[The induction of ventricular fibrillation by transesophageal pacing in subjects with atrial flutter and compromised left ventricular functioning]. / Induzione di fibrillazione ventricolare tramite pacing transesofageo in soggetti con flutter atriale e funzionalità ventricolare sinistra compromessa.

In patients with depressed left ventricular function, the normal precautions during transesophageal atrial pacing may not be sufficient to prevent life threatening arrhythmias. In this article two cases of ventricular fibrillation induced during this technique, aimed at treating atrial flutter, are described.

[Usefulness of temporal bicameral stimulation in the interruption of refractory ventricular tachycardia]. / Utilità della stimolazione bicamerale temporanea nella interruzione delle tachicardie ventricolari refrattarie.

The occurrence of sustained ventricular tachycardia with worsening hemodynamic performance in patients with ischemic heart disease can represent a critical event when the arrhythmia, refractory to antiarrhythmic drugs, recurs after D.C. shock. In this case temporary DDD pacing can be a reliable alternative treatment.

Invasive and echocardiographic evaluation of non-Q myocardial infarction with isolated stenosis of descending anterior coronary artery.

Prognostic and clinical characteristics of acute myocardial infarction (AMI) can usually justify surgical and/or angioplastic approach if the residual ventricular function is still good. Multivessel disease frequently complicates results interpretation. We studied with 2D echocardiography and coronary angiography two groups of patients with one vessel stenosis located on anterior descending (AD) and previous AMI (means 19 days): 23 patients with spontaneous non-Q infarction (group 1), and 23 patients with Q infarction. Left ventricular function was better in group 1. Percent occlusion of AD was lower in group 1 and angiographic AD caliber was significantly higher. Differences between groups were much more evident in subgroups with proximal stenosis of AD: patients of non-Q subgroups had very good left ventricular function but frequently had post-AMI instable angina (88%). Our results underline the usefulness of aggressive diagnostic and therapeutic approach in non-Q AMI, because of higher amount of myocardium at risk.

[The acute, chronic continuous after treatment and chronic intermittent with a variable therapeutic window (4 and 6 hours) hemodynamic effects induced with transdermal nitroglycerin in patients with congestive heart failure]. / Effetti emodinamici acuti e dopo trattamento cronico continuo, cronico intermittente con finestra terapeutica variabile (4 e 6 ore) indotti dalla nitroglicerina transdermica, in pazienti con insufficienza cardiaca congestizia.

The aim of this study was to assess the minimum time interval necessary to avoid the development of tolerance during nitroglycerin patch application. We studied 24 patients, aged 23 to 73 years, with ischemic or idiopathic dilated cardiomyopathy (LV EF less than 0.40) and stable clinical conditions during 30 days before the study. All patients had significant reduction of systemic and pulmonary arterial pressure after sublingual nitroglycerin. After the hemodynamic assessment of the response to the first dose of the nitroglycerin patch, the patients were randomized to 1 of 3 chronic treatment groups: continuous patch application (Group A), intermittent application with 4 hours intervals (Group B), intermittent application with 6 hours intervals (Group C). All patients were studied by right heart Swan-Ganz catheterization; the hemodynamic response to a 10 mg multilayer matrix nitroglycerin patch was assessed before and every hour, in the next 4 hours, after both the first application of the patch and after 1 month of therapy; after chronic intermittent therapy, hemodynamic parameters were also measured 24 hours after drug withdrawal. Hemodynamic parameters were significantly changed after the first nitroglycerin patch application: particularly, mean systemic arterial (MAP), right atrial (RAP) and pulmonary wedge pressures (PWP) declined from 96 +/- 10, 8.9 +/- 1.8 and 20.1 +/- 5 to 81 +/- 6, 4.7 +/- 1.5 and 12.2 +/- 3 mmHg (-15.6, -47.2 and -59.3%, respectively); systemic vascular resistance (SVR) and heart rate (HR) were reduced from 1645 +/- 121 to 1288 +/- 89 dyne.s.cm-5 and from 85 +/- 7 to 81 +/- 7 b/min; lastly, cardiac index (CI), stroke volume (SVI) and stroke work index (SWI) increased from 2.3 +/- 0.3, 28.2 +/- 5 and 28.7 +/- 9 to 2.7 +/- 0.3 l/min/m2, 33.3 +/- 5 ml/min/m2 and 31.5 +/- 8 g.m/m2 (+17.4, 18.1 and 9.7%). After 1 month of either continuous or intermittent patch application with 4 hours intervals, hemodynamic parameters returned to control values with no significant change after patch application. In contrast, after intermittent patch application with 6 hours intervals, a persistent hemodynamic response to nitroglycerin patches was still present.(ABSTRACT TRUNCATED AT 400 WORDS)

[Echocardiographic and cardioangiographic evaluation of non-Q infarction with isolated stenosis of the anterior descending artery]. / Valutazione ecocardiografica e cardioangiografica dell'infarto non Q con stenosi isolata dell'arteria discendente anteriore.

We studied with two-dimensional echocardiography and coronary angiography 2 groups of patients with one-vessel stenosis located on anterior descending (IVA) and previous acute myocardial infarction (AMI; means 19 days): 23 patients with spontaneous non-Q infarction (Group I), and 23 patients with Q infarction (Group II). Left ventricular function was better in Group I (echo score: 2.04 +/- 2.64, angiographic ejection fraction: 65.65 +/- 9.7 in Group I, echo score: 4.78 +/- 3.14, angiographic ejection fraction: 49.47 +/- 9.1 in Group II, p less than 0.001). Percent occlusion of IVA was lower in Group I and angiographic IVA caliper was significantly higher (p less than 0.05). Differences between groups were much more evident in subgroups with proximal stenosis of IVA: patients of non-Q subgroup had very good left ventricular function but frequently had post-IMA unstable angina (78%). Our results underline usefulness of aggressive diagnostic and therapeutic approach in non-Q AMI, because of higher amount of myocardial a risk.

[ST segment depression in precordial leads in patients with inferior acute myocardial infarction: the role of right ventricular involvement]. / Sottoslivellamento anteriore del tratto ST in pazienti con infarto miocardico inferiore acuto: influenza del coinvolgimento ventricolare destro.

The aim of the present study was to evaluate the influence of right ventricular involvement on the magnitude of precordial ST segment depression during inferior acute myocardial infarction. For this reason 61 patients (55 M, 6 F; mean age 53 years--range 38-73 years) admitted in our CCU for inferior acute myocardial infarction were studied by coronary angiography within 3-5 days from the onset of symptoms. The angiography showed either occlusion or critical coronary stenosis ranging as follows: on right coronary artery proximal (Group 1) to the first branch for right ventricle in 22 patients, on right coronary artery distal to the first branch for right ventricle in 25 patients (Group 2) and on circumflex artery (Group 3) in 14 patients. No difference in LAD disease were noted between the 3 groups. Using myocardial scintigraphy (Tc-99m- pyrophosphate) we confirmed the presence or the absence of right ventricular involvement in the 3 groups. In the 3 groups the magnitude of ST segment depression in V2, selected as representative left-sided precordial lead, ranged as follows: Group 1: -0.25 +/- 1.34 mm; Group 2: -1.64 +/- 1.80 mm; Group 3: -2.00 +/- 1.97 mm. In patients with right ventricular involvement (Group 1) there was a statistically significant reduction of precordial ST segment depression either in comparison to Group 2 (p less than 0.01) or to Group 3 (p less than 0.005) but none between Group 3 and 2. (ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of the intravenous administration of captopril in patients with chronic congestive heart failure]. / Effetti emodinamici della somministrazione endovenosa di captopril in pazienti affetti da scompenso cardiaco congestizio cronico.

The aim of the present study was to evaluate the hemodynamic response to the intravenous administration of the angiotensin converting enzyme-inhibitor captopril. Plasmatic renin activity was also monitored. The study population included 10 patients with chronic congestive heart failure: 3 were in the second NYHA functional class, 5 in the third, and 2 in the fourth. The patients received a first dose of 5 mg of captopril followed, after 10 min, by a second bolus-dose of 15 mg. Hemodynamic and hormonal measurements were repeated in the following 4 hours. The greatest hemodynamic effect, considered as the time of maximal mean arterial pressure and systemic vascular resistances decrease, and cardiac index increase, was noted 20 min after the first bolus dose administration. Mean arterial pressure (MAP) decreased by 13% (p less than 0.01), mean pulmonary artery pressure (MPAP) by 14% (p less than 0.05), right atrial pressure (RAP) by 30% (NS), wedge pressure (WPP) by 23% (p less than 0.01), systemic vascular resistances (SVR) by 21% (p less than 0.05), pulmonary vascular resistances by 22% (NS); cardiac index (CI) increased by 12% (p less than 0.05), stroke volume index by 10% (NS). Heart rate didn't change. The plasmatic renin activity (PRA) increased by 339% (p less than 0.01) reaching the maximal level in concomitance with the greatest hemodynamic effect. Hemodynamic changes were already noted 5 min after the first dose and lasted up to 75 min later.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of acute myocardial infarction by indium-111 antimyosin antibodies and correlation with the traditional techniques for the evaluation of extent and localization.

This clinical study evaluated the accuracy of planar myocardial scintigraphy with antimyosin monoclonal antibodies radiolabeled with indium-111 (AMA-Fab) in the detection and localization of acute myocardial infarction (AMI). Fifty-seven patients admitted for suspected AMI were studied; 17 patients underwent thrombolytic therapy with intravenous streptokinase and 11 had clinical signs of reperfusion; 9 had had a previous myocardial infarction. Fifty of 57 patients were discharged from the coronary care unit with a confirmed diagnosis of AMI. The AMA-Fab study results were positive for AMI in 49 patients (98%) and negative in 1 (2%). Among the 7 patients without AMI, 5 had unstable angina, 1 had Prinzmetal's variant angina and 1 had acute pancreatitis. AMA-Fab results were negative in 6 of 7 patients (85%) and positive in 1 (15%). Therefore, the sensitivity and specificity of AMA-Fab scintigraphy were 0.98 and 0.85, respectively. To assess accuracy in defining the extent and location of AMI, AMA-Fab results were compared with those of the electrocardiogram, echocardiogram, technetium-99m pyrophosphate myocardial scintigraphy and coronary angiography and left ventriculography. AMA-Fab scintigraphy showed a good concordance with the traditional techniques in the topographic definition of the infarcted regions. No uptake of AMA-Fab was seen in the regions of previous old infarcts. Ten healthy volunteers also underwent AMA-Fab scintigraphy. No evidence of myocardial tracer uptake was noted in them. No adverse reactions or side effects were noted after injection of AMA-Fab in any patient. It is concluded that planar myocardial scintigraphy with AMA-Fab is a reliable method for AMI detection and location.

[Thromboembolus migrating into the right heart in pulmonary embolism. Echocardiographic and clinico-therapeutic aspects in 7 cases and review of the literature]. / Tromboembolo migrante nelle cavità cardiache destre in corso di embolia polmonare. Aspetti ecocardiografici e clinico-terapeutici su 7 casi e revisione della letteratura.

We report the clinical, echocardiographic and therapeutic aspects and the evolution of 7 cases of right cardiac migrant thromboembolus in pulmonary embolism (5 M and 2 F, aged 43 to 91). Our data are also compared with all the cases reported in the literature (77 patients). During a sample year (1987) we systematically performed two-dimensional echocardiograms (2D Echo) as early as possible in all the patients admitted to our Coronary Care Unit for suspected pulmonary embolism; among 42 patients the diagnosis of pulmonary embolism was confirmed in 30 out of 42 patients. A relatively high incidence of thromboembolus was found (5/30, 17% in 1987); this finding seems to be relative to the early execution of the 2D Echo study (thromboembolus was found in 4/5 patients when 2D Echo was performed within 20 hours and in only 1/23 when 2D Echo was performed later). The 2D Echo was always evocative of freely floating migrant thromboembolus (6 in right atrium, 1 in right ventricle) and no differential diagnosis with thrombi in situ or other masses was necessary. The therapy for 6 patients hospitalized for pulmonary embolism and surviving the first hours (1 patient died immediately) was: surgical in 1 case, medical in the other 5. Medical therapy consisted only of heparin-calcium in one patient and heparin-calcium + dipyridamole in another because of contra-indications for more aggressive therapy. One patient underwent anticoagulant therapy with i.v. heparin. The remaining two underwent fibrinolytic therapy with urokinase and, afterwards, anticoagulant therapy: in 1 case the therapy was started after the embolization of the mass in the pulmonary artery had occurred; in the other one we observed the progressive reduction of thromboembolus until its disappearance within 5 days without any signs of further embolization. All patients survived and were discharged within 25 days, despite the occurrence of lung embolization in 4 of them. The review of 77 cases reported in the literature shows good outcomes for embolectomy when compared with medical therapy, but almost half of the patients underwent surgical therapy directly. Medical therapy experience, particularly with thrombolytic agents (10 cases in all), is still too scarce to exclude its role, as indeed our experience seems to indicate.

[Coronary angiographic study of patients with non-Q myocardial infarct: correlations with the initial electrocardiographic aspect and prognosis]. / Studio coronarografico nei pazienti con infarto miocardico non-Q: correlazioni con l'aspetto elettrocardiografico iniziale e la prognosi.

The purpose of our study was to evaluate, during the early phase, the coronary anatomy of the patients who suffered from an acute non-Q myocardial infarction (non-Q MI) and to correlate it with the ECG findings and with clinical evolution. We studied 76 patients (pts.), mean age 56 +/- 9 years, who had their a first non-Q MI (reinfarctions non included). They all underwent angiographic examination within an average period of 18 days (range 5-30 days). In the whole group of patients it is worthwhile noting: A) the elevated occurrence of left main lesions (11% of pts.) and multivessel disease (60%); B) the great percentage (41%) of patients with open infarct-related vessel but with very critical residual stenosis (above 90% of total lumen); C) the presence of collateral vessels in almost all the pts. (91%) with totally occluded infarct-related artery. During the 12 month follow-up, in all groups was a high occurrence (above 70%) of coronary events (postinfarction angina, reinfarction, aortocoronary by pass or PTCA). Furthermore, it is possible to identify a subgroup of patients presenting ST-segment depression with very unfavourable coronary anatomy (80% had multivessel disease, 30% of which had a left main critical stenosis) and high prognostic risk (90% occurrence of coronary events). In the subgroup with ST-segment elevation there was an elevated percentage (65%) of open infarct-related vessel, but with an important residual stenosis. Considering the advantages of revascularization interventions in these high risk patients with extensive residual jeopardized myocardium, we conclude that it is important that all patients with non-Q MI undergo early coronary angiography.

[Incidence and clinical significance of involvement of the right ventricle in acute inferior myocardial infarction]. / Frequenza e significato clinico del coinvolgimento del ventricolo destro in corso di infarto miocardico acuto inferiore.

UNLABELLED: The purpose of our study was to evaluate, with noninvasive procedures, the incidence and the clinical picture of right ventricular involvement in patients with acute transmural inferior myocardial infarction. Our study group was constituted of 107 consecutive patients admitted to our Coronary Care Unit within 10 hours from the onset of symptoms; in every patient a standard 12-leads ECG and the precordial leads V3R and V4R were obtained at admission in CCU and then every 12 hours. 80 patients underwent B-mode echocardiographic evaluation within 36 hours and in 93 patients a myocardial scintigraphy was performed, between the 48th and 72nd hour from the onset of chest pain, 1-2 hours after injection of Tc-99m-pyrophosphate. RESULTS: 45 patients (42.1%) had ECG positive for right ventricular infarction, 49 patients (51.6%) had positive Tc-99m-pyrophosphate scintigraphy and 24 patients (30%) positive echocardiography. By using the positivity of ECG and another method at least, patients were separated into 2 groups: group A (associated inferior and right infarction) was constituted of 45 patients, and group B (isolated inferior infarction) was constituted of 62 patients. In group A we noted a higher incidence of hypotension (systolic blood pressure less than 100 mmHg) and oliguria (less than 30 ml/h)- p less than 0.01-, of 2nd and 3rd A-V blocks-p less than 0.001- and primary ventricular fibrillation -p less than 0.01. The incidence of parossistic atrial fibrillation, severe bradycardia or SA blocks and of mortality was not statistically different between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum enzymes in acute myocardial infarction after intracoronary thrombolysis.

Serum kinetics of total creatine kinase (CK), CK-MB isoenzyme, aspartate aminotransferase (AST), lactate dehydrogenase (LD) and alpha-hydroxybutyrate dehydrogenase (HBD) activities were studied in twenty patients with acute myocardial infarction randomly assigned to receive either intracoronary urokinase (group A) or conventional (control) therapy (group B). The temporal characteristics of enzyme changes described were the time lag from onset of chest pain until maximum catalytic concentration value, the rate at which enzymes are released into blood, the peak value of the serum enzyme curves and (d) the fractional disappearance rate (Kd) for each enzyme considered. Thrombolytic treatment induced earlier peak times in group A: for CK, 10.8 vs 27.0 h, for CK-MB, 10.4 vs 23.1, for AST, 13.9 vs 31.3, for LD, 24.4 vs 49.1, and for HBD, 20.5 vs 48.5 (for all enzymes, p less than 0.001). The maximal rate of release for the enzymes was at least twofold greater in group A. Enzyme peak activities and Kd were not significantly different between the groups. The most significant discrimination between the two groups was obtained with AST peak time (Hartz overlap index (Oi) = 0.11) and CK-MB peak time (Oi = 0.12).