[False left atrial mass caused by hiatal hernia: a clinical case and review of the literature]. / Falsa massa atriale sinistra causata da ernia iatale: caso clinico e revisione della letteratura.

Two-dimensional echocardiography is the technique of choice for identifying cardiac masses. Unfortunately, adjacent structures compressing the atrial wall may lead to misdiagnosis. Clinicians should promptly recognize this phenomenon and the related diagnostic features. The case of a 90-year-old woman presenting with a history of recent onset effort dyspnea is described. On transthoracic two-dimensional echocardiography a left atrial mass which closely mimicked an atrial myxoma was evident. A tomographic scan revealed a large sliding hiatus hernia, which was confirmed on traditional radiographic examination. The echocardiographic characteristics of the mass are described in detail, as well as a review of the literature for the purpose of a correct differential diagnosis.

[Dual-chamber DDD pacing in NYHA III-IV functional class dilated cardiomyopathy: short and middle-term evaluation]. / L'elettrostimolazione cardiaca bicamerale nella cardiomiopatia dilatativa in III-IV classe funzionale NYHA: valutazione clinico-strumentale a breve e medio termine.

Effectiveness of dual-chamber pacing in patients with dilated cardiomyopathy is still controversial. Our study was performed: to select the most favorable individual atrioventricular (AV) delay; to compare hemodynamic short-term effects in each patient after 2 periods of DDD pacing and sinus rhythm (AV spontaneous); to assess hemodynamic long-term (1 year) effects after DDD pacing at optimum AV delay. In 1996, 9 patients (7 men, 2 women; mean age 69 +/- 5 years) with dilated cardiomyopathy (5 idiopathic, 4 ischemic), NYHA functional class III-IV, ejection fraction < 30%, end-diastolic volume > 60 ml/m2, mitral regurgitation +2/+3, PR interval > or = 200 ms, were enrolled. All patients were implanted with DDD pacemakers and monitored for: ejection fraction and end-diastolic volume (measured by echocardiography and radionuclide angiography); clinical conditions; exercise tolerance and maximum oxygen consumption (by Weber exercise protocol); neurohormonal activity (plasma renin, aldosterone, atrial natriuretic factor). Data were recorded: before DDD implantation; after 2 randomized, single-blind periods of 3 months in VVI mode (at ventricular "sentinel" rate of 50 b/min) and in DDD mode with the optimum AV delay, corresponding for each patient to the minimum end-diastolic volume measured by radionuclide angiography and to the highest cardiac output recorded by echocardiography; after 6 months of DDD pacing with most favorable AV delay. Three more patients died 6 months after (between sixth and twelfth month of follow-up), due to refractory heart failure; 1 patient dropped out because his pacemaker was programmed in VVI mode at low rate, due to intolerance of DDD pacing. Among the other 4 patients no clinical and laboratory parameters were significantly different after 1 year of follow-up. In conclusion, DDD pacing in selected patients with dilated cardiomyopathy showed disappointing results, despite a strict and laboratory monitoring; DDD pacing could be of major benefit in larger populations, according to Doppler mitral flow pattern: those patients with a larger A-wave amplitude could be more sensitive to DDD pacing than those with evidence of poor atrial systole. Moreover, biatral and/or biventricular pacing could also play a significant role.

[Aortic valve replacement in patients over 70: a Doppler echocardiographic study]. / La sostituzione valvolare aortica in pazienti ultrasettantenni: studio ecocardiografico Doppler.

Aortic valve disease is known to be the most frequent valvular disease in the elderly and aortic valve replacement is often the best therapeutic strategy. Hemodynamic performance of prostheses is critical in this subset of patients to ensure an optimal quality of life. Moreover, old patients with small aortic ostia are getting more and more common in clinical practice, making often necessary to implant small prostheses. If a significant pressure drop is not achieved, hypertrophy persists and left ventricular function may not improve. Such conditions have not yet been extensively studied in the elderly. The aim of this study was firstly to assess echocardiographically the performance of aortic prosthetic heart valves in old patients (> or = 70 years) and compare the results obtained in patients with prostheses of different type and size, and secondly to evaluate the postoperative changes in left ventricular hypertrophy and function in a subset of patients with isolated or prevalent aortic stenosis. One hundred fifty-one patients were initially considered; global mortality was 9.3% at 20 +/- 12 months from intervention. In the 75 patients with a postoperative echocardiogram, transprosthetic gradient was 27 +/- 12 (max) and 15.1 +/- 6.6 (mean) mmHg. Mean functional prosthetic area (FPA) was 1.5 +/- 0.5 cm2. No statistically significant differences could be demonstrated between mechanical and biological prostheses. Three groups were identified, according to prosthetic size (Group 1: diameter < 23 mm, Group 2: diameter 23 mm, Group 3: diameter > 23 mm). Among groups, max and mean gradients as well as FPA were found to be significantly different. Respectively max gradient was 33.2 +/- 13, 26 +/- 11, 20.2 +/- 7.2 mmHg (p < 0.05), mean gradient was 17.2 +/- 6.1, 15.4 +/- 7.6, 11.7 +/- 4.3 mmHg (p < 0.01) and FPA was 1.2 +/- 0.3, 1.5 +/- 0.3, 1.8 +/- 0.7 cm2 (p < 0.05 between Group 1 and Group 3). In a subgroup of 31 patients with isolated or prevalent aortic stenosis, a significant interventricular septal thickness reduction was found postoperatively (14.3 +/- 2.3 vs 12.6 +/- 8.0 mm, p < 0.001). Posterior wall thickness decreased similarly, but to a lesser extent; left ventricular diameters and myocardial mass also significantly decreased (left ventricular mass: 186 +/- 45 vs 146 +/- 38 g/m2, p < 0.001). When prosthetic size was considered, septal thickness reduction was more evident in Group 1 and Group 2 (p < 0.05 and p < 0.01). On the contrary, a significant improvement in left ventricular diameters was observed only in Group 3 (p < 0.05). Left ventricular mass decreased significantly in Group 2 and Group 3 (p < 0.01 and p < 0.05). Such improvements could be demonstrated only in those patients (79%) who showed at least a 50% reduction in the transvalvular gradient. In this subset, left ventricular function also significantly improved (fractional shortening: 29 +/- 0.7 vs 33 +/- 0.7%, p < 0.02). In conclusion, aortic valve replacement in the elderly is a safe and effective therapeutic strategy. In patients with small aortic prostheses, the transvalvular gradient was found to be slightly but significantly higher as compared to that of larger prostheses. However, left ventricular function was good and similar in all subgroups. No significant differences were found between mechanical and biological prostheses. In old patients with isolated or prevalent aortic stenosis a significant reduction in left ventricular hypertrophy and mass is observed within 2 years from intervention. An increase in myocardial contractility can also be expected, if at least a 50% reduction in transvalvular gradient is obtained.

[The functional and hemodynamic benefits of automatic atrioventricular interval delay in permanent atrial synchronized pacing]. / Benefici funzionali ed emodinamici dell'accorciamento automatico dell'intervallo atrio-ventricolare nella stimolazione cardiaca permanente di tipo atrio-sincronizzato.

OBJECTIVES: In order to assess possible functional and hemodynamic benefits of different programming of atrioventricular (AV) delay--156 ms fixed vs 156 to 63 adaptive--two maximal exercise tests (cyclette) were performed in 8 patients (6 males, 2 females; 69 +/- 6 years) implanted with Chorus 6003 (Ela Medical, France) DDD pacemakers for complete AV block with normal sinus node function. METHODS: The measured parameters were: pacing rate, cardiac output (thermodilution method), oxygen consumption (2001 gas-exchange analyser), arterial-venous difference (derived from pulmonary oxygen saturation, through an optical-fibers Swan-Ganz catheter coupled to an Oximetric3-Abbott oximeter), human atrial natriuretic factor and lactate plasmatic levels, anaerobic threshold. RESULTS: A better cardiac output (11.4 +/- 1.7 vs 10.1 +/- 1.8 l/min) and oxygen consumption (1521 +/- 425 vs 1408 +/- 465 ml/min) were observed at maximal exercise with adaptive rather than with fixed AV delay programming (p < 0.05); moreover anaerobic threshold point was reached later during exercise test with adaptive AV delay (242 +/- 92 vs 216 +/- 109 sec, p = 0.05). On the contrary, with adaptive and fixed AV delay, there were not statistically different values of maximal heart rate (139 +/- 9 vs 139 +/- 9), levels at maximal exercise of arterial-venous difference (12.5 +/- 2 vs 12.8 +/- 1.4 Vol%O2), human atrial natriuretic factor (63 +/- 17 vs 78 +/- 48 pg/ml), lactate (29 +/- 15 vs 29 +/- 18 mg/dl), and oxygen consumption at anaerobic threshold point (772 +/- 164 vs 786 +/- 229 ml/min). CONCLUSIONS: In DDD pacing adaptive AV delay causes aerobic and hemodynamic benefits.

A new approach to the prevention of endless loop tachycardia in DDD and VVD pacing.

Endless loop tachycardia (ELT) is a possible complication in dual chamber pacing; it is usually prevented by programming the atrial refractory period (PVARP) longer than the retrograde ventriculoatrial (VA) conduction interval; this in some patients limits the upper rate. In 15 patients with a DDD (nine patients) or a single-pass lead VDD pacemaker (six patients) and retrograde atrial activation, telemetric recording documented a significant difference in amplitude of antegrade, and retrograde atrial potentials (VDD 1.21 +/- 0.32 mV vs 0.56 +/- 0.23 mV, P = 0.008; DDD 2.7 +/- 1 vs 1.8 +/- 1 mV, P = 0.038; Student's t-test for paired data). In 3/15 patients ELT stopped after programming of atrial sensitivity to a value greater than the retrograde P wave amplitude; in 11/15 patients this occurred at a sensing value lower than or equal to retrograde P wave amplitude with a high pass band filter operating. One patient required PVARP lengthening. Holter monitoring showed no more ELTs. In most patients with a DDD or single-pass lead VDD pacemaker with widely programmable sensing amplitude and Hi/Low bandpass filters, individual programming of atrial channel sensitivity prevents ELT without affecting the PVARP and, consequently, upper rate limit.

[The echo-dipyridamole test early after acute myocardial infarct: echocardiographic aspects and angiographic correlations]. / Il test eco-dipiridamolo subito dopo infarto miocardico acuto: aspetti ecocardiografici e correlazioni angiografiche.

To assess whether the different mechanical effects of intravenous dipyridamole were correlated with the location and distribution of the coronary arteries stenosis, 98 patients underwent high dose DET 8-10 days after an acute myocardial infarction. Left ventricular regional wall segments were identified in multiple views; a vascular territory was assigned to each coronary vessel. DET was positive in 68.4% of the patients (67/93), 59% (23/39) of those with single vessel disease, and 81% (44/54) of those with multivessel disease. Four different mechanical patterns of positivity of DET were observed: 1) marked worsening of wall motion in the same region showing asynergy (type I); 2) development of new wall motion abnormality adjacent to the infarct zone and located in the same vascular region (type II); 3) development of new wall motion abnormality adjacent to the infarct zone, but located in a different vascular region (type III); 4) development of transient remote asynergy (that is, a new wall motion abnormality in a region normal at rest and not directly adjacent to the infarct zone, type IV). Types I and II (asynergies in the infarct zone coronary bed) were found in patients both with single vessel disease or multivessel disease; by contrast, type III and IV were almost exclusively found in patients with multivessel disease (24/54 and 14/54 respectively) and occasionally in patients with single vessel disease (2/39 and 1/39 respectively). Thus, these two mechanical behaviours during dipyridamole infusion showed to be highly specific for predicting multivessel disease (95% and 97% respectively, sensitivity 44% and 26% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of influence of atrioventricular delay on stroke volume at rest in patients with complete atrioventricular block and dual chamber pacing.

Dual chamber pacing (DDD) maintains atrioventricular (AV) sequence; AV delay programmability modifies the relationship between atrial and ventricular contraction. To evaluate the hemodynamic effects of such a modification, ten patients with a DDD unit for complete AV block were studied by time-motion (M-mode) and Doppler echocardiography during inhibited ventricular pacing (VVI), atrial-triggered ventricular pacing (VDD) and atrioventricular sequential pacing (DVI) at different AV delay (90, 140, 190, 240 msec). A significant improvement in stroke volume (SV) (15%-20%, P less than 0.05) was seen during DDD versus VVI pacing; no changes, however, were observed in the same patient with different AV delay or during DVI versus VDD pacing. These data suggest that programming of AV delay does not affect systolic performance at rest; longer diastolic filling times recorded during DDD pacing with "short" AV delay (90-140 msec) do not seem to be a hemodynamically relevant epi-phenomenon of PM programming.

[Short-term prognostic evaluation of acute myocardial infarct: comparison of 2-dimensional echocardiography, electrocardiography, and the MB-CK index]. / Valutazione prognostica a breve termine dell'infarto miocardico acuto: confronto tra l'ecocardiografia bidimensionale, l'ECG e il CPK-MB.

To compare the non-invasive methods of quantification of acute myocardial infarction (AMI) [two dimensional echocardiography (2DE), standard 12-leads ECG, and enzymatic indices as MB-CK peak activity and MB-CK time activity curve expressed by an extension index (EI-MBCK)] in relation to their prognostic value, 79 patients with a first AMI were evaluated. We have observed in a three months follow-up a total mortality of 12.6%. The infarct size, calculated echocardiographically by a segment score, was correlated with the number of pathological Q waves in the standard ECG (rho= 0.83). Peak MB-CK enzyme and EI-MBCK correlated both with the segment score, but with a lower correlation coefficient (rho= 0.67). To identify patients at different risk, discriminant analysis was used which gave the following limit values for the patients at a very high risk: 2DE score = 17; number of Q waves = 7; peak MB-CK = 176 U/L; EI-MBCK = 54 grEq/m2; for the patients at a very low risk: score = 6; number of Q waves = 2; peak MB-CK = 35; EI-MBCK = 15. To verify if the association of these different techniques could improve the predictivity, a discriminant bivariate function analysis with three variables was calculated. The resulting equation was: Z = 2.31 X 2DE score + 8.59 X number of Q waves - 0.23 X peak MB-CK. Changing peak MB-CK value with EI-MBCK did not improve the statistical significativity. The results have confirmed that the integration of all the three variables improved the prognostic predictivity. According to the risk Z obtained, the patients were allocated into classes of different risk: values of Z greater than 57 or less than 18 could identify patients respectively at a very high or at a very low risk. For values between 37 and 42 the prognosis remains uncertain. Among the three variables, 2DE and ECG showed an equivalent prognostic accuracy, whereas enzyme indices had a lower prognostic influence, especially in the presence of large infarcts. Thus, 2DE, ECG and enzyme indices can identify patients at increased risk; the individual method seems to be inadequate; to obtain valid predictive informations it is necessary to integrate all the three non invasive techniques.