[Electronic medical records: medical and legal aspects, privacy, safety, and legal validity]. / Informatizzazione della cartella clinica: aspetti medico-legali, privacy, sicurezza e validità legale.

Medical records must collect all data concerning in-hospital management of patients: data have to be verified and easily retrievable. Clinicians are responsible for both format and content of medical records. Respect of patient's privacy must be made sure both during on-line management and long-term storage of records. Computerization can offer many advantages to clinicians, but needs some significant adjustments: training and motivation of operators, arrangement of clinical processes and of administrative rules to technological developments. Nevertheless, some important results can be afforded: standardization of procedures, distribution of univocal, verified and ubiquitous data to all concerned operators, protection against undesired retrieval, reliability of effective reports. Preliminary condition is a clinical local area network, widespread into the institution. Database implementation must follow well accepted methodology: flow chart design of data dictionary, standardization of data coding, input of verified data, effective reporting. Access to data must be controlled by sophisticated and sure password system. Back-up of data must be automatically available with adequate timing and methodology. Respect of rules on patient's privacy must be realized whenever possible. Complex clinical records should be made available, containing data, signals and images (both single frames and dynamic sequences), due to continuous technical progress of diagnostic tools. Medical records must be available for long periods of time: database engine and managing tools must be selected among well accepted and largely available producers; informatic assistance must be assured for management and evolution of systems over the years.

RITED (Registro Italiano Test Eco-Dobutamina): side effects and complications of echo-dobutamine stress test in 3041 examinations.

AIM: The aim of the study was to report the incidence and clinical meaning of side-effects caused by echo-dobutamine testing in a large population and to evaluate any possible correlation between dobutamine dose and side-effects. METHODS: The study population consisted of 3041 patients enrolled from January 1994 to August 1995 at 63 centers participating in the Italian Register of Echo-Dobutamine Testing (Registro Italiano Test Eco-Dobutamina, RITED). The four major indications were myocardial infarction older than one month (40.4%), recent myocardial infarction (22.7%), coronary artery disease without a history of myocardial infarction (10.8%) and suspected coronary artery disease (19.3%). Dobutamine was administered in a peripheral vein at 5, 10, 20, 30, 40 micrograms/kg/minute + atropine 1 mg in four divided doses of 0.25 mg/minute. RESULTS: Severe complications were asystole, which went as high as 6" in one patient, and ventricular fibrillation in two patients. The clinical side-effects were headache (2.5%), hypotension (2.2%), nausea (1.7%), bradycardia (1.4%), palpitations (0.5%), tremors (0.3%), dyspnea (0.2%), paresthesia (0.2%) and hypertension (0.2%). Atrial arrhythmia was recorded in 10.6% of patients, while ventricular arrhythmia was recorded in 26.5%. The percentage of supraventricular and ventricular repetitive arrhythmia did not increase with dosage. The cumulative incidence of supraventricular and ventricular repetitive arrhythmia, considered as an interruption criteria, was 6.6% and 5.9%, respectively. CONCLUSIONS: Echo-dobutamine stress test seems to be a very safe and reliable test for unmasking myocardial ischemia or viability in known or suspected coronary artery disease. It has been shown to be widely applicable in clinical practice for outpatients as well, as long as a protected environment is available.

[Echography in aneurysm of the interatrial septum]. / L'ecocardiografia nell'aneurisma del setto interatriale.

Atrial septal aneurysm can be detected by subcostal echocardiography as a bulge of the intermediate interatrial septum, ballooning toward the right atrium. We retrospectively revised 5412 echo examinations, consecutively performed in our laboratory, and we found 14 cases of atrial septal aneurysm (0.26%), mean age 36 +/- 15 years, 9 males and 5 females. In 7 patients atrial septal aneurysm was wide, including the whole atrial septum; in 5, only cranial two-thirds of the septum were involved and in 2, it regarded only the intermediate septum. No patients referred to arrhythmias, syncope, embolism, endocarditis or transient ischemic neurologic disorders. Cardiac abnormalities or defects were associated to atrial septal aneurysm in 12/14 patients: they consisted of atrial septal defect, mitral valve prolapse, false ventricular tendons or persistent Chiari network. Atrial left-to-right shunt was detected in all 6 cases with atrial communication. Considering each single associated cardiac abnormality, the prevalence of atrial septal aneurysm was 7% in patients with atrial septal defect, 1.7% in those with mitral valve prolapse, 6.6% in persistent Chiari network and 0.9% in false ventricular tendons. In conclusion, echocardiography is the first-choice technique to detect atrial septal aneurysm and other related cardiac defects.

Echocardiographic evaluation of right heart responses to sublingual nifedipine in dilated cardiomyopathy.

Twelve patients with dilated cardiomyopathy were studied in order to evaluate whether the favourable effect of Nifedipine on the right heart is due to a direct action of the drug on pulmonary resistances or is related to an improvement of left ventricular function. Echocardiographic examination of left and right heart was performed at basic conditions, after Nifedipine treatment--20 mg sublingually--and after 20 minutes of oxygen breathing (FiO2 75%). This was done in order to verify if oxygen vasodilating action could potentiate the Nifedipine effect. Echocardiographic date were obtained in basic conditions, 10, 20 and 30 minutes after Nifedipine and immediately after oxygen breathing. Ten normal subjects were used for comparison for basic data. Peak Nifedipine activity was observed 10 minutes after administration. At this time inferior vena cava emptying index and systolic pulsation were significantly increased, whereas left and right ventricle isometric contraction time, left and right ventricle ejection time, left and right ventricle isovolumetric relaxation time, end-diastolic left ventricular diameter, inferior vena cava diameters and systolic blood pressure had decreased, thus showing the favourable effect of Nifedipine of both heart sides. Heart rate did not significantly change. Oxygen inhalation induced a significant decrease of right ventricular isovolumetric relaxation and an increase of the inferior vena cava indexes, suggesting an improvement in right heart function, without any change in other parameters. No significant difference was found between data after-oxygen and data obtained 10' after Nifedipine, showing that the Nifedipine effect was not potentiated by oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic aspects of false intraventricular tendons]. / Aspetti ecocardiografici dei falsi tendini intraventricolari.

A series of 4260 consecutive echocardiographic examinations, performed in 5 Cardiological Centers was examined, identifying 125 intraventricular false tendons (FTs) in 100 cases (55 normals and 45 with heart disease) of whom 31 were female and 69 male, aged 3 to 82 years. An anatomo-morphological study was possible in 9 cases, dead for stroke or heart failure, on autopsy, and in 7, on heart surgery. A phonocardiogram was performed in all normals and in 20 patients. On echocardiography, FTs appeared as an echo-producing string-like structure, straight between the septum and the ventricular free wall, mobile during the cardiac cycle, without systolic thickening and any relation with the atrioventricular valvular apparatus. The prevalence of FTs was 2.3%; it was 3.2% to 5.3% in younger people. FTs were located in the right ventricle (4 cases), left ventricle (95 cases) or in both (1 case). Their site was left apical (45 FTs), right apical (2 FTs), right (3 FTs) and left (20 FTs), upper septum-to-free wall (55 cases). In 1 case hypertrophy of trabeculae of the left ventricle was detected. FTs were single (79 cases), double (19 cases), multiple (2 cases), short (42 cases), long (58 cases), thick (45 cases) and thin (55 cases). They showed a membrane-like motion (thick FTs-45 cases) and a valve-like motion (thin FTs-55 cases). Innocent murmur was detected in 50 of 55 normals and related to thin FTs. Of 16 cases examined anatomically and histologically, FTs were fibrous in their distal portion and fibro-muscular in the proximal one in 12 cases, whereas they were entirely fibrous-muscular in 4 cases. The site and location of FTs detected by echo were confirmed by anatomy in all cases. In 4 cases other 9 FTs, not detected on echocardiography, were found. These data suggest that echocardiography is a useful tool to detect intraventricular FTs and differentiate them from other echo-producing structures. Although a relationship between FTs and heart disease has not been found, their presence could be responsible of innocent murmur in many normal subjects.

Detection of atrial septal defect with left-to-right shunt by inferior vena cava contrast echocardiography.

Contrast echocardiography was used before cardiac catheterisation in 37 patients with atrial septal defect and a left-to-right shunt and in 18 patients with a raised right atrial and ventricular pressure to assess the contrast echo effect in the inferior vena cava. Using two dimensional contrast apical echocardiography we found a negative contrast echo effect within the right atrium in many but not all patients with atrial defect. Contrast echoes entering the inferior vena cava during presystole or early to mid-diastole were detected in patients with heart disease causing raised right atrial and ventricular pressures and also in all patients with atrial septal defect. No contrast echo effect in the inferior vena cava was detected in 10 normal subjects. The sensitivity of this contrast pattern in the inferior vena cava in diagnosing atrial septal defect was 100%. When other conditions causing raised right atrial pressure were excluded, the specificity and predictive accuracy were 100% for both. The presystolic contrast echo effect in the inferior vena cava, semiquantitatively graded, correlated with the size of the shunt determined by oximetry. In 20 patients re-examined after the surgical correction of the atrial septal defect, no presystolic contrast echo effect was detected in the inferior vena cava. Contrast echocardiography of the inferior vena cava is a valuable and reliable method for diagnosing atrial septal defect with left-to-right shunt.

An unusual case of congenital double coronary arteriovenous fistula.

A double coronary arteriovenous fistula (CAVF) was observed in a ten-year-old girl. A large, tortuous, and elongated right coronary artery, communicating with the right ventricle, was detected by two-dimensional echocardiography and confirmed at angiography. To our knowledge, no echocardiographic recognition of the origin and termination of a CAVF has been reported previously. Moreover, another fistula, connecting the left anterior descending coronary artery with the main pulmonary artery was also detected by selective left coronary arteriography. The anatomy of double CAVF was confirmed on surgery. A right CAVF draining into the right ventricle and a left CAVF draining into the main pulmonary artery seemed to be a very unusual combination.

Echocardiographic assessment of left ventricular wall motion in hypertrophic cardiomyopathy.

M-mode and two-dimensional parasternal long axis view echocardiography, and left anterior oblique cineangiography were employed to assess the left ventricular wall motion in 10 normal subjects (N) and in 25 patients with hypertrophic cardiomyopathy: 7 patients with symmetric hypertrophy (SH) and 6 patients with apical cardiomyopathy (AHCM) and no intraventricular gradient; 12 patients with hypertrophic obstructive cardiomyopathy and asymmetric septal hypertrophy with resting intraventricular gradient (6 pts) (HOCM-R) or gradient occurring only after isoproterenol infusion (6 pts) (HOCM-I). The left ventricle was divided into five portions: upper and lower septum, upper and lower posterior wall and apex. The excursion and thickness of the upper and lower portions of the septum and posterior wall were measured in all patients and compared to 10 normal subjects (N). From the superimposed end-diastolic and end-systolic echo frames and angio silhouettes a chordal and a radial-chordal method were used, respectively, to measure the motion of the left ventricular wall segments. In SH the left ventricular wall motion was qualitatively similar to N but a little reduced; the thickness was increased and no pressure gradient was present. In AHCM the lower septum, posterior wall, and apex showed significantly increased thickness and motion compared to N and compared to the upper portions of the septum and posterior wall. No gradient was present. In HOCM-R the upper septum moved towards the apex, the lower septum, upper posterior wall and lower posterior wall moved towards the left ventricular cavity. The upper posterior wall was hyperkinetic compared to N and compared to the lower posterior wall, resting gradient and SAM was present in all. In HOCM-I the upper septum moved towards the apex; the posterior wall was hyperkinetic (the excursion was a little wider in the lower posterior wall than in the upper posterior wall). No gradient was recorded at rest, but it could be provoked by isoproterenol. Echocardiography provides precise information on left ventricular wall motion in hypertrophic cardiomyopathy. Hyperkinesis of the lower left ventricular wall is related to AHCM; hyperkinesis of the upper posterior wall and the motion of the upper septum towards the apex are related to HOCM-R. Hyperkinesis of the lower posterior wall is related to HOCM-I. SAM and pressure gradients may be related to the hyperkinesis of the upper posterior wall. Finally, the septum is not an immobile structure in HOCM, since it moves mainly from the base to the apex and a less (or not at all) towards the posterior wall.

Reliability of subcostal TD echocardiography to detect atrial septal defect.

Echocardiography was used in 40 patients with atrial septal defect (ASD), diagnosed by cardiac catheterization. A dilated right ventricle and abnormal interventricular septal motion were observed at M-mode echocardiography in patients with large L-R shunt. The two-dimensional apical four chamber view was reliable to detect the ostium primum type but not the secundum type of ASD. Moreover the presence of false positives reduced the specificity and predictivity of this approach. The two-dimensional subcostal view provided a direct visualization of the interatrial communication (sensitivity, specificity and predictivity = 100%) and whether the defect was in the uppermost, lowermost or midportion of the septum. Subcostal two-dimensional echocardiography is considered valuable and reliable technique to detect atrial septal defect and the type of the defect itself.

Contrast echocardiographic features of pulmonary hypertension and regurgitation.

Linear contrast echo configuration on the pulmonary valve M-mode echogram was assessed in 28 patients with pulmonary hypertension, in 10 with pulmonary regurgitation, and in 10 normal subjects. Contrast echo parallel lines filling the total systolic phase of the pulmonary valve were recorded in normal subjects. Contrast echo lines stopping in early systole around the pulmonary valve mid-systolic notch were seen in all the patients with pulmonary hypertension in relation to changes with the pulmonary flow. Contrast echo lines reversing the early diastole and crossing the pulmonary valve echogram during diastole were detected in all the patients with pulmonary regurgitation, consistent with the reversed flow across the valve. The use of contrast echocardiography to diagnose both pulmonary hypertension and regurgitation may provide further useful information, particularly when the orientation and time of appearance of the contrast echo lines are related to the systolic and/or diastolic phases of the pulmonary valve M-mode echogram.

Effect of nitroglycerin on ST potentials in the post-acute phase of myocardial infarction.

Thoracic electromaps were recorded before and after sublingual nitroglycerin (NG) in 26 subjects 15 and 30 days after acute myocardial infarction (MI), in order to evaluate the effect of the drug on injury potentials. Ten patients with documented left ventricular aneurysm were also studied 5 to 46 months after acute MI. Fifteen min after NG there was a significant decrease, compared with basal values, of ST segment elevations, blood pressure and rate-pressure product on both the 15th and 30th days. The degree of ST potentials reduction was not strictly related to the decrease of myocardial oxygen consumption, as indicated by the rate-pressure product. The response to NG on the 15th day did not predict accurately the evolution of injury potentials. In fact there was no significant correlation between percentages reduction of ST after NG on the 15th day and amplitudes of ST segment elevations present on the 30th day. In the patients with ventricular aneurysm, ST potential decrease and hemodynamic changes after NG were similar to those observed in the other groups studied. Our data suggest that it is not possible to differentiate between ST segment elevations associated with a dyssynergic area and those merely due to ischemic injury on the basis of NG sensitivity, and that ST segment elevations in the acute and subacute phase and long after MI have, at least in part, a similar electrophysiological significance.

Contrast echocardiography of the inferior vena cava.

M-mode and two-dimensional subcostal contrast echocardiography were used in 67 patients and 10 normal subjects to evaluate the contrast echo effect on the inferior vena cava echogram in relation to the cardiac cycle and respiratory events. No contrast echoes were recorded in the inferior vena cava in normals during normal breathing. Contrast echoes were recorded entering the inferior vena cava in systole in 20 patients with tricuspid regurgitation and in pre-systole in patients with atrial septal defect and left-to-right shunt and in some of the patients with elevated right atrial and ventricular end-diastolic pressure. Forced inspiration increased the contrast echo effect and determined the penetration of microbubbles into the inferior vena cava. This latter feature occurred in all the patients and only in 1 normal subject. The entry of the contrast echoes into the inferior vena cava was attributed to the high right atrial ventricular end-diastolic pressure and to the reversed flow, from the right ventricle to the right atrium and inferior vena cava in tricuspid regurgitation and from the left atrium to the inferior vena cava in atrial septal defect. The contrast echocardiographic diagnosis of tricuspid regurgitation appeared to be most reliable. New encouraging results were obtained by this technique in diagnosing atrial septal defect and left-to-right shunt. The first appearance of the contrast, the time of appearance in relation to the cardiac cycle and the direction of the to and fro motion of contrast echoes were the most important factors considered for a correct diagnosis.

[Electrocardiographic exercise test in assessment of hemodynamic patterns of mitral stenosis (author's transl)]. / L'elettrocardiogramma da sforzo nel riconoscimento di aspetti emodinamici della stenosi mitralica.

An ECG exercise test was performed in 36 patients with mitral stenosis, all in sinus rhythm and without digitalis therapy. In 21 subjects (group I = 58.6%) the test was negative, in the other 15 (group II = 41.7%) ischemic abnormalities of the ST segment were recorded during exercise; the mean value for the age is the same in both groups. All patients underwent cardiac catheterization; pulmonary pressure--and in 15 patients also cardiac output with thermodilution technique--were measured at rest and during the same exercise used for the ECG test. No relationship was found between ECG response and pulmonary capillary pressure (PCP), neither at rest nor during exercise, while exercise pressure values were well correlated with those at rest. The group I cardiac index (IC) and systolic index (IS) are significantly higher than in group II; the difference is remarkably more evident for the same indexes recorded during exercise, with splitting values, between the two groups, of 5000 ml/min/m2 for IC and 40 ml/beat/m2 for IS. Heart rate changes induced by exercise were similar in both groups, thus confirming the importance of the behaviour of output indexes. It is therefore possible to identify in mitral disease hemodynamic patterns due to different grouping of pathological features above (PCP) and below (IC) the valvular stenosis. Various hypothesis could be made in order to interpret the relationship between cardiac output and ischemic response to exercise. Anyway our results indicate that exercise ECG test is a non invasive technique useful to identify, among patients affected by mitral stenosis, those with a low IC and, mainly, those in whom this parameter fails to increase adequately with exercise.

[The diagnostic value of bloodless methods and follow-up in young asymptomatic subjects with positive exercise test (author's transl)]. / Valore diagnostico di metodiche incruente e follow-up in soggetti giovani asintomatici con test da sforzo positivo.

Fifty asymptomatic subjects, aged 22 to 40, with normal resting ECG and "ischemic" ST depressions during exercise were followed for 44 +/- 18 months. Coronary events occurred only in two cases. Unexpectedly in 12 subjects the response to maximal exercise became normal. In 25 subjects forced hyperventilation, exercise test after nitroglycerin (TNG), and after propranolol (P) were performed. Hyperventilation determined abnormalities of ventricular recovery in all cases. TNG did not improve the response to exercise, as it does in coronary patients, and even significantly decreased the "ischemic threshold"; after P the exercise test became normal in 20 subjects, while in 5 the electrocardiographic ST depressions were markedly reduced. The responses to pharmacological tests after the follow-up period were similar to the first observation. In 8 subjects, in which exercise ST depressions were particularly impressive, Tallium 201 myocardial scanning at rest and during exercise was performed. Myocardial perfusion imaging did not reveal any defect, thus confirming the non-ischemic nature of the ECG abnormalities. Our results confirm the low predictive accuracy (4%) of a positive stress test in a young asymptomatic population and suggest that, among non-invasive methods, exercise response after TNG is usefull in recognizing the "false positive" tests.