Prevalence of isolated left ventricular diastolic dysfunction in hypertension as assessed by combined transmitral and pulmonary vein flow Doppler study.

In a relatively large population of patients with treated systemic hypertension and normal left ventricular systolic function, prevalence of abnormalities of left ventricular diastolic function, as assessed by Doppler echocardiographic study of mitral and pulmonary vein flow, was high, with 51% of patients showing indirect signs of increased left ventricular end-diastolic pressure. Furthermore, our data documented that a "normal" mitral flow profile does not exclude the presence of an abnormality of left ventricular filling, which could be otherwise identified by combined analysis of a pulmonary vein flow profile.

Failure of low dosage thrombolytic therapy with streptokinase to treat heparin-induced thrombocytopenic-thrombotic syndrome.

We report the case of a 58-year-old man affected by thrombocytopenic-thrombotic syndrome induced by therapy with subcutaneous unfractionated heparin for superficial phlebitis of the left inferior limb. Thrombolytic therapy with low-dosage streptokinase, reported as successful in a previous case described by other authors, was inefficacious and the patient's outcome was unfavourable. Thrombocytopenic-thrombotic syndrome may be a dreadful and often deadly consequence of heparin therapy, and its treatment needs investigation, owing to currently broadening use of anticoagulant treatment with both unfractionated and low molecular weight heparins.

Brief report: 2D-echo diagnosis of interventricular septal perforation by a temporary pacing electrode.

We report the case of an 83-year-old patient affected by hypertensive cardiopathy and admitted to our Division for left ventricular failure and complete atrioventricular block; a temporary electrode was inserted via the right internal jugular vein. A routine 2D-echo examination performed one day later clearly showed the catheter tip in the left ventricular cavity; the interventricular septal perforation was confirmed by the presence of right bundle branch block pattern on surface electrocardiogram. The following clinical course was totally event-free and the patient eventually underwent permanent pacing. A comparison with the few cases of pacing-related myocardial perforations so far described by the literature is made.

Transesophageal measurement of left atrial refractoriness.

During electrophysiological evaluation of supraventricular arrhythmias the transesophageal (TEEP) approach may be the first step but is limited in information available. One difficulty is in measuring left atrial refractoriness, as left atrial capture is seldom detectable either on ECG or via an esophageal lead. The problem may be eliminated and left atrial refractoriness measured via the esophagus, utilizing two or three extrastimuli to scan diastole to determine whether the atrial refractory period has been entered by the first extrastimulus. Measurement of left atrial and/or atrioventricular node or accessory pathway refractoriness then becomes possible.

[Primary mesothelioma of the pericardium with long-term survival]. / Mesotelioma primitivo del pericardio a lungo decorso.

We report the case of a 52-year-old man admitted to our Hospital for a massive pericardial effusion already discovered at an X-ray examination of the chest more than one year before, but never submitted to further investigation. Four months after a first surgical intervention of "pericardial windowing" and a drainage of 1700 ml of clear pericardial fluid, the patient was again hospitalized because of cardiac tamponade and underwent open pericardial drainage. At inspection, the pericardium and the myocardial muscle were fused in a single mass that at histological examination was discovered to be a primary mesothelioma of the pericardium, epithelial type. We discuss the clinical course and review the scientific literature inherent in these rare cases of primary neoplastic diseases of the heart.

[Effectiveness and tolerability of simvastatin in patients with moderate-to-severe hypercholesterolemia. Results of a 12-month study]. / Efficacia e tollerabilità della simvastatina in pazienti con ipercolesterolemia di grado moderato-severo. Risultati a 12 mesi.

Several epidemiological and clinical studies have underlined the close relationship between hypercholesterolemia and risk of coronary heart disease suggesting the opportunity of treating hypercholesterolemic patients according to their associated risk factors. Simvastatin, a drug for the treatment of hypercholesterolemia, is a competitive inhibitor of 3-Hydroxy-Methyl-Glutaryl-CoA reductase, the rate limiting enzyme in cholesterol biosynthesis. In the present study we have assessed the efficacy, safety and tolerability of simvastatin (10-20 mg) administered once daily for a period of 12 months to 50 patients with coronary heart disease (CHD) or at high risk for CHD according to the National Cholesterol Education Program. All patients underwent complete physical examination and laboratory safety tests (including blood cell count, liver function tests, creatine kinase and lipid profile) at baseline and every 6 weeks during treatment. Simvastatin was highly effective in reducing total and LDL cholesterol (-25% and -35% respectively). No significant effect on HDL cholesterol or triglycerides was obtained. Two patients were excluded after 6 weeks of treatment because of a serum creatine kinase increase (more than twice normal values). This was the only drug related side effect. In conclusion our data show that: a) simvastatin treatment is well accepted and compliance is good; b) the effect of simvastatin is evident after the first 6 weeks of treatment and is maintained during the whole treatment time; c) simvastatin is highly effective in lowering total and LDL cholesterol. When considering a patient who has had an atherosclerotic event the best deterrent to the occurrence of a subsequent event (secondary prevention) could be reduction of serum total and LDL cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

[Atrial septal aneurysm and associated anomalies. Personal experience with 38 cases]. / Aneurisma del setto atriale ed anomalie associate. Esperienza personale su 38 casi.

We examined 38 patients discovered to be affected by an atrial septal aneurysm (ASA) during 4014 consecutive echocardiographic examinations on an adult population in an eighteen-month period. ASA is often associated with other abnormalities, mainly mitral valve prolapse (23%), followed by aortic or pulmonary regurgitation, interatrial septal defect, tricuspid valve prolapse. It has been hypothesized that ASA could be a trigger for cardiac arrhythmias or a source of emboli to various districts. However, in our population we were not able to find any patient complaining of significant ASA-related cardiac symptoms nor affected by complications such as cardiac arrhythmias or embolic phenomena. Therefore, in our opinion this entity could be defined as quite benign neither requiring pharmacological therapy nor anticoagulant prophylaxis unless such treatments are indicated by an associated pathology.

Prevalence of aortic valve stenosis in patients affected by gastrointestinal angiodysplasia.

OBJECTIVES: Angiodysplasia is considered to be an important cause of gastrointestinal bleeding in the elderly. An association between idiopathic gastrointestinal bleeding and aortic valve stenosis has been reported in up to 25% of the patients. The association between angiodysplasia mainly of the right colon and aortic valve stenosis has been suggested, but is not proven. The aim of this study was to examine the prevalence of aortic valve stenosis in patients with gastrointestinal angiodysplasia. METHODS: We studied retrospectively 83 patients submitted to gastrointestinal endoscopy and found affected by angiodysplasia. Of them 24 (16M and 8F) had died from causes unrelated to cardiovascular diseases. The 59 patients still alive (27M and 32F) underwent a complete clinical, electrocardiographic and echocardiographic (M-mode, B-mode, pulsed and continuous-wave Doppler) evaluation. RESULTS: Fifteen patients (25%) had a normal examination, both clinical and echocardiographic. Eleven (19%) had minor cardiac abnormalities but had no murmurs. Although no murmurs were present in 15 patients (25%), some echocardiographic abnormalities such as aortic leaflet sclerosis, mitral annular calcification, their association, or trivial mitral regurgitation detectable only at PW-Doppler were found. In 18 patients (31%) both systolic murmurs and valvular abnormalities, as revealed by echocardiographic examination, were detected: 10 had a regurgitant and 8 an ejectional murmur; of these only 1 (1.6%) had a true severe calcified aortic valve stenosis at echo-Doppler examination. CONCLUSIONS: The low prevalence of aortic valve stenosis in patients with gastrointestinal angiodysplasia (1/59 or 1.6%) in this retrospective study argues against the association of gastrointestinal angiodysplasia and aortic valve stenosis.

[Thrombosis of the right atrial appendage. The two-dimensional echocardiographic aspect and the autopsy finding]. / Trombosi dell'auricola destra. Aspetto ecocardiografico bidimensionale e riscontro autoptico.

We report the case of an 80-year-old man affected by hypertensive cardiomyopathy and already admitted to our Division for recurrent episodes of heart failure. He was eventually hospitalized for septic shock secondary to disseminated pneumonia with concomitant left pleural effusion. At 2D-echo examination, a highly echo-reflectant mass was detected in the retrocardiac space. As the patient died notwithstanding the intensive pharmacological care, an autoptic procedure was performed which showed a massive thrombosis of the right atrial appendage. We discuss the 2D-echo imaging and advance a pathogenetic hypothesis after a review of the current literature.

[A clinical case: coronary vasospasm induced by exercise after stopping nifedipine therapy]. / Caso clinico: vasospasmo coronarico indotto dall'esercizio dopo sospensione di terapia con nifedipina.

A 60-year-old man with atypical chest pain not submitted to adequate diagnostic procedures was treated on an empirical basis with nifedipine 20 mg b.i.d. The patient was referred to our institution where a first symptom-limited exercise stress-test during treatment was performed; neither S-T alterations nor clinical symptoms were induced at the maximal tolerated work load. Therefore we suggested a short period of hospital stay to repeat the stress-test after a progressive tapering off of the drug with the aim of obtaining a more definite diagnosis. However the patient refused and an at-home nifedipine withdrawal was planned. Some days later a second test showed marked S-T segment elevation in leads V4 to V6; concomitant high-grade ventricular arrhythmias and anginal pain occurred. Both the ECG alterations and the clinical symptom promptly regressed interrupting the test and administering sublingual isosorbide dinitrate. A coronary angiography performed few days later showed only a single and no significant stenosis of the left anterior descending artery (60%). The clinical and electrocardiographic pictures were therefore attributed to stress-induced vasospastic ischemia. A week later a third maximal stress-test during further treatment with nifedipine was totally negative. The pathophysiological mechanisms of rest and stress-induced vasospastic angina and the usefulness of Ca-blocking agents are discussed.