Thromboembolic risk in atrial flutter. The FLASIEC (FLutter Atriale Società Italiana di Ecografia Cardiovascolare) multicentre study.

AIMS: Patients with atrial flutter are believed to be at lower risk of thromboembolism than patients with atrial fibrillation. However, the incidence of atrial thrombi and the need for anticoagulation in patients with atrial flutter is not well established. METHODS AND RESULTS: A prospective observational multicentre study was undertaken to assess the frequency of atrial thrombi and spontaneous echocontrast and the prevalence for aortic complex atherosclerotic lesions in a cohort of unselected patients with atrial flutter. We evaluated 134 patients (102 male, aged 70+/-9 years); exclusion criteria were history of atrial fibrillation, rheumatic mitral valve disease and mitral mechanical prosthesis. The median of atrial flutter duration was 33 days. Twelve patients had been taking warfarin for more than 7 days. One hundred and twenty-four patients (94%) underwent a transoesophageal echocardiogram, which revealed left atrial appendage thrombi in two patients (1.6%) and right atrial thrombi in one patient (1%). At least moderate left atrial echocontrast was found in 16/124 patients (13%). Complex atherosclerotic aortic plaques were detected in 10 patients (8%). Atrial flutter conversion was attempted in 93/134 patients (69%). At the 1-month follow-up, two patients experienced a thromboembolic event following restoration of sinus rhythm. CONCLUSIONS: Atrial thrombi and echocontrast, and complex aortic atherosclerotic plaques are relatively uncommon in patients with atrial flutter. Post-cardioversion embolism was observed in two patients in our study population.

[Asymptomatic severe aortic stenosis: always surgical treatment? The opinion of the cardiologist]. / Stenosi aortica severa asintomatica: intervento chirurgico sempre? Il parere del cardiologo.

Aortic valve replacement is the effective treatment for symptomatic aortic stenosis. On the other hand, there is some lack of agreement about the optimal timing of surgery in asymptomatic patients. We support the opinion that survival of asymptomatic patients with aortic stenosis is excellent without surgery. At present even if surgical mortality can be minimized, the combined risk of surgery and late complications of a prosthesis exceed the possibility of preventing sudden death and prolonging survival in all asymptomatic patients. It may be useful to identify asymptomatic patients at high risk of sudden death, with abnormal response to exercise, or with left ventricular systolic dysfunction or excessive hypertrophy for early surgery. In the future, when surgical techniques and techniques for the preservation of biological valve are improved, or the risk of thromboembolism associated with mechanical prostheses is reduced, and the freshly harvested matched homografts become more widely available, the indications for aortic valve replacement will be extended to patients with hemodynamically severe aortic valve disease, in the absence of symptoms or left ventricular dysfunction.

Familial atrial septal defect with atrioventricular conduction defects.

Atrial septal defect of the ostium secundum type is almost always sporadic, with multifactorial inheritance. We report a case of a family in which atrial septal defects of the ostium secundum type with atrioventricular conduction defects were observed in four generations: five proven cases and two probable cases. Ten families have been reported as showing atrial septal defect of the ostium secundum type and atrioventricular conduction defects with dominant inheritance. Moreover, in our family the transmission model can also confirm autosomal dominant inheritance. We believe that cardiologists should take a familial approach to atrial septal defect of the ostium secundum type for both research and genetic counseling purposes. In a patient with ASD II, the AV conduction defects should prompt a detailed family history and clinical evaluation of first-degree relatives.

[Pulmonary embolism and cerebral stroke from paradoxical embolism in a young woman]. / Embolia polmonare ed ictus cerebrale da embolia paradossa in una giovane donna.

We describe a case of pulmonary embolism and ischemic stroke due to paradoxical embolism in a healthy young woman taking oral contraceptives to treat an ovarian cyst. It was not possible to identify the site of the thromboembolus. Ultrasound techniques played an important role in identifying the peripheral arterial obstructions and in diagnosing acute pulmonary hypertension. Transesophageal echocardiography provided detailed information on both the morphology and the evolution of the atrial thrombus straddling the foramen ovale within the aneurysmal interatrial septum. The patient was given anticoagulant treatment, initially with heparin and subsequently with warfarin over a period of six months. Repeated ultrasound controls showed no thrombus, regression of the signs of pulmonary hypertension and, lastly unchanged systemic arterial obstruction.

[The ductus arteriosus in healthy newborn infants studied by continuous Doppler guided by two-dimensional Doppler color echocardiography]. / Il dotto arterioso nel neonato sano, studiato con il Doppler continuo guidato dal Doppler bidimensionale a codice di colore.

To characterize the ductus arteriosus shunt after birth, 53 normal newborn infants (36-41 weeks gestation), appropriate in size for gestational age, were examined using two dimensional Doppler echocardiography directed continuous Doppler for evidence of patent ductus arteriosus. The infants were examined within six hours of birth, and every six-eight hours thereafter until ductus arteriosus shunt could no longer be detected. In 51/53 infants, an adequate examination was possible and ductus arteriosus was detected in every infant using the standard precordial approach. Using two dimensional Doppler echocardiography a yellow-orange-red jet, sometimes blue in the central area, directed at the lateral wall of the pulmonary artery was recorded; using continuous Doppler a diastolic or continuous spectral flow into the main pulmonary artery was recorded. Ductus arteriosus shunt could no longer be detected in 7 infants 12 hours after birth, in 26 infants 12-24 hours after birth, in 11 infants 24-36 hours after birth, in 5 infants 36-48 hours after birth and in 2 infants 48-60 hours after birth. A diastolic spectral Doppler flow was present in 38 infants and became continuous before duct closure in 27 infants. In 13 infants it was continuous at first examination and until the ductus arteriosus closure. Both diastolic or continuous spectral Doppler flow could present a flat waveform profile, or a protodiastolic or protosystolic peak velocity. The shunt peak velocity increased significantly with the age i.e. (1.5 +/- 0.7 m/sec mean and SD-), at first examination, vs 2.3 +/- 0.6 m/sec at last examination before ductus arteriosus closure (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Familial pulmonary stenosis: considerations on genetic aspects]. / Stenosi polmonare familiare: considerazione sugli aspetti genetici.

A family with 4 cases of pulmonary valvular stenosis with under-developed or normal right ventricle, is reported. The father and his three daughters were affected. In two of the girls, who were twins, a prenatal diagnosis was made using 2D-echo. The importance of genetic counseling and prenatal diagnosis in the families at risk are underlined.

[Rupture of the interventricular septum in acute myocardial infarct: diagnosis by Doppler color code. Clinical case]. / Diagnosi di rottura del setto interventricolare in corso di infarto acuto del miocardio mediante Doppler a codice di colore. Caso clinico.

Doppler Color Flow Mapping represents the most recent step in the evolution of Doppler techniques that display blood flow signals superimposed on real time, two dimensional echocardiographic images. The following case illustrates the utility of this technique in the diagnosis of a ventricular septal rupture complicating the course of an inferior wall acute myocardial re-infarction. An abnormal blood flow pattern from the left to right ventricle through the ventricular septum was promptly visualized. Early operative intervention may improve the prognosis of acute infarct-related ventricular septal rupture; Doppler Color Flow Mapping and Pulsed Doppler Echocardiography are at present the most rapid and reliable noninvasive techniques in the detection of post-infarct ventricular septal rupture and may greatly expedite medical and surgical management.

[Fetal echocardiography. A horizontal study of biometry and cardiac function in utero]. / Ecocardiografia fetale. Studio orizzontale della biometria e della funzione cardiaca in utero.

The anatomy and the cardiac growth in normal fetal heart was studied by real-time-directed M-mode ultrasound from the 19th gestation week until term. A correct fetal cardiac M-mode recording was obtained in 94 out of 144 women (65%). Echocardiographic variables were plotted against gestational age and respective correlation coefficients were determined by linear regression analysis. A comparison between the variables was studied by paired t-test. Left ventricular, right ventricular, left atrial and right atrial chamber size, interventricular septum thickness, right and left wall thickness, aortic and pulmonary diameter all increased linearly with age. Right ventricle (10.1 +/- 3.1) was slightly larger than left ventricle (9.2 +/- 2.8 mm) (p less than 0.001), the pulmonary artery (7.9 +/- 1.9 mm) was greater than the aorta (7.6 +/- 2 mm) (p less than 0.001), while no significant difference was noted between left atrium (10.8 +/- 3.5 mm) and right atrium (10.1 +/- 2.6 mm), right ventricular wall thickness (2.7 +/- 0.9 mm) and left ventricular wall thickness (3.0 +/- 1.1 mm). The ratios of left ventricular/right ventricular diameter, left atrial/right atrial and left atrial/aortic diameters, the relative wall thickness and arterial vessels diameters did not change significantly throughout the pregnancy. The ratio interventricular septum/posterior wall thickness was 1.14 +/- 0.36 and ratio of 1.5 or greater was found in 14.5% of the fetal normal heart. The ratio left atrial/aortic diameter was 1.32 +/- 0.21 and left atrium was significantly greater than aorta (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Fetal echocardiography. Prenatal diagnosis of hypoplastic left heart syndrome]. / Ecocardiografia fetale. Diagnosi prenatale di sindrome di cuore sinistro ipoplasico.

The authors report of a prenatal ultrasound diagnosis of hypoplastic left heart syndrome (HLHS) in a fetus at 36 weeks' gestation. The diagnosis-was substantiated by a postnatal two dimensional and M-mode echocardiogram and confirmed at postmortem examination. Pertinent findings were the morphology of ventricular cavities and of the mitral valve, and the abnormally increased ratio of right ventricular to left ventricular dimensions (approximately 2) as well as the pulmonary-to-aorta diameter ratio of 1,7. We stress the need of an accurate measurement of ventricular cavities to avoid a falsely positive diagnosis and the importance of a prenatal ultrasound diagnosis of congenital heart anomalies for a correct perinatal management.