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Background: Chronic heart failure (CHF) is a socially relevant condition carrying an adverse prognosis. Systematic analysis is needed of the relationship between quality of life (QoL) – what patients are most interested in – and objective parameters of CHF severity – which largely determines physicians’ care. Methods: We prospectively investigated QoL, as ascertained by the Minnesota Living with Heart Failure Questionnaire, alongside all the currently used objective clinical/instrumental (electrocardiographic, echocardiographic, hemodynamic and functional capacity) indicators of disease severity in 106 consecutive CHF patients. Results: Besides persistence of sinus rhythm (p = 0.007), the only objective parameters that correlated with QoL were NYHA class (p < 0.001) and distance covered during the six minutes walking test (p < 0.001) (two indications of patients’ ability to attend to their daily needs). Presence of left bundle branch block was associated with a worse QoL only in patients with CHF due to ischemic heart disease (p = 0.032). All the other clinical/instrumental parameters showed no relation with QoL (p > 0.150 in all cases). Conclusions: Objective indicators of disease severity, which largely determine physicians’ care, appear to have little bearing on QoL, suggesting that current treatment for CHF fails to satisfy patients’ perceived needs. The possibility of cost-effective nonpharmaceutical therapeutic protocols (e.g. psychological interventions) specifically designed to improve patients’ QoL deserves investigation as a much needed new approach to the management of CHF.

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Although observational studies suggest that hyperhomocysteinemia may be a risk factor for coronary allograft vasculopathy (CAV), prospective data on homocysteine-lowering interventions and CAV development are lacking. We, therefore, randomized 44 de novo heart transplant (HT) recipients to 15 mg/day of 5-methyl-tetrahydrofolate (n = 22), or standard therapy (control group, n = 22) to investigate the effect of homocysteine lowering on the change in coronary intimal hyperplasia during the first 12 months after transplant, as detected by intra-vascular ultrasound (IVUS). Although 12 months after HT, homocysteinemia was lower in folate-treated patients (p < 0.001), coronary intimal area increased similarly in the two groups (p > 0.4). Conversely, hypercholesterolemia and cytomegalovirus infection were both associated with increased intimal hyperplasia (p < 0.04), independently from folate intake. Sub-group analysis revealed that folate therapy reduced intimal hyperplasia in patients with hyperhomocysteinemia before randomization (n = 19; p = 0.02), but increased intimal hyperplasia in patients with normal homocysteine plasma concentrations (p = 0.02). This bimodal effect of folate therapy persisted significantly after adjusting for cytomegalovirus infection and hypercholesterolemia.Despite effective in prevent hyperhomocysteinemia after heart transplantation, folate therapy does not seem to affect early CAV onset. However, sub-group analysis suggests that folate therapy may delay CAV development only in patients with baseline hyperhomocysteinemia, while may favor CAV progression in recipients with normal baseline homocysteinemia.

A 71-year-old man with a history of hypertension and dyslipidemia underwent emergency department due to dyspnea and chest discomfort. Chest radiography revealed cardiomegaly and signs of pulmonary congestion, whereas the ECG was consistent with recent myocardial injury (antero-septal and lateral). Cardiac catheterization showed a huge right coronary artery (RCA) with left coronary artery collateralization.The multidetector computed tomography scan showed an anomalous origin of left coronary artery from the pulmonary trunk, with a tortuous and dilated RCA and right-to-left collateralization. The patient refused surgical correction.Bland-White-Garland syndrome, also known as ALCAPA (anomalous origin of left coronary artery from the pulmonary artery), is a rare but serious congenital coronary anomaly that affects 1 in 300 000 births. Approximately 90% of patients with this malformation die within the first year of life as the result of fatal intractable heart failure and ischemia. Very few patients reach adulthood, and survival beyond infancy depends on the development of adequate collaterals from the RCA. Significant RCA dilation has been seen in adults.These images (Figure 1) were taken of a 71-year-old man, which is the oldest one reported in medical literature. Multidetector computed tomography is very helpful for detection and anatomic definition of coronary anomalies, especially if complex, as shown in this case. DisclosuresNone. Figure.A, Chest radiograph shows cardiomegaly and signs of pulmonary congestion. B through D, Coronary angiography images show the absence of left coronary artery (missing left main [LM]) and a huge RCA. E through H, Multidetector computed tomography images show an anomalous origin of the left coronary artery from the pulmonary trunk, with a tortuous and dilated RCA, which provides 2 collateral branches, from the posterior descending artery (PD) to the left anterior descending coronary artery (LAD) and from the postero-lateral artery (PL) to the obtuse marginal branch. CX indicates circumflex coronary artery; OM, obtuse marginal branch; AO, aorta; PA, pulmonary artery.

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