Injectable fillers: an American perspective.

Since 1981, there has been a significant repertoire of United States Food and Drug Administrtion (FDA) approved fillers for both cosmetic rejuvenation and facial lipoatrophy. Currently available dermal fillers include bovine, human and porcine collagens, hyaluronic acids of animal and biosynthetic origin, poly-L-lactic acid, calcium hydroxylapatite, and polymethylmethacrylate. Many of these fillers were first available in Europe and Canada before their arrival in the United States (USA) and many of the complications known about these products have come from studies conducted both in the USA and abroad. Several of the fillers that are currently available abroad or are used in the USA off-label have been associated with significant complications. The authors review three of these fillers: liquid injectable silicone, DermaLive/DermaDeep, and Bio-Alcamid.

Stress induced cardiomyopathy presenting as acute coronary syndrome: Tako-Tsubo in Mercogliano, Southern Italy.

BACKGROUND: Tako-tsubo syndrome (TTS) in its typical (apical) and atypical (non-apical) forms is being increasingly recognized in the West owing to early systematic coronary angiography in acute coronary syndromes (ACS). AIM OF THE STUDY: To assess the incidence, the clinical characteristics and the outcome of TTS in a single high volume cath lab in Southern Italy over the last 6 years. METHODS: Among 1674 consecutive patients (pts) referred to our coronary care units in the last 6 years (2001-2006) for ACS we selected 6 (0.5%) pts (6 women; age 57 +/- 6 years) who fulfilled the following 4 criteria: 1) transient left ventricular wall motion abnormalities resulting in ballooning at contrast ventricolographic or echocardiographic evaluation; 2) normal coronary artery on coronary angiography performed 5 +/- 9 hours from hospitalization; 3) new electrocardiographic ischemic-like abnormalities (either ST-segment elevation or T-wave inversion) and 4) emotional or physical trigger event. RESULTS: At admission all pts had presumptive diagnosis of ACS and ECG revealed ST elevation in 3 (50%) and T wave inversion with QT elongation in 3 (50%). In the acute phase cardiogenic shock occurred in 2 (33%) and heart failure in 1(16%). Presenting symptoms were chest pain in 6 (100%), dyspnoea in 2 (33%) and lipotimia in 1 (16%). At echocardiographic-ventricolographic assessment, the mechanical dysfunction (ballooning) was apical in all 6 pts ("classic" TTS). In all patients wall motion abnormalities completely reversed within 4.5 +/- 1.5 days. The region of initial recovery was the anterior and lateral wall in 4 cases and the lateral wall in 2 cases. Ejection fraction was 35 +/- 8% in the acute phase and increased progressively at discharge (55 +/- 6%) and at 41 +/- 20 months follow-up (60 +/- 4%, p < 0.001 vs. baseline). All patients remained asymptomatic with minimal (aspirin, beta blockers, antihypertensive and antidislipidemic therapy) treatment. CONCLUSION: Classic TTS is a frequent serendipitous diagnosis after coronary angiography showed "surprisingly" normal findings in a clinical setting mimicking an ACS. Despite its long-term good prognosis life threatening complications in the acute phase can occur.

[Complete congenital atrioventricular block: a case report and review of the literature]. / Blocco atrioventricolare completo congenito; descrizione di un case e revisione della letteratura.

The description of a clinical case of a newborn with congenital complete atrioventricular block, due to maternal connective-tissue disease, is the occasion for a review of the literature. The clinical elements allowing an early diagnosis and treatment of these patients, who often need a permanent pacemaker, are described.

[The electrophysiological bases of aberrant intraventricular conduction during atrial fibrillation]. / Basi elettrofisiologiche della conduzione intraventricolare aberrante durante fibrillazione atriale.

Twenty-four hours electrocardiogram from 4 patients with chronic atrial fibrillation and intraventricular aberrant conduction were analyzed. Aim of the study was to evaluate the reliability of the Ashman's and Akthar's rules in electrocardiographic differential diagnosis between aberrancy and ectopy. We computed parameters related to 10 RR interval preceding the aberrant conduction (AB+ Group), normal complex QRS (AB-Group) and ectopic QRS (E Group): coupling interval (CI), preceding CI cycle (PCL1), preceding PCL1 cycle (PCL2), the difference between PCL1 an PCL2 (delta PCL1), the difference between CI an PCL1 (delta CI), the mean value (RR10) and the standard deviation (RR10SD) of the 10 QRS complexes preceding the end of the sequence. Specificity of Akthar's rule was 48.7% (range 45-50%), sensibility was 90.1% (range 75-100%). PCL2, delta PCL1 and RR10DS were significantly different between AB+ and AB- Group but not between AB+, AB- and E Group. In this work Akthar's rule showed a better reliability than Ashman's rule but specificity was low (probably related to concealed conduction in atrio-ventricular node). RR10DS, but not RR10, were significantly higher in AB+ Group than AB- Group suggesting that acceleration of the cycle length can provoke CVA by increasing the difference between the refractory period of His bundle branches. Aberrant ventricular conduction cannot be determined by a mathematical rule. In the differential diagnosis of wide QRS during atrial fibrillation only morphological analysis of QRS and the study of coupling interval and compensatory pause are helpful.

[Surgical treatment of incessant atrial tachycardia: description of a case]. / Trattamento chirurgico della tachicardia atriale incessante: descrizione di un caso.

A 50 year old woman with no evidence of structural heart disease was referred for ectopic incessant repetitive atrial tachycardia uncontrolled by medical therapy. Intracavitary and transesophageal simultaneous recordings revealed the earliest atrial electrical activity to be located in the left atrium. Intraoperative electrophysiologic mapping demonstrated that the site of earliest atrial activation was in a small diverticulum of the left atrial appendage. Excision of the appendage and isolation of left atrium was carried out with restoration of sinus rhythm. The patient was arrhythmia-free till 24 months later. Surgical treatment appears to be an effective therapeutic option for drug-resistant ectopic atrial tachycardia.

[Double ventricular response to a single atrial stimulation caused by simultaneous anterograde conduction through two atrioventricular nodal pathways]. / Duplice risposta ventricolare ad un singolo stimolo atriale dovuta a conduzione anterograda simultanea in due vie del nodo A-V.

In a patient with atrioventricular nodal reentrant tachycardia, during programmed stimulation, an atrial extrastimulus induced a double ventricular response due to a single atrial depolarization, with simultaneous and delayed anterograde conduction through fast and slow pathways, and induced the tachycardia. Pacing-induced type I block involving both pathways put these pathways out of phase, so that the distal conduction system and the ventricle responded to both the fast and slow pathways anterograde impulses.

[Linking in a phase-3 branch block: the electrocardiographic manifestations]. / Il linking del blocco di branca in fase 3: manifestazioni elettrocardiografiche.

Two cases of phase 3 intraventricular block and linking phenomenon of type 1 and type 2 (or bigeminal rhythm linking) are presented. In the first case, complexes that follow the extrasystolic blocked beat are wide, although they are associated with relative long R-R cycle:type 1 linking. In the second case, bundle branch block and normal conduction alternate in bigeminal extrasystolic beats:type 2 linking. The linking phenomenon is due to concealed retrograde penetration of the bundle branch that is blocked in anterograde direction. It delays the cycle and the refractory period of the bundle branch. Therefore, in type 1 linking, the subsequent stimulus, although occurring with a long R-R cycle, is again blocked in the same bundle branch. In type 2 linking, the R-R cycle and refractory period, occurring after bundle branch block, are shorted because comprised between retrograde activation by extrastimulus and anterograde activation by subsequent sinus stimulus. The subsequent ectopic impulse, although premature, is normally conducted.

[Slow and fast AV nodal pathways in tachycardia complicating Wolff-Parkinson-White syndrome: report of a case]. / Partecipazione delle vie lenta e rapida del nodo AV nella tachicardia della preeccitazione ventricolare: descrizione di un caso.

Electrophysiologic studies in a patient with intermittent ventricular pre-excitation revealed several types of paroxysmal narrow-QRS tachycardia (PSVT). One type of PSVT was characterized by normal retrograde atrial sequences with P waves occurring simultaneously with QRS. This type of PSVT reflected AV nodal reentry with anterograde slow pathway and retrograde fast pathway conduction. A second PSVT reflected alternation of anterograde fast and slow AV nodal pathway conduction and retrograde anomalous pathway conduction. A third PSVT reflected anterograde slow AV nodal pathway and retrograde anomalous pathway conduction. Moreover, discontinuous AV nodal conduction curves (A1A2/H1H2), characteristic of dual AV nodal pathway conduction, were obtained with programmed atrial extra stimulation. These observations suggest that dual AV nodal pathway conduction can coexist with abnormal bypass tract and can be the cause of PSVT in patients with Wolff-Parkinson-White syndrome.