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1.  Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial 
Maggioni, Aldo P. | Greene, Stephen J. | Fonarow, Gregg C. | Böhm, Michael | Zannad, Faiez | Solomon, Scott D. | Lewis, Eldrin F. | Baschiera, Fabio | Hua, Tsushung A. | Gimpelewicz, Claudio R. | Lesogor, Anastasia | Gheorghiade, Mihai | Ramos, Silvina | Luna, Alejandra | Miriuka, Santiago | Diez, Mirta | Perna, Eduardo | Luquez, Hugo | Pinna, Jorge Garcia | Castagnino, Jorge | Alvarenga, Pablo | Ibañez, Julio | Blumberg, Eduardo Salmon | Dizeo, Claudio | Guerrero, Rodolfo Ahuad | Schygiel, Pablo | Milesi, Rodolfo | Sosa, Carlos | Hominal, Miguel | Marquez, Lilia Lobo | Poy, Carlos | Hasbani, Eduardo | Vico, Marisa | Fernandez, Alberto | Vita, Nestor | Vanhaecke, Johan | De Keulenaer, Gilles | Striekwold, Harry | Vervoort, Geert | Vrolix, Mathias | Henry, Philippe | Dendale, Paul | Smolders, Walter | Marechal, Patrick | Vandekerckhove, Hans | Oliveira, Mucio | Neuenschwande, Fernando | Reis, Gilmar | Saraiva, Jose | Bodanese, Luiz | Canesin, Manoel | Greco, Oswaldo | Bassan, Roberto | Marino, Roberto Luis | Giannetti, Nadia | Moe, Gordon | Sussex, Bruce | Sheppard, Richard | Huynh, Thao | Stewart, Robert | Haddad, Haissam | Echeverria, Luis | Quintero, Adalberto | Torres, Adriana | Jaramillo, Mónica | Lopez, Mónica | Mendoza, Fernan | Florez, Noel | Cotes, Carlos | Garcia, Magali | Belohlavek, Jan | Hradec, Jaromir | Peterka, Martin | Gregor, Pavel | Monhart, Zdenek | Jansky, Petr | Kettner, Jiri | Reichert, Petr | Spinar, Jindrich | Brabec, Tomas | Hutyra, Martin | Solar, Miroslav | Pietilä, Mikko | Nyman, Kai | Pajari, Risto | Cohen, Ariel | Galinier, Michel | Gosse, Philippe | Livarek, Bernard | Neuder, Yannick | Jourdain, Patrick | Picard, François | Isnard, Richard | Hoppe, Uta | Kaeaeb, Stefan | Rosocha, Stefan | Prondzinsky, Roland | Felix, Stephan | Duengen, Hans-Dirk | Figulla, Hans-Reiner | Fischer, Sven | Behrens, Steffen | Stawowy, Philipp | Kruells-Muench, Juergen | Knebel, Fabian | Nienaber, Christoph | Werner, Dierk | Aron, Wilma | Remppis, Bjoern | Hambrecht, Rainer | Kisters, Klaus | Werner, Nikos | Hoffmann, Stefan | Rossol, Siegbert | Geiss, Ernst | Graf, Kristof | Hamann, Frank | von Scheidt, Wolfgang | Schwinger, Robert | Tebbe, Ulrich | Costard-Jaeckle, Angelika | Lueders, Stephan | Heitzer, Thomas | Leutermann-Oei, Marie-Louise | Braun-Dullaeus, Ruediger | Roehnisch, Jens-Uwe | Muth, Gerhard | Goette, Andreas | Rotter, Achim | Ebelt, Henning | Olbrich, Hans-Georg | Mitrovic, Veselin | Hengstenberg, Christian | Schellong, Sebastian | Zamolyi, Karoly | Vertes, Andras | Matoltsy, Andras | Palinkas, Attila | Herczeg, Bela | Apro, Dezso | Lupkovics, Geza | Tomcsanyi, Janos | Toth, Kalman | Mathur, Atul | Banker, Darshan | Bharani, Anil | Arneja, Jaspal | Khan, Aziz | Gadkari, Milind | Hiremath, Jagdish | Patki, Nitin | Kumbla, Makund | Santosh, M.J. | Ravikishore, A.G. | Abhaichand, Rajpal | Maniyal, Vijayakukmar | Nanjappa, Manjunath | Reddy, P. Naveen | Chockalingam, Kulasekaran | Premchand, Rajendra | Mahajan, Vijay | Lewis, Basil | Wexler, Dov | Shochat, Michael | Keren, Andre | Omary, Muhamad | Katz, Amos | Marmor, Alon | Lembo, Giuseppe | Di Somma, Salvatore | Boccanelli, Alessandro | Barbiero, Mario | Pajes, Giuseppe | De Servi, Stefano | Greco, Dott Cosimo | De Santis, Fernando | Floresta, Agata | Visconti, Luigi Oltrona | Piovaccari, Giancarlo | Cavallini, Claudio | Di Biase, Matteo | Masini, Dott Franco | Vassanelli, Corrado | Viecca, Maurizio | Cangemi, Dott Francesco | Pirelli, Salvatore | Borghi, Claudio | Volpe, Massimo | Branzi, Angelo | Percoco, Dott Giovanni | Severi, Silvia | Santini, Alberto | De Lorenzi, Ettore | Metra, Marco | Zacà, Valerio | Mortara, Andrea | Tranquilino, Francisco P. | Babilonia, Noe A. | Ferrolino, Arthur M. | Manlutac, Benjamin | Dluzniewski, Miroslaw | Dzielinska, Zofia | Nowalany-Kozie, Ewa | Mazurek, Walentyna | Wierzchowiecki, Jerzy | Wysokinski, Andrzej | Szachniewicz, Joanna | Romanowski, Witold | Krauze-Wielicka, Magdalena | Jankowski, Piotr | Berkowski, Piotr | Szelemej, Roman | Kleinrok, Andrzej | Kornacewicz-Jac, Zdzislawa | Vintila, Marius | Vladoianu, Mircea | Militaru, Constantin | Dan, Gheorghe | Dorobantu, Maria | Dragulescu, Stefan | Kostenko, Victor | Vishnevsky, Alexandr | Goloschekin, Boris | Tyrenko, Vadim | Gordienko, Alexander | Kislyak, Oxana | Martsevich, Sergey | Kuchmin, Alexey | Karpov, Yurii | Fomin, Igor | Shvarts, Yury | Orlikova, Olga | Ershova, Olga | Berkovich, Olga | Sitnikova, Maria | Pakhomova, Inna | Boldueva, Svetlana | Tyurina, Tatiana | Simanenkov, Vladimir | Boyarkin, Mikhail | Novikova, Nina | Tereschenko, Sergey | Zadionchenko, Vladimir | Shogenov, Zaur | Gordeev, Ivan | Moiseev, Valentin | Wong, Raymond | Ong, Hean Yee | Le Tan, Ju | Goncalvesova, Eva | Kovar, Frantisek | Skalina, Ivan | Kasperova, Viera | Hojerova, Silvia | Szentivanyi, Miroslav | Stancak, Branislav | Babcak, Marian | Kycina, Peter | Poliacik, Pavol | Toth, Peter | Sirotiakova, Jana | de Sa, Esteban Lopez | Bueno, Manuel Gomez | Selles, Manuel Martinez | Cabrera, Jose Angel | Freire, Ramon Bover | Gonzalez Juanatey, Jose Ramon | Comin, Josep | Soriano, FranciscoRidocci | Lopez, Alejandro | Vicho, Raul | Lama, Manuel Geraldia | Schaufelberger, Maria | Brunotte, Richard | Ullman, Bengt | Hagerman, Inger | Cizinsky, Stella | Cherng, Wen-Jin | Yu, Wen-Chung | Kuo, Chi-Tai | Chang, Kuan-Cheng | Lai, Wen-Ter | Kuo, Jen-Yuan | Ural, Dilek | Badak, Ozer | Akin, Mustafa | Yigit, Zerrin | Yokusoglu, Mehmet | Yilmaz, Mehmet | Abaci, Adnan | Ebinc, Haksun | Perlman, Richard | Parish, David | Bergin, James | Burnham, Kenneth | Brown, Christopher | Lundbye, Justin | Williams, Celeste | Eisen, Howard | Juneman, Elizabeth | Joseph, Susan | Peberdy, Mary Ann | Peura, Jennifer | Gupta, Vishal | Habet, Kalim | French, William | Mody, Freny | Graham, Susan | Hazelrigg, Monica | Chung, Eugene | Dunlap, Stephanie | Nikolaidis, Lazaros | Najjar, Samer | Katz, Richard | Murali, Srinivas | Izzo, Joseph L. | Callister, Tracy | Phillips, Roland | Lippolis, Nicholas | Winterton, John | Meymandi, Sheba | Heilman, Karl | Oren, Ron | Zolty, Ronald | Brottman, Michael | Gunawardena, D.R. | Adams, Kirkwood | Barnard, Denise | Klapholz, Marc | Fulmer, James
European Heart Journal  2013;34(40):3117-3127.
Aims
The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM).
Methods and results
ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64–0.99; DM: HR: 1.16, 95% CI: 0.91–1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50–0.94; DM: HR: 1.64, 95% CI: 1.15–2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71–1.93; DM: HR: 2.39, 95% CI: 1.30–4.42; P = 0.07 for interaction).
Conclusion
This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without DM.
doi:10.1093/eurheartj/eht342
PMCID: PMC3800848  PMID: 23999456
Aliskiren; Diabetes; Outcomes; Post-discharge
2.  Pleiotropic Effects of Long-term Monotherapy with Rosuvastatin in Dogs with Moderate Heart Failure 
Cardiology  2012;123(3):160-167.
Objective
The objective of this study was to investigate potential pleiotropic effects of rosuvastatin (RSV) in left ventricular (LV) myocardium of dogs with moderate heart failure (HF).
Methods
LV tissue was obtained from HF dogs randomized to 3 months therapy with low dose (LD) RSV (n=7), high dose (HD) RSV (n=7) or to no therapy (Control, n=7), and from 7 normal (NL) dogs. mRNA and protein expression of pro-hypertrophic mediators NGFI-A binding protein 1 (Nab1), phosphatase and tensin homolog (PTEN), phosphoinositide-3 kinase (PI3K) and mammalian target of rapamycin (mTOR); pro-inflammatory cytokine interleukin-6 (IL-6); bone marrow-derived stem cells (BMSCs) markers cKit and Sca1; vascular endothelial (VEGF) and fibroblast (FGF) growth factors and nitric oxide synthase (NOS) isoforms were measured.
Results
Nab1, PTEN, PI3K, mTOR, and IL-6 increased in Controls. HD RSV reduced expression of Nab1, PTEN, PI3K, mTOR, and IL-6 to near normal levels. cKit and Sca1 significantly increased while VEGF and FGF decreased in Controls compared to NL. RSV therapy further increased expression of cKit, Sca1, VEGF and FGF. HD RSV normalized expression of NOS isoforms.
Conclusion
These pleiotropic effects of RSV may account, in part, for the observed beneficial effect of RSV on LV function and structural remodeling.
doi:10.1159/000342082
PMCID: PMC3544002  PMID: 23128666
Inflammation; Cytokines; Growth factors; Nitric oxide synthase; Hypertrophy; Stem cells
3.  Incremental value of pocket-sized imaging device for bedside diagnosis of unilateral pleural effusions and ultrasound-guided thoracentesis 
OBJECTIVES
The present study aimed to assess the additional value of a pocket-sized imaging device (PSID) as an adjunct to plain chest X-rays in the diagnosis of pleural effusion (PE), mainly for those requiring pleural thoracentesis.
METHODS
We performed a thoracic ultrasound examination using a PSID in 73 patients with an abnormal chest X-ray diagnostic for unilateral PE. Abundant PE was defined as an interpleural distance between the diaphragm and visceral pleura (VP) of ≥30 mm at the apex of the 50 mm bisector line of the costodiaphragmatic recess at end expiration.
RESULTS
According to PSID ultrasound evaluation, abundant PE was present in 46 patients (63%), while 27 (37%) patients showed the presence of mild PE or absence of PE. Thoracentesis was performed successfully and without procedure-induced complications in all 46 patients with abundant PE. Using the above-mentioned method, we obtained a high diagnostic accuracy (area under the curve = 0.99) and excellent sensitivity and specificity of 91.7 and 99.9%, respectively, to predict a PE >1000 ml, when VP was >6.3 cm.
CONCLUSIONS
PSID is a useful tool that may integrate and complete the physical examination, also providing additional information to chest X-ray in the clinical management of patients with suspected PE. PSID evaluation can also increase the effectiveness and safety of thoracentesis.
doi:10.1093/icvts/ivs223
PMCID: PMC3445353  PMID: 22815326
Lung ultrasound; Pocket-sized imaging device; Pleural effusion
4.  Atenolol Is Inferior to Metoprolol in Improving Left Ventricular Function and Preventing Ventricular Remodeling in Dogs with Heart Failure 
Cardiology  2008;112(4):294-302.
Objectives
β-Blockers are standard therapy for patients with heart failure (HF). This study compared the effects of chronic monotherapy with 2 different β1-selective adrenoceptor blockers, namely atenolol and metoprolol succinate, on left ventricular (LV) function and remodeling in dogs with coronary microembolization-induced HF [LV ejection fraction (EF) 30–40%].
Methods
Twenty HF dogs were randomized to 3 months of therapy with atenolol (50 mg once daily, n = 6), metoprolol succinate (100 mg, once daily, n = 7) or to no therapy (control, n = 7). LV EF and volumes were measured before initiating therapy and after 3 months of therapy. The change (Δ) in EF and volumes between measurements before and after therapy was calculated and compared among study groups.
Results
In controls, EF decreased and end-systolic volume increased. Atenolol prevented the decrease in EF and the increase in ESV. In contrast, metoprolol succinate significantly increased EF and decreased end-systolic volume. ΔEF was significantly higher and Δend-systolic volume significantly lower in metoprolol succinate-treated dogs compared to atenolol-treated dogs (EF: 6.0 ± 0.86% vs. 0.8 ± 0.85%, p < 0.05; end-systolic volume: −4.3 ± 0.81 ml vs. −1 ± 0.52 ml, p <0.05).
Conclusions
In HF dogs, chronic therapy with atenolol does not elicit the same LV function and remodeling benefits as those achieved with metoprolol succinate.
doi:10.1159/000159123
PMCID: PMC2917737  PMID: 18832825
Heart failure; Myocyte hypertrophy; Ventricular remodeling; Gene expression
5.  Agents with inotropic properties for the management of acute heart failure syndromes. Traditional agents and beyond 
Heart Failure Reviews  2009;14(4):243-253.
Treatment with inotropic agents is one of the most controversial topics in heart failure. Initial enthusiasm, based on strong pathophysiological rationale and apparent empirical efficacy, has been progressively limited by results of controlled trials and registries showing poorer outcomes of the patients on inotropic therapy. The use of these agents remains, however, potentially indicated in a significant proportion of patients with low cardiac output, peripheral hypoperfusion and end-organ dysfunction caused by heart failure. Limitations of inotropic therapy seem to be mainly related to their mechanisms of action entailing arrhythmogenesis, peripheral vasodilation, myocardial ischemia and damage, and possibly due to their use in patients without a clear indication, rather than to the general principle of inotropic therapy itself. This review will discuss the characteristics of the patients with a potential indication for inotropic therapy, the main data from registries and controlled trials, the mechanism of the untoward effects of these agents on outcomes and, lastly, perspectives with new agents with novel mechanisms of action.
doi:10.1007/s10741-009-9153-y
PMCID: PMC2772951  PMID: 19876734
Acute heart failure; Advanced chronic heart failure; Inotropic agents; Prognosis; Istaroxime; Omecamtiv mecarbil
6.  Left atrial enlargement as a predictor of recurrences in lone paroxysmal atrial fibrillation 
The Canadian Journal of Cardiology  2007;23(11):869-872.
BACKGROUND:
A mild increase in left atrial (LA) size predicts arrhythmia onset and adverse events in patients with lone paroxysmal atrial fibrillation (LPAF). However, the role of LA size as a predictor of LPAF recurrences is still controversial.
OBJECTIVE:
The potential role of LA size in affecting the frequency of recurrent episodes in patients with LPAF was investigated.
METHODS:
Fifty-one patients who were admitted for a first episode of LPAF and presenting with one recurrence (group A, n=20), two or three recurrences (group B, n=18), or four or more recurrences (group C, n=13) during an average follow-up period of two years were retrospectively selected. The M-mode LA anteroposterior diameter (LAAPd) was used as an echocardiographic surrogate of LA size.
RESULTS:
At baseline, LA size was normal or borderline in the control group, group A and group B, but significantly increased in group C. At two years’ follow-up, a significant further LA enlargement from baseline was observed in group B (LAAPd 40±1.1 mm versus 40.7±1.2 mm, P<0.01) and in group C (LAAPd 41.4±1.6 mm versus 42.7±1.7 mm, P<0.001), while LA size remained substantially unchanged in the control group and in group A.
CONCLUSIONS:
Observations confirmed the association of increased LA size and LPAF onset, and provide the first evidence for a potential role of LA progressive enlargement as a predictor of arrhythmic recurrences.
PMCID: PMC2651363  PMID: 17876377
Arrhythmia; Atrial fibrillation; Echocardiography; Left atrium
7.  Left Atrial Reverse Remodeling in Dogs with Moderate and Advanced Heart Failure Treated with A Passive Mechanical Containment Device: An Echocardiographic Study 
Journal of cardiac failure  2007;13(4):312-317.
Background
Assessment of global LV remodeling is important in evaluating the efficacy of pharmacologic and device therapies for the treatment of chronic heart failure (HF). The effects of pharmacologic or device therapies on global left atrial (LA) remodeling in HF, while also important, are not often examined. We showed that long-term therapy with the Acorn Cardiac Support Device (CSD), a passive mechanical ventricular containment device, prevents and/or reverses LV remodeling in dogs with HF. This study examined the effects of the CSD on global LA remodeling in dogs with moderate and advanced HF.
Methods and Results
Studies were performed in 24 dogs with coronary microembolization-induced HF. Of these, 12 had moderate HF (ejection fraction, EF 30% to 40%) and 12 advanced HF (EF ≤25%). In each group, the CSD was implanted in 6 dogs and the other 6 served as controls. Dogs were followed for 3 months in the moderate group and 6 months in the advanced HF group. LA maximal volume (LAVmax), LA volume at the onset of the p-wave (LAVp), LA minimal volume (LAVmin), LA active emptying volume (LAAEV) and LA active emptying fraction (LAAEF) were measured from 2-dimensional echocardiograms obtained prior to CSD implantation and at the end of the treatment period. Treatment effect (Δ) comparisons between CSD-treated dogs and controls showed that CSD therapy significantly decreased LA volumes (ΔLAVmax: 3.33 ± 0.70 vs. −2.87±1.31 ml, p=0.002; 7.77 ± 1.76 vs. −0.37 ± 0.87 ml, p=0.002) and improved LA function (ΔLAAEF: −6.00 ± 1.53 vs. 1.85 ± 1.32 %, p=0.003; −2.39 ± 1.10 vs. 3.13 ± 1.66 %, p=0.02) in the moderate HF and advanced HF groups respectively.
Conclusions
Progressive LA enlargement and LA functional deterioration occurs in untreated dogs with HF. Monotherapy with the CSD prevents LA enlargement and improves LA mechanical function in dogs with moderate and advanced HF indicating prevention and/or reversal of adverse LA remodeling.
doi:10.1016/j.cardfail.2007.01.006
PMCID: PMC1939806  PMID: 17517352
Atrium; Echocardiography; Heart failure; Heart-assist device
8.  Acute effects of caffeine and cigarette smoking on ventricular long-axis function in healthy subjects 
Background
Few data exist regarding the direct effects of caffeine and smoking on cardiac function. We sought to explore the acute effects of caffeine assumption, cigarette smoking, or both on left ventricular (LV) and right ventricular (RV) function in a population of young normal subjects.
Methods
Forty-five healthy subjects aged 25 ± 2 years underwent echocardiography. Fifteen of them were non-smokers and habitual coffee consumers (group 1), 15 were smokers and not habitual coffee consumers (group 2), and 15 were smokers and habitual coffee consumers (group 3). Peak systolic (Sa), early diastolic Ea, and late diastolic (Aa) velocity of mitral annulus were measured by pulsed Tissue Doppler, and left atrioventricular plane displacement was determined by M-mode. Tricuspid annular velocities and systolic excursion (TAPSE) were also determined. Measurements were performed at baseline and after oral assumption of caffeine 100 mg in group 1, one cigarette smoking in group 2, and both in group 3.
Results
No changes in ventricular function were observed in group 1 after caffeine administration. In group 2, cigarette smoking yielded an acute increase in mitral Aa (+12.1%, p = 0.0026), tricuspid Sa (+9.8%, p = 0.012) and TAPSE (+7.9%, p = 0.017), and a decrease in the mitral Ea/Aa ratio (-8.5%, p = 0.0084). Sequential caffeine assumption and cigarette smoking in group 3 was associated with an acute increase in mitral Aa (+13.0%, p = 0.015) and tricuspid Aa (+11.6%, p < 0.0001) and a reduction in mitral Ea/Aa ratio (-8.5%, p = 0.0084) tricuspid Ea (-6.6%, p = 0.048) and tricuspid Ea/Aa ratio (-9.6%, p = 0.0003). In a two-way ANOVA model controlling for hemodynamic confounding factors, changes in the overall population remained significant for mitral Aa and Ea/Aa ratio, and for tricuspid Aa and Ea/Aa ratio.
Conclusion
In young healthy subjects, one cigarette smoking is associated to an acute impairment in LV diastolic function and a hyperdynamic RV systolic response. Caffeine assumption alone does not exert any acute effect on ventricular long-axis function, but potentiates the negative effect of cigarette smoking by abolishing RV supernormal response and leading to a simultaneous impairment in both LV and RV diastolic function.
doi:10.1186/1476-7120-6-9
PMCID: PMC2288591  PMID: 18318902
9.  Coronary artery-pulmonary artery fistula: case report 
Background
Coronary artery fistulas are rare congenital or acquired coronary artery anomalies that can originate from any of the three major coronary arteries and drain in all the cardiac chambers and great vessels.
Case presentation
An 11-year-old boy was referred for evaluation of an exertional dyspnoea. He reported recent history of few episodes of shortness of breath associated with moderate entity physical activity. At physical examination a mild continuous murmur could be heard mainly at the level of the second intercostal space of the left parasternal area. A transthoracic echocardiogram showed a continuous flow at color Doppler analysis in the high parasternal short axis view, originating from a small entry site on the wall of the main pulmonary artery. A selective left coronary angiography revealed a fistula connecting the proximal portion of the left anterior descending coronary artery with the main pulmonary artery.
Conclusion
A combination like the one described in the present case is unusual since fistulas originate from the left coronary artery in about 35% of cases and drainage into the pulmonary artery occurs in only 17%.
doi:10.1186/1476-7120-5-19
PMCID: PMC1852294  PMID: 17428337
10.  Takotsubo cardiomyopathy in a Caucasian Italian woman: Case report 
Background
Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levels
Case presentation
A 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.
Conclusion
Takotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.
doi:10.1186/1476-7120-5-18
PMCID: PMC1852545  PMID: 17417970
11.  Hand-held echocardiography: added value in clinical cardiological assessment 
Background
The ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections.
Methods
87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed.
Results
Mean examination time was 6.7 ± 1.5 min. using HHD vs. 13.6 ± 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement).
Conclusion
HHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs.
doi:10.1186/1476-7120-3-7
PMCID: PMC1083417  PMID: 15790409
echocardiography; Hand Held Device; Standard Echocardiographic Device; conclusiveness; agreement

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