Anatomical patterns of patent foramen ovale (PFO): do they matter for percutaneous closure?

AIM: The aim of this study was to describe and classify the various anatomical pattern of patent foramen ovale (PFO) with transesophageal echocardiography (TEE) and to relate such classification to the selection of PFO closure devices. METHODS: This study enrolled 216 PFO patients (118 females) mostly with previous cryptogenic stroke or transitory ischemic attack (TIA) who underwent percutaneous closure of PFO with deep sedation under TEE control. Anatomical patterns were classified as follows: simple: PFO characterised by central/superior eccentric shunt or with a valve mechanism (45%); reduse: widely redundant septum primum (22%); ASA: atrial septal aneurysm (11%); EASA: entire atrial septal aneurysm (1.4%); CRIB: cribriform septum primum (9%); tunnel: tunnel between septum primum and secundum >10 mm (11%). Degree of right-to-left shunt, either at basal condition or at Valsalva manoeuvre, was classified as: 1=mild (45%); 2=moderate (42%); 3=severe (13%). Additional right-atrium anatomical features are also described. RESULTS: Procedure was successful in 100% of the cases. At follow-up recurrent TIA occurred in two patients. Residual shunts were present in 4.9% of the patients after Valsalva manoeuvre. Palpitations were reported in 4%. CONCLUSIONS: Closing the PFO choosing the device following strict anatomical criteria based on TEE assessment allowed excellent immediate and late results minimizing residual shunts.

[Right ventricular heart failure in hyperthyroidism]. / Scompenso cardiaco destro in corso di ipertiroidismo.

Cardiovascular disorders in patients affected with hyperthyroidism are very common; the increase in the heart rate and in inotropism combines with a rise in the cardiac index towards which the reduction in peripheral resistances and an increase in the venous return to the heart contribute. The increase in myocardial excitabi1ity, caused above all by triiodothyronine, may be attended with atrial extrasystoles or even with atrial fibrillation. Congestive heart failure during hyperthyroidism, even if rare, may either reveal itself in association with pre-existent cardiopathy or to be precipitated by tachyar-rhythrmia, particu1arly, by paroxysmal atrial fibrillation. The case is described of a young woman affected with Graves' disease, presenting an ingravescent dyspnoea, in which sinusal tachycardia, the S1Q3 electrocardiographic figure and the echocardiographic reports of a right ventricu1ar overload with pulmonary hypertension and systemic venous congestion, suggest picture of acute pulmonary embolism. The isolated dysfunction of the right ventricle resolved quickly after an adequate antithyroid therapy. The oddness of presentation of Graves' disease in this case would suggest the execution of the thyroid profile for all patients with a primary diagnosis of heart failure, in order to single out hyperthyroid subjects with reversible myocardial dysfunction.

[Mild hypercholesterolemia. Diagnosis and prognosis]. / Ipercolesterolemia lieve. Diagnosi e prognosi.

The finding of normocholesterolaemia, characterized by plasmatic values of total cholesterol < 2 g/l, which may hide silent lipidic alterations, is not by itself sufficient to rule out the existence of cardiovascular risk. First level screening of patients exposed to atherogenic risk must begin from dosage of three basic lipidic indicators, represented by total cholesterol, triglycerides, and HDL cholesterol. By using the values of the three above-mentioned indicators and by applying Friedewald's formula, it is possible to calculate LDL cholesterol indirectly. Atherogenic risk is present when HDL cholesterol and LDL cholesterol show plasmatic concentration inferior to 0.35 g/l and superior to 1,3 g/l respectively. The European Atherosclerosis Society lists five hyperlipidaemic classes, from A to E, determined on the basis of plasmatic levels of cholesterol and triglycerides. Mild hypercolesterolaemia associated with modest atherogenic risk and which largely occurs in people and is frequently underestimated form a diagnostic point of view, contributes to cardiovascular mortality more considerably than more serious forms of hypercholesterolaemia. On the basis of this observation, there originated the programmatic proposal for the prevention of hyperlipidaemic complications, presented by the Authors.

Pharmacological activity of the new calcium antagonist, lacidipine, on isolated preparations.

1. The calcium-channel blocking activity of lacidipine has been studied compared with that of nifedipine and verapamil on the isolated rabbit heart and aorta. 2. All the compounds induced a dose-dependent negative inotropic effect (10(-8)-10(-5) M); although lacidipine showed less, but longer lasting, activity. 3. Lacidipine showed a weak negative chronotropic effect and nifedipine was ineffective. Only verapamil strongly decreased the heart rate. 4. The three calcium antagonists abolished vasopressin-induced coronary spasm and inhibited partially metoxamine-induced coronary spasm. Only lacidipine reduced basal coronary pressure. 5. In the aortic strips, all the compounds antagonized KCl-induced contractions, and they exerted a partial effect on noradrenaline- and angiotensin II-induced contractions.

[The prognosis of the patient with heart failure: an analysis of the most significant clinical and instrumental parameters]. / Prognosi del paziente con insufficienza cardiaca: analisi dei parametri clinici e strumentali più significativi.

Despite the progress of the medical and surgical therapy of cardiac failure, the prognosis of this syndrome remains severe. We studied in a group of cardiac failure patients (n = 203; 18-74 years old) admitted in our division from 1982 to 1987 the most significant clinical and instrumental parameters of prognostic importance. The clinical parameters considered were: age, sex, heart rate, blood pressure, NYHA class, presence of mitral insufficiency, episodes of acute heart failure. The instrumental parameters were: presence of complete left bundle branch block (LBBB), atrial fibrillation, episodes of ventricular tachycardia, cardiothoracic index (C/T), end-diastolic and end-systolic diameters, ejection fraction (EF). Statistical analysis was performed in order to correlate single parameters with mortality. The total survival at 5 years was 50%, being higher in patients with coronary artery disease than in patients with primary dilated cardiomyopathy. The parameters worsening the prognosis were: mitral insufficiency, III-IV NYHA class, occurrence of repeated episodes of acute heart failure in the last year, complete LBBB, C/T greater than 0.55 and EF less than 20%. In conclusion, considering instrumental parameters high risk patients are detected with a precision of 80%.

Hemodynamic advantage of combined administration of oral ibopamine and nitroprusside in patients with ischemic and idiopathic congestive cardiomyopathy.

The hemodynamic effects of combined administration of ibopamine (Ib) (150 mg orally) with nitroprusside (NP) (50-150 micrograms/min intravenously) were compared with those of NP alone in 17 patients with severe congestive heart failure due to coronary artery disease (7 patients) or idiopathic cardiomyopathy (10 patients). Hemodynamic measurements were obtained using a Swan-Ganz thermodilution catheter and a bedside thermodilution cardiac output computer. Nitroprusside alone produced a significant decrease (-12.4%) in mean arterial pressure, mean pulmonary arterial pressure (-28.3%), and systemic vascular resistance (-22.6%), and a significant increase in stroke volume index (23.1%). The administration of combined NP and Ib produced a further significant increase of stroke volume index (20.1%) with a concomitant and significant reduction of systemic vascular resistance (-19.4%); heart rate, mean systemic and pulmonary arterial pressures did not change significantly from the values observed with NP alone. Moreover, stroke work index, although not significantly modified with the vasodilator alone, was significantly increased over control values with NP + Ib association. Although NP alone induced similar effects in both the ischemic and idiopathic cardiomyopathies, the association of Ib gave a more favorable, though not significant, hemodynamic response in the subjects with primitive cardiomyopathy than in the ischemic ones. Thus, the association of Ib to NP therapy, in patients with congestive heart failure, further increases stroke volume index and stroke work index with a concomitant reduction of systemic vascular resistance, without any significant change in mean systemic and pulmonary arterial pressures, or heart rate. These results point out the possibility of associating Ib with other orally active vasodilators in the chronic treatment of congestive heart failure.

Hemodynamic effects of ibopamine in patients with idiopathic congestive cardiomyopathy.

We administered 150 mg of ibopamine orally to 10 patients suffering from idiopathic congestive cardiomyopathy. Hemodynamic function was evaluated by right heart catheterization and by measurement of cardiac output with the thermodilution technique. Ibopamine caused no significant change in heart rate or mean arterial pressure. Cardiac index, stroke volume index, and left ventricular work index all increased significantly by about 30%. Mean pulmonary arterial pressure decreased by about 30%, and systemic vascular resistance decreased by about 20%. The effects peaked at about 3 h and lasted 5-7 h. No side effects were noted. These findings with invasive techniques confirm those of others using noninvasive techniques, and suggest that ibopamine may be useful in the treatment of congestive heart failure.

[Effectiveness and duration of action of nifedipine in effort angina (author's transl)]. / Efficacia e durata d'azione della nifedipina nell'angor da sforzo. Somministrazione acuta.

The anti-anginal activity of nifedipine was studied after a dosage of 10 and 20 mg in nine patients suffering from a typical, stable effort angina pectoris. The effectiveness and the duration of action of nifedipine was evaluated by serial cycloergometer exercise testing repeated after the administration of the two dosage of nifedipine, for six hours. Nifedipine significantly increased exercise tolerance before angina pectoris, with an action lasting at least two hours after 10 mg and six hours after 20 mg. We also evaluated the changing of hemodynamic parameters (heart rate, blood pressure, double product) before and after the drug in the same day.

Cardiovascular effects induced by the injection of a new nonionic contrast medium (Iopamidol): experimental study in dogs.

The hemodynamic effects induced by the injection in the pulmonary artery of the new nonionic water soluble contrast medium Iopamidol were compared with those obtained by the injection of two other currently used contrast media (meglumine diatrizoate and sodium iothalamate). The experiments were carried out in nine mongrel dogs. Hemodynamic variables were continuously measured prior to, during, and for 8 minutes after injection of the contrast media. Injections of iopamidol produced significantly smaller decreases in aortic pressure (p less than 0.01), contractile indices (p less than 0.01), and peripheral resistances (p less than 0.01), and changes in heart rate and in cardiac output were less pronounced. At 3-4 minutes after injection, an increase in Vmaxd was observed with all three contrast media, but it was significantly lower after injecting Iopamidol. The role of hyperosmolality in causing cardiovascular changes is discussed. The less significant changes induced by Iopamidol appear to be the result of its lower osmolality, which is about a third that of meglumine diatrizoate or sodium iothalamate.