Ventricularisation of the left atrium: a rare cause of left ventricular dysfunction in a patient with mitral valve prolapse

Case: A 11 yo girl with Marfan syndrome was referred to cardiac MR (CMR) to measure the size of her thoracic aorta. She had a typical phenotype with arachnodactyly, abnormally long arms, and was tall and slim (156 cm, 28 kg, body mass index 11,5 kg/m2). She complained of no symptoms. Cardiac auscultation revealed a prominent mid-systolic click and an end-systolic murmur at the apex. A recent echocardiogram showed a moderately dilated left ventricle with normal function and a mitral valve prolapse with moderate mitral valve regurgitation. CMR showed a dilatation of the aortic root (38 mm, Z-score 8.9) and a severe prolapse of the mitral valve with regurgitation. The ventricular cavity was moderately dilated (116 ml/m2) and its contraction was hyperdynamic (stroke volume (SV): 97 ml; LVEF 72%, with the LV volumes measured by modified Simpson method from the apex to the mitral annulus). In this patient however, the mitral prolapse was characterized by a severe backward movement of the valve toward the left atrium (LA) in systole and the dyskinetic movement of the atrioventricular plane caused a ventricularisation of a part of the LA in systole (Figure). This resulted in a significant reduction of LVEF: more than ¼ of the apparent SV was displaced backwards into the ventricularized LA volume, reducing the effective LVEF to 51% (effective SV 69ml). Moreover, by flow measurement, the SV across the ascending aorta was 30 ml (cardiac index 2.0 l/min/m2) allowing the calculation of a regurgitant fraction across the mitral valve of 56%, which was diagnostic for a severe mitral valve insufficiency. Conclusion: This case illustrates the phenomenon of a ventricularisation of the LA where the severe prolapse gives the illusion of a higher attachement of the mitral leaflets within the atrial wall. Besides the severe mitral regurgitation, this paradoxical backwards movement of the valve causes an intraventricular unloading during systole reducing the apparent LVEF of 72% to an effective LVEF of only 51%. In addition, forward flow fraction is only 22% after accounting for the regurgitant volume, as well. This combined involvement of the mitral valve could explain the discrepancy between a low output state and an apparently hyperdynamic LV contraction. Due to its ability to precisely measure flows and volumes, CMR is particularly suited to detect this phenomenon and to quantify its impact on the LV pump function.

Right ventricular rupture due to recurrent mediastinal infection with a closed chest.

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right ventricle occurs mainly after sternal reopening, due to either iatrogenic manipulation (wire removal, lesions due to wiring maneuvers) or mechanical shearing forces, producing direct injury. We present a case of RV wall perforation due to infection in a recurrent postoperative mediastinitis with a closed chest. The current literature on treatment of postoperative mediastinitis is also reviewed.

Avaliação da função ventricular esquerda pela sequência de ressonância magnética sem apneia e com múltiplas excitações

OBJETIVO: Avaliar a eficácia da sequência de ressonância magnética com três excitações, para obtenção de volumes e massas ventriculares, em indivíduos com respiração livre, sem apneia. MATERIAIS E MÉTODOS: Em 32 voluntários sadios, foram comparados os volumes e massas do ventrículo esquerdo, obtidos por meio de duas sequências de ressonância magnética em modo cine. A primeira, tradicionalmente utilizada e considerada padrão, em apneia e com excitação única, e a segunda, em respiração livre e com três excitações. Três leitores, com diferentes níveis de experiência, testaram a concordância e a reprodutibilidade. Para a análise estatística foram utilizados o coeficiente de correlação intraclasse, o teste t-pareado, os gráficos de Bland-Altman e o teste do sinal. RESULTADOS: Para os dois observadores mais experientes, os coeficientes de correlação intraclasse foram superiores a 0,913, assim como os níveis descritivos do teste t-pareado acima de 0,05, os gráficos de Bland-Altman com as diferenças distribuídas aleatoriamente em torno do zero e o teste do sinal com seu nível descritivo superior a 0,05. CONCLUSÃO: A sequência testada apresenta ótima concordância e reprodutibilidade em relação à sequência padrão, podendo ser aplicada em indivíduos com limitações respiratórias.

Expressive writing intervention for mothers following the birth of their premature baby.

The birth of a preterm infant is in most cases unexpected and can be a distressing experience for parents. Parents of premature babies report more stress, experience more adjustment difficulties and need for support during the first year after delivery compared to parents of infants born at term. It has been documented that parents may experience posttraumatic stress reactions, anxiety and depression following the premature birth of their baby, which subsequently may impact on the mother-baby-interactions, their attachment relationship and the cognitive, social and behavioural development of the baby. In this pilot study, we offered an expressive writing intervention to women who recently had a premature baby to alleviate their psychological distress and to improve their physical health. During the expressive writing intervention, women were asked to write down their deepest thoughts and feelings about the most traumatic aspect of their experience of having a premature baby for 15 min over three consecutive days. The aims of the study were as follows: (1) To evaluate the effect of expressive writing on psychological and physical health in women who recently had a premature baby. (2) To evaluate the effect of expressive writing on the use of healthcare services and medication in this population. (3) To evaluate the acceptability and feasibility of this intervention for this population. Forty participants were randomly allocated to either the expressive writing intervention group or a wait list control group. Pre- and post questionnaires to evaluate the effectiveness of the expressive writing intervention, as well as their acceptability and feasibility were completed. The intervention took place when the baby was 3 months of corrected age. Post-measures were completed at 1 and 3 months following the intervention. Results and their clinical implications will be discussed with regards to the implementation of this safe and cost-effective method as a preventative measure in the routine care of women who recently gave birth to a premature baby

Use of a ventricular septal defect occluder for apical closure in transapical aortic valve replacement.

During transapical transcatheter aortic valve replacement (TA-TAVR), the apical closure remains a challenge for the surgeon, having the risk for ventricular tear and massive bleeding. Apical closure devices are already under clinical evaluation, but only a few can lead to a full percutaneous TA-TAVR. We describe the successful use of a 9-mm myocardial occluder (ventricular septal defect occluder) that was used to seal the apex after a standard TA-TAVR (using the Sapien XT 23-mm transcatheter valve and the Ascendra + delivery system). The placement of the nonmodified myocardial occluder was performed through the Ascendra + delivery system, with a very small amount of blood loss and an acceptable sealing of the apical tear. This approach is feasible and represents a further step toward true-percutaneous transapical heart valve procedures. Modified apical occluders are under evaluation in animal models.

Adquisició de les codes complexes finals del català per part d'alumnat panjabi: el mètode experimental

En aquest treball estudiem l’adquisició del català per part de parlants que tenen el panjabi com a primera llengua, concretament en relació amb les codes complexes de final de mot, per a aprenents d’un nivell inicial de català

Building complexity in O2-binding copper complexes : site-selective metalation and intermolecular O2-binding at dicopper and heterometallic complexes derived from an unsymmetric ligand

A novel unsymmetric dinucleating ligand (LN3N4) combining a tridentate and a tetradentate binding sites linked through a m-xylyl spacer was synthesized as ligand scaffold for preparing homo- and dimetallic complexes, where the two metal ions are bound in two different coordination environments. Site-selective binding of different metal ions is demonstrated. LN3N4 is able to discriminate between CuI and a complementary metal (M′ = CuI, ZnII, FeII, CuII, or GaIII) so that pure heterodimetallic complexes with a general formula [CuIM′(LN3N4)]n+ are synthesized. Reaction of the dicopper(I) complex [CuI 2(LN3N4)]2+ with O2 leads to the formation of two different copper-dioxygen (Cu2O2) intermolecular species (O and TP) between two copper atoms located in the same site from different complex molecules. Taking advantage of this feature, reaction of the heterodimetallic complexes [CuM′(LN3N4)]n+ with O2 at low temperature is used as a tool to determine the final position of the CuI center in the system because only one of the two Cu2O2 species is formed

Synthesis, structure and physicochemical properties of zinc and copper complexes based on sulfonamides containing 8-aminoquinoline ligands

Sulfonamides obtained by reaction of 8-aminoquinoline with 4-nitrobenzenesulfonylchloride and 2,4,6-triisopropylbenzenesulfonyl chloride were used to synthesize coordination compounds with CuII and ZnII with a ML2 composition. Determination of the crystal structures of the resulting zinc and copper complexes by X-ray diffraction show a distorted tetrahedral environment for the [Cu(qnbsa)2], [Cu(qibsa)2] and [Zn(qibsa)2] complexes in which the sulfonamide group acts as a bidentate ligand through the nitrogen atoms from the sulfonamidate and quinoline groups. The complex [Zn(qnbsa)2] crystallizes with a water molecule from the solvent and the Zn is five-coordinated and shows a bipyramidal-trigonal geometry. The electrochemical and electronic spectroscopy properties of the copper complexes are also discussed.

Improvement of genistein content in solid genistein/-cyclodextrin complexes β

Genistein:β-cyclodextrin complexes with high drug loading (19.22%) were prepared by freeze-drying and characterized by differential scanning calorimetry and hydrogen nuclear magnetic resonance spectroscopy. The spatial configuration of the complex was proposed by means of 2D-NOESY experiment combined with molecular modeling. According to the results obtained, the interaction of genistein with β -cyclodextrin in a 1:1 complex is supposed to occur mainly through the insertion of the guest A-ring in cyclodextrin cavity, without rule out the possibility of inclusion through the B-ring, as previously reported in the literature.