Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Perioperative dental screening and treatment in patients undergoing cardio-thoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections, and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients had never been defined. Following the systematic review several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently and then a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions, and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus can become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Meta-analyses on intra-aortic balloon pump in cardiogenic shock complicating acute myocardial infarction may provide biased results.

OBJECTIVE: Intra-aortic balloon pump (IABP) is the device most commonly investigated in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Recently meta-analyses on this topic showed opposite results: some complied with the actual guideline recommendations, while others did not, due to the presence of bias. We investigated the reasons for the discrepancy among meta-analyses and strategies employed to avoid the potential source of bias. MATERIALS AND METHODS: Scientific databases were searched for meta-analyses of IABP support in AMI complicated by CS. The presence of clinical diversity, methodological diversity and statistical heterogeneity were analyzed. When we found clinical or methodological diversity, we reanalyzed the data by comparing the patients selected for homogeneous groups. When the fixed effect model was employed despite the presence of statistical heterogeneity, the meta-analysis was repeated adopting the random effect model, with the same estimator used in the original meta-analysis. RESULTS: Twelve meta-analysis were selected. Six meta-analyses of randomized controlled trials (RCTs) were inconclusive because underpowered to detect the IABP effect. Five included RCTs and observational studies (Obs) and one only Obs. Some meta-analyses on RCTs and Obs had biased results due to presence of clinical and/or methodological diversity. The reanalysis of data reallocated for homogeneous groups was no more in contrast with guidelines recommendations. CONCLUSIONS: Meta-analyses performed without controlling for clinical and/or methodological diversity, represent a confounding message against a good clinical practice. The reanalysis of data demonstrates the validity of the current guidelines recommendations in addressing clinical decision making in providing IABP support in AMI complicated by CS.

Assessment of left ventricular hypertrophy in patients with essential hypertension. A rational basis for the electrocardiogram.

There is a large body of evidence that the electrocardiogram (ECG) is insensitive in the recognition of left ventricular hypertrophy (LVH), in comparison with the echocardiogram; however, its specificity is high. In this study we further analyzed the performance of the ECG in detecting LVH in 200 consecutive patients (124 men and 76 women, mean age 50.9 years) with mild to moderate essential hypertension, using echocardiographically determined left ventricular mass (LVM) as the standard for comparison. To test the hypothesis that, owing to the high number of true positive findings, the ECG may still be useful for clinical purposes by selecting subsets of hypertensives with higher degrees of LVH, we compared the mean values of LVM index corresponding to either positive (true positive) or negative (false negative) electrocardiographic signs of LVH. In this study 69 patients (34.5%) had echocardiographic LVH, as defined by a LVM index exceeding 125 g/m2 for men and 112 g/m2 for women. Almost all criteria demonstrated high levels of specificity (> or = 89%). In the whole group the Lewis index ((RI - RIII)+(SIII - SI) > or = 17 mm) showed a slight superiority in diagnosing LVH (sensitivity = 43%) in comparison to the remaining criteria; the confidence intervals estimate of sensitivities confirmed such diagnostic superiority only with respect to those criteria with a sensitivity < or = 17%. However, the use of McNemar's test to compare sensitivities of all electrocardiographic criteria at matched specificities (> or = 95%) did not show significant differences (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler evaluation of diastolic function in hypertrophic cardiomyopathy]. / La valutazione Doppler della funzione diastolica nella cardiomiopatia ipertrofica.

Diastolic function may play a significant role in patients affected by hypertrophic cardiomyopathy, because abnormalities in diastolic function, even in presence of a normal systolic function, may determine the clinical features of the disease. Doppler ecocardiography, using a non-invasive and not highly expensive method, easily allows to analize the indexes of diastolic function, as soon as some morpho-functional parameters, represented by extent and localization of the myocardial hypertrophy and presence or absence of obstruction in the left ventricular outflow, which have always been considered relevant in the prognosis together with the typical arrhythmic abnormalities of the disease. The aim of this study was to investigate the behaviour of Doppler ecocardiographic parameters of diastolic function in 38 patients with hypertrophic cardiomyopathy and to analize whether they might be correlated with the morpho-functional patterns and clinical features of the disease, represented by the NYHA functional class and occurrence of ventricular tachycardia during 48 hour ambulatory electrocardiographic monitoring. Diastolic function abnormalities, although occurring in most patients, do not seem to be related with clinical conditions and/or with the typical morpho-functional patterns of the disease; however, an increase in the left atrial size together with a specific increase in the rate of deceleration of flow velocity in early diastole that were detected in patients with ventricular tachycardia, by suggesting a relation between diastolic dysfunction and arrhythmogenic substrate, remarks the importance of the analysis of diastolic function for a better prognostic evaluation of the hypertrophic cardiomyopathy.

[Skin manifestations in 140 kidney transplants]. / Manifestazioni cutanee in 140 trapiantati renali.

Cutaneous lesions can be a significant problem in kidney transplant recipients. The AA report a clinical spectrum of iatrogenic, infectious, preneoplastic and neoplastic skin diseases in 140 renal transplant recipients observed, from march 1988 to july 1991, at the Catholic University in Rome. Iatrogenic skin manifestations were the most common, followed by infections of the skin and preneoplastic and neoplastic cutaneous lesions.

The spectrum of echocardiographic and electrocardiographic abnormalities in nonaffected relatives of patients with hypertrophic cardiomyopathy: a transverse and longitudinal study.

We studied 122 relatives (18 parents, 33 siblings, 57 offspring, 10 nephews and 4 nieces; mean age 34 +/- 19 years) of 33 patients with hypertrophic cardiomyopathy (HC) to analyze the incidence and clinical significance of electrocardiographic and echocardiographic abnormalities. On the basis of conventional echocardiographic criteria 12 first-degree relatives were considered to be affected by HC. Thirteen first-degree relatives and 1 niece were judged as having probable but not definite HC, i.e. left ventricular (LV) wall thicknesses over the 95% upper limit of confidence interval for age and body surface area or borderline ventricular septal thickness but a septal-to-free wall thickness ratio > or = 1.3 in the absence of an identifiable origin. Ninety relatives had normal echocardiographic findings. The remaining 6 subjects were found to have essential hypertension and were therefore excluded from consideration. Electrocardiogram (ECG) showed major or minor abnormalities in all relatives with HC, in 7 of the 14 probably affected by HC and in 20 of the 90 with normal echocardiogram. Of the 122 relatives 44 (38 with normal echocardiogram and 6 probably affected by HC) were reexamined over a mean period of 4.3 years (range 2-7). In the course of the follow-up 3 subjects modified their cardiac status. Two offspring who had at entry LV hypertrophy at ECG as isolated cardiac abnormality developed HC over a period of 5 years. A sibling who had only minor electrocardiographic abnormalities in the first study became probably affected by HC 3 years later.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of left atrial enlargement with electrocardiogram. A misplaced reliance]. / La diagnosi di ingrandimento atriale sinistro per mezzo dell'elettrocardiogramma. Una fiducia malriposta.

We analyzed the performance of the electrocardiogram in the diagnosis of left atrial enlargement in 1000 unselected consecutive patients (585 men and 415 women, mean age 46 +/- 17 years) with different cardiovascular diseases or clinically normal. Echocardiography was used as reference method to assess left atrial dimension. The following electrocardiographic criteria were considered: total P-wave duration in leads D1, D2 or D3 > or = 110 ms; P terminal force in lead V1 equal to or more negative than -0.04 mm-s, and P-wave notching in leads D1, D2 or D3 with a peak to peak interval > or = 40 ms. A total of 89 subjects (8.9%) fulfilled the echocardiographic criteria for left atrial enlargement, defined as a left atrial dimension above the upper limit of the normal 95% predicted interval calculated as a function of age and body surface area. In the whole group 67 subjects (6.7%) had at least one of the electrocardiographic criteria for left atrial enlargement. In only 23 patients there was agreement between electrocardiogram and echocardiogram in the diagnosis of left atrial enlargement. The three electrocardiographic indexes had specificity > or = 97%, however sensitivity was unacceptable (< or = 18%). Negative predictive value was high (> or = 91%) but positive predictive value was poor (< or = 35%).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical relevance of the electrocardiogram in relatives of patients with hypertrophic cardiomyopathy.

Eighty-nine first-degree relatives of 22 patients with an established diagnosis of hypertrophic cardiomyopathy underwent electrocardiographic and echocardiographic screening. Scalar electrocardiogram was abnormal in 30/89 (33.7%) relatives. Of these thirty, eleven had definite evidence of hypertrophic cardiomyopathy at echo; one had borderline hypertrophy and was considered neither affected nor unaffected; four had questionable signs of hypertrophy. The remaining 14 relatives had normal echo-cardiograms. Fifty-nine relatives (66.3%) had normal electrocardiograms; at echo 3 were considered to have borderline hypertrophy, 16 had questionable signs of hypertrophy and 40 were normal. In relatives of patients with hypertrophic cardiomyopathy an abnormal electrocardiogram may reflect different morphologic conditions: a real hypertrophic cardiomyopathy or a myocardial hypertrophy of uncertain significance. Furthermore, in these categories of subjects, an abnormal electrocardiogram with normal echo must be considered with caution.

[The effects of a left bundle-branch block on ventricular repolarization dispersion]. / Effetti del blocco di branca sinistra sulla dispersione della ripolarizzazione ventricolare.

Patients with left bundle-branch block (LBBB) often present electrocardiographic abnormalities and, therefore, are excluded from studies concerning electrocardiographic evaluation of ventricular repolarization. The aim of the study was to assess whether LBBB could influence dispersion of ventricular repolarization. Surface electrocardiograms of 16 patients (9 males and 7 females, mean age 58 +/- 14 years) with episodes of intermittent LBBB were analyzed. Six patients were affected by coronary artery disease, 6 by hypertensive cardiomyopathy and 4 by dilated cardiomyopathy. Maximal QT and JT corrected intervals, QT and JT dispersion, and QT and JT dispersion corrected for heart rate, were obtained before and after LBBB. We observed a significant prolongation of maximal QT (412 +/- 29 vs 433 +/- 25 ms; p < 0.05), and of maximal corrected QT (457 +/- 37 vs 497 +/- 56 ms; p < 0.05) after LBBB. Maximal JT interval, also corrected for heart rate, did not show any significant modification after LBBB. Moreover, we did not observe any significant difference in electrocardiographic parameters of dispersion of repolarization. Our results seem to indicate that LBBB did not alter significantly dispersion of ventricular repolarization. QT dispersion is considered an important marker of risk for incidence of ventricular arrhythmias. If our results will be confirmed in larger groups of patients, analysis of QT dispersion could be extended even to patients with LBBB.

Maternal cardiac systolic and diastolic function: relationship with uteroplacental resistances. A Doppler and echocardiographic longitudinal study.

OBJECTIVE: To test the hypothesis of the existence of a relationship between central and peripheral hemodynamic parameters by the longitudinal evaluation of maternal echocardiographic and uteroplacental resistance modifications during normal pregnancy. METHODS: Forty-three healthy normotensive primigravidae were evaluated at 12 +/- 1, 21 +/- 1, and 33 +/- 1 weeks of gestation with uterine artery color Doppler and maternal echocardiographic examinations to identify morphologic, systolic, and diastolic variables. RESULTS: Cardiac output and stroke volume significantly increased during pregnancy. Uterine resistance index (RI) decreased from the first to the second trimesters (0.72 +/- 0.10 versus 0.54 +/- 0.09, P < 0.001). Left atrial dimensions increased during pregnancy (33.8 +/- 1.9 cm, 38.1 +/- 1.8 cm, 39.3 +/- 2.1 cm, P < 0.001). Left atrial function also increased. Left ventricular mass increased (132 +/- 18 g, 162 +/- 16 g, 174 +/- 27 g, P < 0.001). Diastolic function parameters showed significant modifications: E wave velocity and E/A ratio decreased; A wave velocity and deceleration time of the E wave (DtE) increased; the left ventricular isovolumetric relaxation time (IVRT) decreased significantly (88.7 +/- 6.7 ms, 75.6 +/- 7.7 ms, 71.1 +/- 5.0 ms, P < 0.001) showing a correlation with left atrial dimensions and RI (r = -0.38, r = 0.47, respectively; P < 0.001). CONCLUSIONS: Diastolic cardiac function varies during pregnancy. A relationship between preload (left atrial enlargement), afterload (RI reduction), morphologic, and diastolic function modifications (IVRT reduction, DtE prolongation) appears to exist as a consequence of the hemodynamic modifications which occur during physiologic pregnancy. Diastolic function analysis maybe useful to identify women who fully adapt to pregnancy, and to understand the mechanisms that might be involved in women who show abnormal uterine artery Doppler waveforms.