Gurkan Acar, Karacasu, Turkey Constantina Aggeli, Athens, Greece Tolga Aksu, Kocaeli, Turkey N. Al-Naamani, Boston, Mass., USA Joseph S. Alpert, Tucson, Ariz., USA Giuseppe Andò, Messina, Italy Aristidis Androulakis, Athens, Greece Dimitrios Angouras, Athens, Greece Patrick Antoun, Jacksonville, Fla., USA Yaron Arbel, Tel Aviv, Israel Wilbert S. Aronow, Valhalla, N.Y., USA S. Aydin, Elazig, Turkey Juan Badimon, New York, N.Y., USA Maciej Banach, Lodz, Poland John Barbetseas, Athens, Greece Kristen Barthel, Boulder, Colo., USA Alban-Elouen Baruteau, New York, N.Y., USA Melissa Bates, Iowa City, Iowa, USA Javier Beaumont, Pamplona, Spain Stephanie Benjamin, Northridge, Calif., USA Alexandre Benjo, New Orleans, La., USA Evgeny Berdyshev, Chicago, Ill., USA A. Berezin, Zaporozhye, Ukraine E. Bershad, Houston, Tex., USA Sanjeev Bhattacharyya, London, UK Michael Böhm, Homburg/Saar, Germany Harisios Boudoulas, Athens, Greece Konstantinos D. Boudoulas, Columbus, Ohio, USA Ryan Boudreau, Iowa City, Iowa, USA Alberto Bouzas-Mosquera, A Coruña, Spain Sorin Brener, Brooklyn, N.Y., USA Frank Breuckmann, Arnsberg, Germany Adam S. Budzikowski, Brooklyn, N.Y., USA L. Maximilian Buja, Houston, Tex., USA John W. Calvert, Atlanta, Ga., USA Paul Chai, New York, N.Y., USA Robert D. Chait, West Palm Beach, Fla., USA Shaoliang Chen, Nanjing, China Yi Chu, Iowa City, Iowa, USA

BACKGROUND:We have investigated variations in the C-reactive protein levels in groups of patients with left ventricular dysfunction of various causes.MATERIALS AND METHODS:We have studied 59 patients (ranging from 40 to 80 years, mean age of 64, SD 9) with left ventricular dysfunction caused by dilated cardiomyopathy, valvular heart disease, chronic ischemic cardiomyopathy. These patients have been compared to 30 healthy subjects and to 15 others with acute myocardial infarction. The C-reactive protein levels have been analyzed and correlated to echocardiographic index of the left ventricular function as well as to the clinical parameters.RESULTS:The levels of C-reactive protein show a statistically significant difference between healthy controls and patients with chronic left ventricular dysfunction (0.95mg/l +-0.9 vs 10.17+-13.77; p <0.0001); a statistically significant difference between patients with chronic left ventricular dysfunction and patients with acute myocardial infarction (10.17mg/l+-13.7 vs 30.78+-22.53, p<0.0001), and a statistically significant difference between the group of patients with chronic left ventricular dysfunction of both ischemic and non ischemic origin (15.39mg/l +-18.19 vs 6.83+-8.77, p = 0.0095). When all chronic patients were analyzed together, the levels of C-reactive protein correlated with the New York Heart Association class (r = 0.282, p = 0.015), age (r = 0.231, p = 0.039) and with the end diastolic volume of left ventricle (r = -0.230, p = 0.040).CONCLUSIONS:As shown by increment of C-reactive protein values, the immune system is activated in patients with the chronic left ventricular dysfunction. The patients with the chronic left ventricular dysfunction of an ishemic origin have higher levels of C-reactive protein than those of a non-ischemic origin. This difference could depend on the atherosclerotic process present presumably only in the first group.

Patients with combined valvular-aortic disease undergo surgical reconstruction of the aortic root with a valved composite graft. Two of the techniques used to replace the aortic valve and ascending aorta are Bentall and Cabrol procedures. Cabrol surgical procedure uses a Dacron tube that enables coronary artery revascularization. Graft limb occlusion may however occur.Digital subtraction angiography, magnetic resonance angiography and multidetector computed tomography angiography are useful imaging methods for the evaluation of surgical-related complications.We report the case of a patient treated by the Cabrol technique, who was studied with contrast-enhanced multidetector computed tomography angiography to evaluate long-term post-surgical complications and coronary vessels patency.

The increase of the levels of some cellular enzymes, as CPK and troponins, has been observed and accepted as a sign of cellular death in acute myocardial infarction as well as in other acute coronary syndromes, mainly spontaneous angina. In the latter where, moreover, their level is used in the initial risk stratification of the patients [1, 2]. However, later some investigators [3–7] showed a similar increase, together with the appearance of markers of endothelial dysfunction in a variety of other conditions not necessarily of atherosclerotic origin: dilated and ischemic cardiomyopathies, valvular heart disease, in presence of variable degrees of impairment of the left ventricular function. Their meaning is, therefore, probably not the same and not directly dependent upon the changes induced by atherosclerosis. Actually, in the same chronic heart disease of any cause, several markers of cardiac inflammation and necrosis, of endothelial dysfunction and of neuro-hormonal activation are present. The pertinent data collected by our group are depicted in Figure 1. For this reason, we decided to analyze the behavior of troponins I and T in a group of patients with left ventricular dysfunction not depending on an acute myocardial infarction, and to investigate the relationship between troponins and some clinical and echocardiographic parameters of left ventricular function.

Patients with combined valvular-aortic disease undergo surgical reconstruction of the aortic root with a valved composite graft. Two of the techniques used to replace the aortic valve and ascending aorta are Bentall and Cabrol procedures. Cabrol surgical procedure uses a Dacron tube that enables coronary artery revascularization. Graft limb occlusion may however occur. Digital subtraction angiography, magnetic resonance angiography and multidetector computed tomography angiography are useful imaging methods for the evaluation of surgical-related complications. We report the case of a patient treated by the Cabrol technique, who was studied with contrast-enhanced multidetector computed tomography angiography to evaluate long-term post-surgical complications and coronary vessels patency.

In pazienti con patologia valvolare aortica e dell’aorta ascendente, la tecnica secondo Cabrol contribuisce ad ottenere una buona anastomosi senza la creazione di tensioni per prevenire la formazione di pseudoaneurismi secondari, ma con il rischio di formazione di trombi murali a livello dei condotti protesici. Questa tecnica prevede l’utilizzo di una protesi costituita da un tubo valvolato in poliestere che sostituisce l’aorta ascendente e la valvola aortica e un secondo condotto connesso direttamente e perpendicolarmente al primo che ricongiunge le coronarie. La tomografia computerizzata spirale multistrato, con l’ausilio di stazioni di post-processing tridimensionali dedicate, per l’elevato dettaglio anatomico, può essere considerata un valido strumento diagnostico nel follow-up di tali pazienti. Riportiamo un caso trattato con intervento secondo Cabrol studiato con angio-tomografia multistrato.

OBJECTIVE:Several previous studies evaluated the cardiovascular risk associated with exercise, but only a few papers considered this risk during physical activity in the mountains. The aim of this study was to assess the cardiovascular risk in a population practising physical activity in the mountains. METHODS:We used an observational study design. We estimated the population by integrating the data of presences in the accommodation establishments with data from telephone and on-field interviews. As survey sources of cardiovascular events we used the reports of the Mountain Rescue teams and of the emergency physicians and pathologists operating in the hospitals of the considered mountain area. RESULTS:We estimated that the duration of exposure to risk for the study population was, averagely per year, 12 449 877 person-days. During the study period, we recorded 117 cardiovascular events, namely 38 sudden cardiac deaths, 13 acute coronary syndromes, and five strokes. The remaining 61 events were non-traumatic events with a probable cardiovascular origin. We calculated one cardiovascular event per 319 000 person-days of physical activity in the mountains, one sudden cardiac death per 980 000 and one acute coronary syndrome per 2 895 000 person-days. CONCLUSIONS:The risk of cardiovascular events in the population practising physical activity in the mountains is very low and essentially limited to men over the age of 40, particularly if they do not practise regularly physical activity. For these subjects the risk seems to be associated with physical activity, but not with altitude and other typical aspects of mountains, such as low temperature and difficulties of terrain.

Between March 1970 and May 1976, 564 patients have undergone single or multiple heart valve replacement with the Hancock "SGP" bioprosthesis in our institution. Of these patients, 335 had single mitral, 102 aortic, one tricuspid, and 126 double or triple valve replacement, for a total of 629 xenografts. The long-term results, in terms of clinical improvement, survival, and complications, have been analyzed. Significant valve insufficiency secondary to primitive tissue alterations occurred in three patients, while reoperations were required in two for endocarditis and in two others for mitral stenosis caused by tissue ingrowth.

The survival and quality of life of patients with congenital heart disease have significantly improved in the last 20 years. This is due to more effective medical and surgical care. The new community of grown-up congenital heart patients consists of a few natural survivors with trivial congenital lesions or very rare complex cardiac abnormalities which are naturally compensated, and of more than 75% of patients who had been submitted to cardiac surgery during infancy or childhood. Clinical follow-up is however mandatory for many of them with scheduled times and types of exams to control the effects of sequelae and late complications, and to prevent deterioration and premature death because cardiac surgery may not have resulted in normality. Moreover, these patients have many needs and even more, many questions. Not giving a correct answer to each specific question reduces the entity of surgical success.

INTRODUCTION: there are no certain data regarding the real cardiac assistance of cardiomyoplasty. We tested the use of doppler flow wire for measurement of aortic flow velocity (directly related with cardiac output) in order to demonstrate that this method is able to measure systolic assistance during stimulated beats in cardiomyoplasty. METHOD: the technique has been tested in five coronaropathic patients (M/F = 4/1; age = 61±7.1; atrial fibrillation / sinus rhythm = 1/4; VTD = 76.6±8.26 ml/ mq; EF = 67.4±8.56). The measures were performed during a normal cardiac left catheterization for coronarography using a Flex M Doppler flow wire of .018 inch through a 4F introducer femoral arterial access. Stimulated beats were obtained with a right ventricle stimulator catheter through a femoral venous access. RESULTS: fourth series of measures, composed by 10 normal beats and 1 stimulated beat, were recorded: we measured the maximal peak velocity of beat n°9 (normal) and beat n°1 (post-stimulated beat) of the subsequent series. The values respectively for normal beats and for post-stimulated beats were: first series: 50.4±13.5 and 63.4±17.5 cm/s (P = 0.0091); second series: 65.4±15.4 and 75.2±14.4 cm/s (P = 0.0044); third series: 49.8±8.43 and 62.4±17.7 cm/s (P = 0.0249); fourth series: 56.8±15.4 and 63.4±13.3 cm/s (P = 0.0024). No complications were observed after the procedure. DISCUSSION: Statistical analysis showed a significant increasing in peak flow velocity after the stimulated beats. Therefore the technique is safe and effective and may be sensit ive enough to detect a similar phenomenon related to a real systolic improvement owe to latissimus dorsi graft contraction. In the first two demand dynamic cardiomyoplasty operated patients tested with this method, it has been showed an increase of 10% in aortic flow velocity between stimulated and no-stimulated beats.

No data have been published on real cardiac assistance with demand dynamic cardiomyoplasty. We tested the utility of a Doppler flow wire in measuring beat by beat aortic flow velocity and evaluating cardiac assistance in demand cardiomyoplasty patients. The technique was tested in seven patients (M/W = 6/1; age, 57.1+/-6.2 years; atrial fibrillation/ sinus rhythm = 1/6; New York Heart Association [NYHA] classification = 1.4+/-0.5). Measurements were done using a 0.018 inch peripheral Doppler flow wire advanced through a 5 French arterial femoral sheath. Three 1 minute periods with the stimulator off, and three 1 minute periods with clinical stimulation were recorded. We measured peak aortic flow velocity in all beats. Latissimus dorsi mechanogram was simultaneously recorded. Comparison between preoperative and follow-up data showed significantly higher values of tetanic fusion frequency and ejection fraction at follow-up, whereas mean NYHA class was significantly lower. Statistical analysis showed an increase in aortic flow velocity not only in the assisted versus rest period, but also in assisted versus unassisted beats (8.42+/-6.98% and 7.55+/-3.07%). A linear correlation was found between increase in flow velocity and latissimus dorsi wrap tetanic fusion frequency (r2 = 0.53). In demand dynamic cardiomyoplasty, systolic assistance is significant and correlated to the latissimus dorsi speed of contraction; a demand stimulation protocol maintains muscle properties and increases muscle performance.

Background —The frequency of skin tumors of all types and specifically of squamous cell carcinoma (SCC) is increased in heart transplantation (HT), but the predisposing risk factors are controversial. Methods and Results —We studied 300 patients (age 49±15 years, 258 men, mean follow-up 4.6 years, follow-up range 1 month to 12 years) who were receiving standard double (cyclosporin plus azathioprine) or triple (cyclosporin plus azathioprine plus prednisone) therapy. The first-year rejection score was calculated for endomyocardial biopsy samples (International Society for Heart and Lung Transplantation grade 0=0, 1A=1, 1B=2, 2=3, 3A=4, 3B=5, and 4=6) and used as an indirect marker of the level of immunosuppression. Multivariate analysis (Cox regression) included age at HT, sex, skin type, first-year rejection score, presence of warts and solar keratosis, lifetime sunlight exposure, and first-year cumulative dose of steroids. The incidence of skin tumors of all types increased from 15% after 5 years to 35% after 10 years after HT according to life-table analysis. Age at HT of >50 years ( P =0.03, RR=5.3), skin type II ( P =0.05, RR=2.6), rejection score of 19 ( P =0.003, RR=5.7), solar keratosis ( P =0.001, RR=6.9), and lifetime sunlight exposure of >30 000 hours ( P =0.0003, RR=7.6) were risk factors for SCC. Conclusions —Older age at HT, light skin type, solar keratosis, greater sunlight exposure, and high rejection score in the first year were independently associated with an increased risk of SCC. The progressive increase in cancer frequency during follow-up and the association with high rejection scores suggest that both the length and level of immunosuppression may be relevant. Because cumulative immunosuppressive load is cumbersome to calculate, a high rejection score in the first year may provide a useful predictor for patients at risk.

The delay between onset of symptoms and coronary care unit admission is decisive in the outcome of patients with acute myocardial infarction.To evaluate the influence of the factors that affect the delay in acute myocardial infarction treatment.Multicenter case-control study conducted by 118 coronary care units in Italy. The median and mean times in cases and controls were compared for decision time, home-to-hospital time, and in-hospital time, and the influence of several potential risk factors on the delay was evaluated by comparison of patients admitted more than 6 hours after onset with those admitted within 6 hours after onset.Among 5301 patients with acute myocardial infarction, 590 who came to a coronary care unit after 12 hours were considered cases. Controls included 600 patients treated within 2 hours, 603 between 2 and 6 hours, and 466 between 6 and 12 hours. The median decision time among cases was 50-fold higher than that of controls who presented within 2 hours. Home-to-hospital time and in-hospital time appeared to play a less important role. Among the patient-related variables, advanced age, living alone, low intensity of initial symptoms, history of diabetes, strong pain at onset of the infarction, occurrence of symptoms at night, and involvement of a general practitioner seemed to affect delay significantly.Interventions aimed at reducing the delay in acute myocardial infarction treatment should primarily focus on the help-seeking behavior of patients.

Trimetazidine has been shown to have an antianginal effect, increasing exercise capability without producing any significant change of heart rate or systolic blood pressure. The aim of this study was to compare trimetazidine efficiency to that of another classical antianginal drug. A double-blind crossover trimetazidine versus nifedipine trial was carried out in 39 male patients, mean age 58 years, with effort angina for 5 years on average, and a mean number of weekly attacks of 2.4. Thirteen patients had previous myocardial infarction. Nineteen patients received nifedipine (40 mg per day) then trimetazidine (60 mg per day), and 20 patients received the drugs in the opposite order. Each therapeutic period of 6 weeks was preceded by 1 week of washout with placebo. Drug efficacy was assessed by a bicycle exercise tolerance test, performed at the beginning and at the end of each therapeutic period, and by clinical symptoms observed with placebo or with treatment. The statistical analysis was performed according to a crossover design, with repeated measurements. The decrease of the number of weekly attacks was not significantly different with trimetazidine and nifedipine. Results on the exercise test showed no significant differences for maximum workload, the duration of exercise, ST-segment depression at peak exercise, and the time to 1-mm ST-segment depression. Heart rate and systolic blood pressure were not significantly different at rest and at peak exercise. However, the change in the rate-pressure product at the same workload differed significantly between the drugs: It decreased with nifedipine and remained unchanged with trimetazidine, indicating the difference to be in the mode of action of the drug. In conclusion, trimetazidine was as efficient as nifedipine in stable angina and had a lower incidence of side effects.

Quantitative cineventriculographic measurements (ventricular volumes, ejection fraction, and myocardial mass) were obtained in 15 neonates with pulmonary atresia and intact ventricular septum. There was a wide dimensional range for the right ventricle, from a reduced through normal to enlarged. A restrictive tricuspid valve (less than 12 mm) was associated with a small or diminutive right ventricle. A normal function of the right ventricle was present only in those cases with normal-sized chambers. The left ventricular end-diastolic volume was always greater than normal. The ejection fraction was normal only if a normal myocardial mass was present. Additional abnormalities were frequent in the myocardium of both ventricles, such as extreme thinning of the wall of the right ventricle and hypoplasia or fibroelastosis of the left ventricle. All these factors can lead to a poor surgical prognosis despite good anatomical correction.