[Intracardiac ectopic thyroid: a report of a clinical case with a long-term follow-up]. / Tiroide ectopica intracardiaca: descrizione di un caso clinico con prolungato follow-up.

We describe the prolonged follow-up of a 64-year-old female patient, with an ectopic intracardiac thyroid gland. The mass was first detected 14 years ago, during a routine echocardiographic examination. The patient suffered from episodes of palpitation and cardiac auscultation revealed a systolic murmur. At cardiac surgery a right ventricular mass penetrating most of the interventricular septum was found. The mass was also prolapsing into the pulmonary infundibulum and could not be removed. On histopathology examination, the presence of a normal tissue was demonstrated. Two main clinical events characterized the prolonged follow-up: the gradual development of a massive tricuspid insufficiency, probably due to the strict anatomic relationship between the septal tricuspid papillary muscle and the mass itself; frequent supraventricular arrhythmias, partially refractory to different pharmacologic regimens, which could be ascribed to the chronic overload of the right atrium. The mass size has been stable over the years, and no thyroid hormone derangement was ever found.

[False left atrial mass caused by hiatal hernia: a clinical case and review of the literature]. / Falsa massa atriale sinistra causata da ernia iatale: caso clinico e revisione della letteratura.

Two-dimensional echocardiography is the technique of choice for identifying cardiac masses. Unfortunately, adjacent structures compressing the atrial wall may lead to misdiagnosis. Clinicians should promptly recognize this phenomenon and the related diagnostic features. The case of a 90-year-old woman presenting with a history of recent onset effort dyspnea is described. On transthoracic two-dimensional echocardiography a left atrial mass which closely mimicked an atrial myxoma was evident. A tomographic scan revealed a large sliding hiatus hernia, which was confirmed on traditional radiographic examination. The echocardiographic characteristics of the mass are described in detail, as well as a review of the literature for the purpose of a correct differential diagnosis.

[Dual-chamber DDD pacing in NYHA III-IV functional class dilated cardiomyopathy: short and middle-term evaluation]. / L'elettrostimolazione cardiaca bicamerale nella cardiomiopatia dilatativa in III-IV classe funzionale NYHA: valutazione clinico-strumentale a breve e medio termine.

Effectiveness of dual-chamber pacing in patients with dilated cardiomyopathy is still controversial. Our study was performed: to select the most favorable individual atrioventricular (AV) delay; to compare hemodynamic short-term effects in each patient after 2 periods of DDD pacing and sinus rhythm (AV spontaneous); to assess hemodynamic long-term (1 year) effects after DDD pacing at optimum AV delay. In 1996, 9 patients (7 men, 2 women; mean age 69 +/- 5 years) with dilated cardiomyopathy (5 idiopathic, 4 ischemic), NYHA functional class III-IV, ejection fraction < 30%, end-diastolic volume > 60 ml/m2, mitral regurgitation +2/+3, PR interval > or = 200 ms, were enrolled. All patients were implanted with DDD pacemakers and monitored for: ejection fraction and end-diastolic volume (measured by echocardiography and radionuclide angiography); clinical conditions; exercise tolerance and maximum oxygen consumption (by Weber exercise protocol); neurohormonal activity (plasma renin, aldosterone, atrial natriuretic factor). Data were recorded: before DDD implantation; after 2 randomized, single-blind periods of 3 months in VVI mode (at ventricular "sentinel" rate of 50 b/min) and in DDD mode with the optimum AV delay, corresponding for each patient to the minimum end-diastolic volume measured by radionuclide angiography and to the highest cardiac output recorded by echocardiography; after 6 months of DDD pacing with most favorable AV delay. Three more patients died 6 months after (between sixth and twelfth month of follow-up), due to refractory heart failure; 1 patient dropped out because his pacemaker was programmed in VVI mode at low rate, due to intolerance of DDD pacing. Among the other 4 patients no clinical and laboratory parameters were significantly different after 1 year of follow-up. In conclusion, DDD pacing in selected patients with dilated cardiomyopathy showed disappointing results, despite a strict and laboratory monitoring; DDD pacing could be of major benefit in larger populations, according to Doppler mitral flow pattern: those patients with a larger A-wave amplitude could be more sensitive to DDD pacing than those with evidence of poor atrial systole. Moreover, biatral and/or biventricular pacing could also play a significant role.

[Aortic valve replacement in patients over 70: a Doppler echocardiographic study]. / La sostituzione valvolare aortica in pazienti ultrasettantenni: studio ecocardiografico Doppler.

Aortic valve disease is known to be the most frequent valvular disease in the elderly and aortic valve replacement is often the best therapeutic strategy. Hemodynamic performance of prostheses is critical in this subset of patients to ensure an optimal quality of life. Moreover, old patients with small aortic ostia are getting more and more common in clinical practice, making often necessary to implant small prostheses. If a significant pressure drop is not achieved, hypertrophy persists and left ventricular function may not improve. Such conditions have not yet been extensively studied in the elderly. The aim of this study was firstly to assess echocardiographically the performance of aortic prosthetic heart valves in old patients (> or = 70 years) and compare the results obtained in patients with prostheses of different type and size, and secondly to evaluate the postoperative changes in left ventricular hypertrophy and function in a subset of patients with isolated or prevalent aortic stenosis. One hundred fifty-one patients were initially considered; global mortality was 9.3% at 20 +/- 12 months from intervention. In the 75 patients with a postoperative echocardiogram, transprosthetic gradient was 27 +/- 12 (max) and 15.1 +/- 6.6 (mean) mmHg. Mean functional prosthetic area (FPA) was 1.5 +/- 0.5 cm2. No statistically significant differences could be demonstrated between mechanical and biological prostheses. Three groups were identified, according to prosthetic size (Group 1: diameter < 23 mm, Group 2: diameter 23 mm, Group 3: diameter > 23 mm). Among groups, max and mean gradients as well as FPA were found to be significantly different. Respectively max gradient was 33.2 +/- 13, 26 +/- 11, 20.2 +/- 7.2 mmHg (p < 0.05), mean gradient was 17.2 +/- 6.1, 15.4 +/- 7.6, 11.7 +/- 4.3 mmHg (p < 0.01) and FPA was 1.2 +/- 0.3, 1.5 +/- 0.3, 1.8 +/- 0.7 cm2 (p < 0.05 between Group 1 and Group 3). In a subgroup of 31 patients with isolated or prevalent aortic stenosis, a significant interventricular septal thickness reduction was found postoperatively (14.3 +/- 2.3 vs 12.6 +/- 8.0 mm, p < 0.001). Posterior wall thickness decreased similarly, but to a lesser extent; left ventricular diameters and myocardial mass also significantly decreased (left ventricular mass: 186 +/- 45 vs 146 +/- 38 g/m2, p < 0.001). When prosthetic size was considered, septal thickness reduction was more evident in Group 1 and Group 2 (p < 0.05 and p < 0.01). On the contrary, a significant improvement in left ventricular diameters was observed only in Group 3 (p < 0.05). Left ventricular mass decreased significantly in Group 2 and Group 3 (p < 0.01 and p < 0.05). Such improvements could be demonstrated only in those patients (79%) who showed at least a 50% reduction in the transvalvular gradient. In this subset, left ventricular function also significantly improved (fractional shortening: 29 +/- 0.7 vs 33 +/- 0.7%, p < 0.02). In conclusion, aortic valve replacement in the elderly is a safe and effective therapeutic strategy. In patients with small aortic prostheses, the transvalvular gradient was found to be slightly but significantly higher as compared to that of larger prostheses. However, left ventricular function was good and similar in all subgroups. No significant differences were found between mechanical and biological prostheses. In old patients with isolated or prevalent aortic stenosis a significant reduction in left ventricular hypertrophy and mass is observed within 2 years from intervention. An increase in myocardial contractility can also be expected, if at least a 50% reduction in transvalvular gradient is obtained.

New bileaflet bioprosthesis: early and mid term results.

A new bovine pericardial bioprosthesis (AMB bioprosthesis) with a bileaflet geometry was designed and developed, with the aim of achieving uniform stress distribution within the prosthesis. The ultimate goal was to limit tissue degeneration to a minimum by attaining optimum fluid dynamics, thereby obtaining an extended clinical durability. The two-leaflet, dome-shaped geometry with a central hinge allowed a very low profile, low ventricular projection in the mitral position, large effective orifice area and low gradients. The design of the thin Delrin stent and the centrally crossing bridge was developed using finite element analysis. Pre-clinical laboratory investigations showed very low trans-valvular gradients and no mechanical or tissue failure after 400 million cycle accelerated wear test. The final model of the prosthesis was manufactured by Baxter-Edwards CVS Division and tested in sheep with good results for up to five months. A limited clinical trial was started in January 1990 and stopped one year later encompassing 12 aortic and six mitral implants. The patients were followed clinically and by echocardiography three, six and 12 months, and four years after surgery. Mean gradients were 4 mmHg in the mitral and 10 mmHg in the aortic position with only minimum regurgitation and no tissue failure. We conclude that early and mid term results with this new pericardial bioprosthesis appear to be favorable and intend to closely monitor further outcome within the limited patient population.

Oral vs intravenous dipyridamole echocardiography for detecting coronary artery disease.

The usefulness of the intravenous dipyridamole-echocardiography test (12-lead and two-dimensional [2-D] echo monitoring during dipyridamole infusion) in the diagnosis of coronary artery disease recently has been suggested. However, the intravenous form of dipyridamole is not available for clinical use in some countries and therefore the administration of oral dipyridamole has been employed in combination with echocardiography. In order to evaluate the relative usefulness of the oral (300 mg of pulverized tablets) vs the intravenous (up to 0.84 mg/kg in 10 min) dipyridamole-echocardiography test, we performed the two tests, on different days and in random order, in 28 inhospital patients: 21 had coronary artery disease (seven had one-vessel disease, eight had two-vessel disease, and six had three-vessel disease); seven patients had no significant coronary artery disease. For both tests, the diagnostic end-point was the development of a transient dyssynergy of contraction. Sensitivity was 95 percent for the intravenous and 52 percent for the oral dipyridamole-echocardiography test (p < 0.01); in positive cases, the dyssynergy after the dipyridamole administration appeared at 6.5 +/- 2.5 min for the intravenous and at 27.8 +/- 12.4 min for the oral test (p < 0.01). Specificity was 100 percent for both the intravenous and oral dipyridamole-echocardiography test. One or more extracardiac side effects (headache, gastrointestinal upset, flushing, etc) occurred in 61 percent of the intravenous and 68 percent of the oral tests (p = ns). Nine patients with a positive intravenous and oral dipyridamole-echocardiography test also had a positive exercise-electrocardiography test. A significant correlation between exercise time (ie, the time from onset of exercise and 0.1 m V of ST segment shift) and dipyridamole time (ie, the time from onset of dipyridamole administration and the development of frank dyssynergy) was present for the intravenous (r = 0.6, p < 0.05) but not for the oral test. We conclude that the oral dipyridamole-echocardiography test, in comparison with the intravenous dipyridamole-echocardiography test, has a lower sensitivity and requires a substantially longer imaging time. The dipyridamole time is related to exercise time for intravenous but not for the oral dipyridamole-echocardiography test.

Dipyridamole-echocardiography: clinical usefulness following interventions.

Dipyridamole-echocardiography test response can be expressed not only in a black or white (positive vs negative) code but also, in positive tests, by a gray scale integrating the severity and extent of the dyssynergy as well as the ischemia-free stress time. The recognition of the dyssynergy is important to establish the diagnosis; however, the evaluation of the degree of the induced ischemia, stratified according to spatiotemporal coordinates, is even more important because it accurately predicts the coronary anatomical and functional situation, as well as the prognosis of the individual patient. Furthermore, the "shades of gray" in a positive response have proved useful in assessing the beneficial effects of several interventions: coronary angioplasty; coronary artery bypass surgery; thrombolysis; and medical antianginal therapy. Due to its excellent reproducibility, dipyridamole-echocardiography can play a pivotal role for simple, safe, fast, accurate, and objective assessment of therapeutic interventions, either mechanical or pharmacological, based upon the presence, timing, severity, and extent of dipyridamole-induced dyssynergy.

Dipyridamole echocardiography test. A new tool for detecting jeopardized myocardium after thrombolytic therapy.

BACKGROUND: We wished to assess whether dipyridamole echocardiography test (DET) can detect jeopardized myocardium after thrombolytic therapy. METHODS AND RESULTS: Seventy-six consecutive patients with a first acute myocardial infarction (AMI) were treated with 2 million IU urokinase i.v. within 4 hours of the onset of AMI and underwent high-dose (as much as 0.84 mg/kg over 10 minutes) DET 8-10 days after AMI. The results were correlated to the anatomy of the infarct-related vessel (IRV). In patients with positive DET, we evaluated the wall motion score index (WMSI; a semiquantitative integrated estimation of extent and severity of the stress-induced dyssynergy). WMSI was derived by summation of individual segment scores divided by the number of interpreted segments. In a 13-segment model, each segment was assigned a score ranging from 1 (normal) to 4 (dyskinetic). Fifty-three patients had positive results on DET. Of these, 42 had dipyridamole-induced new wall motion abnormalities (WMAs) confined to the infarct zone or adjacent segments. In these patients, mean WMSI increased from 1.46 +/- 0.26 (at resting conditions) to 1.73 +/- 0.35 (at peak dipyridamole) (p less than 0.01), whereas no significant change was detected in negative patients (1.6 +/- 0.34 versus 1.57 +/- 0.34, p = NS). Coronary angiography showed a patent IRV (TIMI grade 2 or 3) in 53 patients and no or minimal reperfusion (TIMI grade 0 or 1) in 23 patients. A patent IRV with critical residual stenosis was found in 35 of 42 patients with dipyridamole-induced WMAs in the infarct zone and in 18 of 34 patients without WMAs (p less than 0.05). Among the 23 patients with occluded IRVs, nine had collateral flow to the distal vessel; six of these had a positive DET. Thus, the sensitivity and specificity for identifying a critically stenotic but patent IRV or the presence of a collateral-dependent zone were 66% and 93%, respectively. In a subset of nine patients with a positive DET in the infarct zone or adjacent segments, DET and a control coronary angiography were repeated 1-3 months after an angiographically successful (residual stenosis, 50% or less) coronary angioplasty in the IRV. The repeat DET was negative in eight patients (all with patent IRV at control angiography) and again positive in one patient, who showed restenosis at angiography. The WMSI, at resting conditions was similar before and after angioplasty, whereas it differed significantly at peak dipyridamole (1.7 +/- 0.2 versus 1.4 +/- 0.2, p less than 0.01). CONCLUSIONS: DET can identify the anatomy of the IRV, and dipyridamole-induced WMAs within the infarct zone detect regions with jeopardized myocardium that may benefit from intervention.

[Termination of ventricular tachycardia by noninvasive methods]. / Interruzione di una tachicardia ventricolare con metodiche non invasive.

Present paper reports on a patient referred for sustained, hemodynamically well tolerated, ventricular tachycardia, terminated by noninvasive temporary pacing. The tachycardia was refractory to chest tump and intravenous standard drugs (lidocaine and propafenone). Demonstration of spontaneous atrioventricular dissociation and ventricular capture during transesophageal atrial pacing allowed rapid and correct diagnosis. Overdrive with external noninvasive ventricular pacing proved effective in terminating ventricular tachycardia and converting it to sinus rhythm. These observations suggest that noninvasive approach to hemodynamically stable ventricular tachycardia can provide a safe and effective alternative to more aggressive medical management.

Stress testing in the period after infarction.

Dipyridamole echocardiography is gaining popularity as an exercise-independent diagnostic method in patients with suspected or demonstrable coronary artery disease. To assess its safety, feasibility, and diagnostic accuracy in patients recovering from uncomplicated acute myocardial infarction, 131 patients had the test before hospital discharge. The results were compared with those of maximum treadmill testing. We found that dipyridamole-induced transient asynergy remote from the infarct zone was more sensitive (74% versus 53%, p less than 0.05) and specific (97% versus 68%, p less than 0.01) than treadmill testing for detecting multivessel coronary artery disease. In a subgroup of 42 patients treated with thrombolytic therapy, dipyridamole echocardiography was able to detect in 27 the presence of jeopardized but viable myocardium in the infarct zone. An excellent correlation was found between dipyridamole echocardiography responses and infarct vessel patency. Finally, the prognostic impact of dipyridamole echocardiography on patients recovering from acute myocardial infarction was assessed in a consecutive series of 151 patients. Eighteen months of event-free survival was significantly different in patients with positive versus negative dipyridamole echocardiography results (76.1% versus 50.8%, p less than 0.01). The test was also superior to treadmill testing in predicting cardiac events. Thus, dipyridamole echocardiography performed early after acute myocardial infarction is safe, feasible, and accurate for predicting the extent of coronary artery disease and 18-month clinical outcome.

Inhibition of dipyridamole-induced ischemia by antianginal therapy in humans. Correlation with exercise electrocardiography.

BACKGROUND: Dipyridamole echocardiography test (DET: two-dimensional echocardiographic monitoring with dipyridamole infusion up to 0.84 mg/kg in 10 minutes) is a useful tool for the noninvasive diagnosis of coronary artery disease. Aims of the present study were to assess the effects of antianginal drugs on dipyridamole-induced ischemia and to evaluate whether drug-induced changes in DET response may predict variations in exercise tolerance. METHODS AND RESULTS: Fifty-seven patients with angiographically assessed significant coronary artery disease (greater than 70% lumen reduction in at least one major coronary vessel) performed a DET and an exercise electrocardiography test (EET) in random order both off treatment and on antianginal drugs (beta-blockers, calcium antagonists and nitrates, alone or in various combinations). The criterion for DET positivity was a transient dyssynergy of contraction absent or of a lesser degree in the baseline examination. In DET, two parameters were evaluated: the dipyridamole time (i.e., the time from onset of dipyridamole infusion to obvious dyssynergy) and the wall motion score index. DET sensitivity was 91% off therapy and fell to 65% under therapy (p less than 0.01). In the 37 patients who had a positive DET both off and on therapy, the dipyridamole time increased from 6 +/- 3 (off therapy) to 8 +/- 3 minutes (on therapy) (p less than 0.01). The wall motion score index at peak dipyridamole went from 1.38 +/- 0.14 to 1.31 +/- 0.14 (p less than 0.01). EET and DET yielded concordant (positive versus negative) results in 41 of 57 (71%) patients off and in 35 of 57 (61%) on therapy (p = NS). In the subgroup of 38 patients with both positive DET and EET without treatment, the therapy-induced variations in exercise time were significantly correlated with the variations in dipyridamole time (r = 0.5; p less than 0.01), not with variations in wall motion score index (r = 0.3; p = NS). CONCLUSIONS: 1) Antianginal therapy can protect from dipyridamole-induced ischemia and 2) the therapy-induced changes in DET response parallel variations in exercise tolerance and might be useful for the objective, exercise-independent assessment of the therapy efficacy.

[The echo-dipyridamole test early after acute myocardial infarct: echocardiographic aspects and angiographic correlations]. / Il test eco-dipiridamolo subito dopo infarto miocardico acuto: aspetti ecocardiografici e correlazioni angiografiche.

To assess whether the different mechanical effects of intravenous dipyridamole were correlated with the location and distribution of the coronary arteries stenosis, 98 patients underwent high dose DET 8-10 days after an acute myocardial infarction. Left ventricular regional wall segments were identified in multiple views; a vascular territory was assigned to each coronary vessel. DET was positive in 68.4% of the patients (67/93), 59% (23/39) of those with single vessel disease, and 81% (44/54) of those with multivessel disease. Four different mechanical patterns of positivity of DET were observed: 1) marked worsening of wall motion in the same region showing asynergy (type I); 2) development of new wall motion abnormality adjacent to the infarct zone and located in the same vascular region (type II); 3) development of new wall motion abnormality adjacent to the infarct zone, but located in a different vascular region (type III); 4) development of transient remote asynergy (that is, a new wall motion abnormality in a region normal at rest and not directly adjacent to the infarct zone, type IV). Types I and II (asynergies in the infarct zone coronary bed) were found in patients both with single vessel disease or multivessel disease; by contrast, type III and IV were almost exclusively found in patients with multivessel disease (24/54 and 14/54 respectively) and occasionally in patients with single vessel disease (2/39 and 1/39 respectively). Thus, these two mechanical behaviours during dipyridamole infusion showed to be highly specific for predicting multivessel disease (95% and 97% respectively, sensitivity 44% and 26% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Early assessment of coronary artery bypass graft patency by high-dose dipyridamole echocardiography.

To assess the role of high-dose (up to 0.84 mg/kg during 10 minutes) dipyridamole echocardiographic testing in the evaluation of coronary artery bypass graft patency early after surgery, 18 consecutive patients with angina underwent dipyridamole echocardiography and coronary angiography before and 7 to 10 days after bypass surgery. Coronary angiography showed 2- or 3-vessel disease in 7 and 11 patients, respectively. A total of 53 bypass grafts were performed. Before bypass surgery 14 patients had a positive and 4 a negative test result. No complication occurred during the test performed early after surgery. Of the 14 patients with positive dipyridamole echocardiographic results before surgery, 10 had negative and 4 had positive results after surgery. All 4 patients had negative results before and after surgery. In the 4 patients with positive results after dipyridamole echocardiographic testing before and after bypass surgery, dipyridamole time increased from 5.8 +/- 5 to 9.3 +/- 0.9 minutes (p = 0.3) after the procedure and wall motion score index at peak dipyridamole changed from 1.55 +/- 0.2 to 1.28 +/- 0.3 (p = 0.05). Forty-nine of 53 grafts were patent as seen on angiography. Dipyridamole echocardiographic results were positive in 4 of 5 patients who had at least 1 obstructed graft or native vessel obstructed distal to bypass graft insertion. The remaining patient had diagnostic electrocardiographic changes during dipyridamole infusion without wall motion abnormalities. Dipyridamole echocardiographic results were negative in all 13 patients who had complete revascularization. In the 4 patients with positive test results, the procedure correctly identified the localization of the diseased bypass graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of influence of atrioventricular delay on stroke volume at rest in patients with complete atrioventricular block and dual chamber pacing.

Dual chamber pacing (DDD) maintains atrioventricular (AV) sequence; AV delay programmability modifies the relationship between atrial and ventricular contraction. To evaluate the hemodynamic effects of such a modification, ten patients with a DDD unit for complete AV block were studied by time-motion (M-mode) and Doppler echocardiography during inhibited ventricular pacing (VVI), atrial-triggered ventricular pacing (VDD) and atrioventricular sequential pacing (DVI) at different AV delay (90, 140, 190, 240 msec). A significant improvement in stroke volume (SV) (15%-20%, P less than 0.05) was seen during DDD versus VVI pacing; no changes, however, were observed in the same patient with different AV delay or during DVI versus VDD pacing. These data suggest that programming of AV delay does not affect systolic performance at rest; longer diastolic filling times recorded during DDD pacing with "short" AV delay (90-140 msec) do not seem to be a hemodynamically relevant epi-phenomenon of PM programming.

[Doppler echocardiographic analysis of the short-term results of surgical repair of mitral valve prolapse in myxomatous degeneration]. / Valutazione ecocardiografica Doppler dei risultati a breve termine dell'intervento di riparazione di prolasso valvolare mitralico nella degenerazione mixomatosa.

Ten consecutive patients with pure mitral regurgitation due to floppy valve underwent valve repair operations. Postoperative mitral continence or regurgitation and diastolic flow across the valve were evaluated by Doppler echocardiography. Mean follow-up was 6.4 months. Four patients showed minimal and 3 mild regurgitation; no regurgitation was detected in 3. A significant peak diastolic atrioventricular gradient (10 mmHg) was observed in only one patient. All patients showed symptomatic improvement and a decrease in ventricular diameters. Repair of floppy mitral valves is feasible and gives good results. Doppler echocardiography is a useful technique for monitoring postoperative valve function.