[The early echocardiographic diagnosis of a massive pulmonary embolism]. / Diagnosi ecocardiografica precoce di embolia polmonare massiva.

BACKGROUND: In several cases of clinically suspected massive pulmonary embolism (MPE), a lung perfusion scanning and/or a pulmonary angiography are not quickly available or feasible. METHODS: Fifty patients admitted to our ICU with a clinically suspected MPE underwent an echocardiographic (Echo) investigation very shortly after onset (within 2 hours in 38 cases, and within 6 hours in 12). An Echo-Doppler study was also performed in 18 patients. RESULTS: Highly significant differences (p < 0.001) emerged between patients with PE and healthy age-mates for each type of Echo measurement and in all views. The RVDD/LVDD ratio turned out to be the most frequently affected parameter, being altered in 96% of cases. An abnormal diastolic leftward shift of the interventricular septum was detected in 81% of cases. Only one of our 50 patients failed to show any evidence of RV pressure overload; however, this was a patient with a severe dilated cardiomyopathy. In 22 cases in whom hemodynamic monitoring was performed, no significant correlation emerged between RVDD and LVDD, on one hand, mean PAP and cardiac index on the other. All 18 patients examined by Echo-Doppler had mild to moderate tricuspid regurgitation with a peak RV-RA gradient of 38 +/- 7 mm Hg (range 31-53 mm Hg). Seven patients (14%) were found to harbor right heart thrombi when first examined. Overall mortality in this uncommonly high risk population was as high as 28%. CONCLUSIONS: In a clinical setting suggesting a MPE, an Echo study conducted very shortly after onset may corroborate a tentative diagnosis of PE, thereby permitting timely fibrinolytic therapy pending a lung scan and/or angiography, or in situations where such imaging facilities are not available or readily usable.

[Heart surgery complications during diagnostic coronary angiography. The experience of a nondepartmental hemodynamics laboratory]. / Complicanze cardiochirurgiche in corso di coronarografia diagnostica. Esperienza di un laboratorio di emodinamica non dipartimentale.

The records of the Catheter Laboratory at S. Carlo Hospital in Milan (a District General Hospital without Cardiac Surgery Unit) between 1989-1991 were reviewed to determine how often emergency coronary by-pass surgery was performed because of a complication arising during elective coronary arteriography. A total of 1,009 cardiac procedures were performed, 876 (87%) were confined to left ventricular angiography and coronary arteriography in patients with suspected coronary artery disease. Our Catheter Laboratory complications rate was low: death 0.1%, stroke 0, non fatal myocardial infarction 0.8%, arrhythmia 0.5%, femoral haematoma 0.7%, emergency cardiac surgery 0. Case selection, seniority of operators, femoral approach (98% of the cases) with coronary catheters 6 French can explain these good results. In our experience coronary angiography at a District General Hospital is safe, feasible and diagnostic. Besides our main problem is the non emergency access to a Cardiac Surgery Unit after coronary arteriography: our patients have to join a long waiting list at major Regional Centres with an increase in cardiac events.

[Use of the subclavian vein for permanent cardiac stimulation]. / Empleo de la vena subclavia para la estimulación cardíaca permanente.

The experience on 101 cases of permanent cardiac stimulation is reported; in all of them, the access was via the subclavian vein. Punction of the subclavian artery, transient injury of the brachial plexus and pneumothorax, were seen in 4.3 and 3% respectively. Early electrode luxation was observed in 5% of the patients. As late complications there where two cases of destruction of the electrode protecting sheet and one electrode rupture. In spite of the potential risks directly related to the vein puncture, the subclavian puncture offers an excellent alternative for placing definitive pacing electrodes.