Aorto-atrial fistula through the septum in recurrent aortic dissection.

A case of aortic dissection (De Bakey type I) with a fistula to the right atrium through the interatrial septum, diagnosed by transthoracic and transesophageal echocardiography is reported. The patient presented with cardiac failure and a continuous murmur in the right second and third intercostal spaces. The patient underwent successful operative repair.

Resting echocardiography and quantitative dipyridamole technetium-99m sestamibi tomography in the identification of cardiac allograft vasculopathy and the prediction of long-term prognosis after heart transplantation.

AIMS: To evaluate the accuracy of echocardiography in conjunction with quantitative high-dose dipyridamole technetium-99m sestamibi tomography (SPECT) in detecting coronary allograft vasculopathy. METHODS AND RESULTS: Seventy-eight consecutive heart transplant recipients underwent echocardiography while at rest and high-dose dipyridamole SPECT within 48 h of a yearly angiogram. Resting wall motion abnormalities were considered significant if present in two or more segments. SPECT was considered abnormal in the presence of reversible/fixed defects. The coronary angiogram was normal in 53, showed non-significant coronary allograft vasculopathy in 13 and significant (> or = 50% stenosis) coronary allograft vasculopathy in 12 cases. Resting wall motion abnormalities were observed in nine cases and perfusion defects in 20. Echocardiography and SPECT were concordant in 59 cases (five positive and 54 negative); in these, accuracy was 100% for significant coronary allograft vasculopathy and 83% for any coronary allograft vasculopathy. Over 6.5+/-2 years, 17 patients suffered coronary allograft vasculopathy-related events, including death in six and retransplantation in three. Resting wall motion abnormalities, SPECT perfusion defects and angiographic coronary allograft vasculopathy were significant predictors of cardiac events. CONCLUSION: Normal resting wall motion at echocardiography coupled to normal stress myocardial perfusion, rules out the presence of significant coronary allograft vasculopathy in many heart transplant recipients. Conversely, resting wall motion abnormalities and perfusion defects strongly predict cardiac events. Therefore, a strategy which reserves angiography for patients with resting wall motion abnormalities and/or perfusion defects may be safe and cost-effective.

Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair.

METHODS: A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter > 21 mm/m2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. RESULTS: Hospital mortality was 2.0% (CL 0.3-3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25 +/- 15.9). Three late deaths occurred (6.1% CL 2.8-9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9-93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as 'negative late results': persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of > 25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the 'preoperative fraction shortening of the tricuspid annulus' (P = 0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% (P = 0.0001). CONCLUSIONS: The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (> 21 mm/m2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.

[Doppler echocardiography after heart transplantation]. / L'esame ecocardiografico Doppler dopo trapianto cardiaco.

Acute rejection, graft atherosclerosis and infections are the major causes of morbility and mortality after heart transplantation. Therefore clinical follow-up after heart transplantation is usually focused on the early diagnosis and treatment of these complications. The early recognition of acute rejection episodes in cardiac allograft recipients remains a major challenge during follow-up after heart transplantation. The standard method used to identify rejection is endomyocardial biopsy, but this technique shows some important inherent limitations. Even if noninvasive methods are generally considered inaccurate in the early diagnosis of acute rejection, echocardiography is routinely used in the surveillance of heart transplant recipients to monitor allograft function. Furthermore it may be used to screen significant acute rejection episodes, because it can identify several morphologic and functional changes that are related to acute rejection: increase in left ventricular myocardial thickness, changes in ultrasonic texture, pericardial effusion, systolic and diastolic dysfunction. In this setting it is very useful to perform serial echocardiographic examinations, because the changes of echocardiographic and Doppler parameters in comparison with previous examination in each individual patient can be accurate in detecting acute rejection and evaluating the response after immunosuppressive treatment. The development of coronary artery disease (CAD) is the major factor limiting long-term survival. Serial coronary artery angiography remains the only effective diagnostic tool for detecting CAD, while noninvasive tests commonly used in atherosclerotic heart disease are considered inaccurate, due to their low sensitivity. However several studies reported a high accuracy of dobutamine stress echocardiography in the diagnostic and prognostic assessment of CAD. Furthermore, rest wall motion abnormalities and left ventricular systolic dysfunction can identify patients with significant CAD and worse prognosis. In conclusion, echocardiography cannot supplant invasive methods for monitoring acute rejection and CAD, but it is a useful tool for surveillance after heart transplantation.

Left ventricular performance in chronic mitral regurgitation: temporal response to valve repair and prognostic value of early postoperative echocardiographic parameters.

BACKGROUND: The temporal response of the left ventricle due to the relief of volume loading after mitral valve repair, and the prognostic value of early changes in left ventricular size and function, are not fully documented. The purpose of this study was to analyze the evolution of left ventricular performance after surgery, and to evaluate how early postoperative echocardiographic parameters compare with late ventricular function. METHODS: We studied 58 patients with chronic degenerative mitral regurgitation using echocardiography, before, and 9 +/- 3 days and 38 +/- 6 months after mitral valve repair. RESULTS: Between the preoperative and early postoperative study, left ventricular end-diastolic and left atrial size, and ejection fraction decreased, whereas left ventricular end-systolic dimension did not change. Between the early and late postoperative study left ventricular end-systolic size decreased significantly, there was a further decrease in left ventricular end-diastolic dimension and a significant increase in ejection fraction; left atrial size did not change. Multivariate analysis showed that preoperative and early postoperative ejection fraction, and the early postoperative reduction in diastolic dimension were the best predictors of late left ventricular function. CONCLUSIONS: In patients with chronic degenerative mitral regurgitation, the greatest reduction in end-diastolic dimension occurs within 2 weeks of the reversal of volume overload; a significant reduction in end-systolic dimension with an increase in ejection fraction occurs later. In our experience, early postoperative echocardiographic measurements of left ventricular size and function can provide important prognostic information.

The limitations of echocardiography in the overall diagnosis of the morphological lesions associated with infective endocarditis: comparison of echocardiographic and surgical findings.

Echocardiography is commonly accepted as the method of choice for the non-invasive diagnosis of vegetations and other lesions associated with infective endocarditis. To assess the accuracy of echocardiography in the overall diagnosis of the morphological cardiac lesions we retrospectively analyzed and compared the preoperative echocardiographic data with the surgical findings of 120 consecutive cases operated for infective endocarditis. Transthoracic echocardiography (TTE) was used in 60 cases (51 with native and 9 with prosthetic valves), both TTE and transesophageal echocardiography (TEE) in 50 (26 with native and 24 with prosthetic valves) and only TEE in 10 patients who underwent emergency surgery. The echocardiographic diagnosis was correct in all the cases, but incomplete in 26 (16 with native and 10 with prosthetic valves). Most of the incomplete diagnoses occurred regarding vegetations, perforations of the valvular leaflets and perivalvular abscesses. There were no differences between aortic or mitral valves (14/66 vs 11/60; p = ns), native or prosthetic (16/79 vs 10/37; p = ns), TTE or TEE (13/60 vs 13/60; p = ns); however, TEE was performed in more complex cases and in severely ill patients. In six of the incomplete diagnoses, echocardiography preceded surgery by one week or more, and in six the mistakes were not confirmed by the reviewer. In conclusion, our study suggests that an echocardiographic diagnosis of endocarditis may be correct but sometimes incomplete. In patients without prosthetic valves who have a technically-adequate transthoracic echocardiogram, transesophageal echocardiography is not indispensable but should be chosen from time to time. However, the patients with endocarditis and no contraindication to the transesophageal procedure should undergo both transesophageal and transthoracic echocardiography before surgery in order to obtain as much and the most definite information possible. An echocardiographic study should be repeated just before any surgical procedures in patients with active endocarditis. Finally, it needs to be emphasized that the training and clinical judgement of the operator performing the study are important elements determining the results of echocardiographic study.

Which variable of stenosis severity best describes the significance of an isolated left anterior descending coronary artery lesion? Correlation between quantitative coronary angiography, intracoronary Doppler measurements and high dose dipyridamole echocardiography.

OBJECTIVES: This study sought to investigate the angiographic or intracoronary Doppler variables of stenosis severity that best correlate with the results of dipyridamole echocardiography. BACKGROUND: Quantitative coronary angiography and intracoronary Doppler flow velocity assessments are the commonly used techniques for the objective identification of significant coronary artery stenosis. METHODS: Thirty patients with an isolated lesion of the left anterior descending coronary artery (LAD) were studied by means of on-line quantitative coronary arteriography, intracoronary Doppler flow velocity measurements and dipyridamole echocardiography 6 months after percutaneous transluminal coronary angioplasty. The quantitative arteriographic analyses were performed on-line; post-stenotic Doppler flow velocities were measured at baseline and after adenosine infusion. Angiographic and Doppler measurements were compared with the corresponding dipyridamole echocardiographic data and analyzed by discriminant analysis. RESULTS: The dipyridamole echocardiographic response was positive in 11 patients (37%). The best cutoff values for predicting an abnormal echocardiographic response were 1) stenotic flow reserve of 2.8 (p = 0.0001); 2) 59% diameter stenosis (p = 0.0001); 3) minimal lumen diameter of 1.35 mm (p = 0.001); 4) coronary flow reserve of 2.0 (p = 0.0002); and 5) maximal peak velocity of 60 cm/s during hyperemia (p = 0.04). Multivariate analysis identified stenotic flow reserve as the only independent predictor of ischemia during dipyridamole echocardiography. CONCLUSIONS: Stenotic flow reserve is the variable that best describes the functional significance of an isolated LAD lesion, and a value of 2.8 is the best predictor of a positive dipyridamole echocardiographic response. Furthermore, angiographic variables of stenosis severity relate to echocardiographic test results better than intracoronary Doppler variables.

The clinical value of blunting of cyclic gray level variation for the detection of acute cardiac rejection: a two-dimensional, Doppler, and videodensitometric ultrasound study.

Aims of this study were to assess (1) whether videodensitometric analysis of myocardial gray-level variation can distinguish normal from rejecting transplanted hearts in a clinical setting and (2) whether this sign, used in combination with the other conventional two-dimensional and Doppler echocardiographic findings, might improve the accuracy of ultrasound techniques. Thirty heart transplant recipients (23 men; mean age 40 years; range 20 to 54 years) were studied in 87 different situations by endomyocardial biopsy and echocardiographic evaluation. Of the 87 situations, 37 ("rejectors") showed histologic evidence of rejection of mild (n = 17) or moderate (n = 10) severity and 50 ("nonrejectors") did not show rejection processes. Cyclic variation was decreased significantly in rejectors compared with nonrejectors in both the septum (15% +/- 10% versus 25% +/- 11%; p < 0.0001) and the posterior wall (19% +/- 10% versus 25% +/- 12%; p < 0.01). When a cutoff of 20% or greater of cyclic variation in the septal wall was taken as a positivity criterion, it yielded a 70% sensitivity and 70% specificity for identifying rejection. Sensitivity of conventional two-dimensional and Doppler echocardiographic signs was 51% and increased to 89%, increased by the videodensitometric criteria (p < 0.001). Specificity was 92% and decreased to 62% with videodensitometric criteria (p < 0.001). Overall diagnostic accuracy was 75% for conventional two-dimensional echocardiographic Doppler criteria alone and remained unchanged by the addition of videodensitometric criteria. In conclusion, blunting of cyclic gray-level variation induced by rejection is detectable with videodensitometric analysis. The clinical impact of this sign appears to be limited, because the resulting increase in sensitivity is counter-balanced by a reduced specificity compared with the currently available conventional ultrasound techniques.

Significance of pericardial effusion after heart transplantation.

The aim of this study was to evaluate the clinical significance of pericardial effusion after heart transplantation and to assess its correlation with acute rejection. One hundred fifty transplanted patients were followed up for the first year: serial echocardiographic studies were performed on the same day as were the endomyocardial biopsies; hemodynamic studies and coronary angiographies were performed 1 year after transplant. Ten days after surgery, pericardial effusion was absent in 77 patients, small in 52, moderate in 14, and large in 7, and was significantly related to severe postoperative bleeding (p < 0.001). Patients were classified according to the presence and the course of pericardial effusion in group A (absence or disappearance of previous pericardial effusion within 1 month, 107 patients) and in group B (onset, persistence, or increase in pericardial effusion, 43 patients). One hundred nineteen patients experienced > or = 1 acute rejection episode. The evolution of pericardial effusion was different (p < 0.0001) according to the number of acute rejection episodes and biopsy specimens showing acute rejection, histologic grading and time of the first episode, and histologic grading of the most severe acute rejection episode. Furthermore, there was a significant correlation with the cumulative duration of acute rejection episodes (p < 0.005) and the presence of previous cardiac surgical history (p < 0.007), but no correlation with cardiac transplant vasculopathy or with a positive weight mismatch. This study suggests that pericardial effusion in transplant recipients is associated with a higher incidence and more severe histologic grading of acute rejection episodes; its presence indicates the need for stricter monitoring of acute rejection.

Acute rejection after heart transplantation: noninvasive echocardiographic evaluation.

OBJECTIVES: The purpose of this study was to assess the reliability of echocardiography in the noninvasive diagnosis of acute rejection in heart transplant recipients. BACKGROUND: Although echocardiographic results seem to correlate well with allograft rejection, published data are limited and contradictory. METHODS: In 130 transplant recipients, 1,400 serial echocardiograms were recorded within 24 h of endomyocardial biopsy. Increased wall thickness, myocardial echogenicity, pericardial effusion, shorter pressure half-time, isovolumetric relaxation time and a decrease in left ventricular ejection fraction were considered markers of rejection. RESULTS: The distribution of echocardiographic markers revealed highly significant differences between bioptically graded moderate, mild and no rejection and between untreated and treated rejection episodes (both chi-square test, p < 0.0001). Specificity was 98.6% for two markers, but sensitivity was good (80%) for only moderate rejection because of the large number of false negatives in untreated patients with mild rejection. In untreated patients, there was a highly significant difference in the number of echocardiographic criteria between a benign and nonbenign outcome (chi-square test, p < 0.0001). In treated patients, the significant difference in the variation in echocardiographic criteria between favorable and unfavorable responses after 1 week was more pronounced after 2 weeks (t test, p < 0.01 vs. < 0.001). Diastolic indexes and pericardial effusion at 2 weeks seemed to be predictive of therapeutic response. CONCLUSIONS: Poor sensitivity to mild rejection indicates that serial echocardiography cannot supplant endomyocardial biopsy in the early diagnosis of acute rejection, but it seems to be a reliable noninvasive means of identifying acute rejection requiring intensified immunosuppressive therapy and of evaluating outcome.

Coronary artery disease after heart transplantation: non-invasive evaluation with exercise thallium scintigraphy.

In order to assess the value of exercise thallium scintigraphy for the detection and prognosis of graft coronary artery disease, 50 heart transplant patients (mean age 46.7 +/- 11.5 years) were studied within 48 h of their scheduled yearly coronary angiography and subsequently followed up for a mean of 13 +/- 3 months. Angiography revealed normal coronary arteries in 35 patients, and coronary artery disease in 15 (two with type A lesions, seven with type B lesions and six with both). Seven patients had one or more stenoses > or = 50%. Exercise thallium scintigraphy was negative in all patients with normal coronary arteries (100% specificity), and abnormal in 10 of 15 patients with coronary artery disease (67% sensitivity). Fixed defects were seen in six cases, transient defects in two and both in two; the results of the test were abnormal in all seven patients with > or = 50% lesions. During follow-up, none of the patients with a normal exercise thallium scintigraphy experienced any cardiac event; in the group with abnormal results, four cardiac events occurred. Although further studies are needed to confirm these results, exercise thallium scintigraphy seems to be useful in evaluating post-transplant coronary artery disease: it is accurate in detecting the most severe stenoses and provides some prognostic information.

High-dose dipyridamole echocardiography test in coronary artery disease after heart transplantation.

In order to evaluate the usefulness of the high-dose dipyridamole echocardiography test (DET) for the detection of coronary artery disease (CAD) after heart transplant and for the assessment of prognosis, 80 heart transplant patients underwent this test within 48 h of the scheduled yearly coronary angiography. Coronary angiography showed normal coronary arteries in 55 patients and CAD in 25, eight of whom had > 50% luminal narrowing. Segmental hypokinesis on baseline echocardiography was present in 27 patients, 19 of whom had CAD (sensitivity = 76%; specificity = 85%). DET was negative in all the patients with normal coronary arteries (specificity = 100%). Out of 25 patients with CAD, eight had a positive DET and 17 a negative DET (sensitivity 32%), but DET was positive in seven of the eight patients with coronary artery stenosis > 50% (sensitivity 87%). During follow-up (9.8 +/- 4.5 months) seven cardiac events occurred in seven patients, all with CAD and wall motion hypokinesis (six on baseline echocardiogram and four after dipyridamole infusion). In our experience, DET does not seem adequate for the screening of post-transplant CAD, but useful in identifying patients with severe lesions (> 50%). Wall motion abnormalities on baseline echocardiogram or after dipyridamole infusion might identify patients who require closer surveillance. A longer experience is needed to confirm these results.

Color Doppler echocardiographic assessment of atrial septal defect size: correlation with surgical measurements.

In patients with atrial septal defect (ASD), color flow Doppler echocardiography provides visualization of the transseptal jet, the maximal dimension of which can be assumed to correspond to the maximal dimension of the true orifice. To test whether color flow Doppler echocardiography can provide an alternative method for measurement of ASD size, we studied 63 consecutive patients with echocardiographic evidence of ASD. In 48 patients the maximal dimension of the jet was measured in the parasternal, apical, or subcostal four-chamber view or in the parasternal short-axis view. In the remaining 15 patients transesophageal echocardiography was performed because of transthoracic views were inadequate. The transesophageal studies also measured, from two-dimensional images, the maximal transverse discontinuity in the atrial septum. All patients underwent surgical repair, during which the surgeon directly measured the maximal dimension of ASD. Linear regression equations were performed to compare transthoracic and transesophageal dimensions to those measured at operation. Correlation coefficients were as follows for transthoracic versus surgical measurements: r = 0.745, standard error = 4.35, p less than 0.001. Transesophageal measurements derived from both two-dimensional images and echocardiographic jet width showed similar excellent correlation with surgical measurements (n = 0.91, standard error = 4.33, p less than 0.001; and r = 0.919, standard error = 4.42, p less than 0.001, respectively). We conclude that ASD size derived from color flow Doppler echocardiography shows a good correlation with the anatomic maximal dimension observed at operation. Both transesophageal color flow Doppler echocardiography of jet width and direct surgical measurement of the defect provide an accurate estimation of ASD size.

Usefulness of color Doppler in the diagnosis of ventricular septal rupture after myocardial infarction.

Ten consecutive patients with ventricular septal rupture complicating acute myocardial infarction were studied by means of Doppler echocardiography (including two-dimensional, conventional and color Doppler techniques) and bedside right heart catheterization using a Swan-Ganz catheter. One patient died before an operation could be performed. Seven critically ill patients underwent emergency cardiac surgery without preoperative cardiac catheterization, while in two patients it was also possible to undertake coronary angiography before surgery. Two-dimensional echocardiography diagnosed post-infarction ventricular septal rupture in 6 out of 10 patients. Color Doppler revealed the presence and the location of septal rupture in all 10 patients. The color Doppler diagnosis was confirmed either by surgery or necropsy. The estimates of pulmonary artery pressure, obtained by color Doppler-guided continuous wave Doppler beam, were very close to those measured by simultaneous right heart catheterization. In 3 patients, patch leakage occurred 3 days, 15 days and 1 year after the operation. Two-dimensional echocardiography revealed the patch leakage in only one of 3 patients while its location was visualized by color Doppler in all 3 patients. In one patient the color Doppler diagnosis was confirmed at necropsy. In the remaining 2 patients, a small left-to-right shunt was demonstrated by radionuclide studies. Color Doppler echocardiography is a highly sensitive and rapid technique in the diagnosis of postinfarction ventricular septal rupture. In critically ill patients it offers relevant information and may obviate the need for any invasive preoperate investigation.

[Echocardiographic evaluation of mitral valve calcification]. / Valutazione ecocardiografica delle calcificazioni valvolari mitraliche.

Preoperative assessment of calcifications is important in order to choose the correct surgical approach for mitral valve disease. To test the accuracy of echocardiography (ECHO) in the semiquantitative analysis of mitral valve (MV) calcifications we preoperatively echo-studied 66 patients, who were to undergo MV replacement of rheumatic disease. Echocardiograms were performed using a standardized method, recorded on videotape and analyzed by two independent observers. Areas of calcification were identified as dense conglomerate echoes which were brighter than those of adjacent internal structures. After removal, the MVs were evaluated by means of inspection (I), direct radiography (X-ray) and quantitative calcium extraction--EDTA spectrophotometry--(QCa). In the three methods ECHO, I and X-ray, MV calcifications were graded as absent (group 1), mild (group 2) nodular (group 3) and diffuse (group 4). Using the chi square test, no significant differences were found between the three methods, or between ECHO and X-ray, or between ECHO and I, while I grading was slightly lower than X-ray grading (P less than 0.002). Using variance analysis, no significant differences were found in QCa in the three methods within group 1 and 4, whereas significant differences were present within group 2 (P less than 0.002) and group 3 (P less than 0.001), due to the lower sensitivity of I. On the base of the observed distribution of QCa in the removed MVs, the following QCa values: a) less than 20 mg, b) 20-80 mg, c) greater than 80 mg, were considered as the selection criteria for a) absent or mild, b) nodular and c) diffuse calcifications respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic assessment of cardiac allograft rejection.

Twenty-one patients surviving orthotopic cardiac transplantation were studied by serial M-Mode and cross-sectional echocardiography on the same day as endomyocardial biopsy (EBS) (n = 205) during a mean follow-up period of 7.7 +/- 6 months. Results of EBS and the corresponding echocardiograms were divided into three groups: (1) no rejection (62 patients); (2) onset of mild rejection (11 patients); (3) onset of moderate rejection (17 patients). Groups 1 and 3 differed significantly in interventricular septum plus posterior wall thickness (IVS + PWth) (P less than 0.001), LV mass (P less than 0.001), LV ejection fraction (LVEF) (P less than 0.001), increased myocardial echogenicity (ME) (P less than 0.01), impaired RV wall motion (P less than 0.001). Groups 1 and 2 differed significantly only in increased ME (P less than 0.01). Groups 2 and 3 differed significantly in IVS + PWth (P less than 0.05), LV mass (P less than 0.01), LVEF (P less than 0.01), and impaired RV wall motion (P less than 0.01). With acute rejection we observed (1) increase of greater than 4 mm in IVS + PWth (55%), (2) increase of greater than 30% in LV mass (34%), (3) reduction of greater than 10 points in LVEF (27%), (4) RV dilatation and wall motion impairment (31%), (5) appearance or marked increase of pericardial effusion (34%), (6) increased ME (58%). Specificity of the individual criteria ranged from 95.6% to 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac transplantation: role of echocardiography in the diagnosis of rejection]. / Trapianto cardiaco: ruolo dell'ecocardiografia nella diagnosi di rigetto.

Sixteen patients surviving orthotopic cardiac transplantation were studied by M-Mode and two dimensional echocardiography (ECHO) on the same day of cardiac biopsy during (n = 138) a mean follow-up of 6.2 +/- 4 months (range 1-4 months). The following parameters were measured: right ventricular end diastolic internal diameter (RVdD) left ventricular end diastolic internal diameter (LVdD), interventricular septum (IVS) and posterior wall (PW) diastolic thickness, myocardial mass (MM); LV cross sectional area (CSA) and ejection fraction (EF). LV and RV wall motion, pericardial effusion and myocardial echogenicity (brightness) were evaluated by inspection. Every ECHO was compared with the previous one for qualitative and quantitative changes. In the absence of rejection, analysis of the data during the first postoperative week showed the following results: mean EF = 51 +/- 6.8%, dilated overloaded RV (30.4 +/- 4.8 mm), various amount of pericardial effusion; FE increased significantly (55.3 +/- 4%; p less than 0.001) and RVdD decreased (26.6 +/- 5mm; p less than 0.001) after the 2nd week and remained stable thereafter, while pericardial effusion decreased or disappeared. The mean values of the remaining ECHO parameters did not very significantly during the follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic diagnosis of infectious endocarditis on patent ductus arteriosus with involvement of the pulmonary artery and the pulmonary and aortic semilunar valves. Description of a case]. / Diagnosi ecocardiografica di endocardite infettiva su dotto arterioso pervio con interessamento dell'arteria polmonare, delle semilunari polmonari ed aortiche. Descrizione di un caso.

Infective endocarditis is one of the most rare complications of patent ductus arteriosus (PDA). Usually vegetations are localised at the level of the patent ductus and can involve the left branch and the trunk of the pulmonary artery. We report the case of a young woman with PDA, who was admitted to the hospital in severe congestive heart failure due to infective endocarditis. A 2D echocardiographic examination revealed vegetations into the ductus with extension to the pulmonary artery, pulmonary valve and aortic valve. The results of the echocardiographic study enabled us to evaluate the extension of the lesions, to avoid heart catheterization and to decide the most suitable surgical approach for repairing all the damage in one surgical operation.

[Abnormal electrocardiographic changes induced by hypocalcemia secondary to extracorporeal circulation]. / Abnormi alterazioni elettrocardiografiche indotte da ipocalcemia secondaria a circolazione extracorporea.

We report hereby the case of a 20-year-old woman, whose electrocardiogram showed unusual repolarization abnormalities 36 hours after open heart surgery. They were due to pure hypocalcemia (7,1 mg/100 ml) secondary to extracorporeal circulation, were sudden in onset, transient, variable within a few minutes, and immediately suppressed by intravenous calcium chloride. Some of the changes were similar to those already reported in literature (lengthening of QT and ST segments, changes in T wave voltage but not duration) whereas other were quite unusual i.e. the extreme variability and transientness of these changes, the marked ST level alterations and the presence of wide and diphasic U waves. Intravenous administration of 2 g of calcium chloride was followed by immediate and complete normalization of the electrocardiographic tracing.