[Heart rupture during pre-discharge stress test after myocardial infarction]. / Rottura di cuore durante prova da sforzo pre-dimissione dopo infarto miocardico.

A 65-year-old man with a postero-lateral myocardial infarction, complicated by rapid atrial fibrillation was admitted to the Intensive Coronary Care Unit. He received thrombolytic treatment. Electrocardiography and laboratory analysis were suggestive of reperfusion; the rapid atrial fibrillation was converted to sinus rhythm using i.v. amiodarone. Two echocardiograms performed on days 1 and 6 revealed hypokinesis of the postero-lateral wall and a mild reduction in the left ventricular ejection fraction. On day 7, after pharmacological wash-out, he was submitted to a bicycle exercise test: soon after the beginning of the 75 W step, the patient presented cardiac arrest due to electromechanical dissociation and hemopericardium. Despite prolonged cardiopulmonary resuscitation maneuvers and drainage of a few milliliters of pericardial blood, the patient did not survive. At autopsy, a huge clot filling the pericardial space was detected together with two linear 3 cm tears of the left ventricular lateral wall. The authors stress the possibility of unpredictable deaths during a pre-discharge exercise testing; good clinical judgment should therefore be used in deciding which patients should undergo this procedure and appropriate information about its potential risks should be given.

Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.

The prevalence of right-sided cardiac mobile thrombi, "in transit" from the systemic venous system, was 18% in a series of 130 patients with massive pulmonary embolism referred to early echocardiography and receiving thrombolytic drugs (56%) or intravenous heparin (40%). The mortality rate was lower than previously reported and seemed to be related more to clinical and hemodynamic impairment than to presence of thromboembolus.

[Massive pulmonary embolism during the third trimester of pregnancy: effectiveness of thrombolytic treatment with alteplase]. / Embolia polmonare massiva al terzo trimestre di gravidanza: efficacia del trattamento trombolitico con alteplase.

The authors report on a 33-year old woman with massive, life-threatening pulmonary embolism at the third trimester of pregnancy. The diagnosis was rapidly accomplished in the Emergency Department by two dimensional-Doppler echocardiography that showed signs of pulmonary hypertension as well as a large, floating thromboembolus in the right atrium. As the hemodynamic deterioration persisted after treatment with iv heparin, the patient received alteplase 50 mg as a bolus over 5 minutes. About 30 minutes later, a further 50 mg infusion of alteplase was given over 60 minutes because clinical conditions were progressively worsening. After an alteplase dose of 75 mg, the woman showed a definite improvement in clinical-hemodynamic status and echocardiography documented a reduction of right ventricular overload and atrial clot disappearance. Two hours later the patient was submitted to cesarean section, because of the onset of uterine contractions, and delivered a vital baby. The occurrence of uterine bleeding was antagonized by the infusion of fresh-frozen plasma and a moderate anemia was subsequently treated with iron preparations. The mother and her baby were discharged on 16th day in fairly good general conditions. The authors emphasize the leading role of early echocardiography in the clinical decision making and the lifesaving potential of full dose thrombolytic therapy without serious adverse effects.

[Pseudoaneurysm of the right ventricle and rupture of the interventricular septum during the acute phase of myocardial infarct: diagnosis by color Doppler echocardiography]. / Pseudoaneurisma del ventricolo destro e rottura del setto interventricolare nella fase acuta di un infarto miocardico: diagnosi con eco color-Doppler.

The authors describe the association of a right ventricular pseudoaneurysm and ventricular septal rupture at the onset of an acute inferior and right myocardial infarction. The patient, a 84-year-old man, presented with cardiogenic shock and died within a few hours with electromechanical dissociation. The diagnosis was made by Echo-color flow mapping and confirmed at autopsy. The authors point out the singleness of such association and the diagnostic value of Echo-Doppler in the early assessment of the mechanical complications of myocardial infarction.

[The early echocardiographic diagnosis of a massive pulmonary embolism]. / Diagnosi ecocardiografica precoce di embolia polmonare massiva.

BACKGROUND: In several cases of clinically suspected massive pulmonary embolism (MPE), a lung perfusion scanning and/or a pulmonary angiography are not quickly available or feasible. METHODS: Fifty patients admitted to our ICU with a clinically suspected MPE underwent an echocardiographic (Echo) investigation very shortly after onset (within 2 hours in 38 cases, and within 6 hours in 12). An Echo-Doppler study was also performed in 18 patients. RESULTS: Highly significant differences (p < 0.001) emerged between patients with PE and healthy age-mates for each type of Echo measurement and in all views. The RVDD/LVDD ratio turned out to be the most frequently affected parameter, being altered in 96% of cases. An abnormal diastolic leftward shift of the interventricular septum was detected in 81% of cases. Only one of our 50 patients failed to show any evidence of RV pressure overload; however, this was a patient with a severe dilated cardiomyopathy. In 22 cases in whom hemodynamic monitoring was performed, no significant correlation emerged between RVDD and LVDD, on one hand, mean PAP and cardiac index on the other. All 18 patients examined by Echo-Doppler had mild to moderate tricuspid regurgitation with a peak RV-RA gradient of 38 +/- 7 mm Hg (range 31-53 mm Hg). Seven patients (14%) were found to harbor right heart thrombi when first examined. Overall mortality in this uncommonly high risk population was as high as 28%. CONCLUSIONS: In a clinical setting suggesting a MPE, an Echo study conducted very shortly after onset may corroborate a tentative diagnosis of PE, thereby permitting timely fibrinolytic therapy pending a lung scan and/or angiography, or in situations where such imaging facilities are not available or readily usable.

[Early papillary muscle rupture in myocardial infarction, diagnosis with transesophageal echography]. / Rottura precoce di muscolo papillare in corso di infarto miocardico, diagnosi con ecografia transesofagea.

We describe the case of posterior papillary muscle (PPM) rupture with severe mitral regurgitation at the very beginning of an inferior myocardial infarction (MI) in a 79-year-old woman. The diagnosis was made by transesophageal echocardiography (TEE) and confirmed at autopsy. This case confirms the value of TEE in diagnosing PPM rupture and the association of PPM rupture with small posterior myocardial infarction. Moreover the case presents some unusual aspects: the rupture occurred very early; at transthoracic approach, a systolic convergence flow zone was the only sign of mitral regurgitation by color flow mapping; at TEE flail mitral leaflets were absent; in systole, the trunked papillary muscle did not prolapse into the left atrial cavity, but crushed into the atrial side of posterior mitral leaflet, remaining at the atrioventricular level; at autopsy, there was a split PPM with a completely ruptured medial branch. On the atrial side of the posterior mitral leaflet there was an ecchimothic zone, due to the crushing of the PPM.

[The role of the echo-dipyridamole test in the differential diagnosis of chest pain]. / Ruolo del test all'eco-dipiridamolo nella diagnosi differenziale del dolore toracico.

We have verified the utility of echo-dipyridamole test in the diagnosis of chest pain of unsure origin, especially in patients who cannot be quickly submitted to exercise stress test because of permanent abnormalities at basal ECG or because of clinical reasons. 17 patients with chest pain, abnormalities at basal ECG not evolutive and insignificant for myocardial ischemia, absence of enzymatic curve, were admitted to our hospital from September 1988 to January 1990. All these patients were submitted before the ninth and fifteenth day of hospitalization to the echo-dipyridamole test. Drugs were discontinued 3 days before the test. Dipyridamole was administered intravenously in 4 minutes at dosage of 0.56 mg/kg during ECG and echocardiographic monitoring. If no ECG or echocardiographic changes were observed, a second intravenous bolus of dipyridamole at a dosage of 0.28 mg/kg in 2 minutes was made. After the end of infusion continuous ECG and echocardiographic monitoring was performed for 20 minutes at least. Blood pressure was controlled every 3 minutes. Only the major changes in segmental wall motion were considered for analysis to minimize possible errors. Moreover a second physician not present during the test, revised in following the wall motion changes of all the tests. The test was positive in 5 patients (29%) (positive group) and negative in 12 (71%) (negative group). The changes in the heart rate and blood pressure observed during the test were not significantly different in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Color-Doppler echocardiography in electromechanical dissociation. Study of 2 cases]. / Ecocardiografia color-Doppler nella dissociazione elettromeccanica. Studio di 2 casi.

Electromechanical dissociation (EMD) is a condition of cardiac arrest occurring despite the persistence of apparently effective cardiac electric activity. Secondary EMDs are consequence of catastrophic circulatory failure (i.e. great vessel rupture, massive pulmonary embolism, cardiac tamponade), resulting in sudden and critical changes in hemodynamic load. Primary EMDs, on the other hand, occur in presence of intact circulatory system; they are known to be associated with global cardiac ischemia and contraction failure; however, the exact pathophysiologic change, triggering the onset of primary EMD, is still unknown. The current hypothesis of electromechanical uncoupling (a supposed derangement of excitation and contraction linking) has not been demonstrated. On the contrary, in a previous series of 22 2D-echocardiographic evaluations of patients with EMD, wall and valvular motion was visible in the majority of cases. In our Coronary Care Unit we had the opportunity to perform 2D and color-Doppler echocardiogram in 2 patients, developing primary EMD just while the examination was in course; we subsequently completed the examinations in the short pauses of cardio pulmonary resuscitation. Both patients died and necropsy showed in both cases recent large myocardial infarction, without hemopericardium. The analysis of the echocardiograms emphasized the presence of a residual cardiac mechanical activity: minimal segmental wall motion of left ventricle (LV); residual mitral valve motion, but no visible closure; diastolic low-velocity orthograde transmitralic flow; systolic regurgitant flow from LV to left atrium. On the other hand, we didn't observe any systolic flow directed to the LV outflow tract and to the aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

[Blood platelet alpha adrenergic receptors in congestive heart failure. Effects of ACE inhibition]. / I recettori alfa adrenergici piastrinici nello scompenso cardiaco congestizio. Effetti dell'ACE-inibizione.

Platelet alpha-2-adrenergic receptor number and affinity were examined in 12 patients with class IV NYHA congestive heart failure (CHF) and 10 normal volunteers paired for age and sex. Platelet alpha-2-adrenergic receptor number is significantly decreased in CHF patients (178 +/- 18 fmol/mg prot. vs 282 +/- 21 fmol/mg prot. p less than 0.05). After Captopril treatment (6 weeks) alpha-2-receptor number increased but this increase was not statistically significant (236 +/- 28 fmol/mg prot.). This study supports the hypothesis that increased levels of circulating catecholamines in CHF lead to a decrease in platelet alpha-2-adrenoreceptors. Improved cardiac function following administration of Captopril could lead to a withdrawal of sympathetic tone. Captopril may also interact with sympathetic nervous function.

Increase in plasma HDL-cholesterol in hypertensive patients treated with enalapril.

The effects of enalapril on plasma lipoproteins were evaluated in an open study of 12 normolipidemic outpatients with mild-to-moderate essential hypertension (World Health Organization stages I and II). After a two-week washout period, during which placebo was given, the patients received 20 to 40 mg/day of enalapril for 16 weeks. Treatment with enalapril was associated with significant increases in levels of HDL cholesterol (mean, 23%; P less than 0.001) and apoprotein A (mean, 11%; P less than 0.01), largely because of the increase in the subfraction HDL2 (mean, 43%; P less than 0.001), although the subfraction HDL3 also rose (mean, 14%; P less than 0.005). Total cholesterol and LDL cholesterol levels did not change, whereas triglycerides decreased significantly (mean, 26%; P less than 0.001). Apoprotein B was unchanged. Unlike diuretics and most beta-blockers, enalapril favorably affects plasma lipoprotein levels, thus improving the overall cardiovascular risk in hypertensive patients.