Aspirin challenge/desensitisation before coronary stenting in subjects with history of hypersensitivity. A pragmatic approach.

BACKGROUND: Aspirin hypersensitivity may represent a major problem in patients with ischemic coronary disease who need a stenting procedure. In those patients, clinically unsettled reasonably quick desensitisation procedures are needed. In our study we attempted to select the most suitable procedure on the basis of characteristics and severity of ASA hypersensitivity. METHODS: Thirty patients with a history of mild reactions to anti-inflammatory doses of aspirin (> 325 mg) were considered at low risk and underwent a tolerance test in 5 steps. Thirty-one patients, with a history of severe reactions to anti-platelet doses of aspirin 0 mg) underwent a slow desensitisation in 12 steps, reaching a cumulative dose of 150 mg ASA in 220 minutes. RESULTS: In the first group, 29 patients tolerated the challenge. One developed urticaria, thus underwent challenge/desensitisation and achieved tolerance. In the second group, 3 patients did not tolerate the procedure and had to discontinue. CONCLUSION. Our approach to aspirin hypersensitivity in patients needing coronary stenting, based on a severity stratification, allowed to achieve an effective tolerance to aspirin in the majority of subject in a reasonable short time.

Coronary stenting for ST-elevation myocardial infarction vs. other indications in patients on oral anticoagulation: any difference in in-hospital management and outcome?

AIM: The aim of this paper was to compare the in-hospital management and outcome of patients on oral anticoagulation (OAC) undergoing coronary artery stenting (PCI-S) for ST-elevation myocardial infarction (STEMI) vs. other indications. METHODS: One hundred and sixteen patients on OAC at the time of PCI-S who were prospectively enrolled in a multi-center, observational registry, were evaluated. Patients were segregated according to whether PCI-S was performed for STEMI (group 1) or other indications, such as non ST-elevation acute coronary syndromes, stable angina, silent ischemia, etc. (group 2), and the pharmacological and procedural management, as well as the in-hospital outcome, were compared. RESULTS: No significant differences were observed in vascular access site, sheath size and type of stent implanted, nor was significantly different the use of glycoprotein IIb/IIIa inhibitors, and the use and dose of intravenous unfractionated heparin. Although not statistically different, the in-hospital occurrence of death (3.7% vs. 1.1%; OR 3.3; 95% confidence intervals [CI] 0.2-56.0), stent thrombosis (3.7% vs. 1.1%; OR 3.3; 95% CI 0.2-56.0) and major bleeding (7.4% vs. 2.2%; OR 3.4; 95% CI 0.4-25.9) was consistently about 3-fold higher in group 1. CONCLUSION: The in-hospital pharmacological and procedural management of OAC patients undergoing PCI-S for STEMI vs. other indications appears not different. Although not significantly different however, the in-hospital occurrence of major bleeding, as well as of death and stent thrombosis, appears substantially higher in patients treated for STEMI, warranting therefore further larger, prospective studies.

[Severe mitral insufficiency caused by the rupture of the chordae tendinae in acromegaly. Report of a case]. / Insufficienza mitralica severa da rottura di corda tendinea in acromegalia. Descrizione di un caso.

Cardiovascular disease is a common finding in patients with acromegaly. In such patients, heart failure frequently leads to death. Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. Because it is not clear whether acromegaly-related cardiomyopathy is a specific entity and since there are not many necropsy reports regarding mitral valve prolapse in acromegalic patients, we report the case of severe mitral regurgitation due to rupture of the chordae tendinae in a patient with mitral valve prolapse and acromegaly.

Long-term follow-up of stent implantation versus stent-like angioplasty in unstable angina.

Stent-like plain old balloon angioplasty (POBA, < or = 30% residual diameter stenosis) in patients with stable angina resulted in a clinical and angiographic long-term outcome equivalent to stenting. In unstable angina POBA showed lower acute and long-term efficacy than in the stable setting. Data comparing stent-like POBA and coronary stenting in unstable angina are lacking in the literature. The aim of this retrospective single-center study was to compare the long-term effectiveness of stent-like POBA and coronary stenting in unstable angina. From January 1996 to December 1996 we retrospectively examined 187 consecutive patients with unstable angina who underwent coronary angioplasty on a native vessel: 135 had coronary stenting in addition to POBA and 50 achieved a stent-like result with POBA. Two patients, with major contraindication to coronary stenting, who did not reach a stent-like angiographic result, were also treated with only POBA but were excluded from the study. Stent implantation indications were: elective (54 stents, 30%), suboptimal angiographic result (104 stents, 58%), and bail-out situation (21 stents, 12%). Stent implantation showed high angiographic (98.5%) and clinical (95.5%) success. Stent thrombosis occurred only in 2 patients (1.5%). At quantitative coronary angiography the stent group showed a higher post-procedure minimal lumen diameter (2.74 +/- 1.25 vs 2.27 +/- 0.58 mm, p = 0.025), acute gain (1.95 +/- 1.28 vs 1.43 +/- 0.57 mm, p = 0.007) and lower residual stenosis diameter (13.89 +/- 7.43 vs 20.4 +/- 7.28%, p = 0.001) than the stent-like POBA group. At 1-year follow-up the stent group showed a higher event-free survival rate (77.9 vs 64.6%, p = 0.009) mainly due to lower recurrence of angina and repetition of percutaneous procedures. Stent-like POBA procedure and baseline lesion length > or = 10 mm proved to be the only independent predictors of long-term ischemic event occurrence. In conclusion, in unstable angina, stent implantation appears more effective than stent-like POBA to avoid long-term ischemic complications.

Coronary stenting for unstable angina: predictors of 30-day and long-term clinical outcome.

BACKGROUND: Unstable angina is usually caused by acute thrombosis superimposed on a fissured plaque. Coronary artery stenting has been shown to improve short- and long-term results of coronary angioplasty in mainly stable patients with one-vessel disease, but it is uncertain whether its use in an unstable clinical setting can be safe and useful. This study sought to evaluate the results of coronary stenting in unstable angina and to determine patient, lesion and procedure-related predictors of 30-day and long-term ischemic events. METHODS: We studied 266 consecutive patients (mean age 62 +/- 9 years) with unstable angina who underwent coronary artery stenting. The procedure was performed electively in 24%, in bailout situations in 11% and for a suboptimal result of conventional angioplasty in 65%. After stent implantation, patients were treated with anticoagulation (61) on combined antiplatelet therapy (200). Multivariate logistic regression analyses were performed to determine 30-day and long-term predictive factors of ischemic complications. RESULTS: Procedural success was obtained in 261 patients (98.1%). During the first 30 days after stenting, one patient died from cardiogenic shock (0.3%) and six (22%) suffered a non-fatal Q-wave myocardial infarction. Patients with combined antiplatelet therapy had a significantly lower stent thrombosis rate (1.5% versus 11.4%, P = 0.002) than those treated with anticoagulant regimen. At long-term follow-up (17.7 +/- 9.4 months) cardiac mortality myocardial infarction and target-vessel revascularization rates were 0.4%, 1.5% and 9.3%, respectively. In multivessel and diabetic patients, a worse long-term event-free survival was observed. Logistic multivariate analysis revealed bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm as predictors of 30-day ischemic events. In addition, multivessel coronary artery disease and stent application with balloon size of less than 3 mm were predictive of long-term ischemic events. CONCLUSIONS: This study demonstrates that, either electively or after failure of conventional angioplasty, coronary stenting represents an effective therapy for patients with unstable angina. In the same clinical setting, combined antiplatelet therapy is associated with a lower 30-day stent thrombosis rate than anticoagulant therapy. Bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm were shown to be predictors of 30-day ischemic events, whereas multivessel coronary artery disease and stent application with small balloon size were predictive of long-term ischemic events.

Antithrombotic therapy after coronary stent placement.

Subacute stent thrombosis and hemorrhagic complications due to intensive anticoagulant therapy limit the clinical benefit of coronary stenting. Antithrombotic therapy after coronary stent placement has not been standardized yet. From January 1994 to December 1995 a total of 338 Palmaz-Schatz stents were implanted in 285 patients. Procedural success rate was 98.8%. In the initial period, after stent placement, patients were treated with acetylsalicylic acid (ASA) and warfarin (135 patients, Group A), while subsequently, according to the results of other studies, patients were treated with ASA plus ticlopidine (146 patients, Group B). Two hours after sheath removal, Group A patients were treated with intravenous heparin until therapeutic INR (2.5-3.5) was reached; warfarin was stopped 3 months later. In Group B patients 2 hours after sheath removal a treatment with subcutaneous heparin 25,000 IU/die plus ticlopidine 500 mg/die was started. Subcutaneous heparin was maintained until hospital discharge, ticlopidine was stopped after 1 month and ASA was maintained indefinitely. There were no significant differences in baseline characteristics between the two groups. Most patients had unstable angina and in the majority of cases the stent was implanted due to intimal dissection after balloon dilation. Eleven patients had subacute thrombosis of the stent (3.9%): 9 patients were in Group A (6%) and 2 patients were in Group B (1.3%; p = 0.04). Seven patients (6 in Group A, 1 in Group B) were treated with emergency coronary angioplasty and 3 (2 in Group A, 1 in Group B) with coronary bypass; nevertheless 7 patients (6 in Group A, 1 in Group B) had an acute myocardial infarction. Eight patients (6 in Group A, 2 in Group B) had major bleeding due to a large groin hematoma requiring blood transfusion or vascular surgery. In conclusion, after coronary stenting antithrombotic therapy with ASA plus ticlopidine, as compared with anticoagulant therapy, reduces the incidence of both cardiac events and hemorrhagic complications.

Coronary stenting with the half (disarticulated) Palmaz-Schatz stent: immediate results and six-month follow-up.

Coronary stenting with the half disarticulated Palmaz-Schatz stent is particularly suitable for ostial stenoses, diaphragm stenoses, stenoses distal to tortuous segments or coronary bends and localized dissections after balloon angioplasty. Nevertheless very few data regarding the half stent exist and follow-up data are nonexistent. From January of 1994 to December of 1995 a total of 207 half stents were implanted in 175 patients. Most patients had stable or unstable angina and in the majority of cases the stent was implanted due to localized dissection or to suboptimal result. The procedural success rate was 98%. After stent implantation, 82 patients were treated with acetylsalicylic acid (ASA) and oral anticoagulant (group A), whereas 93 were treated with ASA and ticlopidine (group B). Seven patients had subacute thrombosis (5, group A; 2, group B), and six patients had major bleeding (5, group A; 1, group B). Overall, patients in group A had more cardiovascular complications than patients in group B (10, group A; 3, group B; p = 0.047). After 6-mo follow-up, 1 patient had died and 27 patients had symptoms of angina (16%). Thirteen patients underwent a second PTCA (7%) and four patients (2%) were referred for coronary artery bypass. In conclusion, coronary stenting with half Palmaz-Schatz stent appears to be a safe and effective procedure. In selected cases, the half Palmaz-Schatz stent is easier to handle than the complete stent, it is associated with a low rate of clinical restenosis, and it lowers procedural costs.

Results of coronary stenting for unstable versus stable angina pectoris.

Coronary artery stenting has been shown to improve the short- and long-term results of coronary angioplasty in mainly stable patients with 1-vessel disease, but it is uncertain whether its use in an unstable clinical setting may be safe and useful. To evaluate the stenting efficacy in patients with unstable angina, we retrospectively examined our experience with the Palmaz-Schatz balloon expandable stent in 231 consecutive patients. Patients were divided into 2 groups on the basis of symptoms at the time of stent implantation: group U (132 patients) had unstable angina, and group S (99 patients) had stable angina. After stent insertion, patients were treated with anticoagulant or combined antiplatelet therapy. Baseline characteristics of the 2 groups were comparable with the exception of age (higher in the unstable group) and angiographic characteristics of the target lesions (more unfavorable in unstable patients). In both groups, coronary stenting presented a high procedural success rate. Major in-hospital complications occurred in 9 unstable (6.8%) and in 2 stable (2%) patients (p = NS) and were mainly related to subacute stent thrombosis. In both groups, subacute stent thrombosis mostly occurred in patients treated with anticoagulant therapy (7 of 9 unstable patients, 2 of 2 stable patients). At 6-month follow-up, unstable and stable patients had a similar incidence of death (0%), Q-wave myocardial infarction (0%), and need of coronary artery bypass graft (3.2% vs 4%, p = NS), but coronary angioplasty repetition (4.8% vs 14%, p = 0.027) and target vessel revascularization (6.3% vs 17%, p = 0.019) rates were lower in the unstable group. In conclusion, stent insertion increases the short- and midterm coronary angioplasty effectiveness in unstable angina, making it possible to achieve outcomes quite comparable to stable angina. Compared with conventional anticoagulant regimen, combined antiplatelet therapy after placement of coronary stents seems to reduce the incidence of subacute thrombosis also in this clinical setting.

[Implanting of coronary stents in patients with unstable angina]. / L'impianto dello stent coronarico nei pazienti con angina instabile.

In the present study, we retrospectively examined our experience with the Palmaz-Schatz stent in patients with unstable angina to determine: a) different outcomes between patients with stable and unstable angina, b) correlation between the class of unstable angina and 1-month and 6-month results, c) correlation between lesion morphology and procedural complications. From January 1994 to January 1996, 160 patients with unstable angina (Group A) and 104 with stable angina (Group B) underwent coronary stenting. According to the modified Braunwald classification patients with unstable angina were divided into four classes. Lesion morphology was classified in simple and complex. Procedural success was 98% in Group A patients and 99% in Group B patients. We observed 9 (5.6%) major complications in Group A vs 2 (1.9%) in Group B. Subacute thrombosis occurred in 9 patients in Group A and in 2 patients in Group B and these different rates were responsible for the higher number of acute myocardial infarction and urgent revascularization procedures in Group A patients. At 6-month follow-up there were no differences between Group A and Group B patients. Patients in different classes of angina showed a similar cardiac event rate at 1-month and 6-month follow-up. We found 108 complex lesions in patients with unstable angina vs 20 in patients with stable angina (p = 0.0001). Among the 9 patients with unstable angina and subacute thrombosis, 6 had a complex lesion and 3 a simple lesion (NS). In conclusion, patients with unstable angina receiving intracoronary stent have similar clinical outcome at 1-month and 6-month follow-up as compared to patients with stable angina. The class of unstable angina and the complex morphology of the lesion are not related to procedural complications.

Intramural posttraumatic hematoma of the ascending aorta in a patient with a double aortic arch.

We report a case of posttraumatic intramural hematoma (IMH) of the ascending aorta in a patient with a double aortic arch and coronary artery disease. This unusual and asymptomatic finding came to our observation because the patient presented an acute myocardial infarction and underwent coronary angiography. The diagnosis was performed by magnetic resonance imaging (MRI) which defined well the anatomy of aorta and showed the characteristics of the hematoma. The data were useful in planning the surgical repair.

[Endocoronary stent: its use to improve suboptimal outcome of angioplasty]. / Stent endocoronarcio: l'utilizzo per migliorare i risultati subottimali dell' angioplastica.

BACKGROUND: This single-center report describes the results of unplanned coronary stenting for the treatment of suboptimal angiographic results after conventional coronary angioplasty (PTCA), Suboptimal results of PTCA were defined as: a) residual stenosis > or = 30% with TIMI flow 3; b) presence of coronary dissection < 15 mm with TIMI flow 3. PATIENTS: From January 1994 to December 1995, 213 patients with suboptimal result of PTCA underwent coronary stent implantation. RESULTS: Stenting resulted in a technical and angiographic success in 99.5% of patients. In-hospital complications involved acute myocardial infarction (2.3%), coronary artery bypass grafting (1.4%), re-PTCA (2.3%) and vascular complications at the puncture site (1.4%). No deaths occurred. The in-hospital complication rate was similar in the groups of patients stented for coronary dissection or residual stenosis > or = 30%. Instead, the combined antiplatelet treatment group showed lower rates of subacute stent thrombosis (0.8 vs 8.9%; p = 0.011) and major complications (1.6 vs 10%; p = 0.016) than the ASA-warfarin treatment group. At a six-month follow-up, clinical restenosis was detected in 9.5% of patients. Re-PTCA was performed in 7.1% of patients and elective coronary bypass grafting in 2.8%. No acute myocardial infarction occurred and one patient presented a non-cardiovascular death. At the end of the follow-up, only 5.2% of the patient were still symptomatic. CONCLUSIONS: The unplanned use of intracoronary stenting for the treatment of suboptimal result of PTCA improves the immediate angiographic result, reducing the procedural complication rate with good short- and long-term clinical results.

Dynamic planar myocardial perfusion imaging in patients with one-vessel disease with intracoronary injection of technetium 99m teboroxime during papaverine-induced coronary hyperemia.

This study examined the imaging results and kinetics of technetium 99m teboroxime after its intracoronary injection during papaverine-induced coronary hyperemia in patients with one-vessel disease before and after coronary angioplasty. Thirteen patients with > or = 90% diameter stenosis of either the left anterior descending or the left circumflex coronary artery were included. Two patients were excluded because of ventricular tachycardia during papaverine injection in one patient and unsuccessful angioplasty in the second patient. One mCi of technetium 99m teboroxime was injected into the left main coronary artery during coronary hyperemia induced by intracoronary injection of papaverine. Dynamic acquisition in a frame mode (20 sec/frame) was performed for 5 minutes in the left anterior oblique projection with a multicrystal gamma camera before and after successful angioplasty. Ischemic:normal count ratio increased from 0.75 +/- 0.4 before to 1.00 +/- 0.50 after angioplasty (p < 0.1). The T 1/2 of teboroxime was 6.5 +/- 1.5 min in the normal zone and 7.2 +/- 1.9 min in the ischemic zone (p, NS). Perfusion defects were visible in the territory of the stenosed coronary artery in 9 of 11 patients before angioplasty and in 7 of 11 patients after angioplasty. The image quality was excellent in all studies. Thus this study shows that performing dynamic imaging with intracoronary injection of technetium 99m teboroxime is feasible. This technique may be useful to study the impact of angioplasty on coronary flow and tracer kinetics.

[Valvular lesions in the course of nonpenetrating thoracic trauma: their diagnosis by transesophageal echocardiography]. / Lesioni valvolari in corso di trauma toracico non penetrante: diagnosi mediante ecocardiografia transesofagea.

Two cases are reported with nonpenetrating chest trauma and involvement of mitral valve in one case and aortic valve cusps in the other, without aortic rupture. In both patients transesophageal echocardiography allowed us an accurate diagnosis, confirmed by surgical findings. In the patient with involvement of the aortic cusps, the regurgitation developed 3 months after the trauma. In conclusion, cardiac valve injuries are rare but not exceptional following nonpenetrating blunt chest trauma. Transesophageal echocardiography is the imaging technique of choice for these patients. The operator performing the study must be aware of the possible coexistence of different cardiac lesions secondary to blunt chest trauma. In the case of valvular regurgitation the accurate definition of the pathophysiological mechanism is mandatory in order to choose the appropriate surgical strategy. In the case of aortic incompetence of unknown origin, a nonpenetrating chest trauma must be searched out during the clinical interview.

[Percutaneous aortic valvuloplasty in the adult. When and why is now useful?]. / La valvuloplastica aortica percutanea nell'adulto. Quando e per chi è ancora utile?.

Percutaneous aortic valvuloplasty was introduced into clinical practice in 1986 and widely applied in elderly patients with symptomatic aortic stenosis. Nevertheless its results have been unsatisfactory over the mid to long term due to a high incidence of restenosis after 6-12 months. At the same time, patients over 70 years are more frequently undergoing surgical aortic valve replacement with low immediate postoperative mortality and good long term results. Although randomized trials are not available, aortic valve replacement seems to be a definitive therapeutic treatment when compared to the palliative result of aortic percutaneous valvuloplasty. However, since the complication rate of valvuloplasty carried out in cardiological centers with experienced personnel is low, this procedure is still indicated in selected patients. The very old (> 80 years) patients with associated systemic disease, and candidates for major surgery are referred for this procedure. Another indication for aortic valvuloplasty is severe aortic stenosis with cardiogenic shock; in this case, valve dilatation improves clinical status and acts as a "bridge" to surgery, enabling surgical intervention to be carried out at a later date. Nowadays, aortic percutaneous valvuloplasty is a possible alternative to surgical treatment in patients with an absolute surgical contraindication and in those who are in such poor clinical condition that they cannot be immediately referred to surgery. It is also useful for patients requiring urgent non-cardiac surgery (e.g., subjects with gastrointestinal bleeding). We discuss our results with this procedure which concord with those presented in the literature.

[Heart surgery with cardiopulmonary bypass in patients on chronic dialysis treatment: our experience]. / Interventi cardiochirurgici in circolazione extracorporea in pazienti in trattamento dialitico cronico: nostra esperienza.

METHODS: To determine the mortality and the morbidity of cardiac surgery in patients on chronic hemodialysis, we retrospectively reviewed eighteen adult patients (13 males and 5 females) with a mean age of 54.7 years (range: 30-67 years) who underwent cardiopulmonary bypass procedures between 1987 and 1995. The operations included: isolated coronary artery bypass grafting in 12 patients, coronary artery bypass grafting plus mitral ring annuloplasty in 1 patient, mitro aortic valve replacement in 2 patients, isolated aortic valve replacement in 1 patient, aortic valved conduit implantation in 1 patients and mitral valve replacement plus tricuspid annuloplasty in 1 patient. There were 10 and 3 patients in CCS functional classification III and IV respectively; 1 and 4 patients were in NYHA classification II and III respectively. All of them were hemodialyzed the day before surgery: the average time they had been on hemodialysis was 6.5 years. Anesthesia and the cardiopulmonary bypass (CPB) in these patients required attention in order to provide the optimal fluids and electrolytes balance: particularly intravenously administered fluids were kept to a minimum and drug dosages were reduced to recommended levels for anephric patients. An hemoconcentrator was used in all patients during the CPB and, in the last 4 cases, we used a dialysis filter and a sterilized perfusional solution to reduce the level of potassium and to put off postoperative dialysis. RESULTS: In three patients there were major bleeding problems resulting in reoperation; 5 perioperative deaths occurred: two of them due to myocardial infarction and three due to irreversible low cardiac output state. In our experience there were four late deaths: one patient died four months after surgery for chronic heart failure, another one died twelve months after surgery for dilated cardiomyopathy and two patients died respectively seventeen and seventy two months after discharge for myocardial infarction. Two of the remaining patients reported recurrence of angina while the others achieved symptomatic improvement. CONCLUSIONS: In conclusion, cardiac surgery is performed on chronic renal dialysis patients with high mortality and morbidity and it's indicated only if medical treatment is ineffective. The successful surgical results, obtained with an adequate management between surgeons, anesthesiologists and nephrologists, don't assure the long-term survival of the patients.

Intravascular Stenting in a Female Patient with Spontaneous Coronary Dissection and Von WillebrandÕs Disease.

We report a case of spontaneous coronary dissection occurring in a 46-year-old women affected by von WillebrandÕs disease presenting with anterior myocardial infarction. The patient was treated with thrombolytic therapy and stent implantation. We believe that in patients with single vessel spontaneous coronary dissection and unstable clinical condition, coronary stenting may provide an alternative treatment in place of coronary surgery.

[Brucella endocarditis: role of drug treatment associated with surgery]. / Endocardite da brucella: ruolo del trattamento medico associato a quello chirurgico.

Brucella infective endocarditis is an uncommon, but serious complication of brucellosis. The aortic valve is the most commonly affected cardiac valve, and a fearful complication is the formation of aortic root abscess. Due to the characteristics of the infection, medical therapy alone is not sufficient in treating the disease and best results are achieved in combination with surgery. We describe 2 cases of brucella endocarditis involving the aortic valve. Aggressive treatment, with surgery performed during a period of active infection, produced good results in eradication of infection and in preventing fatal complications such as rupture of aortic root abscesses.

Cardiac injury as late toxicity of mediastinal radiation therapy for Hodgkin's disease patients.

BACKGROUND: During the last 20 years Hodgkin's disease (HD) has become one of the most curable neoplasms; in fact, more than 75-80% of patients are expected to achieve long-term relapse-free survival with appropriate therapy. However, overall survival has been affected by intercurrent or treatment-induced diseases such as the increased risk of cardiac toxicity in patients who received mediastinal irradiation. METHODS: The incidence of cardiac abnormalities after mediastinal radiotherapy was assessed in 102 consecutive HD patients who underwent this treatment from January 1970 to December 1980. Basal investigation procedures included electrocardiogram and echocardiography; myocardial perfusion scintigraphy with 201-thallium and coronary arteriography were performed in selected patients. RESULTS: Eleven patients (10.8%) presented cardiac abnormalities, which were asymptomatic in three cases. Eight cases of myocardial ischemia and 3 of constrictive pericarditis were observed. The incidence of late cardiotoxic effects was related to total mediastinal dose and to the irradiation technique. CONCLUSIONS: The increasing duration of follow-up shows that as mediastinal irradiation increases so does the risk of late cardiotoxic side effects. For this reason, a proper treatment strategy should reduce these risk factors through new combined modality protocols and routine evaluation of cardiologic follow-up.