[The usefulness of the echo-dipyridamole test in the early period after an uncomplicated acute myocardial infarct]. / Utilità del test eco-dipiridamolo in fase precoce dopo infarto miocardico acuto non complicato.

OBJECTIVES: The aim of this study was to examine the ability of Dipyridamole Echocardiography Test (DET)--performed early after an acute myocardial infarction (AMI)--to assess: a) the presence of induced ischemia and its relation with coronary artery stenoses; b) the presence of myocardial viability and the comparison with late wall motion; c) the appearance of cardiac events during hospitalization and in the following period. METHODS: Ninety-five patients with AMI, subjected to thrombolytic therapy and without complications, underwent a DET on the 4th-5th day. All had a coronary angiography on the 8th-10th day; stenoses were deemed significative when > or = 70%. DET was carried out after drug discontinuance and following standard protocol; parietal kinesis was analyzed according to a 14 segment model. The myocardium was deemed viable when an improvement of a basal dyskinesis was noted; ischemia was considered when a new asynergy appeared or a basal dyskinesis worsened or enlarged; a wall motion score index (WMSI) was calculated. All 95 pts. had a clinical follow-up at 12 +/- 6 months (3-18); 62 pts. had a late echocardiographic examination at 6 +/- 3 months (3-15). RESULTS: Induced ischemia appeared in 59/95 pts. (62%): in 6/14 pts. (42%) without significative stenoses, in 29/49 pts. (59%) with a single vessel disease, and in 24/32 pts. (75%) with multivessel disease. In identifying multivessel disease, DET sensibility (SE) was 75% and specificity (SP) was 95-97%. In single or no vessel disease WMSI changed from 1.42 to 1.49 (p < 0.0001); in multivessel disease WMSI changed from 1.52 to 1.69 (p < 0.0001). As regards the assessment of diseased vessel(s), DET showed little accuracy when dyskinesis appeared in the basal segments of the inferior and lateral wall or in the mid-apical segments of the anterior and lateral wall; DET properly identified the culprit vessel when dyskinesis appeared in the remaining segments. Myocardial viability was noted in 26% of dyskinetic segments. In single or no vessel disease WMSI changed from 1.41 (basal--> B) to 1.35 (viability phase--> V) and was found 1.31 at the late echocardiography (L): p < 0.0001 between B and V, and between B and L. In multivessel disease WMSI changed from 1.5 (B) to 1.47 (V) and to 1.5 (L): p < 0.05 between B and V, NS between B and L. In comparison with late echocardiography, DET SE was 70%, SP 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 86%. As regards the prognostic value about cardiac events, DET SE was 80% and NPV was 78%; about only major cardiac events, the respective values are 91% and 97%. CONCLUSIONS: DET performed early after an AMI allows a better prognostic assessment, as it provides information about: a) the place and the severity of coronary artery stenoses; b) the presence and the extension of induced ischemia and of myocardial viability; c) the risk of subsequent cardiac events.

Single coronary artery, anomalous origin of the right coronary artery from the left anterior descending artery.

We present a patient with an abnormal origin of the right coronary artery from the left anterior descending artery. The patient had chest pain probably related to myocardial ischaemia. This anomaly is very rare and has previously been reported in only three cases. The abnormal vessel travelled rightwards and remained anterior to the main pulmonary artery, it was free of significant stenosis. The mechanism of anterior myocardial ischaemia remains unexplained.

The response of the coronary collateral circulation to acute administration of nifedipine: an angiographic and ergometric study.

To evaluate the role of collaterals in patients with effort angina we retrospectively compared the coronary cineangiograms of 14 subjects ("responders") who improved their exercise tolerance after acute nifedipine therapy with 14 subjects ("non-responders") with the same symptomatology who did not respond to the same treatment. The status of collaterals was graded with a score from a minimum of 0 to a maximum of 5. The responders showed a greater score than the non-responders (3 +/- 1 vs. 1 +/- 1, P less than 0.001), whereas there was no difference in the number of stenosed vessels between the two groups (1.8 +/- 0.9 vs. 2 +/- 0.8). Thus, in patients with effort angina and critical coronary stenosis, the presence of an efficient coronary collateral circulation can favour the increase in coronary flow reserve after vasodilator therapy. Our results suggest that the grading of collaterals may add useful information to the simple classification of one-, two- or three-vessel coronary artery disease.

[Efficacy of oral nitroglycerin in the therapy of exertion angina]. / Efficacia della nitroglicerina per via buccale nella terapia dell'angina da sforzo.

A sample of 14 patients suffering from stable effort angina has been examined by means of exercise ECG test, in order to evaluate the efficacy, the onset of action and duration of effect of buccal nitroglycerin in the treatment of effort angina. The optimal dose of buccal NTG was predetermined for each patient through the analysis of heart rate changes (increase of at least 10 beats/min) and/or of blood pressure modifications (decrease of at least 10 mmHg). By applying a randomized double-blind design, the variations observed during exercise ECG tests after 20 minutes and 4 hours from the administration of buccal NTG (at the given dosage) or of placebo, have been evaluated. The following variables have been analyzed: heart rate, blood pressure, double product, time of onset of angina and/or of ST depression, amount of ST depression, duration of exercise test and maximum work-load. No significant changes have been observed for heart rate, blood pressure and double product both at the maximum effort and at the same level of effort as in the basal test. For each of the remaining variables a significant difference has been shown in favour of buccal NTG as compared to placebo, both after 20 min. and 4 hs. More in detail, the duration of the exercise test has been 6.14 +/- 2.77 mins on buccal NTG and 4.42 +/- 2.08 mins on placebo (+ 38%; p less than 0.05) after 20 mins and 6.40 +/- 3.19 on buccal NTG and 5.15 +/- 2.73 on placebo, after 4hs (+ 24%; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Basic problems in coronary revascularization]. / Problemi di base per la rivascolarizzazione coronarica.

The author reminds briefly the physiopathological basis of coronary circulation and points out the hydraulic factors as the most important for the maintenance of myocardial flow. That's the reason he shows the great actuality of the new therapies of acute and chronic coronary insufficiency (thrombolysis and angioplasty) fit for taking off the obstacles to anterograd flow.

[Prognostic evaluation with invasive technics in patients with hyperkinetic ventricular arrhythmias]. / Valutazione prognostica con metodiche invasive di pazienti con aritmie ipercinetiche ventricolari.

The prognostic value of induction of ventricular tachycardia (VT) by programmed electrical stimulation (PES) was analyzed in 123 patients: 64 (Group I) with spontaneous recurrent VT and 59 (Group II) without a history of serious arrhythmias. Thirty-three patients with spontaneous VT underwent coronary and left ventricular angiography to compare electrical instability with the presence of ventricular disfunction and/or the extent of coronary artery disease (CAD). PES reproducibly induced VT in 49/64 patients with spontaneous VT (sensitivity = 77%) and in 6/59 patients without VT (specificity = 90%). Twenty-two patients (66%) had ventricular disfunction defined by an ejection fraction of less than or equal to 40% or regional wall motion abnormalities. Only 4 patients (33%) had proximal 3-vessel CAD. The mean follow-up period was 16 +/- 12 months. Eight of Group I patients died suddenly and 24 had recurrent symptomatic VT. Three of Group I patients died (1 cardiac failure, 2 non-cardiac deaths), all the survivors were free of serious arrhythmias. In Group I patients mortality was correlated with: recent anterior myocardial infarction, inducible sustained VT with PES, ejection fraction less than or equal to 0.40, ventricular ipoasynergy and or at least one coronary stenosis greater than or equal to 70%. This study suggests that inducible VT is a marker of the risk of sudden death. Electrical instability may occur independent from the etiology of cardiopathy, ventricular disfunction and extent of CAD, but these parameters are correlated to global and sudden mortality in the group of patients with spontaneous VT.

[Fixed subvalvular left ventricular outflow tract obstruction. Comparison of the diagnostic usefulness of mono- and bi-dimensional echocardiography]. / Ostacolo all'efflusso del ventricolo sinistro sottovalvolare fisso. Confronto tra utilità diagnostica della ecocardiografia mono-bidimensionale.

Because Cross-Sectional Echocardiography offers the advantage of correct spatial orientation, it is said to permit a more exact localization of the level of the outflow tract obstruction and a determination of the nature of the lesion. Our experience confirms that B-Mode Echo is more reliable in diagnosing an extensive sub-valvular narrowing, while the existence of a thin sub-valvular membrane can also be detected by M-Mode examination. The latter has moreover proven very useful in that it records indirect signs of obstruction, such as a mid-systolic closure of the aortic cusps. We therefore suggest that both methods should be employed in studying these patients.

[Mitral insufficiency associated with interatrial defect (ostium secundum). Problems of diagnosis and surgical treatment]. / L'insufficienza mitralica associata a difetto interatriale (ostium secundum). Problemi di diagnosi e di terpaia chirurgica.

Of the 255 patients under observation of the AA. with ostium secundum interatrial defect who underwent surgery, 23 (9%) presented an associated mitral regurgitation. All patients had a hemodynamic test and a complete contrahistography, 8 patients polygraphic and 5 patients echocardiographic examinations. The clinical data alone, ecgraphic and Rx, supplied sufficient indications for a correct diagnosis in 87% of the cases. 22 patients underwent surgery: the septal defect was corrected in all patients, mitral regurgitation only in 9; in 5 by valve substitution, in 4 through conservative techniques. Only one patient died of cerebral coma. A report is made on the data relative to the clinical history, Rx, ecgraphic and hemodynamic examinations of the 23 patients under observation, the various anatomosurgical aspects of the valvular alterations, and the criteria adopted for the surgical correction of the mitral regurgitation.

[Bypass of the outlet of the left ventricle with a Hancock valve tube: report of two cases surgically treated (author's transl)]. / Il bypass della via di efflusso del ventricolo sinistro con tubo valvolato di Hancock. A proposito di due casi operati.

The Authors describe two cases in which the outlet of the left ventricle was recreated by means of a bypass with a valve tube. The first is a case of correct levo-transposition of the great vessels with atresia of the pulmonary, in which a valve tube was applied between the inverted left ventricle and the right branch and trunk of the pulmonary. The second is a case of "long" fibrous subvalvular aortic stenosis, a relapse from former correction of membranous subaortic stenosis, in which bypass was applied between the left ventricle and the ascending aorta. This latter method, adopted by McGoon, is held by the Authors to be easier to apply and more physiological in its hemodynamic effects. The clinical and instrumental results were good in both cases. The hemodynamic and cardioangiographic controls carried out in the second case, 4 months after the surgical operation, showed the normal functioning of the prosthesis, an outflow equal to 60.3% of the total capacity through the bypass, and the ample neostomy of the left ventricle in systolic phase.

[Coronary collateral circulation in coronary atherosclerosis (author's transl)]. / Il circolo collaterale coronarico nella cardiopatia arteriosclerotica.

The coronary collateral circulation of 162 patients suffering from atherosclerosis and coronary insufficiency (coronary artery disease) was studied. It was found to be present in 44 patients, or 27.1%; homocoronary in 9%, intercoronary in 90.9%. As other Authors have previously reported, anastomotic circulation is more developed when the coronary occlusion exceeds 75%. Not one of the 44 cases with normal coronary arteries or occlusion inferior to 75% presented collateral circulation. In addition, it was found to be present more frequently in cases with three branch lesions. The time of insurgence of coronary insufficiency seems to condition the development of anastomotic circulation which appears more frequently when the symptoms have been present for more than 5 years (43.9%). Anastomotic circulation is also found more frequently (48.4%) in patients who have suffered myocardial infarction and who have angina. Collateral circulation was not found in any of the 46 patients with unstable isolated angina; this seems to show the importance, in its pathogenesis, of the functional factor (spasm). In conclusion, we may say that anastomotic circulation is more developed: 1) in cases of severe occlusive lesions (in severe coronary occlusive disease/atherosclerosis) (85%);2) in three branch lesions; 3) in cases of long standing symptomatology; 4) in stable angina and in angina t infarction.

[Coronarographic and ventriculographic aspects of 76 cases of unstable angina (authors transl)]. / Dati coronarografici e ventricolografici in 76 casi di angina instabile

-- Coronarographic and ventriculographic aspects of 76 patients with unstable angina were analyzed. 8 cases (10%) had normal coronary arteries, 9 (11.8%) had slight stenotic lesions (less than 50%), 59 (77.6%) had serious stenosis. The stenosis concerned only one principal branch in 22 patients (37.2%), 2 branches in 24 (40%), 3 branches in 13 (22%). In 77-79% of cases, ventricular contractility was normal. A collateral circulation was found in 58% of cases, but no link was discovered between the coronaric lesions and the clinical type of angina. The course of the illness was studied during the hospitalization and post-hospitalization period for an average observation time of 14 months (55 cases). The course of illness type depends on the number of affected branches and the myocardial contractility. In 25% of the patients with lesions in 3 branches there was an unfavourable course of illness (either infarction or death), whilst where there were lesions in one or two branches, negative results were 11% and 15% respectively. Patients with normal coronary arteries or slight stenosis had no unfavourable course of illness. In 37% of patients with altered contractility, an unfavourable course of illness was found, as against 27% with normal contractility. The presence of collateral circulation doesn't seem to influence the course the illness takes. A coronarographic examination seems to be an essential elelment in deciding on the prognosis of unstable angina.

[Subaortic membranous stenosis associated with infundibular pulmonary stenosis. Case report (author's transl)]. / Stenosi subaortica membranosa associata a stenosi polmonare infundibulare Descrizione di un caso clinico

A case of combined congenital discrete subaortic stenosis and infundibular pulmonic stenosis is described. Clinical, haemodynamic data and surgical results are reported. Only one similar case has been previously described.