Disseminated Scedosporium apiospermum infection in renal transplant recipient: long-term successful treatment with voriconazole: a case report.

Scedosporium apiospermum, the asexual form of Pseudallescheria boydii, is a ubiquitous fungus that represents an unfrequent complication of immune suppression. It accounts for 20% of all non-Aspergillus mold infections in organ transplant recipients. The infection can be localized or disseminated in multiple organs, including lungs, brain, joints, tendons, and skin, and is difficult to treat, due to resistance of S apiospermum to amphotericin B and other antifungal agents. The mortality rate is about 50%. To our knowledge, there are no prospective studies or registries of transplant recipients to guide diagnosis and there are no evidence-based recommendations for the optimal management of this infection. We report a case of S apiospermum infection in a woman with renal transplantation. The first occurrence of infection was a solitary nodule on the forearm, which was surgically excised. Two following relapses were disseminated to the knee, the Achilles tendon, and the skin of the left leg. The infection was successfully treated with voriconazole, but due to the severe iatrogenic immune suppression, a strong reduction in immunosuppressant drugs was needed.

Left ventricular stroke work reserve as prognostic marker in severe heart failure.

AIM: We sought to determine whether an invasive approach based on Swan-Ganz catheterization, coupled with a pharmacologic stressor, might help stratify prognosis in patients with severe heart failure and uniformly depressed indices of cardiac function. METHODS: We studied 31 unselected consecutive patients with scalar doses of dobutamine (2.5-10 microg/kg/min) after baseline hemodynamic evaluation. Changes in stroke work index (SWI) from baseline to peak effect (stroke work reserve, SWR) were recorded, and patients classified as responders (SWR above the median) or non-responders to dobutamine (SWR below the median). One-year follow-up data were recorded. RESULTS: All patients completed the dobutamine challenge test without complications. Dobuta-mine increased SWI from 17+/-9 to 26+/-13 mg/ beat/m2 (P<0.0001 vs baseline), with a median increase of 6.4 g/beat/m2. Basal SWI was not related to stroke work reserve. The only predictor of response to dobutamine was a smaller left ventricular end-diastolic volume (135+/-28 vs 205+/-90 mL/m2; P=0.007). After 1 year, only 7 patients were alive, while 10 had successful transplantation. Transplant-free survival was 47% in responders vs 0% in non responders (P=0.007). At multivariate analysis, none of baseline hemodynamic parameters was predictive of survival. Only age and a SWR above the median were significant independent predictors of survival in this model. CONCLUSIONS: This study allows us to draw the following conclusions: 1) 1-year mortality in severe heart failure remains extremely high; 2) baseline hemodynamics dos not predict survival; 3) a positive response to dobutamine identifies a subgroup with significant lower mortality at 1 year; 4) this response is an independent predictor of survival and is more likely to occur in the presence of a less dilated left ventricle.

Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism.

BACKGROUND: To investigate the frequency of cardiac troponin I (cTnI) increases in patients with pulmonary embolism (PE) and to assess the correlation between this finding, the clinical presentation, and outcomes. METHODS: Consecutive patients admitted to the coronary care unit with acute PE were prospectively enrolled between January 2000 and December 2001. cTnI was sequentially determined. Various cut off concentrations were analysed, but patients were categorised prospectively as having increased or no increased cTnI based on a cut off concentration of 0.6 ng/ml. The main outcome measure was in-hospital mortality. RESULTS: On admission, 14 of the 48 patients (29%) had cTnI concentrations greater than the receiver operating characteristic curve value used to diagnose acute myocardial infarction (> 0.6 ng/ml). Subsequently, six patients developed increases for an overall prevalence of 42% (20 of 42). The prevalence was higher when lower cut off concentrations were used: 73% (35 of 48) at the 99th centile and 60% (29 of 48) at the 10% coefficient of variability. Increased cTnI > 0.6 ng/ml was associated with a slower oxygen saturation (86 (7)% v 93 (4)%, p < 0.0001) and more frequent involvement of the main pulmonary arteries as assessed by spiral computed tomography (100% v 60%, p = 0.022). In-hospital mortality was 36% (5 of 14) of patients with increases > 0.6 ng/ml v 3% (1 of 42) of patients with lower concentrations (p = 0.008). Increased cTnI > 0.6 ng/ml on admission was the most powerful predictor of mortality (p = 0.046). CONCLUSIONS: In high risk patients with acute PE, cTnI was frequently detected on admission. It was the strongest independent predictor of mortality.

Outcome of percutaneous coronary angioplasty (PTCA) performed in a low-volume institution by low-volume operators, evaluated by means of the one-month major adverse cardiac event rate.

BACKGROUND: Since an inverse relationship between percutaneous coronary angioplasty (PTCA) case-load and in-hospital major adverse cardiac events (MACE) exists, we intended to evaluate the performance of low-volume PTCA operators, during the first year of our interventional program, by applying the more accurate index represented by the MACE rate within the first month. METHODS: The data relative to both the PTCA procedure and the control visit 3-4 weeks later, were retrospectively reviewed. Death, myocardial infarction and need for revascularization were the end-points evaluated, both globally and with respect to the individual operators. RESULTS: During 1999, 61 consecutive patients (53M, 8F; mean age: 59.9+/-10.4 years) were treated by two full-trained operators. Stable angina was the indication in 75% of cases. Comorbidities as diabetes and prior revascularization, were present in 16 and 5% of cases, respectively. Multivessel procedures were performed in 33% of cases, with a total number of lesions of 84 (77% A/B1 type). Stents were implanted in 70% of cases, as a bail-out in 12%. Procedural success rate was 93%. Overall one-month MACE rate was 3.3%, accounted for by 1 in-hospital emergency coronary surgery occurred to operator 1 (3.6% one-month MACE rate) and 1 elective coronary operation performed in a stable patient previously treated by operator 2 (3% one-month MACE rate). CONCLUSIONS: PTCA performed in a low-volume center by low-volume operators is not necessarily associated with a poor outcome, provided that adequate selection of low-risk cases is accomplished. Although only 52% of the Italian centers met in 1999 the recommended volume standards, reaching optimal case-load should anyway be pursued. Some time should however be conceded, provided that close monitoring of one-month MACE rate shows adequate performance of both the institution and the operators.

Predictors of mortality at 30 days in high-risk patients treated with direct or rescue stenting for acute myocardial infarction: a single center experience.

BACKGROUND: Coronary stenting in acute myocardial infarction (AMI) is associated with a very low adverse event rate when performed at selected centers in clinical trials. However, because of exclusion criteria, a low-risk population is usually selected, while potential benefits of stenting should be investigated in an unselected population, including a larger proportion of high-risk patients. METHODS: We analyzed results obtained in 120 consecutive high-risk patients (mean age, 64 years; range, 38-95 years; 76% male), so defined according to the presence of 1 of the following: age > 75 years; Killip class 3; cardiogenic shock; 3-vessel or left main disease; ejection fraction < 45%; anterior AMI; previous bypass surgery; and/or out-of-hospital cardiac arrest. A primary procedure was performed in 63 patients and a rescue procedure in 57 patients. Stenting was attempted in all patients in which coronary occlusion could be crossed with the guidewire (117/120) and was successful in 115/117 (98%). RESULTS: Procedural success (TIMI 3 flow and residual stenosis < 20%) was obtained in 105 patients (88%), while a suboptimal result (TIMI 2 flow) was achieved in 9 patients (8%). At 30 days, twenty patients had died (17% mortality). For patients non in cardiogenic shock, 30-day mortality was 3.2%. At multivariate analysis, cardiogenic shock (p < 0.0001), peak CK-MB mass (p = 0.01), and suboptimal result (p = 0.018) were significant independent predictors of 30-day mortality. Rescue procedures were associated with a significant protective effect with respect to mortality (p = 0.033). CONCLUSION: In our series, high-risk patients treated with percutaneous intervention for AMI had a very high mortality rate in the presence of cardiogenic shock, despite the use of stents, intra-aortic balloon pumping and abciximab. In the remaining patients, acceptable results were obtained even in the presence of 1 or more risk factors. Rescue stenting does not seem to be associated with increased risk compared to primary stenting.

Reduced right ventricular ejection fraction as a marker for idiopathic dilated cardiomyopathy compared with ischemic left ventricular dysfunction.

BACKGROUND: Evidence for the role of right ventricular (RV) function is emerging in patients with heart failure of different etiologies. Studies conducted in dilated cardiomyopathy (IDC) showed a high prevalence of RV dysfunction unrelated to the severity of pulmonary hypertension. The aim of the study was to investigate the role of RV dysfunction in ischemic versus nonischemic patients. METHODS: A series of 153 patients with left ventricular (LV) dysfunction (defined as a LV ejection fraction <45%) of either ischemic (n = 61, coronary artery disease [CAD] group) or nonischemic (n = 92, IDC group) origin were studied invasively. Besides routine catheterization data, RV volumes and ejection fractions were obtained angiographically. Reference data were collected in a control group of healthy subjects. RV dysfunction was defined as a RV ejection fraction <35% and ventricular concordance as a <10% difference between RV and LV ejection fraction. The LV/RV end-diastolic volume ratio was calculated to assess the relative dilatation of the ventricular chambers. Hemodynamic and angiographic data were compared in the 2 groups by univariate and multivariate logistic regression analysis. RESULTS: Patients with IDC and CAD had comparable LV ejection fractions (29% +/- 3% vs 31% +/- 8%, P not significant) and mean pulmonary pressures (27 +/- 12 mm Hg vs 26 +/- 11 mm Hg, P not significant); the LV/RV end-diastolic volume ratio was identical in the 2 groups (1.26 +/- 0.4 vs 1.24 +/- 0.4, P not significant). RV ejection fraction was significantly lower in IDC compared with CAD (33% +/- 10 % vs 46% +/- 11%, P <.0001), with a prevalence of RV dysfunction in the IDC group of 65% compared with 16% in the CAD group (P <.0001); similarly, the prevalence of ejection fraction concordance was 74% versus 33%, respectively (P <.0001). At multivariate analysis, a low RV ejection fraction was a powerful independent predictor of IDC compared with CAD (odds ratio 0.91, 95% confidence interval 0.87-0.94, P <.0001). RV dysfunction had a positive predictive value of 75% and a negative predictive value of 78% for the diagnosis of IDC; for ventricular concordance, these values were 81% and 69%, respectively. The correlation between mean pulmonary artery pressure and RV ejection fraction was weaker in the IDC group compared with the CAD group (R(2) = 0.032, P =.047 and R(2) = 0.172,P <.0001, respectively). CONCLUSION: In the presence of LV dysfunction, a reduced RV ejection fraction is a powerful marker for IDC compared with CAD, independent of age, pulmonary hypertension, LV function, and ventricular dimensions. These findings support the concept that IDC is frequently characterized by a biventricular involvement and that the presence of RV dysfunction represents a distinguishing feature of this disease.

Abciximab in rescue coronary angioplasty after full-dose tissue-type plasminogen activator.

BACKGROUND: Rescue angioplasty is a complex procedure because of frequent reocclusions secondary to a paradoxical pro-thrombotic effect brought about by thrombolytic therapy. Administration of abciximab may improve procedural results but its utilization in this setting is limited by the potential hemorrhagic risk. Very few data on this approach are currently available in the medical literature. METHODS: After failed full-dose tissue-type plasminogen activator (tPA), 30 patients (23 males, 7 females, mean age 64 +/- 13 years) referred for rescue angioplasty received abciximab (0.25 mg/kg bolus + 0.125 mcg/kg/min x 12 hour infusion) (Abc+ group). The procedural results, hemorrhagic complications and in-hospital outcome observed in these patients were compared to those of 35 patients submitted to rescue angioplasty in the same time period (1997-1999) who did not receive abciximab (Abc- group). RESULTS: In the Abc+ group, 11 patients (37%) were in Killip class 3-4, 14 (47%) had multivessel disease, and 4 (13%) had previous bypass surgery. In all Abc+ patients, factors suggestive of procedural failure were present (i.e. saphenous vein graft occlusion, intraluminal thrombus, dissection, reocclusion, slow flow). The periprocedural heparin dose was 5,000 IU in Abc+ and 100 IU/kg in Abc-patients (range 5,000-10,000 IU). The procedure was successful in 29 Abc+ (97%) and in 34 Abc- patients (97%). A hemoglobin drop > 5 g occurred in 3 Abc+ (10%) and in 4 Abc- patients (11%) with a similar incidence of blood transfusion in the two groups. In all these cases, significant bleeding occurred at the vascular access site. There were 2 in-hospital deaths in Abc+ and 1 in Abc- patients. CONCLUSIONS. Selected patients undergoing rescue angioplasty may be treated with abciximab without an undue increase in hemorrhagic complications. Larger studies are needed to confirm the feasibility of this approach and to assess its potential benefits.

[Ventricular pre-excitation: electrophysiopathology, criteria for interpretation and clinical diagnosis. References for geriatrics]. / La pre-eccitazione ventricolare: elettrofisiopatologia, criteri interpretativi e inquadramento clinico. Riferimenti di Geriatria.

The authors review the state-of-the-art on ventricular pre-excitation in medical and arrhythmological literature in order to facilitate the recognition of the various clinical forms, like classic and occult Wolff Parkinson withe syndrome and Lown Ganong Levine syndrome. A historical introduction reviews our electrophysiopathological knowledge of the electrical activation and conduction of ventricular pre-excitation compared to normal, starting from the anatomic discovery of conduction pathways to the possible use of transesophageal electrostimulation and endocavity mapping to study electric potentials. Avantgarde technologies have also been developed to eliminate anomalous pathways firstly by using a direct current dirscharge and secondly radiofrequency. Atrioventricular electric activation has been widely illustrated in normal subjects in order to create a model for comparison with pathological ventricular pre-excitation: the upper left portion of the septum is no longer the first zone to trigger the kinetic mechanism compared to the early fascicular fraying of the homonymous branch. Instead the upper right part of the septum is activated earlier owing to the anomalous fascia connected on this side to the right branch through their septal arborisations. As a result, this new conduction pathway activates the ventricular masses earlier through an anomalous route, given that there is no further contact with the atrioventricular nodes which act as a control. A similar situation is found in the left branch block where the ventriculogram is late with a normal PR, unlike pre-excitation when an early delta wave is present with a short PR. Electric conduction is also illustrated based on new knowledge of the circuit structures and the rings theory. Orthodromic tachycardia is distinguished from the antidromic form, double accessory pathway tachycardia, ectopic reciprocant atrial fibrillation tachycardia and occult bundle tachycardia which is studied using transesophageal stimulation with a time threshold of 70 ms for ventricular-atrial retrograde activation. The stimulation techniques using single or repeated extrastimulus are explained for this purpose, as well as those with serial extrastimulation and the physical characteristics of the circuit based on the ratio between voltage and resistance. The authors also report the practical aims of electrostimulation for determining the electric threshold of the anomalous circuit in terms of refractoriness, electric atrial stability, reciprocity and the occurrence of the macro re-entry. Lastly, the authors describe electric conduction by anomalous pathways based on the criterion of conduction and activation, both of which are analysed and compared on the basis of the intrinsicoid deflection morphology on the surface ECG: the aberrant qRs usually suggests an antidromic ventricular activation and retrograde conduction between atrium and ventricle, while normal intrinsicoid deflection demonstrates that the activation is orthodromic and the conduction anterograde, namely ventricle-atrial. Having been reproduced in a synoptic synthesis, these manifestations show a regular electrophysiological pattern because they are dissimilar from the behaviour of the monophasic bioelectric potential of the cardiac cells specialised in the conduction of the stimulus, whether they represent a normal or pathological electric pathway. The study is rounded off by the analysis of the reciprocant tachycardias and their re-entry varieties related to the type of the anomalous bundles. A number of types of re-entry can be identified: sinusal re-entry (micro re-entry), atrial re-entry, re-entry in the atrio-ventricular node, re-entry tachycardia and the so-called triggered type. The discussion of the electrophysiopathological aspects of pre-excitation is followed by the clinical forms of ventricular pre-excitation that can be divided into 3 main types. The different ECG clinical pictures are set out in the summary table, together with the type of shunt and activation and possible variants, following Rosenbaum s classic paint: the common type B, the rare type A and a last variant, the C type. This section also describes the positional peculiarities of the Kent-Paladino bundle, the left ventricular, septal (anterior and posterior) and the multiple-bundle ones. The authors also illustrate the criterion and meaning of endocavity mapping in the search for anomalous bioelectric potentials that identify the pathway or the location of the endocardiac bundle and/or foci to be eliminated. A new echocardiographic technique is described with a conventional M mode, digitalised 2D and tissular Doppler which has a comparable ability to identify the anomalous pathways of electric conduction using a non-invasive method. (ABSTRACT TRUNCATED)

Stent thrombosis: incidence and related factors in the R.I.S.E. Registry(Registro Impianto Stent Endocoronarico)

Although stent thrombosis has been greatly reduced by adequate stent expansion with high-pressure balloon inflations and by the use of antiplatelet drugs, this event is still frightening, as it may lead to acute myocardial ischemia resulting in acute myocardial infarction or sudden death. Therefore, the definition of factors associated with stent thrombosis may provide a better understanding of the mechanisms underlying this phenomenon and may permit us to define therapeutic strategies to further reduce its occurrence. The purpose of this study was to assess factors responsible for the occurrence of stent thrombosis after coronary stent implantation in 939 consecutive patients enrolled in the Registro Impianto Stent Endocoronarico (R.I.S.E. Study Group). Consecutive patients undergoing coronary stent implantation at 16 medical centers in Italy were prospectively enrolled in the registry. Clinical data, and qualitative and quantitative angiographic findings were obtained from data collected in case report forms at each investigator site. The study group consisted of 781 men and 158 women with a mean age of 59 yr: 1,392 stents were implanted in 1,006 lesions and expanded at a maximal inflation pressure of 14.7 +/- 3 atm. The great majority of patients (92%) received only antiplatelet drugs after coronary stenting. During hospitalization there were 45 major ischemic complications in 39 patients (4.2%): 13 events were related to acute or subacute thrombosis (1.4%). Another stent thrombotic event occurred in the first month of follow-up. On multivariate logistic regression analysis, stent thrombosis was related to the following factors: unplanned stenting (OR 3.46, 95% CI 1.65-7.23), unstable angina (OR 3.37, 95% CI 1.11-10.14) and maximal inflation pressure (OR 0.83, 95% CI 0.75-0.93). In conclusion, this registry shows that in an unselected population of patients undergoing coronary stenting, stent thrombosis occurs in less than 2% of patients and is significantly related to unplanned stent implantation, unstable angina, and maximal inflation pressure. The incidence of this phenomenon is likely to be further reduced by the use of new potent antiplatelet drugs, such as platelet glycoprotein IIb/IIIa antagonists.

[Frequency and antibiotic susceptibility of urinary pathogens isolated in the microbiology and virology laboratory of the Careggi General Hospital in the period July-December 1996]. / Frequenza e sensibilità agli antibiotici di patogeni urinari isolati nel laboratorio di microbiologia e virologia dell'Azienda Ospedaliera di Careggi nel periodo luglio-dicembre 1996.

BACKGROUND: The aim of the study was to evaluate the isolation frequency and antibiotic susceptibility of pathogens isolated form urinocoltures. METHODS: 2192 bacterial strains obtained from urine cultures with bacterial count > 100,000 UFC/ml were examined in our Laboratory from July through December 1996. Inpatients as well as outpatients were considered. Five different ward typologies were taken into account (Surgery, Medicine, Obstetrics, Spinal Unit and High Risk Wards). Isolation frequencies were evaluated for each ward, but in order to get an adequate statistical sample they were divided into in two categories, e.g. strains isolated from inpatients and from outpatients. Antibiotic susceptibility was also evaluated dividing the data into the same two categories. For strains isolated with lower frequencies that was not possible, and data from inpatients were grouped with data from outpatients. RESULTS: The results obtained show that bacterial species most frequently isolated among inpatients are Escherichia coli (45.7%), Enterococcus faecalis (16.8%), Proteus mirabilis (9.1%), Pseudomonas aeruginosa (6.9%) and Klebsiella pneumoniae (6.4%). Those most frequently isolated among outpatients are Escherichia coli (58.1%), Enterococcus faecalis (12.3%), Proteus mirabilis (9.1%), Klebsiella pneumoniae (4.4%) and Coagulase negative staphylococci (4.0%). As far as antibiotic susceptibility is concerned, whenever a statistically significant difference in sensitivity could be observed between strains isolated from inpatients and strains isolated from outpatients, sensitivity was always higher for outpatients strains. CONCLUSIONS: Isolation frequency and antibiotic susceptibility are different depending on the place of origin of the patients (inpatients/outpatients). This implies a different approach to the empiric therapy in urinary tract infections.

Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS).

BACKGROUND: Although the association of ticlopidine and aspirin has been shown to be superior to anti-vitamin K agents and aspirin after coronary stent implantation in low-risk patients, the latter combination has remained an unproven reference regimen for high-risk patients until recently. METHODS AND RESULTS: We randomized 350 high-risk patients within 6 hours after stent implantation to receive during 30 days either aspirin 250 mg and ticlopidine 500 mg/d (A+T group) or aspirin 250 mg/d and oral anticoagulation (A+OAC group) targeted at an international normalized ratio of 2.5 to 3. The primary composite end point was defined as the occurrence of cardiovascular death, myocardial infarction, or repeated revascularization at 30 days. Patients were eligible if (1) the stent(s) were implanted to treat abrupt closure after PTCA; (2) the angiographic result after implantation was suboptimal; (3) a long segment was stented (>45 mm and/or >/=3 stents); or (4) the largest balloon inflated in the stent had a nominal diameter of

Stent implantation versus balloon angioplasty in chronic coronary occlusions: results from the GISSOC trial. Gruppo Italiano di Studio sullo Stent nelle Occlusioni Coronariche.

OBJECTIVES: In this multicenter, randomized trial we evaluated whether stent implantation after successful recanalization of a chronic coronary occlusion reduced the incidence of restenosis. BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) in chronic total occlusions is associated with a higher rate of angiographic restenosis and reocclusion than PTCA in subtotal stenoses. Preliminary reports have suggested a decreased restenosis rate after stent implantation in coronary total occlusions. METHODS: We randomly assigned 110 patients with recanalized total occlusion to Palmaz-Schatz stent implantation, followed by 1 month of anticoagulant therapy versus no other treatment. The primary end point was the minimal lumen diameter (MLD) of the treated segment at follow-up, as determined by quantitative angiography at a core laboratory. RESULTS: Repeat coronary angiography was performed 9 months after the procedure in 88% of patients. The MLD (mean +/- SD) at follow-up was 1.74 +/- 0.88 mm in patients assigned to stent implantation and 0.85 +/- .75 mm in patients assigned to PTCA (p < 0.001). Stent implantation was associated with a lower incidence of restenosis (defined as diameter stenosis > or =50% at follow-up) (32% vs. 68%, p < 0.001) and reocclusion (8% vs. 34%, p = 0.003) than balloon PTCA. Likewise, stent-treated patients had less recurrent ischemia (14% vs. 46%, p = 0.002) and target lesion revascularization (5.3% vs. 22%, p = 0.038), but experienced a longer hospital stay. CONCLUSIONS: Palmaz-Schatz stent implantation after successful balloon PTCA of chronic total occlusions improves the midterm angiographic and clinical outcome and could be the preferred treatment option in selected patients with occluded vessels.

Predictors of major in-hospital ischemic complications and length of hospital stay after coronary stenting.

Although recent data show that coronary stenting reduces procedural complications and late restenosis, major concern has been expressed about the greater hospital cost associated with the use of this device as compared to conventional coronary angioplasty. Since length of hospital stay after surgical procedures is a major determinant of resource use, the identification of variables associated with an excessively long hospital stay after intracoronary stent placement may have important practical consequences. The purpose of this study was to assess factors responsible for the occurrence of in-hospital complications and prolonged hospital stay after coronary stenting in 939 consecutive patients enrolled in the Registro Impianto Stent Endocoronarico (RISE Study Group). Consecutive patients undergoing coronary stent implantation at 16 medical centers in Italy were prospectively enrolled in the Registry. Clinical data, qualitative and quantitative angiographic findings were obtained from data collected in case report forms at each investigator site. Major ischemic complications were considered death, Q-wave myocardial infarction, emergency bypass surgery and emergency repeat angioplasty. The study group consisted of 939 patients (781 men, 158 women with a mean age of 59 years) in whom 1392 stents were implanted in 1006 lesions and expanded at a maximal inflation pressure of 14.7 +/- 3 atmospheres. The great majority of patients (92%) received only antiplatelet drugs after coronary stenting. During hospitalization, there were 45 major ischemic complications in 39 patients (4.2%): 13 events were related to acute or subacute thrombosis (1.4%). On multivariate logistic regression analysis, the following factors were predictive of in-hospital complications: increasing age (OR 2.19, 95% CI 1.18-4.07), unplanned stenting (OR 3.46, 95% CI 1.65-7.23) and maximal inflation pressure (OR 0.83, 95% CI 0.75-0.93). Mean hospital stay after stent implantation was 4.1 +/- 4.4 days and was related, by multivariate regression analysis, to female sex (p = 0.0001), prior bypass surgery (p = 0.03), non-elective stenting (p = 0.0001), use of anticoagulation (p = 0.0001) and development of major ischemic complications (p = 0.0001). This Registry shows that in an unselected population of patients undergoing coronary stenting, major ischemic complications occur at a relatively low rate (4.2%) and thrombotic events can be kept at 1.4%, despite the omission of anticoagulation in the great majority of patients. Length of hospital stay was affected by the occurrence of major ischemic complications, unplanned stenting, use of anticoagulation, female sex and prior bypass surgery. Accumulating experience, further reduction in complications and complete omission of anticoagulation may decrease length of hospital stay, thus reducing the use of resources after coronary stenting.

[Ventricular pre-excitation in Wolff Parkinson White syndrome in the aged]. / La pre-eccitazione ventricolare da sindrome di Wolff Parkinson white nell'anziano.

AIM: To evaluate any differences in ventricular pre-excitation secondary to Wolff Parkinson White syndrome in the aged compared to young and adult patients. EXPERIMENTAL DESIGN: a clinical study was performed using a comparative prospective criterion with retrospective analysis. The duration of follow-up ranged between one and ten years. SETTING: the series was collected from the Cardiology Clinic of the Health District and the Cardiology Division of Gorizia, both forming part of no. 2 Isontina Health Service. PATIENTS OR PARTICIPANTS: the series included 17 patients suffering from Wolff Parkinson White syndrome who were divided into two study groups: 9 elderly patients and 8 young patients. The latter were subdivided into a first subgroup of 4 cases with Wolff Parkinson White syndrome with ECG positive for the presence of delta waves, and a second subgroup also with Wolff Parkinson White syndrome secondary to bundle. INTERVENTIONS: some young patients with Wolff Parkinson White syndrome who were symptomatic for tachycardia underwent ablative surgery with radiofrequency of the bundle. PARAMETERS: all patients underwent cardiological screening focused in particular on surface electrocardiogram. Those cases with Wolff-Parkinson White syndrome with occult bundle underwent transesophageal electrostimulation to find the conduction threshold of the anomalous bundle. RESULTS: Adult-elderly patients: six subjects were diagnosed with antero-septal and left ventricular Kent's bundle (type B common) and 3 cases with Mahaim-Wiston bundle (type A rare). Surface ECG revealed the presence of left ventricular hypertrophy in 6 cases, left anterior hemiblock and total block of the left branch in 3 cases, as well as myocardial pseudonecrosis correlated to Wolff Parkinson White syndrome. Young patients: four out of this group were affected by Kent's bundle with type B Wolff Parkinson White syndrome and the same number suffered from the same syndrome caused by occult bundle. Patients in the first subgroup showed an antero-septal, transitional and left ventricular orientation of Kent's bundle, with the onset of 2 cases of orthodromic and antidromic reciprocal rhythm respectively and 1 case of atrial fibrillation. The refractory nature of the anomalous pathway was not very high in 2 cases, equal to 60 milliseconds and 240 milliseconds with the proposed ablation of the anomalous bundle.

[The Registry for Angioplasty in Infarction (RAI): brief preliminary report on the main indicators and process of acute outcome]. / Registro per l'Angioplastica nell'Infarto (RAI): breve report preliminare dei principali indicatori di processo e di esito acuto. Conto di Tutti i Ricercatori del RAI.

BACKGROUND: Emergency coronary angioplasty can be the treatment of choice in selected patients with acute myocardial infarction in centers with adequate facilities and organization. METHODS: A multicenter observational study in patients with high-risk acute myocardial infarction was conducted to evaluate the quality of emergency angioplasty treatment according to process, acute and long-term outcome, and use of resources. RESULTS: The RAI registry included 345 patients with high-risk acute myocardial infarction who were admitted to six participating centers over a thirteen-month period. Emergency coronary angiography was performed in 261 patients (76%) and was followed by immediate angioplasty in 236 of them (68%). Mean door-to-procedure time was 58 +/- 47 min. Severe left ventricular failure was present at admission in 35 (13%) of the 261 patients with emergency coronary angiography; and 29 of them were in cardiogenic shock (11%). Overall, in-hospital mortality for patients with angioplasty was 7.6%; i.e., 43% and 3.7% for patients with and without shock, respectively. CONCLUSIONS: Despite logistical limitation, in centers with emergency angioplasty programs this treatment can be performed with favorable process and acute outcome characteristics in patients with high-risk myocardial infarction.

[Measurements of productivity and efficiency of a first level director in a cardiology referral clinic. Their use in the final determination of work load in accordance with DL 29/1993]. / Misure di produttività e di efficienza per i medici dirigenti di I livello in una struttura cardiologica di riferimento. Loro utilizzo ai fini della determinazione dei carichi di lavoro secondo il DL 29/1993.

BACKGROUND AND OBJECTIVES: The law demands that the work-load (WL) in the Public Health Service be defined, and also dictates audit criteria referring to: a) the total activities performed during the previous three years; b) the standard times (STD) required to perform the different activities; c) the degree of demand fulfillment (DDF). Aim of this study is to establish the WL of 19 cardiologists (C) operating in a referral Hospital. METHODS: We examined the years 1993-1995. We calculated all medical procedures (P) carried out by our Institute ("procedure" method), and we determined the theoretical time needed to perform them based on STD. The activities of the Coronary Unit (CCU) and of the Ward (W) have been evaluated based on the duty-time table ("presence" method). The sum of the hours calculated with the two methods is the theoretical duty-time per week (TDT = sigma P x STD Time + CCU hours + W hours). We then measured the actual duty-time (ADT). By comparing TDT and ADT we obtained an efficiency index EI = [(TDT - ADT)/TDT]%. The DDF has been estimated based on the waiting-lists. RESULTS: We noticed an increase in invasive P and related activities, and a stable trend or a small decrease in non-invasive P, except for echography. TDT was always found to be superior to ADT (1993: 731.3 vs 670; 1994: 742.7 vs 670.9; 1995: 734 vs 652.1) with an increasing IE (8.3; 9.6; 11.1 respectively). We found rather high figures for extra hours per week (mean 31.6), C time (mean 34.9) and hours lost for vacation, illness, etc. (mean 137.5/week, equal to duty-time of more than three C). When GCS was considered, the total WL was 770 hours per week, equal to a duty-time of 19.25 C. CONCLUSIONS: WL evaluation allows a better understanding of operating conditions ina ward, it is essential when C are committed to pursue specific objectives, and it represents a basis to monitor efficiency. The reliability of WL largely depends upon STD; this underscores the fundamental role of Scientific Societies to prevent a tool intended for a better utilisation of human resources from becoming a pure instrument of cost-containment.

[Percutaneous occlusion of small patent ductus arteriosus with detachable Gianturco spring coils. Preliminary results]. / Occlusione percutanea del dotto di botallo con spirali di Gianturco con Rilascio controllato. Risultati preliminari.

INTRODUCTION: Botallo's duct occlusion with Gianturco coils is effective in the fistulas with max. diameter of 3.3 mm. The insertion technique does not permit to control coil positioning inside the fistula and the coil itself may migrate to the pulmonary artery. We report our experience with a new system of temporary hookup of the coil proximal end to a metal thread (Cook device) which permits to change the position of the coil or to replace it. MATERIALS AND METHODS: We treated 6 patients with persistence of Botallo's duct (O: 2-3.5 mm, mean: 2.9 mm). The duct was occluded in 5/6 patients. The coil migrated to the pulmonary artery in a case where the hookup system permitted to retrieve and then replace it with a bigger coil which was also retrieved because it was too big for the small aorta. No complications were observed. RESULTS: Follow-up chest films at 24 hours showed coil stability and color Doppler US confirmed the occlusion. The patients were discharged after 24 hours. The follow-up at 6 months confirmed the procedure success. CONCLUSIONS: The hookup system was effective to control coil positioning and to extract and replace the coils. The effectiveness of this occlusion technique would be improved if a wider range of coil sizes and types were available.