistant atrial tachycardia was added to the condition in the early postoperative period with no response to medical therapy, requiring DC cardioversion. Than the patient immediately became haemodynamically stable; left and right ventricle functions on echocardiography were improved and he was able to be discharged 34 days post transplantation. He is symptom free at 1month follow up with normal cardiac function. Conclusion Acute severe left ventricular dysfunction in cardiac allograft occurring in association with severe neurological injury and drug addiction; maintained well after appropriate medical therapy.

Takotsubo Syndrome \u2013 Predictable from brain imaging data

Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, with a hospital-mortality rate similar to acute coronary syndrome (ACS). However, the aetiology of TTS is still unknown. In the present study, a multivariate pattern analysis using machine learning with multimodal magnetic resonance imaging (MRI) data of the human brain of TTS patients and age- and gender-matched healthy control subjects was performed. We found consistent structural and functional alterations in TTS patients compared to the control group. In particular, anatomical and neurophysiological measures from brain regions constituting the emotional-autonomic control system contributed to a prediction accuracy of more than 82%. Thus, our findings demonstrate homogeneous neuronal alterations in TTS patients and substantiate the importance of the concept of a brain-heart interaction in TTS.

急性心肌梗塞合并心功能不全的诊疗进展

急性心肌梗塞常合并有急性心功能不全和(或)左室功能下降，对于心肌梗死后期的心功能不全发生率，短期及长期的致死率有显著影响。研究发现及时开通急性心肌梗死患者罪犯血管(溶栓或急诊PCI或溶栓后PCI，搭桥治疗)，急性心肌梗死合并心功能不全发生率明显下降，仍有一部分急性心肌梗死患者合并有急性心功能不全及(或)左室功能不全，且这两种并发症常并存，互相影响，导致急性心肌梗死后“存活”患者的心功能不全的发生率增加。如何预防心肌梗死后急性心功能不全的发生，目前仍是临床关注的问题。下面就急性心肌梗塞合并心功能不全的流行病学，分型，机制等方面进行综述。 Acute myocardial infarction is often accompanied with acute cardiac inefficiency and/or left ventricular dysfunction that affects the incidence of cardiac insufficiency and short term and long-term mortality. The study found that the timely opening of blood vessels (thrombolysis or emergency PCI or thrombolysis after PCI, bypass treatment), in acute myocardial infarction pa-tients with acute myocardial infarction, remarkably reduce the acute cardiac inefficiency and/or left ventricular insufficiency, but there are still some patients with acute myocardial infarction have acute cardiac incomplete function and/or left ventricular dysfunction, these two complica-tions often coexist, and affect each other, leading to acute myocardial infarction “surviving” pa-tients increasing incidence of cardiac insufficiency. How to prevent the incidence of acute cardi-ac insufficiency in myocardial infarction patients which is focus in clinical. The overview is about the epidemiology, typing, and mechanisms of acute myocardial infarction with acute cardiac insufficiency.

Takotsubo Cardiomyopathy after Hybrid Repair of Thoracic and Thoracoabdominal Aortic Aneurysm

Context: Takotsubo cardiomyopathy is characterized by transient and acute left ventricular dysfunction with apical dyskinesia in the absence of coronary artery disease. The pathophysiology of this rare disease is considered to be associated with physical and psychological stress. Recently published case reports have described the association between Takotsubo syndrome and various surgical procedures as the causative stress factors. However, Takotsubo cardiomyopathy is extremely rare in patients who have undergone cardiovascular surgery. Case report: Here, we report a rare case of Takotsubo cardiomyopathy developing after thoracic endovascular aortic repair for chronic dissecting aortic aneurysm. Conclusion: This patient developed Takotsubo cardiomyopathy 14 days after thoracic endovascular aortic repair, potentially because of the prolonged perioperative physical and psychological stress induced by multi-stage surgery. To our knowledge, this is the first report of Takotsubo cardiomyopathy after thoracic endovascular aortic repair. Through this report, we emphasize the importance of considering the possibility of Takotsubo cardiomyopathy in patients presenting symptoms of cardiogenic shock and unexplained hemodynamic deterioration, despite having undergone relatively less-invasive cardiovascular surgery. Early diagnosis is required to initiate appropriate treatment and to minimize the chance of complications.

The use of N-acetylcysteine in patients with acute coronary syndrome and diastolic left ventricular dysfunction, in accordance with the level of high-sensitivity C-reactive protein

The use of N-acetylcysteine in patients with acute coronary syndrome and diastolic left ventricular dysfunction, in accordance with the level of high-sensitivity C-reactive protein

Effects of Combined Milrinone and Levosimendan Treatment on Systolic and Diastolic Function During Postischemic Myocardial Dysfunction in a Porcine Model.

It is not known whether there are positive or negative interactions on ventricular function when a calcium-sensitizing inotrope is added to a phosphodiesterase inhibitor in the clinical setting of acute left ventricular (LV) dysfunction. We hypothesized that when levosimendan is added to milrinone treatment, there will be synergetic inotropic and lusitropic effects. This was tested in an anesthetized porcine postischemic global LV injury model, where ventricular pressures and volumes (conductance volumetry) were measured. A global ischemic injury was induced by repetitive left main stem coronary artery occlusions. Load-independent indices of LV function were assessed before and after ventricular injury, after milrinone treatment, and finally after addition of levosimendan to the milrinone treatment. Nonparametric, within-group comparisons were made. The protocol was completed in 12 pigs, 7 of which received the inotrope treatment and 5 of which served as controls. Milrinone led to positive lusitropic effects seen by improvement in tau after myocardial stunning. The addition of levosimendan to milrinone further increased lusitropic state. The latter effect could however not be attributed solely to levosimendan, since lusitropic state also improved spontaneously in time-matched controls at the same rate during the corresponding period. When levosimendan was added to milrinone infusion, there was no increase in systolic function (preload recruitable stroke work) compared to milrinone treatment alone. We conclude that in this model of postischemic LV dysfunction, there appears to be no clear improvement in systolic or diastolic function after addition of levosimendan to established milrinone treatment but also no negative effects of levosimendan in this context.

Long-Term Outcomes for Different Forms of Stress Cardiomyopathy After Surgical Treatment for Subarachnoid Hemorrhage.

Stress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH. We studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission. Among 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8-20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6-17.2). SAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.

Initiation or maintenance of beta-blocker therapy in patients hospitalized for acute heart failure

Background Beta-blockers have been recommended for patients with heart failure and reduced ejection fraction for their long-term benefits. However, the tolerance to betablockers in patients hospitalized with acute heart failure should be evaluated. Objective To estimate the proportion of patients hospitalized with acute heart failure who can tolerate these agents in clinical practice and compare the clinical outcomes of patients who can and cannot tolerate treatment with beta-blockers. Setting Two reference hospitals in cardiology. Methods Retrospective cohort study of consecutive patients hospitalized for acute heart failure between September 2008 and May 2012. Population-based sample. During the study period, 325 patients were admitted consecutively, including 194 individuals with an acute heart failure diagnosis and systolic left ventricular dysfunction and ejection fraction ≤45%, who were candidates for the initiation or continuation of beta-blockers. Main outcome measure The percentage of patients intolerant to beta-blockers and the clinical characteristics of patients. Results On admission, 61.8% of patients were already using beta-blockers, and 73.2% were using beta-blockers on discharge. During hospitalization, 85% of patients used these agents for some period. The main reasons for not using betablockers were low cardiac output syndrome (24.4%), bradycardia (24.4%), severe hypotension or shock (17.8%), and chronic obstructive pulmonary disease (13.3%). Patients who were intolerant or did not use a beta-blocker had a longer hospital stay (18.3 vs. 11.0days; p<.001), greater use of vasoactive drugs (41.5 vs. 16.3%; p<.001, CI 1.80-7.35), sepsis and septic shock (RR=3.02; CI 95% 1.59-5.75), and higher mortality rate during hospitalization (22.6 vs. 2.9%; p<.001; CI 3.05-32.26). Conclusion Beta-blockers could be used in 73.2% of patients hospitalized for acute heart failure. Patients who can not tolerate BB presented a higher frequency of adverse clinical outcomes including frequency of sepsis, use of vasoactive drugs, average length of hospitalization, and death.

17 A case-control study with computational modelling of acute left ventricular dysfunction

Introduction The pathophysiology of acute left ventricular dysfunction after acute ST-elevation myocardial infarction (STEMI) is incompletely understood. In this study, we carried out a case-control study of left ventricular (LV) biomechanical behaviour in vivo using an immersed boundary-finite element (IB/FE) method. Methods Cardiac magnetic resonance images were acquired from six healthy volunteers (the healthy group) and six patients with acute LV dysfunction post-acute STEMI (the MI group) with no-reflow, defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery. The two groups were age matched. The passive and active myocardial parameters were determined from the measured in vivo data (LV cavity volume and strain) to match the LV dynamics in diastole and systole. Results Student’s t-test was used for significance test. Our results show that even though the average measured peak cuff-pressure in the MI group is much lower than the healthy group (122 ± 21 vs. 150 ± 20mmHg, p Conclusions In summary, we have shown for the first time that, compared with controls, patients with recent ST-elevation myocardial infarction exhibit increased active tension generation in combination with predictable changes in end-diastolic volume and ejection fraction. Active tension generation is a novel biomechanical index, and its clinical and prognostic significance merits further study. Funding British Heart Foundation (PG/14/64/31043)

Predicting Persistent Left Ventricular Dysfunction Following Myocardial Infarction: The PREDICTS Study

BackgroundPersistent severe left ventricular (LV) systolic dysfunction after myocardial infarction (MI) is associated with increased mortality and is a class I indication for implantation of a cardioverter-defibrillator. ObjectivesThis study developed models and assessed independent predictors of LV recovery to >35% and ≥50% after 90-day follow-up in patients presenting with acute MI and severe LV dysfunction. MethodsOur multicenter prospective observational study enrolled participants with ejection fraction (EF) of ≤35% at the time of MI (n = 231). Predictors for EF recovery to >35% and ≥50% were identified after multivariate modeling and validated in a separate cohort (n = 236). ResultsIn the PREDICTS (PREDiction of ICd Treatment Study) study, 43% of patients had persistent EF ≤35%, 31% had an EF of 36% to 49%, and 26% had an EF ≥50%. The model that best predicted recovery of EF to >35% included EF at presentation, length of stay, prior MI, lateral wall motion abnormality at presentation, and peak troponin. The model that best predicted recovery of EF to ≥50% included EF at presentation, peak troponin, prior MI, and presentation with ventricular fibrillation or cardiac arrest. After predictors were transformed into point scores, the lowest point scores predicted a 9% and 4% probability of EF recovery to >35% and ≥50%, respectively, whereas profiles with the highest point scores predicted an 87% and 49% probability of EF recovery to >35% and ≥50%, respectively. ConclusionsIn patients with severe systolic dysfunction following acute MI with an EF ≤35%, 57% had EF recovery to >35%. A model using clinical variables present at the time of MI can help predict EF recovery.

Variability May Be the "Law of Life," but Blood Pressure Variability May Forebode a Shorter Life.

Genetic, phenotypic, and physiologic variability complicate the understanding, diagnosis, and treatment of almost all disease states. Historically, blood pressure (BP) variations across clinic visits were viewed as random fluctuations without clinical or prognostic significance. However, emerging evidence suggests that these long-term fluctuations, termed BP visit-to-visit variability, portend a range of adverse health events in the general and kidney disease populations. 2-4 Higher BP visit-to-visit variability has been associated with acute myocardial infarction (MI), stroke, and left ventricular dysfunction. 5 Such adverse clinical outcomes have proved particularly difficult to modify among patients with chronic kidney disease due to the complex interplay of traditional and kidney disease–specific risk factors involved in cardiovascular disease pathogenesis. The prospect of long-term BP visit-to-visit variability as a novel modifiable cardiovascular risk factor has generated enthusiasm among some because it potentially represents a new therapeutic target through which to improve patient outcomes.

Cardiac structure and function, and ventricular-arterial interaction 11 years following a pregnancy with preeclampsia

Preeclampsia (PE) is associated with acute left ventricular dysfunction. Whether these changes eventually resolve remains unclear. This study assessed left and right ventricular structure and function, and ventricular-arterial interaction in 15 women 11 years after a pregnancy with PE and 16 matched control subjects with a normal pregnancy. We found normal left and right ventricular dimensions, systolic function, and global left ventricular strain, with no differences between the groups. In addition, indices of diastolic function, left and right atrial size, and amino-terminal pro-brain natriuretic peptide were normal and did not differ between the groups. Women with a previous PE had impaired night/day ratios for systolic and diastolic ambulatory blood pressure. However, indices of aortic stiffness or ventricular-arterial coupling did not differ between the groups. In conclusion, we could not demonstrate remaining alterations in systolic or diastolic left or right ventricular function, or in ventricular-arterial interaction in women 11 years after PE.

Cardiorenal Syndrome Type 5 in Sepsis: Role of Endotoxin in Cell Death Pathways and Inflammation

Background/Aims: Cardiorenal Syndrome Type 5 (CRS Type 5) is characterized by concomitant cardiac and renal dysfunction in the setting of different systemic disorders, such as sepsis. In this study, we investigated the possible relationship between endotoxin levels, renal cell death and inflammation in septic patients with CRS Type 5. Methods: We enrolled 11 patients with CRS Type 5. CRS Type 5 was defined according to the current classification system. AKI was defined by Acute Kidney Injury Network (AKIN) criteria. Acute cardiac dysfunction was documented by echocardiography as acute left and/or right ventricular dysfunction leading to decreased ejection fraction. Endotoxin activity was measured by the Endotoxin Activity Assay (EAA). Plasma from CRS Type 5 patients was incubated with renal tubular cells (RTCs) and cell death levels were evaluated. Plasma cytokines levels were measured as well. Results: Accordingly to EAA levels, patients were divided into two groups: 45.4% of patients had low endotoxin activity level (negative EAA), while 54.5% of patients showed high endotoxin activity (positive EAA). RTCs incubated with plasma from EAA positive patients showed significantly higher apoptosis levels and higher caspase-3 activation compared to cells incubated with plasma from EAA negative patients, and a significant positive correlation was observed between EAA levels and RTC apoptosis levels. Furthermore, IL-6 and IFN-γ levels were significantly higher in CRS Type 5 patients with positive EAA. Conclusion: Our data suggest a possible relationship between endotoxin levels and renal cell death in septic patients with CRS Type 5. Furthermore, this study highlights the presence of renal apoptosis, the immune deregulation and the strong inflammation in CRS Type 5 patients, especially in those with high endotoxin activity.

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy.

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

Predictors of ventricular remodelling in patients with reperfused acute myocardial infarction and left ventricular dysfunction candidates for bone marrow cell therapy: insights from the BONAMI trial.

Few data are available regarding the relation of left ventricular (LV) mechanical dyssynchrony to remodelling after acute myocardial infarction (MI) and stem cell therapy. We evaluated the 1-year time course of both LV mechanical dyssynchrony and remodelling in patients enrolled in the BONAMI trial, a randomized, multicenter controlled trial assessing cell therapy in patients with reperfused MI. Patients with acute MI and ejection fraction (EF) ≤ 45% were randomized to cell therapy or to control and underwent thallium single-photon emission computed tomography (SPECT), radionuclide angiography, and echocardiography at baseline, 3months, and 1year. Eighty-three patients with a comprehensive 1-year follow-up were included. LV dyssynchrony was assessed by the standard deviation (SD) of the LV phase histogram using radionuclide angiography. Remodelling was defined as a 20% increase in LV end-systolic volume index (LVESVI) at 1year. At baseline, LVEF, wall motion score index, and perfusion defect size were significantly impaired in the 43 patients (52%) with LV remodelling (all p < 0.001), without significant increase in LV mechanical dyssynchrony. During follow-up, there was a progressive increase in LV SD (p = 0.01). Baseline independent predictors of LV remodelling were perfusion SPECT defect size (p = 0.001), LVEF (p = 0.01) and a history of hypertension (p = 0.043). Bone marrow cell therapy did not affect the time-course of LV remodelling and dyssynchrony. LV remodelling 1year after reperfused MI is associated with progressive LV dyssynchrony and is related to baseline infarct size and ejection fraction, without impact of cell therapy on this process.

Abstract 17041: Impact of Different Patterns of Left Ventricular Ballooning in Patients With Stress (Takotsubo) Cardiomyopathy: Single Center Clinical Experience

Introduction: Stress cardiomyopathy (SCMP) is characterized by acute reversible left ventricular (LV) dysfunction, and it is well accepted that SCMP can show various patterns with or without apical involvement. However, clinical data describing characteristics and outcomes according to the patterns of LV ballooning are lacking. Methods: We retrospectively identified 549 consecutive patients (age, 64±15 years; 328 female) with SCMP in a single tertiary hospital from Jan 2009 to June 2014. They were divided into 2 groups with typical apical ballooning (group 1) and atypical patterns sparing the LV apical segment (group 2). Clinical characteristics and outcomes including in-hospital mortality were explored. Results: Apical ballooning was most common (n=394, 71.8%) and group 2 included mid-ventricular ballooning (21.7%), basal ‘inverted’ ballooning (2.9%), global hypokinesia (1.8%), localized ballooning (1.1%), and isolated right ventricular ballooning (0.7%). Group 1 was characterized by higher mean age (67±13 vs. 55±17 years, p&lt;0.001) with higher prevalence of coronary risk factors including obesity, hypertension, hyperlipidemia and diabetes mellitus. Emotional stress was a triggering event in a very limited patients comprising &lt; 5%, whereas physical stress associated with underlying medical conditions comprised more than 70%. Distribution of triggering events was similar between groups. ECG abnormalities including T wave inversion, ST segment elevation, QT prolongation and atrial fibrillation were more frequent in group 1 than group 2 with lower LV ejection fraction. However, in-hospital mortality was comparable between groups (24% vs. 21%, p=0.52). Conclusions: Apical sparing ballooning develops in up to 30% of patients with SCMP. Younger age, favorable medical conditions, less severe ECG changes, and higher LV ejection fraction cannot translate to lower mortality in this group. Physicians’ vigilance is needed to improve clinical outcomes.

Acute left ventricular dysfunction complicating pregnancy on ECMO: Tri-iodothyronine to the rescue with real time transesophageal echocardiography

Cardiac dysfunction is a common accompaniment to severe sepsis. Clinical management of the same complicating pregnancy presents unique challenges balancing maternal and fetal well-being. Can short-term intravenous (IV) tri-iodothyronine (T3) be used in the management of these patients? T3 has been reported in varied clinical settings to favorably affect cardiac lusitropy, inotropy, and chronotropy without significant side effects.We report a case of acute severe left ventricular dysfunction in a pregnant woman with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation managed with short-term IV T3. Hemodynamic stability was rapidly achieved and the improvement in contractility imaged in real time by transesophageal echocardiography.<Learning objective: Tri-iodothyronine (T3) rapidly affects cardiac inotropy, lusitropy, chronotropy, and systemic vascular resistance. Widespread application of intravenous T3 for treatment of heart failure is currently limited by a paucity of scientific literature. Selective short-term intravenous T3 use is an underutilized adjunct in the management of acute left ventricular dysfunction.>

Matrix metalloproteinases and their tissue inhibitor after reperfused ST-elevation myocardial infarction treated with doxycycline. Insights from the TIPTOP trial

BackgroundThe TIPTOP (Early Short-term Doxycycline Therapy In Patients with Acute Myocardial Infarction and Left Ventricular Dysfunction to Prevent The Ominous Progression to Adverse Remodelling) trial demonstrated that a timely, short-term therapy with doxycycline is able to reduce LV dilation, and both infarct size and severity in patients treated with primary percutaneous intervention (pPCI) for a first ST-elevation myocardial infarction (STEMI) and left ventricular (LV) dysfunction. In this secondary, pre-defined analysis of the TIPTOP trial we evaluated the relationship between doxycycline and plasma levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs). MethodsIn 106 of the 110 (96%) patients enrolled in the TIPTOP trial, plasma MMPs and TIMPs were measured at baseline, and at post-STEMI days 1, 7, 30 and 180. To evaluate the remodeling process, 2D-Echo studies were performed at baseline and at 6months. A 99mTc-SPECT was performed to evaluate the 6-month infarct size and severity. ResultsDoxycycline therapy was independently related to higher plasma TIMP-2 levels at day 7 (p<0.05). Plasma TIMP-2 levels above the median value at day 7 were correlated with the 6-month smaller infarct size (3% [0%–16%] vs. 12% [0%–30%], p=0.002) and severity (0.55 [0.44–0.64] vs. 0.45 [0.29–0.60], p=0.002), and LV dilation (−1ml/m2 [from −7ml/m2 to 9ml/m2] vs. 3ml/m2 [from −2ml/m2 to 19ml/m2], p=0.04), compared to their counterpart. ConclusionsIn this clinical setting, doxycycline therapy results in higher plasma levels of TIMP-2 which, in turn, inversely correlate with 6month infarct size and severity as well as LV dilation.