The tensor apparatus in double-orifice mitral valve: interpretation of echocardiographic findings.

We describe a rare case of double-orifice mitral valve discovered with echocardiography. The tensor apparatus composed of four papillary muscles and anomalous attachment of chordae tendineae represents the main findings. Two supernumerary muscles in combination with the altered chordal insertion on the central portion of the anterior mitral leaflet are responsible for the V-shaped ("seagull wing") and spectacle-like features of the mitral valve in the short-axis view. These altogether allow precise identification of this congenital malformation.

Diagnostic criteria and management of subacute ventricular free wall rupture complicating acute myocardial infarction.

In this prospective study we evaluated the value of the main diagnostic criteria for postinfarction subacute rupture of the ventricular free wall. Two-dimensional echocardiograms and recordings of right atrial pressure and waveform were immediately obtained in every patient exhibiting rapid clinical and/or hemodynamic compromise in the acute infarction setting. The same protocol was applied to patients referred from other hospitals for suspected myocardial rupture. In 28 cases a subacute free wall rupture was identified. In most of the patients the diagnosis was based on the demonstration of hemopericardium and cardiac tamponade by echocardiography, cardiac catheterization and, occasionally, by pericardiocentesis. In 2 instances, the identification of intrapericardial echo densities suggesting clots, in the absence of cardiac tamponade, allowed a diagnosis of subacute rupture. Direct, but indistinct visualization of myocardial rupture was obtained in 4 cases. Among the 28 patients with this complication, 4 died while awaiting surgery and 24 underwent surgical repair (mortality rate 33%). Long-term outcome of survivors was favorable. Various myocardial lesions underlie postinfarction subacute free wall rupture. Clinical presentation varied widely. The diagnosis was based, usually but not always, on the association of hemopericardium and signs of cardiac tamponade. An organized approach to management of this complication of acute myocardial infarction was suggested.

Comparison of impedance cardiography with thermodilution and direct Fick methods for noninvasive measurement of stroke volume and cardiac output during incremental exercise in patients with ischemic cardiomyopathy.

In the last decade, an inexpensive and simple noninvasive method (i.e., transthoracic electrical bioimpedance cardiography, has been tested in healthy subjects and patients with various heart disease for measuring stroke volume and cardiac output at rest and/or during exercise. However, the results are still controversial, especially when measurements are obtained during exercise and data on reproducibility during exercise are lacking. Twenty-five consecutive patients (20 men and 5 women, mean age 48 +/- 9 years) in sinus rhythm with documented coronary artery disease and a previous myocardial infarct were studied. Patients were divided into 2 groups. Group A had ischemic cardiomyopathy, characterized by left ventricular (LV) enlargement and LV ejection fraction depression (35 +/- 8%). Group B had normal LV dimensions and ejection fraction (62 +/- 9%). After a familiarization study, all patients underwent an exercise test with gas exchange analysis and hemodynamic measurements. Stroke volume and cardiac output were simultaneously obtained at rest and at the end of each work rate stage with 3 methods: impedance, thermodilution, and direct Fick. Group A reached a lower peak oxygen uptake (56%), peak work load (60%), and peak systolic blood pressure (69%) than group B. Cardiac output and stroke volume were significantly greater at submaximal and peak exercise in group B than in group A (p < 0.0001). There were no significant differences in stroke volume and cardiac output in the 3 techniques at any matched work rate. There was no significant difference between measurements obtained by 2 experienced observers or between those obtained on 2 exercise tests performed on 2 different days. These results demonstrate that impedance cardiography is a noninvasive, simple, accurate, and reproducible method of measurement of cardiac output and stroke volume over a wide range of workloads.

[Treatment of recurrent supraventricular tachyarrhythmias with flecainide or a flecainide and amiodarone combination]. / Trattamento delle tachiaritmie sopraventricolari ricorrenti mediante flecainide o associazione di flecainide ed amiodarone.

The acute electrophysiologic effects and therapeutic efficacy of intravenous and oral flecainide were assessed in 18 patients with recurrent supraventricular tachyarrhythmias, resistant to conventional antiarrhythmic agents. They were 22 to 76 years old (mean 50). Twelve patients underwent electrophysiologic study for the investigation of tachyarrhythmias. Of the whole four patients had functional longitudinal AH dissociation (dual AV pathways). These patients had provocable intra-AV nodal reentrant tachycardia (Group I). Six patients had a direct accessory AV pathway, that showed bidirectional conduction in 5 and retrograde conduction alone in 1 (Group II). These patients had provocable atrioventricular reentrant tachycardia using the accessory pathway as the retrograde limb of the tachycardia circuit. Two patients suffered from automatic supraventricular tachycardia (Group III). Group IV included patients with paroxysmal atrial flutter or fibrillation. The patients of this group did not discontinue chronic treatment with amiodarone. After baseline electrophysiologic evaluation, intravenous flecainide (2 mg/Kg body weight over 5 minutes) was given to patients of I and II group during induced reentrant tachycardia. Flecainide was administered to other patients during spontaneous episodes of tachyarrhythmias. Flecainide resulted in tachycardia termination in all patients of group I and in 4 patients of group II (66%). Tachycardia termination was due to block in the retrograde limb of the circuit. Before termination tachycardia cycle length increased significantly, mainly as the result of an increase in ventriculo-atrial conduction time. After intravenous flecainide therapy, reentrant SVT was non inducible in the patients of group I and in 4 patients of group II. Flecainide was successful in the acute termination of 100% of automatic supraventricular tachycardia and 75% of fibrillation. The patients with atrial flutter developed a faster ventricular rate.(ABSTRACT TRUNCATED AT 250 WORDS)

The diisobutyryl ester of N-methyldopamine, ibopamine: evaluation of electrophysiological properties and arrhythmogenicity studies.

The electrophysiological properties of ibopamine (SB-7505), the 3,4-diisobutyryl ester N-methyldopamine, was evaluated in 8 patients with syncopes of unknown etiology or with suspected disease of the sinus node or due to I-II degree AV block. A complete electrophysiological examination, including atrial and ventricular stimulation, was performed both in baseline conditions and within 1 h after oral administration of ibopamine 200 mg in a single dose. The study showed a slight reduction in effective refractory periods in the right atrium (-4.26%), the atrio-ventricular node (-6.45%) and the right ventricle (-6.79%) after ibopamine. Ibopamine was not found to facilitate the occurrence of atrial and/or ventricular arrhythmias. A 24-h dynamic Holter ECG performed in baseline conditions and during administration of ibopamine 200 mg t.i.d. showed no changes in baseline heart rate, nor was any increase in the number of atrial or ventricular extrasystoles detectable. It may therefore be concluded that ibopamine, when administered at the above dosages to the patients studied, does not modify heart rate or sinus function parameters to a statistically significant extent. It also reduces effective refractory periods in the right atrium, in the atrioventricular node and in the right ventricle without inducing or facilitating the occurrence of atrial or ventricular arrhythmias.

Monitored long-term treatment with ibopamine in patients suffering from severe congestive heart failure.

50 patients with congestive heart failure underwent monitored long-term treatment aimed at evaluating the effect of ibopamine (SB-7505), the 3,4-diisobutyryl ester of N-methyldopamine, on their condition. Ibopamine was administered alone or in combination with traditional therapy mainly at a dose of 100 mg t.i.d. Clinical scores and NYHA (New York Heart Association) functional classes improved. Biochemical parameters showed no adverse modifications. Mild transient side-effects probably related to ibopamine occurred in two patients.

[Echocardiographic and clinical correlations in infectious endocarditis of the left heart]. / Correlazioni ecocardiografiche e cliniche nella endocardite infettiva del cuore sinistro.

UNLABELLED: The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. CONCLUSIONS: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of the anti-arrhythmic effects of propafenone and aprindine in the treatment of refractory chronic ventricular arrhythmias. A randomized double-blind crossover study controlled with placebo]. / Confronto tra l'efficacia antiaritmica del propafenone e dell'aprindina nel trattamento di aritmie ventricolari croniche resistenti. Studio randomizzato crossover, a doppio cieco, controllato con placebo.

A placebo-controlled, randomized, double-blind, crossover study was performed in 14 patients with chronic, resistant, ventricular arrhythmias in order to evaluate the efficacy and safety of two new antiarrhythmic agents, propafenone and aprindine. After an initial placebo phase, patients received orally either propafenone (600 mg daily) or aprindine (150 mg daily for the first two days and 50 mg every 12 hours successively) for five days. This treatment was followed by a drug-free period (placebo II); patients were then crossed over to the alternative drug. A 24-hour Holter recording was performed during the last 48 hours of the initial placebo phase and on the final day of each phase of the crossover period. Analysis of Holter recordings revealed that the mean hourly PVCs frequency, for the group, was similar during the two control periods. Significant reduction in the mean hourly frequency of PVCs from control levels was observed in 78% of the patients during propafenone therapy and in 42% during aprindine therapy. For the whole group, propafenone induced a significant reduction of the average PVCs/h frequency (p less than 0.05), whereas the aprindine was ineffective. Finally no patient experienced side effects with propafenone, whereas aprindine caused side effects in three patients (dizziness, tremor, ataxy).

[Comparison of various indirect methods for evaluation of sinus function]. / Comparaison de différentes méthodes indirectes d'évaluation de la fonction sinusale.

Sinus node function was evaluated by Mandel, Strauss and Narula's methods in 60 consecutive patients: 20 females, 40 males; average age 59 +/- 17 years. Three had second degree sinoatrial block, 2 had bradycardia-tachycardia syndromes and 10 had sinus bradycardia. The corrected sinus node recovery time was 414 +/- 417 ms. It exceeded 520 ms in 8 cases, 5 where the two other methods confirmed sinus node dysfunction, 1 where the two other methods showed no abnormality. In the last two patients pathological results with Narula's method coincided with normal values with Strauss' method but the basal sinus cycle and the post return cycle differed from one method to the other. The atriosinoatrial conduction time estimated by Narula's method was 274 +/- 117 ms. In the thirteen cases where it exceeded 300 ms abnormal results were also recorded with Strauss' (11 cases) and/or Mandel's method (7 cases). The atriosinoatrial conduction time assessed by Strauss' method was 239 +/- 106 ms. It exceeded 300 ms in 18 patients. In these patients the results of Narula and Mandel's methods were normal in 7 cases. This discordance cannot be explained either by variations in the catheter position, or by the duration of the basal sinus or the post return cycles. This raises the question of penetration of the sinus node by the last stimulus when Narula's technique is used. A significant linear correlation was observed between the atriosinoatrial conduction time assessed by Narula's method and the atriosinoatrial time assessed by Strauss' method (N = 60; r = 0,59) and with the corrected sinus node recovery time (N = 60; r = 0,43) and a double linear correlation was found with these two parameters (N = 60; r = 0,62). There was no significant linear correlation between the atriosinoatrial conduction time assessed by Strauss' method and the corrected sinus node recovery time (N = 60; r = 0,27). The atriosinoatrial conduction time evaluated by Narula's method seems to be intermediary between the two other parameters which seem to be independent of each other.

[Echocardiographic diagnosis of aneurysm of Valsalva's sinus with fistulization into the right atrium]. / Diagnosi ecocardiografica dell'aneurisma del seno di Valsalva fistolizzato in atrio destro.

The preoperative diagnosis of an aneurysm of the posterior sinus of Valsalva with rupture into the right atrium was made by echocardiography in a 21-year-old patient. The M-mode echocardiography revealed the following findings: 1) a vibrating anomalous structure, continuous with the aortic wall, was present in the right atrium. The echo-producing mass was the wall of the aneurysm, which adhered to the septal leaflet of the tricuspid valve during early-to-mid systole and had an abrupt posterior motion in late systole. In diastole, the wall of the aneurysm descended into the tricuspid orifice and its motion was similar to that of the septal leaflet of the tricuspid valve; 2) an echocardiographic sweep from the aorta to the left ventricle showed that the posterior wall of the aorta "crossed" the mitral orifice; 3) the pulmonic and tricuspid valves were normal. The 2-D echocardiographic findings gave support to the M-mode diagnosis: 1) in the short-axis view (at the level of the aorta) two lines of echoes came off the right side of the aortic wall and invaded the right atrium. These echoes were produced by the walls of the aneurysm; 2) in the apical four-chamber view the aneurysm descended into the tricuspid orifice in diastole, whereas it was lifted by the septal leaflet of the tricuspid valve in systole. The aneurysm appeared as vibrating lump on the closed tricuspid valve. Recognition of these features provides a potential non-invasive way to diagnose this anomaly. To our knowledge this is the first description of the characteristic echocardiografic picture of an aneurysm of the sinus of Valsalva with rupture into the right atrium.

[Aneurysm of the membranous septum associated with interventricular patency. Echocardiographic study]. / Aneurisma del setto membranoso associato a pervieta' interventricolare. Studio ecocardiografico.

It has been documented by others that spontaneous closure or diminution in size of membranous ventricular septal defect is often associated with aneurysmal formation of the membranous septum. In a series of 51 patients, who underwent cardiac catheterization and cineangiocardiography for evaluation of the severity of a ventricular septal defect, 7 patients showed an aneurysm of the membranous interventricular septum (VSA) associated with a small ventricular septal defect (VSD). M-mode echocardiography was useful in the detection of VSA in 6 of them. Echocardiographic findings were not uniform in all cases. In most instances they consisted of linear echoes, that seemed to come off from the base of the interventricular septum and to protrude within the right ventricle in systole; the echoes from the VSA showed a coarse fluttering. Even if errors can be minimized by a correct technique, anomalous echoes from the VSA might however be confused with those of other anatomical structures (aortic root, tricuspid valve, etc.). M-mode echocardiography seems to be useful for the followup of patients with membranous VSD. The detection of VSA by ultrasonic means should suggest a good prognosis for VSD, possibly avoiding the need for repeat invasive studies.

[Congestive heart failure in genetic hypertrophic cardiomyopathies (ASH) (author's transl)]. / Lo scompenso cardiaco nelle cardiomiopatie ipertrofiche di natura genetica (ASH).

Of a total sixtytwo patients covering all the spectrum of genetic ASH, who were studied by heart catheterization, M-mode echocardiography and phonomechano cardiography, five patients (four with the obstructive variety of the disease) showed clinical evidence of chronic congestive heart failure with ankle edema and hepatomegaly (group I). Their data were compared with those of fifteen "obstructed" patients who were not in heart decompensation (group II). No statistically significant differences were found between groups I and II in terms of L.V. internal transverse dimensions and in terms of L.V. systolic function. Conversely a statistically significant difference was found between the two groups in terms of left atrial and right ventricular dimensions (P less than 0,001), which were markedly increased in groups I. These findings strongly suggest that in patients with ASH and congestive heart failure there is a reduction in L.V. compliance (or distensibility), whereas L.V. systolic function is essentially preserved. The persistence of severe L.V. outflow obstruction in four patients of I group gives further confirmation to these observations. The use of beta-blockers (in association or not with cardiac glycosides) seems therefore to preserve its validity in the treatment of patients with ASH and heart failure, particulary when severe L.V. outflow obstruction is present. Cardiac glycosides are indicated in the forms with little or no obstruction to L.V. ejection.

[The tricuspid valve prolapse. Clinical significance and diagnostic problems (author's transl)]. / Il prolasso della valvola tricuspide. Significato clinico e problemi diagnostici.

Systolic prolapse of the tricuspid valve is a relatively unknown anatomo-clinical entity. In this communication etiology, clinical significance and diagnostic problems of this condition are reported and discussed. The frequent association with mitral valve prolapse and the coexistence of skeletal and cardiac anomalies strongly suggest the role of congenital factors and the degenerative nature of this valvular abnormality. Pathophysiology of leaflets prolapse remains unexplained for those few reported cases of isolated tricuspid invovlement. The clinical diagnosis of tricuspid valve prolapse is difficult, since the characteristic physical signs of tricuspid incompetence are uncommon, while apical mid-systolic click-late systolic murmur may indicate mitral valve prolapse, tricuspid valve prolapse, or a combination of the two. In the reported cases selective right ventriculography (R.A.O.) has shown pansystolic or late systolic prolapse of anterior and inferior leaflets (without or with varying degree of tricuspid incompetence) or isolated late systolic prolapse of the inferior cusp. M-mode echocardiography has shown great value in the diagnosis of tricuspid valve prolapse. On the echocardiogram several types of abnormalities have been noted which correlated well to angiocardiographic data. Tricuspid valve prolapse is of clinical importance, since this condition may be associated with significant tricuspid incompetence, a high incidence of cardiac arrhythmias, and possibly with bacterial endocarditis.

[Echocardiographic patterns of congenital aneurysm of the sinus of Valsalva. Review of literature and report of three cases (author's transl)]. / Aspetti ecocardiografici dell'aneurisma congenito del seno di Valsalva. Rassegna della letteratura e descrizione di 3 casi.

The (M-mode) echocardiographic patterns of three patients with congenital aneurysm of the right sinus of Valsalva are reported. In two patients the aneurysm ruptured into the right ventricular cavity. In the third case, in which the lesion was associated with coarctation of the aorta, no communication was shown between the aorta and other cardiac chambers. The characteristic echocardiographic features of the right coronary sinus aneurysm (either with or without rupture in the right ventricular cavity) consist of: 1) The presence of echoes (referable to the right aortic cusp pattern of motion) encroaching the right ventricular outflow tract. 2) The presence of the same box-shaped echoes at a low level of the left ventricular cavity, which seem to "cross" the septum (from the left to the right ventricular outflow tract). These images would reflect the "prolapse" of the affected cusp. Other common, but non-specific echocardiographic features of the lesion are: an indistinct contour of the anterior wall of the aortic root (probably due to dilatation of the right coronary sinus) and systolic indentations on the right anterior aortic cusp echoes.