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.

Pefloxacin in the antibacterial treatment of immunodepressed patients.

Pefloxacin 800 to 1200 mg daily was given for 3 to 20 days, orally or intravenously, to 84 immunocompromised patients. Five patients dropped out because of side effects and 2 for other causes. Treatment efficacy was evaluated in 77 patients, 43 men and 34 women, aged 18 to 80 years. Immunodepression resulted from malignancy in 46 patients, LAS/ARC or AIDS in 28, and from unknown causes in 3. Fifty-eight patients had documented infections (respiratory-tract infections 29, urinary-tract infections 13, septicemia 10, other 6) and 19 had a fever of unknown origin (FUO). Cure or significant improvement of symptoms was achieved in 81% of patients with documented infections and in 74% of patients with FUO. Side effects (mainly gastrointestinal disturbances and skin rash) occurred in 7 patients (8.2%), including dropouts. These results suggest that pefloxacin may be useful for the antibacterial treatment of immunodepressed patients.

[Non-invasive evaluation with continuous Doppler of the systolic pressure of the right ventricle in patients with tricuspid insufficiency]. / Valutazione non invasiva con Doppler continuo della pressione sistolica del ventricolo destro in pazienti con insufficienza tricuspidale.

Tricuspid regurgitation (TR) is detected by Doppler echocardiography in a high proportion of patients with right ventricle pressure or volume overload. Continuous wave Doppler (CW) provides a noninvasive estimation of the transtricuspid systolic pressure gradient, applying the modified Bernoulli formula to the maximum velocity of the TR jet. The purpose of this study was to test the accuracy of the CW prediction of systolic right ventricular pressure (RVPs), obtained adding a clinical estimate of the mean right atrial pressure (RAPm) to the Doppler derived pressure gradient. The study population consisted of 22 adult patients with Doppler proved TR, undergoing right heart catheterization (cath) for mitral valve disease (12 pts), atrial septal defect (8 pts), dilated cardiomyopathy (1 pt) or pulmonary hypertension (1 pt). Two studies were duplicated after nifedipine administration. TR was graded by pulsed Doppler flow mapping as mild in 7, moderate in 11, severe in 4 pts. RAPm was estimated clinically from the inspection of neck veins pulsatility (mmHg = pulsatility cm+5/1.3). At CATH RVPs ranged from 27 to 80 (46 +/- 17) mmHg, RAPm from 0 to 13 (6 +/- 3) mmHg. RVPs Doppler prediction showed a close correlation with CATH (r .97, SEE 4.2 mmHg), with a slight mean underestimation (-2 +/- 4 mmHg) (Fig. 3, Tab. I). The discrepancies between CW and CATH ranged from -9 to +10 mmHg, almost entirely due to inaccuracy of the RAPm clinical estimate (r .48, see 3.8 mmHg) (Fig. 4, Tab. I).(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular septal rupture after myocardial infarction: diagnosis by two-dimensional and pulsed Doppler echocardiography.

Rupture of the ventricular septum in the acute phase of myocardial infarction (MI) requires prompt recognition for correct management. The 2-dimensional and pulsed Doppler echocardiographic findings are reported from 11 patients with ventricular septal (VS) rupture. VS rupture was confirmed by cardiac catheterization in 9 patients, surgery in 4 patients and necropsy examination in 3 patients. Two-dimensional echocardiography (echo) directly visualized the rupture in 7 patients and assessed the size and location of an associated aneurysm in 10. In all patients, M-mode pulsed Doppler echo allowed detection of the left-to-right shunting due to VS rupture, but failed to indicate the rupture site. M-mode pulsed Doppler echo was reliable for detecting VS rupture after MI. Conversely, 2-dimensional echo was less effective in the direct visualization of the rupture, but provided anatomic and functional information that was useful in medical and surgical management. Thus, the techniques are complementary and should be used in combination for the assessment of VS rupture in acute MI.

Pulsed Doppler diagnosis of tricuspid insufficiency.

To verify the ability of Pulsed Doppler Echocardiography (PDE) to detect flow abnormalities in tricuspid insufficiency (TI), 27 normal controls and 83 heart patients (pts) were studied. The latter group underwent an invasive diagnostic evaluation. The PDE examination did not reveal any significant systolic flow alteration in the normal controls. However, in the heart patients, a systolic turbulence was recorded within the right atrium both on audio and on graphic system (Time Interval Histogram-TIH) in 28 cases. Angiography showed tricuspid regurgitation in 24 pts. The sensitivity of PDE was 92%, the specificity was 93% and the predictive value was 96%. There were two false negative and four false positive cases. In conclusion, Pulsed Doppler Echocardiography is a highly reliable technique for the qualitative diagnosis of tricuspid insufficiency in patients with acquired heart disease. Left-to-Right shunts, namely left-to-right atrium and left ventricle-to-right atrium, can create flow disturbances that mimic tricuspid insufficiency. No criteria were identified, which correlated well with the angiographic severity of the tricuspid regurgitation.

[Echocardiographic diagnosis of left atrial thrombosis (author's transl)]. / Diagnosi ecocardiografica della trombosi dell'atrio sinistro.

70 consecutive patients undergoing heart surgery for mitral valve disease were studied: at operation 6 of them exhibited left atrial thrombi (LAT). Dimension of the thrombi varied from a hazel-nut to an orange, 4 of them adhered to the posterior atrial wall, 2 of these obliterated the left atrial appendage, one partially and the other totally, invading also the left atrial cavity as far as mitral orifice. In 5 cases LAT appeared of old onset, possibly with recent apposition; in one case the thrombus was mainly recent. All the cases had been assessed preoperatively using M-mode and two-dimensional echocardiography: the diagnosis of LAT was made in 5 pts, the only thrombus missed was the one located in the left atrial appendage. Angiocardiography was performed in 4 pts, showing left atrial thrombi in one case. Two-dimensional echocardiography (2D E) demonstrated a high sensitivity by revealing LAT in 5 cases out of 6, with good definition of shape and location. The LAT appeared as echoproducing masse with well defined borders and "muscle" density in 4 cases; in 3 they were seen protruding into the atrial cavity and in one case they were seen located above the posterior mitral leaflet. M-mode revealed multiple echoes parallel to the posterior atrial wall in the first 3 cases, whereas in the fourth it provided no particular finding for the diagnosis. In the only case of recent onset LAT, 2DE showed a single strong echo, parallel to the posterior atrial wall both in long and short-axis views, separated from the atrial wall by an echo-free space of 1.5 cm. Similar features resulted at the M-mode echocardiography. In conclusion, 2DE with gray-scale has an high sensitivity for detecting LAT, in particular when thrombi are old and located in the left atrial cavity. Recent onset thrombi are more difficult to demonstrate and it is possible that the "fresh" component of an old thrombus is missed.

[Human cytomegalovirus and congestive cardiomyopathy (author's transl)]. / Citomegalovirus umano e cardiomiopatia congestizia.

Congestive cardiomyopathy in 3 cases, in which occurrence of human Cytomegalovirus (CMV) infection was demonstrated, is described. In all cases significant rise in total CMV antibodies and in early antigen-antibodies was found: CMV was also isolated from urine and saliva in one, a 13 years old boy, and only from urine in the others two patients, 20 and 26 old men. Immunoglobulin M was raised only in the first case, in which CMV infection was likely in act: instead in the others two CMV infection was late primary or recurrent. The possibility of CMV infection as etiological agent of dilatative cardiomyopathy with congestive heart failure in this 3 cases is, in our opinion, strongly suggestive.

[The electrocardiogram in cardiomyopathies]. / L'elettrocardiogramma nelle cardiomiopatie.

The electrocardiogram of 27 patients with congestive cardiomyopathy (CMC), 15 with obstructive (CMO) and 13 with hypertrophic without obstruction (CMH) have been studied. Cardiac catheterization, angiography, coronary arteriography, and, in some cases, echocardiography, were performed. The study was carried out in an attempt to define certain patterns of each CM with emphasis on the ischaemic-like features, as infarct pattern, symmetrical T wave inversion, ST elevation, non-typical troubles of ventricular repolarization and on the electrophysiology of these findings. Suggestive for CMC were: (1) prolonged PR, (2) high frequency of arrhythmias and conduction defects, especially complete left bundle branch block with abnormal left axis deviation, (3) left atrial enlargement and ventricular hypertrophy. Suggestive for CMO: (1) low incidence of arrhythmias and conduction defects, (2) left atrial enlargement and ventricular hypertrophy. Infarct pattern, symmetrical T wave inversion and other ischaemic-like features were equally found in all groups of CM, without any statistical difference. Pathogenesis of cardiomyopathy, particularly of CMH, is discussed, carrying out a review of literature.

[The congestive cardiomiopathy. A clinical study of the hypotrophic-hypokinetic forms (congestive) (author's transl)]. / La cardiomiopatia congestizia. Studio clinico delle forme ipotrofiche-ipocinetiche (congestizie)

Based on classifications proposed by Anglosaxon and French authors who were the first to become interested in the so-called cardiomyopathies of unknown origins, 41 cases clinically classified as hypotrophic-hypokinetic (congestive) cardiomyopathies are presented. After a period of clinical observation, 21 cases were studied hemodynamically, with ventriculography and coronaryarteriography, with phonocardiography (35 cases) and follow-up from some months to 6 years. Post mortem studies were performed in 6 patients, five of whom died of congestive heart failure or thromboembolism and one of sudden death. It was concluded that these entities are hypotrophic-hypokinetic cardiomyopathies with a clinical pattern of congestive heart failure and with unknown aethiologic factors. Treatment as far as indications and efficacy are discussed.

[Peripartum cardiomyopathy (author's transl)]. / La cardiomiopatia peripartum

Three cases of peripartum cardiomyopathy (CMP PP) are presented. In our opinion this term is more correct than post-partum cardiomyopathy. The study was performed both clinically and hemodynamically; patients were followed up for a long period (in one case up to 14 years). Although there were consistent differences in the rise and development of the disease, the clinical and laboratory results could be put together clearly. In the light of this clinical experience, a wide revision of the literature on the topic was carried out, using the hypotrophic-hypokinetic forms of cardiomyopathy (congestive) as a comparison with peripartum cardiomyopathy, which seem to be clinically correlated.