Patent foramen ovale and cryptogenic stroke: from studies to clinical practice: Position paper of the Italian Chapter, International Society Cardiovascular Ultrasound.

BACKGROUND: Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists. AIMS: This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO. METHODS: All studies published in the literature on PFO and cryptogenic stroke are considered and discussed. RESULTS: We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke. CONCLUSION: After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.

Comparisons of anterior segment biometry between Chinese and Caucasians using anterior segment optical coherence tomography.

PURPOSE: To compare anterior segment parameters between eyes of Chinese and Caucasians using anterior segment optical coherence tomography and to evaluate the association between these parameters and anterior chamber angle width between the two ethnic groups. METHODS: 60 Chinese and 60 Caucasians, 30 with open angles and 30 with narrow angles (defined as Shaffer grade < or =2 in > or =3 quadrants during dark room gonioscopy) in each group, were consecutively enrolled. One eye of each subject was randomly selected for imaging in a completely darkened room. Measurements, including anterior chamber depth (ACD), scleral spur-to-scleral spur distance (anterior chamber width (ACW)), anterior chamber angle width, iris convexity and iris thickness, were compared between the groups. The associations between angle opening distance and biometric measurements were evaluated with univariate and multivariate regression analyses. RESULTS: There were no differences in age, axial length, anterior chamber angle measurements, pupil diameter and iris convexity between Chinese and Caucasians in both open-angle and narrow-angle groups. However, the ACD and ACW were smaller and the iris was thicker in Chinese. In the multivariate analysis, the ACD was the most influential biometric parameter for angle opening distance in both Chinese and Caucasians. After adjusting the effects of axial length, age and sex, ACD and ACW were significantly smaller in Chinese. CONCLUSIONS: Chinese eyes had smaller ACD, smaller ACW and greater iris thickness than Caucasians. ACD was the most influential parameter in determining the angle width in both ethnic groups.

Heart failure and diabetes: left ventricular systolic function.

AIM: Heart failure is the main cause of mortality and morbidity in general population, annual mortality rate is 20%, in spite of pharmacological treatments or other therapies. Cardio-vascular events and diabetes tight correlation is well known, while it is less evaluated diabetes and heart failure correlation is less studied, heart failure as left ventricular systolic function impairment. Cardiovascular disease rate is decreasing, systolic heart failure rate is raising. Our study goal is to evaluate which role diabetes plays in determining systolic heart failure, diagnosed by echocardiographical examination. METHODS: Four hundred and fifty consecutive patients, systolic heart failure prone, diagnosed by left ventricular ejection fraction less than 40%, were included. Exclusion criteria were rheumatic or congenital valve diseases. Mean age was 78.3 years (53-93 years), 286 were women and 164 men. Statistical analysis were performed by parametric t-Student test and not parametric chi2 test. High significant difference was assessed for P<0.05. RESULTS: Seventy six (16.9%) patients were diabetes prone (D), 374 (83.1%) were diabetes free, so not diabetic (ND). Forty three men were D (56.5%), 131 ND (35%). Diabetic mean age was 74.7 years (52-88), not diabetic was 79.3 (53-93). Six D (7.8%) and 21 ND patients (5.6%) were hypercholesterolemia prone. Eight D (10.5%) and 18 ND (10.1%) patients were smokers. Twenty eight D (36.8%) and 107 ND patients (28.6%) were hypertensive. Thirty three D (43.4%) and 88 ND (26.4%) patients were coronary artery disease prone, 3 of 33 (3.9%) D and 28 of 88 (7.4%) ND ischemic patients were myocardial infarction prone. Twenty one D (27.6%) and 106 ND (28.3%) patients were atrial fibrillation prone. There were not statistical significant difference among D and ND patients for following variables: sex, smoke, total cholesterolemia, hypertension and atrial fibrillation. We found an high significant difference for mean age (P<0.005) and coronary artery disease prone patients (P<0.007), but not for myocardial infarction prone subjects (P<0.1). CONCLUSIONS: Diabetes, not depending by other common cardiovascular risk factors, causes systolic heart failure, in prone patients, on an younger age, and in the same time an higher coronary artery disease rate, but not an higher myocardial infarction rate, because the coronary artery disease is often a microvascular one, and it leads to heart failure rather than myocardial necrosis.

[Arrhythmic risk in essential hypertension: late potentials]. / Il rischio aritmico nell'ipertensione essenziale: i potenziali tardivi.

AIM: A higher incidence of cardiac death exists in patients with essential hypertension, and it is higher still in those with ventricular arrhythmia. The purpose of noninvasive diagnostic imaging in hypertensive patients is to determine those with a greater risk for arrhythmia. In previous studies on hypertension, one of the inclusion criteria is diastolic blood pressure <95 mmHg, which, however, is a low selectivity criterion. Instead, our study emphasizes the need to evaluate the incidence of ventricular arrhythmia in hypertensive patients not yet receiving drug therapy and to formulate the diagnosis based on 24-h ambulatory arterial blood pressure monitoring, which represents a more selective criterion than the diastolic pressure value proposed by the World Health Organization (WHO). METHODS: A total of 128 consecutive patients with essential hypertension classified according to WHO criteria underwent 24-h monitoring, 85 (66.4%) of which presented with a mean 24-h arterial pressure >135/85 mmHg. These patients were then evaluated using mono- and two-dimensional echocardiography and 24-h dynamic Holter monitoring to detect arrhythmias and the presence of left ventricular later potentials. RESULTS: Left ventricular hypertrophy was present in 60 (70.6%) patients and absent in 25 (29.4%). Based on the Lown classification of ventricular arrhythmia, 20 (23.5%) patients had Grade I arrhythmia, 5 (5.9%) Grade II, 4 (4.7%) Grade III, 9 (10.6%) Grade IVA, 20 (23.5%) Grade IVB, 12 (14.1%) Grade V, 15 (17.6%) clinically unremarkable arrhythmia, and 17 (20%) had late potentials because they tested positive to at least 2 out of three criteria, and 2 patients were positive to all 3 criteria. CONCLUSION: Our study findings demonstrated a significant correlation between left ventricular hypertrophy and grade of arrhythmia (r=0.552; p<0.0001) and late potentials (r=0.405; p<0.001). The presence of late potentials was also found to correlate significantly with grade of arrhythmia (r=0.593; p<0.001). These patients present with a more severe stage of the disease and should therefore receive more aggressive treatment to prevent sudden cardiac death resulting from arrhythmia.

[Silent ischemia and ventricular arrhythmias in essential hypertension]. / Ischemia silente ed aritmie ventricolari nell'ipertensione essenziale.

BACKGROUND: Silent ischemia episodes rate is 4-5% among over fifty aged people. Patients affected by hypertension have higher coronary artery disease rate than people with normal blood pressure. An increased mortality is present among patients affected by essential hypertension, especially if affected by silent ischemia and /or ventricular arrhythmias. In all previous study about hypertension, the inclusion criterion was a diastolic blood pressure >95 mmHg, that is a low selective one. The aim of study is to evaluate ventricular arrhythmias rate, in hypertensive patients, without pharmacological therapy, and diagnosed by 24 hours ambulatory blood pressure monitoring (ABPM), so using a more selective criterion than WHO rules. METHODS: 128 consecutive patients with hypertension diagnosis by WHO rules, were screened for 24 hours ambulatory blood pressure measurement (ABPM); 85 of them (66.4%) had 24 hours mean blood pressure >135/85 mmHg. These 85 patients were screened for M-mode, B-mode echocardiography and 24 hours electrocardiogram monitoring by Holter. RESULTS: Sixty patients (70.6%) were affected by left ventricular hypertrophy, 25 were free (29.4%) According to the Lown and Wolf classification for ventricular arrhythmias 20 patients (23.5%) had a Grade I arrhythmia, 5 (5.9%) had a Grade II, 4 (4.7%) had a Grade III, 9 (10.6%) had a Grade IV A, 20 (23.5%) had a Grade IV B, 12 (14.2%) had a Grade V and 15 patients (17.6%) were free from premature ventricular complexes. 40 patients (47%) had one or more ST depression episodes longer than 60 . The range of episodes number is 1-22, mean 6.8; their duration range is 1-16 minutes, mean 7.6 minutes. In our study, left ventricular hypertrophy correlate significantly with arrhythmia Lown score, r=0.552 for p<0.0001 and also with silent ischemia as ST depression r=0.51, p<0.004. The correlation, between arrhythmia score and ST depression, r=0.042, p<0.021 is not highly significant. CONCLUSIONS: The conclusion is drawn that using a more selective criterion for the diagnosis of hypertension, it is possible to identify patients affected by a more severe stage of disease, and detect them for primary prevention of coronary events.

Ventricular arrhythmias and left ventricular hypertrophy in essential hypertension.

BACKGROUND: Patients with essential hypertension and/or left ventricular hypertrophy and ventricular arrhythmias suffer from an increased mortality rate. In all previous studies on hypertension, the criterion for inclusion was diastolic blood pressure > 95 mmHg. This is a low selective threshold. Our study attempted to evaluate the incidence of ventricular arrhythmia in hypertensive patients not receiving pharmacological treatment and diagnosed by 24-h ambulatory blood pressure monitoring (ABPM), therefore using a more selective criterion than WHO guidelines. METHODS: Hundred-twenty-height consecutive patients with hypertension diagnosed on the basis of WHO guidelines were screened for 24-h ambulatory blood pressure measurement. Eighty-five (66.4%) presented a 24-h mean blood pressure > 135/85 mmHg. All 85 patients were screened for M-mode, B-mode echocardiography, PW Doppler and 24-h ECG Holter recordings. RESULTS: Sixty patients (70.6%) were affected by left ventricular hypertrophy and 25 were free (29.4%). Thirty-six patients (42.4%) had left ventricular diastolic dysfunction, 49 were free (57.6%). According to Lown and Wolf's classification of ventricular arrhythmia, 20 patients (23.5%) presented Grade I arrhythmia, 5 (5.9%) presented Grade II, 4 (4.7%) Grade III, 9 (10.6%) Grade IVA, 20 (23.5%) Grade IVB, 12 (14.1%) Grade V and 15 patients (17.6%) were free from premature ventricular complexes, namely Grade 0 arrhythmia. Left ventricular hypertrophy was found to correlate significantly with the arrhythmia score, r = 0.552 for p < 0.0001. Moreover, left ventricular diastolic dysfunction correlated significantly with the arrhythmia score, r = 0.495 for p < 0.0001. There was also a good correlation between left ventricular hypertrophy and left ventricular diastolic dysfunction, r = 0.616 for p < 0.0001. Among patients affected by left ventricular diastolic dysfunction and left ventricular hypertrophy, the correlation with the arrhythmia score was even closer, r = 0.586 for p < 0.0007. CONCLUSIONS: We conclude that by using a more selective criterion for the diagnosis of hypertension, we can identify patients with a highly significant statistical correlation between left ventricular hypertrophy and ventricular arrhythmia score, and also between diastolic dysfunction and the ventricular arrhythmia score, due to a more severe stage of disease. It is useful to detect those patients affected by ventricular arrhythmias for the primary prevention of major cardiovascular events.

[A critical evaluation of intrauterine diagnostic possibilities of congenital cardiopathies]. / Valutazione critica delle possibilità diagnostiche intrauterine delle cardiopatie congenite.

The authors illustrate the possibilities for intrauterine diagnosis of congenital heart disease stressing limits and possibilities.

[Respiratory function and mitral stenosis. Physiological aspects and clinical correlations]. / Funzionalità respiratoria e stenosi mitralica. Aspetti fisiopatologici e correlazioni cliniche.

A qualitative and quantitative assessment of respiratory deficiency in patients with N.Y.H.A. Class II mitral stenosis is presented with the standard screening of respiratory mechanics providing the parameters.