[Cardiovascular disease in early collagen diseases]. / Alterazioni cardiovascolari nelle fasi precoci delle malattie del connettivo.

AIM: The purpose of this paper was to verify whether there is any sign of involvement of the cardiovascular system in the early stages of collagen diseases. METHODS: Seventeen patients (10 female and 7 male, average age 41.35 +/- 9.85 years) (group A) recruited at the Ambulatory of Internal Medicine for suspected collagen diseases with period of onset of the symptomatology less than 6 months, were analyzed. Ten patients were excluded from the study: 8 had been suffering from systemic lupus erythematosus (SLE) for a number of years, 2 were older than 80 and were suffering from concomitant pathologies (diabetes mellitus and hypertension) which would have invalidated the evaluation of valvular changes like thickening. The patients were followed up for 2 years. Clinical diagnosis was made in many cases many months after the observation using the criteria of the American Rheumatic Association (ARA). All patients were subjected to titration of the following autoantibodies by means of the immuno-fluorimetry method: ANA, anti-ENA (SSA, SSB, SM, SM-RNP, SCL-70, Jo-1), anti-nDNA, anti-histones. The cardiological evaluation was carried out by echography (Cardioline 12 leads) and echocardiographic examination (Aloka 2000 and HP sonos 5500 with 2.5 and 3.5 MHz probe) looking for thickening of both valvular flaps (> 3 mm for the mitral and > 2 mm for the aorta), myocardial involvement by studying global and regional kinesis of the left ventricle; pericardial involvement. The control group consisted of 17 healthy subjects with the same sex and age distribution (10 male, 7 female, average age 40.35 +/- 9.80 years) (group B). RESULTS: Eleven patients (64%) proved to be suffering from SLE, 3 (17%) from mixed collagen diseases (MC), 3 (17%) from systemic sclerosis (SS). Cardiac anomalies were observed in 12 patients: in 3 (17%) mitral valve thickening was observed (2 with SLE, 1 with SS), in 2 (11%) thickening associated with mitral valve insufficiency (with MC), in 1 (5%) isolated mitral valve insufficiency (with SLE), in 1 (5%) thickening and slight aortic insufficiency (with SLE), in 1 (5%) mitral valve vegetations (with SLE), in 2 (11%) pericardial effusion (with SLE), in 2 (11%) diastolic changes (with SS). The parameters relative to wall thickness between the 2 groups showed statistically significant differences (mitral 3.1 +/- 0.7 vs 2.3 +/- 0.4 P = 0.0005; aorta 1.7 +/- 0.2 vs 1.5 +/- 0.3 P = 0.03). CONCLUSIONS: In patients observed in the early stages of collagen diseases, cardiac involvement was observed in 70% of cases, but the data require confirmation in a larger sample. The authors, however, believe that the early identification of such involvement is useful from both the diagnostic point of view and from the point of view of patient treatment.

[Prevalence of aneurysm of the interatrial septum in the general population and in patients with a recent episode of cryptogenetic ischemic stroke: a tissue harmonic imaging transthoracic echocardiography study in 5.631 patients]. / Prevalenza di aneurisma del setto interatriale nella popolazione generale e in pazienti con recente stroke criptogenetico: studio ecocardiografico transtoracico con seconda armonica tessutale in 5.631 pazienti.

Cerebral ischemia is among the principal causes of mortality and morbidity in industrialized countries being responsible of 10-12% of all deaths and of an elevated number of permanent disability. The cardio-embolic forms may be responsible of the 30-35% of cerebrovascular acute syndrome, nevertheless in a significant percentage of cases, especially among young people, cerebral ischemic episodes are not induced by these cardio-embolic forms: these cases are defined as cryptogenetic stroke/TIA. In these patients cardiac abnormalities represented by an aneurysm of the interatrial septum (ASA) and by a patent foramen ovale (PFO) have been frequently observed. The purpose of our prospective, study was to evaluate, through transthoracic echocardiography and tissue harmonic imaging (ETT-THI), the prevalence of ASA in the general population (group A) and the prevalence of ASA-FOP in a subgroup of patients with recent episode of cryptogenetic ischemic stroke/TIA (group B). We studied in a prospective manner from January 1 2003 to October 31t 2004 n. 5.631 patients. The presence of ASA was found in 3.2% of patients of group A, while in patients of group B we identified an ASA in 32% and a POF in 42% of the cases. Using a ETT-THI, our study shows in a wide range of a non selected population a prevalence of ASA greater than in previous studies. Such high prevalence in the general population of patients submitted to echocardiography and the higher frequency in subjects with recent cryptogenetic stroke, suggests to search carefully these abnormalities at the level of the interatrial septum using the harmonic imaging method.

[Impact of left ventricular patterns and diastolic dysfunction on hemodialysis patients]. / Pattern cardiaci geometrici e disfunzione diastolica nel paziente uremico: quale l'impatto sul trattamento dialitico?

BACKGROUND: Left ventricular hypertrophy is the main manifestation of uraemic cardiomyopathy and predicts both cardiovascular events and death independently of conventional risk factors. Diastolic dysfunction is often associated with left ventricular hypertrophy, and accounts for up to 30% of heart failure. The aim of this study was to estimate the impact and the prevalence of left ventricular hypertrophy, its geometric models and diastolic dysfunction on haemodialysis patients, as well as the relationship with cardiac troponin, a specific marker for myocardial damage. METHODS: We enrolled in the study 31 patients (26 on haemodialysis, 5 on peritoneal dialysis) and 31 normal healthy subjects as the control group. Echocardiographic measurements were carried out according to the recommendations of the American Society of Echocardiography. Left ventricular mass was calculated according to the Devereux formula and indexed to height 2.7 We carried out Doppler echocardiography to study the diastolic function by measurements of isovolumic relaxation period (IVRT), E-wave deceleration time (DTE) and E/A ratio. We measured cardiac troponin using a third generation electrochemiluminescence immunoassay. We did the statistical analysis with the t test for comparison among groups, and we established correlations using the Pearson and Spearman correlation test. We considered values of p<0.05 to be statistically significant. RESULTS: Eccentric hypertrophy was the most frequent pattern (n=17; 55%), followed by normal cardiac geometry (n=7; 23%) and concentric hypertrophy (n=5; 16%). Only a minority of patients (n=2; 6%) showed concentric remodelling. Systolic dysfunction was present in 3 patients (EF<50%). Diastolic dysfunction was present in 24 out of 31 HD patients, that had abnormal relaxation pattern, characterised by prolonged IVRT, prolonged DTE and E/A ratio <1. Only one patient had restrictive filling pattern with reduced DTE and E/A ratio >2. Fourteen patients (45%) had E/A ratio < or =0.5, 10 patients (32%) had E/A ratio >0.5<1 and 7 patients (13%) had E/A ratio > or =1. DTE was prolonged in 14 patients (45%) and IVRT was prolonged in 6 patients (19%). The patients with E/A ratio < or =0.5 (n=14; 45%) suffered major hypotensive episodes during dialytic sessions compared to patients with E/A ratio >0.5, we found this difference to be statistically significant (p < 0.01). We observed the E/A ratio to be negatively correlated with age (r = -0.41; p=0.02) whereas DTE was positively correlated with posterior wall thickness (r =0.36; p= 0.05) and interventricular septum thickness (r =0.45; p=0.01). Cardiac troponin was positively correlated with age (r =0.50; p=0.00), left ventricular mass (r =0.41; p=0.02), posterior wall thickness (r =0.41; p=0.02) and interventricular septum thickness (r =0.39; p=0.03) but not with diastolic dysfunction parameters. Serum cardiac troponin was elevated (> or =0.10 micro g/L) in 12 patients (38.7%) and was associated with eccentric hypertrophy in all the cases. We detected no significant differences among groups with normal left ventricular geometry and left ventricular hypertrophy in the duration of the dialytic treatment, but we noted a statistically significant difference in relationship to age (p=0.03). CONCLUSIONS: Left ventricular hypertrophy is associated with diastolic dysfunction, both cause of hypotensive episodes during dialytic treatments and heart failure in patients with normal systolic function. The non invasive assessment of left ventricular diastolic function would represent an important advancement in the diagnosis and prevention of heart failure in haemodialysis patients.

[Functional heart murmur and echocardiography: a solved problem?]. / Soffio cardiaco funzionale ed ecocardiografia: un problema risolto?

BACKGROUND: Is it really vanished the need for echocardiography in the differential diagnosis of functional pediatric murmurs? METHODS: To this aim 260 children (132 males, 128 females; age range 1-84 months) were examined with auscultatory cardiac murmur. All children underwent a clinical and instrumental evaluation (ECG and echocardiography) from two pediatric cardiologists with independent assessment. RESULTS: Two hundred and ten patients (Group A) were evaluated clinically with functional murmur, 45 patients (Group B) with pathological murmur, 5 patients (Group C) with uncertain pathology. ECG showed changes in 1 Group B patient. Echocardiography showed pathology in 15 Group A patients (6 patients with patent foramen ovale, 5 patients with interatrial defect, 2 patients with bicuspid aortic valve, 1 patient with mitral insufficiency, 1 patient with restrictive cardiomyopathy). Pathology was excluded in 3 Group B patients, and in 2 Group C patients. In our clinical analysis echocardiography showed sensitivity 75%, specificity 97%, positive predictive value 90%, and negative predictive value 92%. CONCLUSIONS: In our experience we suggest to perform echocardiographic examination in children with functional murmur for complete assessment.

[Etiopathogenesis of dilated cardiomyopathies]. / Eziopatogenesi delle cardiomiopatie dilatative.

This study was carried out on 43 patients affected by dilated cardiomyopathy to investigate some of the etiopathological hypotheses on this illness. The Authors investigated: the persistence of virus genoma (coxsackie, HBV) on endomyocardial biopsies; the pattern of the II class major histocompatibility complex (MHC) were in the blood lymphocytes; the microvascular aspect of coronary circulation in the endomyocardial biopsies. Finally, in a separated group of 19 patients, the microvascular circulation was studied on skin biopsies and correlated with diabetic, valvular and normal subject. The results showed a 14% positivity for the presence of the virus genoma and a significant predominate of DR5 in the II class MHC of patients with a worse ventricular function. Capillary vessels of the coronary microcirculation were dilated in the 48% of the patients, especially in more compromised subjects. Viral myocarditis seem to play a role in the etiopathogenesis of dilated cardiomyopathies (DCM) and the pattern of MHC could influence the progression of the illness. The microcirculation is probably a pathophysiological aspect. No etiological hypothesis seems to predominate.