Results of total correction of tetralogy of Fallot performed in adults.

Today, total correction of tetralogy of Fallot is rarely performed in adults. In a 10-year period, 40 patients aged 20 to 67 years underwent intracardiac repair in our institution. Twenty-eight of them had had a palliative procedure 11 to 30 years earlier. Preoperatively, 23 patients were in New York Heart Association (NYHA) Functional Class II, 14 were in Class III, and 3 were in Class IV. Operative mortality was 2.5% (1/40). Follow-up ranged from 1 year to 11 years (average, 3 years). One patient died of a noncardiac cause 4 years after operation. Residual cardiac defects were observed in 4 patients. Postoperatively, 30 patients were in NYHA Functional Class I, 8 were in Class II, and 1 was in Class III. Major ventricular arrhythmias were recorded in 7 (35%) of 20 patients. Radionuclide angiography demonstrated impaired right ventricular function in 8 patients. Left ventricular impairment was present in 2. Total correction of tetralogy of Fallot can be performed safely in adults with low mortality and good functional improvement. The incidence of residual cardiac defects is low. The long-term importance of impaired ventricular function and arrhythmias remains to be ascertained.

Patients with acute myocardial infarction in northern Italy are often infected by Helicobacter pylori.

BACKGROUND: The classical risk factors for acute myocardial infarction (AMI) fail to explain all the epidemiological variations of the disease. Among the new risk factors recently reported, several infectious agents appear to increase the risk of AMI. In particular, acute and chronic respiratory diseases due to Chlamydia pneumoniae, and Helicobacter pylori (H. pylori) infection seem to be strongly involved. The aim of this work is to determine the prevalence of H. pylori infection in a group of male patients with AMI, in a case-control study, where a group of blood donors matched for sex and age served as control. We searched for the classical risk factors in all patients. METHODS: We studied 212 consecutive male patients, aged 40-65 years, admitted for AMI at the Coronary Care Units at Hospitals in three towns of Northern Italy. H. pylori infection was assessed by the highly specific and sensitive 13C-urea breath test and by presence of antibodies (IgG) against H. pylori in circulation. Volunteer blood donors attending our Hospital Blood Bank served as controls. Among the patients we investigated the presence of hypertension, cholesterol and glucose levels in serum, fibrinogen in plasma and the smoking habit. RESULTS: H. pylori infection was present in 187/212 (88%) of the patients and in 183/310 (59%) of the control population (p < 0.0001). Classical risk factors for AMI did not differ among patients with and without H. pylori infection. CONCLUSION: Patients admitted to the Coronary Care Unit for acute myocardial infarction had a notably higher prevalence of H. pylori infection than the general population. The classical risk factors for coronary disease were equally present in all patients with AMI irrespective of H. pylori status.

Ischemic cardiovascular disease and Helicobacter pylori. Where is the link?

Coronary heart disease (CHD) is the leading cause of death in western countries. Although several major risk factors have been identified, they fail to account for all the epidemiological variants of the disease, thus warranting research into novel causal agents. Cardiovascular diseases have long been associated with chronic infections acting through the activation of inflammatory pathways, and antibiotic therapy has been shown to produce a dramatic decrease in the rate of disease recurrence in patients with a history of myocardial infarction or unstable angina. The link between Helicobacter pylori (H. pylori) infection and CHD, first described by Mendall et al. in 1994, has been the subject of a multitude of epidemiological and clinical studies; however, these have been so heterogeneous that not two of them are based on a comparable selection of patients and focused on the same kind of disease, e.g. stable coronary heart disease or acute myocardial infarction. Evidence from animal studies supports the thesis that H. pylori plays an extremely important role in the acute phase of myocardial infarction: the bacterium causes platelet aggregation and induces pro-coagulant activity in experimentally infected mice. H. pylori may also contribute to atherosclerosis through an auto-immune process against endothelial cells or an increased concentration of homocysteine in the blood due to decreased levels of folic acid and cobalamin. The exact role of H. pylori cannot yet be fully assessed: there is a clear and present need for further studies with appropriate epidemiological and clinical approaches to investigate through prospective and interventional trial the possible causal relationship between H. pylori and CHD.

Infection by Helicobacter pylori and acute myocardial infarction. Do cytotoxic strains make a difference?

The classical risk factors for acute myocardial infarction (AMI) fail to explain all the epidemiological variations of the disease. Among the risk factors recently reported, several infectious agents appear to increase the risk of AMI. Helicobacter pylori (H. pylori) infection, a bacterium involved in duodenal and gastric ulcer, gastric cancer and MALT-lymphoma, seems to be strongly associated with AMI. More virulent (anti-CagA positive) strains of the bacterium are almost exclusively the causative agents of such diseases. To determine the prevalence of H. pylori infection and of virulent strains, a case-control study was conducted in a group of male patients with AMI. A group of patients consecutively admitted to the Emergency Care Unit served as controls. We studied 223 consecutive male patients, mean age 60.2 (range 40-79) years, admitted for AMI to the Coronary Care Units at Hospitals in two towns of Northern Italy, 223 age matched male patients (mean age 61.8, range 40-79 years) admitted to the Emergency Care Unit, served as control. H. pylori seroprevalence was assessed by presence of antibodies (IgG) against H. pylori and anti-CagA in circulation. Among the patients we investigated the presence of hypertension, levels of cholesterol and glucose in serum, fibrinogen in plasma and smoking habits. H. pylori infection was present in 189/223 (84.7%) of the patients and in 138/223 (61.8%) of the control population (p < 0.0001 OR 3.42 [IC 95% 2.12-5.54]). The anti-CagA antibodies were detected in 33.8% of infected patients with AMI (64/189) versus 26.8% in the control subjects (37/138) (p:0.17, OR 1.40 [IC 95% 0.84-2.33]). Classical risk factors for AMI did not differ among patients with and without H. pylori infection. Patients admitted to the Coronary Care Unit for acute myocardial infarction had a notably higher prevalence of anti-H. pylori not restricted to virulent strains, when compared to a population of patients referred to the Emergency Care Unit. The classical risk factors for coronary disease were present in the patients with AMI irrespective of H. pylori status.

[Ischemic cardiovascular diseases. Correlation with Helicobacter pylori infection]. / Patologie cardiovascolari ischemiche. Correlazione con l'infezione da Helicobacter pylori.

Coronary heart disease is the primary cause of mortality in western countries. The well-established ("classical") risk factors cannot fully explain epidemiological variations of this disease. From several years infections have been linked to ischemic vascular events and recent studies pointed to the role of Helicobacter pylori (H. pylori), a spiral Gram negative bacterium, that chronically infects human stomach and is involved in the pathogenesis of gastritis and peptic ulceration. Systematic reviews of studies have suggested the existence of a possible weakly positive association between this bacterium and coronary heart disease, but this could be due to confounding bias and influenced by the degree of investigations heterogeneity. Experiments from animal studies demonstrated that H. pylori infection in mice induces the formation of platelet aggregates and in contrast to Chlamydia pneumoniae it has not been found in the plaque: therefore, the role of H. pylori, could be even more important in the acute phase of myocardial infarction. There is the need for extensive prospective studies to evaluate the incidence of these diseases in relation to the presence of H. pylori infection. Appropriately randomized studies employing an antibiotic treatment for patients affected by ischemic vascular disease will answer the question of whether H. pylori has a causal role in the pathogenesis of acute myocardial infarction and ischemic stroke.

Ultra-early risk stratification after myocardial infarction via pharmacological stress echocardiography: the relative value of resting function, viability and myocardial ischemia.

BACKGROUND: Echocardiographically recognized resting function, myocardial viability (by low-dose dobutamine) and stress-induced ischemia (by high-dose dipyridamole) are potent predictors of subsequent events, but their relative value in patients evaluated very early after acute myocardial infarction remains to be established. AIM OF THE STUDY: To assess the feasibility and usefulness of an integrated approach with resting and pharmacological stress echo for risk stratification in patients evaluated very early after myocardial infarction. METHODS: Sixty acute myocardial infarction patients without contraindications to stress testing, and who were being given thrombolytic therapy, underwent resting echo (16-segment model of left ventricle, each segment scored from 1 = normo-hyperkinetic to 4 = dyskinetic), high-dose dipyridamole (up to 0.84 mg/kg over 10') and low-dose dobutamine (up to 10 mcg/kg/min) echo on the third-fourth day after drug withdrawal. The response was "ischemic" with a dipyridamole-induced increase in the regional score > 1 in segments with a resting score < 3, and "viable" with a dobutamine-induced decrease in the regional score > 1 in segments with resting score > 1. All patients underwent coronary angiography on the tenth-twelfth day after the acute event, and all of them were followed up for 15 +/- 10.04 months. RESULTS: Ischemia elicited by dipyridamole appeared in 29 patients (48%) and dobutamine-induced viability was observed in 28 (47%). Ischemic events occurred in 26 patients (43.4%), five of which during the early in-hospital period. There were three deaths (5%), one re-AMI (1.7%), 7 Canadian Class III-IV angina (12%) and 15 (25%) early revascularization procedures undertaken independently of stress echo results. Events occurred in 21 patients (72%) with dipyridamole-induced ischemia and in 5 (16%) without it (p < 0.001). Likewise, events occurred in 13 patients (46.4%) with dobutamine-induced inotropic recovery and in 13 (40.6%) without it (p = ns). Event-free survival occurred in 64% of dipyridamole-positive patients, as opposed to 90% of dipyridamole-negative patients (p = 0.025). Dipyridamole echocardiographic test sensitivity and specificity for events were 81 and 74%, respectively. Sensitivity and specificity for events of dobutamine viability were 46 and 55%, respectively. In a multivariate logistic analysis, dipyridamole-induced myocardial ischemia was the strongest predictor of subsequent events (p = 0.01). According to Cox analysis, dipyridamole positivity had a relative risk estimate of 4. CONCLUSIONS: Pharmacological stress echo is feasible even very early after acute myocardial infarction via a useful approach based on low-dose dobutamine to assess myocardial viability, and high-dose dipyridamole to assess ischemia. For risk stratification purposes, stress-induced myocardial ischemia outperforms resting function and myocardial viability, and it is independent of angiographic data. Revascularization procedures do not seem to be effective when only viability is present.

[Risks of contraception and pregnancy in patients with congenital cardiopathies. Retrospective study on 108 patients]. / Rischi della contraccezione e della gravidanza in pazienti con cardiopatie congenite. Studio retrospettivo in 108 pazienti.

108 women with congenital heart disease in child-bearing age (16-38 years, mean age 28) were followed up for a period of ten years. Possible complications of contraceptive methods, and incidence of full-term pregnancies, spontaneous abortions and cardiovascular complications during pregnancy and delivery, were considered. Half of these patients had a cyanotic congenital heart disease, 23 had left-to-right shunt mainly at atrial level, 18 had right and 14 left ventricular outflow tract obstruction. 60 women had previous surgical procedures for their congenital heart disease. 83% of the patients were in NYHA functional class I-II. No complications were found during oral contraceptive regimen during intrauterine device insertion with antibiotic prophylaxis, except for the development of pulmonary hypertension in one patient with an atrial septal defect. 146 pregnancies occurred, but only 89 were full-term. There was a high number of interrupted pregnancies, rarely for medical reasons. The incidence of spontaneous abortion was similar to that of normal population (18% versus 10-15%). Maternal cardiovascular complications were found in the 22% of the full-term pregnancies, but were well controlled by medical treatment. In conclusion, good family planning and pregnancies are possible in most young females with congenital heart disease. In the absence of cyanosis and pulmonary hypertension, oral contraception does not carry any particular risk. With appropriate medical care intrauterine devices may be an alternative in high risk patients. In the presence of a good cardiac function, a normal full-term pregnancy with an healty baby is the rule. A cesarean section is seldom needed.

[Thromboembolic pulmonary hypertension]. / L'ipertensione polmonare tromboembolica.

Pulmonary hypertension due to recurrent thromboembolism is a rare disease but life-threatening. We evaluated 18 patients (11 female, 7 male) with this pathology between 1973 and 1991. We compared clinical features and evolution of our patients with the ones of the literature. The mean interval between beginning of symptoms and diagnosis was 5 years (range 1-10 years) and the most frequent symptom was increasing dyspnoea. In 2 of our patients there were well definite predisposing causes for thromboembolism (intracardiac catheters), 6 of the others had a previous episode of acute pulmonary embolism. Mean pulmonary arterial pressure was 50 mmHg and low output was present in 8 of these. Lung perfusion scintigraphy was diagnostic in 98% of cases showing segmental defects and pulmonary angiography confirms diagnosis revealing abrupt cut-off of cases showing segmental defects and pulmonary angiography confirms diagnosis revealing abrupt cut-off a major pulmonary artery. Angiographic evaluation of thrombus extent and location was difficult. In a small number of patients was found lupus anticoagulant, deficiency of protein C, of protein S and of antithrombin III. Mortality in medical treatment was 39% at a mean follow-up of 4-5 years. Progression of pulmonary hypertension was due to recurrent pulmonary embolism only in 30-40% of cases. The role of caval filter is not well established. Thromboendarterectomy shows immediate good results at short time but the long-term results are not known.

[Incidence and significance of ventricular arrhythmia after surgical correction of Fallot's tetralogy]. / Frequenza e significato delle aritmie ventricolari dopo correzione chirurgica della tetralogia di Fallot.

Patients may die suddenly after surgical repair of tetralogy of Fallot. Ventricular arrhythmias (VA) have been considered the possible cause of sudden death in such patients by many Authors. We evaluated the incidence and severity of VA in a group of 65 patients (25 females and 40 males) after surgical repair of tetralogy of Fallot. The age at the time of follow-up varied between 8 and 47 years. We divided our population into 4 groups (A, B, C, D) according to the surgical results (poor and good) and to the age of total correction (less than 12, greater than 12 years). We tested the presence and severity of VA in the different groups of patients and we found a significant difference in the incidence of VA between patients who underwent surgery before and after the age of 12 years (p = 0.0083). The surgical result did not show a significant relation with VA (p = 0.47). Among the patients submitted to surgical repair in the adult age, however, more serious VA are present in those with poor surgical result, and both our cases of sudden death occurred in this kind of patient. We speculate that postoperative ventricular arrhythmias are related to right ventricular function, which in turn appears to be worse in patients who underwent surgical correction at a later age. At last only perspective trials will be able to assess the significance of VA and their relationship with sudden death in this kind of patient.

Is ventricular arrhythmia in repaired tetralogy of Fallot an effect of operation or a consequence of the course of the disease? A prospective study.

Ventricular arrhythmia is common after repair of tetralogy of Fallot. Such arrhythmia could be caused by damage at surgical repair or it could be part of the course of the disease. Fifty patients, 32 aged 1-7 years and 18 aged 13-43 years at surgical repair, underwent 24 hour electrocardiographic monitoring before and 2-75 (mean 44) months after repair. Before operation none of the younger group had appreciable ventricular arrhythmia, whereas ventricular arrhythmia was already present in eight (45%) of 18 patients in the older group. At follow up ventricular arrhythmia was present in four patients from the younger group and seven from the older group. Three of these four younger patients had had insertion of a conduit from the right ventricle to the pulmonary artery or reoperation. Six of the seven older patients had had appreciable ventricular arrhythmia before operation. New ventricular arrhythmia developed in only two (5%) of the 43 patients who had uncomplicated repair of tetralogy of Fallot. Thus the high frequency of ventricular arrhythmia after repair of tetralogy of Fallot cannot be attributed to the effect of operation alone because in the majority of patients it was already present before operation. Preoperative ventricular arrhythmia occurred almost exclusively in older patients; this suggests that early surgery may reduce the occurrence of this late complication.

Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus.

In a series of 416 women with congenital heart disease seen in the Royal Brompton National Heart and Lung Hospital, London, and the Hospital Giovanni Bosco, Torino, Italy, there were 822 pregnancies. The outcomes of 96 pregnancies in 44 patients with cyanotic congenital heart disease were studied. Patients with the Eisenmenger reaction were excluded. Patients were divided arbitrarily into groups according to the type of maternal congenital cardiac anomaly, and factors influencing maternal and fetal outcome were evaluated. The incidence of maternal cardiovascular complications was high (32%), with one death from endocarditis 2 months after delivery. Forty-one (43%) of 96 pregnancies resulted in a live birth; 15 (37%) were premature. Mean weight of full-term infants was 2575 g. Univariate analysis suggested that maternal disease, Ability Index, hemoglobin, and arterial oxygen saturation before the pregnancy were factors that discriminated between successful and unsuccessful fetal outcome, with hemoglobin and arterial oxygen saturation being the most important predictors. Women with cyanotic congenital heart disease can go through pregnancy with a low risk to themselves, with frequent treatable complications, but there is a high incidence of miscarriage, premature births, and low birth weights. An incidence of congenital heart disease in the fetus of 4.9% (2 of 41 live births) is higher than that found in the normal population.

Retained barium n the appendix: diagnostic and clinical significance.

The significance of prolonged retention of barium in the appendix in an asymptomatic patient has been debated. Four patients, with retained barium in the appendix for several months after gastrointestinal barium studies, who then developed acute appendicitis, are reported and analyzed. Thirty-one patients who retained appendiceal barium longer than 72 hr after radiographic examination of the gastrointestinal tract were followed for over 1 year. No patient developed appendicitis. Five patients underwent abdominal surgery for other indications and there was no evidence of appendicitis. In 11 patients, who had abdominal radiographs 6 days to 4 months after detection of appendiceal barium, the barium had disappeared. The connotation of the term "barium appendicitis" as initially reported is questioned. Preliminary data in this report suggest that no causal relationship exists between prolonged retention of barium and future acute appendicitis and that normal appendices can expel barium in variable time periods. Etiologic connotation between prolonged appendiceal barium retention and future acute appendicitis should be erased. Retained barium in the appendix can be used as an acid in the precise radiographic diagnosis of acute appendicitis.

[Ebstein's anomaly in adults]. / La cardiopatia di Ebstein nell'età adulta.

Eighteen patients (11 women and 7 men) with Ebstein's anomaly recognized in adult age (18-55 years, mean 31.5) were followed in our Department for 3-13 years (mean 7 years). Echocardiographic and cardiac catheterization studies were performed in the majority. Clinical and echocardiographic findings were evaluated in the follow-up period. During the first assessment mild cyanosis was present in 14 cases. Nine patients were in NYHA class I, 6 in NYHA class II, 2 in NYHA class III and 1 in NYHA class IV. Eleven patients complained of palpitations. A Wolff-Parkinson-White (WPW) syndrome was present in 4 cases. At cardiac catheterization, done in 14 patients, a moderate-severe tricuspid regurgitation was found in 7 patients. In 8 cases there was a mild right-to-left shunt at atrial level. During the follow-up period there was 1 sudden death. In all patients with the WPW syndrome, the symptoms were well controlled by medical treatment. Systemic embolism was a major complication in 3 patients (all with patent foramen ovale and right-to-left shunt). During the follow-up period surgery was performed in 3 patients for a worsening of the tricuspid incompetence. Good early and late results were obtained in all 3 patients. The clinical conditions remained stable in the other 14 cases. Seven women out of 11 had 1 or more pregnancies (all together 14 pregnancies). In conclusion, in our experience Ebstein's anomaly diagnosed in adult life is a benign and stable disease, particularly if the patient is asymptomatic; surgical correction must be performed if the patient becomes symptomatic either because of paradoxical embolism or because of worsening of the tricuspid regurgitation.

[Aortic dissection after aortic valve replacement: clinical and anatomic features]. / Dissecazione aortica dopo sostituzione valvolare aortica: caratteristiche cliniche e anatomiche.

BACKGROUND: Cardiac surgery has become a possible cause of ascending aortic dissection, particularly in patients who have undergone aortic valve replacement. METHODS: From January 1979 to December 1989, 134 patients with angiographic evidence of aortic dissection, were studied in the Haemodinamic Laboratory of the University of Turin. Twelve of these patients (7 men and 5 women), mean age 51.6 years, had been previously operated for aortic valve replacement. We evaluated incidence, clinical and anatomic features of ascending aortic dissection in this group. RESULTS: A dilated ascending aorta with a mean diameter of 4.92 cm. was noted in all these patients. The interval between valve replacement and diagnosis of aortic dissection was 57 months (range 1 day to 9 years). Reoperation was performed in 11 patients. Four intraoperative deaths occurred and 2 other patients died in the early post-operative period. Survival rate at 12 months was 50%. Our incidence of ascending aortic dissection after aortic valve replacement was 0.66% (10 patients out of 1499 operated for aortic valve replacement) and it is in agreement with reports from other Authors in literature. CONCLUSIONS: Replacement of the ascending aorta must be considered if an important dilatation of aortic root is found at time of aortic valve surgery. New efforts must be undertaken to identify patients at high risk for this complication because an elevated mortality rate is observed in reoperation for aortic dissection.