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.

[The diagnosis of prosthesis pathology in biological and mechanical valves. I. Clinical and echocardiographic evaluation]. / Diagnostica della patologia protesica di valvole meccaniche e biologiche. I. Valutazione clinica ed ecocardiografica.

We retrospectively evaluated the clinical and echocardiographic findings of 50 patients with documented malfunctioning of cardiac prosthetic valves. The prostheses, mechanical or biological, were in 24 cases in a mitral and in 26 cases in an aortic position. Prosthetic dysfunction was due to thrombosis, fibro-calcific degeneration, fibrous cloth, bacterial infection, dehiscence, mismatch. The clinical features were represented by cardiac insufficiency of different degrees, up to global congestive failure unresponsive to medical treatment, by sudden low-output syndrome, arrhythmias, angina. The changes in auscultatory findings have appeared important clues to prosthetic malfunction, but we stress the necessity of an instrumental documentation of the type and grade of dysfunction. Echocardiography has represented an essential tool for a rapid and accurate noninvasive diagnosis of prosthetic pathology. The echocardiographic examination, except 2 false negatives, has consistently provided informations useful for therapeutic decisions. In 7 cases in critical clinical conditions (refractory heart failure or shock) the echocardiographic examination has afforded the exact documentation and identification of prosthetic pathology, allowing by itself a surgical decision.

[Prosthetic pathology of mechanical and biological valves in the mitral and aortic position. II. Hemodynamic-angiographic evaluation and anatomo-surgical aspects]. / Patologia protesica di valvole meccaniche e biologiche in posizione mitralica ed aortica. II. Valutazione emodinamico-angiografica ed aspetti anatomo-chirurgici.

The catheterization parameters of 42 patients with surgically confirmed prosthetic valve malfunction were retrospectively analyzed in order to evaluate the role of hemodynamic and angiocardiographic examination in the diagnosis of prosthetic complications. The invasive investigation provided in all cases more precise informations regarding the type and grade of prosthetic malfunction as compared to noninvasive techniques. Transvalvular gradients could be quantified, the amount of regurgitation could be defined and associated lesions (paraprosthetic aneurysms, aortic root dissection, fistulas secondary to bacterial endocarditis) could be recognized. The surgical exploration confirmed prosthetic malfunction in all cases except two, with fibrous tissue ingrowth: at the moment this complication is not distinguishable from thrombosis and no specific diagnostic signs have been described either with invasive or noninvasive techniques. In our experience the patients who can benefit from hemodynamic examination are: patients with echocardiographic examination of poor technical quality, patients in whom noninvasive investigations can not completely explain the clinical status ("false negative" echocardiograms, multiple prosthetic valves), all cases in whom cardiac surgery requires a precisely detailed evaluation of the prosthetic malfunction. The opportunity or necessity to perform an invasive study in patients with clinically suspected or proven prosthetic malfunction should be discussed individually.

[Cardiac insufficiency caused by iatrogenic arteriovenous fistula]. / Scompenso cardiaco da fistola artero-venosa iatrogena.

Two cases of iatrogenic arterio-venous fistula complicated by heart failure are described. A 50 year-old woman was admitted to the hospital with congestive heart failure and a questionable diagnosis of congestive cardiomyopathy. A continuous murmur heard over the lumbar spine close to a surgical scar from an intervention on the L4-L5 disc that the patient had undergone six months before, led to the diagnosis of an arterio-venous fistula. Angiography demonstrated a direct communication between the right iliac artery and the right iliac vein. After surgical closure of the fistula normal cardiac function was restored. The second patient (a sixty-year-old woman) had undergone surgical mitral valve replacement with a Hancock bioprosthesis 18 months before the current admission. In the post-operative period the percutaneous insertion of an intravenous line through the left jugular vein had been unsuccessfully attempted. She had mild heart failure which was ascribed to incompetence of the bioprosthetic valve. A continuous murmur in the left supraclavear area suggested the presence of an arterio-venous fistula. Angiography showed a direct communication between the supraclavear branch of the left subclavian artery and the left subclavian vein. The fistula was successfully closed. Both cases confirm the potential harmfulness for the vascular bed of certain surgical interventions and intravascular monitoring techniques. When heart failure of uncertain etiology appears in patients previously submitted to the one of the above mentioned procedures, a careful clinical examination can lead to a correct diagnosis of iatrogenic arterio-venous fistula, whose surgical correction is usually followed by the restoration of a normal cardiac function.