[The usefulness of transesophageal echocardiography in the diagnosis of arrhythmogenic cardiomyopathy of the right ventricle]. / Utilità dell'ecocardiografia transesofagea nella diagnosi di cardiomiopatia aritmogena del ventricolo destro.

OBJECTIVES: The aim of this study was to evaluate the usefulness of transesophageal echocardiography (TEE) for the diagnosis of arrhythmogenic right ventricle cardiomyopathy (ARVC). PATIENTS: Using TEE and the standard transthoracic echocardiography (TTE), we studied 19 patients affected with hyperkinetic ventricular arrhythmias with a LBBB pattern, as well as 10 normal control subjects (C). METHODS: We calculated the following parameters: the fractional area change (FAC) of the end-diastolic right ventricule (RV) area; the global wall motion score (WMS) by the algebraic sum of the score of each of the 9 wall segments including the inflow, outflow and apex of RV; the asynergy index (AI) by the percentage of the 9 segments with a score > or = 2; the average thickness of moderator band and papillar muscles (ATMP); the echo reflectivity score (ERS) and the structural abnormalities score (SAS) of RV. The diagnosis of ARVC was proposed when RV segmental wall motion abnormalities were visualized, or when a decrease of the ventricular FAC and dysmorphic aspects were contemporaneously present. The results of the two echocardiographic approaches were compared, and in arrhythmic patients (A) echocardiographic results were compared with those obtained by cineventriculography (CVG), which we had adopted as the reference diagnostic method. RESULTS: The comparison between A and C showed significant differences for all parameters if calculated by the TEE (p < 0.003-0.0001), except for ATMP if calculated by TTE (p < 0.003-0.0001). The comparison between TEE and TTE approaches did not show any difference in the C group while in the A group only FAC and ERS resulted similar; the values of the remaining parameters were significantly greater if calculated by TEE than by TTE (WMS = 7.3 +/- 4.1 vs 4.3 +/- 2.3: p < 0.01; AI = 22.6 +/- 18.5 vs 11.6 +/- 10.3: p < 0.05; ATMP = 6.1 +/- 0.9 vs 5 +/- 1.2 mm: p < 0.04; SAS = 2.2 +/- 0.8 vs 1.4 +/- 0.7: p < 0.002). In 17 of the 19 patients who were clinically suspected to be affected with ARVC the diagnosis was confirmed by CVG; 12 of them (70%) were correctly identified by TTE and 17 (100%) by TEE. One of the two negative patients was erroneously considered positive both by TTE and TEE. CONCLUSIONS: TEE is a usefull diagnostic tool for ARVC and is more accurate than TTE for the identification of the concealed or dubitative forms of the disease.

[Empiric treatment with amiodarone in patients with sustained ventricular tachyarrhythmia. Results of a long-term follow-up]. / Trattamento empirico con amiodarone in pazienti con tachiaritmie ventricolari sostenute. Risultati a medio e lungo termine.

The long-term follow-up of 52 pts (36 M, 16 F, mean age: 62 years) with sustained ventricular tachyarrhythmias (SVT) was analyzed to assess the efficacy and feasibility of empiric amiodarone treatment. Forty-five pts had organic heart disease (mean EF: 38.3%) and 7 pts no overt heart disease. Twenty pts suffered from syncope or cardiac arrest secondary to sustained ventricular tachyarrhythmias (mean: 2.35 episodes) and 32 did not. All pts were given amiodarone empirically (mean dose: 390 mg) and followed-up for a mean period of 29.5 months (range 1-137). Two pts (3.8%) died of non cardiac causes, 5 (9.6%) of non sudden cardiac death and 7 (13.4%) of sudden death. Fifteen pts (28.8%) experienced non fatal arrhythmic recurrences. Four out of 7 pts who died suddenly experienced non fatal arrhythmic recurrence before death. The actuarial incidence of cardiac death was 10.8, 22.7, 31.5, 31.5% at 1, 2, 3 and 5 years; the actuarial incidence of sudden death was 8.9, 12, 22.1, 22.1% at 1, 2, 3 and 5 years; the actuarial incidence of non fatal arrhythmic recurrences was 17.4, 26.3, 26.3, 26.3, 44.7% at 1, 2, 3, 4 and 5 years. Univariate analysis identified recent myocardial infarction, NYHA functional class, detection of frequent and/or repetitive premature ventricular contractions on Holter monitoring and non fatal arrhythmic recurrences as predictors of cardiac death (p less than 0.05), while only non fatal arrhythmic recurrences were associated with sudden death (p less than 0.05). Twenty-two pts (42.3%) developed side effects. Nine (17.3%) discontinued amiodarone: 6 pts (11.5%) because of side effects and 3 inadvertently.(ABSTRACT TRUNCATED AT 250 WORDS)

[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)

[Predictive value of the ajmaline test in dysfunction of the sinus node. Prospective 4-year follow-up relative to 77 patients]. / Valore predittivo del test all'ajmalina nelle disfunzioni del nodo del seno. Follow-up prospettico di 4 anni relativo a 77 pazienti.

To establish the usefulness of Ajmaline test for the evaluation of sinus node function, 77 pts (47 M, 30 F, mean age +/- SD = 61 +/- 15 yrs) first underwent an electrophysiologic study and then were followed-up for a mean period of 46.3 months. The following parameters were determined before and after i.v. administration of Ajmaline (1 mg/kg in 1 minute): sinus cycle length (SCL), corrected sinus node recovery time (CSNRT) and sino-atrial conduction time (SACT). The pts were divided into 3 groups: Group A: 10 pts without clinical or electrocardiographic signs of sinus node dysfunction (SND) and with normal control CSNRT and SACT (less than or equal to 500 and less than or equal to 120 msec, respectively); Group B: 46 pts with clinical-electrocardiographic signs of suspected or apparently not severe SND (sinus bradycardia greater than or equal to 40 beats/min and/or syncopes with positive vagal manoeuvres) and/or slightly abnormal control CSNRT (greater than 500 less than or equal to 600 msec) and/or SACT (greater than 120 less than or equal to 150 msec); Group C: 21 pts with clinical-electrocardiographic signs of apparently severe SND (sinus bradycardia less than or equal to 39 beats/min, sino-atrial block, sinus arrest) and/or definitely prolonged control CSNRT and/or SACT (greater than 600 and greater than 150 msec, respectively). The Ajmaline test was considered negative for the presence of a severe SND if SCL was not prolonged after the administration of the drug more than 20% and CSNRT and SACT were not prolonged more than 50% compared to the control values. Otherwise the Ajmaline test was considered positive. Twenty-seven out of the 77 pts studied underwent permanent pacemaker implantation (23 immediately after the electrophysiologic study and 4 during the follow-up). The following results were obtained: the Ajmaline test was negative in 100% of group A, 87% of group B and 48% of group C pts and positive in 0% of group A, 13% of group B and 52% of group C pts; during the follow-up a negative test resulted predictive in 56 out of 60 pts (92%) and a positive test in 16 out of 17 pts (94%). The predictive accuracy of the test was, therefore, 93.5%. These results indicate that Ajmaline test is an useful provocative test for disclosing, during electrophysiologic studies, pts who have severe SND and for selecting those who need pacemaker implantation.