[Left atrial myxoma evidenced by silent acute myocardial infarction]. / Myxoma atriale sinistro manifestatosi con infarto del miocardio acuto silente.

A 64-year-old female patient was in-hospital admitted due to a traumatic femoral fracture. A routinely performed ECG showed signs of anterior acute myocardial infarction, clinically silent, and pathological levels of myocardial serum enzyme were recorded. The echocardiographic-Doppler examination confirmed the LV dyssynergy of contraction and, unexpectedly, revealed a large peduncolated and mobile mass in left atrium, connected to the interatrial septum and prolapsing in left ventricle, referable to myxoma. In the clinical history of the patient, a previous cerebral transitory ischemic attack was present (probably due to myxomatous embolization), but no any other cardiovascular symptoms. The patient successfully underwent coronary angiography, which showed no coronary artery disease, and cardiac surgery for tumoral removal. On the basis of clinical and instrumental data, also acute myocardial infarction may be considered a very likely consequence of a intracoronary embolus. Systemic embolization from left atrial myxomas are frequent; however, the involvement of coronary tree, with clinical manifestations and diagnosis during life, is extremely rare. Complete lack of symptoms due to atrial myxoma and myocardial infarction, and the fortuitous diagnosis of both diseases are peculiar findings of the reported case. Many systemic embolizations from myxomas, although sources of tissue damages, may likely occur without symptoms and may be unrecognized during acute period.

[Propafenone and flecainide in the therapy of ventricular arrhythmias]. / Il propafenone e la flecainide nella terapia delle aritmie ventricolari.

Flecainide and propafenone are antiarrhythmic drugs of the class 1C (Vaughan and Williams) commonly used for ventricular arrhythmias. The purpose of the present study was to evaluate the efficacy of these drugs in 170 consecutive patients with ventricular arrhythmias who referred to our cardiological ambulatory. The study population was divided into two groups according to the absence (group A,82 patients) or presence of organic heart disease (group 1B: 51 patients with left ventricular ejection fraction (LVEF) >35%; group 2B: 37 patients with LVEF<35%). Ventricular arrhythmias were evaluated with a 48 hours Holter monitoring at baseline, and with a control 24 hours Holter monitoring at 15 days (for optimizing the dosage), at 5 months and at 10 months from the beginning of antiarrhythmic therapy. Patients of group A were randomly assigned to antiarrhythmic treatment (flecainide 150-300 mg/die or propafenone 450-900 mg/die). For patients of group B, such choice was leaded by the clinical and strumental data (32 patients were treated with flecainide, 56 patients with propafenone). In the 160 patients who ended the 10 months follow-up, we observed the following results: patients of group A showed a mean percentage reduction in incidence of premature ventricular complexes (PVC) after therapy in comparison to basal conditions of 93% and 89% with flecainide and propafenone, respectively, after a treatment of 5 months (p < 0.001); after 10 months mean percentage reduction of PVC was 91% with each drug (p = n.s.); complex ventricular events (CVE) were reduced of 90% and of 100% after 5 and 10 months, respectively, of treatment with flecainide and of 100% both after 5 and 10 months of treatment with propafenone (p = n.s.) -- patients of group 1B showed a mean percentage reduction of PVC of 87% and 84% after 5 and 10 months, respectiively, of treatment with propafenone (p = n.s.); after 5 months of therapy mean percentage CVE reduction was 66% with flecainide and 86% with propafenone (p < 0.001); after 10 months this mean reduction was 53% with flecainide and 73% with propafenone (p < 0.001). -- patients of group 2B showed a mean reduction of PVC of 59% and 58% after 5 and 10 months of therapy with flecainide, and of 65% and 67% after 5 and 10 months of therapy with propafenone (p = n.s.); CVE were reduced of 28% with flecainide and of 47% with propafenone after 5 months of treatment (p < 0.001) and of 36% with flecainide against 52% with propafenone after 10 months (p < 0.01). In the present study there was no significant difference between the two drugs in terms of tollerance and collateral effects (8% with flecainide vs 7%, with propafenone). Our results confirm the efficacy of the 1C class drugs in the treatment of "essential" ventricular arrhytmias. This efficacy appears reduced in non selected patients with organic heart disease. In these latter patients propafenone has shown more efficacy than flecainide in reducing CVE.

[Infections in intensive care units]. / Le infezioni nelle unità di terapia intensiva.

Hospital acquired infections are one of the most serious problems of public health. The problem of hospital infections assumes greatest relevance especially for patients in intensive care units (ICU). In these patients both the incidence (about 40%) and the mortality rate (non infected patients 13%; infected patients 47%) of infections is particularly high. Low respiratory tract represents the most frequent localization of ICU infections (30-50%). The causal pathogens are represented in more than 50% of cases by Gram-negative bacilli provided with low virulence and normally present in patients and in the hospital environment. The pathogenesis of infections in ICU is multiform, deriving from the interplay of many factors: the impairment of organic defenses; the age of the patients, often at the upper or lower limits; the multi-pathology and severity of underlying disease; the side effects of medical therapy (immunodepression); the closeness of many patients in narrow wards, that allows the diffusion of infections; the presence in the hospital environment of many pathogens with poly-antibiotic resistance. The control and prophylaxis programs should include: interventions on ICU structure in order to optimize the building projects and maintain high standard quality; training programs for medical and nursing personnel; interventions on patient-related factors; surveillance protocols (events documentation and monitoring of intervention results).

[Coenzyme Q10: contractile dysfunction of the myocardial cell and metabolic therapy]. / Coenzima Q10: disfunzione contrattile della cellula miocardica e terapia metabolica.

Coenzyme Q10, a mitoquinone involved in mitochondrial energy synthesis and the removal of free radicals, may be lacking in a number of cardiac pathologies leading to reduced contractile activity. The administration of exogenous coenzyme Q10 may help to improve contractile activity. In order to assess this hypothesis 63 patients suffering from altered myocardial contractile function (29 dilated cardiopathies, 15 valvular cardiopathies, 19 ischemic cardiopathies) which presented a NYHA class above 2 were selected. The study was open and patients were subdivided into two groups, one of which received conventional therapy alone whereas the other also received exogenous coenzyme Q10. After 4 months of follow-up clinical (NYHA class, effort tolerance) and echocardiographical (ventricular diameter and contraction fraction %) parameters were evaluated. In those patients treated with coenzyme Q10 and suffering from dilated cardiomyopathy a significant reduction in the NYHA class and a marked improvement in echocardiographic parameters were observed at the end of this period. The variations observed in other groups of patients treated were less conspicuous and not always statistically significant. The results of this study confirm that the association of coenzyme Q10 and conventional therapy may lad to a marked improvement in contractile function and correlated clinical conditions.

[Efficacy of ubidecarenone in the treatment of patients with cardiac insufficiency]. / Efficacia dell'ubidecarenone nel trattamento di pazienti affetti da insufficienza cardiaca.

In 11 patients suffering from medium to severe heart failure, we performed a clinical and instrumental study to evaluate the effectiveness of ubidecarenone (60 mg/die in a single oral dose), in addition to conventional treatment with digitalis and diuretics. After an 8-month follow-up in most patients we observed a significant improvement in clinical symptoms and in quality of life. Furthermore we were able to demonstrate a statistically significant decrease in left atrium dimensions (p less than 0.01), end-diastolic (p less than 0.01) and end-systolic (p less than 0.05) left ventricular diameters and a significative reduction in the distance of the septum from the e point of the mitral valve (p less than 0.05), expression of significant improvement of cardiac output.