Can short-term verapamil therapy reduce the recurrence of atrial fibrillation after successful low energy intracardiac cardioversion?

BACKGROUND: Calcium-lowering drugs seem to be able to reduce the recurrences of atrial fibrillation (AF) after cardioversion by preventing electrical remodeling of atrial cells. The aim of our study was to prospectively evaluate the efficacy of short-term verapamil therapy associated with propafenone or amiodarone in reducing recurrences of AF after low energy intracardiac cardioversion. METHODS: Eighty-two patients with chronic AF (mean duration 6.1 months, range 1-96 months) underwent low energy intracardiac cardioversion. Forty-one patients (Group A) were instructed to suspend antiarrhythmic therapy 48 hours before the procedure (only chronic amiodarone was allowed). The subsequent 41 patients (Group B), in addition to previous prescriptions, had to take verapamil (120 mg twice daily) for 3 days before low energy intracardiac cardioversion and for 7 days after cardioversion. A right atrium-coronary sinus or right atrium-left pulmonary artery electrode configuration was indifferently utilized. Propafenone (450-900 mg daily) or amiodarone (200 mg daily) was prescribed to all patients after cardioversion. RESULTS: Sinus rhythm was acutely restored in 80 patients (97.6%): the mean number of shocks delivered was 2.3 (range 1-5); the mean energy required was 10.5 J (range 7.2-19.8 J). No statistically significant differences were found between the right atrium-coronary sinus vs right atrium-left pulmonary artery electrode configuration regarding the energy required and the number of shocks delivered. Group A and Group B showed the same number of AF recurrences at the first month of follow-up. CONCLUSIONS: In our study, short-term verapamil treatment associated with propafenone or amiodarone seems to be useless for the prevention of recurrent AF after low energy intracardiac cardioversion.

Validation of the ejection fraction-velocity ratio: a new simplified "function-corrected" index for assessing aortic stenosis severity.

A new echocardiographic method for the evaluation of aortic stenosis (AS) severity has recently been introduced: the fractional shortening-velocity ratio (FSVR = fractional shortening/4 Vmax(2)). An important advantage of the method is the possibility of avoiding the difficulties related to the measurement of left ventricular outflow tract in calcific AS for assessing the continuity equation. FSVR, however, also shows some significant limitations especially in patients with regional wall motion abnormalities and conduction defects. To overcome this problem, we developed a new index: the ejection fraction-velocity ratio (EFVR = ejection fraction/4 Vmax(2)), where percent ejection fraction and Vmax have been obtained with an apical echocardiographic approach. In 343 consecutive patients with AS, aortic valve area was measured by cardiac catheterization (Gorlin), whereas FSVR and EFVR were calculated by echo-Doppler examination performed within 24 hours. Mean valve area was 0.70 +/- 0.30 cm(2), mean EFVR was 0.78 +/- 0.41, and mean FSVR was 0.45 +/- 0.26. The linear correlation area-EFVR was highly significant (r = 0.88). Correlation valve area-FSVR was also significant (r = 0.82). EFVR allowed identification of patients with severe AS (area

Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis.

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS. PA systolic pressure between 31 and 50 mm Hg was used to define mild to moderate PH, whereas PA systolic pressure >50 mm Hg was used to define severe PH. PA systolic pressure showed no significant difference according to age and sex, although it was significantly higher in patients in New York Heart Association functional classes III and IV and in patients with coexistent systemic hypertension than in the others. PH was absent in 136 patients (35%, group 1), mild to moderate in 196 patients (50%, group 2), and severe in 58 patients (15%, group 3). Only the prevalence of overt heart failure was significantly higher in group 3 patients. AS severity was similar among the 3 groups, and PA systolic pressure showed no relation to aortic valve area in the entire population. Also, a poor correlation was found between PA pressure and left ventricular (LV) ejection fraction (r = -0.28), with several patients having moderate or severe PH despite a preserved LV systolic function. PA systolic pressure significantly correlated with LV end-diastolic pressure (r = 0.50) and with PA wedge pressure (r = 0.84). Furthermore, transpulmonary pressure gradient, an index of resistance across the pulmonary vascular bed (obtained as the difference between PA mean and PA wedge pressure), was significantly higher in patients with PH, especially in those with a marked increase in PA systolic pressure, suggesting a reactive component of PH.

Low energy intracardiac cardioversion of chronic atrial fibrillation by single femoral approach: safety and effectiveness of the procedure.

BACKGROUND: Low energy intracardiac cardioversion has recently been introduced into clinical practice to treat both acute and chronic atrial fibrillation. It has also been suggested that low energy intracardiac cardioversion has a higher efficacy rate in restoring sinus rhythm than conventional external cardioversion. METHODS: A prospective study was started in 41 patients (mean age 64.5 years) with chronic atrial fibrillation (mean duration 6.5 months), in order to obtain more data on low energy intracardiac cardioversion concerning: 1) time required to perform low energy intracardiac cardioversion by single venous femoral approach; 2) acute efficacy; 3) incidence of complications; 4) persistence of sinus rhythm after 1 month. RESULTS: Twenty patients had right atrium-coronary sinus (Group A) and 20 right atrium-left pulmonary artery (Group B) electrode configuration for defibrillation. In 1 patient the configuration was not available. In all patients (100%) sinus rhythm was acutely restored. No statistically significant differences were found between the two groups concerning mean energy and impedance required to obtain cardioversion. With mild sedation the discomfort induced by the electrical shock was minimal or mild. Only 44% of patients were in sinus rhythm 1 month after low energy intracardiac cardioversion, in spite of adequate pharmacological therapy. CONCLUSIONS: Low energy intracardiac cardioversion by single venous femoral approach may be considered a very effective and not time consuming procedure in acutely restoring sinus rhythm, with low complication rate; in addition the procedure was well accepted by all patients.

[Is a more efficient operative strategy feasible for the emergency management of the patient with acute chest pain?]. / E realizzabile una strategia operativa più efficace per la gestione in urgenza del paziente con dolore toracico acuto?

Patients with acute chest pain are a common problem and a difficult challenge for clinicians. In the United States more than 5 million patients are examined in the emergency department on a yearly basis, at a cost of 6 billion dollars. In the CHEPER registry the prevalence of patients with chest pain in the Emergency Department was 5.3%. Similarly, in 1997 at our institution the prevalence was 4.8%. Only 50% of the patients are subsequently found to have cardiac ischemia as the cause of their symptoms and 50-60% of them showed a non-diagnostic electrocardiogram (ECG). Twenty-five-50% of chest pain patients are not appropriately admitted to the hospital and despite this conservative approach, acute myocardial infarction is misdiagnosed up to 8% of patients with acute chest pain who are released from the emergency department without further evaluation, accounting for approximately 20% of emergency department malpractice in the United States. Important diagnostic information is covered by the patient's medical history, physical examination, and ECG, but often this approach is inadequate for a definitive diagnosis. Creatine kinase (CK) and CK isoenzyme--cardiac muscle subunit (CK-MB)--are traditionally obtained in the emergency department in patients admitted for suspected acute coronary syndrome. Mass measurements of CK-MB have improved sensitivity and specificity, and to date this is the gold standard test for diagnosis of acute myocardial infarction. CK-MB, however, is not a perfect marker because it is not totally cardiac specific and does not identify patients with unstable angina and minimal myocardial damage. There are no controlled clinical impact trials showing that these tests are effective in deciding whether to discharge or to appropriately admit the patient with suspected acute coronary syndrome. Relevant investigative interest has recently been focused on new markers for myocardial injury, including myoglobin, cardiac troponins T and I. Myoglobin, a sensitive but not specific marker for cardiac damage, increases earlier than CK-MB and cardiac troponins. It should be used early after symptom onset and in conjunction with a more specific marker of myocardial damage. Cardiac troponins T and I are highly specific markers for cardiac damage, rise parallel to CK-MB and remain elevated longer, up to 5 to 9 days. They are useful for detection of less severe degrees of myocardial injury, which may occur in several patients with unstable angina who are at higher risk of cardiac events. Recent studies suggest that cardiac troponins have good diagnostic performance and prognostic value in the heterogeneous population of patients seen in the Emergency Department with acute chest pain. Despite these promising data, several analytical and interpretative problems in the routine use of cardiac troponins must be solved. Incremental value of echocardiography in acute chest pain patients is still uncertain. Echocardiography can be recommended as an adjunctive test if readily available during acute chest pain or prolonged pain, especially in patients without previous myocardial infarction. Rest myocardial radionuclide imaging has been studied in the emergency department setting and although the overall diagnostic performance and prognostic value of sestamibi has been found to be promising, it is not suitable, in our country, for extensive clinical use. ECG exercise stress test in the emergency department population has been shown to be safe and it has a good negative predictive value for cardiac events. It should be recommended that any institution identify specific and shared protocol and strategies for management of patients with chest pain. These should include basal clinical evaluation, serial ECG and the use of specific and sensitive myocardial markers. Adjunctive tests, such as echocardiography, nuclear studies and stress tests should be employed when indicated taking into account local facilities.

Clinical impact of local implementation of agreed guidelines for the management of patients with acute myocardial infarction.

OBJECTIVE: This study sought to assess the impact of local implementation of clinical practice guidelines on the pattern of care and outcome in patients admitted to the Coronary Care Unit (CCU) with acute myocardial infarction. BACKGROUND: Development of clinical practice guidelines is among the most popular of the methods intended to promote translation of results from clinical trials into routine care. However, very little is known about the actual impact on routine care of the clinical guidelines for managing patients with acute myocardial infarction. METHODS: We reviewed a prospectively collected cohort of consecutive patients discharged with a diagnosis of acute myocardial infarction from S. Maria degli Angeli, a large community-based hospital in northeast Italy. Eighty-six patients treated in 1996 (before guideline implementation) were compared with 70 patients treated in 1997 (after guideline implementation) with respect to patterns of use of guideline-directed pharmacotherapies for acute myocardial infarction, diagnostic testing, length of CCU stay and clinical outcome. RESULTS: The two groups were similar in male gender, age, infarct location and severity. Patients managed before guideline implementation were less likely to receive thrombolysis (36 vs 50%; p = 0.05), i.v. beta-blockers at admission (13 vs 31%; p = 0.002), oral beta-blockers at CCU discharge (45 vs 74%; p = 0.0003). When these were given, patients managed before guideline implementation received lower dosages of i.v. heparin, as manifested by a lower proportion of patients reaching adequate aPTT levels at 24 hours (14 vs 62%, p < 0.0001), and of oral beta-blockers (-50%, p < 0.0001), and higher dosage of aspirin (+100%, p < 0.0001). The time to mobilization (+1 day) and the length of CCU stay (+0.5 day) were longer in patients managed before guideline implementation (p < 0.0001). Incidence of major complications was similar between the two groups (19 vs 13%, respectively; p = ns). CONCLUSIONS: Patients with myocardial infarction managed after local implementation of clinical practice guidelines were more likely to receive evidence-based effective pharmacotherapies, and to have earlier mobilization and earlier discharge from CCU. This study strongly supports the role of local implementation of clinical practice guidelines to optimize management of patients with acute myocardial infarction.

[Results of coronary surgery in mildly symptomatic patients with left ventricular dysfunction, multivessel disease and stenotic single residual patent vessel]. / Risultati della chirurgia coronarica nei pazienti paucisintomatici con disfunzione ventricolare sinistra, malattia multivasale e unico vaso residuo pervio stenotico.

BACKGROUND: While efficacy of coronary artery bypass surgery in patients with depressed left ventricular function and myocardial ischemia is widely recognized, its results in patients in the absence of clinical evidence of myocardial ischemia remain uncertain. The purpose of this study was to evaluate the effects of coronary revascularization in comparison with conventional medical therapy in subjects with ischemic cardiomyopathy and myocardial ischemia presumed on the basis of angiographic anatomy but not demonstrated by functional testings. METHODS: We selected retrospectively patients who underwent coronary angiography from 1986 trough 1993 and met the following criteria: presence of three-vessel coronary artery disease, occlusion of two and significant luminal narrowing (> or = 50%) of the third major epicardial artery, left ventricular dysfunction (ejection fraction < or = 40%), no angina or presence of mild angina, absence of inducible ischemia on exercise test and, when performed, of redistribution in the vascular territory of the patent vessel. RESULTS: Thirty-one consecutive patients underwent isolated surgical revascularization treatment, while thirty medically treated patients with matched clinical characteristics were selected. Age (61 +/- 10 vs 62 +/- 9), gender (M/F 27/3 vs 24/7), NYHA class I-II (53 vs 62%) or NYHA III-IV (47 vs 38%), incidence of previous infarction (87 vs 94%), number of reversible defects in the vascular territory of the patient vessel on stress scintigraphy (0.6 vs 0.5), patent vessel (right coronary artery 7 vs 10; left circumflex 14 vs 12; left anterior descending 9 vs 9) and left ventricular ejection fraction (28 +/- 8 vs 31 +/- 7), were similar in the two groups (medical vs surgical). Surgically treated patients exhibited a lower proportion of overall cardiac deaths (7/31, 23% vs 19/30, 63%; p < 0.001), and more prolonged survival (67 +/- 9.3 vs 34 +/- 2.5 months; p = 0.04, Mantel and Cox test) than medically treated patients, respectively. The incidence of perioperative myocardial infarction was 10% (3/31). Causes of cardiac death were myocardial ischemia (9/19; 47%), sudden death (5/19; 26%) and heart failure (5/19; 26%) in medical patients, while were surgery (3 cases) and surgery related infection (1 case) (total 4/7; 57%), myocardial ischemia (1/7; 14%), sudden death (1/7; 14%) and heart failure (1/7; 14%) in surgical patients. Cox proportional hazard regression analysis with survival as the dependent variable, identified treatment, surgical or medical, as the best predictor of cardiac events (chi square improvement 9.36, p = 0.002). The next most powerful predictors were NYHA class and ACE-inhibitors treatment (chi square improvement 4.47 and 2.79, respectively). CONCLUSIONS: In patients with left ventricular dysfunction, multivessel coronary artery disease and single patent but stenotic residual vessel, coronary artery bypass grafting appear to offer a better survival than medical therapy, even in the absence of clinically evident myocardial ischemia.

[The ST/HR slope and coronary stenoses]. / ST/HR slope e stenosi coronariche.

BACKGROUND: The heart rate adjustment of ST depression (ST/HR Slope) has been shown by some authors to markedly improve the accuracy of treadmill exercise electrocardiogram for identifying and quantifying coronary artery disease. However, other authors have obtained different results. In the present study the results of our exercise electrocardiography laboratory are compared with the data obtained from the literature. METHODS: Fifty patients (46 males and 4 females, age range 60 +/- 7 years) with suspect or certain coronary artery disease were referred for a routine treadmill exercise electrocardiogram, and subsequently underwent cardiac catheterization and selective coronary cineangiography to assess the severity of coronary obstruction. All patients exercised according to a recently reported modification of the standard Bruce protocol, proposed by Kligfield et al, for a more accurate evaluation of the ST/HR Slope, which was calculated in real time by a computerized system. Patients with coexisting valvular heart disease, cardiomyopathy, left bundle-branch block on the resting ECG, myocardial infarction within 8 weeks, diabetes mellitus, hypertensive response during exercise testing (diastolic blood pressure > 95 mm Hg and/or systolic blood pressure > 190 mm Hg), abnormalities or variations of the coronary arteries, were excluded from this study. RESULTS: This method correctly identified 13 of 14 patients with multivessel coronary artery disease and 35 of 36 with less severe disease: one patient was false negative and another one false positive. Thus, in our exercise electrocardiography laboratory this approach shows a sensitivity of 93%, a specificity of 97%, a positive predictive value of 93% and a negative predictive value of 97% for the detection of severe coronary disease. CONCLUSIONS: These findings suggest that, in patients selected as in this study, the ST/HR slope is a good method which improves the clinical usefulness of the treadmill exercise electrocardiogram in coronary artery disease.

[Comparison of exercise thallium-201 perfusion scintigraphy and coronarography in the prognostic stratification of patients with post-infarction residual ischemia]. / Confronto tra scintigrafia perfusoria con 201-tallio da sforzo e coronarografia nella stratificazione prognostica dei pazienti con ischemia residua post infartuale.

The goals of this study were: 1) to determine and compare the prognostic utility of exercise 201Thallium scintigraphy with coronary angiography in patients with residual ischemia at the symptom limited bicycle exercise testing performed at hospital discharge after a first uncomplicated acute myocardial infarction 2) to verify the ability of perfusion scintigraphy to identify better than coronary angiography a subset of these patients at low risk for future events, despite the ischemic response at the exercise stress testing. Accordingly, follow-up data were obtained prospectively for 72 consecutive patients with adequate left ventricular rest systolic function, and with exercise induced greater than or equal to 1 mm ST-segment depression and/or typical angina pectoris. A planar 201Thallium scintigraphy and coronary angiography were performed within 2 months after acute myocardial infarction. By 31 +/- 29 months 38 patients had no events, while 34 experienced a cardiac event: 3 died of cardiac causes, 2 had nonfatal recurrent myocardial infarction, 29 were rehospitalized for severe class III or IV angina pectoris (4 were treated medically, 25 were revascularized: 20 had coronary bypass surgery, 5 coronary angioplasty). Each of the 3 angiographic classification of coronary artery disease (number of vessels with greater than or equal to 70% reduction of luminal diameter, jeopardy score and Gensini score) accurately identified patients with subsequent cardiac event by Mantel and Cox analysis (respectively p = 0.01, p = 0.0000, p = 0.002). Among 201Thallium variables, the number of segments demonstrating redistribution on delayed images (p = 0.0000), the number of segments with persistent defect (p = 0.0003) and increased 201Thallium uptake by the lungs (p = 0.0100) effectively stratified the probability of survival by the same analysis. Furthermore, the number of perfusion defects, either transient or persistent, with exercise 201Thallium scintigraphy provide additive prognostic information to any of the 3 angiographic coronary artery disease classifications considered. On the contrary, when 201Thallium stress findings are known, coronary angiography data in general are not additive in risk stratification. 17 patients with no reversible perfusion defect remained stable at follow up (52 +/- 28 months) despite development of typical angina pectoris (11/17) and/or ischemic ST segment depression (12/17) during exercise testing.(ABSTRACT TRUNCATED AT 400 WORDS)

[Arrhythmologic study of 50 patients with arrhythmogenic disease of the right ventricle: prognostic implications]. / Studio aritmologico in 50 pazienti con malattia aritmogena del ventricolo destro: implicazioni prognostiche.

UNLABELLED: Arrhythmogenic right ventricular disease is a syndrome which involves a wide spectrum of anatomo-clinical features. It is characterised by different levels of right ventricle anomaly, and by life-threatening "right" hyperkinetic ventricular arrhythmias. Fifty consecutive pts were retrospectively examined at the Arrhythmological Centre in Trento between 1977 and 1988. The results of rigorous arrhythmological, echocardiographic and angiographic criteria showed that all pts were affected by arrhythmogenic right ventricular disease. CASE STUDY: 39/50 (78%) males, 11/50 (22%) females; age 30.6 years (11-78) at the time of the first study. METHODS: clinical history in 50/50 pts, electrocardiogram in 50/50 pts, Holter monitoring in 50/50 pts, ergometric test in 49/50 pts, non-invasive analysis using signal-averaging QRS in 17/50 pts, 2D echocardiogram in 50/50 pts, angiography in 38/50 pts, electrophysiological endocavitary study in 35/50 pts. RESULTS: familial 2/50 (4%); 1/50 (2%) was in class II NYHA; first arrhythmia at 24.6 years (8-60); most severe arrhythmia at 27.7 years (9-74). Forty-three out of fifty patients (86%) were symptomatic for arrhythmias: 28/50 (56%) as a result of stress; 20/50 (40%) had life-threatening symptoms; 6/50 (12%) had aborted sudden death. Arrhythmogenic right ventricular disease was "localized" in 42/50 (84%) and "diffused" in 8/50 (16%) and was associated with anomalies of the left ventricle in 30/50 (60%). Electrocardiogram showed: right bundle branch block in 10/50 (20%), negative T wave on the right precordial leads in 19/50 (38%), delayed ventricular potentials in 4/17 (23.5%). Using the electrocardiogram, Holter monitoring and electrophysiological endocavitary study the following were documented: a) clinical ventricular tachycardia in 40/50 (80%): non-sustained ventricular tachycardia in 10/50 (20%), sustained ventricular tachycardia in 30/50 (60%); b) electrically induced ventricular tachycardia in 26/35 (74.2%): non-sustained ventricular tachycardia in 8/35 (22.8%), sustained ventricular tachycardia in 18/35 (51.4%) (clinical sustained ventricular tachycardia in 18/18); c) multiform ventricular tachycardia in 12/50 (24%) (diffused arrhythmogenic right ventricular disease in 3/12 and associated anomalies of the left ventricle in 11/12); d) pleomorphic sustained ventricular tachycardia in 9/30 (30%) (diffused arrhythmogenic right ventricular disease in 2/9, and associated anomalies of the left ventricle in 8/9). Forty-two out of fifty patients (84%) underwent antiarrhythmic treatment. When the study was carried out 6.6 years (1 month-22 years) had passed since the first symptom; follow-up was 2.1 years (1 month-11 years) while the interval between the first symptom and the last check-up was 8.4 years (1-30 years); 2/50 dropped out and 2/50 died suddenly.(ABSTRACT TRUNCATED AT 400 WORDS)

Interobserver and echo-angio variability of two-dimensional colour Doppler evaluation of aortic and mitral regurgitation.

Colour Doppler flow mapping (CD) has proved to be a very sensitive and specific means of diagnosing valvular regurgitation and obtaining a rapid semiquantitative estimation of the severity of regurgitation itself. We tried to compare a semiquantitative evaluation of aortic and mitral regurgitation, without time-consuming calculations of regurgitant jet areas, with the conventional visual semiquantitative angiographic estimation. We have also evaluated in detail the interobserver variability of this type of semiquantitation. Two independent observers (OB) have reviewed CD studies of a selected group of 47 consecutive patients who underwent both cineventriculography and aortography for aortic regurgitation (AR) and/or mitral regurgitation (MR), then graded as mild, moderate or severe. At CD, AR and MR were classified as present or absent and graded as mild, moderate or severe. The following interobserver percentage agreements were noted for AR presence or absence, AR grade, MR presence or absence, MR grade, respectively: 96%, 83%, 96%, 83%. Likewise, the respective echo-angio agreements were 90%, 58%, 80%, 70%. Agreement was significant (P less than 0.001) in all cases. Thus, good interobserver and echo-angio agreement was found in the CD assessment of AR and MR. However, under- or overestimation of CD vs. angio was noted in several cases (mostly by one grade). Underestimation of CD vs. angio was 27% for AR and 18.5% for MR; overestimation of CD vs. angio was 15% for AR and 11.5% for MR. CD has proved to be a useful technique not only for the qualitative but also for the semiquantitative evaluation of aortic and mitral regurgitation, as assessed in the same subjects, with good interobserver agreement.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic findings of left ventricular hypertrophy and normalization of parameters of left ventricular function in patients with previous evidence of dilated and poorly contracting left ventricle and coexisting systemic hypertension.

We report 6 cases of dilated left ventricle with poor left ventricular function and coexisting systemic hypertension in whom left ventricular hypertrophy and normalization of left ventricular function and dimensions have been subsequently documented by M-mode and two-dimensional echocardiographic follow-up studies. Four patients were in New York Heart Association functional Class IV, one in Class III, and one in Class II when first seen. Normalization of left ventricular function and dimensions and features of left ventricular hypertrophy (fractional shortening from 15.0 +/- 5.2 to 39.7 +/- 5.4, left ventricular end-diastolic diameter from 6.6 +/- 0.6 to 4.6 +/- 0.6 cm, left ventricular end-systolic diameter from 5.6 +/- 0.8 to 2.8 +/- 0.6 cm, left ventricular end-diastolic radius/posterior wall thickness from 3.1 +/- 0.5 to 2.0 +/- 0.4, interventricular septum thickness from 1.2 +/- 0.3 to 1.5 +/- 0.3 cm, left atrium from 4.6 +/- 0.6 to 3.5 +/- 0.9 cm) were achieved after adequate medical treatment at the end of the follow-up (11-39 months). It appears from this study that normalization of left ventricular dimensions and function with features of left ventricular hypertrophy can occur after adequate treatment in patients with echocardiographic findings of dilated and poorly contracting left ventricle and coexisting systemic hypertension. It is conceivable, in such cases, to classify the dilatation of the left ventricle as secondary and to suggest the hypothesis of a cause-effect relationship between therapy and normalization of left ventricular parameters with findings of left ventricular hypertrophy. Further studies are needed to clarify this phenomenon.

[Comparison of continuous wave Doppler and heart catheterization in the determination of the mean transvalvular gradient in mitral stenosis. A simultaneous beat to beat analysis]. / Confronto tra Doppler ad onda continua e cateterismo cardiaco nella determinazione del gradiente medio transvalvolare nella stenosi mitralica. Analisi contemporanea battito su battito.

Continuous wave Doppler echocardiography (CWD) is widely used in the assessment of pressure gradients in patients with valvular heart disease, utilizing the simplified Bernoulli equation. However determination of non-simultaneous mean pressure gradient (MG) in mitral stenosis (MS) from CWD recordings has often been described as being unsatisfactory. Therefore, the purpose of this study was to compare the estimates of trans-mitral MG derived from CWD with gradients measured simultaneously at cardiac catheterization (beat to beat analysis). We studied 3 patients (pts) with MS (1 man and 2 women, aged 55, 55 and 62 years respectively); one patient (pt) was in sinus rhythm and 2 were in atrial fibrillation. In each pt the trans-mitral flow velocity curve was obtained simultaneously with trans-mitral gradient measured directly at cardiac catheterization (cath). In this way it was possible to obtain a beat to beat correlation between Doppler and cath in 181 beats taken from the 3 pts. These beats were selected from a total number of 321 beats because of their excellent quality for analysis (74 beats were obtained from the first pt, 38 from the second pt and 69 from the third pt). Mean diastolic velocity, defined as the mean of maximal velocities throughout diastole, was obtained for each beat by planimetring the envelope of the spectral velocity profile. MG was calculated from mean velocity by applying the simplified Bernoulli equation (delta P = 4V2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value and limitations of 2-dimensional echocardiography in the identification of arrhythmogenic right ventricular dysplasia]. / Valore e limiti dell'ecocardiografia bidimensionale nell'identificazione della "displasia ventricolare destra aritmogena".

The aim of this study was to evaluate the value and limitations of Cross-sectional Echocardiography (CSE) in the diagnosis of Arrhythmogenic right ventricular dysplasia (ARVD). Diagnosis was based on accepted clinical, electrocardiographic, electrophysiologic and angiographic criteria. CSE criteria for the diagnosis are segmental right ventricular wall motion abnormalities of unknown cause, usually associated with localized or diffuse dilatation of right ventricular (RV) chamber and with the presence of localized anomalies consisting of sacculation or bulging of RV wall. Comparison of CSE and RV angiographic findings was performed in 8 patients with ARVD (6 men and 2 women, aged 10 to 37 years, mean 28 years). CSE and angiography compared closely when diffuse RV enlargement and wall motion abnormalities were identified by both techniques. Bulging and sacculation of the RV wall at CSE predicted the presence of similar lesions at angiography, but agreement for specific location was poor and, in addition, CSE showed low sensitivity in their detection. The inherent different information provided by the two methods added to the subjectivity of the qualitative analysis probably accounts for the inconsistencies. Therefore in patients with diagnosed ARVD RV enlargement, otherwise unexplained, associated with wall motion abnormalities and localized anomalies at CSE strongly supports the diagnosis and avoids the need for angiography. By other hand, in patients with high clinical suspicion of ARVD a negative CSE study can not exclude the diagnosis and angiography should be indicated.

Abnormal myocardial texture demonstrated by ultrasound in two patients with idiopathic haemochromatosis.

We studied by cross-sectional echocardiography seven patients affected by idiopathic haemochromatosis without clinical signs of heart failure. In two patients the heart muscle showed a peculiar echocardiographic texture at the level of the endocardium. No differences were noticed in clinical and haematological findings of the patients with and without abnormal texture. Increased echogenicity of the subendocardial myocardium should be looked for in patients with idiopathic haemochromatosis.

Normalization of variables of left ventricular function in patients with alcoholic cardiomyopathy after cessation of excessive alcohol intake: an echocardiographic study.

An excessive alcohol intake has been reported as one of the possible causes or risk factors of 'alcoholic cardiomyopathy'. The possibility that this cardiomyopathy may improve or even reverse if the alcohol abuse has been terminated has been suggested, but unequivocal echocardiographic documentation of this improvement has never been described. This study reports the normalization of cardiac chamber dimensions and of variables of left ventricular function documented by M-mode and cross-sectional echocardiographic follow-up studies, after cessation of excessive consumption of alcohol, in three cases of alcoholic cardiomyopathy.

Heterogeneity of left ventricular wall dynamics in normal hearts and in chronic aortic regurgitation. A two-dimensional echocardiographic study.

The variation in shape, in the global and regional function of the left ventricle (LV) was quantitated by using Two-Dimensional Echocardiography (TDE) in 20 normal subjects (N) (17 males, 3 females, with a mean age of 21.2 years, age range 15 to 34) and compared to 20 patients with aortic regurgitation (AR) (14 males, 6 females with a mean age of 31 years, age range 16 to 51). The left ventricle was subdivided into two TDE short axis cross-sections at the papillary muscle (PM) and at the mitral valve (MV) level. Wall motion was assessed by the following indices; endocardial systolic fractional area change (FAC), wall thickening (Wth) and circumferential fiber shortening (S). The ejection fraction (EF), the diastolic (EID) and systolic eccentricity index (EIS), the end-diastolic volume (EDV), the end systolic volume (ESV) and the LV mass (M) were estimated using a 4 chamber apical view. Measurements of sectional cavity areas, muscle areas and endocardial perimeters were obtained twice independently by two observers using a computer aided system, to achieve the final results as the mean of the 4 measurements. Paired t-test showed a statistically significant variation between PM and MV for FAC in N (p less than 0.001). A statistically significant difference (p less than 0.01) was found for EID between N and AR. The EIS was not significantly different in the two groups. In AR a significant difference was found between EID and EIS (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Equilibrium angioscintigraphic evaluation of sequential changes in right ventricle function in patients with lower myocardial infarct and ischemic co-involvement of the right ventricle: long-term study]. / Valutazione angioscintigrafica all'equilibrio delle variazioni sequenziali della funzione ventricolare destra in pazienti con infarto miocardico inferiore e coinvolgimento ischemico del ventricolo destro: studio a lungo termine.

The purpose of this study was to define the sequential changes in global and regional right ventricular function, using equilibrium gated radionuclide angiography, following transmural inferior myocardial infarction (IMI) and associated ischemic right ventricular involvement. 24 patients with IMI underwent radionuclide angiography within 72 hours of onset of chest pain; subsequent studies were done at 13 +/- 5 days and at 6 +/- 2 months. Scintigraphic evidence of ischemic right ventricular involvement was defined by depression of right ventricular ejection fraction (less than 40%) and regional wall motion abnormalities (hypo-a-dyskinesia of right ventricular free wall). Significant improvement of global right ventricular ejection fraction was observed in 15 patients at the second study, and in 21 patients at the third study. Right ventricular regional wall motion showed similar improvement from the initial to the final studies. Significant changes in right ventricular function occurred without concurrent changes in global and regional left ventricular ejection fraction. We concluded that patients with IMI and ischemic right ventricular involvement show frequently improvement of global and regional right ventricular function over time. This changes tend to occur early and without significant modifications in left ventricular function. The good prognosis observed in our patients, despite the high incidence of in hospital complications, might be related to the improvement of right ventricular function.

[Determination of the transvalvular gradient using continuous wave Doppler in patients with mitral stenosis. Correlation with the hemodynamic method]. / Determinazione del gradiente transvalvolare mediante Doppler ad onda continua in pazienti con valvulopatia mitralica. Correlazione con il metodo emodinamico.

In order to assess the reliability of Doppler echocardiography in the determination of mean mitral gradient 38 consecutive patients (pts) affected by rheumatic mitral valve stenosis (MS) were analyzed by continuous wave Doppler echocardiography (CWD). Cardiac catheterization (CATH) was performed within 24 hours from echocardiographic examination. The mean diastolic mitral gradient (MG) at CATH was calculated by planimetry from simultaneously recorded left ventricular and pulmonary artery wedge pressure. The maximal velocity profile through the mitral valve was used to calculate pressure gradient by CWD. A mean mitral gradient was calculated for each patient by the planimetered velocity profile throughout diastole. MG determined by CATH ranged from 6 to 31 mmHg (mean 15.2 +/- 6.0); MG determined by CWD ranged from 4 to 18 mmHg (mean 10 +/- 3.7). The correlation between CWD and CATH by linear regression analysis was: y = 0.53 X + 1.8; r = 0.85; p less than 0.001. Mean % error of CWD in the assessment of MG was 34.7%. In conclusion this study indicates that CWD seems systematically underestimate MG with respect to CATH. The identification of CWD flow tracings "optimal" for analysis could not represent the maximal velocity of transmitral jet, which is a complex three dimensional entity. In addition non-simultaneous determinations of gradient and day-to-day variations in cardiac output may account for discrepancies between CWD and CATH measurements.