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Capecitabine is an orally available fluoropyrimidine carbamate that selectively delivers fluorouracil (5-FU) to tissues expressing high levels of thymidine phosphorylase (TP) such as tumors. The drug has demonstrated efficacy in metastatic breast cancer, colorectal, and pancreatic cancer. Although these are considered safe drugs, a growing body of literature reports adverse cardiac effects. Clinical trials indicate that capecitabine has a cardiac toxicity similar to that of infused fluoropyrimidines such as 5-FU. Here, we review cardiotoxicity in the use of fluoropyrimidines, with particular attention toward capecitabine. We also describe a severe, reversible cardiac event that occurred in a 39-year-old woman, with no cardiac risk factors, treated with capecitabine for advanced breast cancer. This review and our experience confirm that fluoropyrimidine cardiotoxicity is an infrequent but documented side effect. Oncology patients under treatment should be closely observed and monitored for cardiac symptoms with particular attention in case of signs or symptoms of cardiovascular complications. The implementation of cardio-oncology interdisciplinary teams should, in the future, reduce the impact of cancer treatment-associated cardiotoxicity syndromes. [ABSTRACT FROM AUTHOR]

Venomous bites are medical emergencies that may result in life-threatening clinical effects. Cardiovascular complications are uncommon but they can be dangerous if not early detected and treated. Cerebral and myocardial infarction are described; myocarditis as consequence of viper envenomation in humans are very rare, almost anedoctal. We present the case of a 33-year-old man, working as keeper in a reptile zoo, who arrived after a viper bite of the Vipera aspis species, on the left wrist. The patient presented with clouded sensorium, edema of the lips and tongue, rapidly worsened with angioedema, and the need for oro-tracheal intubation; severe thrombocytopenia and anemia were treated with transfusions of platelet, plasma and red blood cells. The left hand and arm worsened, with compartment syndrome, treated with surgical fasciotomy. From a cardiological point of view, the patient presented a sudden drop in blood pressure, electrocardiographic anterior and infero-lateral ST depression, pericardial effusion and hypokinesia of the interventricular septum on echocardiography, and a significant increase in troponin T. Cardiac magnetic resonance imaging confirmed the myocarditis, with the presence of septal and anterior intramyocardial edema in T2 weighted sequences, with prolonged T2 time at T2 mapping analysis, without late gadolinium enhancement areas. Cardiological and general clinical conditions gradually improved only after the antivenom was administred. This is one of the rare cases of viper bite myocarditis with echocardiographic and magnetic resonance imaging documentation in Europe; it emphasizes the importance of identifying uncommon complications of venomous snake-bites and the prompt administration of antivenom, even though snake bites are less frequent at our latitudes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Ultrasound-guided axillary vein access is an effective alternative to conventional subclavian and cephalic access for cardiac implantable electronic device implantation. The aim of this study was to compare the safety, efficacy, and radiation exposure data of the ultrasound-guided axillary approach with other conventional access techniques. The study population included 130 consecutive patients, stratified as 65 (64% male; median age, 79 years) in the study group and 65 (66% male; median age, 81 years) in the control group. We performed a retrospective not-randomized analysis by comparing ultrasound-guided axillary vein puncture with subclavian and cephalic approaches in order to test the effect on X-ray exposure, total procedure time, and complications. Significant differences were observed in terms of radiation exposure, including fluoroscopy time (median, 95 s [study group] vs. 193 s [control group]; P < .001), air kerma (median, 29 mGy [study group] vs. 55.7 mGy [control group]; P < .001), and dose-area product (median, 8219 mGy·cm 2 [study group] vs. 16736 mGy·cm 2 [control group]; P < .001). The median procedure time was 45 min in the study group but 50 min in the control group ( P < .05). Complications occurred in 6 control group patients (1 urticaria contrast medium-related, 3 pneumothorax, 2 subclavian artery puncture) and 2 study group patients (2 axillary artery puncture). We conclude that the ultrasound-guided axillary venous approach is a fast, feasible, and safe technique for cardiac lead implantation. It allows a significant reduction in fluoroscopy time without prolonging the procedural time. This approach offers direct visualization of the vessel during the puncture, so it can be useful in patients who cannot receive contrast medium, those who require "difficult" thoracic approaches (emphysema, too much or too little fat tissue), or those on anticoagulant therapy., Competing Interests: The authors report no conflicts of interest for the published content. No funding information was provided., (Copyright: © 2023 Innovations in Cardiac Rhythm Management.)

We report a case of left atrial extrinsic compression caused by an esophageal food bolus in a patient presenting with acute heart failure. Transthoracic echocardiography along with contrast-enhanced CT showed evidence of esophageal dilation producing left atrial compression. Esophageal endoscopy and fragmentation of the bolus, allowing the accumulated food to descend into the stomach, produced a rapid improvement of hemodynamic and clinical status. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:259-261, 2018., (© 2017 Wiley Periodicals, Inc.)

Aims: In the present study, we compare different echocardiographic cardiac dyssynchrony parameters, both of intraventricular and interventricular dyssynchrony, in order to predict response to cardiac resynchronization therapy (CRT)., Methods and Results: In a population of 77 heart failure patients scheduled for CRT, we measured the interventricular mechanical delay (IVMD) and we analyzed six different parameters of intraventricular dyssynchony: the tissue Doppler imaging (TDI) septum-lateral wall delay, the systolic dyssynchrony index; the three-dimensional SD of the time to reach minimum systolic volume for 16 left ventricular segments (3D-SDI); the speckle-tracking radial, circumferential and longitudinal dyssynchrony. At 6 months of follow-up, 61 (79%) patients were responders (≤15% in left ventricular end-systolic volume). On baseline analysis, 3D-SDI, radial strain, longitudinal strain and circumferential strain and IVMD were significantly higher in responder group (10.8 ± 3.9 vs. 7.6 ± 1.8% for 3D-SDI; P = 0.003; 212 ± 91 vs. 125 ± 36 ms for radial strain, P = 0.0003; 185 ± 83 vs. 134 ± 53 ms for longitudinal strain, P = 0.02; 190 ± 80 vs. 130 ± 54 ms for circumferential strain, P = 0.006; 45 ± 21 vs. 30 ± 20 ms for IVMD; P = 0.01). On univariate and multivariate analysis, only IVMD was significantly associated with a complete echocardiographic response to CRT. 3D-SDI and radial strain present the better values of sensitivity and specificity, overall if associated to an evaluation of IVMD (sensitivity 76%, specificity 88%, for 3D-SDI + IVMD; sensitivity 80% and specificity 85% for radial strain + IVMD)., Conclusion: The novel parameters, such as 3D-SDI and speckle-tracking (particularly radial strain), offer better diagnostic accuracy in identifying patients who are responders to CRT. The addition of the contemporary parameter of IVMD improves the diagnostic accuracy.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia, with a high recurrence rate, especially during the first months after cardioversion (CV). Few parameters have been evaluated as predictors for the maintenance of sinus rhythm (SR), with limited results. Recently total atrial conduction time (TACT) has been proposed as independent predictor of AF recurrence. The aim of this study was to investigate the prognostic value of TACT, measured using PA-TDI duration, to predict 1-year maintenance of restored SR after electrical CV., Methods and Results: In a population of 104 patients (58 male, aged 70 ± 9) with persistent AF, submitted to external electrical CV, we performed a complete echocardiogram after restoring SR. The TACT was estimated by measuring the time delay between the onset of the P-wave in lead II of the surface electrocardiogram and the peak A'-wave on the tissue Doppler imaging (TDI) tracing of the left atrial lateral wall (so-called PA-TDI duration). After a mean follow-up of 14 ± 2 months, 34 (33%) patients had recurrent AF, whereas 70 (67%) patients maintained SR. At multivariate analysis only PA-TDI was identified as independent predictor of AF recurrence (HR 1.04; 95% CI 1.03-1.06; P < 0.001). Receiver operator characteristics curve analyses demonstrated a high degree of discrimination (area under the curve 0.923); with a cut point of 152 msec, we obtain a good diagnostic accuracy (sensitivity 91%, specificity 87%)., Conclusion: The TACT using TDI is an independent predictor of AF recurrence and can be used to predict the maintenance of SR after external electrical CV., (© 2014, Wiley Periodicals, Inc.)

Isolated supravalvular pulmonary stenosis is a rare finding, usually evidenced in the pediatric age. Here, we report a case of a 76-year-old patient with isolated, severely obstructive, pulmonary supravalvular stenosis. The peculiarity of the present case is the paucity of symptoms and lack of changes in right heart sections, despite of the importance of stenosis. The report confirms the utility of transthoracic two- and three-dimensional echocardiography and transesophageal echocardiography in the detection and quantification of this rare anomaly., (© 2014, Wiley Periodicals, Inc.)

Aims: In the last few years, n-3 polyunsaturated acids (PUFAs) have been extensively studied for the prevention of AF, mostly in patients without heart failure (HF) or LV dysfunction. This post-hoc analysis of the GISSI-HF trial assessed the effect of n-3 PUFAs on AF in patients with chronic HF without AF at study entry over a median follow-up of 3.9 years., Methods and Results: In the GISSI-HF trial, 6975 patients with chronic HF were randomized to 1 g daily of n-3 PUFAs or placebo on top of recommended therapy for HF. Of these, 1140 (16.3%) had AF at baseline ECG and were excluded from the present analysis. AF during the trial was defined as the presence of AF on the ECGs done at each visit during the trial or AF as a cause of worsening HF or hospital admission or as an event during hospitalization. Dietary fish consumption and the circulating levels of n-3 PUFAs (the latter in a subset of 1203 patients) were also available. Among the 5835 patients without AF at study entry, 444 randomized to n-3 PUFAs (15.2%) and 408 to placebo (14.0%) developed AF (unadjusted hazard 1.10, P = 0.19). Lower circulating n-3 PUFA levels were independently associated with higher AF prevalence at study entry, but not with its new occurrence., Conclusions: Despite an inverse relationship between plasma n-3 PUFA levels and prevalent AF, this study found no evidence that 1 g daily n-3 PUFA supplementation in patients with chronic HF reduces incident AF.

Accidental or deliberate ingestion of poisonous herbs has become an increasingly common phenomenon over the last years. From existing literature data and case reports from emergency room visits or poison control centers, an overview is presented of the potential cardiotoxic manifestations following intoxication by wild herbal plants of the territory. The effects of the consumption of cardiac glycoside-containing plants (e.g., digitalis) are discussed along with tachyarrhythmias induced by Aconitum napellus L., Atropa belladonna L., Mandragora officinarum L. or Ephedra distachya L. herbs, and hypertensive crises associated with licorice abuse. For each plant, a brief historical and botanical background is provided, focusing on pathophysiology of intoxication and cardiotoxic effects on the basis of the most recent literature. Finally, medical management of intoxication, from both a general and cardiological viewpoint, is reviewed.

Prosthetic valve endocarditis (PVE) due to staphylococcus aureus is associated with high morbidity and mortality. Paravalvular abscess formation is a common complication of PVE at the aortic position, but fistula formation is rarely seen. The transesophageal echocardiography is the "gold-standard" exam to detect PVE. We present a case of a 69-year-old patient with prosthetic aortic valve endocarditis, paravalvular abscess, and fistula in right atrium, where the diagnosis was made with three-dimensional transthoracic echocardiography, without transesophageal evaluation., (© 2012, Wiley Periodicals, Inc.)

Aims: Transoesophageal echocardiography (TEE) with contrast administration is still considered as the reference method for the detection of patent foramen ovale (PFO) with interatrial shunt, but it is a semi-invasive exam. The aim of the present study is to evaluate a role of two- and three-dimensional transthoracic echocardiography (TTE and R3DTE) as a diagnostic alternative to transcranial Doppler ultrasound (TCD) and TEE for detection of atrial right-to-left shunt., Methods and Results: Seventy-five patients with history of cerebrovascular events were subjected to four diagnostic examinations: TCD, TTE, R3DTE, and TEE, with bubble contrast. Bubbles in the left atrium within three cardiac cycles were considered diagnostic for PFO and later as a pulmonary shunt. Greater than 20 bubbles in the left atrium were considered a large shunt and <20 a small shunt. Every exam was read blinded to the results of the others. From the 75 enrolled patients, 62 (82.6%) patients showed right-to-left shunt with TEE; the results were also positive in 53 patients using TCD (70.6%), in 53 using R3DTE (70.6%), and in 55 using TTE (73.3%) (P = NS). There is a statistically significant superiority for TEE in the capacity of detecting shunts compared with TCD (P < 0.024), TTE (P < 0.018), and R3DTE (P < 0.018). The TEE presents a superior ability to recognize mild/moderate interatrial shunts respect to other exams (P = 0.003), without differences for shunts of high degree. In comparison to the TEE, the sensitivity is 89% for TTE, 88% for R3DTE, and 85% for TCD; the specificity is 100% for TTE and R3DTE, and 90% for TCD; the positive predictive value is 100% for TTE and R3DTE, and 98% for TCD; and the negative predictive value is 65% for TTE, 65% for R3DTE, and 53% for TCD. Considering only for mild/moderate shunts, the diagnostic accuracy is clearly inferior (sensitivity 63% for TTE, 58% for R3DTE, and 53% for TCD)., Conclusion: In this cohort of patients, TEE confirms the role of 'gold standard' exam for the detection of PFO; the non-invasive methods, and the TTE in particular, present a good diagnostic accuracy, but are inferior to the TEE because of the low negative predictive value and the non-optimal detection of small shunts. If the only purpose of TEE is the detection of significative interatrial shunt, TEE can be replaced by TTE. The R3DTE presents a good diagnostic accuracy, provides a better anatomical definition of the interatrial septum, and may have a role in this setting of patients, but does not add a lot to the TTE for the diagnosis.

Advanced Digitalis intoxication is a rare event, mainly associated with overdose in patients with Digitalis therapy. We report an unusual case of acute 'familiar' digitalis poisoning in three patients who had eaten potato dumplings flavoured with leaves of Borago officinalis L. unconsciously mixed with leaves of Digitalis purpurea L. A complicated clinical course with marked bradyarrhythmias was presented, with good evolution thanks to the use of digoxin-specific antibody Fab fragments. The theme of the domestic use of plants with medicinal effects has been treated and discussed.

Familial hypokalemic periodic paralysis is an autosomal dominant muscle disorder characterized by episodic attacks of muscle weakness, accompanied by a decrease in blood potassium levels. It is based on genetic mutations in the genes CACNA1S (most frequent, encoding the skeletal muscle calcium channel) and SCN4A (10% of cases, encoding the sodium channel). Few cases have been reported with cardiac dysrhythmia. We report a rare case of a patient with a novel SCN4A mutation who presented, on ECG, extreme bradycardia and syncopal sinus arrest that required a temporary pacemaker implant

Right cardiac thrombosis is an infrequent complication after pacemaker implant. We report a patient who received a biventricular implantable cardioverter defibrillator, with a large mobile thrombus, adherent to the left ventricular lead. This catheter was partially dislocated, with a large, mobile loop through the right atrium and right ventricle; so the lead thrombus could alternately obstruct the pulmonary valve and the tricuspid valve. We believe that this is the first case of left ventricular lead thrombosis, in which the surgical treatment included thrombectomy with conservation of the catheter that was anchored to the internal right atrial wall in order to limit its great motility, maintaining the contribution to the cardiac resynchronization.

Paradoxical embolism and patent foramen ovale have represented an issue of great interest during the last years, because of the strong correlation with cryptogenic stroke in young patients. The coexistence of pulmonary and paradoxical embolism is even more rare. We present the case of a patient with evidence of concomitant pulmonary embolism and paradoxical systemic arterial embolism, which suggests the presence of patent foramen ovale. The available literature about this infrequent clinical event is also reviewed.

Background: Several studies demonstrated the efficacy of amiodarone pretreatment in achieving bet-ter outcomes after electrical cardioversion of atrial fibrillation. In the majority of cases, oral amiodarone for at least 1 month was administered, with the result of lengthening of pre-cardioversion time. Only one study in the literature reported high-dose amiodarone infusion, showing an increase in the incidence of slow arrhythmias. The aim of this study was to test the efficacy of pretreatment infusion of a single dose of amiodarone few hours before electrical cardioversion in restoring sinus rhythm and reducing the incidence of early arrhythmic recurrences., Methods: The study was retrospective. We analyzed a population of 155 patients with persistent atrial fibrillation, from May 2003 to November 2005. The first group of 86 patients was treated with amiodarone at the dose of 4 mg/kg in 30 min, few hours before electrical cardioversion; the second group of 69 patients was treated with electrical cardioversion without pharmacological pretreatment. The two groups were homogeneous for age, sex, coronary artery disease, duration of arrhythmia, atrial dimensions, left ventricular ejection fraction, and paddle position for electrical cardioversion., Results: There were no significant differences between the two groups in terms of efficacy of cardioversion (95.3 vs 91.3%, p = NS). Pretreatment with bolus of amiodarone significantly reduced the incidence of immediate recurrence (3.5 vs 17.4%, p < 0.05) and the mix of immediate and early recurrence (19.7 vs 33.3%, p < 0.05). There were no significant differences in the incidence of late recurrences (17.4 vs 13%, p = NS). There were no significant bradyarrhythmias in the two groups. Amiodarone pretreatment did not reduce energy delivery to obtain cardioversion., Conclusions: Amiodarone pretreatment with intravenous bolus few hours before electrical cardioversion reduces short-term recurrences of atrial fibrillation. It does not reduce energy delivery of electrical cardioversion and does not increase the incidence of slow arrhythmias. Randomized prospective studies are warranted to confirm these findings.

We present the case of a patient with Ebstein's defect surgically corrected, and a complete right bundle branch block (RBBB) documented on echocardiogram. After an episode of near syncope due to a high-grade atrioventricular (AV) block, the patient was assisted with a bicameral DDDR pacemaker implanted with traditional right ventricular apical pacing. After the DDDR, and after stimulation with an AV delay of 180 ms, a narrow QRS complex was observed. Meanwhile, the typical left bundle branch block morphology of the right ventricular pacing and the native RBBB morphology were missing. The QRS complex narrowing persisted, even with physical activity and also with the heart rate progression. An echocardiographic study confirmed an improvement of the cardiac resynchronization parameters with this programmed stimulation.

We present an atypical case of postinfarction left ventricular pseudoaneurysm involving the posterobasal septal wall, with protrusion into the right ventricle, associated with a small septal defect and left-to-right shunt. In this case, a conservative approach was adopted rather than surgical management, and the patient had a good clinical outcome. Subsequent evaluation with two-dimensional colour Doppler, three-dimensional echocardiography and 16-slice computed tomography is reported.

Bradycardic effects of severe weight loss are well known like those observed in anorexia nervosa resulting from an increase in vagal tone associated with a low calorie-protein diet. We here report the case of a 19-year-old patient with asymptomatic severe bradycardia, which developed after voluntary weight loss of more than 30 kg during a few months. In absence of symptoms, ventricular arrhythmia or structural heart disease, and owing to normal ventricular function, no permanent pacemaker implantation was undertaken. After a follow-up of more than 15 years, clinical conditions are stable, the patient is asymptomatic and bradycardic, and no changes in weight are reported.

IgG and IgM anti-cardiolipin antibodies (aCL) were measured in 60 patients with ischaemic heart disease by an immunoenzymatic assay. aCL levels higher than normal were detected in 12 of 40 patients (30%) with acute myocardial infarction (AMI) and in 7 of 20 patients (35%) with angina pectoris (AP). These values were significantly higher (p < 0.05) than those detected in the control group (3/40; 7.5%). As regards the clinical picture, the complications and the outcome of the disease, no difference was observed between aCL-positive and negative patients with AMI. 9 of 12 aCL-positive patients with AMI showed increased levels of aCL in a blood sample obtained in day 1 after admission. Therefore, we must admit such positivity as preexistent to the myocardial infarction. These data together with the high prevalence of aCL in patients with AP suggest that an association should exist between raised levels of aCL and increased risk for AMI in patients with coronary artery disease.