Minimal influence of traditional surgical risk factors on mortality in contemporary aortic valve replacement.

AIM: Transcatheter aortic valve implantation is increasingly presented as an alternative to aortic valve replacement in the high risk surgical candidate. We review the outcomes of isolated aortic valve replacement to identify contemporary results of aortic valve replacement in such high risk patients. METHODS: Retrospective analysis of 846 patients (mean age 68.7 ± 11.8 years) who underwent aortic valve replacement in a single institution from 1999 to 2008. We considered 10 risk factors as follows: female gender (395 patients, 46.7%), age, left ventricular ejection fraction, New York Heart Association Class, preoperative creatinine clearance, body mass index, peripheral vascular disease (49 patients, 5%), cerebrovascular disease (42 patients, 4.9%), chronic obstructive pulmonary disease (87 patients,10.2%), and redo surgery (53 patients, 6.2%). RESULTS: Twenty-five patients died (2.9%). Age (P=0.032; OR 1.07 per each year increase) was the only significant independent predictor of mortality. Length of stay in the hospital was correlated with age (P<0.0001), New York Heart Association Class (P<0.0001) creatinine clearance (P=0.005) and redo surgery (P=0.006). CONCLUSION: Contemporary aortic valve replacement is a low risk procedure for most patients. Historical risk factors which have been used to define high risk and inoperability, such as pulmonary disease, reoperations, decreased left ventricular ejection fraction and vascular disease, may not be relevant in the current era. This observation should be considered if such criteria are used to define patients for transcatheter aortic valve implantation.

A ruptured right sinus of Valsalva diverticled aneurysm: echocardiographic diagnosis and surgical repair.

Aneurysms of sinus of Valsava (SV) are uncommon heart lesions resulting from either a congenital deficiency or an acquired degeneration of the aortic wall. Usually these lesions are asymptomatic and incidentally diagnosed by echocardiography. Therefore when rupture occurs, they might require a prompt surgical operation. We report the case of a 58-year-old man who suddenly developed chest pain. On physical examination a new finding of sistodyastolic murmur was detected. On two-dimensional echocardiography was evidenced an aneurysm of the right SV ruptured in the right atrium. The patient was submitted to urgent surgery. Surgical aneurysm exclusion was achieved through a double access either transaortic and trans-right atrium approach. The right SV was obliterated by suturing a dacron patch on the aortic site while complete exclusion of the aneurysm expanding in the right atrium, was acquired through the right atrium itself, by 5/0 continous prolene suture line. The postoperative course was uneventful and the patient was discharged on 6th postoperative day. Transesophageal echocardiography represent the gold standard technique to assess this disease and to plan the adequate surgical treatment. The management of an asymptomatic, non ruptured aneurysm is not clear, however surgery is advisable when the aneurysm is complicated by rupture with an acceptably low operative risk and good long-term outcome.

Impact of Closed-Loop Stimulation, overdrive pacing, DDDR pacing mode on atrial tachyarrhythmia burden in Brady-Tachy Syndrome. A randomized study.

AIMS: Atrial overdrive pacing algorithms increase Atrial Pacing Percentage (APP) to reduce Atrial Tachyarrhythmia (AT) recurrences in patients with Brady-Tachy Syndrome (BTS). This study aimed to compare AT burden and APP in BTS patients treated with conventional DDDR pacing, DDD+ overdrive or Closed-Loop Stimulation (CLS). METHODS AND RESULTS: One hundred and forty-nine BTS patients were included (72 male, mean age 74+/-9), who received a dual chamber pacemaker (Philos DR or Inos 2+CLS, Biotronik GmbH, Berlin, Germany) programmed in DDD at 70min(-1). At 1-month follow-up, DDDR, DDD+ or CLS algorithms were activated according to randomization. Follow-up visits for data collection were performed at 4 and 7 months. Non parametric statistical tests (Kruskal-Wallis H-test, Dunn test, Spearman coefficient) were used to analyse not-normally-distributed samples. At 7 months, AT burden was significantly lower in CLS group (20.3+/-63.1min/day, P<0.01) compared to DDDR (56.0+/-184.0min/day) and DDD+ group (63.1+/-113.8min/day). APP was higher in CLS (89.0+/-13.2%) and in DDD+ group (97.9+/-2.7%) than in DDDR group (71.1+/-26.7%, P<0.001). The correlation found between AT burden and APP was very weak: at 7-month follow-up the Spearman coefficient was -0.29 (P=NS) in CLS, -0.52 (P<0.01) in DDD+, -0.22 (P=NS) in DDDR. CONCLUSIONS: CLS pacing was associated with a significantly lower AT burden,compared to the other pacing algorithms. Moreover APP was significantly higher in DDD+ and in CLS mode, than in DDDR. APP weakly correlated with AT burden only in DDD+ mode, though the lowest AT burden level was obtained in the CLS group where no significant correlation was found.

A semi-automatic algorithm for reducing the time spent on routine follow-up of cardioverter defibrillators.

BACKGROUND: The routine follow-up of cardioverter defibrillators (CD) is a time-consuming procedure. AIM of the STUDY and METHODS: The present study was a prospective randomized cross-over evaluation on the clinical usefulness of a specific semi-automatic software algorithm (Quick Check) for CD follow-up, available in CPI Guidant systems (CD and programmer). Time-saving, while ensuring all the required data and patient safety, was evaluated in a large group of patients (105), recruited in different centers. In the same session and under a physician's supervision all patients underwent a follow-up with the aid of Quick Check or a standard follow-up, in a randomized sequence. Each patient served as his own control. RESULTS: In the overall population of 105 patients, the time spent for follow-up was reduced by Quick Check from 186+/-105 sec to 106+/-67 sec (p<0.0001) (43% reduction). The reduction in time spent for follow-up with Quick Check was the same (43% reduction) in patients with detected episodes (n=38) (from 241+/-144 sec to 138+/-95 sec (p<0.0001)) and in patients without detected episodes (n=67) (from 154+/-52 sec to 88+/-34 sec (p<0. 0001)). No adverse events or deletion of potentially useful data was detected by the supervising physician. CONCLUSIONS: Use of a specific software algorithm for routine follow-up of implanted CDs allows a significant shortening of the time spent on routine follow-up, thus reducing costs. The supervision of a physician is a guarantee of patient safety.

[Treatment of recurrent supraventricular tachyarrhythmias with flecainide or a flecainide and amiodarone combination]. / Trattamento delle tachiaritmie sopraventricolari ricorrenti mediante flecainide o associazione di flecainide ed amiodarone.

The acute electrophysiologic effects and therapeutic efficacy of intravenous and oral flecainide were assessed in 18 patients with recurrent supraventricular tachyarrhythmias, resistant to conventional antiarrhythmic agents. They were 22 to 76 years old (mean 50). Twelve patients underwent electrophysiologic study for the investigation of tachyarrhythmias. Of the whole four patients had functional longitudinal AH dissociation (dual AV pathways). These patients had provocable intra-AV nodal reentrant tachycardia (Group I). Six patients had a direct accessory AV pathway, that showed bidirectional conduction in 5 and retrograde conduction alone in 1 (Group II). These patients had provocable atrioventricular reentrant tachycardia using the accessory pathway as the retrograde limb of the tachycardia circuit. Two patients suffered from automatic supraventricular tachycardia (Group III). Group IV included patients with paroxysmal atrial flutter or fibrillation. The patients of this group did not discontinue chronic treatment with amiodarone. After baseline electrophysiologic evaluation, intravenous flecainide (2 mg/Kg body weight over 5 minutes) was given to patients of I and II group during induced reentrant tachycardia. Flecainide was administered to other patients during spontaneous episodes of tachyarrhythmias. Flecainide resulted in tachycardia termination in all patients of group I and in 4 patients of group II (66%). Tachycardia termination was due to block in the retrograde limb of the circuit. Before termination tachycardia cycle length increased significantly, mainly as the result of an increase in ventriculo-atrial conduction time. After intravenous flecainide therapy, reentrant SVT was non inducible in the patients of group I and in 4 patients of group II. Flecainide was successful in the acute termination of 100% of automatic supraventricular tachycardia and 75% of fibrillation. The patients with atrial flutter developed a faster ventricular rate.(ABSTRACT TRUNCATED AT 250 WORDS)

[Infarct rupture of the heart. A clinical case operated on with success]. / Rottura infartuale del cuore. Caso clinico operato con successo.

A 48-year-old woman was admitted for acute myocardial infarction with a normal clinical course. On the fifth day a new chest pain occurred, with low cardiac output and high central venous pressure; a pericardial effusion was present at the echocardiogram. The clinical picture improved with intensive medical care but, on the tenth day, there was a relapse with a life-threatening heart tamponade. An emergency operation was performed without previous heart catheterization. The pericardium was tense and contained about 300 ml of clots; in a wide infarcted area of the lateral wall of the left ventricle two small perforations were evident. Primary reconstruction was accomplished with interrupted stitches supported by Teflon felt strips. The bypass weaning was easy and the postoperative clinical course uneventful. We believe that the cardiac rupture is a surgical emergency; the non-invasive diagnosis is possible; the coronary angiography and revascularization must be postponed.

The diisobutyryl ester of N-methyldopamine, ibopamine: evaluation of electrophysiological properties and arrhythmogenicity studies.

The electrophysiological properties of ibopamine (SB-7505), the 3,4-diisobutyryl ester N-methyldopamine, was evaluated in 8 patients with syncopes of unknown etiology or with suspected disease of the sinus node or due to I-II degree AV block. A complete electrophysiological examination, including atrial and ventricular stimulation, was performed both in baseline conditions and within 1 h after oral administration of ibopamine 200 mg in a single dose. The study showed a slight reduction in effective refractory periods in the right atrium (-4.26%), the atrio-ventricular node (-6.45%) and the right ventricle (-6.79%) after ibopamine. Ibopamine was not found to facilitate the occurrence of atrial and/or ventricular arrhythmias. A 24-h dynamic Holter ECG performed in baseline conditions and during administration of ibopamine 200 mg t.i.d. showed no changes in baseline heart rate, nor was any increase in the number of atrial or ventricular extrasystoles detectable. It may therefore be concluded that ibopamine, when administered at the above dosages to the patients studied, does not modify heart rate or sinus function parameters to a statistically significant extent. It also reduces effective refractory periods in the right atrium, in the atrioventricular node and in the right ventricle without inducing or facilitating the occurrence of atrial or ventricular arrhythmias.

[Echocardiographic and clinical correlations in infectious endocarditis of the left heart]. / Correlazioni ecocardiografiche e cliniche nella endocardite infettiva del cuore sinistro.

UNLABELLED: The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. CONCLUSIONS: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary spasm following myocardial revascularization. Clinico-therapeutic considerations in a successfully treated case]. / Spasmo coronarico dopo rivascolarizzazione miocardica. Considerazioni clinico-terapeutiche relative ad un caso trattato con successo.

A 30-year-old man had a spasm of the anterior descending coronary artery and received a bypass graft. The spasm which caused several cardiac arrests was relieved by intracoronary injection of nitrates and verapamil. The patient was discharged 13 days after surgery, receiving nitrates and calcium antagonists. Four months after operation he remains asymptomatic.

[Congestive heart failure in genetic hypertrophic cardiomyopathies (ASH) (author's transl)]. / Lo scompenso cardiaco nelle cardiomiopatie ipertrofiche di natura genetica (ASH).

Of a total sixtytwo patients covering all the spectrum of genetic ASH, who were studied by heart catheterization, M-mode echocardiography and phonomechano cardiography, five patients (four with the obstructive variety of the disease) showed clinical evidence of chronic congestive heart failure with ankle edema and hepatomegaly (group I). Their data were compared with those of fifteen "obstructed" patients who were not in heart decompensation (group II). No statistically significant differences were found between groups I and II in terms of L.V. internal transverse dimensions and in terms of L.V. systolic function. Conversely a statistically significant difference was found between the two groups in terms of left atrial and right ventricular dimensions (P less than 0,001), which were markedly increased in groups I. These findings strongly suggest that in patients with ASH and congestive heart failure there is a reduction in L.V. compliance (or distensibility), whereas L.V. systolic function is essentially preserved. The persistence of severe L.V. outflow obstruction in four patients of I group gives further confirmation to these observations. The use of beta-blockers (in association or not with cardiac glycosides) seems therefore to preserve its validity in the treatment of patients with ASH and heart failure, particulary when severe L.V. outflow obstruction is present. Cardiac glycosides are indicated in the forms with little or no obstruction to L.V. ejection.

[The tricuspid valve prolapse. Clinical significance and diagnostic problems (author's transl)]. / Il prolasso della valvola tricuspide. Significato clinico e problemi diagnostici.

Systolic prolapse of the tricuspid valve is a relatively unknown anatomo-clinical entity. In this communication etiology, clinical significance and diagnostic problems of this condition are reported and discussed. The frequent association with mitral valve prolapse and the coexistence of skeletal and cardiac anomalies strongly suggest the role of congenital factors and the degenerative nature of this valvular abnormality. Pathophysiology of leaflets prolapse remains unexplained for those few reported cases of isolated tricuspid invovlement. The clinical diagnosis of tricuspid valve prolapse is difficult, since the characteristic physical signs of tricuspid incompetence are uncommon, while apical mid-systolic click-late systolic murmur may indicate mitral valve prolapse, tricuspid valve prolapse, or a combination of the two. In the reported cases selective right ventriculography (R.A.O.) has shown pansystolic or late systolic prolapse of anterior and inferior leaflets (without or with varying degree of tricuspid incompetence) or isolated late systolic prolapse of the inferior cusp. M-mode echocardiography has shown great value in the diagnosis of tricuspid valve prolapse. On the echocardiogram several types of abnormalities have been noted which correlated well to angiocardiographic data. Tricuspid valve prolapse is of clinical importance, since this condition may be associated with significant tricuspid incompetence, a high incidence of cardiac arrhythmias, and possibly with bacterial endocarditis.

[Echocardiographic patterns of congenital aneurysm of the sinus of Valsalva. Review of literature and report of three cases (author's transl)]. / Aspetti ecocardiografici dell'aneurisma congenito del seno di Valsalva. Rassegna della letteratura e descrizione di 3 casi.

The (M-mode) echocardiographic patterns of three patients with congenital aneurysm of the right sinus of Valsalva are reported. In two patients the aneurysm ruptured into the right ventricular cavity. In the third case, in which the lesion was associated with coarctation of the aorta, no communication was shown between the aorta and other cardiac chambers. The characteristic echocardiographic features of the right coronary sinus aneurysm (either with or without rupture in the right ventricular cavity) consist of: 1) The presence of echoes (referable to the right aortic cusp pattern of motion) encroaching the right ventricular outflow tract. 2) The presence of the same box-shaped echoes at a low level of the left ventricular cavity, which seem to "cross" the septum (from the left to the right ventricular outflow tract). These images would reflect the "prolapse" of the affected cusp. Other common, but non-specific echocardiographic features of the lesion are: an indistinct contour of the anterior wall of the aortic root (probably due to dilatation of the right coronary sinus) and systolic indentations on the right anterior aortic cusp echoes.

[Cardiac echinococcosis simulating myocardial necrosis in a 9 year-old boy. Diagnosis and surgical treatment (author's transl)]. / Echinococcosi cardiaca in paziente di 9 anni, simulante necrosi miocardiac. Diagnosi e trattamento chirurgico.

The case of a 9 year-old, admitted for precordial pain, electrocardiographic signs of myocardial necrosis, deformity of the cardiac border at X Rays examinations, is reported. The diagnosis of cardiac echinococcosis was suspected once excluded other causes of myocardial infarction in children. Angiocardiography was the most useful diagnostic tool. The cyst was successfully removed with the aid of cardiopulmonary bypass. Cardiac echinococcosis gives rise, usually, to minor electrocardiographic changes; nevertheless, patients with electrocardiographic signs of necrosis can undergo surgical treatment without increased operative risk. Follow-up at several months after successful operation does not show return to normal electrocardiogram.

Electrolytic phenomena and massive gas generation around pacemaker electrodes. Clinical presentation of an unusual pacing failure.

An unexpected clinical presentation of an unusual pacing failure has been observed in two patients who had had recent implantation of a pacemaker model whose electrodes were made of an nonnoble metal alloy. An intermittent current leakage from the output capacitor and possibly from the output transistor accounted for electrolytic corrosion at the anode, premature depletion of the battery, heart muscle damage and for massive gas generation around electrodes, leading to right ventricular perforation, pneumopericardium and subcutaneous thoracic emphysema. The occurrence of this syndrome shows that, if nonnoble metals are used for electrodes, more attention should be addressed to those conditions which add to polarization problems, as is current leakage from the output circuit components.