Malpratice claims in cardiology and cardiac surgery: A medico-legal issue.

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Systemic inflammation is related to coronary microvascular dysfunction in obese patients without obstructive coronary disease.

BACKGROUND AND AIMS: Obesity, systemic inflammation and changes in the heart functions are associated with increased cardiovascular risk. This study aimed to investigate coronary microvascular dysfunction as an early marker of atherosclerosis in obese patients without any evidence of cardiovascular disease. METHODS AND RESULTS: 86 obese subjects (aged 44 ± 12 years, body mass index (BMI) 41 ± 8 kg m(-2)), without evidence of heart disease, and 48 lean controls were studied using transthoracic Doppler echocardiography for detecting coronary flow reserve (CFR). A value of CFR ≤ 2.5 was considered abnormal. We measured interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and adiponectin in all patients. Patients with abnormal CFR underwent coronary multislice computed tomography (MSCT) in order to exclude an epicardial stenosis. CFR in obese subjects was lower than in lean subjects (3.2 ± 0.8 vs. 3.7 ± 0.7, p = 0.02) and was abnormal in 27 (31%) obese patients and in one (2%) control (p < 0.0001). All subjects with abnormal CFR showed no coronary stenosis at MSCT. At multivariable analysis, IL-6 and TNF-α were the only determinants of CFR (p < 0.02 and p < 0.02, respectively). At multivariable logistic regression analysis, IL-6 and TNF-α were the only determinants of CFR ≤ 2.5 (p < 0.03 and p < 0.03, respectively). CONCLUSIONS: CFR is often reduced in obese subjects without clinical evidence of heart disease, suggesting a coronary microvascular impairment. This microvascular dysfunction seems to be related to a chronic inflammation mediated by adipocytokines. Our findings may explain the increased cardiovascular risk in obesity, independently of BMI.

Status of the circle of Willis and intolerance to carotid cross-clamping during carotid endarterectomy.

PURPOSE: During carotid endarterectomy (CEA), an intolerance to the cross-clamping (CC) can occur. The purpose of this study was to evaluate whether preoperative magnetic resonance angiography (MRA) can predict CC intolerance. MATERIAL AND METHODS: Seventy-one patients (57 males, 14 females, mean age 71.8 years, age range 46-86 years) underwent 71 CEA procedures under local anaesthesia. Before CEA, patients underwent an MRA of the Circle of Willis (CoW) and were then classified into three groups: group A consisted of patients with a complete CoW, group B included patients with one agenesia/obstruction in the CoW and group C comprised patients with two or more agenesiae/obstructions in the CoW. The association between the number of anatomical variants in the CoW, corrected for the status of the contralateral carotid artery, and the onset of CC intolerance was evaluated. RESULTS: The prevalence of intolerance to CC was 15.5% (11/71). The Fisher test and logistic regression analysis showed a statistically significant association between the intolerance to CC and two or more agenesiae/obstructions in the CoW (p value < 0.00001 and p < 0.001, respectively). No neurological complications were observed. CONCLUSION: The results of our study showed that two or more agenesiae/obstructions of the CoW identified by MRA were associated with a high risk of intolerance to CC during CEA.

Associations between carotid artery wall thickness and cardiovascular risk factors using multidetector CT.

BACKGROUND AND PURPOSE: It has been demonstrated that the increase in CAWT is associated with an increased risk of stroke and its severity. The aim of this study was to determine whether CAWT evaluated by MDCTA is associated with the following cardiovascular risk factors: hypertension, diabetes mellitus, dyslipidemia, and smoking. MATERIALS AND METHODS: This was a retrospective study. One hundred sixty-eight patients (120 men; mean age, 68.96 years ± 11.2 years SD) were analyzed by using a multidetector row CT scanner. In each patient, CAWT was measured by using an internal digital caliper. Continuous data were described as the mean value ± SD and were compared by using the Student t test. We performed simple logistic regressions to evaluate the association between CAWT and the following: hypertension, diabetes mellitus, dyslipidemia, and smoking. A P value < .05 indicated statistical significance. RESULTS: The distal common CAWT varied from 0.5 to 1.5 mm. We observed that hypertension and diabetes mellitus were associated with increased (>1 mm) CAWT (P = .0041 and P = .0172, respectively). There was no significant association between increased CAWT and dyslipidemia or smoking. CONCLUSIONS: In our selected group, the results of this work show that an increased CAWT is associated with the cardiovascular risk determinants hypertension and diabetes. Further studies are necessary to evaluate whether it is possible to apply our observations to the general population.

Imaging of the endoleak after endovascular aneurysm repair procedure by using multidetector computer tomography angiography.

Abdominal aortic aneurysms (AAA) are an important cause of death in elderly men. Most used treatment options are endovascular aneurysm repair (EVAR) and open surgical repair. After the endovascular stent graft placement, however, several complications may occur and an important complication of EVAR is endoleak formation which occurs in approximately one-fourth of patients. Endoleak represents a blood flow outside the stent graft lumen but within the aneurysm sac. For these reasons, unlike the minimal imaging follow-up that is typically performed after surgical repair, patients undergoing EVAR require a life-long postoperative surveillance imaging. In the last years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (multidetector CT angiography, MDCTA), CT imaging became the most commonly used examination for endoleak detection. Moreover, the volume data obtained can be further rendered to generate high quality two-dimensional (2D) and three-dimensional (3D) images, that allow a better distinction between Endoleak type II, III and IV. Purpose of this study was to review and describe MDCTA potentialities in the detection of endoleak after EVAR procedures.

Immediate- and late-hemodynamic coronary effects of tadalafil in men with erectile dysfunction and coronary artery disease.

We investigated whether coronary flow reserve (CFR) can be modified by tadalafil, a long-acting phosphodiesterase 5 (PDE5) inhibitor, in patients with documented coronary artery disease (CAD). CFR was non-invasively evaluated in 12 men with a positive history for erectile dysfunction (ED) and angiographically documented CAD, in the distal portion of the left anterior descending coronary artery, free from critical stenosis, with contrast enhanced echocardiography at time zero (T0). Then, after 20 mg tadalafil was orally administered CFR measurement was repeated after 2 h (T1) and after 24 h (T2). Doppler curves suitable for the analysis were obtained in all patients (CFR feasibility: 100%). The peak diastolic velocity after adenosine infusion increased from 71.3+/-14.3 cm/s at T0 to 82.5+/-24.0 at T1 (P=NS) and to 89.5+/-21.1 at T2 (P=0.0010). CFR after tadalafil increased significantly from 2.6+/-0.3 at T0 to 3.1+/-0.7 at T1 (P=0.0078) and a further increment was found at T2 (3.5+/-0.9; P=0.0010 vs T0). Our study shows that oral administration of tadalafil exerts a long standing, potentially beneficial effect on coronary microvasculature in patients with ED.

Detection of early impairment of coronary flow reserve in patients with systemic sclerosis.

OBJECTIVE: To investigate whether coronary flow reserve (CFR), measured by a new non-invasive method, is impaired early in patients with systemic sclerosis (SSc) and whether CFR impairment correlates with clinical or functional measures, or both. METHODS: 27 patients with SSc without clinical evidence of ischaemic heart disease and 23 control group subjects matched for age and sex were studied. CFR was evaluated in the left anterior descending coronary artery (LAD) with a new non-invasive method: contrast (Levovist) enhanced transthoracic Doppler during adenosine infusion. The pulsed wave Doppler examination of blood flow velocity was recorded in the LAD at rest and after maximum vasodilatation by adenosine infusion. RESULTS: In patients with SSc, without clinical evidence of ischaemic heart disease, CFR was impaired (p=0.0001). 14/27 patients with SSc had severe reduction of the CFR (< or =2.5) compared with controls (p=0.002). A non-significant trend between mean CFR and the severity and duration of the disease was also seen. CONCLUSIONS: CFR is often reduced in patients with SSc, suggesting early preclinical cardiac involvement in SSc. This impairment in coronary microvasculature is detectable by a non-invasive echocardiographic method and in this study was more common in the diffuse form of SSc.

Chronic venous ulcer treatment with fascial pedunculated graft.

AIM: Chronic venous ulcer treatment is often time consuming and requires a high degree of compliance from the patient. This derives not only from venous hypertension but also from chronic structural and metabolic changes of underlying tissues which impair the healing process. It therefore becomes necessary to improve the ulcer tissue condition in order to accelerate the healing process. This is obtained mainly with the improvement of local haemodynamics and secondly by direct action on the ulcer. The aim of the study is to evaluate the efficacy of a treatment with a pedunculated flap of fascia as an additional treatment of chronic venous ulcer. METHODS: Four patients classified C6 according to the CEAP classification were treated for chronic venous ulcer with correction of venous hypertension (saphenectomy or ligature of incompetent perforating veins). The patients also underwent rotation of a fascial pedunculated flap transferred from the sural area to the perimalleolar area. After 7-15 days they had a free skin graft in the treated area. RESULTS: All patients were discharged on the 3(rd) postoperative day after the flap rotation. In 3 patients the ulcer healed within 30 days and in a 4(th) patient within 45 days. No recurrence was observed. CONCLUSION: With this method the healing time seems to be shortened compared to the typical evolution in patients treated with only reflux control followed by conservative therapy. Associating fascial flap in the treatment of chronic venous ulcers improves the bed on which the free skin graft is applied. We can also hypothesize that this procedure restores the aponeurotic barrier between deep venous circulation and superficial microcirculation with the ensuing improvement in local venous hypertension.

Validation of a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) for the evaluation of coronary flow reserve: comparison with intracoronary Doppler flow wire.

OBJECTIVES: We tested the hypothesis that coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD) as assessed by a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) is in agreement with CFR measurements assessed by intracoronary Doppler flow wire. BACKGROUND: Contrast-enhanced transthoracic second harmonic echo Doppler is a novel noninvasive method to detect blood flow velocity and reserve in the LAD. However, it has not yet been validated versus a gold-standard method. METHODS: Twenty-five patients undergoing CFR assessment in the LAD by Doppler flow wire were also evaluated by contrast-enhanced transthoracic Doppler to record blood flow in the distal LAD at rest and during hyperemia obtained by adenosine i.v. infusion. In five patients CFR was evaluated twice (before and after angioplasty). RESULTS: As a result of the combined use of i.v. contrast and second harmonic Doppler technology, feasibility in assessing coronary flow reserve equaled 100%. The agreement between the two methods was high. In fact, in all but five patients the maximum difference between the two CFR measurements was 0.38. Overall, the prediction (95%) interval of individual differences was -0.69 to +0.72. Reproducibility of CFR measurements was also high. The limits of the agreement (95%) between the two measurements were -0.32 to +0.32. CONCLUSIONS: Coronary flow reserve in the LAD as assessed by contrast-enhanced transthoracic echo Doppler along with harmonic mode concurs very closely with Doppler flow wire CFR measurements. This new noninvasive method allows feasible, reliable and reproducible assessment of CFR in the LAD.

Contrast-enhanced transthoracic second harmonic echo Doppler with adenosine: a noninvasive, rapid and effective method for coronary flow reserve assessment.

OBJECTIVES: The purpose of this study is to evaluate the feasibility in detecting blood flow in the left anterior descending coronary artery (LAD) using transthoracic color Doppler (CD) imaging (in both second harmonic and fundamental mode) along with contrast enhancement and to verify if this new noninvasive method along with adenosine is safe, rapid and effective in assessing coronary flow reserve (CFR). BACKGROUND: Feasibility of contrast-enhanced transthoracic Doppler recording (in both second harmonic and fundamental mode) of blood flow velocity in the LAD has not been assessed. Adenosine has a greater vasodilator potency and more favorable kinetics than dipyridamole and thus it can be more suitable for assessing CFR in conjunction with this method. METHODS: Sixty-one patients with angiographically patent LAD underwent CD (both in fundamental and harmonic mode) as well as color-guided pulsed wave (PW) Doppler recording of blood flow velocity in the distal LAD before and after intravenous contrast injection. A second group of patients (n = 77), undergoing coronary angiography, was submitted to transthoracic contrast-enhanced PW Doppler recording of blood flow velocity in the LAD using harmonic CD as a guide, at rest and during adenosine-induced hyperemia. RESULTS: Harmonic CD along with echo contrast consistently improved blood flow detection in the LAD; the success rate in detecting flow of optimal quality was 88% with this approach, whereas it was 11% and 16% with CD in fundamental mode, respectively, before and after contrast. Pulsed wave Doppler results paralleled those of harmonic CD (p < 0.001 contrast harmonic vs. fundamental). In the second group of patients coronary angiography revealed 0% to <40% stenosis in 24 patients (group I), > or =40% to < or =75% in 17 patients (group II) and >75% stenosis in 34 patients (group III). There was a significant difference in CFR among the three groups of patients; CFR for peak diastolic velocity was (mean +/- SD): 2.88+/-0.7 (group I), 2.09+/-0.5 (group II) and 1.51+/-0.5 cm/s (group II) (p < 0.05 group I vs. both group II and group III; p < 0.05 group II vs. group III). The whole examination took less than 10 min. CONCLUSIONS: Contrast-enhanced second harmonic Doppler recording of blood velocity in the LAD is highly feasible and in combination with adenosine it is a rapid, safe and effective method for assessing CFR ratio.

Intracranial haemorrhage during exercise testing.

We describe the occurrence of an intraparenchymal (thalamic) haemorrhage during a stress test in a hypertensive 52-year-old man who had suffered from myocardial infarction 3 months earlier. Common causes of spontaneous haemorrhage, such as arteriovenous malformation, aneurysms, neoplasm, bleeding disorders or vasculitis were excluded. This single neurological complication was observed from among 8000 exercise tests performed in our Institute from 1987 to 1993.

Spontaneous rupture of an aneurysm of the left gastroepiploic artery.

This report describes the successful surgical treatment of a ruptured aneurysm of the left gastroepiploic artery. These aneurysms represent a very small fraction of visceral aneurysms.

Surgical treatment of hydatidosis.

Hydatidosis is particularly widespread in some geographic areas. Among these Sardinia presents one of the highest incidences. The authors examine the results obtained of 382 patients submitted to surgery between 1973 and 1989. The average age was 38.9 years. Liver involvement was observed in 215 cases, lung involvement in 167 cases, while localizations in other organs were rare. Forty liver cysts and 54 lung cysts were complicated preoperatively. The patients were submitted predominantly to total or subtotal cysto-pericystectomy (270 cases), parenchymal resection (75 cases), simple cystectomy (40 cases). Total postoperative mortality was 2.35%. Postoperative time was significantly shorter after cysto-pericystectomy and after parenchymal resection than after simple cystectomy. Patients suffering from multiple or complicated cysts were given supplementary chemotherapy.

The importance of presynaptic beta receptors in Raynaud's disease.

The purpose of the present study was to investigate the effect of atenolol, a beta 1-selective blocker, along with flunarizine, a calcium antagonist, in the management of Raynaud's disease. Forty patients with Raynaud's disease were randomized into a trial in which atenolol (50 mg daily) was given with flunarizine (10 mg daily). During the trial all patients were subjected to finger photoplethysmography and were given a diary to note daily the number and duration of the crises and presence or absence of pain and paresthesia. The association of atenolol with flunarizine caused an 80% reduction in the number of vasospastic crises, a significant increase (p less than 0.001) in the photoplethysmographic wave amplitude, and complete disappearance of pain and paresthesia. These results were not observed in patients treated with a placebo. Flunarizine reinforces the action of atenolol in causing a decrease in vasoconstriction in patients with Raynaud's disease, as observed previously by us, in that it acts directly on the beta-presynaptic receptors or on the calcium slow channels connected to the beta-receptors. The present study confirms that the principal role in the physiopathologic progression of Raynaud's disease seems to be played by a modification of the beta-presynaptic receptors in the nerve endings of the peripheral vessels.

Chest injuries. A review of 195 patients.

A retrospective analysis is presented of 195 consecutive patients with chest trauma, hospitalized from 1976 to 1984 at the Institute of Pathology and Surgery of the University of Cagliari. The most frequent causes were traffic accidents. In 11 patients the trauma was penetrating while 184 presented with blunt trauma. Conservative treatment was performed in 106, pleural drainage or thoracentesis in 29, and surgery in 60. Early osteosynthesis was performed in the 22 patients with flail chest and in 15 with multiple depressed fractures. Total mortality was 4.1%, and 13.6% in patients with flail chest. All deaths were associated with significant extrathoracic injuries.