Heart, Lung and Circulation

Editorial Board

2010-02-01

Neurogenic Heart Disease: From Voodoo to Tako-tsubo

Richmond Jeremy — 2010-02-01

In this issue of the journal, Teh and co-authors present a case series and review of Tako-tsubo syndrome in the Australian setting . With a relatively large series, the authors confirm that the clinical characteristics of the syndrome are similar to those originally described in the Japanese population. There is also the same relationship with stress, both physical and emotional, and the same apparent prognosis.

A Single-centre Report on the Characteristics of Tako-tsubo Syndrome

Andrew W. Teh, Gishel New, Jennifer Cooke — 2010-02-01

Background: Tako-tsubo cardiomyopathy is an increasingly recognised phenomenon characterised by chest pain, ECG abnormalities, cardiac biomarker elevation and transient left ventricular dysfunction without significant coronary artery obstruction.Aims: To report the clinical and echocardiographic characteristics from a large single-centre Australian series of patients with Tako-tsubo syndrome.Methods: We prospectively collected data on 23 consecutive patients presenting between November 2005 and November 2007. Baseline demographics, ECG, echocardiography and coronary angiography were performed on nearly all patients.Results: All patients presented with chest pain; 87% were female. Various stressors were noted and cardiac Troponin-T was elevated in 91% of patients. All patients had non-obstructive coronary disease at angiography. 19/23 patients had initial and subsequent echocardiography. Mean ejection fraction was 50% at baseline and 64% at follow-up (p<0.0001). Right ventricular dysfunction was present in eight, dynamic left ventricular outflow tract obstruction in two, diastolic dysfunction in seven and two patients had the mid-cavity variant.Conclusions: This large prospective single-centre Australian series of Tako-tsubo syndrome is in concert with previous published series. Complete recovery of left ventricular function on echocardiographic follow-up was typical. Although its pathogenesis remains unclear, early distinction from acute coronary syndromes is important and the prognosis is reassuringly good.

Acute Ischaemic Ventricular Septal Defect—A Formidable Surgical Challenge

Amul Kumar Sibal, Shalvin Prasad, Peter Alison, Parma Nand, David Haydock — 2010-02-01

Background: To evaluate our surgical results for Acute Ischaemic Ventricular Septal Defect and suggest practice guidelines.Methods: Retrospective review of data from patient records between 1992 and 2006 for presentation, surgical approaches, morbidity and mortality, statistically analysed to derive guidelines for management.Results: We had 36 patients with a mean age of 70.44(±6.34) years. Fourteen patients had inferior defects. Twenty-eight patients were in shock (22 on pre-operative IABP). Severe LV and RV dysfunction were present in 18 and 20 patients respectively. At surgery, 17 had infarct resection with patching while 18 had repair with infarct exclusion. Concomitant CABG was performed in 15. One patient was re-operated on for mitral valve replacement and one for recurrent VSD. Recurrent VSD was common (11 patients). Two of these patients underwent percutaneous device closure of whom one died. Prolonged ICU and hospital stay was normal. Early mortality was 52.78% (inferior defects—85.71% and anterior defects—31.82%). Inferior VSD (OR 7.7) and pre-operative shock (OR 6.7), predicted mortality. The subgroup of inferior VSD with shock had mortality equating that with medical management published in literature.Conclusions: Acute Ischaemic VSD is a grim surgical disease marked by residual shunts and high mortality. Patients with inferior defects with shock should be offered surgery only under exceptional circumstances.

Lipid Profile and Non-enzymic Antioxidant Status in Patients with Acute Coronary Syndrome in South India

2010-02-01

Aims and objectives: Elevated lipid profile and reduced antioxidants accelerate the formation of atherosclerosis. Multiple lines of evidences have suggested that increased lipids and low antioxidants are the major risk factors for the incidence of acute coronary syndrome. Oxidative stress evaluation is now considered as an index for the assessment of development of coronary artery disease. Therefore, we studied association of the levels of non-enzymic antioxidants and lipid profile in controls and patients with acute coronary syndrome (ACS).Methods and results: The present study was carried out on 485 patients admitted to the emergency care unit, of whom 89 patients were diagnosed as non-cardiac chest pain (NCCP). Total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were analysed along with non-enzymic antioxidants such as vitamin C, vitamin E, reduced glutathione, MDA and protein thiol in controls and patients with ACS. The levels of total cholesterol and LDL-cholesterol were significantly raised in patients when compared to controls in contrast to lowering of HDL-cholesterol levels in patients than controls. Vitamin C, vitamin E, reduced glutathione, MDA and protein thiol levels were significantly lowered in patients than controls (p<0.05).Conclusion: Oxidative stress and lipid profile should be included as important markers in the early detection of acute coronary syndrome.

The Combined Pharmacological Stress Echocardiography Protocol for Predicting Improvement of Global Left Ventricular Systolic Function After Revascularisation

Zainab Abdel-Salam, Wail Nammas — 2010-02-01

Background: We compared the prognostic power of three pharmacological stress echocardiography protocols for predicting improvement of global left ventricular systolic function following revascularisation.Methods: We enrolled 100 consecutive patients with significant coronary stenosis/occlusion and regional dys-synergy in the affected artery territory. Patients underwent assessment of regional and global left ventricular systolic function. They underwent then three pharmacological stress echocardiography protocols: low dose dobutamine, infra-low dose dipyridamole, combined protocol. All patients underwent coronary revascularisation. Echocardiography was repeated 8 weeks later. Predicted function improvement by the three protocols was compared with actual improvement.Results: The combined protocol was more sensitive to predict systolic function improvement after revascularisation, but less specific, the diagnostic accuracy was similar among the three protocols. A cutoff value of 6 viable segments best predicted global function improvement with the combined protocol.Conclusions: The combined protocol has a higher sensitivity but lower specificity to predict global left ventricular systolic function improvement after revascularisation, as compared to the other two protocols.

Cardiac Troponin I Levels and Alveolar-arterial Oxygen Gradient in Patients with Community-acquired Pneumonia

2010-02-01

Background: Patients with community-acquired pneumonia (CAP) appear to have cardiac stress as demonstrated by elevated B-type natriuretic peptide (BNP). We hypothesised that myocardial stress and decrease in oxygenation might also lead to elevations of cardiac troponin I (cTnI) levels in serum.Objective: The aim of this study was to see if cTnI was associated with the alveolar-arterial oxygen gradient (ΔA-a), a marker of severity in CAP.Methods: Retrospective cohort study of 901 CAP patients with no evidence of acute coronary syndrome presenting to a large, tertiary-care, urban teaching hospital over a 3-year period.Results: A strong linear trend between log10cTnI and ΔA-a was observed (r2=0.76) with a statistically significant Spearman correlation coefficient (rs=0.75; p<0.0001) between cTnI and ΔA-a. A cTnI value of 0.5ng/ml discriminated mild CAP from moderate-severe CAP with an OR=208 (95% CI: 50.5–408; p<0.0001).Conclusions: These data suggest that decreased blood O2 levels as suggested by elevated ΔA-a may lead to acute myocardial damage and that cTnI may be useful as a biomarker to stratify risk in subjects with CAP.

Cardiac Isoform of Alpha 2 Macroglobulin and Its Reliability as a Cardiac Marker in HIV Patients

2010-02-01

Background: Cardiac isoform of alpha 2 macroglobulin (CA2M), a serum protein (182000Mr) has been used as a diagnostic molecular marker for cardiac manifestations in HIV and diabetic patients. This study investigates the reliability of CA2M as an early diagnostic marker for cardiac manifestations in HIV patients and factors that could possibly influence their levels.Methods: A total of 206 serum samples were analysed from HIV patients with cardiac diseases (68), with non-cardiac ailments (48), opportunistic infections (34) and without other co-morbidities (56). The immuno-cross-reactivity between human serum CA2M and anti-rat CA2M antibody was tested and quantified by sandwich enzyme linked immunosorbent assay (ELISA).Results: The CA2M levels were high in HIV patients with cardiac diseases irrespective of the manifestations. The CA2M levels were not influenced by opportunistic infections, non-cardiac ailments and patient parameters like age, sex, duration of illness, past history of other co-morbidities.Conclusion: CA2M can be used as a reliable early diagnostic marker in HIV patients with cardiac manifestations. CA2M levels were not influenced by other patient parameters.

Left Main Coronary Artery Atresia Diagnosed with 128-MDCT

Ricardo Duarte, João C. Costa, Gabriel Fernandez — 2010-02-01

A 61-year-old female with intermittent chest discomfort and an inconclusive exercise treadmill test was submitted for a non-invasive coronary angiography with 128-multidetector computed tomography (MDCT) with prospective triggering (1.7mSv). The coronary arteries were free of atherosclerotic coronary artery disease (CAD). However, MDCT clearly demonstrated a congenital anomaly of the coronary arteries, with absence of the left coronary ostium and left main trunk (black arrow). A dominant right coronary artery (RCA) provided blood supply via conus branch (white arrow) to the left anterior descending (LAD) and left circumflex (Cx) arteries, which were located at their normal position. The conus branch (white arrow) coursed anteriorly to the main pulmonary artery. Subsequent invasive coronary angiography confirmed the MDCT findings.

Pulmonary Vein Stenosis: A Complication of Atrial Fibrillation Ablation Treated with Stenting

Akshay Mishra, Vince Deen, Richard Slaughter, Darren L. Walters — 2010-02-01

We report a case of severe pulmonary vein stenosis in multiple vessels despite obtaining a satisfactory electro anatomical merge during the ablation (). He was treated with stenting in 3 veins with a good recovery both clinical and radiological.

Early Extubation Following Cardiac Surgery in Neonates and Infants

Issam El-Rassi, Antoine Soueide — 2010-02-01

We read with great interest the paper by Winch et al. . However, we do not agree with their bold approach concerning immediate extubation in neonates and infants following cardiac surgery. Postoperative mechanical ventilation for hours or even days, has been the standard practice in infants and children undergoing cardiac surgery. Although early extubation is associated with lower costs and reduced adverse events related to the endotracheal tube and prolonged mechanical ventilation , we believe that immediate extubation in the operating room is associated with great challenges that need further discussion.

Reply: Early Extubation Following Cardiac Surgery in Neonates and Infants

Peter D. Winch, Aymen Naguib — 2010-02-01

We appreciate the comments offered by El-Rassi et al. in critique of our article . The practice of extubating neonates and children immediately following cardiac surgery has been previously discussed in the literature and is not unique to our institution . Our data contributes to the existing literature by illustrating that the practice is safe (over 800 patients reviewed), and attempts to identify which factors are predictive of success.

The Australasian Society of Cardiac and Thoracic Surgeons

2010-02-01

The Cardiac Society of Australia and New Zealand

2010-02-01

NEW Heart Foundation practice tools for managing hypertension

2010-02-01

Guide for Authors

2010-02-01

Heart, Lung and Circulation

Editorial Board

Contents

Neurogenic Heart Disease: From Voodoo to Tako-tsubo

A Single-centre Report on the Characteristics of Tako-tsubo Syndrome

Acute Ischaemic Ventricular Septal Defect—A Formidable Surgical Challenge

Lipid Profile and Non-enzymic Antioxidant Status in Patients with Acute Coronary Syndrome in South India

The Combined Pharmacological Stress Echocardiography Protocol for Predicting Improvement of Global Left Ventricular Systolic Function After Revascularisation

Cardiac Troponin I Levels and Alveolar-arterial Oxygen Gradient in Patients with Community-acquired Pneumonia

Cardiac Isoform of Alpha 2 Macroglobulin and Its Reliability as a Cardiac Marker in HIV Patients

Left Main Coronary Artery Atresia Diagnosed with 128-MDCT

Pulmonary Vein Stenosis: A Complication of Atrial Fibrillation Ablation Treated with Stenting

Early Extubation Following Cardiac Surgery in Neonates and Infants

Reply: Early Extubation Following Cardiac Surgery in Neonates and Infants

The Australasian Society of Cardiac and Thoracic Surgeons

The Cardiac Society of Australia and New Zealand

NEW Heart Foundation practice tools for managing hypertension

Guide for Authors