Integrated ultrasound evaluation of dissecting aneurysm of the aorta by the combined use of transesophageal echocardiography and intravascular ultrasound.

In order to obtain complete ultrasound imaging of the entire aorta, transesophageal echocardiography and intravascular ultrasound were performed on 3 patients with acute (2 cases) or chronic (1 case) aortic dissection. In each case the integrated use of transesophageal echocardiography and intravascular ultrasound provided an accurate evaluation of the dissection and of its anatomic extension.

Ventricular premature beats in young subjects without evidence of cardiac disease: histological findings.

This report describes the results of right ventricle endomyocardial biopsies from 26 subjects (mean age 27 +/- 10 years) with premature ventricular beats and normal cardiac anatomy and mechanical function. Light microscopy examination revealed normal myocardium in 10 subjects (38%), acute myocarditis in two (7%), borderline myocarditis in one (3.5%), non-specific histological abnormalities including cellular hypertrophy, fibrosis and degenerative changes in 11 (42%), vasculitis in one (3.5%) and findings compatible with right ventricular dysplasia in the final subject (3.5%). The frequency of ventricular premature beats, as assessed by Holter monitoring, and the results of electrophysiological testing did not correlate with histopathological findings and their severity. These data indicate that some young subjects with premature ventricular beats of unknown origin have abnormal right ventricular biopsy findings. Adequate follow-up will probably demonstrate the clinical utility of these observations.

[Invasive hemodynamic assessment and interventional therapy]. / Valutazione emodinamica invasiva e terapia interventistica.

Cardiovascular diseases are the main reason for hospitalization and usually followed by a conservative therapeutic approach. Due to the improvement over the last few years in the results of surgery in the elderly, the number of hemodynamic studies has increased. Hemodynamic studies are generally performed in elderly patients with symptomatic valvular heart disease and acute myocardial infarction with complications. The incidence of complications in the elderly during catheterization and coronarography is higher than in younger but still low. Cardiovascular hemodynamics in the elderly is determined by a combination of lifestyle, the presence of cardiac diseases that increase in prevalence with advancing age (e.g., coronary artery disease) and age-related changes in cardiovascular hemodynamic per se. With age, the tunica media of major blood vessels stiffens. This produces a elevation of systolic blood pressure (afterload) in many elderly patients which in turn increases left ventricular (LV) wall stress and results in mild compensatory LV hypertrophy. This compensatory hypertrophy normalizes wall stress, but produces pertubations in diastolic function such as: a reduction in the rate of both diastolic and LV peak filling, a diminished diastolic compliance associated with LV hypertrophy and a greater dependence upon left atrial contraction to maintain cardiac output. Recently the proportion of these patients who have percutaneous transluminal coronary angioplasty (PTCA) is growing. PTCA can be performed with a high rate of clinical success. Complete revascularization is low, particularly in patients with trivessel disease. The most common reasons for incomplete revascularization were: vessels with chronic total occlusion and vessels with diffuse disease. The rate of major cardiac complications was high among patients at high-risk in the presence of trivessel disease and low left ejection fraction. Long-term results were encouraging. For 90% of patients who had clinical success after PTCA, the end results continued to be beneficial. In conclusion, PTCA is a valid therapeutic alternative in elderly patients with coronary artery disease. In subsets of patients with single and bivessel disease, the short- and long-term outcome is very favourable. In patients with triple vessel disease, early clinical success rate is low but the long-term success rate is, however, acceptable.

Hemodynamic study of intravenous propionyl-L-carnitine in patients with ischemic heart disease and normal left ventricular function.

Propionyl-L-carnitine was given intravenously to ten patients with chronic ischemic heart disease who had normal left ventricular function and had not had a previous myocardial infarction. Subsequently, pulmonary and systemic circulation, left ventricular function, and the relationship between the ventricle and afterload were evaluated. This drug, at a dose of 15 mg/kg, improves ventricular function by easing the load and by enhancing cardiac efficiency. The ejection impedance is reduced with a consequent increase in stroke volume as a result of a) a decrease in systemic and pulmonary resistance and b) an increase in arterial compliance. Arterial pressure is maintained due to an increase in total external heart power. Since the tension time index shows a proportionally smaller increase in the energy requirement, it follows that cardiac efficiency has been improved and ventricle-afterload matching is optimal. These results suggest but do not prove that propionyl-L-carnitine exhibits a positive inotropic property.

[Effects of gallopamil on coronary blood flow and vasomotility]. / Effetti del gallopamil sul flusso e sulla vasomotilità coronarica.

Using quantitative coronary arteriography, the luminal area was measured in the proximal, middle and distal third of a normal coronary vessel in basal condition and 15 min after 0.005 mg/Kg ic gallopamil (Group 1); 15 min after ic placebo (Group 2); 15 and 30 min after iv gallopamil at a dose of 0.03 mg/Kg (Group 3A) and 0.05 mg/Kg (Group 3B). A significant (p less than 0.001) vasodilation was observed in all segments in Group 1 and only in distal segment (p less than 0.05) in Group 3B. Neither did the heart rate, systolic blood pressure nor the coronary driving pressure show any changes. In the second section of this study, we analyzed the effects of the drug on coronary blood flow and resistance in 8 patients without clinical and/or objective evidence of coronary artery disease. Using thermodilution technique, the coronary sinus blood flow (CSBF) and coronary resistance (CR) were measured in basal condition and 5, 10, 15 and 30 min after 0.05 mg/Kg iv gallopamil. We observed a significant (p less than 0.001) increase of CSBF after 10 min and a significant decrease of CR after 10 min (p less than 0.001) and 15 min (p less than 0.05). In conclusion, our results suggest that the anti-ischemic effect of gallopamil can be related not only to the reduction of myocardial oxygen requirement, but also to an improvement of coronary blood flow with a decrease in coronary resistance.

Doppler continuous-wave analysis of grafted mammary artery as a non-invasive technique for static and dynamic assessment of coronary flow in man.

In this paper, Doppler continuous-wave analysis of blood velocity in the internal mammary artery, anastomosed to the left coronary vascular bed in humans who have undergone myocardial revascularization, is proposed as a non-invasive technique to study coronary blood flow during physiological procedures which cause it to change. Blood velocity curves obtained in normal and anastomosed internal mammary arteries were compared during hyperventilation and the Valsalva manoeuvre. During hyperventilation, blood velocity increased in the normal mammary but not in the anastomosed artery. During the expiratory effort of the Valsalva manoeuvre, the mean blood velocity decreased in the normal mammary artery but it did not change significantly in the anastomosed artery. Variations in the mean velocity were largely prevented by simultaneous and well-balanced increases and decreases in the diastolic and systolic velocities, respectively.

Functional and structural abnormalities in patients with dilated cardiomyopathy.

Passive diastolic properties of the left ventricle were determined in 10 control subjects and 12 patients with dilated cardiomyopathy. Simultaneous left ventricular angiography and high fidelity pressure measurements were performed in all patients. Left ventricular chamber stiffness was calculated from left ventricular pressure-volume and myocardial stiffness from left ventricular stress-strain relations with use of a viscoelastic model. Patients with dilated cardiomyopathy were classified into two groups according to the diastolic constant of myocardial stiffness (beta). Group 1 consisted of seven patients with a normal constant of myocardial stiffness less than or equal to 9.6 (normal range 2.2 to 9.6) and group 2 of 5 patients with a beta greater than 9.6. Structural abnormalities (percent interstitial fibrosis, fibrous content) in patients with dilated cardiomyopathy were assessed by morphometry from right ventricular endomyocardial biopsies. Heart rate was similar in the three groups. Left ventricular end-diastolic pressure was significantly greater in patients with cardiomyopathy (18 mm Hg in group 1 and 22 mm Hg in group 2) than in the control patients (10 mm Hg). Left ventricular ejection fraction was significantly lower in groups 1 (37%) and 2 (36%) than in the control patients (66%). Left ventricular muscle mass index was significantly increased in both groups with cardiomyopathy. The constant of chamber stiffness (beta*) was slightly although not significantly greater in groups 1 and 2 (0.58 and 0.58, respectively) than in the control group (0.35). The constant of myocardial stiffness beta was normal in group 1 (7.0; control group 6.9, p = NS) but was significantly increased in group 2 (23.5). Interstitial fibrosis was 19% in group 1 and 43% (p less than 0.001) in group 2 (normal less than or equal to 10%). There was an exponential relation between both diastolic constant of myocardial stiffness (beta) and interstitial fibrosis (IF) (r = 0.95; p less than 0.001) and beta and fibrous content divided by end-diastolic volume index (r = 0.93; p less than 0.001). It is concluded that myocardial stiffness can be normal in patients with dilated cardiomyopathy despite severely depressed systolic function. Structural alterations of the myocardium with increased amounts of fibrous tissues are probably responsible for the observed changes in passive elastic properties of the myocardium in patients with dilated cardiomyopathy. The constant of myocardial stiffness (beta) helps to identify patients with severe structural alterations (group 2), representing possibly a more advanced stage of the disease.

Programmed stimulation in patients with minor forms of right ventricular dysplasia.

Programmed electrical stimulation (PES) was performed in 17 patients, mean age 31 +/- 8 years, with minor forms of right ventricular dysplasia diagnosed because of (1) premature ventricular beats (PVBs) of left bundle branch block (LBBB) morphology; (2) no clinical or non-invasive evidence of cardiac abnormalities; (3) angiographic evidence of right ventricular wall motion abnormalities and bioptic findings of fibro-adipose infiltration. Fifteen patients had frequent and complex PVBs while two had sustained ventricular tachycardia (VT). During PES, sustained VT was induced in 2/2 patients with spontaneous sustained VT; ventricular repetitive responses were induced in 2/15 cases (13%) with complex and frequent PVBs. In conclusion, in minor forms of right ventricular dysplasia, PES induces VT only in patients with clinical VT; on the contrary, in patients with PVBs it is only possible to induce repetitive ventricular responses in a small proportion of cases; it is therefore not possible to select patients at high risk of developing severe ventricular arrhythmias.

Right ventricular dysplasia: an ultrastructural study.

Ultrastructural observations on myocardial biopsies from patients developing clinical and/or echocardiographic and haemodynamic signs of dysplasia of the right ventricle did not reveal morphological defects of the myocardiocyte contraction apparatus, but showed evidence of fibrosis of the myocardial interstitium and modifications of the structures involved in the transmission of the action potential into the cardiac cells as well as of the junctional system between them. Interstitial adipocytes and intracellular lipid droplets were not increased in number.

Right ventricular dysplasia: angiographic study.

At the moment, the most reliable method for diagnosing right ventricular dysplasia is considered to be angiography. Morphological alterations such as the presence of akinetic/dyskinetic areas, aneurysmatic dilatations and deep anteroapical fissuring, not necessarily associated with an increase in ventricular volume, are understood to be angiographic criteria indicating dysplasia. To verify their diagnostic value, these abnormalities have been evaluated in: (1) 33 patients suspected of having dysplasia because of PVBs with LBBB morphology and with 'borderline' involvement of the right ventricle or without instrumental evidence of cardiac disease (Group A); (2) 16 subjects with no arrhythmia and normal left ventricular angiography, coronary and bioptic findings (Group B); (3) 36 patients with a clinical, angiographic and bioptic diagnosis of dilated idiopathic cardiomyopathy (Group C). In 48.5% of the patients in Group A, angiography showed localized akinesia/dyskinesia (12 patients), small conical outpouchings persisting during systole (10 patients) and apical deep fissuring (two patients). In 81% of these patients, endomyocardial biopsy showed the presence of fibrous and/or adipose tissue in at least 20% of the examined sample. Angiographic abnormalities suggesting dysplasia were found in none of the normal subjects and only in two of the 36 patients with dilated cardiomyopathy (5.5%).

[Effect of intracoronary and intravenous administration of propranolol on coronary vasomotility at rest and during exercise]. / Effetto della somministrazione endocoronarica ed endovenosa di propranololo sulla vasomotilità coronarica a riposo e durante esercizio.

The effect of intracoronary and intravenous propranolol on coronary vasomotion was evaluated in 30 patients with coronary artery disease. Luminal area of a normal and a stenotic coronary segment was determined at rest, during supine bicycle exercise and 5 min after 1.6 mg sublingual nitroglycerin administered at the end of the exercise test using biplane quantitative coronary arteriography. Patients were divided into 3 groups: Group I (n = 12) served as control Group II consisted of 10 patients with intracoronary administration of 1 mg propranolol and Group III of 8 patients with intravenous administration of 0.1 mg/kg propranolol prior to the exercise test. In the control Group there was coronary vasodilation (+23%, p less than 0.01) of the normal and coronary vasoconstriction (-29%, p less than 0.001) of the stenotic vessel segment during bicycle exercise. After sublingual administration of 1.6 mg nitroglycerin there was vasodilation of both normal (+40%, p less than 0.001 vs rest) and stenotic (+12%, NS vs rest) segments. In Group II intracoronary propranolol was not accompanied by a change in coronary area but both normal (+13%, p less than 0.05) and stenotic (+22%, p less than 0.05) segments showed coronary vasodilation during bicycle exercise. After sublingual nitroglycerin there was further vasodilation of both normal (+31%, p less than 0.001 vs rest) and stenotic (+45%, p less than 0.01 vs rest) arteries. In Group III intravenous administration of propranolol was associated with a decrease in coronary luminal area of both normal (-24%, p less than 0.001) and stenotic (-41%, p less than 0.001) segments. During dynamic exercise there was coronary vasodilation of both segments when compared to the data after intravenous injection of propranolol but there was no change in luminal area (normal vessel-2%, NS vs rest; stenotic vessel-3%, NS vs rest) when compared to the resting data. After sublingual administration of 1.6 mg nitroglycerin both normal (+21%, p less than 0.001) and stenotic (+46%, p less than 0.001) segments showed coronary vasodilation. It is concluded that supine bicycle exercise in patients with coronary artery disease is associated with vasodilation of the normal and vasoconstriction of the stenotic coronary arteries. Intravenous administration of propranolol is followed by coronary vasoconstriction of both normal and stenotic coronary arteries probably due to secondary mechanisms (reduction in heart rate and contractility) because it is not observed after intracoronary injection of propranolol and it is overridden by bicycle exercise and sublingual nitroglycerin.

[Doppler velocimetry of the internal mammary artery anastomosed to the anterior descendent coronary artery: a noninvasive analysis of coronary circulation]. / Velocimetria Doppler dell'arteria mammaria interna anastomizzata sulla discendente anteriore: analisi non invasiva della circolazione coronarica.

This study analyses the static and dynamic characteristics of the flow curves obtained by continuous wave Doppler flow velocity analysis in the internal mammary artery (IM) under normal conditions and after left anterior descending coronary artery by-pass. The IM flow velocity curve has the characteristics of a muscular artery both in basal conditions and during hyperventilation and Valsalva manoeuvre. On the other hand, the by-passed IM shows a typically phasic flow velocity curve, the diastolic flow prevailing over the systolic as is commonly the case in the coronary circulation. This curve also shows variations characteristic of the coronary circulation during Valsalva manoeuvre, whereas it is not affected by the alterations induced by hyperventilation in the area of the respiratory muscles. Continuous wave Doppler flow analysis of the by-passed IM can therefore be considered a reliable method for evaluating coronary flow in man. The fact that this method is non-invasive makes it obviously advantageous and widens its field of application not only to strictly diagnostic evaluations but also to physiopathological and therapeutical ones.

[Acute effects of propionyl-L-carnitine on anomalies of parietal kinetics of the left ventricle induced by atrial pacing in patients with ischemic heart disease. A bidimensional echocardiographic study]. / Effetti acuti della propionil-L-carnitina sulle anomalie della cinetica parietale del ventricolo sinistro indotte dal pacing atriale in pazienti con cardiopatia ischemica. Studio ecocardiografico bidimensionale.

This double-blind randomized placebo (PL) controlled study was undertaken to evaluate, by 2D echo transesophageal atrial pacing (TAP), the effects of acute iv administration of a new compound propionyl-L-carnitine (PLC) on atrial pacing (AP) induced left ventricular wall motion abnormalities. Twelve male patients with coronary artery disease and normal regional motion at rest, after a preliminary 2D echo-TAP, on the eight and thirteenth day of trial were subjected to 2D echo-TAP 30 min after iv administration of 15 mg/Kg PLC or PL. For analysis, the left ventricle was divided into 11 segments. A wall motion score (WMS), evaluated at 130 b/min and at 150 b/min, was derived by adding together the scores assigned to each segment. Wall motion was graded +2 (normokinetic), +1 (hypokinetic), 0 (akinetic), -1 (dyskinetic). Left ventricular ejection fraction (EF) was evaluated at rest and at 150 b/min. Statistical analysis of the results was performed using a 2-way analysis of variance. The WMS at 130 b/min improved significantly after PLC vs PL from 18.66 +/- 2.46 to 19.50 +/- 2.77 (p less than 0.02). The WMS at 150 b/min improved significantly after PLC vs PL from 16.00 +/- 2.95 to 16.91 +/- 3.47 (p less than 0.01). The EF at rest was not significantly unchanged after PLC. The EF at 150 b/min was significantly different after PLC vs PL, from 53.6 +/- 7.36 to 55.6 +/- 6.45 (p less than 0.05). The blood pressure and the double product at rest and at 150 b/min were not unchanged after PLC.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective evaluation of gallopamil in patients with chronic stable angina. Exercise testing, Holter monitoring, cross-sectional echocardiography and plasma levels.

In this double-blind, randomized placebo-controlled study the effects of two dosages of gallopamil on exercise tolerance were evaluated in 12 patients with stable effort angina. After a pre-study screening aimed at assessing the reproducibility of the exercise response, the patients entered the study which consisted of three 7-day consecutive periods during which placebo or gallopamil 50 mg t.i.d. or gallopamil 75 mg t.i.d. were administered according to a randomized sequence. 24-hour Holter monitoring and cross-sectional echocardiography were performed on the 6th and 7th day of each treatment period, respectively. On the 7th day of each treatment period, patients underwent an exercise test 2 and 8 h after the last administration of gallopamil or placebo. Blood samples for plasma gallopamil concentrations were taken just before each exercise test. The results were analysed using a three-way analysis of variance; intergroup differences were evaluated by the Newman-Keuls test. At 2 h, 11 patients with placebo and three with gallopamil experienced angina; both dosages of gallopamil significantly prolonged exercise time and -1 mm time and also reduced ST segment depression and the rate-pressure product at submaximal workload. No significant change in the rate-pressure product was observed either on the appearance of 1 mm ST depression or at peak exercise. At 8 h, 11 patients with placebo and gallopamil 50 mg t.i.d. and 10 with gallopamil 75 mg t.i.d. experienced angina; although exercise time was significantly prolonged by both dosages of gallopamil, the increase in -1 mm time and reduction of ST segment depression at submaximal workload did not reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Abnormal coronary vasomotility in subjects with normal coronary arteries and reduced reserve of coronary flow]. / Abnorme vasomotilità coronarica in soggetti con coronarie normali e ridotta riserva di flusso coronarico.

A reduced coronary flow reserve has been reported in patients with ischemia-like symptoms and normal coronary arteries. In 13 such subjects both coronary vasomotion and flow reserve were studied. The luminal area of the proximal and distal third of the left anterior descending and left circumflex artery were determined by biplane quantitative coronary arteriography using a computer-assisted system. Subjects were studied at rest, during submaximal supine bicycle exercise (4.0 min, 116 W) and 5 min after sublingual administration of 1.6 mg nitroglycerin. Heart rate, mean pulmonary and aortic pressure as well as the percent change of both proximal and distal luminal area were determined. In 10 of the 13 subjects, coronary sinus blood flow was measured by coronary sinus thermodilution technique at rest and after dipyridamole infusion (0.5 mg/Kg in 15 min) 10 +/- 5 days after quantitative coronary arteriography. Coronary flow ratio (dipyridamole/rest) and coronary resistance ratio (rest/dipyridamole) were determined in these subjects. Subjects were divided into 2 groups according to the behaviour of the coronary vessels during exercise (vasodilation = Group 1, vasoconstriction = Group 2). Coronary vasodilation of the proximal (luminal area + 26%; p less than 0.001) and distal (+ 45%; p less than 0.001) artery was observed in 7 subjects (Group 1) during exercise and after sublingual nitroglycerin (+46%; p less than 0.001 and +99%; p less than 0.001, respectively). In Group 2 (n = 6), however, there was coronary vasoconstriction of the distal vessel segments (-24%; p less than 0.001) during exercise, whereas the proximal coronary artery showed vasodilation (+ 26%; p less than 0.001) during exercise. Following sublingual nitroglycerin, both vessel segments elicited vasodilation (distal coronary + 44%; p less than 0.001, proximal coronary artery +47%; p less than 0.001). Coronary flow ratio amounted to 2.5 in Group 1 and to 1.2 in Group 2 (p less than 0.05) and coronary resistance ratio to 2.7 in Group 1 and to 1.2 in Group 2 (p less than 0.05), respectively. Thus, among subjects with ischemia-like symptoms and normal coronary arteries there is a subgroup of patients (Group 2) with an abnormal dilator response of the distal coronary arteries to the physiologic dilator stimulus of exercise and a reduced dilator capacity of the resistance vessels after dipyridamole (= abnormal coronary vasodilator syndrome). The nature of this exercise-induced distal coronary vasoconstriction is not clear but might be due to an abnormal neurohumoral tone which may cause or contribute to the blunted vascular response during exercise.