[Pseudoaneurysm and aneurysm of the left ventricle. Discription of a case and long-term follow-up]. / Pseudoaneurisma e aneurisma del ventricolo sinistro. Descrizione di un caso e follow-up a lungo termine.

UNLABELLED: Left ventricle pseudoaneurysm is an uncommon complication of myocardial infarction; urgent operation is usually recommended, because of the high rate of severe complications. We report a single case with coexistence of a true aneurysm and a pseudoaneurysm, asymptomatic after three years of follow up in the absence of surgery. CASE REPORT: The patient, female, aged 69, was observed after an event of prolonged chest pain; ECG showed inferolateral necrosis. Echocardiographic examination showed: left ventricle enlargement with postero-lateral akinesis and septo-apical aneurysm, thin apical thrombosis and mild mitral regurgitation; a non-contractile concameration, aside of lateral wall, containing some thrombotic material and communicating with the left ventricle through a little hole (gap of echoes), crossed by a very little inflow jet. The diagnosis of coexisting septo-apical "true" aneurysm and postero-lateral pseudoaneurysm was confirmed with CT scan, NMR and left ventriculography. Coronary angiography showed total occlusion of LAD and a critical stenosis of mid LAD. The patient refused the operation. In 36 months follow-up no symptoms nor significant echocardiographic changes were observed. DISCUSSION: The pseudoaneurysm is caused by slow fissuration of the myocardium (after a myocardial infarction) with adhesion of pericardium and fibrosis, resulting in a saccular cavity, communicating with the left ventricle by a little hole; on the contrary the more frequent "true" aneurysm is a progressive dilatation and thinning of the ventricular wall, with parietal fibrotic degeneration. Echocardiography may be useful in differential diagnosis, but an excellent quality of the images is required and false negatives and positives are frequent. In this case the echocardiographic features include the thickness of the pseudoaneurysmal wall, the very low flow through the communication hole and the minimal mitralic involvement. CONCLUSION: This particular pattern, when accurately assessed, could probably be predictive of low risk and favorable prognosis in patients with pseudoaneurysm.

[Massive pulmonary embolism during the third trimester of pregnancy: effectiveness of thrombolytic treatment with alteplase]. / Embolia polmonare massiva al terzo trimestre di gravidanza: efficacia del trattamento trombolitico con alteplase.

The authors report on a 33-year old woman with massive, life-threatening pulmonary embolism at the third trimester of pregnancy. The diagnosis was rapidly accomplished in the Emergency Department by two dimensional-Doppler echocardiography that showed signs of pulmonary hypertension as well as a large, floating thromboembolus in the right atrium. As the hemodynamic deterioration persisted after treatment with iv heparin, the patient received alteplase 50 mg as a bolus over 5 minutes. About 30 minutes later, a further 50 mg infusion of alteplase was given over 60 minutes because clinical conditions were progressively worsening. After an alteplase dose of 75 mg, the woman showed a definite improvement in clinical-hemodynamic status and echocardiography documented a reduction of right ventricular overload and atrial clot disappearance. Two hours later the patient was submitted to cesarean section, because of the onset of uterine contractions, and delivered a vital baby. The occurrence of uterine bleeding was antagonized by the infusion of fresh-frozen plasma and a moderate anemia was subsequently treated with iron preparations. The mother and her baby were discharged on 16th day in fairly good general conditions. The authors emphasize the leading role of early echocardiography in the clinical decision making and the lifesaving potential of full dose thrombolytic therapy without serious adverse effects.

[Pulmonary thromboembolism. A clinical case with unusual presentation]. / Malattia tromboembolica polmonare. Descrizione di un caso clinico a presentazione insolita.

The authors describe a rare case of pulmonary thromboembolism with unusual clinical findings and emphasized the large difficulty encountered in formuling a correct diagnosis in a reasonable time. A man, 60 years old, was admitted to a Medical Division of our hospital for the appearance of chest pain and epigastric pain during effort in the last year. He smoked 20 cigarettes a day and drank wine (1 or 2 litres a day). He was affected by hypercholesterolemia and in the past reported relapsed thrombophlebitis in the left leg. Four years before admission to our hospital he underwent large and small left saphenectomy. He had no cardiac events in the past. After a non significant exercise stress test the patient was treated with nitrates and asa and was discharged from the hospital. At home the symptoms increased and after 8 months the patient was admitted again to the Cardiologic Division of the hospital. At admission he reported dyspnea and chest pain at rest, not only during effort and the ECG showed negative T waves in anterior and inferior leads. Intravenous heparine, nitrates and calcium antagonists stabilized the clinical picture. The following examinations revealed: reduction of the T wave negativity at the ECG registered during chest pain; mild enlargement of the heart at the chest roentgenogram; normal value of the left ventricle and apical and midseptal by ipokinesia at the transthoracic echocardiogram; normal coronary artery at the coronary arteriography. "Vasospastic angina" was diagnosed and the patient was discharged after 20 days, asymptomatic. After 15 days he returned to the hospital again for chest pain, dyspnea, hypotension and syncope despite therapy. At physical examination he showed a painful left tibio-tarsal tumefaction, an increased and splitting second heart sound in the pulmonary area and a systolic murmur in the third and fourth left interspace. The ECG showed a severe anterior ischemia, while a new transthoracic echocardiogram revealed a considerable dilatation of the right atrium, right ventricle and the main pulmonary artery with severe tricuspid regurgitation and pulmonary hypertension (mean PAP about 50 mmHg). The following pulmonary perfusion scintigraphy confirmed the diagnosis of pulmonary embolism and the selective right and left pulmonary arteriography exhibited multiple thrombi and large intravascular filling defects. The right heart catheterization confirmed a chronic precapillary pulmonary hypertension (mean PAP = 55 mmHg). About 24 hours after these examinations the patient died because of a cardiac arrest with electromechanical dissociation. Pulmonary thromboembolism is a potentially fatal disease characterized by a largely variable clinical presentation. Frequently pulmonary embolism diagnosis is difficult especially when clinical findings are unusual. In the case observed the "typical" chest and epigastric pains associated with the electrocardiographic findings directed diagnosis towards myocardial ischemia. Also after the coronary arteriography that showed normal coronary artery, the erroneous diagnosis persisted. Pulmonary embolism was correctly diagnosed too late to begin an effective therapy. These unusual clinical findings and diagnostic mistakes are stressed and critically reviewed in the article.

[An unusual case of "catecholamine necrosis" caused by accidental digitalis poisoning]. / Un raro caso di "necrosi catecolaminica" da intossicazione digitalica accidentale.

Toxic manifestations of digitalis are one of the most prevalent adverse drug reactions encountered in clinical practice. The estimated incidence is about 20% in hospitalized patients in the USA. The authors describe a rare case of myocardial "catecholamine necrosis" (anteroseptal myocardial infarction) during accidental digitalis intoxication. A male patient, 75 years old, suffering from cirrhosis and ascites, take on by mistake a tablet of digoxin 0.25 mg. four times at day for eleven days. He hadn't heart disease in the past. At the eleventh day the patient showed a deep tiredness and so he was submitted to a clinical examination and electrocardiogram. The ECG demonstrated an anteroseptal myocardial infarction in the second-third electrical stage. The patient was hospitalized. The successive examination revealed: very high plasma digitalis concentrations; an increase of the serum levels of CPK and LDH; a significant increase of plasmatic and urinary catecholamine levels which return to normal values after fifteen days; apical akinesia at the echocardiographic examination; no signs of residual myocardial ischemia to the echo-dypiridamole stress test; normal coronary artery to the coronary arteriography and absence of coronary artery spasm to the ergonovine test. Furthermore the abdominal echography and the abdominal computerized tomography didn't reveal surrenal disease but showed an important liver disease. The patient was free from other cardiac events in the follow-up. Generally, during the digitalis intoxication we observe various rhythm and conduction disturbances. Instead in this case no serious arrhythmias were registered and the main expression of the drug toxicity was an anteroseptal myocardial infarction with undamaged coronary artery. Also the usual extracardiac symptoms and signs of the digitalis intoxication were absent in this case. All these observations can be explained with the pathological increase of the cathecholamine levels, indirectly induced by digitalis; with the direct toxic effect of the drug at the myocardic level; with the contemporary absence of ionic disturbances; with the concomitant liver disease. The direct toxic effect of the digitalis produced an increase in calcium ions availability for the electromechanical coupling and an increase of the intramyocardial pressure; the increase of the adrenergic activity determined contemporary an increase in the oxygen consumption of the myocardial cells, a rise of vascular tone and coronary artery tone and a reduction of the duration of the diastole. All these factors provoked a "primary and secondary" ischemia which evolved toward a real "cathecholamine necrosis" and produced a myocardial infarction. This hypothesis explains the myocardial infarction in absence of injury at the coronary arteriography and without coronary spasm at the ergonovine test; moreover it explains the transient increase in cathecholamine plasma levels observed in the acute phases an normalized after fifteen days. The "cathecholamine necrosis" is an anatomical definition, nevertheless in our opinion it gives account of the rare clinical situation observed.

Clinical features of 24 patients on regular hemodialysis treatment (RDT) for 16-23 years in a single unit.

Careful investigation of the clinical conditions of patients on maintenance hemodialysis for about 20 years in a single dialysis unit was of great interest for evaluation of the pathological consequences in long-term survivors of insufficient correction of uremia and of the dialysis treatment "per se". We analyzed the outcomes for a cohort of 116 patients who started RDT before 1976 and the clinical conditions of the 24 patients still on RDT in our unit at the end of 1991 (average duration of treatment = 222 +/- 23 months). Actuarial survival was 72% at 10 years and 43% at 20 years. Rehabilitation of the 24 survivors was rather good: 13 were able to work, 8 were retired or unable to work, but able to care for most personal needs. Actual body weight, anthropometric parameters and biochemical parameters revealed a well-preserved nutritional status. Anemia improved from 23 +/- 7 at the start of RDT to 31 +/- 8 in the 21 patients never treated with erythropoietin. Blood pressure was normal without therapy in 18 patients and elevated in 6. Mild-to-moderate left ventricular hypertrophy was present in all the 6 patients with arterial hypertension and in only 6 of the 18 normotensive patients. The ratio of early diastolic filling to filling during atrial contraction (E/A ratio) was < 1 in 16 patients: it was 1.05 +/- 0.43 in 9 patients with stable intradialysis blood pressure and significantly lower (0.73 +/- 0.15) in 12 patients with recurrent intradialysis hypotension. Supraventricular arrhythmias were detected by Holter monitoring in 41% and ventricular arrhythmias in 35% of patients. Extensive vascular calcifications were present (in 100% of patients in the abdominal aorta), but only 4 patients showed clinical signs of peripheral vascular disease. Subperiosteal resorption was detected radiologically in the hands of 59% of patients. Bone histology, interpretable for only 20 patients, revealed no bone lesions in 1 case (5%), mild mixed osteodystrophy in 3 cases (15%), advanced mixed osteodystrophy in 5 cases (25%), osteodystrophy with predominant hyperparathyroidism in 2 cases (10%), osteodystrophy with predominant osteomalacia in 6 cases (30%), and aplastic bone disease in 3 cases (15%). Moderate aluminum staining was found in only 4 patients and was more marked in earlier biopsies taken before withdrawal of the aluminium-containing phosphate-binding drugs.(ABSTRACT TRUNCATED AT 400 WORDS)

[Reuse of single-use catheters: a dilemma to be clarified]. / Riutilizzo di cateteri mono-uso: un dilemma da riportare in luce.

This paper proposes a cost benefit approach in evaluating reuse of single-use catheters, introducing cost of disposal and the concept of financial risk. An estimation of relevant variable and fixed costs is discussed, according to conditions and prices presently existing in Northern Italy. A formal model is developed to compare alternative reuse and no-reuse strategies. Use of internal versus external (Service centers) sterilization is also briefly scrutinized. A short review of literature concerning reuse is aimed to place the issue in the proper framework, listing critical problems as far as safety, risks of rupture, identification and control procedures, legal responsibility, informed consent by the patient. The conclusion is proposed that reuse of Medium-to-High cost catheters is highly profitable from the economic standpoint, subject to the condition that stringent quality procedures and controls are implemented to assess reasonable safety on behalf of the patient. Further, size of potential savings and gain in number of procedures performed are likely to request at least some institutional attention. Last, pooling relevant risks among several institutions is a plausible way to lower costs and make reuse possible also to smaller centers. The model may be used for self-assessment purposes concerning reuse introduction; the actual estimate of risk is critical in evaluating results.

[Chronic pulmonary hypertension caused by left axillary vein thrombosis. Report of a clinical case]. / Ipertensione polmonare cronica da trombosi della vena ascellare sinistra. Descrizione di un caso clinico.

Deep venous thrombosis (DVT) of the upper extremity is infrequent, occurring with an incidence estimated at 1-3% of that of DVT of the lower extremity; acute pulmonary embolism following upper extremity DVT is very uncommon; thromboembolic chronic hypertension is quite rare. Therefore a case of chronic thromboembolic pulmonary hypertension due to a non-traumatic ("spontaneous") left axillary vein thrombosis is described: in this case only the double lung transplantation has been shown to be effective in the treatment of advanced cardiopulmonary disorder.

[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.

[Aortic valve insufficiency in aortic dissection: an unusual case]. / Insufficienza valvolare aortica in corso di dissezione aortica: descrizione di un caso insolito.

An unusual case of aortic valvular regurgitation due to a type A aortic dissection is described: using transesophageal echocardiography a large intimal flap is shown prolapsing into the left ventricle outflow tract during diastole causing aortic regurgitation.

[An unusual cause of arterial and venous pulmonary hypertension]. / Su una causa insolita di ipertensione polmonare arteriosa e venosa.

A 49 year old woman with syphilis of recent onset was repeatedly admitted to the hospital on account of recurrent dyspnoea and hemoptysis. The symptoms and radiological signs indicated the presence of a "cardiac lung". The ECG disclosed right ventricular overload which was confirmed by echocardiography. The left heart was normal, not only on echocardiography but also on cardiac catheterization, which documented severe pulmonary hypertension, partly precapillary, partly postcapillary. The presence of chronic lung congestion in the absence of pathological findings pertaining to the left heart lead to the diagnosis of pulmonary venous occlusive disease. However, pulmonary angiography showed notable and widespread arterial amputations which are not present in this syndrome. Autopsy provided the correct diagnosis: sclerosing mediastinitis localized at the hilum with prevalent involvement of both arterial and venous pulmonary vessels.

Echocardiographic aspects of pulmonary arterial hypertension in chronic lung disease.

An echocardiographic M-mode study has been performed on 58 patients with pulmonary arterial hypertension at rest or on exercise, with chronic lung disease, either obstructive (41 cases of COLD) or restrictive (17 cases of interstitial lung disease, ILD) in nature. The average Ppa was practically the same (i.e. 27.3 +/- 11.7 mmHg and 26.0 +/- 8.0 mmHg respectively) in the two groups of patients, even though the COLD patients were older than the ILD patients (58.7 +/- 9.3 vs 38 +/- 11 years). The echo detection of the pulmonary valve was successful in only 35% of COLD patients and in 86% of ILD patients (p less than 0.01). A multiple regression analysis disclosed a rather weak, but nevertheless statistically significant, correlation (p less than 0.01) between 1) Ppa and the ratio of right ventricular to left ventricular end-diastolic volume, and 2) between right ventricular end-diastolic pressure and septal systolic displacement. The standard error of estimated versus actual Ppa taking into account the ventricular and septal echo variables was as high as +/- 7.63 mmHg, thus preventing a reliable prediction of Ppa in individual cases. An echocardiographic pattern of pansystolic mitral valve prolapse was observed in 29% of ILD patients, but never in cases with COLD.

Two-dimensional echocardiography and radionuclide angiocardiography in pulmonary hypertension.

In precapillary pulmonary hypertension two-dimensional echocardiography documents anatomo-functional alterations of valvular and cavitary structures of the heart in real time. It supplies useful information on ventricular interdependence and on the motion of the interventricular septum. In the same kind of pathology first pass or equilibrium radionuclide angiocardiography has been used for the calculation of the ejection fraction of the right ventricle, both at rest and during exercise, breathing either air or pure oxygen. The Authors think that these two methods are complementary. For this reason they decided to associate them and they report here their preliminary experience. Their first observations seem to show that the association of the two techniques is useful in the study of the dimensions and shape of the two ventricles and for the visualisation of even regional abnormalities in motion of the interventricular septum.

[Dyssynergia of the left ventricle in idiopathic prolapse of the mitral valve. Kinetocardiographic study of 50 cases]. / Dissinergie del ventricolo sinistro nel prolasso idiopatico della mitrale. Studio cinetocardiografico di 50 casi.

Fifty patients with idiopathic mitral valve prolapse (MVP), diagnosed by M-mode ecocardiography and free of other cardiovascular disease, were studied by kinetocardiography (KCG), to detect the presence of left ventricular dyssynergy. Kinetocardiography showed paradoxical outward movements (POM) in 27 patients: these movements were pansystolic in 13 patients. The results were normal in 20 patients, unclear in 3 patients. POM were more frequently found in positions K4, K3 and K5. A comparison among results obtained with KCG and the other noninvasive techniques we used (ECG, ecocardiography and phonocardiography) showed that ectopic beats were more frequently associated with POM, which also were more frequent in patients with prolapse of both mitral leaflets and with pansistolic prolapse. Finally POM were recorded in patients with atypical or silent MVP. We conclude that KCG is an useful noninvasive technique to discover left ventricular dyssynergy in patients with MVP.

Relation of kinetocardiogram to systolic time intervals in patients with old myocardial infarction.

Left ventricular function was studied noninvasively in a group of 35 patients with noncomplicated and complicated old myocardial infarction (MI) by means of kinetocardiography (KCG) and systolic time intervals (STI). Discriminant analysis with a group of 130 normal subjects documented that STI were significantly abnormal and that the abnormalities, i.e. prolongation of the preejection period, shortening of left ventricular ejection time and increase of PEP/LVET were more evident in patients with complicated old MI. KCG was more or less abnormal in all the patients studied, with the more striking abnormalities in those with complications. A good correlation was found between KCG and STI abnormalities. We consider that KCG is able to detect in a sensitive way abnormalities of left ventricular contraction in patients with old MI and that, most probably, alterations of STI in these patients are mainly due to incoordinate left ventricular contraction.

Myocardial infarction in a child aged ten with Duchenne muscular dystrophy.

The authors describe the clinical picture, ECG, vectorcardiographic, and serum enzyme assays in one case of acute myocardial infarction occurring after a severe physical exertion in a child aged 10 with progressive muscular dystrophy of the Duchenne type. The picture differs considerably from the electrical aspects of "pseudonecrosis" that interstitial fibrosis of some portions of the left ventricle may produce in this myopathy.

[Unusual echocardiographic aspect of the pulmonary valve in a case of congestive cardiomyopathy]. / Insolito aspetto ecocardiografico della valvola polmonare in un caso di cardiomiopatia congestizia.

A 38 years old woman with congestive cardiomyopathy, mild pulmonary hypertension and pulmonic valve unusual M-Mode echocardiographic pattern is described. A very important right ventricle failure, as in our patient, could explain this echocardiographic picture.