Prevalence of isolated left ventricular diastolic dysfunction in hypertension as assessed by combined transmitral and pulmonary vein flow Doppler study.

In a relatively large population of patients with treated systemic hypertension and normal left ventricular systolic function, prevalence of abnormalities of left ventricular diastolic function, as assessed by Doppler echocardiographic study of mitral and pulmonary vein flow, was high, with 51% of patients showing indirect signs of increased left ventricular end-diastolic pressure. Furthermore, our data documented that a "normal" mitral flow profile does not exclude the presence of an abnormality of left ventricular filling, which could be otherwise identified by combined analysis of a pulmonary vein flow profile.

Single-lead VDD pacing. A case of cross-talk.

The haemodynamic and electrophysiological benefits of dual chamber pacing are well recognized at the cost of a more complex and expensive implant. In selected groups of patients VDD-mode dual chamber pacing offers the advantages of dual chamber pacing with the use of a single catheter and is nowadays gaining increasing popularity. The following report describes an uncommon and potentially harmful pacemaker malfunction secondary to the dislodgement of the catheter.

Prevalence of late potentials in adult aortic stenosis.

Sudden death and syncope are well-recognized clinical manifestations of valvular aortic stenosis (AS). Furthermore, patients with left ventricular hypertrophy due to hypertension have a greater prevalence of late potentials (LP) compared with normal subjects. Chronic pressure overload in AS is frequently characterized by development of left ventricular hypertrophy. The aims of this study were (1) to determine the prevalence of LP in patients with moderate to severe AS, and (2) to investigate the relationship between LP and left ventricular hypertrophy. Signal-averaged electrocardiograms (SAECG) were recorded using a 40 Hz high pass filter in 32 patients (19 M and 13 F), aged 69 +/- 11 years with AS, and in 25 age- and sex-matched controls. QRS duration (QRSD) < 114 ms, low amplitude signal of last 40 ms (LAS40) < 38 ms and root mean square voltage of last 40 ms (RMS40) > 20 microV were considered normal. LP were considered to be present if at least two of the above criteria were abnormal. Each patient underwent a complete echo-Doppler examination and the following parameters were measured; aortic valve area, fractional shortening, left ventricular end-diastolic diameter and mass index. Coronary arteriography was performed in 17 (53%) patients. LP were present in 8 out of 32 (25%) AS patients and in 1 out of 25 controls (4%); this difference was statistically significant (P < 0.006). No difference with regard to age, sex, presence of congestive heart failure, angina, syncope, complex ventricular arrhythmias and coronary artery disease was found in AS patients with and without LP. No correlation was found between indices of left ventricular structure and function and each SAECG parameter. In conclusion, the prevalence of LP in patients with AS is higher than in controls and the presence of LP in AS might be related to factors other than coronary artery disease and left ventricular mass and/or function.

A peculiar form of pacemaker syndrome in DDD pacing.

This paper documents the occurrence of a peculiar form of PM syndrome despite the presence of DDD pacing. This occurred because the post atrial refractory period was set inappropriately. Our aim is to highlight the intriguing nature of the syndrome and the need to rule out a concealed form of PM syndrome every time an implanted patient suffers from unexplained and confounding symptoms.

Brief report: 2D-echo diagnosis of interventricular septal perforation by a temporary pacing electrode.

We report the case of an 83-year-old patient affected by hypertensive cardiopathy and admitted to our Division for left ventricular failure and complete atrioventricular block; a temporary electrode was inserted via the right internal jugular vein. A routine 2D-echo examination performed one day later clearly showed the catheter tip in the left ventricular cavity; the interventricular septal perforation was confirmed by the presence of right bundle branch block pattern on surface electrocardiogram. The following clinical course was totally event-free and the patient eventually underwent permanent pacing. A comparison with the few cases of pacing-related myocardial perforations so far described by the literature is made.

Transesophageal measurement of left atrial refractoriness.

During electrophysiological evaluation of supraventricular arrhythmias the transesophageal (TEEP) approach may be the first step but is limited in information available. One difficulty is in measuring left atrial refractoriness, as left atrial capture is seldom detectable either on ECG or via an esophageal lead. The problem may be eliminated and left atrial refractoriness measured via the esophagus, utilizing two or three extrastimuli to scan diastole to determine whether the atrial refractory period has been entered by the first extrastimulus. Measurement of left atrial and/or atrioventricular node or accessory pathway refractoriness then becomes possible.

[Primary mesothelioma of the pericardium with long-term survival]. / Mesotelioma primitivo del pericardio a lungo decorso.

We report the case of a 52-year-old man admitted to our Hospital for a massive pericardial effusion already discovered at an X-ray examination of the chest more than one year before, but never submitted to further investigation. Four months after a first surgical intervention of "pericardial windowing" and a drainage of 1700 ml of clear pericardial fluid, the patient was again hospitalized because of cardiac tamponade and underwent open pericardial drainage. At inspection, the pericardium and the myocardial muscle were fused in a single mass that at histological examination was discovered to be a primary mesothelioma of the pericardium, epithelial type. We discuss the clinical course and review the scientific literature inherent in these rare cases of primary neoplastic diseases of the heart.

[Electrocardiogram ambulatory monitoring: technological evolution and current prospectives]. / Il monitoraggio ambulatoriale dell'elettrocardiogramma: evoluzione tecnologica ed attuali prospettive.

The value of ambulatory ECG monitoring in the investigation of arrhythmic or ischemic events with paroxysmal patterns is well-known and its use is widespread. More recently, technical advances in informatics and in ECG signal digitizing have rapidly developed the current available ambulatory ECG instruments, reducing the time necessary for pattern analysis meanwhile assuring acceptable accuracy and reliability of the results. ECG recording techniques other than traditional Holter monitoring are now available such as transtelephonic transmission of ECG signal recorded in real time or previously stored in solid state memory by intermittent recorders that can be switched on by the patients himself at the first prodroms or at the end of the event. These "loop recorders" make it possible to indefinitely extend ECG monitoring time, reducing costs and increasing record sensitivity in comparison to conventional Holter monitoring. Moreover, recent technological development of Holter monitoring makes it possible to perform heart rate variability analysis and late potentials research in addition to traditional analysis of cardiac rate and ventricular repolarization. Thus Holter recording may become, combined with other usual risk factors, a polyparametrical non invasive approach to sudden cardiac death risk assessment characterised by low cost/benefit ratio and by large screening capacity.

[Thrombosis of the right atrial appendage. The two-dimensional echocardiographic aspect and the autopsy finding]. / Trombosi dell'auricola destra. Aspetto ecocardiografico bidimensionale e riscontro autoptico.

We report the case of an 80-year-old man affected by hypertensive cardiomyopathy and already admitted to our Division for recurrent episodes of heart failure. He was eventually hospitalized for septic shock secondary to disseminated pneumonia with concomitant left pleural effusion. At 2D-echo examination, a highly echo-reflectant mass was detected in the retrocardiac space. As the patient died notwithstanding the intensive pharmacological care, an autoptic procedure was performed which showed a massive thrombosis of the right atrial appendage. We discuss the 2D-echo imaging and advance a pathogenetic hypothesis after a review of the current literature.

Rate of progression of valvular aortic stenosis in adults.

Until recently the hemodynamic severity of valvular aortic stenosis (AS) was evaluated only by cardiac catheterization. Now, Doppler echocardiography allows a noninvasive and accurate assessment of AS severity and can be used to study its progression with time. The progression of AS was assessed during a follow-up period of 6 to 45 months (mean 18) by serial Doppler examinations in 45 adult patients (21 men and 24 women, mean age 72 +/- 10 years) with isolated AS. The following parameters were serially measured: left ventricular outflow tract diameter and velocity by pulsed Doppler, peak velocity of aortic flow by continuous-wave Doppler, to calculate peak gradient by the modified Bernoulli equation, and aortic valvular area by the continuity equation. At the initial observation, 13 of 45 patients (29%) were symptomatic (1 angina, 1 syncope and 11 dyspnea); during follow-up, 25 (55%) developed new symptoms or worsening of the previous ones (5 angina, 3 syncope and 17 dyspnea); 11 underwent aortic valve replacement and 3 died from cardiac events. Baseline peak velocity and gradient ranged between 2.5 and 6.6 m/s, and 25 and 174 mm Hg, respectively; aortic area ranged between 0.35 and 1.6 cm2. With time, mean peak velocity and gradient increased significantly from 4 +/- 0.7 to 4.7 +/- 0.8 m/s (p less than 0.01), and 64 +/- 30 to 88 +/- 30 mm Hg (p less than 0.01), respectively. A concomitant reduction in mean aortic area occurred (0.75 +/- 0.3 to 0.6 +/- 0.15 cm2; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[The physiopathology of dual-chamber cardiac stimulation. Apropos a case with a dual-chamber pacemaker, left atrial standstill and heart decompensation]. / Fisiopatologia della stimolazione cardiaca bicamerale. A proposito di un caso con pacemaker bicamerale, paralisi atriale sinistra e scompenso cardiaco.

The paper describes the clinical case of an elderly patient with heart failure, the possessor of a dual-chamber pacemaker programmed in DDD mode, in whom a complete interatrial block with left atrial standstill was diagnosed. The authors discuss the physiopathological aspect of the case which is a paradigmatic example of the problems related to dual-chamber pacing. In particular, the utility of an echo-Doppler assessment of the mechanical activity of the atria is emphasized together with a careful choice of the optimal atrioventricular delay in programming and the follow-up of dual-chamber pacing.

[Estimation using unipolar transesophageal recording of the interatrial conduction time in patients with paroxysmal atrial flutter and fibrillation]. / Stima con derivazione unipolare transesofagea del tempo di conduzione interatriale nei pazienti affetti da flutter e fibrillazione atriali parossistici.

Twenty-three consecutive subjects (age 46.7 +/- 21, range 13-78) addressed to our attention for symptoms attributed to documented or suspected supra ventricular arrhythmias underwent transesophageal electrophysiologic study. On the basis of the preliminary investigations 15 proved free from organic heart disease, 2 were affected with ischemic heart disease (secondary angina), 6 with hypertensive cardiomyopathy. In each patient the sensibility, specificity and positive predictive value of the following reports regarding the occurrence of paroxysmal fibrillation and flutter (Ffap) were evaluated: a) echo reports of left atrial enlargement; b) ECG signs of atrial enlargement; c) interatrial conduction time (TCIA) assessed with unipolar transesophageal recording. As TCIA we adopted the time interval intercurrent from the first low-voltage deflection of the esophageal P wave (far field) and the apex of the intrinsecoid deflection of the same wave. TCIA proved significantly longer in the 12 patients affected with Ffap compared with those free from documented paroxysmal or inducible arrhythmias or affected with paroxysmal junctional reciprocating tachycardias: 76.6 +/- 11 vs 51.8 +/- 11.7; p less than 0.001. A TCIA greater than 63 msec characterizes with satisfactory sensibility and specificity the occurrence of Ffap: sens. 75%, spec. 91%, positive predictive value 90%. Echo and ECG reports of atrial enlargement behave as highly specific but not sufficiently sensitive indexes of the occurrence of Ffap: sens. 42%, spec. 100%, pos. pred. val. 100% and sens. 17%, spec. 100%, pos.pred.val. 100% resp. We concluded that TCIA is an index correlated with and predictive of the occurrence of Ffap in patients symptomatic for cardiopalmus or neurologic symptoms in the absence of other arrhythmias detectable with Holter monitoring which are able to produce clinical symptoms.

[Holter monitoring with a pill-shaped esophageal electrode]. / Monitoraggio Holter con elettrodo esofageo a pillola.

This study analyzes the possibility of using an oesophageal lead in the ambulatory ECG monitoring in order to improve the diagnostic effectiveness of the method by reliable identification of atrial activity. The oesophageal Holter monitoring was performed on 19 patients (pts) (8 F and 11 M, aged 34 to 79 years). These patients posed precise diagnostic problems unsolved by previous conventional Holter recordings. The oesophageal Holter recording was carried out with a Spacelabs recorder, model 90205 with two channels. One electrode was positioned in the standard lead CM5 and the second in the oesophagus using an Esodyn 2 electrode with a dynamic configuration made by C.B-Bioelettronica (Calenzano, Florence). The oesophageal lead was connected with the recorder by filter model EHF-4. The electrode was swallowed by the patient and the best position regulated on the P diphasic deflection of the highest amplitude. The monitoring allowed correct identification of the P wave over a 24-hour period. The arrhythmia which required the oesophageal Holter monitoring was recorded again in 15 of 18 patients examined. In each of these cases it was possible to solve the diagnostic question. The following arrhythmias were found: constant time correlation between the P deflection and the QRS in accordance with a supraventricular tachycardia with intraventricular conduction delay (4 pts); A-V dissociation in accordance with a ventricular tachycardia (2 pts); pause caused by atrioventricular block 2:1 (1 pt), second degree sinus-atrial block (1 pt), blocked premature atrial beats (4 pts); premature ventricular and premature atrial beats with intraventricular conduction delay (3 pts).(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of left ventricular filling in patients with systemic hypertension. A Doppler echocardiographic study.

To assess left ventricular (LV) diastolic function in patients with hypertension, a Doppler echocardiographic study of transmitral blood flow (TBF) was performed in 46 hypertensive patients (H), 18 without (H1) and 28 with (H2) left ventricular hypertrophy and in 25 age-matched normal subjects (N). All patients showed normal systolic function. The following indices of Doppler TBF were measured: peak flow velocity during early filling (Evel), atrial systole (Avel) and their ratio (E/Avel); area under early filling phase (Earea), area under atrial systole (Aarea), expressed as a percentage of total diastolic area and their ratio (E/Aarea); deceleration half-time (DHT) of early filling phase. When compared with N, H1 and H2 showed significant reductions in early filling indices and an increase in atrial contribution parameters. (Evel = 0.62 +/- 0.1(N), 0.52 +/- 0.1(H1) P less than 0.01, 0.44 +/- 0.1(H2) P less than 0.001; Earea = 56 +/- 5(N), 48 +/- 5(H1) P less than 0.001, 43 +/- 6(H2) P less than 0.001; Avel = 0.49 +/- 0.1(N), 0.59 +/- 0.1(H1) P less than 0.01, 0.69 +/- 0.14(H2) P less than 0.001; Aarea = 26 +/- 5(N), 41 +/- 4(H1) P less than 0.001, 47 +/- 7(H2) P less than 0.001). Also DHT was significantly prolonged, compared with N (80 +/- 12 msec), in H1 (90 +/- 12 msec, P less than 0.01) and H2 (105 +/- 20 msec, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)