[Car driving after cardiac surgery: clinical aspects, regulations, and legal implications]. / Impatto degli esiti di interventi cardiochirurgici sulla guida dell'automobile: aspetti clinici, medico-legali e normativi.

BACKGROUND: Car driving is one of the most perceived problems by patients after cardiac surgery. The aim of this study was to evaluate the influence of cardiac surgery and median sternotomy on driving performance after a cardiac rehabilitation program. METHODS: Seventy-four consecutive patients, usual car drivers, admitted to our Cardiac Rehabilitation Center after cardiac surgery, were evaluated 60 days from discharge using a five-item questionnaire. Questions were related to resume of car driving, problems related to car driving, and seatbelt wearing. RESULTS: The analysis of the answers indicated that 36% of patients (62% females, 26% males; p = 0.01) stopped car driving after cardiac surgery, owing to the lack of security or fear of either the patients or their relatives. Sixty-four patients continued to drive, however 39% of them reported problems related to driving (irritation, poor concentration, fear, parking maneuvers). Because of persistent post-surgical chest pain, 15% of patients avoided wearing seatbelts, and 7% asked for exclusion following unconventional procedures. CONCLUSIONS: After cardiac surgery, 1 out of 3 patients stops car driving, particularly among female gender; 1 out of 7 patients is seatbelt no wearers and about half of them claim for exemption following procedures not codified. Thus, common rules and recommendations from Scientific Societies are highly warranted.

Echocardiographic estimation of pulmonary pressures.

Cardiac ultrasound plays a pivotal role in assessing pulmonary artery pressures. Estimation of right atrial pressure can be derived from the dimensions and respiratory variation of the inferior vena cava and Doppler modalities provide an accurate and comprehensive evaluation of right ventricular and pulmonary artery pressures. Peak pulmonary artery pressure can be calculated from continuous wave Doppler sampling of the tricuspid regurgitant jet, while pulsed wave Doppler sampling of the pulmonary regurgitant jet allows evaluation of mean and diastolic pulmonary artery pressures. In patients with tricuspid regurgitation that is either absent or not adequately detectable by Doppler method, Doppler right ventricular outflow tract investigation can be helpful. Recent data indicate that analysis of right ventricular function using myocardial Doppler echocardiography may also provide new insights for the non-invasive estimation of pulmonary artery pressures. In particular, right ventricular isovolumic relaxation time measured by myocardial Doppler echocardiography at the tricuspid annulus may provide an alternative method for estimating pulmonary artery pressure, especially in patients with tricuspid regurgitation not detectable or spectral Doppler not properly interpretable.

[Mitral valve prolapse]. / Il prolasso valvolare mitralico.

Mitral valve prolapse (MVP) is still a clinical challenging problem. In this report, we review the main characteristics of this entity. Epidemiology of MVP, which relies on the diagnostic criteria adopted, and the incidence of complications, both arrhythmic and structural, are influenced by the characteristics of the population studied, which may lead to bias in data interpretation. Even the definition of MVP may differ according to the cardiologist's or cardiac surgeon's point of view. Usually, cardiologists define MVP as the protrusion of all or part of the mitral leaflets into the left atrium, independent of maintenance of coaptation. Therefore, using this definition, mitral regurgitation is considered as a complication rather than a diagnostic criterion. Arrhythmias, either supraventricular or ventricular, are other possible complications, mostly not life-threatening and associated with myxomatous degeneration of the valve. Diagnosis of MVP is based on echocardiography, which provides detailed anatomic and functional evaluation of the affected valve. Leaflet thickness and motion as well as presence and severity of mitral regurgitation can be assessed, with important diagnostic and prognostic implications. Echocardiographic evaluation of the mitral valve requires a systematic approach in order to define the leaflet/scallop involved and the mechanisms of mitral regurgitation. To this aim, three-dimensional reconstruction may add further insights into objective rendering of mitral valve pathology. Finally, surgical timing in mitral regurgitation due to MVP is an evolving issue and the likelihood of surgical repair is a crucial factor in the optimal timing of surgical intervention, especially in asymptomatic patients with severe mitral regurgitation.

Bedside diagnosis and follow-up of patients with pleural effusion by a hand-carried ultrasound device early after cardiac surgery.

OBJECTIVES: The aim of this study was to assess the potential value of hand-carried ultrasound (HCU) devices in the diagnosis and follow-up of patients with pleural effusion (PE) after cardiac surgery. METHODS: Seventy consecutive patients were evaluated at bedside early after cardiac surgery, in the upright sitting position, using an HCU device on hospital admission and every 3 days until hospital discharge. The posterior chest wall was scanned along the paravertebral, scapular, and posterior axillary lines. For each hemithorax, an effusion index was derived as the sum of the intercostal spaces between the lower and upper limits of the PE along the lines of scanning, divided by 3. A standard chest radiograph was performed in all patients on hospital admission and at hospital discharge, and was qualitatively scored (0, absent; 1, small; 2, large PE). The findings of the HCU device and radiograph were compared using kappa statistics and the Kruskal-Wallis test. RESULTS: A chest ultrasound was feasible in all patients (mean [+/- SD] time, 5 +/- 2 min). Compared with the chest ultrasound, a physical examination showed a sensitivity of 69% and a specificity of 77%. On hospital admission, the HCU device detected a PE in 72 of 140 hemithoraxes. Agreement with the finding of the radiograph was 76% (kappa = 0.52). In 15 hemithoraxes, the HCU device revealed a PE that had not been diagnosed using the radiograph. Conversely, in 18 hemithoraxes a PE that had been diagnosed with a radiograph was not confirmed by the HCU device. The correlation between ultrasound and radiographic scores was statistically significant (p < 0.001). At hospital discharge, a PE was present in 31 of 140 hemithoraxes according to the findings of the HCU device, and in 38 of 140 hemithoraxes according to the findings of the radiograph (agreement, 78%; kappa = 0.44). CONCLUSIONS: In patients early after cardiac surgery, HCU devices allow rapid PE detection and improve the clinical diagnosis. Compared to a radiograph, this method offers the unique advantage of the bedside evaluation of patients without the need for radiation exposure.

[Digital echocardiography laboratory]. / L'acquisizione e la gestione delle immagini nel laboratorio digitale di ecocardiografia.

The implementation of a digital echocardiography laboratory exists today using the DICOM (Digital Imaging Communication in Medicine) standard to acquire, store and transfer echocardiographic digital images. The components of a laboratory include: 1) digital echocardiography machines with DICOM output, 2) a switched high-speed local area network, 3) a DICOM server with abundant local storage, and 4) a software to manage image and measurement information. The aim of this article was to describe the critical components of a digital echocardiography laboratory, discuss strategies for implementation, and describe some of the pitfalls that we encountered in our own implementation of the digital third level echocardiography laboratory.

Permanent pacing lead insertion through the cephalic vein using an hydrophilic guidewire.

The cephalic vein (CV) should be preferred to the subclavian vein for the insertion of permanent pacing leads because of better results. Unfortunately, the direct lead introduction using the standard CV cutdown is often unsuccessful. This study evaluated the efficacy and safety of a steerable hydrophilic guidewire (HGW) for lead insertion through the CV. An HGW was successfully introduced through the cephalic vein and into the subclavian vein. Over a 6-month period, 115 consecutive patients underwent pacemaker implantation. In nine (7.8%) patients, the cephalic vein did not allow lead or guidewire introduction. The direct introduction of the leads through the CV was successful in 55 (51.9%) of 106 patients. In 14 (12.2%) additional patients, a lead was inserted through the CV using a standard guidewire. The use of an HGW and of a split introducer allowed successful insertion of at least one lead in 35 (30.4%) additional patients. Overall, the HGW was successful in 35 (94.6%) of 37 of patients in which the technique was attempted. The CV approach was successful in 104 (90.4%) of 115 patients. In conclusion, the use of an HGW allows the insertion of a pacing lead through the CV in the great majority of patients in whom direct introduction and the use of a standard guidewire had failed. The technique significantly improves the success rate of the CV approach and may help to improve the acute and long-term results of permanent cardiac pacing.