[Coronary angioplasty in unstable angina at rest. Influence of the degree of clinical instability on the immediate and long-term results]. / La angioplastica coronarica nella angina instabile a riposo. Influenza del grado di instabilità clinica sui risultati immediati e a distanza.

BACKGROUND: Coronary angioplasty in patients with unstable angina is associated with higher rate of complications and less favourable long term results in contrast to those patients with stable angina. OBJECTIVES: To establish whether temporary clinical stabilization of at least 48 hours prior to PTCA in patients with angina at rest carries an improvement in immediate and long term results. METHODS: A survey was carried out on 188 consecutive patients with recent onset angina at rest. Analysis included immediate results, complication rate, and 1 year follow up status. Patients were divided in 2 groups in accordance with Braunwald classification: i.e. on the basis of absence (Group II B, 90 patients) or presence (Group III B, 98 patients) of spontaneous angina at rest in the 48 hours prior of PTCA. Patients excluded were those with early postinfarction angina (15 days) and those with unstable angina following coronary restenoses after PTCA. RESULTS: The 2 groups were similar with regard to the main baseline clinical and angiographic characteristics, with the exception of intravenous administration of heparin and nitrates at the time of PTCA (47% in Group II B vs 85% in Group III B, p < 0.01) and the rate of intracoronary thrombus in the angiograms before dilatation (3% vs 15% respectively, p < 0.05). Complication rate was 2% in Group II B (2 acute myocardial infarction--AMI) and 4% in Group III B (1 death and 3 emergency By-pass operation) (p = n.s.). Clinical success was achieved in 93% of II B patients and 92% in Group III B (p = n.s.). During 12 months follow-up no significant difference in adverse events was found in either groups. There were no late deaths. Two patients in both groups experienced AMI. Thirtyone per cent of patients in Group II B and 34% in Group III B complained of recurrence of angina. The 12-months event free survival (the absence of AMI, repeat PTCA, by-pass operation and recurrence of angina) was 62% in both groups. CONCLUSIONS: In patients with unstable angina who underwent intensive pharmacological treatment including intravenous heparin and nitrates, the results of PTCA showed no negative influence of spontaneous angina which occurred in the 48 hours prior the procedure. To obtain complete clinical stabilization over a 48 hour waiting period would therefore appear to be no longer warranted.

[Basal left anterior oblique projection in 2-dimensional echocardiography: its usefulness in defects of the atrioventricular septum]. / La sezione obliqua anteriore sinistra basale in ECO 2D: utilità nei difetti del setto A-V.

The defects of the A-V septum have been recently classified into classes with separate orifices and classes with common orifice on the basis of the presence or not of a tissue tongue which joins the two bridging anterior and posterior leaflets as single differential feature. The diagnostic usefulness of the subxiphoid projection by conventionally called left oblique anterior basal has been evaluated. It indicates in a single plan-section the two bridging leaflets together with the connecting tongue. In 18 cases of defect of A-V septum echo-angiographic correlation was made. The 2D-echo diagnosed in 10 cases a defect of A-V septum with common orifice and in 8 cases a defect of A-V septum with separate orifices. On the contrary the angiocardiography pointed out in 9 cases a defect of A-V septum with separate orifices. Ten of the eighteen patients examined underwent an operation, which has always confirmed the echocardiographical diagnosis; even in the unique case of echo-angio disagreement the diagnosis of 2D-echo was confirmed. Therefore we propose the above-mentioned projection in order to obtain a more accurate non invasive definition in the defects of A-V septum.

Anomalous muscle bundle of the sub-pulmonary outflow in tetralogy of Fallot.

This case report deals with the clinicopathologic correlations in a 50-year-old man with tetralogy of Fallot, in whom the classical pulmonary stenosis by deviated infundibular septum was intensified by an anomalous muscle bundle located in the sub-pulmonary infundibulum.

[Tetralogy of Fallot. Subcostal approach in bidimensional echocardiography]. / Tetralogia di Fallot. Approccio sottocostale in ecocardiografia bidimensionale.

We have evaluated the diagnostic accuracy of subxyphoid 2-dimensional (2-D) echocardiography in Fallot's tetralogy by employing two planes defined as left anterior oblique (LAO) and right anterior oblique (RAO), similar to the respective angiographic axial projections. Echocardiographic and angiographic findings were compared in 39 patients. The pulmonary branches, the trunk, the infundibulum, the septal defect and the aorta were identified in all cases, the pulmonary valve in 97% and associated defects in 71%. The LAO view was best suited for an overall diagnosis and for the visualization of the left pulmonary branch, of the pulmonary anulus, and of the overriding of the aorta. The RAO proved optimal for the evaluation of the right pulmonary branch, of the infundibulum and of the relationship between ventricular septal defect and adjacent structures. It is concluded that the subxiphoid approach is a valuable technique for the 2-D echocardiographic evaluation of Tetralogy of Fallot.

Postoperative pathology of complete atrioventricular defects.

Necropsy data on 15 patients, who died after operations for complete atrioventricular defect (CAVD), were reviewed in order to analyze the possible determinants of death. Two infants had undergone a palliative procedure--pulmonary artery banding (Group I); three patients had had prosthetic replacement of one or both atrioventricular (AV) valves (Groups II); and the remaining 10 had had conservative repair with plastic reconstruction of the AV valves (Group III). The most notable pathological findings related to death were as follows: Group I, left ventricular hypoplasia in both infants; Group II, prosthetic dysfunction in all patients; Group III, extracardiac diseases in two-patients and cardiac lesions in six. In Group III severe pulmonary vascular obstructive disease (PVOD) was observed as an isolated finding in two patients and in combination with residual intracardiac anomalies in another two. Analysis of the incidence of PVOD demonstrated that irreversible changes may occur within the first year of life in babies with Down's syndrome, and that these changes well correlate with the calculated pulmonary vascular resistance (PVR) values. From the results of this study we have reached the following conclusions: (1) Prosthetic valve replacement has to be avoided because of a high incidence of prosthesis-related complications and the effectiveness of conservative repair; (2) residual untreated anomalies may affect the outcome of operation and should be accurately recognized and weighted preoperatively; (3) PVOD can occur in CAVD even before the first year of life and can be reliably assessed by the measurement of PVR. High degrees of PVOD frequently interfere with the surgical success, particularly when residual intracardiac anomalies are present. Therefore, we suggest that surgical correction be planned, when indicated, during the first 6 months of life.