Early and subtle abnormalities of left ventricular function in clinically stable coronary artery disease patients with normal ejection fraction.

BACKGROUND: It has been reported that, in the initial phase of ischemic cardiomyopathy, the earliest alterations of left ventricular function are detected during the relaxation phase. The aim of this study was to look for precocious abnormalities in the early stage of ischemic cardiomyopathy in both left ventricular systolic and diastolic phases. METHODS AND RESULTS: Using simultaneous left ventricular catheterization and echo-Doppler techniques, we studied both systolic and diastolic function in 44 (37 males and 7 females, mean age 55.7+/-8) normotensive, clinically stable, coronary artery disease patients with normal left ventricular ejection fraction in comparison to 9 age- and sex-matched normal control subjects (7 males and 2 females, mean age 54.7+/-9). Mean values of E deceleration time, tau, left ventricular end-diastolic volume and pressure, and end-systolic volume and lowest diastolic pressure were significantly higher (from P<.05 to P<.01), whereas mean dP/dt/P values significantly lower (P<.05) in coronary artery disease patients than in controls. A strict relationship (P<.001) between dP/dt/P and tau, left ventricular lowest and end-diastolic pressure was found in all subjects studied. CONCLUSION: Early and subtle abnormalities in parameters of both systolic and diastolic function can be found in the majority of coronary artery disease patients with normal ejection fraction.

Detection of early abnormalities of left ventricular function by hemodynamic, echo-tissue Doppler imaging, and mitral Doppler flow techniques in patients with coronary artery disease and normal ejection fraction.

We have investigated the possibility of detecting early abnormalities of left ventricular function at the initial phase of ischemic cardiomyopathy. Sixteen normotensive patients with coronary artery disease and normal left ventricular ejection fraction and 6 control patients were studied by invasive hemodynamic techniques in combination with transmitral Doppler flow or with echo-tissue Doppler imaging. The extent of the percentage of left ventricular longitudinal shortening and the systolic peak velocity at echo-tissue Doppler were significantly higher in the control patients than in patients with ischemic cardiomyopathy (P <.01). Left ventricular end-diastolic pressure was higher (P <.05), whereas mean values of isovolumic contraction and relaxation indexes (dP/dt/P: P <.05; +dP/dt: P <.05; -dP/dt: P <.01) were lower in patients with ischemic cardiomyopathy. Tau was significantly longer in ischemic patients (42.7 +/- 8.8 versus 34.5 +/- 3.7 ms, P <.05). In the control patients, the aortic valve closure to peak E interval by transmitral Doppler flow was significantly longer than that measured by echo-tissue Doppler (P <.001), whereas in patients with ischemic cardiomyopathy, this interval difference was still present and significantly shorter (P <.05). In patients with coronary artery disease and normal ejection fraction, minor and early abnormalities of left ventricular function related to isovolumic contraction and relaxation as well as to longitudinal shortening could be detected. In addition, a suction-like effect, detected during early filling evaluation with echo-tissue Doppler, is significantly decreased but not abolished during the early stages of coronary artery disease.

Aortic intramural hematoma: an increasingly recognized aortic disease.

Aortic intramural hematoma (IMH) is a rarely diagnosed pathological condition that is not well characterized to date. We diagnosed IMH in 4 of 31 patients with suspected aortic dissection admitted to our coronary care unit from 1992 to 1995. In all 4 cases, IMH was located in the ascending aorta. At the time of hospitalization, all patients showed tachycardia, hypotension and pericardial effusion. Diagnosis of IMH was made by transesophageal echocardiography and computed tomography. We performed aortography in 2 patients, but it was non-diagnostic in both of them. One patient died before surgery. Autopsy confirmed the diagnosis of IMH and showed severe pericardial effusion. In another patient, the diagnosis was confirmed during successful surgery, while the remaining 2 patients recovered after medical therapy. The 3 surviving patients are still under follow-up control 12, 16 and 20 months after the initial acute event. We briefly discuss the epidemiological, clinical, diagnostic, therapeutic and prognostic aspects of IMH.

Abnormal ventricular repolarization mimicking myocardial infarction after heterocyclic antidepressant overdose.

In 2 young adult women who experienced acute heterocyclic antidepressant intoxication, we found a quite unusual electrocardiographic pattern characterized by abnormal ST-tract elevation in the right precordial leads associated with a marked QRS widening (right bundle branch block and left anterior fascicular block type). Because serum electrolyte imbalance and acute myocardial ischemic events were excluded, the mechanism by which antidepressant overdose may produce such elevation of the ST tract remains unclear.

Left-ventricular outflow tract obstruction by mitral valve ring calcification and proximal septal hypertrophy in elderly patients. Presentation of 2 clinical cases.

The pathophysiology, clinical presentation and prognosis of left-ventricular obstruction still represent an important cardiological problem. Various anatomical and/or functional mechanisms can cause this phenomenon. This report concerns 2 patients over 75 years old in whom the simultaneous presence of localized proximal septal hypertrophy and massive calcification in the anterior portion of the mitral valve ring provoked significant systolic intraventricular gradients. Cardiac rhythm disturbances and consequent variability of R-R intervals, found in both subjects, appear fundamental in determining the value of such gradients. Occasionally an anterior mitral ring calcification may bring about left-ventricular outflow tract obstruction in aged hearts where localized hypertrophy of the proximal portion of the intraventricular septum is present.

Single coronary artery-right ventricular fistula with a partially thrombosed large aneurysm of its proximal tract in a 66-year-old man.

An exceptional combination of three major coronary anomalies: a single coronary artery, a congenital coronary-right ventricular fistula and a large proximal coronary aneurysm were found in a living 66-year-old patient suffering from post-myocardial ischaemic heart disease. Each coronary anomally and their influence on the clinical situation of the patient are briefly discussed.

Effect of dobutamine on left ventricular relaxation and filling phase in patients with ischemic heart disease and preserved systolic function.

The beneficial effects of dobutamine on left ventricular systolic and diastolic phases have been described in patients with congestive heart failure. Its influence on left ventricular diastolic phase in patients with preserved systolic function, absence of dys- or akinetic areas, and left ventricular dilatation has not yet been adequately investigated. Thus a simultaneous echo-Doppler and hemodynamic study was performed in 15 patients with ischemic heart disease and preserved systolic function in order to assess the effect of dobutamine on left ventricular relaxation and filling phase. The infusion of dobutamine at a rate of 10 micrograms/kg/min induced a marked inotropic action, as shown by the significant increase in positive dP/dt (from 1392 +/- 224 to 2192 +/- 295 mmHg/sec, p < 0.001), dP/dt/P (from 32 +/- 8.1 to 50 +/- 17 sec-1; p < 0.0001), and in peak of systolic pressure (from 143 +/- 25 to 168 +/- 36 mmHg; p < 0.005). In addition, dobutamine reduced the end-systolic volume index (from 30 +/- 16 to 26 +/- 19 ml/m2; p < 0.05), the end-systolic stress (from 222.2 +/- 65.3 to 198.4 +/- 84 g/cm2; p < 0.006), and had favorable effects on relaxation and the early filling phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Digitalis and heart failure: does digitalis really produce beneficial effects through a positive inotropic action?

Although digitalis was introduced to medicine long ago, the drug is still extensively used in clinical practice today. Opinions on its mechanism of action have undergone much change in the course of time, and the way in which cardiovascular effects are produced is still not completely clear. Limitations and contraindications for the use of digitalis substances are reported, especially in the treatment of ischemic heart disease. Preliminary data regarding the effects of digitalis on the diastolic phase are unfavorable, although the relationship between digitalis and diastolic function ought to be studied in greater depth in various clinical conditions. In spite of many recent trials, the old question of the usefulness of digitalis in the chronic treatment of patients in sinus rhythm and heart failure is still debated. An important clinical benefit in the chronic use of digitalis appears restricted to a relatively small proportion of patients with severe congestive heart failure, while in the majority of chronically treated subjects the effects of the drug are scanty or insignificant. The beneficial effect of digitalis used chronically is essentially believed to be due to its positive inotropic action. Since the vagomimetic and the antiadrenergic effects of digitalis have been demonstrated to be independent from its inotropic action, they could be considered determinants of the clinical benefits of digitalis. These indirect effects may be useful in the control of the negative neuroendocrine response developing during congestive heart failure. Thus the statement that digitalis is essentially an inotropic agent seems restrictive; its definition should reflect the favorable effects obtained in some cases of congestive heart failure rather than its various and contrasting underlying mechanisms of action.

[The diagnosis by a Doppler color echocardiographic method of an aortocaval fistula following the rupture of an aortic aneurysm into the inferior vena cava]. / Diagnosi con metodica ecocardiografica e Doppler a colori di fistola aortocavale conseguente a rottura di aneurisma aortico in cava inferiore.

We describe a clinical case presenting 2 rare features. The first was a spontaneous aortocaval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second infrequent feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-color Doppler flow imaging (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination showed an aneurysm of the descending aorta that communicated to a dilated inferior vena cava. Furthermore, flow study with color Doppler showed a continuous turbulent, mixed (arterial and venous) blood flow into the inferior vena cava.

Diagnosis of an aorto-caval fistula by echo 2D color Doppler flow imaging and echocardiographic probe.

We describe a clinical case presenting two unusual features. The first was a spontaneous aorto-caval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second uncommon feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-Doppler color flow (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination revealed an aneurysm of the abdominal aorta that communicated with a dilated inferior vena cava. Furthermore, flow study with pulsed color Doppler revealed a continuous turbolent, mixed (arterial and venous) blood flow into the vena cava.

[Effects of i.v. nicardipine in the treatment of hypertensive crisis]. / Effetti della nicardipina e.v. nel trattamento delle crisi ipertensive.

The availability of i.v. nicardipine has urged us to prove this drug in the treatment of hypertensive attacks (SAP greater than or equal to 210 mmHg and/or DAP greater than or equal to 110 mmHg). Two groups of patients (each made up of ten subjects) were treated with 2 mg and 5 mg respectively of i.v. nicardipine injected for 4 min while mean systolic and diastolic arterial pressure and heart rate were registered until three hours. I.V. nicardipine administration induced in both groups of patients a decrease in systolic pressure from 20 to 30% while diastolic arterial pressure decreased from 15 to 18% in the first group and from 20 to 25% in the second one. Heart rate showed an initial mild increase following arterial vasodilator action of nicardipine whereas it decreased significantly from 120 min in the presence of an unchanged hypotensive effect of the drug. One patient did not respond to nicardipine while another felt chest pain and palpitations. In conclusion our results are satisfactory and argue for the inclusion of nicardipine among the drugs that may be considered useful for the treatment of hypertensive attacks.

Sudden dilatation of right ventricle in two patients with thrombosis of a mitral Björk valve detected by echocardiography: different aspects of acute and chronic overloads of the right ventricle in these patients.

Acute thrombotic obstruction of disc valve prosthesis is a rare but catastrophic event without an immediate correct diagnosis and precocious treatment (Amman et al., 1984; Assanelli et al., 1986; Copans et al., 1980; Mann et al., 1986; Gibson et al., 1974; Johnson et al., 1973; Ledain et al., 1986). That is the main reason it is important to consider each helpful sign in order to recognize such a situation. We detected an important dilatation of the right ventricle in two patients with different stages of thrombosis of mitral Björk, the first one had also a chronic dilatation of the right ventricle due to tricuspid regurgitation. The clinical and pathophysiological aspects of these unusual situations are described in this article.

Dynamic left-ventricular tract outflow obstruction: a late complication of mitral valve replacement.

The case presented is a 47-year-old woman with left-ventricular outflow tract obstruction which was the late complication of mitral valve replacement (4 years later). The diagnosis was made using two-dimensional Doppler echocardiography (echo-2D Doppler) and confirmed by cardiac catheterization. Protrusion of the prosthetic ring towards the intraventricular septum reducing the diameter of the outflow tract to 7-8 mm and creating a dynamic obstruction (30 mm Hg on cardiac catheterization, and 44 and 75 mm Hg on echo-2D Doppler basally and after isoamyl nitrite inhalation, respectively) was recorded. The echo-2D Doppler technique appears to be useful in detecting this postsurgical mitral complication.

[Dynamic obstruction of the left ventricular outflow as a late complication of mitral valve replacement. Case report]. / Ostruzione dinamica all'efflusso ventricolare sinistro insorto tardivamente dopo sostituzione valvolare mitralica. Descrizione di un caso.

The obstruction of the left ventricular tract outflow following mitral valve surgery, as a late complication, is rarely reported in the literature. The case of a 47-yr-old woman, who, after mitral valve surgery, developed dynamic left ventricular tract outflow obstruction four years later is reported. This alteration was detected by 2D echo-Doppler. The echocardiographic findings were: 1) Normal function of the mitral prosthesis. 2) An equal pressure-gradient of 44 mmHg at rest and of 75 mmHg after amyl nitrite at three examined levels: below, above and at the level of the aortic valve. 3) A hyper-echo image in the peri-annular region, probably representing fibrous degeneration around the valve ring, which was the likely cause of the obstruction. Th data were confirmed by cardiac catheterization. The echocardiographic technique appears to be a useful tool to detect and study this complication of mitral valve surgery.

Serial cross-sectional echocardiographic detection of multiform floating right-heart thromboemboli. A case report.

This report describes a case in which serial cross-sectional echocardiographic examinations allowed us to make the diagnosis and to follow anatomical evolution of pulmonary thromboemboli. Frequent (three times a day for seven days) echocardiographic surveillance of thromboemboli allowed us to assess the effectiveness of the therapeutic approach.

[Effects of intravenous flecainide in the treatment of paroxysmal or recent-onset atrial fibrillations]. / Effetti della flecainide endovenosa nel trattamento delle fibrillazioni atriali parassistiche o di recente insorgenza.

Intravenous flecainide (2 mg/Kg for 15 min) was used in 30 patients (18 men and 12 women aged 23 to 85 years: mean 62) with recent or paroxysmal atrial fibrillation: 5 patients returned to sinus rhythm during flecainide administration while other 23 patients did it not later than 2 hours. Treatment with intravenous flecainide proved to be safe without significant side effects. Further investigations are required to define the effects of flecainide in the treatment of atrial fibrillation; at the moment it must be admitted that flecainide acetate is a useful, safe, fast acting drug for the conversion of paroxysmal or recent atrial fibrillation to sinus rhythm.

Hemodynamic effects of celiprolol at rest and during exercise; a comparison with enalapril.

The antihypertensive effects of once-daily administration of celiprolol 400 mg were compared with those of once-daily enalapril 20 mg in 20 mild to moderate essential hypertensives in a single-blind study in which the subjects were randomized to 2 weeks' treatment with either drug, preceded by 2 weeks of placebo administration. Supine and standing systolic blood pressure (SBP), diastolic pressure (DBP), and heart rate (HR) were measured at rest and during exercise (exercise bicycle with increasing work loads up to 100 watts) at the end of either period, 20 to 24 hr after drug or placebo administration. Compared to placebo, both celiprolol and enalapril reduced resting supine and standing SBP and DBP to a marked and similar extent; resting HR was unaffected by enalapril, while celiprolol produced modest reductions. During exercise, however, celiprolol significantly attenuated rises in SBP and HR, while enalapril did not. Indexes of cardiac function at rest obtained by echocardiography and systolic time intervals were unaffected by either drug. Thus, despite similar reductions by both drugs in resting blood pressures, celiprolol produced better antihypertensive effects during exercise than enalapril.