Left ventricular shape, afterload and survival in idiopathic dilated cardiomyopathy.

Because idiopathic dilated cardiomyopathy is characterized by elevated wall stress and a more spherical left ventricle, the relations among shape, afterload and survival were examined. Thirty-six patients with cardiomyopathy were prospectively studied by two-dimensional echocardiography. Data included echocardiographic short- and long-axis cavity dimensions, their ratio and, with cuff systolic blood pressure, meridional and circumferential end-systolic stress and their ratios. Survivors (n = 16) were followed up for 52 months (range 40 to 76); nonsurvivors (n = 20) died an average of 11 months after study. Survivors had a smaller left ventricular end-diastolic short-axis dimension (6.4 versus 7.1 cm, p less than 0.03) but a similar long-axis length (8.6 versus 8.3 cm). However, overall cavity shape or the ratio of short- to long-axis end-diastolic dimensions was more spherical in those with poorer survival (ratio 0.76 versus 0.68, p less than 0.02). Meridional and circumferential end-systolic stresses were similar in the two groups, but stress was more evenly distributed in the long- and short-axis planes in nonsurvivors (meridional/circumferential stress ratio 0.57 versus 0.52 in survivors, p less than 0.05). Improved survival was associated with an end-diastolic short-axis dimension less than 7.63 cm, a short- to long-axis ratio less than 0.76 and a meridional to circumferential stress ratio less than 0.54. Life table analysis revealed a 28% mortality rate in patients with all three of these characteristics compared with 100% in patients with none. Survivors and nonsurvivors did not differ in systolic cavity dimension, wall thickness, relative wall thickness, cavity volume, percent posterior wall thickening or fractional shortening.(ABSTRACT TRUNCATED AT 250 WORDS)

Variable responses of mitral valve motion and flow in systemic hypertension and in idiopathic dilated cardiomyopathy.

The relation between transmitral flow and diastolic mitral valve motion were examined in 17 normal persons, 14 patients with hypertension and 12 patients with idiopathic dilated cardiomyopathy. M-mode echograms were analyzed for early and late diastolic mitral leaflet separations, their ratio and E-F slope. Pulsed Doppler transmitral flow was analyzed for early and late velocities, their ratio and early flow deceleration. Early diastolic mitral valve leaflet separation was reduced in patients with hypertension (at 28 +/- 5 mm [p less than 0.05] ) and in patients with cardiomyopathy (at 22 +/- 3 mm [p less than 0.01] ). Flow velocity was also reduced in patients with hypertension (at 52 +/- 11 cm/s [p less than 0.05] ) and in patients with cardiomyopathy (at 48 +/- 15 cm/s [p less than 0.01] ). However, early leaflet separation and flow velocity were not related (r = 0.26). Late diastolic leaflet separation was similar (at 25 +/- 5 mm) in normal subjects and in those with hypertension (at 23 +/- 6 mm), but was reduced in patients with cardiomyopathy (at 18 +/- 3 mm [p less than 0.01] ). In contrast, late flow velocity was increased in patients with hypertension (at 52 +/- 12 cm/s [p less than 0.05] ) but unchanged in patients with cardiomyopathy (at 42 +/- 16 cm/s). The ratio of early to late leaflet separation was similar in all groups, whereas the ratio of flow velocities was reduced in hypertensive patients. Neither the E-F slope not early flow deceleration was altered in either pathologic group. Thus, hypertension and cardiomyopathy had similar effects in early rather than late diastole.(ABSTRACT TRUNCATED AT 250 WORDS)

Contribution of afterload, hypertrophy and geometry to left ventricular ejection fraction in aortic valve stenosis, pure aortic regurgitation and idiopathic dilated cardiomyopathy.

To investigate the relation of left ventricular (LV) afterload, hypertrophy, geometry and systolic pump function, 17 normal persons, 24 patients with aortic stenosis (AS), 20 with aortic regurgitation (AR) and 15 with idiopathic dilated cardiomyopathy (DC) were studied. Two-dimensional echograms were used to assess end-systolic meridional and circumferential stresses and their ratio, LV mass, relative wall thickness (h/R ratio) and the ratio of LV minor axis to length, used as an index of shape. Independently obtained ejection fraction (EF) was used to determine which patients had normal (EF greater than or equal to 55%) and which had depressed (EF less than 55%) pump function. Patients with AS and low EF had similar LV mass (228 vs 215 g) but larger LV cavity (5.6 vs 4.5 cm), lower h/R ratio (0.53 vs 0.73, p less than 0.01), and therefore higher circumferential stress (336 vs 268 kdyne/cm2, p less than 0.05). Compared with normal persons, patients with DC had a lower h/R ratio (0.28 vs 0.38, p less than 0.01), higher circumferential stress (362 vs 215 kdyne/cm2, p less than 0.01) and more uniform stress distribution (meridional to circumferential stress ratio 0.57 vs 0.39, p less than 0.01), implying that meridional stress overestimates effective afterload. Afterload excess and LV shape change may be important to pump function in patients with AS or DC. In contrast, in those with AR, no significant shape differences were noted, although LV mass was higher in those with low EF (279 vs 211 g, p less than 0.05). Depressed pump function may result from impaired myocardial performance in AR without afterload excess.

Utility of transesophageal echocardiography in the conservative management of prosthetic valve endocarditis.

Prosthetic valve endocarditis is a formidable complication following cardiac valve replacement. Surgical intervention has resulted in a significant reduction in mortality when certain complications prevail. We report two such cases of prosthetic valve endocarditis in which the use of transesophageal echocardiography permitted close surveillance during medical therapy and thus avoided the need for surgical intervention. Therefore, with the improved ability to monitor disease progression with transesophageal echocardiography, nonsurgical management of prosthetic valve endocarditis remains an option.

The utility of transesophageal echocardiography in the management of renal cell carcinoma with intracardiac extension.

The accurate assessment of the distal extent of vena caval invasion of renal cell carcinoma into the hepatic veins, inferior vena cava, and right atrium is critical before surgical resection. We present two cases of renal carcinoma with vena caval extension in which preoperative transesophageal echocardiography accurately assessed tumor extent and guided surgical therapy. The role of transesophageal echocardiography in comparison to other diagnostic modalities is discussed.

Cardiac sarcoidosis masquerading as a metastatic tumor: the role of transthoracic and transesophageal echocardiography.

We present an unusual case of biopsy-proven myocardial sarcoidosis in which the transthoracic and transesophageal echocardiographic findings suggested metastatic tumor involvement of the myocardium and pericardium. The pathologic, clinical, and echocardiographic features of cardiac sarcoidosis are reviewed, with emphasis on the role of echocardiography.

Long-term follow-up of mitral paraprosthetic regurgitation by transesophageal echocardiography.

Paravalvular regurgitation (PVR) is an uncommon complication of mitral valve replacement (MVR). Although severe PVR is almost always repaired immediately when recognized during surgery, there are little data available on the management of patients with mild and moderate PVR. This study includes eight patients with mild (n = 6) and moderate (n = 2) PVR identified by transesophageal echocardiography at the time of MVR who were treated conservatively. Clinical and echocardiographic follow-up was obtained at a mean of 16.3 months. Two of six patients with mild PVR at the time of MVR and two of two patients with moderate PVR at the time of MVR deteriorated clinically and echocardiographically over time. We suggest that moderate PVR should be corrected at the time of valve-replacement surgery, if this can be performed without high operative risk. Mild PVR should probably also be repaired, if this can be performed at low risk, because some will progress. Patients left with mild PVR after surgery, or patients in whom PVR is recognized only after surgery, should be followed up carefully with serial clinical and echocardiographic examinations.

Superior vena caval thrombosis detected by transesophageal echocardiography.

Three patients with clinical suspicion of bacterial endocarditis, induced by either pacemaker or indwelling catheter, underwent transesophageal echocardiography. High short-axis cuts through the great vessels, however, revealed the presence of superior vena caval thrombus in all three patients. Transesophageal echocardiography is more sensitive in establishing the diagnosis of superior vena caval thrombus than surface echocardiography. Comparison of transesophageal echocardiography with other diagnostic modalities is needed in assessing its overall sensitivity and specificity.

Transesophageal echocardiography in the diagnosis of the persistent left superior vena cava.

Three patients with suspected persistent left superior vena cava (PLSVC) diagnosed by transthoracic echocardiography underwent single-plane transesophageal echocardiography. In all three patients transverse cuts through right atrium and coronary sinus demonstrated the presence of PLSVC. Agitated contrast injection into the left antecubital vein opacified PLSVC and coronary sinus in all cases. Transesophageal echocardiography is superior to transthoracic echo in the diagnosis of PLSVC and associated cardiac anomalies.

Mycotic aneurysm of the descending thoracic aorta: the role of transesophageal echocardiography.

Mycotic aneurysms of the aorta are prone to rupture. Thus rapid and accurate diagnosis is essential so that surgical repair can be undertaken. We report a case of mycotic aortic aneurysm caused by mitral valve endocarditis. The aneurysm situated at the junction of the thoracoabdominal aorta was readily detected by transesophageal echocardiography. Computed tomography and aortography were complementary to transesophageal echocardiography in establishing the diagnosis. The patient underwent successful repair and acute inflammation of the aneurysm was present at histologic examination.

A novel approach to calculation of mean mitral valve gradient by Doppler echocardiography.

The Doppler-derived mean mitral valve gradient (DeltaP(M)) based on the simplified Bernoulli equation requires computerized integration of the Doppler signal and evaluation by a technician with the use of special equipment. We have noted empirically that the DeltaP(M) can be derived by the equation DeltaP(M) = (P(P) - P(T)) / 3 + P(T). Peak (P(P)) and trough (P(T)) pressures are derived from the simplified Bernoulli equation (P = 4V(2)). This equation can be used by the experienced observer to calculate the mean mitral valve gradient without specialized equipment. The purpose of this study is to validate the above empirically derived equation in patients with mitral stenosis. We retrospectively reviewed 41 consecutive studies done at our institution from October 1, 1997, through September 30, 1998, in which mean mitral valve gradient was assessed. Each study was reviewed and the DeltaP(M), P(P), and P(T) were measured for 3 beats by using the software package on an HP Sonos 2500. DeltaP(M) was also calculated with our formula. A linear regression model was used to compare the results of the measured versus the calculated DeltaP(M). The following sub-categories were also evaluated: transthoracic studies (TTE), transesophageal studies (TEE), native valve gradients (NV), prosthetic valve gradients (PV), sinus rhythm (SR), and atrial fibrillation (AF). The results of the regression analysis of the entire population of mean versus calculated DeltaP(M) are n = 41, r = 0.99, P <.001, and standard error of the estimate (SEE) = 0.67. The regression results for the subgroups are as follows: TTE: n = 30, r = 0.99, P <.001, SEE = 0.51; TEE: n = 11, r = 0.99, P <.001, SEE = 59; NV: n = 26, r = 0.99, P <.001, SEE = 0.59; PV: n = 15, r = 0.98, P <.001, SEE = 0.84; SR: n = 23, r = 0.99, P <.001, SEE = 0.58; and AF: n = 18, r = 0.98, P <.001, SEE = 0.82. In conclusion, the simple formula that we have derived is an accurate method for calculation of mean mitral valve gradient, and it is accurate over multiple subgroups. Furthermore, the formula allows visual verification of mean mitral gradient without specialized software.

Evaluation of hemolysis in patients with prosthetic heart valves.

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.

[Apropos of 1 case of anisakiasis contracted in Sicily]. / A propos d'un cas d'anisakiase contractée en sicile.

The authors describe a case of anisakiasis in Sicily. The diagnosis was based on the knowledge that a contaminated fish, Lepidopus caudatus, had probably been absorbed, as well as on clinical intestinal symptoms, intestinal lesions observed by endoscopy and O.G.D.S, duodenal infiltration by eosinophilic polymorphonuclear, positive ELISA anisakis serology and successful treatment by albendazole.

[Parasitological research conducted between 1982 and 1991 in a sample of Zinvie (Benin) residents]. / Recherche parasitologique conduite entre 1982 et 1991 chez un échantillon de sujets résidents a Zinvie (Bénin).

The authors point out the frequency of intestinal parasitism in Zinvie (Benin). Out of 18,512 samples, 9,554 (51.60%) were found positive. The main parasites found were: Ankylostoma duodenale, Ascaris lumbricoides, Amoeba, Giardia lamblia. The authors underline the polyparaitism 16.75%.

[Occupational activity with risk of leptospirosis. Prevention and health surveillance]. / Rassegna delle attività lavorative a rischio d'infezione da leptospire. Prevenzione e sorveglianza sanitaria.

The analysis of the epidemiological studies carried out in Italy give us the idea for a very precise survey of the occupational leptospirosis. We have identified the occupational hazards and the precautionary measures. In Italy the first epidemiological data about human leptospirosis goes back to 1917. During following decades were highlighted several occupational forms of leptospirosis, specifically seasonal epidemics among rice-workers. Epidemiological studies carried out in Italy from 1950 to 1990 showed that leptospirosis was again widespread although precautionary measures and there was a probable spread of the "minor leptospirosis" at the same time of common cases of "major leptospirosis". The latest data issued by Ministry of the Health related years '94-'97 confirm the persistence of leptospirosis, for the most part in the north. However there is a problem of underestimate because many times human leptospirosis show itself with minor clinical forms. In the working environment is essential the function of the Medico Competente. He must avail himself of the precautionary measures for the biological risk specified in D.lgs 626/94.

[Serologic investigation on the prevalence of Leptospira spp infection in occupationally exposed subjects]. / Indagine sierologica sulla prevalenza di infezione da Leptospira spp in soggetti occupazionalmente esposti.

BACKGROUND: Leptospirosis is a worldwide zoonotic infection with a high in tropical regions. OBJECTIVE: The aim of the present survey was to verify the occurrence of diffusion of leptospirosis infections in Eastern Sicily, in some groups (6 veterinarians, 34 farmers and 28 abattoir workers), who were considered at high occupational risk. METHODS: Serologic investigation were performed using the immunological method (Martin Petit test); the Leptospira serovars considered were: ictero-haemorrhagiae (Bianchi 1); canicola (Alarik); pomona (Mezzano 1); grippo-typhosa (Moskva V); bratislava (Riccio 2); sejroe (Topino 1); hardjo (Hardjoprajitno); saxkoebing (Mus 24). RESULTS: Contagion was observed in 16 subjects out of 68 (23.5%), and the anti-leptospira antibodies detected were canicola, hardjo, sejroe grippo-typhosa e ictero-haemorrhagiae. CONCLUSIONS: The authors stress the importance carrying out periodic health surveillance in subjects working in wet and contaminated environments or who are continuously in contact with animals receptive to infections. The present study also confirms the need to adopt preventive measures such as vaccines, and control programs for activities at high risk.

[Francesco Redi and the birth of experimental parasitology]. / Francesco Redi et la naissance de la parasitologie expérimentale.

Francesco Redi (1626-1697) born in Arezzo (Tuscany, Italy), an encyclopedic mind simultaneously naturalist, physician and poet is the founder of scientific and experimental parasitology by his works published in 1668 and 1684. In the first he showed the impossibility of spontaneous generation of insects (flies) and in the second are described over hundred species of parasites (helminths, mites, insects) from vertebrates and invertebrates with excellent illustrations. He has also recommended various antiparasitic remedies and specified their pharmacological action. It is besides under his influence that two of his disciples: Bonomo and Cestoni will rediscover and redescribe in 1687 the itch-mite (Sarcoptes scabiei var. hominis).

How to compare doses of different antipsychotics: a systematic review of methods.

BACKGROUND: The ability to calculate equivalent dosage is important when comparing or switching between doses of different antipsychotics in the treatment of schizophrenia. It is also necessary when designing antipsychotic comparator trials which control for dosage. METHOD: A systematic review to identify and critically evaluate the methods available for the estimation of antipsychotic dose equivalence was conducted. Electronic searches were carried out using Medline and PubMed and additional information was requested from pharmaceutical companies. The identified methods were evaluated against specific criteria regarding scientific rigour, quality of source data underpinning the method, clinical applicability and utility. RESULTS: Eleven articles were identified that described methodologies for antipsychotic dose equivalence. Seven of these referred to calculated methods, including chlorpromazine equivalence, maximum dose and daily-defined dose, and relied on an evidence base from both fixed and flexible dosing data. The remaining four described consensus methods which were based on the knowledge and experience of experts. Chlorpromazine was used as the standard comparator drug in the majority of the calculated equivalence studies, whereas risperidone was used for most consensus methods. CONCLUSIONS: Comparison of methods for calculating antipsychotic dose equivalence suggests that different methods yield different equivalencies and the evidence is not sufficiently robust for any of these to be considered as a gold standard method. Thus, choice of method may introduce bias, either an over or underestimate of equivalent dosage, when designing head-to-head, antipsychotic, fixed-dose trials. Consequently, clinical trial reports should routinely include justification of the choice of method for calculating dose equivalence.