Subcutaneous metastasis--the first sign of hepatocellular carcinoma in chronic virus C hepatitis patient--Case report.

Hepatocellular carcinomas make up 90% of primary liver cancers. The association between the hepatic carcinoma and virus B and C infection has been already proven. Hepatocellular carcinoma develops, in most cases, on a background of cirrhosis and rarely in hepatitis. The case we have chosen to report distinguishes itself due to the unusual extra-hepatic metastatic location of a hepatocellular carcinoma in a patient with Chronic HCV hepatitis.

An enhanced method for accessory pathway localization in case of Wolff-Parkinson-White syndrome.

This paper presents an analysis of the Arruda accessory pathway localization method for patients suffering from Wolff-Parkinson-White syndrome, with modifications to increase the overall accuracy. The Arruda method was tested on a total of 79 cases, and 91.1% localization performance was reached. After a deeper analysis of each decision point of the Arruda localization method, we considered that the lead aVF was not as relevant as other leads (I, II, III, V1) used. The branch of the decision tree, which evaluates the left ventricle positions, was entirely replaced using different decision criteria based on the same biological parameters. The modified algorithm significantly improves the localization accuracy in the left ventricle, reaching 94.9%. An accurate localization performance of non-invasive methods is relevant because it can enlighten the necessary invasive interventions, and it also reduces the discomfort caused to the patient.

Pre-operative transthoracic real-time three-dimensional echocardiography for a better surgical strategy.

UNLABELLED: In this study we aimed to evaluate the three-dimensional (3D) transthoracic echocardiography (TTE) in the assessment of cardiac valve morphology. METHODS: Bidimensional (2D) and real-time 3D TTE was performed in 104 patients consecutive with cardiac catheterisation, prior to valve surgery. Using surgical findings as the gold standard, 2D and 3D TTE were compared for adequate recognition and accurate detection of morphology. A scoring protocol was used for recognition of the valvular segments (0= inadequate, 1 = adequate). RESULTS: Adequate echographic visualization of the valve segments was more frequently obtained by 3D than 2D TTE imaging (731/770 by 3D TTE vs. 693/770 by 2D TTE, p < 0.01). The valve leaflets segments were more clearly identified by 3D TTE rather than by 2D TTE (502/531 vs. 471/531, p <0.01). The assessment of commissures was similar by both methods (229/239 vs. 222/239, p=0.09). Total 3D TTE scores for mitral and aortic valves were significantly better than 2D ITE scores (mean score 12.91+/-1.62 by 3D vs 11.58+/-1.02 by 2D, p=0.02). This superiority of 3D TTE was irrespective of rhythm (p <0.05 for both sinus rhythm and atrial fibrillation). Using surgical classification of valvular disease as gold standard, the sensibility and specificity were 91% and 84 % for 3D TTE, and 85% and 77% for 2D TTE, respectively. CONCLUSIONS: Real-time 3D was superior to 2D TTE forthe accurate localization and identification of valvular pathology, irrespective of heart rhythm.

The influence of left bundle branch-block and cardiac dyssynchrony on 2D-strain parameters in patients with heart failure complicating ischemic cardiomyopathy.

UNLABELLED: Coronary artery disease is the underlying cause in approximately two-thirds of patients with heart failure. Torsional and longitudinal deformations are essential components of left ventricular (LV) performance. Electric conduction defects can reduce LV ejection fraction (LVEF) and decrease cardiac output. AIM: To investigate the influence of left bundle branch-block (LBBB) and cardiac dyssynchrony on 2D-strain parameters in patients with HF complicating ischemic cardiomyopathy. METHODS: We analyzed 106 consecutive patients with HF complicating ischemic cardiomyopathy, in sinusal rhythm. LV strain, LV twist and LV torsion were measured by echocardiographic 2D-strain imaging. LV dyssynchrony was assessed using validated tissue Doppler parameters. Patients were divided into three groups: HF with normal LVEF (group 1), HF with reduced LVEF without LBBB (group 2) and with LBBB (group 3). RESULTS: LVEF, LV strain, LV torsion and LV twist were significantly better in group 1 (each p < 0.01). In group 3, LV torsion and LV twist were significantly lower compared to group 2 (0.80 +/- 0.4 vs. 1.21 +/- 0.23 degrees/cm, p = 0.007, and 5.18 +/- 2.4 vs. 8.31 +/- 1.5 degrees, p = 0.004, respectively), but LV strain and LVEF were not different between group 3 and 2 (-4.91 +/- 2.3 vs. -6.28 +/- 1.8%, p = 0.056, and 30.6 +/- 8.8 vs. 34.4 = 8.3%, p = 0.11, respectively). Cardiac dyssynchrony induces a reduction of all 2D-strain analyzed parameters (each p < 0.05). CONCLUSION: In HF complicating ischemic cardiomyopathy, LBBB and cardiac dyssynchrony induce a reduction of LV strain, torsion and twist. In patients with reduced LVEF, LBBB induces predominantly a significant reduction ofLV torsion and LV twist, while LV strain was apparently not influenced.

Left atrial surface cut point to detect trapezoidal shape for characterisation of atrial anatomical remodeling.

BACKGROUND: Complete geometrical and shape characterization of left atrium has not been performed. Ellipse formula has been proved to underestimate the real LA volume. The aim of the study is to analyze the relation between LA area and shape in order to predict their value in the assessment of the severity of anatomical remodeling. METHODS: 216 consecutive patients (pts) aged 53 +/- 27 years were included. The following parameters were assessed: LA dimensions (LAd=M-mode, parasternal long axis, LAt and LA1 are the measurements of short- and long-axis in apical four chamber view), LA surface in apical four chamber view (LAs). A new measurement was introduced, the basal dimension of the LA (LAb) as the maximal transverse distance at the base of LA apical four chamber view. LA measurements were calculated at end-systole (maximal). Trapezoidal LA shape was defined if transverse dimension < basal dimension. RESULTS: LAs ranged 10.5-54.5 cm2. Trapezoidal LA was found in 149 pts. ROC curve for prediction trapezoidal LA showed a 0.89 area under the curve. The analysis demonstrates a cutoff value of 22.3 cm2 for LAs to detect trapezoidal shape with a sensitivity of 85% and specificity of 82.5%. The simple regression analysis demonstrated a statistically significant linear correlation between LAd and LAs (r2=0.63, p<0.0001) but LA1 was better correlated with LAs (r2=0.7, p<0.0001). Trapezoid LA with atrialization of the pulmonary veins and predominant dilatation of bazal atrium than annular side may explain underestimation of LA volume using ellipse formula. CONCLUSION: LAs is a reliable parameter and may be the best choice to estimate LA dilatation; LAs is related to shape remodeling; LA1 is a better parameter than LAd for estimating LA dilatation and complete characterization of LA remodeling should include shape definition and LAb.

Anti-arrhythmic effects of I (Na), I (Kr), and combined I (Kr)-I (CaL) blockade in an experimental model of acute stretch-related atrial fibrillation.

INTRODUCTION: Atrial dilatation is commonly associated with atrial fibrillation (AF), but the electrophysiological mechanisms and the implications for anti-arrhythmic therapy are poorly understood. In a model of acute stretch-related AF in isolated rabbit hearts, we evaluated the electrophysiological effects of three different anti-arrhythmic drugs: dofetilide, flecainide and BRL-32872 (associating I (Kr) and I (CaL) blocking properties). METHODS: After 30 min of sustained stretch-related AF, we perfused BRL 10-7 M, BRL 3.10-7 M, BRL 10-6 M, flecainide 2.4 10-6 M and dofetilide 10-7 M and iteratively measured atrial effective refractory periods (ERPs), AF inducibility and AF cycle length (AFCL) 15, 30 and 60 min after drug perfusion, respectively. RESULTS: After a significant shortening of the ERPs by acute atrial stretch in the five groups individually (p < 0.001, stretch vs baseline for each group individually), drug perfusion led to a strong lengthening of AFCL, a very significant prolongation of ERPs (p < 0.001 vs stretch) and a reduction of AF inducibility (p < 0.01 vs control group) for each of the five experimental groups. The relative ERP increase was comparable in all groups, whereas a significantly lower AF inducibility was observed in the BRL 10-6 M group (p < 0.05 vs other BRL concentrations). CONCLUSION: In a model of acute stretch-related AF, dofetilide, flecainide and BRL-32872 terminated AF and prevented its immediate reinduction after having comparatively prolonged AFCL and ERPs. These comparative results suggest that those drugs are equally efficacious, albeit with different mechanisms, in the setting of acute atrial stretch.

Time movement timing parameters validation using tissue Doppler imaging in patients with dilated cardiomyopathy.

UNLABELLED: The aim of the study was to compare similar time-movement (TM) and tissue Doppler (TDI) timing parameters and to predict their value in assessment of systolic asynchrony for biventricular pacing indication. METHODS: 41 patients (pts) aged 56.4 +/- 11.2 years with dilated cardiomyopathy were included. PARAMETERS: QRS duration (QRSd); septal (S), posterior (P), lateral (L) and posterolateral (PL) wall delays, as the time from QRS onset to maximal wall contraction (parasternal, 4 chamber view and subcostal incidence); left ventricular mechanical delays (LVD) time interval from maximal contraction between interventricular septum and posterior (LVDp), lateral (LVD1) and posterolateral (LVDp1) wall, both in TM and TDI; TDI measurements were performed using both color and pulsed TDI (from onset of QRS to the end of S wave); isovolumic relaxation time (IRT) in each wall using TDI; An error parameter (Er) was assessed for each measurement as the difference in similar timing parameters TM-TDI. RESULTS: LVDp = 111 +/- 69ms, LVD1 = 132 +/- 62ms, LVDp1 = 151 +/- 77ms; 26 pts presented QRSd > 120 ms (LBBB), 15 pts had QRSd < 120 ms. LVD > 100 ms was found in 32 pts; LVD were significantly higher in LBBB pts. There was no correlation between QRSd and echocardiographic parameters. Er ranged from 0-80 ms. Er > 30 ms were found in pts with fragmented wall motion and IRT > 30 ms. The most delayed wall was PL (42% pts), L (38%) and P (30%). CONCLUSION: Intraventricular asynchronized contraction occurs even in pts with normal QRS duration; these changes can be easily and accurately detected using simple TM timing parameters. The most delayed site to be stimulated can be found either using TDI or TM.

Glomectomy in carotid sinus syncope and associated arrythmias: symptomatic bradycardia, atrial flutter and atrial fibrillation.

UNLABELLED: The main causes of neurally mediated syncope (NMS) are carotid sinus syndrome (CSS) and vasovagal syncope. Long before, carotid sinus denervation was performed for different diseases, but for the first time we consider glomectomy (G) as a surgical treatment for NMS and related arrhythmias, alone or associated with cardiac pacing (PM). METHODS: We used Nakayama's technique for bronchial asthma, modified by us: removal of hypersensitive carotid glomus and presinusal lymphadenectomy. Forty five patients (pts) with recurrent NMS (cardioinhibitory 14 pts, mixed 31 pts) were included: 41 males, 4 females, aged 23-84 (mean 60 yrs). The diagnosis was documented clinically by carotid sinus massage, ECG-Holter, electrophysiologic studies, head-up tilt test. Malignant orthostatic syndrome was present in 4 pts, tussive syncope in one, sick sinus syndrome (SSS) in 6 pts, atrial fibrillation and flutter in 6 pts, AV block in 2 pts. Thirty four pts underwent G alone; 6 pts-G and PM; 5 pts-PM alone, 3 pts-G plus carotid endarterectomy. RESULTS: of G were excellent. All pts became free of syncope (max. follow-up 10 yrs). In addition, stable sinus rhythm was obtained in two pts (one with severe atrial fibrillation, another with persistent atrial fibrillation). In pts with SSS, A-V block or atrial fibrillation with bradycardia, PM was inserted (DDDR or VVIR). However, in pts with vasodepressor component of NMS, symptoms persist until G was performed. CONCLUSIONS: We conclude that our data support the efficiency of G in pts with NMS (either cardioinhibitor or vasodepressor), as well as in related arrhythmias. PM is indicated in pts with associated diseases: intrinsic SSS, AV block, atrial fibrillation with bradycardia.

Dual renin angiotensin system blockade in patients with acute myocardial infarction and preserved left ventricular systolic function.

UNLABELLED: The activation of the renin-angiotensin system (RAS) is a major determinant of ventricular remodeling. We prospectively assessed whether the dual RAS blockade (angiotensin II AT 1-receptor blocker and angiotensin-converting enzyme inhibitor therapy) in patients with acute myocardial infarction (AMI) who were treated by primary percutaneous coronary intervention (PCI) and stenting provides benefit on the improvement of the left ventricle function. A secondary aim is to demonstrate that triple therapy with angiotensin-converting enzyme (ACE) inhibitors, angiotensin II AT 1-receptor blockers (ARBs) and beta blockers does not increase cardiovascular morbidity, cardiovascular mortality and all cause mortality. METHODS: We investigated 44 patients with AMI with ST elevation undergoing primary PCI and stenting. All patients received standard therapy including an ACE inhibitor and a beta blocker. We divided the patients into two groups, A and B. Valsartan was added to the standard therapy within the first 6 hours from the onset of AMI in group A. We assessed cardiovascular and all cause mortality, incidence of major acute coronary events (MACE), incidence of non-fatal AMI, the evolution of left ventricle ejection fraction (LVEF), wall motion score index (WMSI) and left ventricle end-systolic and end-diastolic diameters. The follow-up period was one year. RESULTS: There were no statistically significant differences between groups regarding cardiovascular and all cause mortality, incidence of MACE, incidence of non-fatal MI. LVEF significantly increased at 1 year in both groups. In both groups the reduction of end-systolic and end-diastolic diameters at 1 year was statistically significant. Echocardiographic findings demonstrated also a significant decrease of WMSI at 1 year in both groups. CONCLUSIONS: The dual renin-angiotensin system blockade (ARBs and ACE inhibitor) has proved its beneficial effect on the improvement of left ventricular function, without increasing cardiovascular mortality and incidence of non fatal myocardial infarction (MI) in patients with AMI treated by primary PCI and stenting within a 1 year follow-up period.

Is age correlated with dynamic atrial decremental conduction properties?

UNLABELLED: Atrial fibrillation (AF) has been associated with premature beats and decreased atrial conduction velocities. On the other hand, prevalence of AF is increased in the elderly. The aim is to evaluate and analyze the relation between age, atrial size and a new index of dynamic interatrial conduction time (iaCT) in a homogeneous population of patients (pts) with structurally normal heart without AF. METHODS: 45 patients (pts) without structural heart disease aged 53 +/- 20 years referred for electrophysiologic study were analyzed. To examine the atrial electrophysiologic characteristics we studied interatrial conduction time (iaCT), double potentials and fragmented atrial activity during premature stimulation of high right atrium; prior to investigation, all antiarrhythmic drugs were withdrawn for an appropriate period of time. The following parameters were assessed: baseline iaCT (iaCTb) between high right atrium (HRA) and distal coronary sinus (CS), iaCT during HRA pacing S1S1 600ms (iaCTS1), maximum prolongation of iaCT during S2 and S3 delivery (iaCTS2, iaCTS3). We calculated a derived parameter: maximum prolongation iaCT/decremental index (DI)= iaCT S3-ia CTS1/iaCTS1%. The following echocardiograhic parameters were assessed: left atrial dimensions and surface (LAs), right atrial dimension and surface (RAs), total atrial surface (TAs=LAs+RAs) and left atrial volume (LAv) calculated using ellipse formula. RESULTS: iaCT ranged from 42 to 87ms; DI ranged from 16 to 52%. Simple regression analysis demonstrated a statistically significant linear correlation between the age of pts and HRA DI (r = 0.76, r2 = 0.55, p <0.0001). A trend toward a significant correlation was found between TAs and DI (r=0.64, r2=0.41, p<0.0001) LAv and DI (r=0.59, r2=0.35, p<0.0001). No significant correlation was found in this group between age and iaCT. Atrial double potentials and fragmentated electrograms were recorded using HRA stimulation in CS leads in 7 pts (15%) all aged >35 years. Pts were divided into two groups: 17 pts with normal electrophysiologic findings and 28 pts with junctional reentrant tachycardia. There were no significant differences between subgroups concerning the main studied parameters. CONCLUSIONS: This study shows a direct better correlation for age than atrial size in the relation with the dynamic behaviour interatrial conduction, suggesting that higher incidence in AF in the elderly might be also a consequence of the higher incidence of atrial conduction disturbances.

Echocardiographic evidences of increased left ventricular pressure and atrial dilatation in patients with drug-resistant paroxystic atrial fibrillation and structurally normal heart.

UNLABELLED: Global myocardial index (GMI) has been significantly related to left ventricular filling pressure. We hypothesized that GMI and echographic indicators of atrial dilatation were significantly different in pAF pts compared to normals. METHODS: 39 patients (pts) without structural heart disease, aged 52+/-10 years with pAF were compared to 36 control-matched pts aged 48+/-16 years. Following parameters were assessed: P-wave duration (Pd), GMI, left atrial dimensions (LAd=M-mode, parasternal, LAt and LAI are measurements of short and long-axis apical four chamber view), surface (LAs), volume (LAv), total ejection fraction (LA EF), right atrial dimension (RAd) and surface (RAs), total atrial surface (TAs=LAs+RAs). LAv was calculated using ellipse formula pi/6 (LAdxLAlxLAt). RESULTS: There was no difference between the 2 groups concerning Pd (p=0.1), LA EF (p=0.23), LAd (p=0.08) and LAt (p=0.06) while the rest of the parameters were significantly higher in pAF pts: GMI: 0.5+/-0.17 vs 0.36+/-0.06 (p=0.001); LAI: 5.4+/-0.5 vs 4.5+/-0.3 cm2 (p=0.001); LAs was founded increased in pAF pts (20.6+/-5.7 vs 16.3+/-2.1 cm2, p=0.001); TAs: 40.6+/-6.9 vs 30.6+/-5.1 cm2, p=0.0001; LAv: 51.6+/-10.4 vs 37.2+/-9.3 ml (p=0.0001). CONCLUSIONS: Although apparently without structural heart disease, pAF pts presented evidence of increased filling pressions in left ventricle and indirect markers of atrial stretch. The role of increased intra-atrial pressure in pts pFA and predictive value of these parameters need to be evaluated in a larger number of patients.

Absence of correlation between QRS duration and echographic parameters of ventricular desynchronization. Can we still trust the electrocardiographic criteria?

UNLABELLED: The aim of the study was to assess if echographic ventricular desynchronization parameters measured in patients with dilated cardiomyopathy (DCM) and severe heart failure are correlated with the duration of the QRS on surface electrocardiogram. METHODS: This study included 51 pts aged 58.8 +/- 7.4 years with idiopathic DCM. The following parameters were measured: QRS duration; effective contraction time (ECT) measured as the interval between QRS onset and closure of aortic valve, interventricular delay (IVD) measured as the time between onset of aortic and pulmonary flow, left ventricular mechanical delay (LVD) as the time from maximal interventricular septum contraction and posterior wall contraction, posterior (P), lateral (L) and posterolateral (PL) wall delays, as the time from QRS onset to maximal wall contraction. Regional postsystolic contraction was defined in a given wall as the difference (contraction delay - ECT)> 50ms. RESULTS: 29 pts presented complete LBBB, 22 pts had QRS duration < 120 ms. 39 pts had a postsystolic contraction of the PL wall (32 pts of the L wall and 26 pts of the P wall). 16 pts with QRS duration <120 had a postsystolic contraction of the PL wall (as for the LBBB the rest of 39 pts). In 40 pts the sequence of regional ventricular contraction was: P-L-PL wall (16 pts with QRS<120). LVD was > 100 ms in 36 pts (26 pts with LBBB and 10 with QRS<120). 27 of pts with LBBB and 6 with QRS <120 ms presented IVD> 30ms. There was no correlation between the QRS duration and the parameters listed above. CONCLUSIONS: In DCM pts there is no correlation between the duration of the QRS and echocardiographic parameters of ventricular desynchronization. Mechanical ventricular de-synchrony can be observed in patients with QRS duration < 120 ms.

Global myocardial index in patients with multisite pacing.

UNLABELLED: Global myocardial index (GMI) is a sensitive echocardiographic indicator of overall cardiac function. The aim of this study was to compare the GMI changes induced by Bi-V pacing to the variations in clinical, electrocardiographic and echocardiographic parameters currently used for evaluation of ventricular resynchronization in order to test the potential marker of positive clinical response. PATIENTS AND METHODS: This study included 35 consecutive patients (pts), aged 65.7+/-7.5 years, implanted with an endocavitary Bi-V pacemaker for drug refractory severe heart failure. NYHA class was evaluated before implantation and at day 30. QRS duration (QRSd), echocardiographic interventricular delay (IVD), and GMI were determined in the paced and non-paced situation at day 1, 7 and 30 after implantation. RESULTS: NYHA class improved from 3.5+/-0.3 to 2.4+/-0.4 (p<0.01). GMI improved significantly (p<0.0001) after Bi-V in all pts from 1.25 +/- 0.5 to 0.77 +/- 0.34 and remained stable all along the study. GMI decrease (dGMI) in pts with NYHA functional class improvement > 0.5 was 0.52 +/- 0.16while dGMI in pts with NYHA functional class improvement < or = 0.5 was 0.21+/- 0.19. dGMI was statistically correlated with IVD shortening (r=0.67, p<0.0001) but not with QRSd shortening. CONCLUSION: The GMI improves during Bi-V pacing, mostly in responders pts and the improvement remains unchanged after the implant. The GMI decrease induced by Bi-V pacing is correlated with the IVD shortening and NYHA functional class improvement.

Predisposition to efficient mammary tumor metastatic progression is linked to the breast cancer metastasis suppressor gene Brms1.

Tumor metastasis is one of the most important clinical aspects of neoplastic disease because patient mortality is frequently attributable to disseminated rather than primary tumors. However, it still is not possible to definitively distinguish those individuals at high risk for disseminated disease, who would benefit from aggressive adjuvant therapy, from the low-risk patients who might be spared the side effects of additional anticancer therapy. To identify factors that predispose toward metastatic disease, we have used a genetic approach. Using a highly metastatic model of mammary cancer, we identified previously inbred mouse strains (DBA/2J, NZB/B1NJ, and I/LnJ) that harbor genetic factors that significantly suppress metastatic efficiency. In this study, we report the results of four experiments to localize the genetic map locations of the metastasis efficiency modifier genes. One statistically significant locus was identified on proximal Chr 19 designated Mtes1. Secondary candidate intervals were detected on Chrs 6, 9, 13, and 17. Interestingly, Mtes1 colocalizes with the murine orthologue of the human breast cancer metastasis suppressor gene Brms1, suggesting that allelic variants of Brms1 might be responsible for the metastasis suppression observed.

[Postoperative flat anterior chamber. The therapeutic approach]. / Atalamia postoperatorie. Atitudine terapeutica.

OBJECTIVE: The study of clinical entities followed by postoperative flat anterior chamber and their therapeutical possibilities. Retrospective study of all flat anterior chamber cases in a series of 315 patients operated for glaucoma. There were 16 flat anterior chamber cases with ocular hypotony, 3 cases with pupillary block and 9 cases with ciliary block. Stage I flat anterior chamber cases with ocular hypotony responded well to medical treatment. The most efficient surgical procedures were the application of additional sutures and excision of the over filtering bleb. The most frequent complications are: secondary cataract (75%), filtering failure (25%) and uveitis (18.75%). Flat anterior chamber cases with pupillary block resulted from obstruction and were managed with a new peripheral iridectomy. Flat anterior chamber cases with ciliary block had a severe evolution and didn't show any improvement under medical therapy. All cases were managed successfully by vitreous surgery (especially using pars plana aspiration). The incidence of postoperative flat anterior chamber can be reduced by accurate surgical procedure. Most of flat anterior chamber cases with ocular hypotony had a favorable evolution under medical treatment. Cases associated with intraocular hypertension needed surgical management.

[Functional results in the surgery of congenital cataract]. / Rezultatele functionale în chirurgia cataractei congenitale.

During 1983-1993, 202 patients (a total of 230 eyes), 113 males and 117 females, were operated. From these, 47 selected cases could not be properly followed and the functional results were established only after repeated checking. In these cases, the surgical techniques consisted of 7 cryoextractions, 47 extracapsular extractions and 18 irrigations-aspirations in double stream. 47 lens implants have been introduced, 43 were Fedorov [correction of Fyodorov]-type with pupillary fixation and 4 were posterior chamber implants. The visual acuity was almost the same to both the patients who have benefited from implants and to those corrected with contact lens or glasses.