Pericardial drainage for pericardial tamponade: surgical management criteria.

Aim of this study is the review of our experience in 82 patients treated by pericardial drainage for cardiac tamponade, to assess the efficacy and safety of different techniques and the related indications. The causes of pericardial effusion were: malignancy in 8 patients (9.7%), post-cardiac surgery in 12 (14.6%), while the others patients were admitted at our Institution with no identified preoperative diagnosis. Thirty-eight patients (46%) underwent subxiphoid pericardial drainage and 44 (54%) were operated on by catheter pericardiocentesis. There were no perioperative deaths. Two patients, who initially underwent pericardiocentesis, needed urgent sternotomy: the first patient developed a severe hypotension and bradicardia related to a vagal reaction and the other one because of accidental right ventricle puncture. Our experience indicates that subxiphoid pericardiocentesis provides expeditious, effective and durable treatment, with low morbidity, in case of pericardial effusions related to all causes. We believe that echocardiography is a powerful tool in the diagnosis and management of pericardial effusion. We conclude that pericardiocentesis seems to be the procedure of choice for patients with pericardial tamponade requiring an emergency treatment.

Isolated and preclinical impairment of left ventricular filling in insulin-dependent and non-insulin-dependent diabetic patients.

BACKGROUND: Diabetes mellitus can induce a pattern of myocardial pathology known as specific diabetic cardiomyopathy, even if this is not clearly specified. HYPOTHESIS: The aim of our study was to evaluate the presence of preclinical myocardial damage in insulin- and non-insulin-dependent diabetic patients and controls by assessment with Doppler echocardiography. METHODS: Twenty insulin-dependent diabetic (IDDM) patients, 10 non-insulin-dependent diabetic (NIDDM) patients, and 12 healthy individuals (C) as controls, matched for age, gender, and without overt cardiovascular disease, were assessed in this study. RESULTS: Systolic function parameters presented normal values in the three groups, with the exception of a slight reduction in ventricular volume indices in the NIDDM group. Diastolic function was clearly impaired in both groups of patients versus that in healthy controls. In particular, ventricular filling was impaired in the NIDDM compared with the IDDM patients, especially the peak early filling rate E (p < 0.001). Moreover, in the IDDM group, the duration of diabetes (p < 0.01) and glycosilated hemoglobin value (HbA1C, p < 0.02) were higher than in the NIDDM group. Multiple regression analysis showed a significant inverse correlation between HbA1C and peak late filling rate A (R2 = 0.28) in both groups of patients and a direct correlation between velocity time integral E and age, duration of diabetes, and HbA1C (R2 = 0.46). The two groups presented a small, homogeneous number of cases with initial microangiopathy and borderline autonomic neuropathy, associated with microalbuminuria. Doppler echocardiography showed an early impairment of left ventricular filling, as well as an early preclinical alteration of myocardial function in diabetic patients, especially in the NIDDM group. CONCLUSION: These early signs of cardiomyopathy could constitute a predisposing condition toward the high cardiac morbidity and mortality rate in diabetic patients.

[Doppler echocardiographic study of left ventricular function in patients with systemic lupus erythematosus]. / Studio ecocardiografico Doppler della funzione ventricolare sinistra in pazienti con lupus eritematoso sistemico.

This study was aimed at investigating abnormalities in left ventricular size and function in patients with systemic lupus erythematosus without overt cardiovascular manifestations, in order to detect a very early impairment in myocardial function. Seventeen females and 1 male with systemic lupus erythematosus of 4 to 20 year duration and without clinical evidence of heart disease were studied. Twelve healthy volunteers, matched for age, sex and quatelet index, were utilized as controls. Each patient had a two-dimensional M-mode echocardiographic and Doppler examination. In patients with systemic lupus erythematosus there was an increase in left ventricular ejection fraction (p < 0.001), a slight reduction of end-diastolic volume index and a significant decrease of end-systolic volume index (p < 0.001). In the same patients we also found prolongation of the isovolumic relaxation time (p < 0.02), a clear impairment of diastolic filling parameters. Peak E velocity was lower (p < 0.01), peak A velocity was higher (p < 0.01), with a clear lowering, of the corresponding E/A ratio (p < 0.001) in patients with systemic lupus erythematosus.

Myocardial indium-111 antimyosin uptake after uncomplicated coronary artery bypass surgery.

The prevalence of myocardial damage after coronary artery bypass grafting is related to the criteria of its evaluation. Indium-111 monoclonal antimyosin antibody scintigraphy has been shown to be highly sensitive and specific for even small areas of myocardial necrosis or injury like those of myocarditis or transplant rejection. Our purpose was to evaluate, by using this method, myocardial damage after uncomplicated coronary artery bypass grafting. Uptake of this radio tracer was evaluated after coronary artery bypass grafting in 14 informed and consenting consecutive patients without previous myocardial infarction, with no post-surgical complications and a favorable postoperative course, following coronary artery bypass grafting for stable angina pectoris. Monoclonal antimyosin antibody indium-111 74 MBq (Myoscint Centocor) was injected on the third postoperative day; planar images in the anterior, left anterior oblique 45 degrees and 70 degrees projections were obtained 24 and 48 h later and analyzed for myocardial uptake. Indium-111 antimyosin uptake was present in 10 out of 14 patients (71.4%); it was diffuse in 6 and localized in 4. The ratio of the maximal counts in the myocardium to the counts in the adjacent lung background was measured and found elevated: 1.94 +/- 0.23, higher than the normal values reported in the literature. Indium-111 antimyosin uptake was clear in a group of patients after uncomplicated coronary artery bypass grafting. No correlation was observed between indium-111 antimyosin uptake or heart to lung ratio and creatine kinase, creatine kinase isoenzyme MB, glutamic oxalacetic transferase levels, duration of cardiopulmonary bypass or aortic cross-clamp time, while elevated serum beta myosin heavy chain fragments (IRMA Pasteur) were observed (1378 +/- 238 microU/l). This study suggests that some degree of myocardial damage, though silent, is common after coronary artery bypass grafting.

Perioperative myocardial cell damage assessed by immunoradiometric assay of beta-myosin heavy chain serum levels in patients undergoing coronary bypass surgery.

In order to investigate myocardial cell damage in patients undergoing coronary bypass surgery, serum levels of cardiac myosin fragments, using monoclonal antibodies to myosin beta heavy chains, were measured in serial blood samples of 85 patients, 79 male and 6 female, 43-66 years old, after a total of 86 internal mammary artery and 137 saphenous vein graft implants. Eight patients had perioperative acute myocardial infarction (MI), detected by abnormal Q waves and a rise of CK-MB levels. After surgery, beta-myosin levels increased from post-operative day 3 and reached peak values on day 5 in patients without and in day 7 in patients with perioperative MI, in these 8 patients, myosin peak levels were greater as compared to 77 patients without perioperative MI (3452 +/- 1596 vs. 761 +/- 494; P < 0.01). There was a correlation between myosin peak levels and creatine kinase (CK) (r = 0.71; P < 0.05) and CK-MB peak levels (r = 0.74; P < 0.05) only in the patients with perioperative MI, but not in the patients without MI. There was no correlation between myosin peak levels and the times of aortic cross clamping or cardiopulmonary bypass. Peak myosin levels over 75% confidence limits of the mean were found in 23 patients; post-operative low output syndrome occurred in 10 of these 23 patients and in 7 out of 62 patients with peak myosin levels within 75% of the mean (P < 0.005). The increase in beta-myosin heavy chain serum levels observed in almost all patients undergoing coronary surgery suggests lesser perioperative damage of the contractile apparatus, which could be detected by the usual enzyme and ECG criteria. The higher prevalence of low output syndrome in patients with higher increases in myosin levels suggests more pronounced damage to the contractile apparatus in these patients. The higher myosin levels clearly indicate the presence of perioperative MI.

[Critical myocardial ischemia in systemic lupus erythematosus. Case report]. / Ischemia miocardica critica in corso di lupus eritematoso sistemico. Descrizione di un caso clinico.

We present the clinical case of a 26-year-old woman, suffering systemic lupus erythematosus for 15 years, who suddenly had coronary heart disease with angina pectoris on mild effort. Thallium 201 exercise test demonstrated clearcut anteroseptal and apical perfusion defects, whereas repeated echocardiography showed a hypokinetic anteroseptal segment; ECG also reported new Q wave in lead V4. After stronger corticosteroid and immunosuppressive treatment, angina pectoris attenuated and perfusion defects disappeared within few months. We hypothesize a coronary artery vasculitis in the course of systemic lupus erythematosus, probably associated with early coronary artery atherosclerosis.

[Radioisotope angiography in the differential diagnosis between aneurysm and pseudoaneurysm of left ventricle. Report of a case]. / L'angiografia radioisotopica nello studio discriminante tra aneurisma e pseudoaneurisma ventricolare sinistro. Descrizione di un caso.

We describe the case of a patient with large posteroinferior left ventricular aneurysm following myocardial infarction. Contrast ventriculography, Doppler echocardiography, as well as radionuclide angiography indicated a small orifice that was in communication with the ventricular cavity. These data suggested the presence of left ventricular pseudoaneurysm. Thus a short-term surgical intervention was performed, but the diagnosis was not confirmed by surgical observation; indeed the presence of a true aneurysm was demonstrated. Our study confirms the diagnostic difficulties by invasive and non invasive techniques in the precise identification of postinfarct pseudoaneurysm. This observation suggests the remarkable interest of our radionuclide ventriculographic results, not usually observed. Thus, we point out the possibilities of several nuclear cardiology imaging in the study of diagnostic problems concerning the analysis of these conditions of myocardial pathology.

[Assessment of perioperative myocardial damage based on circulating heavy chain myosin fragments]. / Valutazione del danno citomiocardico perioperatorio mediante dosaggio dei frammenti circolanti delle catene pesanti di miosina.

To evaluate myocardial damage induced by coronary bypass surgery, to construct a reference data set in postoperative patients and to ascertain the impact of perioperative myocardial infarction on myosin release from sarcolemmal membrane we serially measured levels of serum fragments of myosin heavy chains by means of monoclonal antibody immunoradiometric assay (MYOSIN IRMA ERIA Pasteur). After surgery serum levels of myosin increased from third postoperative day and peaked on seventh day. Peak myosin levels did correlate with enzymatic activities of CPK (r = 0.69; p < 0.001) and of CPK-MB (r = 0.75; p < 0.001). Six patients suffered postoperative myocardial infarction: in these patients myosin levels were significantly different from those without infarctions (3651 +/- 1569 versus 699 +/- 206 ng/ml; p < 0.01). No correlation could be demonstrated between cardiopulmonary bypass time or aortic cross clamp duration. The rise of myosin levels observed in nearly all patients suggests a minor intraoperative damage to the contractile apparatus that sometimes is diagnosed as myocardial infarction and often does not meet clinical diagnostic criteria.

[Right ventricular function before and 6 months after aortocoronary bypass. A radioisotope angiographic study]. / La funzione ventricolare destra prima e sei mesi dopo bypass aorto-coronarico. Studio angiografico radioisotopico.

The aim of the present paper is the study of the changes induced on right ventricular function after myocardial revascularization with aortocoronary bypass graft. Two-three days before and 6 months after operation gated radionuclide ventriculography has been performed in 25 patients with previous myocardial infarction (MI), anterior in 16 patients and inferior in 9. At postoperative examination, right ventricular ejection fraction (EF) was slightly but significantly reduced (p less than 0.01), while peak ejection and filling rates were unchanged. Symmetric parameters of left ventricular function did not show changes at post-operative control, except a clear-cut rise of left ventricular peak filling rate (p less than 0.05). Before operation, in patients with previous anterior MI, left ventricular EF was slightly less and right ventricular EF slightly more than in patients with previous inferior MI; after operation right ventricular EF significantly decreased (p less than 0.01) only in patients with previous anterior MI. No correlation has been demonstrated in pre- postoperative changes of the observed parameters, neither between the two groups of previous MI nor between right and left ventricular cavity. Six months after myocardial revascularization, left ventricular performance, as examined with radionuclide angiography, was practically unchanged except for improvement of diastolic function, while right ventricular performance was moderately impaired, more in patients with previous anterior MI than in those with previous inferior MI.

[Left ventricular function a short time after myocardial revascularization surgery: radioisotope angiographic study]. / La funzione ventricolare sinistra a breve termine dall'intervento di rivascolarizzazione miocardica: studio angiografico radioisotopico.

The short-term effects after coronary bypass surgery on left ventricular function were studied in 65 patients with coronary artery disease. Each patient underwent gated radionuclide left ventriculography on the second-third day before and 5-7 days after coronary bypass surgery. After surgery, global ventricular ejection fraction had a significant increase, anteroseptal wall motion was unchanged, while apical motion and mainly inferoposterior motion were significantly increased. The most important improvement of inferoposterior motion was observed in 18 patients who had complete revascularization of the previously infarcted inferior segments, while in the 11 patients with incomplete revascularization of the same area, inferoposterior motion had a slight increase. There was a slightly significant direct linear correlation between size and direction of the anteroseptal and inferoposterior motion changes. The patients were divided in subgroups related to the site and number of obstructed coronary vessels as well as of implanted grafts; the computed parameters showed similar changes in all subgroups. After surgery, peak ejection rate showed an evident increase, and time to peak reciprocally shortened. Peak filling rate, which had reduced preoperative values, was found clearly improved, with a corresponding shortening of the time to peak; these results confirmed that diastolic ventricular damage was a reversible disturbance related to myocardial ischemia. In 8 of the 65 patients, 24 hours urinary catecholamine levels showed similar values at both pre and postoperative radionuclide controls. In conclusion, the radionuclide angiography showed an evident improvement of left ventricular function during a short period following surgery, suggesting a better myocardial perfusion after revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of left main coronary stenosis. Notes on 179 consecutive patients.

The authors report the clinical haemodynamic and angiographic data and early and late postoperative results of 179 patients consecutively operated on for left main coronary artery stenosis. Operative mortality was 3.9%; incremental risk factors were identified by univariate analysis and included female sex, unstable angina pectoris and congestive heart failure. Late postoperative mortality was 4.9%. After a mean follow-up of 31 months overall survival is 91.6%; the great majority of survivors are doing well, free from anginal pain, while 16.4% of patients experience recurrent angina pectoris of lesser severity than before operation (I-II C.C.S. class) and well controlled by medical treatment alone.

Effect of mifentidine on histamine-stimulated human atrium "in vitro": comparison with ranitidine and cimetidine.

The new H2-antagonist mifentidine was tested on human atrium, in comparison with cimetidine and ranitidine, for its activity against histamine-induced inotropic effect. Mifentidine was found to be 10 times more potent than ranitidine and 100 times more potent than cimetidine. The kinetics of the three compounds are typical of a competitive antagonism and the pA2 value was of 8.60, 6.35, 5.94 for mifentidine, ranitidine and cimetidine, respectively. Our data confirm previous findings in another isolated heart preparation, namely the guinea-pig papillary muscle.

[Stenosis of the common trunk of the left coronary artery: operative indications and risks]. / Stenosi del tronco comune della coronaria sinistra: indicazioni e rischio operatorio.

39 patients with left main coronary artery stenosis (17% of all coronary patients) have been operated of myocardial revascularization from January 1982 to May 1983. 21 patients had right coronary artery occlusion; 17 had peripheral coronary artery stenosis, 3.58 bypass grafts/patient have been implanted; in 11 patients (28%) myocardial revascularization was thought incomplete. There have been 2 postoperative deaths (5.1%) and 3 myocardial infarctions (7.7%). Authors believe that in this group of patients operative risk is higher than in patients with 3 vessel disease (less than 2% in 1982) because, in sight of the poor short-term prognosis with conservative therapy, there is surgical indication even in the presence of peripheral stenosis. Frequent clinic and haemodynamic critical status of these patients worsen operative risk so that any technical fault may be lethal.