Demand dynamic cardiomyoplasty: mechanograms prove incomplete transformation of the rested latissimus dorsi.

BACKGROUND: In dynamic cardiomyoplasty, standard stimulation produces high fatigue resistance but also undesirable dynamic characteristics of the latissimus dorsi (LD). Based on results of intermittent stimulation in animals we introduced demand stimulation, a lighter regimen of LD activity-rest stimulation, and the mechanogram, a noninvasive method to determine the contractile characteristics of LD wrap. METHODS: Surgery and standard stimulation was according to the technique of Carpentier and Chachques, demand stimulation and LD wrap mechanogram were as we previously described. The LD contraction is synchronized to heart systole by mechanogram and echocardiography, and extent of transformation by tetanic fusion frequency analysis. A total of 22 patients were studied to date. Data for the 8 subjects who attained 6-month follow-up are reported. Four of them were lightly stimulated from the conditioning period, whereas 4 others were converted to light and then demand stimulation after years of standard stimulation. Patients were followed up with respect to survival, functional class, hospital admission rate, medication used, cardiopulmonary exercise testing, and LD wrap mechanography. RESULTS: Latissimus dorsi wrap slowness reverses by the activity-rest regimen, even after years of standard stimulation (Tetanic fusion frequency of 11 +/- 2 Hz after standard stimulation vs 30 +/- 3 Hz after demand regimen, p < 0.0001). After demand dynamic cardiomyoplasty there are no deaths. Quality of life is substantially improved with significant reduction of heart failure symptoms (New York Heart Association class: preoperative 3.0 +/- 0.0, post-demand dynamic cardiomyoplasty 1.5 +/- 0.2, p < 0.0001). In the subgroup of patients lightly stimulated from LD conditioning, exercise capacity tends to increase over preoperative values more than 2 years after operation (VO2 max: preoperative 12.3 +/- 0.7 vs 16.6 +/- 1.7 post-demand dynamic cardiomyoplasty, p = 0.05). CONCLUSIONS: Demand stimulation and mechanography of the LD wrap are safe procedures that could offer long-term benefits of dynamic cardiomyoplasty to patients with pharmacologically intractable heart failure.

[Extensive cardiac angiosarcoma in the course of immunosuppressive therapy after kidney transplant]. / Esteso angiosarcoma cardiaco in corso di terapia immunosoppressiva post-trapianto renale.

We present a case of a 49-year-old man who underwent a kidney transplant. Treatment with azathioprine and steroid was increased due to an initial rejection of the allograft. Six months later, the patient experienced palpitations and precordial pain: the electrocardiogram recorded atrial fibrillation and the echocardiogram showed moderate pericardial effusion and the presence of a right atrial mass with infiltration into the interatrial septum and right ventricle. Computed tomography imaging confirmed the tumoral mass and magnetic resonance imaging revealed the extensive involvement of the right atrium, right ventricle and superior vena cava, suggesting the presence of an angiosarcoma of the heart. Despite chemotherapy the patient died within 1 month. The diagnosis was confirmed by autopsy, histological section, and electron microscopy examination.

Estimating mean pulmonary wedge pressure in patients with chronic atrial fibrillation from transthoracic Doppler indexes of mitral and pulmonary venous flow velocity.

OBJECTIVES: We sought to obtain a noninvasive estimation of mean pulmonary wedge pressure (MPWP) in patients with chronic atrial fibrillation (AF). BACKGROUND: It has previously been demonstrated that MPWP can be reliably estimated from Doppler indexes of mitral and pulmonary venous flow (PVF) in patients with sinus rhythm. Doppler estimation of MPWP has not been validated in patients with AF. METHODS: MPWP was correlated with variables of mitral and pulmonary venous flow velocity as assessed by Doppler transthoracic echocardiography in 35 consecutive patients. The derived algorithm was prospectively tested in 23 additional patients. RESULTS: In all patients the mitral flow pattern showed only a diastolic forward component. A significant but relatively weak correlation (r = -0.50) was observed between MPWP and mitral deceleration time. In 12 (34%) of 35 patients, the pulmonary vein flow tracing demonstrated only a diastolic forward component; a diastolic and late systolic forward flow was noted in the remaining 23 patients (66%). A strong negative correlation was observed between MPWP and the normalized duration of the diastolic flow (r = -0.80) and its initial deceleration slope time (r = -0.91). Deceleration time > 220 ms predicted MPWP < or = 12 mm Hg with 100% sensitivity and 100% specificity. When estimating MPWP by using the equation MPWP = -94.261 PVF deceleration time -9.831 Interval QRS to onset of diastolic PVF -16.337 Duration of PVF + 44.261, the measured and predicted MPWP closely agreed with a mean difference of -0.85 mm Hg. The 95% confidence limits were 4.8 and -6.1 mm Hg. CONCLUSIONS: In patients with chronic AF, MPWP can be estimated from transthoracic Doppler study of PVF velocity signals.

Idiopathic apical left ventricular aneurysm in hypertrophic cardiomyopathy. Report of 3 cases, and review of the literature.

In a review of 160 cases of hypertrophic cardiomyopathy which underwent hemodynamic studies, 3 cases of apical aneurysm of the left ventricle of unidentifiable etiology were found. Bearing in mind the rarity of apical idiopathic left ventricular aneurysms, the authors believe this association with hypertrophic cardiomyopathy is of some interest and point out the possible pathogenetic mechanisms.

[Exercise-induced R wave changes in normals and coronary patients. Computer analysis of CB5 lead (author's transl)]. / Comportamento dell'onda R durante sforzo in soggetti normali e coronaropatici. Analisi automatica della derivazione CB5.

Changes in R-wave amplitude (delta R) during treadmill test were studied in 84 coronary artery disease (CAD) patients and in 150 normal subjects. The evaluation of ECG recordings (CB5 lead) was carried out by a computer program. At maximal exercise, R-wave decreased by 2.1 +/- 2.8 mm in normal subjects, while in CAD patients mean delta R was significantly lower (0.4 +/- 1.7 mm). When the evaluation of delta R was performed at comparable heart rate and work load values, no significant differences were observed between normals and CAD patients. Using as criterion for a positive test an ischemic ST segment depression greater than or equal to 1.0 mm, the diagnostic sensitivity was 66.7%, while the specificity was 94.0%. When an increase or no change in R-wave was taken as evidence of an abnormal response, sensitivity and specificity values were 57.1% and 65.3% respectively. After a critical review of different parameters able to affect delta R, the difficult physiopathological evaluation and the poor diagnostic reliability of delta R were emphasized. The different heart rate and work load values attained by normals and CAD patients proved to be a further confounding factor in delta R comparison between the two groups.