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Background Bacterial pericarditis is a rare, rapidly progressive, and highly fatal infection, even with drainage and antibiotics. Gram-positive cocci, specifically Streptococcus pneumoniae, have been the most common cause of bacterial pericarditis from either haematogenous dissemination, or spread from another adjacent site of infection. Following the introduction of antibiotics in the 1940s and more recently the pneumococcal conjugate vaccine, the incidence has drastically decreased. Case summary A previously healthy young male was diagnosed with acute pericarditis with no signs of haemodynamic compromise on initial presentation. Several hours later, he became unstable suffering from cardiac tamponade and septic shock. Despite urgent pericardiocentesis and drainage of purulent fluid, culture positive for streptococcus pneumoniae, multi-organ failure was eventually fatal. Discussion We describe a rare case of primary S. pneumoniae purulent pericarditis leading to tamponade, septic shock, and death. Due to the high mortality rate of purulent pericarditis, a high index of suspicion is needed in order to initiate appropriate therapy with antibiotics and drainage.

The perception that women represent a low risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are under-represented, leading to limited knowledge of CV and systemic impact effects of several treatment modalities on women’s health. Thus, in this consensus a group of female Cardiologists from the Hellenic Society of Cardiology present the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies, that may be implemented in daily clinical practice in order to eliminate underestimation and undertreatment of CVD in female population.

Myocardial bridges are often asymptomatic but may need therapy when causing ischaemia. They have rarely been reported in children or in association with CHD, where symptomatology may be mistakenly attributed to the CHD. We report a case of multiple myocardial bridges causing ischaemia in an adolescent with pulmonary stenosis and discuss management.

Introduction Acute aortic dissection (AAD) represents surgical emergency and current literature mainly consists of postoperative outcome reports. Long term outcome and quality of life have not extensively been investigated. Purpose This is a single center study to assess long term outcome and quality of life of patients who underwent emergency surgery for AAD. Methods From January 2007 until December 2009, 74 consecutive patients were operated for AAD type A in our hospital. Seventeen died during hospital stay and 12 died during follow-up. Mean follow up was 108±10 months. Seventeen patients refused to answer the SF-36 questionnaire; therefore our study group consists of 28 patients. The SF-36 Questionnaire was retrospectively obtained by phone calls, the first, fifth and tenth postoperative year and 2 summary scores are reported, physical (PCS) and mental (MCS). Results Our in-hospital mortality was 23%, late mortality 21.1% and the overall mortality was 39.2%. Significant differences in both physical and mental score over time were found among the 28 long-term survivors (Table). Both PCS and MCS at 1st, 5th and 10th year did not differ compared to age-matched general population but compared to subjects with one or more chronic diseases both PCS and MCS were both significantly better at 5yrs in our patients vs controls (p=0.0028 and p=0.0259, respectively). Likewise, at 5 years PCS but not MCS was better in comparison to subjects with a history of one hospitalization the preceding year (p=0.035 and p=0.1, respectively). Descriptive statistics of physical and mental component summary score over time Score 1 year (FU1) 5 years (FU2) 10 years (FU3) p-value Mean (SD) Mean (SD) Mean (SD) PCS 45.4 (7.7) 50.3 (7.0) 46.8 (9.2) 0.008* MCS 42.8 (15.1) 49.7 (12.7) 49.1 (12.3) 0.001** PCS, Physical component summary; *1 vs 5: p=0.003, 1 vs 10: p=0.469, 5 vs 10: p=0.027. MCS, Mental component summary; **1 vs 5: p=0.001, 1 vs 10: p=0.001, 5 vs 10: p=0.939. SD, standard deviation. Conclusion Quality of life improves after the 1st post-operative year and is comparable to healthy subjects. Although acute dissection is a catastrophic event with high mortality despite successful and timely repair, long term survival and quality of life on the long term are favorable.

We present the case of a 68-year-old woman, currently asymptomatic but with a history of paroxysmal atrial fibrillation and tachycardia-bradycardia syndrome, for which she underwent a DDD pacemaker implantation and was started on oral anticoagulants. A recent chest X-ray (figure 1), for respiratory infection, was performed and the patient was referred to our institution for evaluation. Following diagnostic procedures, the patient was successfully operated on. heartjnl;105/8/656/F1F1F1Figure 1Preoperative chest X-ray (A) and chest CT with contrast (B). QUESTION: What is the most likely diagnosis?Mitral stenosis.Pericardial cyst.Left atrial appendage aneurysm.Left atrial myxoma.Atrial septal defect.

BACKGROUND: Inflammation plays an important role in the initiation and progression of acute aortic dissection (AAD). New inflammatory indices derived from full cell blood count and its differential may be associated with increased risk. We evaluated platelet‐lymphocyte (PLR), red cell distribution width (RDW) and RDW/PLT's (platelets) (RPR) in AAD. METHODS: We studied 120 consecutive patients with AAD type I admitted for emergency surgery (group I), 121 consecutive patients with aortic aneurysms of the ascending aorta prior to elective repair (group II) and 121 controls (group III), age and sex matched. RESULTS: PLR was significantly higher in group I vs both groups II and III (P

Clinical introduction A 53-year-old woman with no previous medical history complained of easy fatigue over the last 6 months. She had a positive family history for coronary artery disease but no other risk factors. On physical examination, a 3/6 pansystolic murmur was heard over the apex, and the lung auscultation was unremarkable. Her ECG showed a left anterior fascicular block, with poor R wave progression in the anterior leads (see online supplementary image A). A subsequent echocardiogram revealed a slightly dilated for the patient’s body surface area (BSA) (1.73 m2) left ventricle (55/35 mm), with preserved systolic function and a moderate functional mitral regurgitation. The estimated pulmonary artery pressure was 45 mm Hg. During treadmill radionuclide scintigraphy, her exercise tolerance was normal, with good inotropic response, and 96% oxygen saturation at rest and at peak exercise. A 2 mm ST segment depression was noted at peak effort, which persisted well into recovery (see online supplementary image B). The scintigraphy scan showed extensive reversible anteroapical wall ischaemia (see online supplementary image C). At this point she was referred to us for right and left heart catheterisation. Intracardiac pressures and saturations were: right atrium (RA)RA=3 mm Hg, right ventricle (RV)=26/3 mm Hg, Pulmonary artery (PA)=26/10/mean 16 mm Hg, pulmonary capillary wedge pressure (PCWP)=11 mm Hg, left ventricle (LV)=110/10 mm Hg, Aorta (Ao)=110/60/mean 80 mm Hg, Superior vena cava saturation (SVCsat)=62%, RAsat=62%, PAsat=78%, Aosat=96% and estimated pulmonary to systematic flow ratio (Qp/Qs)=1.8. Her coronary angiography and CT angiography are shown in figure 1A,B. Supplementary material 1 Supplementary material 2 Supplementary material 3 Question What is the most likely diagnosis? Right coronary fistula to right ventricle Kawasaki disease with fistula Anomalous origin of the left coronary artery from the pulmonary artery Persistent truncus arteriosus

Cardiovascular events may occur even after complete revascularization in patients with coronary artery disease. We measured preoperative osteopontin (OPN) levels in 131 consecutive patients (66.5±10years old, 117 men and 14 women) with left ventricular ejection fraction of50.7±9.2%and low logistic EuroScore (3.5±3.2%) undergoing elective Coronary Artery Bypass Grafting (CABG) surgery. Patients were prospectively followed up for a median of 12 months (range 11–24). The primary study endpoint was the composite of cardiovascular death, nonfatal myocardial infarction, need for repeat revascularization, and hospitalization for cardiovascular events. Pre-op OPN plasma levels were 77.9 (49.5, 150.9). Patients with prior acute myocardial infarction (AMI) had significantly higher OPN levels compared to those without [131.5 (52.2, 219) versus 73.3 (45.1, 125),p=0.007]. OPN levels were positively related to EuroScore (r=0.2,p=0.031). Pre-op OPN levels did not differ between patients who had a major adverse event during follow-up compared to those with no event (p=0.209) and had no effect on the hazard of future adverse cardiac events [HR (95% CI): 1.48 (0.43–4.99),p=0.527]. The history of AMI was associated with increased risk of subsequent cardiovascular events at follow-up (p=0.02). OPN is associated with preoperative risk assessment prior to low-risk CABG but did not independently predict outcome.

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.

Transcatheter aortic valve implantation (TAVI) is a novel therapeutic option for severe aortic stenosis in old patients with high surgical risk. The aim of this study was to assess changes in quality of life (QoL) along with functional status and late survival after this procedure.Thirty-six consecutive patients (80.5 ± 5.9 years, 21 men and 15 women) with a logistic Euroscore of 29.7 ± 13.7 underwent TAVI using the 18-Fr CoreValve prosthesis. Aortic valve prosthesis was inserted retrograde using a femoral or a subclavian arterial approach. QoL was evaluated by administering the Short Form 36 (SF-36) tool and the shorter SF-12 version 2 (SF-12v2) questionnaires before and 1-year after TAVI.TAVI was successfully performed in all patients. The estimated 1-year overall survival rate using Kaplan-Meier method was 68%. One-year follow-up also showed a marked improvement in echocardiographic parameters (peak gradient 76.2 ± 26.1 vs 15.4 ± 7.8 mm Hg, P.001; aortic valve area 0.7 ± 0.1 vs 2.6 ± 2.7 cm(2), P.001) with a significant change in New York Heart Association class (3 ± 0.7 vs 1.2 ± 0.4, P.001). Both preprocedural summary SF-36 and SF-12v12 physical and mental scores showed a significant improvement 1 year after TAVI (21.6 vs 46.7, P.001; 42.9 vs 55.2, P.001; 22 vs 48.9, P.001; 43.3 vs 52.2, P.001, respectively).Our results show a marked 1-year clinical benefit in functional status and physical and mental health in patients who underwent TAVI.

Ischemia modified albumin (IMA), as measured using the albumin cobalt binding test, is currently the most promising biomarker for early detection of ischemia before the onset of irreversible cardiac injury. This paper reviews the information available on IMA, including its pathophysiology, analysis, clinical applications and future perspectives. The data provided was identified by a search of MEDLINE using the terms IMA, biomarkers and ischemia. IMA may be useful to cover the complete diagnostic window of patients presenting with acute coronary syndromes (ACS) in the Emergency Department, along with the electrocardiogram and cardiac troponins. Preliminary data regarding the significance of IMA in the prognosis of either ACS or following revascularization need further study.

Any increase of cardiac biomarkers after coronary artery bypass grafting (CABG) indicates myocyte necrosis and is likely to be related to an impaired outcome. We investigated whether ischaemia-modified albumin (IMA), a biomarker of ischaemia, is also raised following CABG.We studied 50 stable consecutive patients undergoing elective isolated CABG on cardiopulmonary bypass, of whom 46 were men and four women, aged 64 +/- 9 years. Blood samples were obtained the day before the operation (pre-op) as well as immediately after the operation, 24 h postoperatively (post-op) and the fourth day post-op and assayed for creatine kinase, the MB isoenzyme of creatine kinase, cardiac troponin-I, albumin and IMA.The typical rising and falling pattern of myocardial necrosis of all three cardiac enzymes was observed post-op (p0.0001). IMA increased significantly following CABG at all three time points (113 +/- 43, 106.7 +/- 22.6 and 110.2 +/- 12.5 U ml(-1), respectively) compared with pre-op values (91.7 +/- 10.5 U ml(-1)), (p0.0001); the sample immediately post-op was significantly higher compared with the following samples (immediately post-op vs 24 h, p = 0.008 and immediately post-op vs 4 days, p = 0.03, with no significant difference between the last two). IMA level changes during the study course were independent of the albumin changes. Haemoglobin decreased significantly post-op (p0.0001 vs baseline) whereas serum creatinine did not differ during the study period.IMA increases significantly following CABG but whether or not this carries a prognostic significance remains to be elucidated.

Ischemia modified albumin (IMA) is considered a biomarker of myocardial ischemia. We sought to investigate whether IMA plasma levels change during pharmacological stress test, in patients with stable coronary artery disease.We studied 37 patients undergoing non-invasive evaluation with a pharmacological stress test, either with radionuclide myocardial perfusion imaging with adenosine or stress echocardiography with dobutamine. Peripheral venous samples were collected before the stress test (baseline), at the end of adenosine infusion or at the peak dose of dobutamine and 60 min after the completion of the stress test for IMA measurement.IMA plasma levels significantly increased at peak vs. baseline (91.28+/-9.59 U/ml vs. 97.97+/-9.69 U/ml, p0.0001) and subsequently, decreased significantly at 60 min compared to peak (97.97+/-9.69 U/ml vs. 94+/-15.22 U/ml, p=0.016), returning to values similar to those at baseline (p=0.134). Similarly, in patients with a negative stress test, IMA significantly increased at peak compared to baseline (91.08+/-10.03 U/ml vs. 99.58+/-8.43 U/ml, p=0.006) and returned to baseline at 60 min (99.58+/-8.43 U/ml vs. 91.83+/-7.93 U/ml, p=0.019), the 60 minute levels being similar to baseline values (p=0.212). Conversely, in patients with a positive stress test, IMA significantly increased at peak compared to baseline (91.38+/-10.13 U/ml vs. 97.17+/-10.34 U/ml, p=0.006) and although decreased at 1 h, this did not reach statistical significance compared either to the baseline or to the peak values (95.04+/-17.76 U/ml vs. 91.38+/-10.13 U/ml, p=0.315 and 95.04+/-17.76 U/ml vs. 97.17+/-10.34 U/ml, p=0.235, respectively).IMA plasma levels change significantly during pharmacologic stress testing, in patients with coronary artery disease, but with no difference between the positive and the negative tests.

BACKGROUND transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe aortic stenosis considered inoperable or at high operative risk, but the long-term outcome remains unknown. HYPOTHESIS we assessed the 4-year clinical and echocardiographic outcomes of patients undergoing TAVI with the self-expanding Medtronic CoreValve prosthesis. METHODS sixty-three patients (mean age 80 ± 6 years) with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (Logistic EuroSCORE 28.8 ± 10.9%) were included in this study. RESULTS all-cause cumulative mortality at 1, 2, 3 and 4 years was 14.3, 25.4, 28.6 and 36.5%, respectively. The cumulative incidence of documented major stroke at 4 years was 6.3%. In survivors, there was a significant improvement in functional status at 4 years. Paravalvular leak (trivial/mild to moderate) was observed in the majority of patients post-TAVI with no case of progression to severe regurgitation at 4-year follow-up. In multivariate analysis, independent predictor for increased all-cause mortality was left ventricular ejection fraction

The authors investigated whether neutrophil to lymphocyte ratio (N/L) can contribute to the diagnosis and risk assessment in patients with type A acute aortic dissection (AAD).The authors studied 120 consecutive patients with type A AAD (group I) and compared them with 121 consecutive patients with chronic aneurysms (group II) and 121 age- and sex-matched healthy subjects (group III).It was found that white blood cell count, N/L, D-dimer and C-reactive protein were significantly higher in group I versus both groups II and III (p0.001 for all comparisons). White blood cell count and D-dimer were much higher in patients who died compared to survivors in group I (p = 0.023 and p = 0.033, respectively). A cutoff value of N/L4.6 was associated with 0.89 sensitivity and 0.91 specificity for AAD.High N/L may contribute to the diagnostic evaluation and prompt immediate therapy in patients with type A AAD.

Objectives We sought to investigate whether heart-type fatty acid binding protein (H-FABP), a new marker of myocardial necrosis, increases in relation to elective cardioversion of atrial fibrillation (AF). Methods We studied 25 consecutive patients (61 ± 16 years old, 21 men) admitted to our hospital for elective cardioversion of AF. Peripheral venous samples were drawn immediately before cardioversion, one hour and 24 h after the procedure and assayed for H-FABP. Results A mean of 309 ± 183 J was used for cardioversion. Successful cardioversion in sinus rhythm was achieved in 18 patients (72%). Serum levels of H-FABP did not change significantly either in relation to the procedure [1385 (256–17,127) pg/mL at baseline, 1125 (290–15,238) pg/mL 1 h post and 1045.5 (66–2981) pg/mL 24 h post cardioversion, p = 0.37] or to the success of the procedure. Conclusion H-FABP does not significantly change following elective cardioversion for AF and we, therefore, speculate that myocardial necrosis does not occur during cardioversion.

ZD4522 - a new HMG-CoA reductase inhibitor - causes rapid and profound reductions in plasma LDL-C levels in patients with primary hypercholesterolaemia

Aims: To test the hypothesis that ketanserin augments coronary collateral blood flow and decreases myocardial ischemia during balloon angioplasty. Methods and Results: Forty-four patients with single vessel disease and stable angina were studied. Collateral flow was determined during balloon inflations, based on the distal velocity time integral (13 patients) or on coronary wedge/mean arterial pressure measurements (10 patients). The 2nd and 3rd inflations lasted the same time and between them 1.5 mg intracoronary ketanserin in 10 ml normal saline was administered over 3 min. In 21 control subjects normal saline alone was given. In the flow velocity group the velocity time integral was 78.5 ± 53.1 mm during the 2nd inflation and 106.0 ± 43.2 mm during the 3rd (p < .05), while the ST deviation was 1.1 ± .7 and .7 ± .7 mm, respectively (p. < .05). In the intracoronary pressure group the CWP/MBP was .40 ± .10 during the 2nd inflation and .45 ± .11 during the 3rd (p. < .05), while the ST deviation was 1.2 ± .8 and .8 ± .8 mm respectively (p. < .05). In the controls no variables changed during the tested inflations. Conclusion: Intracoronary administration of ketanserin augments coronary collateral flow and decreases myocardial ischemia during balloon angioplasty. This could be of clinical significance in the management of acute ischemic syndromes.

Early diagnosis and treatment are pivotal for patients with acute aortic dissection (AAD). D-dimer is a rule-out diagnostic test for pulmonary embolism but there is evidence that it may also be applicable to AAD. We evaluated plasma D-dimer, white cell blood count (WBC), C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (BNP) in 18 consecutive patients with established AAD, 21 consecutive patients with dilated ascending aortas scheduled for elective surgery and 8 normal subjects. Patients with AAD had significantly higher elevated D-dimer, compared to chronic aneurysms and normal controls (p

Aim Ischaemia modified albumin (IMA) is considered a marker of myocardial ischaemia, in contrast to the biomarkers of myocardial injury [creatine kinase (CK), the MB isoenzyme of CK, and cardiac troponin I (Tn-I)] that are released when cardiac necrosis occurs. Ischaemia modified albumin has been reported to increase following percutaneous coronary intervention and in acute coronary syndromes. We sought to determine whether IMA increases following radiofrequency (RF) ablation. Methods and results We studied 40 consecutive patients who underwent RF catheter ablation; 20 were men and 20 women and their age was 47 ± 16 (16–77) years. All patients underwent electrophysiological study and subsequent RF ablation. Peripheral venous samples were collected before the procedure (baseline), immediately after the procedure, 2 h post-procedure and the following day (20 h post-procedure) and assayed for CK, the MB isoenzyme of CK, cardiac Tn-I and IMA. Ischaemia-modified albumin plasma levels did not differ significantly at all four time points, baseline, and following ablation ( P = 0.5974), whereas CK, CK-MB, and Tn-I increased significantly at all time points compared with baseline ( P < 0.0001). Post-ablation, all but three 3 CK measurements were in the normal range; 14 patients had CK-MB plasma levels above the upper limit of normal; all but one patient had Tn-I elevated. Conclusion The IMA plasma levels do not change significantly following RF ablation, unlike biomarkers of myocardial injury, implying that myocardial necrosis occurs without preceding ischaemia.

Objectives. This study sought to compare hormone replacement therapy (HRT), simvastatin and their combination in the management of hypercholesterolemia in postmenopausal women with coronary artery disease (CAD).Background. Lipid-lowering therapy reduces mortality in hypercholesterolemic women with CAD. In postmenopausal women HRT seems to increase survival, particularly those with ischemic heart disease, and this is partly due to changes in lipid levels.Methods. We studied 16 postmenopausal women with CAD and fasting total cholesterol

The effect of β-adrenergic blockade on coronary collateral blood flow has not been clarified. We examined the acute effects of β-adrenergic blockade on coronary collateral blood flow. Fifteen patients (Part A) with stable angina were studied while undergoing coronary angioplasty. According to the protocol, all patients underwent a minimum of three balloon inflations. Collateral flow velocity was determined during balloon inflations using the Doppler flow guidewire positioned distally to the lesion. The two tested balloon inflations, the second and third, were maintained for the same length of time. Between the second and third balloon inflations, 1 mg of propranolol was administered IC into the treated artery. Ten controls were studied following saline infusion. In 10 other patients (Part B), the effect of 1 mg IC propranolol on the coronary artery area distal to the lesion was studied, and five patients served as controls. In the treated group, in Part A blood pressure remained stable during the balloon inflations tested. Heart rate decreased from 79 ± 11 to 73 ± 12 beats/min (P < .05), velocity time integral from 9.6 ± 8.2 to 6.6 ± 4.1 cm (P < .05), and ST elevation from 1.3 ± .9 to .9 ± 1.0 mV (P < .05) between the second and third balloon inflations. In the controls the variables examined did not change during the balloon inflations tested. In Part B, neither propranolol nor normal saline had any significant effect on coronary artery lumen area. Thus, IC administration of β-adrenergic blockade decreases coronary collateral blood flow, and this potentially worsens the ischemic zone. However, β-adrenergic blockade ameliorates myocardial ischemia during coronary angioplasty.

17β-estradiol, administered acutely, protects ischemic myocardium in male rabbits. In the present study we investigated the effect of short-term estrogen on myocardial infarct size in oophorectomized female rabbits. We oophorectomized 24 sexually mature New Zealand white female rabbits. Twelve animals were left untreated and 12 received oral conjugated estrogens, 0.15 mg/day, for 4 weeks. At a second stage, a third group of 12 oopherectomized female rabbits was treated with intramuscular conjugated estrogens, 1 mg/day, also for 4 weeks. All rabbits underwent 30 minutes of coronary artery occlusion and 2 hours of reperfusion while on anesthesia with IV pentobarbital. Infarct and risk area were delineated by Zn-Cd fluorescent particles and tetrazolium chloride staining. The infarct size was expressed as a percentage of the risk zone (I/R %). Data are reported on 26 animals that survived the treatment period and the experiment. Heart rate, systolic, and mean blood pressure and double product did not differ between the three groups at baseline, ischemia, and reperfusion. The infarct size of the risk zone was significantly smaller in the intramuscular group compared with both the oral and the placebo group (18.5 ± 3.5% vs. 41.3 ± 9.2% and 43 ± 8.4%, respectively, P = 0.03). Conjugated estrogens, administered intramuscularly at a high dose, protect ischemic myocardium in oophorectomized female rabbits.

OBJECTIVES We examined whether ischemia-modified albumin (IMA) plasma levels change during exercise stress testing (EST) in patients with known coronary artery disease and whether the induced changes differ between positive and negative exercise tests. BACKGROUND Ischemia modified albumin is considered a marker of myocardial ischemia and increases after coronary angioplasty and in acute coronary syndromes. METHODS We studied 40 consecutive patients with established coronary artery disease who underwent EST. Venous samples, for IMA measurement, were collected before the stress test (baseline), at peak exercise, and 60 min after the completion of the exercise test. RESULTS There was significant difference in the IMA values at the 3 prespecified time points (p = 0.012), whereas there was no interaction between the IMA changes and the result of the stress test, whether positive or negative (p for the interaction term = 0.94). Baseline, peak EST, and post-EST IMA levels were similar in patients with positive and negative exercise tests (p = 0.61). The IMA significantly decreased at peak exercise compared with baseline values in positive (p < 0.0001) and in negative EST (p = 0.012). Moreover, IMA concentration increased 60 min after EST compared with peak-EST values in positive (p < 0.0001) and in negative tests (p = 0.003), returning to pre-EST levels in both groups. CONCLUSIONS The IMA plasma levels change significantly during exercise testing in patients with coronary artery disease, but there is no difference between positive and negative stress tests; this possibly implies that the observed changes do not reflect myocardial ischemia.

BACKGROUND Cardiac hypertrophy is associated with numerous alterations in the coronary circulation. OBJECTIVE To test the hypothesis that, during angioplasty, the coronary collateral blood flow during repetitive coronary occlusions increases more in hypertensives than it does in normotensives. METHODS We studied 34 patients (22 normotensives and 12 hypertensives) with stable angina and single-vessel disease undergoing coronary angioplasty during two similar balloon inflations. Each balloon inflation was maintained for 120 s. The coronary blood flow velocity was estimated using the Doppler-flow guide wire, which was positioned distally to the lesion. Flow velocities were recorded before balloon deflation. RESULTS The average peak velocity increased by 29.0 +/- 14.7 mm/s in the hypertensives and decreased by 9.4 +/- 4.9 mm/s in the normotensives (P < 0.01) during the second balloon inflation, whereas the velocity-time integral increased by 33.1 +/- 19.2 mm and decreased by 14.3 +/- 11.3 mm (P < 0.05), respectively. The ST-segment elevation decreased by 1.13 +/- 1.27 and by 0.17 +/- 0.16 mV, respectively (P = 0.01). The increase in the average peak velocity which occurred during the second balloon inflation was related to the left ventricular mass (r = 0.47, P = 0.004). CONCLUSION These results indicate that the coronary collateral blood flow velocity improves with repetitive coronary occlusions during angioplasty in patients with systemic hypertension and that this increase is correlated to the left ventricular mass.

Mean platelet volume (MPV) and platelet size distribution width (PDW) are markers of platelet (PLT) size and variability in PLT size as well as PLT activation [1–3]. Reduced PLT count and increased MPV values have been reported in unruptured abdominal aortic aneurysms [4,5]. Others, however, have noted lower PLT indices (MPV and PDW) in patients with aortic aneurysm compared to age-matched controls [6]. High-grade inflammation is associated with low MPV whereas low-grade inflammation is associated with high MPV; inflammation may play a role in pathogenesis of aneurysm formation and rupture [3]. We studied PLT indices in patients with acute aortic dissection (AAD), chronic aortic aneurysms and age and sex matched normal subjects. We studied, prospectively, 100 consecutive patients with AAD admitted to our hospital for emergency surgery (group I), 100 patients with chronic aneurysms of the ascending aorta scheduled for coronary angiography prior to elective surgical repair (group II) and 100 age and sex matched normal subjects who served as controls (group III). The diagnosis was confirmed for all patients with computed tomography. Dissection was classified according to the Stanford criteria. In patients with AAD, blood samples were obtained as soon as the patient came to hospital and for patients in group II the morning of the admission, prior to catheterization. All patients gave informed consent and the study protocol was approved by the Ethics Committee of our institution. The authors of this manuscript have certified that they comply with the PrinciplesofEthicalPublishingintheInternationalJournalofCardiology. PLT indices were evaluated with anautomatic counter, including PLT count, MPV, PDW and MPV/PLT ratio (Coulter LH780, Hematology Analyzer, Beckman, Miami, USA).Bloodsamples were collected in tubes with potassium ethylenediaminetetraacetate and were analyzed 1 h after venipuncture. We also measured D-dimers with Elisa (Vidas Ddimer, Biomerieux, France) and CRP with an immunoturbidimetric method (Cobas Integra, Roche, Mannheim, Germany). The groups were compared by means of chi-square or Fishers' exact test, Kruskal Wallis test or non-parametric one-way analysis of variance, Mann–Whitney test and Spearman rank correlation coefficient, as appropriate. Baseline characteristics for all three groups are presented in Table 1. In type A dissection, 8 patients died before surgery and the remaining were all but one operated; this patient declined surgery. There were 3 deaths in the operating room and 7 post-operative deaths. In type B dissection, 2 patients died on arrival to our unit; 2 patients were transferred elsewhere for vascular surgery and 1 was operated on site; the remaining 10 were managed conservativelyand did well. Ingroup II, there were 2 deaths. As expected, aortic cross clamping time and cardiopulmonary bypass time were significantly longer in group I than in group II (p b 0.001) whereas the duration of hospitalization was similar in the 2 groups (p = 0.192). Table 2 illustratestheresultsofstudiedbiochemicalvariablesamong groups. Within group I, PLT count was lower [186 (146,212) vs 222 (195,264)] and the MPV/PLT ratio was higher [0.047(0.036, 0.059) vs 0.037(0.033, 0.04)] in type A dissection compared to type B (p = 0.009 and p = 0.008, respectively). In addition, MPV as well as the MPV/PLT ratiowere significantlylowerinpatientswithmore extensivedissection with involvementof the abdominal aorta and the iliacarteries; in detail, when comparing thoracic vs thoracic–abdominal vs thoracic–abdominal–iliacdissection,MPVwas8.7(8.1,9.5),7.9(7.4,8.4)and8.1(7.1,8.7), respectively (p = 0.013) and MPV/PLT ratio was 0.05 (0.037, 0.062), 0.041 (0.036, 0.047) and 0.038 (0.034, 0.048), respectively (p = 0.042).

Transcatheter aortic valve implantation (TAVI) is a tremendous therapeutic advance for patients with severe aortic stenosis and high-surgical risk. Since TAVI-treated patients are elderly with multiple co-existing conditions, limited life expectancy and disproportionate health-care expenditures, the aspect of the health-related quality of life (HRQoL) benefits becomes of fundamental importance. Based on recent evidence, TAVI appears to improve significantly HRQoL measures compared with optimal standard care, which are restored to age-adjusted population norms over time.

Background Biomarkers for monitoring progression and prognosis of thoracic aneurysm are of great interest. Homocysteine (Hcy) induces elastolysis in arterial media and may directly affect fibrillin-1 or collagen whereas lipoprotein (Lp) (a) inhibits elastolysis by reducing activation of matrix metallopeptidase-9. Methods We studied 31 consecutive patients with acute aortic dissection (AAD) admitted for emergency surgery (group I, 60±13years old, 25 men), 30 consecutive patients with chronic aneurysms of the ascending aorta (group II, 67±12years old, 24 men) and 20 healthy controls (group III, 58±15years old, 14 men). We evaluated Hcy, folate, B12, Lp(a) and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism at baseline. Results Hcy, folate and B12 differed significantly among the 3 studied groups ( P =0.016, P =0.004 and P =0.001, respectively). The levels of Hcy and B12 were significantly higher in group I compared to both groups II and III ( P =0.05 and P =0.002, P P =0.017, respectively) and without significant differences between groups II and III ( P =0.083 and P =0.124). Folate was significantly lower in group I compared to both groups II and III ( P =0.001 and P =0.006, respectively) and without marked difference between groups II and III ( P =0.409). No significant difference was found in serum levels of Lp (a) ( P =0.074) or among the frequency of MTHFR C677T genotypes. Conclusions Patients with AAD present with higher Hcy and lower folate compared to both chronic aneurysms and controls.

Osteopontin (OPN) is a multifunctional protein associated with vascular injury and has been linked to atherosclerosis and inflammation. We sought to investigate whether OPN changes in relation to coronary artery by-pass grafting (CABG) surgery.We studied 50 consecutive patients (63 ± 10 years old, 6 women and 44 men) undergoing elective CABG. Plasma OPN levels were determined by an enzyme-linked immunosorbent assay at baseline and in 24 and 72 h, post-operatively. Cardiac enzymes - creatine kinase, the MB isoenzyme of creatine kinase, troponin-I- and C-reactive protein (CRP) were also determined at all three time points.OPN levels 72 h post-op decreased significantly compared to pre-op and 24h post-op levels (p0.001) whereas there was no difference between the pre-op and first post-op values (p=0.57). The relative change in OPN levels between pre-op and 72 h post-op correlated negatively with absolute troponin-I levels at 72 h post-op (-0.51, p=0.005). OPN levels 72 h post-op correlated significantly with CRP at baseline (r=0.73, p=0.002).OPN plasma concentrations decreased after CABG surgery in the early post-operative period. The significance of this observation needs further investigation.

OBJECTIVE--To study the outcome of pregnancy in women with artificial heart valves treated in major European centres, and to compare the safety and efficacy of different anticoagulant regimens and of mechanical and bioprosthetic valves. DESIGN--Retrospective study. METHOD--The information was obtained by questionnaire sent to all major cardiac centres in Europe sending one cardiologist from each centre a covering letter suggesting that the questionnaire be handed on where appropriate to the most relevant colleague. RESULTS--214 pregnancies were reported in 182 women; 151 pregnancies in 133 women with mechanical valves, and 63 pregnancies in 45 women with bioprostheses. Most women were in New York Heart Association class I or II and in sinus rhythm. 150 women with mechanical valves and 11 (17%) with bioprostheses received anticoagulants during pregnancy. One patient with an aortic valve prosthesis refused to take anticoagulants. Including the spontaneous abortions reported as well as the therapeutic abortions 83% of the pregnancies in women with bioprostheses and 73% in those with mechanical valves resulted in a healthy baby, full term or premature, who did well (NS). The incidence of stillbirths (3% and 6%) and of reported spontaneous abortions are excluded (because they are unlikely to have been fully reported), the success rate was 91% for women with bioprosthetic valves and 84% for women with mechanical valves (NS). 114 (53%) of the women had taken warfarin for some part of the pregnancy (46 (40%) of these during the first trimester) but there were no embryopathies. There were 13 valve thromboses (four fatal), eight embolic events (two fatal), and seven bleeds in women with mechanical valves. Most of these complications occurred with heparin but fatal aortic valve thrombosis occurred in the one woman who refused anticoagulant treatment out of the 151 women with mechanical valves. There were no maternal deaths in the bioprosthesis group but in 17/49 (35%) of these valves functional deterioration led to urgent replacement during pregnancy (two) or soon after. CONCLUSIONS--The outcome of pregnancy was similar for women with mechanical valves or bioprostheses. Warfarin treatment was safe and effective and was not associated with embryopathy. Heparin treatment was associated with more thromboembolic complications and more bleeding complications. Bioprostheses deteriorate rapidly during pregnancy.

Left main coronary artery aneurysms (LMCA) are usually asymptomatic and are rarely encountered during coronary angiography. The most serious complications include coronary thrombosis, acute myocardial infarction and sudden death. Atherosclerosis is the most common cause, although several autoimmune diseases and congenital abnormalities have been associated with the presence of coronary aneurysms. The case of a symptom-free 63-year-old man with a giant LMCA and severely ectatic coronary arteries is presented.

Heart-type fatty acid-binding protein (H-FABP) is a marker of myocardial necrosis, but whether it increases during myocardial ischemia is not known. This study investigated whether serum levels of H-FABP change during adenosine stress testing and nuclear imaging in patients with stable coronary artery disease.Thirty stable patients with established coronary artery disease on their medications were studied. Sampling was performed before the stress test, at the end of adenosine infusion, as well as 1, 2 and 3 h after the completion of the infusion.No difference in H-FABP serum levels were found at the five pre-specified time points in the overall group (p=0.99); furthermore, there was no significant difference regardless of the test result – positive (p=1) or negative (p=0.98).It is concluded that H-FABP does not change significantly during pharmacologic stress testing in patients with known coronary artery disease and there is no difference whether there is inducible ischemia or not.

Background: Acute aortic dissection (AOD) is associated with high mortality and early diagnosis and treatment are essential. Ischemia-modified albumin (IMA) is a marker of myocardial ischemia whereas cardiac enzymes are released when myocardial necrosis occurs. We investigated, for the first time, whether IMA increases in AOD either at presentation or after surgery. Methods: We studied 46 consecutive patients with documented AOD; we also evaluated 13 consecutive patients with dilated ascending aortas scheduled for elective surgery and admitted for preoperative coronary angiography; 46 age-matched normal subjects served as controls. Only patients with acute onset of symptoms were included. We evaluated IMA, cardiac enzymes, N-terminal pro-B-type natriureticpeptide, albumin, C-reactive protein (CRP), and D-dimers on admission, 24 hr post-operatively and 4 days post-operatively. Duration from symptom onset to the first sample was 23±17 hr. Results: IMA did not differ between patients with AOD at presentation (93±19 U/ml), patients with chronic aneurysms (90±14 U/ml) and normal controls (91±9 U/ml). In addition, IMA did not change significantly after surgical repair. IMA, at baseline, however, correlated positively with time from symptom onset as well as CRP levels (P=0.05 and P=0.007, respectively). Conclusion: IMA is not elevated in AOD when blood sampling is performed within 23±17 hr after symptom onset nor increases after surgery. J. Clin. Lab. Anal. 24:399–402, 2010. © 2010 Wiley-Liss, Inc.

We sought to investigate the short- and long- term effects of bosentan therapy on endothelial, inflammatory and fibrotic markers in patients with pulmonary arterial hypertension (PAH) and the relation to clinical and hemodynamic responses.We studied 16 patients with moderate-severe idiopathic PAH, in WHO functional class II-IV, despite conventional treatment. Patients received additional treatment with bosentan, 62.5 mg twice daily for 1 month, followed by 125 mg twice daily for 11 months. Study endpoints included 6-min walking distance (6MWD), mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and plasma levels of intracellular cell adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), IL-6 and brain natriuretic peptide (BNP). Patients were assessed at baseline, 2 months and 12 months after initiation of bosentan.At 2 months there was an improvement in 6MWD (p0.001) and functional class (p0.001) and a marked fall in PVR (p0.001), ICAM-1 (p0.001), IL-6 (p0.001)and BNP (p = 0.001). At 12 months, 6MWD was further improved (p0.001), PVR remained significantly improved (p0.001), mPAP was significantly decreased (p0.001) and ICAM-1, IL-6 and BNP remained significantly lower (p0.001). Significant correlations were found between changes in ICAM-1 and cardiac index (r = 0.59, p = 0.01), IL-6 and PVR (r = 0.51, p = 0.04), BNP and 6MWD (r = -0.53, p = 0.03) and BNP and PAP (r = 0.51, p = 0.04) between 2- and 12-months treatment.In patients with moderate-severe PAH, the addition of bosentan to therapy, exerts favorable anti-inflammatory effects, which are associated with clinical and hemodynamic improvement.

Background: Pulmonary hypertension (PH) may be associated with subendocardial ischaemia. We investigated whether ischaemia-modified albumin (IMA), an established marker of ischaemia, is elevated in stable patients with PH.Methods: We studied 32 patients with PH and an equal number of age-matched normal volunteers. We assessed serum IMA levels with the albumin cobalt-binding test.Results: Patients’ mean ± SD (range) pulmonary arterial pressure was 56 ± 12 (33–73) mmHg and their exercise capacity was 394 ± 145 (121–688) m in the 6-min walk test. IMA was 92 ± 14 (69–115) U ml−1 in the patient group and 93 ± 9.4 (76–122) U ml−1 in the control group with no significant difference between the two (p = 0.85), although almost one-third of the patients had detectable troponin-I.Conclusions: We conclude that IMA, a marker of ischaemia, does not differ in patients with advanced clinically stable PH compared with normal subjects.

The present study reports the incidence, management and clinical outcome of coronary perforations in 5 of 2991 patients (0.1%) undergoing percutaneous coronary intervention, with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques. There was 1 type I, 1 type II and 3 type III perforations. One perforation was guidewire related, 2 perforations occurred after stent deployment and two occurred during stent-post dilatation with balloons. Restoration was obtained by prolong balloon inflation in three cases. Subsequent cardiac tamponade occurred in 2 patients, requiring pericardiocentesis. One patient died in the cath lab. due to electromechanical dissociation. At follow-up, 3 out of 4 patients were asymptomatic and one had bypass surgery for restenosis. Treatment of coronary perforation requires rapid detection, angiographic classification, and immediate occlusion of perforation site, pericardiocentesis, haemodynamic support and reversal of heparin anticoagulation.

Background Biomarkers of myocardial necrosis may be increased in patients with chronic heart failure. We investigated whether ischaemia-modified albumin (IMA), a marker of ischaemia, is also elevated in patients with compensated heart failure, due to dilated cardiomyopathy (DCM). Methods We studied 42 patients with DCM and an equal number of age-matched normal volunteers. We assessed IMA serum levels with the albumin cobalt binding test. Results IMA was 89.9 ± 13.1 (71–117) KU/L in the patient group and 93.9 ± 9.9 (76–122) KU/L in the control group, with no significant difference between the two ( P = 0.11). However, IMA differed significantly according to the New York Heart Association classification ( P = 0.003) and was negatively correlated with the left ventricular ejection fraction ( r = −0.40, P = 0.014). Conclusions We conclude that IMA, a marker of ischaemia, does not differ in patients with clinically stable DCM compared with normal subjects, but varies significantly in relation to the severity of the disease.

We have previously shown that estrogen administered in ovariectomized female rabbits significantly reduce myocardial infarct size. We now investigated whether the phytoestrogen genistein similarly protects ischemic myocardium and whether this is associated with its antioxidant properties. In addition, we examined whether genistein abolishes preconditioning, since at high doses, it inhibits tyrosine kinase.We studied five groups of New Zealand white female rabbits. Group A (n = 12) were normal controls, group B (n = 14) were ovariectomized 4 weeks prior to the experiment, group C (n = 10) were ovariectomized and treated with genistein (0.2 mg kg(-1) day(-1) subcutaneously) for 4 weeks before the experiment, group D (n = 12) had intact gonads and were treated with genistein (0.2 mg kg(-1) day(-1) subcutaneously) for 4 weeks before the experiment and group E (n = 8) were ovariectomized 4 weeks prior to the experiment and treated with a single dose of genistein (0.2 mg kg(-1) day(-1) subcutaneously) just prior to the experiment. All animals underwent 30 min of heart ischemia and 120 min of reperfusion, with (subgroup I) or without (subgroup II) preconditioning. Malondialdehyde (MDA) concentration just before the experiment was determined.We found significant differences between the groups-p0.0001 in factorial ANOVA. The groups with preconditioning had significant smaller infarcts compared to those without-AI vs AII (10.66 +/- 1.42% vs 43.22 +/- 2.67%), BI vs BII (18.53 +/- 2.36% vs 43.05 +/- 8.37%), CI vs CII (10.17 +/- 2.07% vs 44.5 +/- 5.47%), DI vs DII (14.98 +/- 2.36% vs 37.79 +/- 3.92%) and EI vs EII (17.11 +/- 3.24% vs 42.08 +/- 3.42%), p0.0005. Ovariectomy was not associated with larger myocardial infarctions-AII vs BII, p = NS. Genistein, for 4 weeks, did not protect ischemic myocardium in either ovariectomized or non-ovariectomized animals-BII vs CII and AII vs DII, p = NS. There was no significant difference between the preconditioned animals, with intact gonads or ovariectomized (AI vs BI, p = NS), ovariectomized with or without genistein (BI vs CI, p = NS) and non-ovariectomized whether treated with genistein or not (AI vs DI, p = NS). A single dose of genistein did not offer any protection (EII vs BII, p = NS), nor did it modify the preconditioning effect (EI vs BI, p = NS). We found no significant difference in MDA plasma levels between the groups.Genistein, at this dose, does not reduce infarct size per se nor abolishes the protection induced by preconditioning, in both ovariectomized and non-ovariectomized animals. Preconditioning offers myocardial protection in animals with intact gonads as well as estrogen deprived; bilateral ovariectomy, at least during short-term, is not associated with larger myocardial infarcts compared to control animals. In addition estrogen deprivation, during short term, as well as genistein do not modify oxidative stress.

17-Beta-estradiol inhibits smooth muscle cell proliferation and migration and accelerates endothelial cell repair in response to balloon injury. The aim of this study was to determine whether administration of estrogen is associated with decreased neointimal hyperplasia after stenting in the porcine model.Twenty-two farm female pigs 7 months old were oophorectomized and at the third day normal saline (11 pigs) or 20 mg of estradiol valerate (11 pigs), modified release, were administered intramuscularly. At the 10th day after oophorerectomy, 1 or 2 stainless steel stents were implanted in the right coronary artery in each pig, and at the 17th day, normal saline or 10 mg estradiol valerate, modified release, were administered intramuscularly in the two groups. Pigs were sacrificed 28 days after stent implantation and histomorphometric analysis of the coronary arteries was performed (20 stents from the estrogen and 18 stents from the control groups). In the estrogen group, neointimal proliferation area was 1.42+/-0.55 mm(2), whereas in the control group, 1.96+/-0.89 mm(2) (p=0.02). Area stenosis was 39+/-13% and 49+/-16% in the two groups, respectively (p=0.07). Re-endothelialization was 2.67+/-0.34 and 2.22+/-0.46 in the two groups, respectively (p0.010). The injury score was similar between the two groups.These data suggest that intramuscular administration of estrogen accelerates the endothelial cell repair in response to injury and reduces intimal hyperplasia in the porcine model.

Homocysteine may be an independent risk factor for coronary artery disease (CAD), and the risk is at least as strong for women as for men. Homocysteine levels are lower in women compared with men, and homocysteine is lower during pregnancy and higher during menopause.To investigate the effects of hormone replacement therapy (HRT), simvastatin, and their combination on plasma homocysteine levels, we treated 16 postmenopausal, hypercholesterolemic women with CAD with HRT (0.625 mg conjugated equine estrogens [CEE] combined continuously with 2.5 mg medroxyprogesterone), 20 mg simvastatin, and their combination in a randomized, placebo-controlled study. Each treatment period was 8 weeks long, with a 4-week washout interval. Plasma homocysteine levels were evaluated at the end of each treatment period.Only HRT, alone and in combination with simvastatin, significantly reduced homocysteine levels compared with placebo (11.82 +/- 0.74 and 12.22 +/- 0.71 vs 13.58 +/- 0.83 micromol/L, respectively, p0.05). Simvastatin had no effect (13.02 +/- 0.94 micromol/L), and the combination therapy was not better that monotherapy with HRT.Oral HRT reduces homocysteine plasma levels, whereas simvastatin has no effect. If confirmed by randomized, prospective studies with clinical end points, HRT may be considered for women with mild hypercholesterolemia and high homocysteine levels.

Estrogen administration promotes angiogenesis and perfusion in oophorectomized rabbits with chronic limb ischemia. In the present study we tested whether gender affects angiogenesis and arteriogenesis in a rabbit model of chronic hind limb ischemia.Ischemia was induced in one hind limb of five oophorectomized (Ooph), seven non-oophorectomized (NonOoph) female and eight male New Zealand White rabbits by excision of the femoral artery. Ten days after the induction of ischemia (day 0) and at days 15 and 30 systolic calf blood pressure was measured in the ischemic and non-ischemic hind limbs. Revascularization in the ischemic limb was expressed as ischemic/normal limb blood pressure, capillary/muscle fiber density, and non-capillary, non-lymphatic vessels/muscle fiber density after examination of light microscopic sections taken from the abductor muscle of the ischemic limb at the time of death (day 30). Ischemic/normal blood pressure at day 30 in males was 0.62 +/- 0.22, in NonOoph 0.64 +/- 0.09 (P=ns vs. males) and in Ooph 0.39 +/- 0.05 (P0.05 vs. males and NonOoph), (F=4.69, P=0.02). Ischemic capillary/muscle fiber in males was 0.96 +/- 0.09, in NonOoph 0.95 +/- 0.06 (P=ns vs. males) and in Ooph 0.83 +/- 0.09 (P0.05 vs. males and NonOoph), (F=5.93, P=0.01). Ischemic non-capillary, non-lymphatic vessels/muscle fiber density in males was 0.11 +/- 0.02, in NonOoph 0.12 +/- 0.03 (P=ns vs. males) and in Ooph 0.08 +/- 0.02 (P0.05 vs. NonOoph), (F=5.05, P=0.02).Gender does not influence angiogenesis and arteriogenesis in the rabbit model of chronic hind limb ischemia. However, estrogen deficiency induced by oophorectomy negatively affects angiogenesis and arteriogenesis.

A patient with exertional angina and left main and two vessel coronary artery disease (left anterior descending and circumflex artery), with normal left ventricular function, underwent elective coronary artery bypass grafting, on extracorporeal circulation. The obtuse marginal branch was considered ungraftable, and a composite arterial graft (left internal mammary anastomosed to the radial artery) was inserted to the distal left anterior descending artery …

Coronary artery steal via a large unligated intercoastal side-branch of the internal mammary artery graft has been previously described in two case reports. We report a series of 7 patients with post-operative angina in whom microcoil embolization of such branch was performed. In 5 patients in whom complete occlusion of the branch was achieved, anginal symptoms were relieved; in contrast the 2 patients with persistent flow through the intercostal branch remained symptomatic despite all their grafts being widely patent. We conclude that large unligated intercostal branches of the IMA graft may be related with post-operative angina and their embolization is a simple, safe, and effective procedure.

Background: Although there are many studies concerning the effects of long-term oestrogen administration on systemic haemodynamics in postmenopausal women, the effects of oestrogen in patients with chronic heart failure are not defined. Aim: The goal of this study was to evaluate the acute haemodynamic effects of oestrogen in male patients with chronic heart failure. Methods and results: We studied 15 men with advanced heart failure (NYHA II–IV, EF

Controversy exists regarding inhibition of ischemic preconditioning in hyperlipidemic animals. In this study, we tested the hypothesis that hyperlipidemia inhibits the normal reduction of myocardial ischemia on repeated balloon inflations (BIs) during angioplasty.We studied 33 patients undergoing coronary angioplasty. All underwent a minimum of three BIs. Patients were grouped according to the following plasma cholesterol levels: 13 patients had total cholesterol levels200 mg/dL (the normal cholesterol group); and 20 patients had total cholesterol levelsor = 200 mg/dL (the elevated cholesterol group). Surface ST-segment elevations were recorded at the end of each BI.In the normal cholesterol group, the mean (+/- SD) ST-segment elevation decreased from 0.21 +/- 0.15 mV during the first BI to 0.11 +/- 0.11 mV during the third BI (p0.05). In the elevated cholesterol group, the respective decrease was from 0.18 +/- 0.16 to 0.14 +/- 0.15 mV (p = not significant) [between-group comparisons: F = 3.97; p = 0.02]. The decrease in ST-segment elevation was correlated with the total cholesterol levels (r = -0.48; p = 0.005), the low-density lipoprotein (LDL) cholesterol levels (r = -0.50; p = 0.003), and the high-density lipoprotein/LDL levels (r = 0.44; p = 0.01).Hyperlipidemia prevents the normal reduction of myocardial ischemia on repeated BIs during angioplasty. This leads to the clinical implication that reduction of cholesterol plasma levels, apart from its other known benefits, could also have a beneficial effect on cardioprotection.

Objective: To test whether type II diabetes prevents the recruitment of collaterals and the normal reduction of myocardial ischaemia on repeated balloon inflations during coronary angioplasty. Methods: Two groups of patients were studied. A collateral circulation group consisted of 56 patients, 18 diabetic and 38 non-diabetic. All underwent a minimum of three balloon inflations. A pressure guide wire was used for the measurement of coronary wedge pressure (mm Hg). The angioplasty protocol was repeated in another group of 57 patients (myocardial ischaemia group) using both surface and intracoronary ECGs to assess myocardial ischaemia. Results: In diabetic patients, mean (SD) coronary wedge pressure was 35 (12) mm Hg during the first balloon inflation, 39 (15) mm Hg during the second (p < 0.05 v first inflation), and 42 (17) mm Hg during the third (p < 0.05 v first inflation); in non-diabetic patients the respective values were 36 (16), 37 (16), and 37 (16) mm Hg (F = 4.73, p = 0.01). The ratio of coronary wedge pressure to mean arterial pressure in diabetic patients in the three balloon inflations was 0.33 (0.11), 0.36 (0.13), and 0.39 (0.15), respectively (p < 0.05 v the first inflation); and in non-diabetic patients it was 0.33 (0.15), 0.34 (0.15), and 0.35 (0.15) (F = 1.92, p = 0.15). In the diabetic group the response was independent of the type of treatment. No difference between diabetic and non-diabetic patients was observed in the normal reduction of myocardial ischaemia on repeated balloon inflations. Conclusions: Type II diabetes does not prevent the recruitment of collateral vessels and the normal reduction of myocardial ischaemia on repeated balloon inflations during coronary angioplasty in single vessel disease, regardless of the type of antidiabetic treatment.

P studies have demonstrated distal coronary vasoconstriction immediately after percutaneous transluminal coronary angioplasty (PTCA). It was presumed that this coronary vasoconstriction is the result of intimal injury or endothelial dysfunction,1 abnormal autoregulatory tone,2–4 formation of vasoactive substances,5,6 impaired release of endothelialderived relaxing factor,7 and activation of adrenergic neural reflexes.8 Endothelin-1 (ET-1) levels have been found to be elevated after PTCA.9 ET-1 produces very potent and marked vasoconstriction in vitro as well as in vivo.10 ET-1 binds to at least 2 receptors: in blood vessels, endothelin A (ETA) receptors are present only on vascular smooth muscle cells and cause contraction, whereas endothelin B receptors are on endothelium, causing vasodilatation, and on vascular smooth muscle cells, causing contraction. In healthy men, the major receptor causing vasoconstriction, at least in the systemic circulation, is the ETA receptor.11–13 Endogenously produced ET-1 contributes to the maintenance of basal coronary artery tone in humans with and without coronary artery disease.14 The aim of this study was to test the hypothesis that ETA receptor stimulation contributes to the coronary artery vasoconstriction observed after PTCA. We studied 22 consecutive patients, mean age 58 6 7 years, scheduled to undergo elective PTCA for an isolated obstructive lesion and willing to participate. The study conformed to the principles outlined in the Declaration of Helsinki, and was approved by the hospital ethics committee. All patients gave informed consent. All patients fulfilled the following entry criteria: (1) history of chronic stable angina pectoris $3 months, and (2) angiographic appearance of lesions displaying an internal diameter reduction .50%. Exclusion criteria were unstable angina, a history of previous myocardial infarction, left main stem disease, angiographic evidence of coronary collaterals, total and subtotal occlusive lesions, lesions adjacent to a bifurcation, diabetes mellitus, depressed left ventricular function (,55%), valvular heart disease, systolic blood pressure ,100 mm Hg, or any concurrent illness. Patients were randomly allocated to receive an intracoronary infusion of BQ-123 (n 5 11) or normal saline 0.9% (n 5 11). The 2 groups had similar clinical characteristics (Table 1). All procedures were performed in patients in the fasting state, without the use of premedication. Antianginal medications were discontinued for $12 hours before the procedure. No other medication apart from heparin and BQ-123 was given until the end of the protocol. PTCA was performed using a standard technique.9 Heparin was administered as a bolus at the beginning (5,000 IU intra-arterially) and during the procedure to maintain an activated clotting time of .300 seconds. Two balloon inflations were performed for each patient with a 5-minute resting interval. If the clinical and angiographic result was satisfactory after the second balloon inflation, the patient was randomized to 1 of the 2 groups. Patients who developed dissections at the dilated site, needed stent implantation for any reason, or had an unsatisfactory angiographic result after the second balloon inflation were excluded from the study. Hemodynamic measurements (heart rate and blood pressure) and coronary arteriograms recorded by hand injection were recorded at baseline (before angioplasty initiation) and 5 and 25 minutes after the second balloon inflation, with the guidewire in place. The study was completed when the arteriogram was obtained 25 minutes after the second balloon inflation. Five minutes after the second balloon inflation, BQ-123 (Clinalfa, Switzerland) or saline was infused through the guiding catheter at a constant rate of 1 ml/min (300 nmol/min) for 20 minutes. This dose of BQ-123 (total dose of 6 mmol) has been shown not to From Onassis Cardiac Surgery Center, Athens, Greece; and Department of Medical Sciences, University of Edinburgh, Western General Hospital, Edinburgh, Scotland. Dr. Kyriakides address is: Onassis Cardiac Surgery Center, 356 Sygrou Avenue, Athens 17674, Greece. E-mail: zskyr@otenet.gr. Manuscript received September 7, 2000; revised manuscript received and accepted November 6, 2000. TABLE 1 Clinical and Angiographic Characteristics of the Patients Studied

Objective: Promoting angiogenesis may be an effective treatment for patients with diffuse peripheral vascular disease. This study investigated whether estrogen can promote angiogenesis and perfusion in a rabbit model of chronic limb ischemia. Methods and results: Ischemia was induced in one hindlimb of 24 oophorectomized New Zealand White rabbits. Ten days later (day 0), they were randomized into 4 groups for intramuscular treatment in the ischemic limb: controls receiving saline at day 0; Estrogen-1 group receiving estradiol valerate, modified release (EVMR), 1 mg/kg at day 0; Estrogen-2 group receiving EVMR 1 mg/kg at days 0 and 15; and Estrogen-3 group receiving EVMR 2 mg/kg at day 0. Revascularization was evaluated by clinical indexes, such as ischemic/normal limb systolic blood pressure (BPR), and capillary density/muscle fiber in the abductor muscle of the ischemic limb at the time of death (day 30). At day 30 the BPR was increased in all groups (0.39±0.08 in the controls, 0.52±0.11 in the Estrogen-1 group, 0.65±0.13 in the Estrogen-2 group and 0.61±0.16 in the Estrogen-3 group, F = 2.39, P = 0.04). The capillary/muscle fiber at day 30 was 0.87±0.09, 1.08±0.15, 1.01±0.14 and 1.10±0.9 ( F = 5.01, P = 0.01), respectively, in the 4 groups. The capillary/muscle fiber was related to BPR ( r = 0.48, P