[Cardiac tamponade preceding skin involvement in progressive systemic sclerosis]. / Tamponamento cardiaco come manifestazione di esordio della sclerosi sistemica progressiva.

The frequency of pericardial involvement in Systemic Sclerosis (SSc) is high on autoptic or echocardiographic studies, but the clinical recognition of pericarditis with or without effusion is rare. We describe a case of a 71-year-old female with no previous history of heart disease, who presented with a large pericardial effusion and tamponade that required pericardial drain. She had suffered from Raynaud's phenomenon since 25 years. Six weeks after hospital discharge she complained of skin hardening on left leg. Pericardial tamponade is a very rare manifestation of SSc and occurs both early or late in the course of the disease, but in our case it preceded the recognition of scleroderma. We have only identified two other cases of pericardial effusion preceding cutaneous involvement in scleroderma.

[Prolongation of the QT interval and torsade de pointes caused by ketanserin]. / Allungamento dell'intervallo QT e torsione di punta da ketanserina.

The authors report the case of an 84-year-old man with mild aortic valvular disease and arterial hypertension who developed marked QT interval prolongation and several lipotimic and syncopal attacks after 3 months of treatment with ketanserin (40 mg/day). The correlation between ketanserin, QT prolongation and symptoms was assessed by withdrawal and subsequent re-administration of the drug. Continuous ECG monitoring revealed the occurrence of QT prolongation and symptomatic runs of torsade de pointes ventricular tachycardia. The Authors suggest that treatment with ketanserin needs careful patients selection and follow-up.

Acute coronary occlusion after recent coronary angioplasty. Association with exercise and successful treatment with intracoronary thrombolysis.

A case of coronary occlusion occurred seven days after successful percutaneous transluminal coronary angioplasty. The acute complication occurred shortly after a negative exercise stress test and was resolved with intracoronary urokinase.

[Torsade de pointes induced by quinidine: a case treated successfully with verapamil]. / Torsione di punta indotta da chinidina. Descrizione di un caso trattato con successo con verapamil.

The Authors report a case of incessant torsade de pointes, associated with QT prolongation, due to the proarrhythmic effect of quinidine, which was successfully treated with i.v. verapamil. The arrhythmia occurred after oral administration of quinidine polygalacturonate (550 mg + 275 mg + 275 mg over a 4-hour period) for the conversion of atrial fibrillation in a 41-year-old woman with mild mitral stenosis and regurgitation. Verapamil was administered as an i.v. bolus (5 mg at a rate of 1 mg/min) and with in four minutes the arrhythmia disappeared. The electrophysiological mechanisms of torsade de pointes and the potential role of Ca+(+)-channel-blocking agents in its treatment are briefly discussed.

[Transcatheter fulguration of the atrioventricular junction in supraventricular hyperkinetic arrhythmia. Immediate and long-term results]. / Folgorazione transcatetere della giunzione atrio-ventricolare nelle aritmie ipercinetiche sopraventricolari. Risultati immediati e a distanza.

Transcatheter direct-current ablation of the atrio-ventricular junction is a recently developed technique in the treatment of medically refractory supraventricular tachycardia. Twenty patients underwent this procedure between July 1987 and May 1989 and were followed-up for a mean period of 8.3 +/- 6 months (range 1-23). Indication for ablation included atrial flutter in 4 patients, atrial fibrillation in 8, atrial tachycardia in 1, atrio-ventricular nodal re-entrant tachycardia in 4, atrioventricular re-entrant tachycardia (concealed pathway) in 2, permanent junctional reciprocating tachycardia in 1. These arrhythmias were resistant to a mean of 3.3 +/- 1.7 antiarrhythmic drugs. A mean of 1.4 +/- 0.59 (range 1-3) electrical shocks, with a mean energy of 285 +/- 135J (range 200-700), were delivered during 1-2 sessions. In all patients a persistent complete atrio-ventricular block was achieved. Immediate complications included transient hypotension in 2 pts, acute pulmonary edema in 1, premature ventricular complexes in 4, non sustained ventricular tachycardia in 4, sustained ventricular tachycardia in 1. Late complications included thrombophlebitis of the right femoral vein in 2 pts; one of them died suddenly as a result of massive pulmonary embolism 10 days after the procedure. Follow-up evaluation reveals chronic complete atrio-ventricular block in all patients. Symptoms related to pre-existing arrhythmia are absent in all pts and none of them is currently taking antiarrhythmic drugs. Two patients with DDD pacing had pacemaker mediated re-entrant tachycardia and 1 patient with VVIR pacing developed a pacemaker syndrome. This experience confirms that transcatheter fulguration of atrio-ventricular junction is an effective technique. However, possible severe complications related to the procedure suggest this approach be restricted to patients with very symptomatic and drug-refractory supraventricular tachyarrhythmias.

[Prolonged myocardial ischemia after the high-dose dipyridamole test]. / Ischemia miocardica prolungata dopo test al dipiridamolo ad alta dose.

The intravenous dipyridamole test is considered a safe procedure with a very low incidence of severe cardiac effects and is routinely used in the diagnosis and prognosis of coronary artery disease. We report the case of a 63-year-old female with negative exercise stress test who developed prolonged and extensive myocardial ischemia after the high-dose intravenous dipyridamole echocardiography test. Aminophylline and nitroglycerin were employed but were ineffective and the patient was successfully treated with systemic thrombolysis. At coronary angiography, 48 hours later, a 50% stenosis in the proximal LAD was documented. We stress that high-dose intravenous dipyridamole can induce a severe ischemic response whose occurrence is unpredictable according to the pre-test clinical features.

[Primary heart arrest during dynamic ECG in the myocardial infarct patient during convalescence. Contribution of 4 cases]. / Arresto cardiaco primario durante ECG dinamico nell'infartuato in fase di convalescenza. Contributo di 4 casi.

Four cases of cardiac arrest occurred during Holter monitoring are described. All patients had sustained an acute myocardial infarction thirteen-fourteen days prior to recording and were fully mobilized. In all of them the fatal arrhythmic event was ventricular fibrillation (VF). ECG analysis revealed an increase in heart rate before initiation of VF in one patient only. Warning ventricular arrhythmias were present in two patients. Transient ST segment changes during monitoring were noted in all patients. In three cases the arrhythmia was initiated by an ectopic ventricular beat (EVB) with R-on-T phenomenon; in two of them the EVB occurred after a sinus beat following a long post-ectopic pause. The different electrical events able to induce VF showed a variable and unpredictable pattern of occurrence and association in different patients and at different times in the same patient. Therefore, no specific "trigger" of the fatal arrhythmia could be identified.

[Diverticular aneurysm of the right atrium]. / Aneurisma diverticolare dell'atrio destro.

A case of right atrium aneurysm (diverticulum) detected in an asymptomatic 61-year-old woman is described. Diagnosis was made according to echocardiographic and echocontrastographic findings and was confirmed by both angiographic data and surgical pathology. The rarity of this finding and the possibility of a correct non-invasive assessment can be considered the two most peculiar features of this case.

[Bidimensional echocardiographic diagnosis of the pulmonary valve agenesis syndrome in the newborn infant. Description of 2 cases]. / Diagnosi ecocardiografica bidimensionale della sindrome di agenesia della valvola polmonare nel neonato. Descrizione di due casi.

We describe the cases of two neonates affected by the syndrome of pulmonary valve agenesis, in whom non-invasive diagnosis was possible by two dimensional echocardiography. The echocardiographic features we describe are the following: enlargement of the right ventricle in association with ventricular septal defect, malalignment type, dilatation of the right ventricular outflow tract, massive dilation of the main and branch pulmonary arteries, annular pulmonary stenosis. At the expected site of the pulmonary valve two ridges were seen, which did not have the typical motion of a fully developed valve. The ventricular septal motion was paradoxical in both cases. The diagnosis was confirmed at cardiac catheterization and the two neonates underwent operation unsuccessfully. The anatomic post-mortem examination confirmed the echocardiographic and angiographic findings. As successful treatment of this syndrome is difficult, we believe that a non-invasive echocardiographic diagnosis is very useful in order to avoid or, at least, delay a high risk cardiac catheterization.

[Echocardiographic aspects of persistence of the right valve of the venous sinus]. / Aspetti ecocardiografici della persistenza della valvola destra del seno venoso.

The aim of this work is to demonstrate the possibility to identify persistent right sinus venous valve and to differentiate it from other right sided heart pathology by two dimensional echocardiography. We report the echocardiographic findings observed in three out of 215 paediatric patients we examined for clinically suspected congenital heart disease in 12 months period. The first patient was a 24 hours old newborn with transient pulmonary hypertension; the second one was a 6 months old child with pulmonary atresia, severe right ventricular hypertrophy, atrial septal defect and patent ductus arteriosus; the third patient, aged 6 months, had atrial septal defect and mild pulmonary stenosis. In all three patients a particular linear structure was seen, as a membrane that crossed the right atrium from the orifice of the inferior vena cava towards the atrial septum. This structure was identified as persistent right sinus venosus valve according to its morphology, its position into the right atrium and its connection to the atrial septum. The incidence of this echocardiographic finding was 1.4% in our series. In the first case contrast echocardiography from the inferior vena cava demonstrated the deviation of blood flow caused by the persistent sinus valve, although no intra-atrial pressure gradient was shown at cardiac catheterization. In the second patient who died during the operative procedure for making a systemic-pulmonary anastomosis, post mortem examination showed a membranous structure connecting the orifice of the inferior vena cava to the atrial septum.(ABSTRACT TRUNCATED AT 250 WORDS)