[The diagnostic and therapeutic procedures in pulmonary embolism: a survey in the Veneto Region]. / Iter diagnostici e terapeutici nell'embolia polmonare: inchiesta nella Regione Veneto.

BACKGROUND: Pulmonary embolism is one of the most frequent cardiopulmonary diseases, but it is often under- or misdiagnosed. In order to address this issue and to identify flow charts that are commonly used in pulmonary embolism diagnosis and treatment, 191 clinical wards of internal medicine, cardiology, geriatrics, pneumology and intensive care units, located in the Veneto Region, were surveyed. METHODS: An anonymous questionnaire was mailed to each ward in order to collect clinical diagnostic information on all pulmonary embolisms which occurred during 1993. Among the returned questionnaires, 114 (59.6%) had usable information for the analysis. RESULTS: The vast majority of participating centers reported in 1993 less than 10 pulmonary embolism events. No significant differences were observed between internal medicine, geriatrics, pneumology wards and intensive care units. The reported events, however, were slightly higher in the divisions of cardiology with an annual average of 12 events per center. First level diagnostic procedures, such as ECG, chest X-ray and arterial blood gas analysis were chosen and performed in all patients. Interestingly, Doppler echocardiography, which is often not included in official guidelines for pulmonary embolism diagnosis, was performed in 56% of the participating centers. On the contrary, ventilation-perfusion lung scanning, which is considered highly predictive in many diagnostic algorithms, was underutilized (35% perfusion scan, 20% ventilation scan). This underuse was probably due to technical and organizational difficulties. Pulmonary angiography, the most accurate procedure for the diagnosis of pulmonary embolism, was performed in 28% of the patients. During the acute phase, intravenous heparin was commonly used; 91% of patients received the infusion continuously, 4% intermittently. Thrombolysis was performed in 25% of the patients. The preferred drugs were recombinant tissue-plasminogen activator (67%), followed by urokinase (20%) and streptokinase (13%). To start thrombolytic therapy, 20% of the interviewed clinicians considered sufficient the evidence of clinical manifestations of pulmonary embolism confirmed by echocardiographic data. At discharge, prescription of oral anticoagulant drugs was common (78%) for at least 6 months (47%). Standardized procedures for the diagnosis and treatment of pulmonary embolism were already implemented in 13% of the participating centers. CONCLUSIONS: These data suggest a common effort to define unanimous conventional protocols in the management of pulmonary embolism. It should be underlined, however, that a particular attention to the clinical manifestations and a productive collaboration among clinicians with different expertise are required to improve the diagnosis and treatment of pulmonary embolism.

Pulmonary hypertension associated with human immunodeficiency virus infection. Report of two cases and review of the literature.

Recent reports have suggested a possible association between HIV-1 infection and "idiopathic" pulmonary hypertension (PH), but the pathogenetic role of the viral agent has not been fully defined yet. We report the cases of two white males positive for human immunodeficiency virus type 1 (HIV-1) who presented with clinical and hemodynamic diagnosis of pulmonary hypertension. They were heterosexual, non-hemophiliac, heroin abusers with no signs of clinical AIDS. Neither one of the patients had opportunistic lung infections or any other cause of secondary pulmonary hypertension. In one case, peculiar clinical and electrocardiographic features of PH were associated with signs of thrombotic thrombocytopenic purpura (TTP). The association between PH and HIV-1 infection might be explained by a severe alteration of pulmonary endothelial cell homeostasis secondary to HIV-1 viral infection.

Follow up after spontaneous coronary artery dissection: a report of five cases.

Five cases of spontaneous coronary artery dissection (SCAD) are reported, three in women and two in men (mean age 44 years; range 28-65), all of whom suffered a myocardial infarction. Common risk factors for coronary artery disease were present in the two men; in the female group one patient was taking an oral contraceptive, one was in the postpartum period, and the third was a smoker. Only the three women received intravenous alteplase and their ejection fraction was normal; both men had impaired left ventricular function. Two patients had SCAD of the left anterior descending coronary artery and three of the right coronary artery. Only the two men had angiographic features of coronary atherosclerotic involvement. No patients required surgical revascularisation or percutaneous transluminal coronary angioplasty. At a mean follow up of 27 months (range 6 to 40) all patients were alive and all but one were asymptomatic.

[Peripartum cardiomyopathy: clinical, echocardiographic and biopsy aspects]. / Cardiomiopatia peripartum. Aspetti clinici, ecocardiografici e bioptici.

In order to characterize the features of peripartum cardiomyopathy, clinical, echocardiographic and right ventricular endomyocardial bioptic data obtained from 6 patients (pts) (age range: 34.1 +/- 5.5. yrs) who fulfilled peripartum cardiomyopathy diagnostic criteria, were analyzed. Five of these pts had clinical and non-invasive studies for a mean period of 41.6 +/- 59.6 months. All but one were multiparous. Five developed heart failure one month before delivery. Three patients had active myocarditis at endomyocardial biopsy and were treated with immunosuppressive therapy. At follow-up, 3 pts improved by two or three grades of the NYHA functional classification. All 3 showed a reduction in the left ventricular end diastolic diameter (from 3.9 +/- 0.4 to 3.4 +/- 0.3 cm/m2) and a normalization of the shortening fraction in 2 (from 15 to 36% and from 13 to 46% respectively) at echocardiography. These two patients had active myocarditis at the first endomyocardial biopsy. At follow-up, all 3 pts with active myocarditis showed histological evidence of healed myocarditis. In conclusion, peripartum cardiomyopathy is characterized by a high incidence of active myocarditis and improvement seems more frequent in this subgroup of pts.

[Post-infarct rupture of the interventricular septum. 2-dimensional, continuous Doppler, pulsed and color-coded echocardiographic evaluation]. / Rottura post-infartuale del setto interventricolare. Valutazione ecocardiografica bidimensionale, Doppler continuo, pulsato e con codice di colori.

Rupture of the interventricular septum is an infrequent but always serious complication of acute myocardial infarction. It requires accurate timely diagnosis to decide the proper treatment and eventual surgical intervention. Echo-color-Doppler-cardiography appears to have such diagnostic capacities. In a total of 403 pts, with acute myocardial infarction we found 7 pts (1.7%) with suspected interventricular septum rupture; 5 with infero-posterior infarction and 2 with an anterior one. In 4 pts shock and death occurred rapidly, 2 pts were submitted to angiography and then to surgery with a good outcome, 1 pt died immediately after surgical repair. Echocardiographic findings were: 1) by 2-D (7 pts), direct visualization of septal rupture in 5/7, all with infero-posterior infarctions; 2) by pulsed wave Doppler (5 pts), detection of a typical systolic turbulence on the right septum in 5/5 pts, 3 with infero-posterior myocardial infarction, 2 with an anterior one; 3) by color Doppler (3 pts), detection of a "mosaic" color-jet expanding into the right ventricle in 3/3 pts, 2 with an anterior and 1 with an infero-posterior myocardial infarction. This technique immediately located two small ruptures which had not been easily detected by pulsed Doppler alone. In conclusion, echocolordopplercardiography appears to be a reliable method for the detection of ventricular septal rupture after myocardial infarction in so timely and accurately a manner as to rule out more aggressive procedures, angiography and surgery.