[Integrated clinical record: unique document for diverse uses]. / Cartella clinica integrata: documento unico per competenze diverse.

Technological and scientific development and changes in the health system have led to modifications and greater complexity in health documents and clinical records, without there being at the same time definition of guidelines on their correct compilation and formulation. The present study was designed to develop a single Integrated Clinical Record that combines, on the one hand, data of all medical, nursing and technical interventions and, on the other, involves the patient in all decisional processes of diagnosis and treatment during the hospitalization period. All phases of the project related to development of the Integrated Clinical Record are discussed. The data of 240 new clinical records regarding patients admitted consecutively over a period of 6 months are reported. The results show a progressive reduction of compilation errors and an improved management of the patient's clinical course. The innovative aspects of the new clinical record are discussed, with particular reference to the system of quality management, within which context the clinical record has to function, and to the modalities of check, audit and improvement.

[Cardiac echinococcosis: 2 cases treated surgically]. / Echinococcosi cardiaca: due casi trattati chirurgicamente.

Cardiac hydatid disease represents 0.02-2% of the possible locations of the parasite. In these last few years we have seen an increase in the percentage of cardiac hydatid disease treated with surgery. The Authors report on two patients who underwent surgery for the excision of cardiac hydatid cysts. The Authors agree that in spite of the rarity of cardiac hydatid disease it should be investigated routinely by two-dimensional echocardiography in the presence of hepatic or pulmonary hydatid disease in order to prevent the possible spread of the parasite throughout the body.

[Echography in aneurysm of the interatrial septum]. / L'ecocardiografia nell'aneurisma del setto interatriale.

Atrial septal aneurysm can be detected by subcostal echocardiography as a bulge of the intermediate interatrial septum, ballooning toward the right atrium. We retrospectively revised 5412 echo examinations, consecutively performed in our laboratory, and we found 14 cases of atrial septal aneurysm (0.26%), mean age 36 +/- 15 years, 9 males and 5 females. In 7 patients atrial septal aneurysm was wide, including the whole atrial septum; in 5, only cranial two-thirds of the septum were involved and in 2, it regarded only the intermediate septum. No patients referred to arrhythmias, syncope, embolism, endocarditis or transient ischemic neurologic disorders. Cardiac abnormalities or defects were associated to atrial septal aneurysm in 12/14 patients: they consisted of atrial septal defect, mitral valve prolapse, false ventricular tendons or persistent Chiari network. Atrial left-to-right shunt was detected in all 6 cases with atrial communication. Considering each single associated cardiac abnormality, the prevalence of atrial septal aneurysm was 7% in patients with atrial septal defect, 1.7% in those with mitral valve prolapse, 6.6% in persistent Chiari network and 0.9% in false ventricular tendons. In conclusion, echocardiography is the first-choice technique to detect atrial septal aneurysm and other related cardiac defects.

Echocardiographic evaluation of right heart responses to sublingual nifedipine in dilated cardiomyopathy.

Twelve patients with dilated cardiomyopathy were studied in order to evaluate whether the favourable effect of Nifedipine on the right heart is due to a direct action of the drug on pulmonary resistances or is related to an improvement of left ventricular function. Echocardiographic examination of left and right heart was performed at basic conditions, after Nifedipine treatment--20 mg sublingually--and after 20 minutes of oxygen breathing (FiO2 75%). This was done in order to verify if oxygen vasodilating action could potentiate the Nifedipine effect. Echocardiographic date were obtained in basic conditions, 10, 20 and 30 minutes after Nifedipine and immediately after oxygen breathing. Ten normal subjects were used for comparison for basic data. Peak Nifedipine activity was observed 10 minutes after administration. At this time inferior vena cava emptying index and systolic pulsation were significantly increased, whereas left and right ventricle isometric contraction time, left and right ventricle ejection time, left and right ventricle isovolumetric relaxation time, end-diastolic left ventricular diameter, inferior vena cava diameters and systolic blood pressure had decreased, thus showing the favourable effect of Nifedipine of both heart sides. Heart rate did not significantly change. Oxygen inhalation induced a significant decrease of right ventricular isovolumetric relaxation and an increase of the inferior vena cava indexes, suggesting an improvement in right heart function, without any change in other parameters. No significant difference was found between data after-oxygen and data obtained 10' after Nifedipine, showing that the Nifedipine effect was not potentiated by oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anomalous bands of the left ventricle. Study with echocardiography and Doppler ultrasound]. / Bandas anómalas del ventrículo izquierdo. Estudio con ecocardiografía y Doppler.

Of a total of 3654 echocardiographic and Doppler studies, found 95 left ventricular bands. We described the different Echo-patterns. Color-flow Doppler mapping demonstrated normal left ventricular inflow and outflow, and also lack of turbulence around the band. We conclude left ventricular bands are an abnormal but not Pathological finding.

[Echocardiographic aspects of false intraventricular tendons]. / Aspetti ecocardiografici dei falsi tendini intraventricolari.

A series of 4260 consecutive echocardiographic examinations, performed in 5 Cardiological Centers was examined, identifying 125 intraventricular false tendons (FTs) in 100 cases (55 normals and 45 with heart disease) of whom 31 were female and 69 male, aged 3 to 82 years. An anatomo-morphological study was possible in 9 cases, dead for stroke or heart failure, on autopsy, and in 7, on heart surgery. A phonocardiogram was performed in all normals and in 20 patients. On echocardiography, FTs appeared as an echo-producing string-like structure, straight between the septum and the ventricular free wall, mobile during the cardiac cycle, without systolic thickening and any relation with the atrioventricular valvular apparatus. The prevalence of FTs was 2.3%; it was 3.2% to 5.3% in younger people. FTs were located in the right ventricle (4 cases), left ventricle (95 cases) or in both (1 case). Their site was left apical (45 FTs), right apical (2 FTs), right (3 FTs) and left (20 FTs), upper septum-to-free wall (55 cases). In 1 case hypertrophy of trabeculae of the left ventricle was detected. FTs were single (79 cases), double (19 cases), multiple (2 cases), short (42 cases), long (58 cases), thick (45 cases) and thin (55 cases). They showed a membrane-like motion (thick FTs-45 cases) and a valve-like motion (thin FTs-55 cases). Innocent murmur was detected in 50 of 55 normals and related to thin FTs. Of 16 cases examined anatomically and histologically, FTs were fibrous in their distal portion and fibro-muscular in the proximal one in 12 cases, whereas they were entirely fibrous-muscular in 4 cases. The site and location of FTs detected by echo were confirmed by anatomy in all cases. In 4 cases other 9 FTs, not detected on echocardiography, were found. These data suggest that echocardiography is a useful tool to detect intraventricular FTs and differentiate them from other echo-producing structures. Although a relationship between FTs and heart disease has not been found, their presence could be responsible of innocent murmur in many normal subjects.

Echocardiographic evaluation of inferior vena cava wall motion and pulmonary flow velocity responses to sublingual nifedipine.

Echocardiographic and cardiac catheterization were used to test the effect of Nifedipine, sublingually administered, on the right heart function and pulmonary flow velocity and pressure in 25 cases. Systolic and mean pulmonary pressure, wedge pressure, mean right atrial and ventricular end-diastolic pressure, aortic pressure, and total pulmonary resistance decreased after Nifedipine in 10 patients who underwent diagnostic cardiac catheterization. While pulmonary flow velocity, expressed as the slope of the contrast echo lines on the pulmonary valve, increased as a mean value after Nifedipine, it showed different behaviour in single cases and thus failed to provide any reliable conclusion as to the effect of Nifedipine. Nifedipine slightly reduced the internal diameters of the inferior vena cava and significantly increased the values of collapsibility and emptying indexes and pulsation. The results confirm the beneficial effect of Nifedipine on right heart function and pulmonary bed. In addition, echocardiography is seen to be a valuable and reliable non-invasive means of testing the acute and chronic effects of either Nifedipine or other drugs on the right heart sections.

Echocardiographic assessment of the inferior vena cava wall motion for studies of right heart dynamics and function.

Using subcostal echocardiography, 97 patients with diseases involving the right side of the heart and 15 normal subjects were examined in order to study the inferior vena cava (IVC) wall motion. All cases had a diagnostic cardiac catheterization and routine echocardiogram. The jugular pulse (JP) was recorded in 35 random cases contemporary to the IVC and tricuspid valve (TV) tracings. The aim of the study was to evaluate the variations of the IVC diameters in different cardiopathies and in relation to the right atrial mean pressure and the time-relationship of the IVC wall motion related to the cardiac rhythm and cycle, respiratory events, and JP and TV waves. The a, b, v, and y waves were identified on the IVC tracings and related to the respective waves of the JP and the points of closure and opening of the TV. The IVC a and v waves were coincident with the TV closure and opening, and therefore, considered as moments of maximal presystolic and systolic filling of the IVC. The JP a wave inscribed before, whereas the v wave did so after the same IVC waves, respectively. The IVC a wave was due to the atrial contraction and influenced by the cardiac rhythm. The emptying index (EI) was calculated from the diameters in a and b as a - b/a X %, whereas the collapsability index (CI) was calculated from the expiratory and inspiratory diameters as Ex - In/Ex X %, obtaining a good correlation with the right atrial mean pressure. Finally, the percentage systolic pulsation (SP) was calculated from the diameters in b and v as b - v/b X %. The indices of function of the IVC have been very useful in the evaluation of patients with raised heart pressure, tricuspid regurgitation, and pericardial effusion. From the present investigation it results that the IVC wall motion, more so than the JP waves, is an expression of right atrial and ventricular events, and that the above indices are an expression of the atrial and ventricular function in relation to the hemodynamic situation.

Detection of atrial septal defect with left-to-right shunt by inferior vena cava contrast echocardiography.

Contrast echocardiography was used before cardiac catheterisation in 37 patients with atrial septal defect and a left-to-right shunt and in 18 patients with a raised right atrial and ventricular pressure to assess the contrast echo effect in the inferior vena cava. Using two dimensional contrast apical echocardiography we found a negative contrast echo effect within the right atrium in many but not all patients with atrial defect. Contrast echoes entering the inferior vena cava during presystole or early to mid-diastole were detected in patients with heart disease causing raised right atrial and ventricular pressures and also in all patients with atrial septal defect. No contrast echo effect in the inferior vena cava was detected in 10 normal subjects. The sensitivity of this contrast pattern in the inferior vena cava in diagnosing atrial septal defect was 100%. When other conditions causing raised right atrial pressure were excluded, the specificity and predictive accuracy were 100% for both. The presystolic contrast echo effect in the inferior vena cava, semiquantitatively graded, correlated with the size of the shunt determined by oximetry. In 20 patients re-examined after the surgical correction of the atrial septal defect, no presystolic contrast echo effect was detected in the inferior vena cava. Contrast echocardiography of the inferior vena cava is a valuable and reliable method for diagnosing atrial septal defect with left-to-right shunt.

An unusual case of congenital double coronary arteriovenous fistula.

A double coronary arteriovenous fistula (CAVF) was observed in a ten-year-old girl. A large, tortuous, and elongated right coronary artery, communicating with the right ventricle, was detected by two-dimensional echocardiography and confirmed at angiography. To our knowledge, no echocardiographic recognition of the origin and termination of a CAVF has been reported previously. Moreover, another fistula, connecting the left anterior descending coronary artery with the main pulmonary artery was also detected by selective left coronary arteriography. The anatomy of double CAVF was confirmed on surgery. A right CAVF draining into the right ventricle and a left CAVF draining into the main pulmonary artery seemed to be a very unusual combination.

Echocardiographic assessment of left ventricular wall motion in hypertrophic cardiomyopathy.

M-mode and two-dimensional parasternal long axis view echocardiography, and left anterior oblique cineangiography were employed to assess the left ventricular wall motion in 10 normal subjects (N) and in 25 patients with hypertrophic cardiomyopathy: 7 patients with symmetric hypertrophy (SH) and 6 patients with apical cardiomyopathy (AHCM) and no intraventricular gradient; 12 patients with hypertrophic obstructive cardiomyopathy and asymmetric septal hypertrophy with resting intraventricular gradient (6 pts) (HOCM-R) or gradient occurring only after isoproterenol infusion (6 pts) (HOCM-I). The left ventricle was divided into five portions: upper and lower septum, upper and lower posterior wall and apex. The excursion and thickness of the upper and lower portions of the septum and posterior wall were measured in all patients and compared to 10 normal subjects (N). From the superimposed end-diastolic and end-systolic echo frames and angio silhouettes a chordal and a radial-chordal method were used, respectively, to measure the motion of the left ventricular wall segments. In SH the left ventricular wall motion was qualitatively similar to N but a little reduced; the thickness was increased and no pressure gradient was present. In AHCM the lower septum, posterior wall, and apex showed significantly increased thickness and motion compared to N and compared to the upper portions of the septum and posterior wall. No gradient was present. In HOCM-R the upper septum moved towards the apex, the lower septum, upper posterior wall and lower posterior wall moved towards the left ventricular cavity. The upper posterior wall was hyperkinetic compared to N and compared to the lower posterior wall, resting gradient and SAM was present in all. In HOCM-I the upper septum moved towards the apex; the posterior wall was hyperkinetic (the excursion was a little wider in the lower posterior wall than in the upper posterior wall). No gradient was recorded at rest, but it could be provoked by isoproterenol. Echocardiography provides precise information on left ventricular wall motion in hypertrophic cardiomyopathy. Hyperkinesis of the lower left ventricular wall is related to AHCM; hyperkinesis of the upper posterior wall and the motion of the upper septum towards the apex are related to HOCM-R. Hyperkinesis of the lower posterior wall is related to HOCM-I. SAM and pressure gradients may be related to the hyperkinesis of the upper posterior wall. Finally, the septum is not an immobile structure in HOCM, since it moves mainly from the base to the apex and a less (or not at all) towards the posterior wall.

Reliability of subcostal TD echocardiography to detect atrial septal defect.

Echocardiography was used in 40 patients with atrial septal defect (ASD), diagnosed by cardiac catheterization. A dilated right ventricle and abnormal interventricular septal motion were observed at M-mode echocardiography in patients with large L-R shunt. The two-dimensional apical four chamber view was reliable to detect the ostium primum type but not the secundum type of ASD. Moreover the presence of false positives reduced the specificity and predictivity of this approach. The two-dimensional subcostal view provided a direct visualization of the interatrial communication (sensitivity, specificity and predictivity = 100%) and whether the defect was in the uppermost, lowermost or midportion of the septum. Subcostal two-dimensional echocardiography is considered valuable and reliable technique to detect atrial septal defect and the type of the defect itself.

Contrast echocardiographic features of pulmonary hypertension and regurgitation.

Linear contrast echo configuration on the pulmonary valve M-mode echogram was assessed in 28 patients with pulmonary hypertension, in 10 with pulmonary regurgitation, and in 10 normal subjects. Contrast echo parallel lines filling the total systolic phase of the pulmonary valve were recorded in normal subjects. Contrast echo lines stopping in early systole around the pulmonary valve mid-systolic notch were seen in all the patients with pulmonary hypertension in relation to changes with the pulmonary flow. Contrast echo lines reversing the early diastole and crossing the pulmonary valve echogram during diastole were detected in all the patients with pulmonary regurgitation, consistent with the reversed flow across the valve. The use of contrast echocardiography to diagnose both pulmonary hypertension and regurgitation may provide further useful information, particularly when the orientation and time of appearance of the contrast echo lines are related to the systolic and/or diastolic phases of the pulmonary valve M-mode echogram.

Subxiphoid echocardiographic assessment of left ventricular wall in old myocardial infarction.

We studied by cineangiography and standard and subxiphoid echocardiography the left ventricular wall motion in 50 patients with old myocardial infarction and 10 normal subjects. Coronary artery angiography showed a good correlation with the electrocardiographic site of infarction and with the asynergic areas detected by cineventriculographic examination and bidimensional echocardiography. From the correlation of data related to the asynergic areas detected by angiographic and echocardiographic methods it was possible to establish that subxiphoid approach allows to visualize the posterior-lateral wall whereas the parasternal approach the posterior-inferior wall of the left ventricle. Two-dimensional echocardiography from the subxiphoid approach resulted to be a useful and reliable technique for detecting the apical asynergies. The left ventricular wall motion parameters detected by M-mode echocardiography showed significant modifications in all the groups either in the comparison SUBX versus ST or in that with the control group. The subxiphoid approach either M-mode or bidimensional was, therefore, useful in the evaluation of the asynergic areas of the left ventricular lateral wall. The association of SUBX with ST provides further information on the left ventricular wall motion and then, since different areas are visualized with the two techniques, on the extent of myocardial damage.

Contrast echocardiography of the inferior vena cava.

M-mode and two-dimensional subcostal contrast echocardiography were used in 67 patients and 10 normal subjects to evaluate the contrast echo effect on the inferior vena cava echogram in relation to the cardiac cycle and respiratory events. No contrast echoes were recorded in the inferior vena cava in normals during normal breathing. Contrast echoes were recorded entering the inferior vena cava in systole in 20 patients with tricuspid regurgitation and in pre-systole in patients with atrial septal defect and left-to-right shunt and in some of the patients with elevated right atrial and ventricular end-diastolic pressure. Forced inspiration increased the contrast echo effect and determined the penetration of microbubbles into the inferior vena cava. This latter feature occurred in all the patients and only in 1 normal subject. The entry of the contrast echoes into the inferior vena cava was attributed to the high right atrial ventricular end-diastolic pressure and to the reversed flow, from the right ventricle to the right atrium and inferior vena cava in tricuspid regurgitation and from the left atrium to the inferior vena cava in atrial septal defect. The contrast echocardiographic diagnosis of tricuspid regurgitation appeared to be most reliable. New encouraging results were obtained by this technique in diagnosing atrial septal defect and left-to-right shunt. The first appearance of the contrast, the time of appearance in relation to the cardiac cycle and the direction of the to and fro motion of contrast echoes were the most important factors considered for a correct diagnosis.

[Effects of amyl nitrite on left ventricular systole times in normal subjects and those with aortic valvulopathy. Echophonomechanographic assessment]. / Effetti del nitrito d'amile sui tempi sistolici del ventricolo sinistro in soggetti normali e con valvulopatia aortica. Studio eco-fonomeccanocardiografico.

Echophonomechanographic traces showing systole times, the circumferential restriction time, and the ejection fraction were compared in normal subjects, those with aortic stenosis, and those with aortic insufficiency under basal conditions and after 45" inhalation of amyl nitrite. Significant changes in these parameters after stimulation were noted in the normal subjects only, while the differences between the two groups of patients and the controls were also statistically significant under both experimental conditions. The fact that the diseased subjects did not reach the values noted in the controls is attributed to a latent contractility defect under basal conditions that is rendered evident by amyl nitrite. Stress is laid on the usefulness of the drug in the detection of left ventricle myocardial contraction defects via the analysis of ventricular function.

[Echocardiographic evaluation of mitral stenosis: significance of Pc-To/Ac-Mo ratio (author's transl)]. / Valutazione ecocardiografica della stenosi mitralica. Significato del rapporto Pc-To/Ac-Mo.

The echocardiographic tracings of 40 subjects with pure or prevalent mitral stenosis are obtained. The modification of the isovolumetric relaxation time of the right (Pc-To) and the left (Ac-Mo) ventricle, measured from echocardiographic tracings, versus the values of systolic (PSP cat.) and wedge (PVCP cat.) pulmonary pressure are studied in 15 sinusal rhythm patients who underwent cardiac catheterization. The variations of Pc-To versus Ac-Mo and of Pc-To/Ac-Mo ratio versus the most important indices of mitral stenosis and right ventricular performance evaluation are studied in all the patients. Good correlation has been found between Pc-To and Ac-Mo ratio and PSP, PVCP, E-F, Wells index, Yigitbasi index, RICT/RVET, RPEP/RVET, mitral surface; poor correlation has been found between Pc-To/Ac-Mo ratio and left atrial dimension and stroke volume, while no-significant correlation has been found between this ratio and the ejection fraction, V cf, delta S%. For values of Pc-To/Ac-Mo ratio less than 1.20, 1.20 greater than and less than 1,50, greater than 1.50 the stenosis has been considered, respectively, mild, moderate and severe. The Pc-To/Ac-Mo ratio, obtained from echocardiographic tracings, is considered a useful index in the evaluation of the severity of the stenosis and of the pulmonary pressure variations in the presence of mitral stenosis.

[Echocardiographic aspects of left atrial thrombosis in 1 case of severe mitral stenosis]. / Aspects échocardiographiques d'un thrombus de l'oreillette gauche dans un cas de sténose mitrale sévère.

The principal echocardiographic features of the main cardiovascular emergencies are discussed. After setting out a method of detailed analysis for echocardiography, the changes found in the main causes of severe chest pain, systemic embolisation and sudden heart failure are described. Special emphasis is laid on the signs of aortic root dissection, pericarditis and tamponade, ruptured valve, the mechanical complications of acute myocardial infarction and, in particular, on the assessment of residual myocardial function. Finally, the authors maintain that echocardiography should be a systematic complementary investigation for patients in the coronary care unit.