Sodium-glucose cotransporter 2 inhibitor dapagliflozin prevents ejection fraction reduction, reduces myocardial and renal NF-κB expression and systemic pro-inflammatory biomarkers in models of short-term doxorubicin cardiotoxicity.

Background: Anthracycline-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in patients with cancer. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) exert multiple cardiometabolic benefits in patients with/without type 2 diabetes, chronic kidney disease, and heart failure with reduced and preserved ejection fraction. We hypothesized that the SGLT2i dapagliflozin administered before and during doxorubicin (DOXO) therapy could prevent cardiac dysfunction and reduce pro-inflammatory pathways in preclinical models. Methods: Cardiomyocytes were exposed to DOXO alone or combined with dapagliflozin (DAPA) at 10 and 100 nM for 24 h; cell viability, iATP, and Ca++ were quantified; lipid peroxidation products (malondialdehyde and 4-hydroxy 2-hexenal), NLRP3, MyD88, and cytokines were also analyzed through selective colorimetric and enzyme-linked immunosorbent assay (ELISA) methods. Female C57Bl/6 mice were treated for 10 days with a saline solution or DOXO (2.17 mg/kg), DAPA (10 mg/kg), or DOXO combined with DAPA. Systemic levels of ferroptosis-related biomarkers, galectin-3, high-sensitivity C-reactive protein (hs-CRP), and pro-inflammatory chemokines (IL-1α, IL-1ß, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified. After treatments, immunohistochemical staining of myocardial and renal p65/NF-kB was performed. Results: DAPA exerts cytoprotective, antioxidant, and anti-inflammatory properties in human cardiomyocytes exposed to DOXO by reducing iATP and iCa++ levels, lipid peroxidation, NLRP-3, and MyD88 expression. Pro-inflammatory intracellular cytokines were also reduced. In preclinical models, DAPA prevented the reduction of radial and longitudinal strain and ejection fraction after 10 days of treatment with DOXO. A reduced myocardial expression of NLRP-3 and MyD-88 was seen in the DOXO-DAPA group compared to DOXO mice. Systemic levels of IL-1ß, IL-6, TNF-α, G-CSF, and GM-CSF were significantly reduced after treatment with DAPA. Serum levels of galectine-3 and hs-CRP were strongly enhanced in the DOXO group; on the other hand, their expression was reduced in the DAPA-DOXO group. Troponin-T, B-type natriuretic peptide (BNP), and N-Terminal Pro-BNP (NT-pro-BNP) were strongly reduced in the DOXO-DAPA group, revealing cardioprotective properties of SGLT2i. Mice treated with DOXO and DAPA exhibited reduced myocardial and renal NF-kB expression. Conclusion: The overall picture of the study encourages the use of DAPA in the primary prevention of cardiomyopathies induced by anthracyclines in patients with cancer.

Combinatorial immune checkpoint blockade increases myocardial expression of NLRP-3 and secretion of H-FABP, NT-Pro-BNP, interleukin-1ß and interleukin-6: biochemical implications in cardio-immuno-oncology.

Background: Immune checkpoint blockade in monotherapy or combinatorial regimens with chemotherapy or radiotherapy have become an integral part of oncology in recent years. Monoclonal antibodies against CTLA-4 or PD-1 or PDL-1 are the most studied ICIs in randomized clinical trials, however, more recently, an anti-LAG3 (Lymphocyte activation gene-3) antibody, Relatlimab, has been approved by FDA in combination with Nivolumab for metastatic melanoma therapy. Moreover, Atezolizumab is actually under study in association with Ipilimumab for therapy of metastatic lung cancer. Myocarditis, vasculitis and endothelitis are rarely observed in these patients on monotherapy, however new combination therapies could expose patients to more adverse cardiovascular events. Methods: Human cardiomyocytes co-cultured with human peripheral blood lymphocytes (hPBMCs) were exposed to monotherapy and combinatorial ICIs (PD-L1 and CTLA-4 or PD-1 and LAG-3 blocking agents, at 100 nM) for 48 h. After treatments, cardiac cell lysis and secretion of biomarkers of cardiotoxicity (H-FABP, troponin-T, BNP, NT-Pro-BNP), NLRP3-inflammasome and Interleukin 1 and 6 were determined through colorimetric and enzymatic assays. Mitochondrial functions were studied in cardiomyocyte cell lysates through quantification of intracellular Ca++, ATP content and NADH:ubiquinone oxidoreductase core subunit S1 (Ndufs1) levels. Histone deacetylases type 4 (HDAC-4) protein levels were also determined in cardiomyocyte cell lysates to study potential epigenetic changes induced by immunotherapy regimens. Results: Both combinations of immune checkpoint inhibitors exert more potent cardiotoxic side effects compared to monotherapies against human cardiac cells co-cultured with human lymphocytes. LDH release from cardiac cells was 43% higher in PD-L1/CTLA-4 blocking agents, and 35.7% higher in PD-1/LAG-3 blocking agents compared to monotherapies. HDAC4 and intracellular Ca++ levels were increased, instead ATP content and Ndufs1 were reduced in myocardial cell lysates (p < 0.001 vs. untreated cells). Troponin-T, BNP, NT-Pro-BNP and H-FABP, were also strongly increased in combination therapy compared to monotherapy regimen. NLRP3 expression, IL-6 and IL-1ß levels were also increased by PDL-1/CTLA-4 and PD-1/LAG-3 combined blocking agents compared to untreated cells and monotherapies. Conclusions: Data of the present study, although in vitro, indicate that combinatorial immune checkpoint blockade, induce a pro- inflammatory phenotype, thus indicating that these therapies should be closely monitored by the multidisciplinary team consisting of oncologists, cardiologists and immunologists.

Cardiotoxicity and pro-inflammatory effects of the immune checkpoint inhibitor Pembrolizumab associated to Trastuzumab.

BACKGROUND: The immunotherapy has revolutionized the world of oncology in the last decades with considerable advantages in terms of overall survival in cancer patients. The association of Pembrolizumab and Trastuzumab was recently proposed in clinical trials for the treatment of Trastuzumab-resistant advanced HER2-positive breast cancer. Although immunotherapies are frequently associated with a wide spectrum of immune-related adverse events, the cardiac toxicity has not been properly studied. PURPOSE: We studied, for the first time, the putative cardiotoxic and pro-inflammatory effects of Pembrolizumab associated to Trastuzumab. METHODS: Cell viability, intracellular calcium quantification and pro-inflammatory studies (analyses of the production of Interleukin 1ß, 6 and 8, the expression of NF-kB and Leukotriene B4) were performed in human fetal cardiomyocytes. Preclinical studies were also performed in C57BL6 mice by analyzing fibrosis and inflammation in heart tissues. RESULTS: The combination of Pembrolizumab and Trastuzumab leads to an increase of the intracellular calcium overload (of 3 times compared to untreated cells) and to a reduction of the cardiomyocytes viability (of 65 and 20-25%, compared to untreated and Pembrolizumab or Trastuzumab treated cells, respectively) indicating cardiotoxic effects. Notably, combination therapy increases the inflammation of cardiomyocytes by enhancing the expression of NF-kB and Interleukins. Moreover, in preclinical models, the association of Pembrolizumab and Trastuzumab increases the Interleukins expression of 40-50% compared to the single treatments; the expression of NF-kB and Leukotriene B4 was also increased. CONCLUSION: Pembrolizumab associated to Trastuzumab leads to strong cardiac pro-inflammatory effects mediated by overexpression of NF-kB and Leukotriene B4 related pathways.

WITHDRAWN: Prognostic Value of Pharmacologic Stress Echocardiography in Diabetic Patients.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 202-208, . The duplicate article has therefore been withdrawn.

Prognostic value of intra-left ventricular electromechanical asynchrony in patients with mild hypertrophic cardiomyopathy compared with power athletes.

OBJECTIVES: We sought to assess the indexes of myocardial activation delay, using Doppler myocardial imaging (DMI), as potential diagnostic tools and predictors of cardiac events in patients with hypertrophic cardiomyopathy (HCM) compared with power athletes. BACKGROUND: the distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with HCM, which results in heterogeneity of regional LV systolic function. METHODS: The study population comprised 70 young patients with HCM (mean (SD) age 29.4 (5.9) years) with mild septal hypertrophy (15-19 mm) and 85 age and sex matched athletes with septal thickness >12 mm, followed up for 44.4 (10.8) months. Using pulsed DMI, myocardial peak velocities, systolic time intervals, and myocardial intraventricular and interventricular systolic delays were measured in six different basal myocardial segments. RESULTS: DMI analysis showed in HCM lower myocardial both systolic and early diastolic peak velocities of all the segments. Patients with HCM also showed significant interventricular and intraventricular delay (p<0.0001), whereas athletes showed homogeneous systolic activation of the ventricular walls. During the follow up, seven sudden deaths occurred in the HCM group, while no cardiovascular event was observed in the group of athletes. In patients with HCM, intraventricular delay on DMI was the most powerful independent predictor of sudden cardiac death (p<0.0001). An intraventricular delay >45 ms identified with high sensitivity and specificity patients with HCM at higher risk of ventricular tachycardia and cardiac events (test accuracy 90.6%). CONCLUSIONS: DMI may be a valid supporting tool for the differential diagnosis between HCM and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up. Accordingly, such patients may benefit from early intensive treatment and survey. MINIABSTRACT: Doppler myocardial imaging may represent a valid supporting tool for the differential diagnosis between mild hypertrophic cardiomyopathy (HCM) and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up.

Association between intraventricular myocardial systolic dyssynchrony and ventricular arrhythmias in patients with hypertrophic cardiomyopathy.

BACKGROUND: The distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with hypertrophic cardiomyopathy (HCM), which results in regional heterogeneity of LV systolic and diastolic function. The aim of the study was to evaluate LV regional systolic asynchrony in patients with HCM by pulsed Doppler myocardial imaging (DMI). METHODS: We studied 35 HCM patients and 45 age- and sex-matched controls. By the use of DMI, the following five different basal myocardial segments were measured: systolic peak velocity (Sm); early- and late-diastolic peak velocities; pre-contraction time (Q-Sm) (from the beginning of Q-wave of ECG to the onset of Sm); intraventricular systolic delay (IntraV-Del) (difference of Q-Sm in different LV myocardial segments); interventricular delay (InterV-Del) (difference of Q-Sm between the most delayed LV segment and right ventricular lateral wall). RESULTS: DMI analysis showed in HCM lower myocardial systolic and early-diastolic peak velocities of all the analyzed segments. As for time intervals, controls showed homogeneous systolic activation of the ventricular walls. Conversely, HCM group, despite the absence of intraventricular conduction defects by surface ECG, showed significant both Inter- and IntraV-Del (P < 0.0001). Linear regression models pointed out independent positive associations of IntraV-Del with LV outflow gradient and septal wall thickness in HCM (P < 0.001). An IntraV-Del >30 msec well differentiated controls and HCM. In addition, an IntraV-Del > 45 msec (ROC curve) identified a subgroup of HCM patients with nonsustained ventricular tachycardia during Holter monitoring (90.9% sensitivity and 95.8% specificity). CONCLUSIONS: The impairment of intrarventricular systolic synchronicity is strongly related to increased septal thickness and LV outflow-tract gradient in HCM. DMI analysis may be able to select subgroups of HCM patients at an increased risk of ventricular tachyarrhythmias.

Right ventricular myocardial dysfunction in adult patients late after repair of tetralogy of fallot.

AIM OF THE STUDY: To detect in adult patients late after repair of Tetralogy of Fallot (TOF) possible correlation between myocardial parameters assessed at rest by Tissue Doppler (TD) and cardiac performance during physical effort. METHODS: Doppler echo, treadmill test and pulsed TD of both mitral and tricuspid annulus were performed in 25 healthy subjects and in 40 adult patients who had undergone surgery for TOF at a mean age of 1.4+/-0.5 years. Exclusion criteria were echocardiographic evidence of residual pulmonary, either stenosis or regurgitation. By use of TD, the following parameters were assessed: systolic peak velocities (Sm), pre-contraction time, contraction time, early (E(m)) and late (A(m)) diastolic velocities, E(m)/A(m) ratio, relaxation time. By treadmill test, we measured: maximal heart rate (HR), systolic blood pressure (SBP), rate-pressure product, maximal workload, time duration of the exercise. RESULTS: the two groups were comparable for left ventricular measurements and for all transmitral and transtricuspid Doppler indexes, while tricuspid ring diameter was increased in TOF. TD analysis showed in TOF lower S(m), E(m) and E(m)/A(m) ratio and prolonged PCT(m) and Rt(m) at tricuspid annulus level, despite comparable TD mitral annulus indexes. By treadmill test, TOF showed reduced time of exercise, number of METS reached and rate-pressure product. Multiple linear regression models evidenced in TOF independent positive association between tricuspid Em velocity and time of exercise (p<0.0001), achieved METS at peak effort (p<0.001) and rate-pressure product (p<0.001). An E(m) peak velocity of tricuspid annulus lower than 0.13 m/s showed 90% sensitivity and 93% specificity in identifying TOF patients unable to perform maximal exercise test. CONCLUSIONS: despite normal Doppler parameters, adult patients late after correction of TOF showed impaired right ventricular myocardial function. In these patients pulsed TD may be taken into account as a valuable supporting tool to predict the effort response and possibly to assess long-term follow-up of cardiac functional reserve.

Right ventricular myocardial activation delay in adult patients with right bundle branch block late after repair of Tetralogy of Fallot.

Electromechanical interaction, with prolonged QRS duration due to right ventricular (RV) overload, has been described as a predictor of unfavorable outcome in patients late after correction of Tetralogy of Fallot (TOF). Aim of our study was to evaluate myocardial function and activation delay of both left and right ventricles in TOF patients. Doppler echo, treadmill test and pulsed Tissue Doppler (TD) were performed in 25 healthy subjects and in 30 adult patients who had undergone surgery for TOF, all with right bundle branch block on ECG. Exclusion criteria were evidence of residual pulmonary either stenosis or regurgitation. By use of TD, the level of both LV mitral and RV tricuspid annulus were measured: systolic (Sm), early- and late-diastolic (Em and Am) regional peak velocities. The indexes of myocardial systolic activation were calculated: precontraction time (PCTm) and interventricular activation delay (InterV-del) (difference of PCTm between RV and LV segments). The two groups were comparable for LV diameters and for Doppler indexes, while QRS duration was prolonged and RV end-diastolic diameter was increased in TOF. By TD analysis, only at the level of tricuspid annulus TOF patients had lower Sm and Em, and increased RV PCTm ( p<0.001 ) and InterV-del ( p<0.0001 ), even after adjustment for heart rate (HR) and QRS duration. By treadmill test, TOF showed reduced cardiac functional reserve. In seven patients non-sustained ventricular tachycardia was documented during physical effort. By multivariate analysis, RV Em ( p<0.001 ), and InterV-del ( p<0.01 ) were independently associated to maximal workload at peak effort. The same InterV-del was an independent determinant of risk of ventricular arrhythmias during effort ( p<0.01 ). A cut-off point of Em peak velocity of tricuspid annulus <0.13 m/s at rest showed a sensitivity of 91% and a specificity of 88% in identifying TOF patients with submaximal exercise test. A cut-off point of InterV-del >55 ms showed 87% sensitivity and 88% specificity to detect increased risk of ventricular arrhythmias during effort. In TOF patients, TD analysis at rest may be taken into account as a non-invasive and easy-repeatable tool to predict cardiac performance during physical effort, and to select subgroups of patients at increased risk of ventricular arrhythmias.

[Management programs for elderly patients with chronic heart failure]. / Programmi di gestione dell'anziano con scompenso cardiaco cronico.

PURPOSE: Most patients with heart failure are elderly with multiple coexisting diseases and heart failure is the most common discharge diagnosis in elderly hospitalized patients. Despite major advances in the pharmacotherapy of heart failure, hospitalization rates remain high, owing in large part to a multitude of psychosocial, behavioral, and financial factors that serve as barriers to effective compliance with prescribed treatment. In the last decade, several models have been proposed in order to optimise the long-term management of elderly patients with heart failure. DESIGN: A review of most significant and recent models available was performed. RESULTS: Several studies have documented the efficacy of specialized multidisciplinary heart failure disease management programs in terms of reducing hospital utilization, improving quality of life, functional capacity, patient satisfaction, compliance with diet and medications and decreasing cost of care. CONCLUSIONS: At present, the greatest challenge in managing elderly heart failure patients is to more effectively implement proven treatments and disease management systems.

Prognostic value of pharmacological stress echocardiography in diabetic patients.

Our study was undertaken to assess the prognostic significance of pharmacological stress echocardiography in 325 diabetic patients. Pharmacological stress echocardiography was performed for diagnosis of coronary artery disease in 128 patients, and for risk stratification in 197 patients. Follow-up was 34 months. Cardiac-related death and non-fatal myocardial infarction were considered hard events. During the follow-up period, there were 38 deaths and 23 acute non-fatal myocardial infarctions. By univariate analysis, a pharmacological stress echocardiography positive response for ischaemia indicated an increased risk of cardiovascular death. However, by multivariate analysis, advanced age and peak ejection fraction <40% were the only independent predictors of cardiac death. The same peak ejection fraction (EF) <40%, rest wall motion score index and previous myocardial infarction were independent predictors of hard events. After dividing the population into two subgroups on the basis of EF at rest, only a peak EF <40% and a pharmacological stress echocardiography positive test were powerful independent predictors of cardiovascular mortality.

Cumulative effect of complete left bundle-branch block and chronic atrial fibrillation on 1-year mortality and hospitalization in patients with congestive heart failure. A report from the Italian network on congestive heart failure (in-CHF database).

BACKGROUND: Many clinical variables have been proposed as prognostic factors in patients with congestive heart failure. Among these, complete left bundle-branch block and atrial fibrillation are known to impair significantly left ventricular performance in patients with congestive heart failure. However, their combined effect on mortality has been poorly investigated. The aim of this study was to determine whether left bundle-branch block associated with atrial fibrillation had an independent, cumulative effect on mortality for congestive heart failure. METHODS AND RESULTS: We analysed the Italian Network on congestive heart failure (IN-CHF) Registry that was established by the Italian Association of Hospital Cardiologists in 1995. One-year follow-up data were available for 5517 patients. Complete left bundle-branch block and atrial fibrillation were associated in 185 (3.3%) patients. In this population the cause of congestive heart failure was dilated cardiomyopathy (38.4%), ischaemic heart disease (35.1%), hypertensive heart disease (17.3%), and other aetiologies (9.2%). This combination of electrical defects was associated with an increased 1-year mortality from any cause (hazard ratio, HR: 1.88; 95% CI 1.37-2.57) and sudden death (HR: 1.89; 95% CI 1.17-3.03) and 1-year hospitalization rate (HR: 1.83; 95% CI 1.26-2.67). CONCLUSIONS: In patients with congestive heart failure, the contemporary presence of left bundle-branch block and atrial fibrillation was associated with a significant increase in mortality. This synergistic effect remained significant after adjusting for clinical variables usually associated with advanced heart failure. We can conclude that this combination of electrical disturbances identifies a congestive heart failure specific population with a high risk of mortality.

Usefulness of Doppler tissue imaging for the assessment of right and left ventricular myocardial function in patients with dual-chamber pacing.

The aim of the study was to evaluate by Doppler tissue imaging (DTI) the combined effects of atrio-ventricular (AV) delay and heart rate (HR) changes on global and segmental right (RV) and left (LV) ventricular diastolic function in 15 patients with dual-chamber pacemakers paced in the DDD mode. RV and LV inflow velocities and regional systolic and diastolic pulsed-wave (PW) DTI parameters were analyzed at four different pacing modes: (1) HR 70 beats/min, AV delay 125 ms; (2) HR 70 beats/min, AV delay 188 ms; (3) HR 89 beats/min, AV delay 125 ms; (4) HR 89 beats/min, AV delay 188 ms. For each pacing mode selected, RV diastolic filling velocities always prevailed over LV ones. As for RV and LV adaptation to the four different stimulation protocols, a higher paced rate and a prolonged AV delay caused across both the AV valves a decrease of E wave and of E/A ratios. The intersegmental comparison of PW-DTI parameters outlined that RV free wall exhibited significantly higher peak systolic (Sm) and early-diastolic (Em) wall velocities, and longer systolic ejection time. Considering separately RV and LV segmental physiology at the four programmed pacing modes, an increase in HR determined a progressive shortening of systolic ejection times in all the segments analyzed. Moreover, in each region the Em/Am ratio decreased with higher HR and longer AV delay. Conversely, Em encountered a progressive reduction in RV free wall, while remaining quite unchanged in all the LV regions. Both ventricles shared a similar pattern of global and regional adaptation to programmed HR and AV delay modifications, consisting in a progressive greater contribution of late diastole to ventricular filling at higher HR and more prolonged AV delay. However, at a regional level the right ventricle exhibited higher systolic and diastolic wall velocities than all left ventricular regions.

[Glossary of terms of management and quality]. / Glossario dei termini di management e qualità.

The implementation of a quality management system (QMS) in the health-care world is nowadays mandatory. This is a specific request not only of local laws but also of the World Health Organization which recently said that "By the year 2000, there should be structures and processes in all member States to ensure a continuous improvement in the quality of health care". In addition, we are bombarded by demands from patients, physicians, employers and the administration. However a QMS is something new for the medical doctor. We think that the first step to divulge the culture of quality in our field is to have a good knowledge of the specific terminology used in the QMS. This glossary explains the meaning of more than 80 terms related to the QMS.

[Beta blockers in elderly with heart failure]. / I betabloccanti nel paziente anziano con scompenso cardiaco.

Despite the importance of beta-blockers for secondary prevention after acute myocardial infarction, several studies suggested that they are substantially underutilized, particularly in elderly patients. Actually no randomized clinical trial including elderly patients with heart failure treated with beta-blockers is reported in the literature. However, previous studies showed that beta-blocker therapy was associated with a reduction in total cardiac mortality (-40%) of elderly patients with acute myocardial infarction without left ventricular dysfunction. Furthermore, a meta-analysis of five trials including 1729 patients aged > 60 years with heart failure evidenced a non-significant trend versus total mortality reduction in patients receiving beta-blockers (odds ratio 0.68, 95% confidence interval 0.51-0.93, p = 0.4).

[The appropriateness of hospital admissions: reflections for a global approach]. / L'appropriatezza dei ricoveri: alcune riflessioni per un approccio globale.

In accordance with a recent definition, appropriateness of medical care is a diagnostic-therapeutic intervention with a correct use of resources and competency, and a procedure that satisfies the request of patients. This definition considers not only the risk/benefit relationship but also the interaction between costs and benefits. In this light, the concept of appropriateness needs a global approach. The identification of the Mission and Vision of the structure, the use of medical guidelines, the distribution of documents which inform patients on the procedures carried out in the hospital and the modalities of access to the structure, the implementation of procedures which define hospital admission and finally the random check of medical records could represent important steps to implement a quality system aimed at guaranteeing the appropriateness of hospital admissions in accordance with the international standards for total quality management ISO 9000.

Noninvasive assessment of left and right internal mammary artery graft patency with high-frequency transthoracic echocardiography.

OBJECTIVES: The aim of this study was (1) to visualize internal mammary artery grafts (IMAG) on coronary artery by transthoracic echocardiography and (2) to assess the patency of the grafts. METHODS: Twenty-three patients (21 men, 56 +/- 6 years) with previous coronary artery bypass grafting were studied at baseline and after they underwent low-dose dipyridamole infusion. The parameters obtained were systolic (SPV) and diastolic (DPV) peak velocities and their ratio (DPV/SPV); the dipyridamole infusion to baseline ratio of DPV was an index of IMAG blood flow reserve (FR). Two groups of patients were selected at baseline: group A, (n = 12) with a DPV/SPV >1, and group B (n = 11), with a DPV/SPV <1. RESULTS: The IMAG was identified in all patients. Intraluminal flow signals obtained with pulsed wave Doppler showed a biphasic pattern (1 systolic and 1 diastolic wave). After dipyridamole infusion was administered, flow velocities increased in 11 of 12 patients in group A and in 5 of 11 patients in group B. In group A the DPV/SPV increased from 1.79 +/- 0.47 to 1.8 +/- 0.43 (P = not significant), and the FR was 1.8 +/- 0.4. In group B the DPV/SPV increased from 0. 46 +/- 0.05 to 0.5 +/- 0.09 (P = not significant), and the FR was 1. 3 +/- 0.41. Coronary angiography showed the graft patency in all patients in group A and in 5 patients in group B with increased flow velocity after dipyridamole infusion. In the identification of graft stenosis at baseline, DPV/SPV showed 100% sensibility and 58% specificity, and FR showed 92% sensibility and 84% specificity. CONCLUSION: Doppler echocardiographic evaluation of the IMAG is a simple noninvasive method to assess the functional impairment of the vessel.

[ISO 9000: guidelines for a total quality system in health]. / ISO 9000: linee guida per un sistema di qualità nel mondo sanitario.

The Italian National Health System has recently been revised and reorganized. In the new scenario, the quality of the service being provided is considered extremely important. The international ISO 9000 standard has made it possible to implement a total-quality management system that can be documented and certified independently by a third party. Several hospitals in Italy and abroad have implemented a total-quality system according to ISO 9000 standards in order to provide a service that can satisfy the expectations of the patients in a controlled and efficient way. This article describes ISO 9000, proposes its application to ensure quality in the structures and organizations involved in the national health system and reports several examples of how the standard has been implemented in hospitals.

[Value of transesophageal echocardiography in the diagnosis of paravalvular aortic abscess]. / Valore dell'ecocardiografia transesofagea nella diagnosi di ascesso paravalvolare aortico.

Paravalvular abscesses are a serious complication of aortic endocarditis. Echocardiography is the method of choice for the visualization of the valve-attached vegetations, however the detection of endocarditis-associated abscesses by transthoracic approach is extremely difficult. Recently transesophageal echocardiography has been proved as an excellent tool to correctly detect these lesions. We report on two patients with endocarditis-associated abscesses in whom transesophageal echocardiography allowed us to diagnose paravalvular abscesses not recognized by transthoracic echocardiography; furthermore in the first patient, performing two successive transesophageal examinations before and after antibiotic therapy, we could follow the evaluation of aortic abscess which became a fistula draining into the left ventricular outflow tract. In conclusion these two cases suggest that transesophageal echocardiography should be always performed in patients suspected or known to have endocarditis and that a following examination is indicated to assess any evolving echocardiographic finding.