Melanoma relapse over a pacemaker pocket: case report and integrated management strategies.

We report the first related case of a metastasis from melanoma appeared on a pacemaker device pocket. The stadiation exams showed that this is the only localization of the pathology. The integrated management from both cardiologic and dermatologic surgery was described. It was composed by two interventions, a first time for the implant of a new device contralaterally, and later by the surgical intervention, with exeresis of the lesion, radical lymph node dissection of the axilla and plastic reconstruction. The previous pacemaker implant may hypothetically create a favourable environment for metastatic cells ingrowth. This could be explained by a chronic inflammatory reaction and capsule formation around the device as previously reported, or by a blockage of lymphatic drainage in this specific site.

Biventricular pacing concomitant to on-pump heart surgery: a case series.

AIM: The aim of this paper was to report the authors' experience on biventricular epicardial pacing (BEP) as first-choice procedure concomitant to on-pump heart surgery for other definite indications. METHODS: BEP was performed in 13 consecutive patients with stage IV heart failure (HF) undergoing on-pump cardiac surgery for other definite indications. All patients were treated with optimized pharmacologic therapy, and showed complete left bundle branch block and reduced (<30%) left ventricular ejection fraction. RESULTS: In all patients, effective BEP was achieved. All patients were discharged alive; functional, ECG and echocardiographic parameters showed significant improvement, better observed at 4-month interval. However, a high mortality rate was noticed during follow up (about 70% at 6 months) with a significant number of sudden cardiac deaths. The absence of functional improvement in the mid-term period (4-month control) related to a poor prognosis. CONCLUSIONS: Epicardial lead placement during cardiac surgery of severe HF patients is safe and effective. A clear evaluation of the effect of BEP alone is precluded because of the interference of the concomitant indications for cardiac surgery and the absence of randomization. The high rate of sudden death noticed in this study raises the important question of whether implantation of a defibrillator would be warranted in such population.

Atrial natriuretic factor and concomitant hormonal, hemodynamic and renal function changes after slow continuous ultrafiltration.

We treated a patient with refractory biventricular heart failure, dilutional hyponatremia and prerenal azotemia, by means of ultrafiltration. After ultrafiltration, gas exchange and cardiac output improved, with concomitant reduction of systemic and pulmonary vascular resistances. Despite a decrease of right atrial and wedge pressure, atrial natriuretic factor rose and plasma renin activity decreased.

[The midterm clinical results of myocardial revascularization with the internal mammary artery]. / Risultati clinici a medio termine della rivascolarizzazione miocardica con arteria mammaria interna.

After a 3-year (1985-1988) experience of myocardial revascularization using internal mammary artery (AMI) grafts and after having excluded (1986) an higher operative mortality and morbidity, clinical medium-term results have been analysed. The first 144 patients discharged alive after AMI bypass surgery in 1985 were clinically evaluated, with a mean interval of 21 months from surgery (range: 5-29 months). Exercise electrocardiographic test was performed by 100 patients, and angiography repeated in 15. Actuarial survival function was estimated by Cutler-Ederer method: 2-year actuarial survival was 99.3 +/- 0.7% (94 +/- 1.8%, when operative deaths were included). Non fatal myocardial infarction occurred in 3 patients and, at follow-up, 26 were symptomatic for angina: 2 patients underwent re-operation and 2 angioplasty. Two years after AMI bypass surgery, actuarial estimate of ischemic event-free patients was 70.9 +/- 4.5% (67.7 +/- 4.5%, when operative deaths were included): 73 out of 100 exercise tests were negative for both angina and ischemia, although only 43 patients, reached maximal work load; 9 were positive for both angina and ischemia and 18 for ischemia only. All patients who underwent angiographic evaluation (15 patients, 11 of whom because of angina relapse) had AMI grafts open, while in only 4 patients all the implanted grafts were open.

Aortocoronary bypass results: a discriminant multivariate analysis of risk factors of operative mortality.

Clinical results of coronary artery bypass surgery have been evaluated analyzing operative mortality and its related risk factors. Four hundred and thirty seven consecutive patients undergoing coronary artery bypass surgery between January 1979, and December 1983, form the clinical material of this study. The gender of patients was male in 89% of the cases, the age ranged from 34 to 78 years with a mean of 54.8 +/- 8.2 (SD); patients with combined surgical procedures were excluded. The operative mortality was 5.49% (24 patients); no significant difference was found between years of the observation period. Death was due to cardiac causes in 75% of cases. Statistical analysis carried on 14 clinical, angiographic and surgical variables identified as significant risk factors of operative mortality age (p = 0.002) and cross-clamp time (p = 0.016). Both of these increased their weight when entered in a stepwise logistic regression. The EF also showed a value close to statistical significance (p = 0.06).

[Giant cell arteritis of cardiologic relevance: polymorphism of the clinical manifestations and therapeutic indications]. / Le arteriti a cellule giganti di interesse cardiologico: polimorfismo delle manifestazioni cliniche ed indicazioni terapeutiche.

Three cases of giant cell arteritis have been admitted to our Institution from 1985 to 1989, with different diagnoses: aortic dissection, left atrial myxoma and fever of unexplained origin. The diagnosis of giant cell arteritis (GCA)/temporal arteritis (TA), biopsy proven, allowed us to institute an effective corticosteroid treatment. These 3 cases of TA permit us to emphasize the systemic vascular involvement in GCA/TA, with the aorta and its major branches being the districts mainly affected; the polymorphism of clinical manifestations at onset; the importance of constitutional symptoms that can dominate other clinical manifestations. Concomitant involvement of the aorta and its major branches, and of small sized arteries, permits regarding Horton's disease as an overlap syndrome between "pulseless disease" of Takayasu and systemic necrotizing vasculitides of the polyarteritis nodosa group. A prompt diagnosis of this arteritis is needed, because of the good therapeutic opportunities with corticosteroids, and because of the possibility of serious vascular and ocular complications without therapy.

[Reliability of electrocardiographic criteria for the diagnosis of apical myocardial infarct]. / Attendibilità dei criteri elettrocardiografici per la diagnosi di infarto miocardico apicale.

Electrocardiographic criteria for the diagnosis of apical myocardial infarction are still debated. Aim of the present study is to evaluate if there is an electrocardiographic pattern useful in the diagnosis of apical AMI using biplane ventriculography as "gold standard" technique. For this reason, we studied 75 patients at the first AMI with a-dyskinesis in the apical zone on biplane ventriculography (segments 3 and 7 according with CASS nomenclature). By the means of ventriculography we have selected 2 groups: a first group of 19 patients with a-dyskinesis confined to apical zone and a second group of 56 patients with a-dyskinesis in the apical zone and surrounding regions. In the 2 groups we found different electrocardiographic changes. In the first group (a-dyskinesis in the apical zone only) we found the ECG pattern of anterior AMI in 14 (73.7%), antero-inferior AMI in 2 (10.5%), antero-lateral AMI in 1 (5.3%) and inferior-posterior AMI in 2 patients (10.5%), respectively; in the second group (a-dyskinesis in the apical and surrounding zones) we observed 31 (55.4%) anterior, 7 (12.5%) antero-lateral, 7 (12.5%) antero-inferior and 11 (19.6%) inferior-posterior myocardial infarctions. Our study did not allow to recognize a "typical" ECG pattern associated with the "apical" infarction seen at ventriculography.