[Dilated thyrotoxic cardiomyopathy]. / Cardiomiopatia dilatativa tireotossica.

We report a case of reversible, dilated cardiomyopathy due to thyrotoxicosis, which occurred in a young male without any underlying heart disease. The patient presented a clinical picture of cardiogenic shock related to severe left ventricular dilation and dysfunction and with new-onset atrial fibrillation and very high ventricular rate. In spite of vigorous medical therapy, there was only a mild improvement of clinical and hemodynamic status and ventricular rate persisted inappropriately elevated. Subsequently, laboratory test results allowed for recognition of thyrotoxicosis (secondary to Graves's disease) and then specific thyrostatic treatment was added. There was a prompt clinical improvement and parallel, progressive reversal of left ventricular dysfunction. The patient could be converted to normal sinus rhythm and one week later was discharged in good condition. We discuss the pathophysiological mechanism for the induction of this rare form of thyrotoxic cardiomyopathy and emphasize that awareness of this possible presentation of hyperthyroidism is essential to identify patients with potentially reversible dilated cardiomyopathy.

Pseudoaneurysm of the left ventricle: a rare sequela to mitral valve endocarditis.

Pseudoaneurysms of the left ventricle are a very unusual sequela to mitral valve endocarditis. We report the case of a 62-year-old woman who developed postendocarditis submitral left-ventricular pseudoaneurysm, which was diagnosed by means of transesophageal echocardiography. The mitral valve was replaced with a prosthesis, and the mouth of the pseudoaneurysm was closed with a patch. We discuss the possible mechanism of development of this unusual sequela to mitral valve endocarditis and emphasize the diagnostic value of transesophageal echocardiography.

Single coronary artery: a case report.

We report a case of a 47-year-old woman with a previous myocardial infarction, in whom coronary angiography showed a right-type single coronary artery (arising from a single ostium in the right sinus of Valsalva) without associated obstructive lesions. We have demonstrated that the transesophageal echocardiogram was complementary to angiography in the assessment of retroaortic course of the anomalous left main coronary artery.

Aortic valve fibroelastoma: transesophageal echocardiographic diagnosis and surgical excision.

An asymptomatic 31-year-old woman was admitted for evaluation of a heart murmur accidentally discovered at a routine medical examination. A transesophageal echocardiogram disclosed an ostium secundum atrial septal defect and a small mass attached to the inner surface of the non-coronary cups of the aortic valve. The patient underwent closure of the atrial septal defect and excision of the mass without damage to the aortic valve. Hystological analysis of the mass was consistent with the diagnosis of papillary fibroelastoma. Papillary fibroelastoma is the most common of the cardiac valve tumors. It is benign, generally small and asymptomatic, but it has a definite tendency to produce serious embolic complications. Therefore, elective surgical resection is usually recommended. The tumor is most often an incidental finding at autopsy; occasionally it is recognized during life in patients evaluated for embolic events of unclear ethiology. This is one of a few cases in which the diagnosis of a completely asymptomatic fibroelastoma has been accomplished preoperatively, thus allowing a successful surgical therapy.

Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality.

BACKGROUND: A retrospective study of 444 patients undergoing urgent and emergent coronary artery bypass grafting for acute coronary insufficiency was performed to identify the risk factors for hospital death specifically associated with the clinical severity of the acute coronary insufficiency syndrome. METHODS: The patients were divided into three groups-urgent, emergent A, and emergent B-on the basis of the evolution of the clinical pattern of the acute coronary insufficiency syndrome on full medical treatment. The three categories were defined as follows: urgent (257 patients), surgical revascularization could be delayed for 24 to 36 hours after surgical consultation because of adequate control of ischemia; emergent A (127 patients), prompt myocardial revascularization was required because medical treatment achieved only transient regression of an unrelenting ischemic pattern; and emergent B (60 patients), prompt myocardial revascularization was required because the acute coronary insufficiency was entirely refractory to medical treatment. RESULTS: Mortality rates were 7.4% for the urgent group, 13.4% for the emergent A group, and 31.7% for the emergent B group. Multivariate analysis identified the following as risk factors for hospital mortality: ejection fraction (p = 0.023) and aortic cross-clamp time (p = 0.10) for the urgent group; aortic cross-clamp time (p = 0.017), ejection fraction (p = 0.03), and nonuse of blood cardioplegia (p = 0.04) for the emergent A group; and cardiogenic shock (p = 0.00), preoperative ischemic interval (p = 0.00), aortic cross-clamp time (p = 0.018), and nonuse of blood cardioplegia (p = 0.012) for the emergent B group. CONCLUSIONS: A more exact definition of patient risk can be achieved when predictive outcome models are constructed using the risk factors specifically related to each level of clinical severity of the ischemic syndrome.

Repair of a ruptured sinus of Valsalva aneurysm. Associated with annuloaortic ectasia and coarctation of the aorta in a patient with Marfan syndrome.

We report the case of a 16-year-old boy with Marfan syndrome who presented in severe congestive heart failure secondary to rupture of an aneurysm of the sinus of Valsalva into the right atrium, a condition that was aggravated by coarctation of the aorta. The patient also had a large aneurysm of the ascending aorta with the characteristics of annuloaortic ectasia. The patient underwent successful surgical correction and is asymptomatic 3 years after the repair.

[Asymptomatic left ventricular myxoma in pregnancy: echocardiographic diagnosis and surgical treatment]. / Mixoma ventricolare sinistro asintomatico in gravidanza: diagnosi ecocardiografica e terapia chirurgica.

Myxoma arising from the endocardial wall of the ventricles is rare. We describe here the case of a young woman in whom an asymptomatic left ventricular myxoma was incidentally discovered at the 35th week of pregnancy by transthoracic echocardiography. The echocardiogram revealed a huge intraventricular mass attached to the apex and prolapsing to the aortic valve during systole. On the basis of this ominous feature, the woman was promptly submitted to caesarean section and, after 10 days, to surgical removal of the mass.

[Surgical revascularization in acute coronary insufficiency: an analysis of the risk factors for hospital mortality in urgencies and emergencies]. / Rivascolarizzazione chirurgica dell'insufficienza coronarica acuta: analisi dei fattori di rischio di mortalitaà ospedaliera in urgenza ed emergenza.

OBJECTIVES: A retrospective analysis of 444 patients (Pts) with acute coronary insufficiency (A.C.I.) submitted to coronary artery bypass grafting between January '85 and December '92 was performed in order to identify incremental risk factors associated with perioperative mortality and to evaluate whether prediction of mortality can be accomplished utilizing risk models specifically linked to the severity of myocardial ischemia. METHODS: Based on clinical and ECGraphic standpoints three different groups were identified: urgent group, comprehensive of 257 Pts. in whom, because of full medically controlled ischemia, myocardial revascularization could be delayed until to 24-48 hours. Emergency-A group, comprehensive of 127 Pts with recurrent ischemia despite medical therapy, but with no signs of coronary insufficiency at the time of institution of cardiopulmonary bypass (CPB). Emergency-B group, comprehensive of 60 Pts operated on after a mean preoperative ischemic interval of 3.9 +/- 2.4 hours who presented unrelenting signs of ischemia, either persisting since the inception of the clinical picture or lasting for over 30 minutes at the time of institution of CPB; among those, 27 Pts were in cardiogenic shock. RESULTS: Mortality rate in the three groups was respectively: 7.4%, 13.4%, 31.7%. Multivariate analysis identified the following risk factors of in-hospital mortality: urgent group: aortic cross-clamping time (A.C.C.T.) (p = 0.10) and ejection fraction (E.F.) (p = 0.023). Emergency-A group: A.C.C.T. (p = 0.017), E.F. (p = 0.023) and non-use of blood cardioplegia (B.C.) (p = 0.04). Emergency-B group: cardiogenic shock (p = 0.00), preoperative ischemic interval > 6 hours (p = 0.00), A.C.C.T. (p = 0.018) and non-use of B.C. (p = 0.012). CONCLUSIONS: A useful stratification of Pts with A.C.I. in three different groups, each with its own risk model, can be obtained by means of clinical-ECGraphic criteria alone. Different prognostic weights can be attributed to the variables A.C.C.T., E.F. and non-use of B.C. depending on clinical status. A significant reduction of mortality rate in Pts with cardiogenic shock can be achieved by the utilization of individually-tailored surgical management.

[The isolated agenesis of a branch of the pulmonary artery. A case report: its diagnosis and therapy]. / Agenesia isolata di un ramo dell'arteria polmonare. Presentazione di un caso: diagnosi e terapia.

We illustrate a case of so-called right pulmonary artery agenesis, discovered in a 3-month-old baby. This kind of malformation is rarely reported in neonatal age being most often discovered in the adulthood. The patient presented with cardiac failure, cyanosis and radiological features of cardiomegaly and left side pulmonary venous congestion. The diagnosis was strongly suspected by two-dimensional echocardiography and confirmed at cardiac catheterization. The patient was successfully operated upon with connection of main pulmonary artery to hilar right pulmonary artery. To the best of our knowledge, this is the first reported case of diagnosis and effective surgical therapy of right pulmonary artery agenesis in neonatal age.

["Myocardial bridge" and "intramural LAD pathway" are not just a semantic problem]. / "Ponte miocardico" e "decorso intramurale dell'IVA" non solo un problema semantico.

The angiographic definition of "Myocardial Bridge" universally applies to signify systolic narrowing of a coronary segment by strips of myocardial tissue. The Authors report the clinical history of two patients suffering from effort angina and transient myocardial ischemia, in whom coronary angiography showed no atherosclerotic lesions, but wide systolic kinking of the left anterior descending (LAD) artery, without systolic luminal obstruction. The definition of "Intramural LAD Pathway" has been put off in place of "Myocardial Bridge", making a distinction not simply semantic but between two different angiographic and pathologic pictures. It is very likely indeed that coronary flow impairment, solely systolic in myocardial bridge, takes places mainly during diastole in Intramural LAD Pathway.

[Idiopathic dilatation of the atria: a syndrome? Description of a case of idiopathic biatrial dilatation, review of the literature and a proposal for a pathogenetic interpretation]. / La dilatazione idiopatica degli atri: una sindrome? Descrizione di un caso di dilatazione idiopatica biatriale, revisione della letteratura e proposta di interpretazione patogenetica.

Idiopathic severe dilatation of bilateral atrial and urethero-pelvic systems was found in a 53-year-old woman. Degeneration of muscle fibers without inflammation is a constant feature of idiopathic atrial enlargement. Degenerative process can extensively involve atrial wall (generalized dilatation) or can be localized (aneurysmal dilatation). In both types of lesion clinical features are related to atrial arrhythmias and to compression on atrio-ventricular valves and ventricles by the enlarged atria. Only the outcome of the atrial arrhythmias can help to distinguish between the two conditions: development of irreversible atrial standstill in generalized dilatation and definitive restoration of sinus rhythm, following surgery, in aneurysmal dilatation. In each atrium, a different rate of incidence of the two types of dilatation has been documented in the literature: as for the right atrium, more than 40 cases of generalized dilatation have been reported and only 4 of the aneurysmal type. On the other hand, isolated left atrial enlargement was of aneurysmal type in all 30 reported cases. Biatrial dilatation was generalized in 7 cases and due to multiple aneurysms in a single case. The Authors support the hypothesis that idiopathic atrial dilatation could be due to a degenerative process affecting the atrial components derived from primitive atria, in which the muscular layer is structured into pectinate muscles. They also suggest to distinguish, even from the etiopathogenetic point of view, between aneurysmal dilatation (localized and fortuitous lesion) and generalized dilatation (diffuse degeneration of pectinate muscles). This distinction could well related with the different outcome of atrial arrhythmia in the two types of dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrophysiologic effects of propafenone in subjects with pre-existing excito-conduction disorders]. / Effetti elettrofisiologici del propafenone in soggetti con pre-esistenti turbe della eccitoconduzione.

Few data are currently available regarding the electrophysiological effects of Propafenon administration in patients with pre-existing excito-conduction system disturbances. We have performed electrophysiological evaluation in 18 patients (15 males and 3 females, mean age 61 +/- 9 years - 4 patients with sinus bradycardia, 5 pts with AVN block, 4 patients with bundle branch block and normal HV and 5 patients with bundle branch block and prolonged HV) before and after intravenous administration of Propafenon (1 mg/Kg B.W. in 5 minutes). Propafenone administration decreased the heart rate, significantly lengthened AH and HV intervals, lengthened atrial, ventricular and, above all, AVN refractory periods. In no cases sinus pauses, marked bradycardia, spontaneous A-V block or additional intraventricular conduction disturbances were observed. We conclude that: due to its marked electrophysiological effects on AVN and His-Purkinje system, Propafenon is electively indicated for the treatment of ventricular arrhythmias and paroxysmal supraventricular tachycardia with AVN reentry; Propafenon intravenous administration appears to be safe also in pts with preexisting excitation and conduction disturbances.

[Mexiletine: electrophysiologic effects]. / Mexiletina: effetti elettrofisiologici.

A complete electrophysiological evaluation has been performed before and after the intravenous administration of Mexiletine (M.) (3 mg/Kg/B.W. in 5 minutes) in 28 patients (pts) (6 pts with normal conduction system, 4 pts with sick sinus syndrome, 5 pts with intranodal AV block, 13 pts with bundle branch block, of which 4 with pathological HV and 1 with intrahisian conduction defect). With the exception of a shortening of QTc interval in all the pts, the drug did not significantly affect any other electrophysiological parameters. In the patient with intrahisian conduction defect, M. prolonged the H1 - H2 interval. A statistically significant increase of heart rate has been also observed in a second group of 8 pts with normal sinus function, in whom M. administration was preceded by Atropine (I.V. bolus 0,04 mg/Kg/B.W.). This finding seems to exclude a vagolytic effect of M. The conclusions derived from our experience and pertinent literature are the following: M. is not useful in the treatment of supraventricular arrhythmias because it has negligible effects on atrial and AV nodal conduction; the drug may be safely employed in the treatment of ventricular arrhythmias in pts with atrial and/or AV nodal conduction defects; special caution must be employed when the drug is utilized in pts with sick sinus syndrome and/or with marked intraventricular conduction defects.