Coronary angioplasty of chronic occlusions: factors predictive of procedural success.

In a retrospective study of 365 chronic total occlusions that were submitted for angioplasty, we studied the influence of 27 clinical, morphologic, and procedural variables as possible predictors of successful outcomes. Success rate was shown to be significantly influenced by the following variables: operator experience (41% in early patients, first 6 months; 73% in late patients, last 6 months of entire series; p less than 0.001), duration of occlusion (less than or equal to 1 month, 89%; 1 to 3 months 87%; greater than or equal to 3 months 45%; unknown 60%; p less than 0.001), morphology of occlusion (tapered, 83%; abrupt, 51%), length of occlusion (less than or equal to 15 mm, 71%; greater than 15 mm, 60%; p less than 0.001), and bridging collaterals (present, 29%; absent, 67%; p less than 0.001). None of the other clinical, angiographic, or procedural variables correlated with the success rate of coronary angioplasty. The calculated probability for an experienced operator (greater than 100 occlusions attempted) to successfully open an occlusion with favorable morphology (less than or equal to 1 month old, short, tapered, without bridging collaterals) is 99%. An attempt by the same operator to open an occlusion with unfavorable structure (greater than or equal to 3 months old, long, untapered) has only 47% probability of success. The probability increases to 84% when the occlusion is tapered. We concluded that in addition to the duration and the length of occlusion, tapered morphology, bridging collaterals, and operator experience can predict successful angioplasty in chronic total coronary occlusion.

Congenital hypothyroidism and pericardial effusion.

A group of infants, affected by congenital hypothyroidism diagnosed through the neonatal screening program, was investigated with echocardiography to detect the presence of pericardial effusion. We studied the relationship between the effusion and the etiology of hypothyroidism, established through thyroid scintiscanning. Our data show a high prevalence of effusion in hypothyroid patients, without other clinical signs of cardiac involvement as well as a relationship between the etiology of hypothyroidism and the presence of effusion. This seems to be much more frequent in those forms which can imply a more severe hormonal defect, particularly during fetal life (agenesis/dyshormonogenesis). Furthermore, the high prevalence of pericardial effusion suggests to start the L-T4 replacement therapy with lower dosages as commonly advised, in order to avoid a cardiac involvement.

[Coronary angioplasty in patients with compromised left ventricular function]. / Angioplastica coronarica in pazienti con funzione ventricolare sinistra compromessa.

One thousand one hundred and thirty-two percutaneous transluminal coronary angioplasties have been performed at Centro Cuore Columbus in Milan between January 1987 and September 1989. The whole population was divided into two groups: Group A (90 patients with ejection fraction less than or equal to 0.40); Group B (678 patients with ejection fraction greater than 0.40. Mean ejection fraction in Group A (0.35) was significantly lower (p less than 0.0001) than in Group B (0.56). In each group three subsets were identified: subgroup 1: total obstruction of two major epicardial vessels plus severe stenosis of the patent one; subgroup 2: total obstruction of one vessel plus severe stenosis on a different remote one; subgroup 3: all patent vessels with one or more severe stenoses on one or all. We attempted percutaneous transluminal coronary angioplasties on 923 stenosed and 161 totally obstructed vessels, with a primary success of 95 and 56% respectively. We experienced 36 major complications (7 deaths, 10 acute myocardial infarctions, 19 emergency aortocoronary bypasses in 21 patients (2.7% of the whole population). Subgroup A1 (7 patients with ejection fraction less than or equal to 0.40 and attempted percutaneous transluminal coronary angioplasties on the sole patent vessel) showed the lowest success rate (44%) and the highest complication rate: 3 deaths (42.8%); 1 acute myocardial infarction (14.2%); 3 emergency aorto-coronary by-pass (42.8%). The 83 patients in group A2 and A3, with reduced ejection fraction, did not have significantly higher complication rate than all group B patients, with normal ejection fraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients.

Few data are available about cardiac involvement in AIDS. We examined 102 consecutive patients with AIDS diagnosed clinically and serologically (Walter Reed Stage 5 and 6), by means of TM and cross-sectional echocardiography with the aim of detecting cardiac abnormalities. None of the patients had overt clinical signs of heart failure. Fifty-five (54%) patients showed persistent tachycardia, diminished left ventricular (LV) wall thickness (mean 7.6 +/- 0.2 mm) and decreased percentage LV fractional shortening (27 +/- 5). In 42 (41%) there was a globular and poorly contracting LV. Thirty-nine (38%) patients had pericardial effusion which was moderate in 30 and small in nine. In four patients, valvular endocarditic vegetation was shown--on the tricuspid valve in three, on the aortic valve in one: all of them were drug addicts; in three (2.9%) patients a cardiac mass was found which proved to be a localization of Kaposi's sarcoma in two. Twenty-five (24.5%) patients died; necropsy showed cardiac chamber dilation, and thin LV walls in 18. On microscopic examination, myocardial fibrosis and lymphocyte infiltration with cell necrosis were observed. We conclude that cardiac abnormalities are common in AIDS. Impairment in LV contractility as assessed from fractional shortening appears to be the most common echocardiographic finding, followed by LV wall thinning, pericardial effusion and eventually by LV cavity dilation. This evolution is suggestive of myocardial damage and supports the hypothesis that dilated cardiomyopathy may be a cardiac complication of AIDS.

Focal lymphocytic myocarditis in acquired immunodeficiency syndrome (AIDS): a correlative morphologic and clinical study in 26 consecutive fatal cases.

In 26 consecutive cases with acquired immunodeficiency syndrome (AIDS) the main cardiac findings were Kaposi's sarcoma in 2 cases, microfocal myocardial abscess in 1, subendocardial infarct necrosis in 2, contraction band necrosis in 13, lymphocytic myocarditis in 9, intramyocardial lymphocytic infiltrates without myocell necrosis in 7 and epicardial lymphocytic infiltrates in 4. No patient had congestive heart failure. However, two-dimensional echocardiography performed in eight patients demonstrated functional abnormalities in six (fractional shortening ranging from 18 to 30%, globular shape, hypokinesia, mild ventricular dilation). Four of these six patients had lymphocytic myocarditis and two had lymphocytic infiltrates in the myocardium and epicardium without myocell necrosis. No lymphocytic infiltrates were seen in the two cases with a normal echocardiogram. Quantitative analysis indicated that involvement of the heart by lymphocytic myocarditis is inadequate in itself to explain dysfunction. It remains to be established 1) whether lymphocytic myocarditis is a possible indication of a more widespread molecular disorder, and 2) what its eventual relation with dilated cardiomyopathy will be.

[Effect of the sympathetic activation and its inhibition on left ventricular mechanics in mitral prolapse. Echocardiographic study in 35 patients]. / Effetto dell'attivazione simpatica e della sua inibizione sulla meccanica ventricolare sinistra nel prolasso della mitrale. Studio ecocardiografico in 35 pazienti.

Mitral valve prolapse (MVP) is characterized by arrhythmias, atypical anginal chest pain and left ventricular (LV) wall motion abnormalities. The role of autonomic nervous system (ANS) as the origin of these disturbances is still debated. The aim of the study was to determine the possible interference between left ventricle (LV) mechanics and ANS. 35 consecutive patients with MVP (24 female, 11 male) (mean age 30 +/- 9 years), matched with a homogeneous control group, were examined by means of 2D-Echo during resting conditions and during sympathetic activation induced by passive orthostatism (90 degrees Tilting). At rest, no significant difference was found between the two groups regarding heart rate (HR), LV volume (LVV), ejection fraction (EF). Tilting produced a significant increase in HR (p less than 0.1) and LVV reduction (p less than .01) in both groups; on the other hand, EF did not change significantly. At 2D-Echo, LV abnormal wall motion at rest in 10/35 (29%) MVP, increasing to 17/35 (49%) was found during Tilting. This abnormality consisted in LV wall reduced systolic thickening and motion, localized in the antero-apical region in 11 patients (54%) and in the posterior wall in 6 patients (36%). Thirteen MVP patients with LV abnormal contraction patterns were re-examined after two weeks of beta-adrenergic blockade (200 mg Metoprolol orally per day). In all of them, LV abnormalities disappeared while LVV and EF remained unchanged. These data stress the role of the ANS in inducing LV abnormalities in patients with MVP.

Echocardiographic diagnosis of congenital bicuspid aortic valve in gonadal dysgenesis.

Among the gonadal dysgenesis, Turner's syndrome (T.S.) is often associated with cardiovascular malformations, mainly of the aorta. In order to assess noninvasively the incidence of those abnormalities we have evaluated 36 consecutive female patients (pts) with gonadal dysgenesis, mean age 13.3 +/- 2 years, range 3-24 years, without a prior history of cardiovascular disease, by clinical examination chromosomal karyotyping, 12 leads electrocardiography (ECG), and by Time Motion (TM) and Two-Dimensional (2D) Echocardiography (Echo). The following parameters were considered: presence of an auscultatory systolic ejection click (SEC); evidence of a bicuspid aortic valve (BAV); aortic valve stenosis (AVS); aortic valve eccentricity index (AVEI); left ventricle wall hypertrophy (LVWH). 9 pts out 36 (25%) presented a BAV at the 2D Echo; 8 pts out of 36 (22%) presented a SEC, 3/9 (33%) mild AVS, 2/9 (22%) displayed AVEI on TM study and 3/9 (33%) had LVWH. These findings indicate that an isolated BAV is present in a high percentage of pts with gonadal dysgenesis, more than before suspected. Echocardiography shows to be particularly useful and reliable in the assessment of that abnormality.

[Contrast echocardiography in the diagnosis of tricuspid insufficiency. Evaluation before and after cardiosurgical intervention in 24 patients]. / L'ecocontrastografia nella diagnosi dell'insufficienza tricuspidale. Valutazione prima e dopo intervento cardiochirurgico in 24 pazienti.

26 patients (pts) (8 males and 18 females), mean age 50 +/- 9 years, with rheumatic valve (MV) disease, candidates to MV replacement, were examined by contrast echocardiography (CE) before and after surgery. This was done in order to assess pre and postoperatively the presence of associated tricuspid regurgitation (TR) and to evaluate the short and long-term results of the operation on the TR itself. For assessing TR, the systolic presence, intensity and persistence of the microbubbles of the contrast medium injected into an antecubital vein, were observed within the inferior vena cava (IVC). We used synchronous time motion (TM) and two dimensional (2D) echocardiography from subcostal view. TR was classified as follows: severe (massive systolic opacification and persistence of the microbubbles in the IVC for at least 20 seconds); moderate (moderate systolic opacification lasting less than 20 seconds); mild (slight systolic opacification lasting less than 10 seconds); insignificant TR (sporadic appearance of the contrast medium into the IVC). On the average, the examination was carried out 48 hours before surgery, 15 days after and, in pts undergoing De Vega tricuspid valvuloplasty, 14 months after the operation. At pre-operative examination, massive TR was found in 16 pts, only 6 of whom showed clinical signs of TR. The findings were confirmed at surgery in 15 pts who underwent not only MV replacement but also tricuspid repair. In the other pts, agreement was found between CE and surgery as far as moderate TR was concerned, meanwhile mild CE TR was not confirmed at surgery. Sensitivity (SN) was 100%, specificity (SP) 38%, positive predictive value (PPV) 78%, negative predictive value (NPV) 100%. Excluding CE mild TR, SP and PPV raised to 75% and 95% respectively, meanwhile SN and NPV remained 100%. Short term post-operative follow-up CE performed on 13 out of the 15 pts with tricuspid repair showed no signs of TR in 7 and slight signs in 6. Furthermore, in those pts undergoing simple MV replacement, CE showed a marked reduction of the contrast echographic effect. Long term post-operative follow-up CE performed in the 13 pts with tricuspid repair showed no signs of TR in 9, slight signs in 3. Moreover in two pts massive TR due to late mitral prosthesis detachment was diagnosed by means of CE and confirmed at cardiac catheterization and surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Ambulatory blood pressure monitoring (24 h), basal blood pressure and left ventricular echocardiographic findings in young adults.

Left ventricular (LV) echocardiography and ambulatory monitoring of blood pressure (BP) were performed in 50 normal 20-year-old subjects previously followed longitudinally for 4 years with annual measurements of basal BP (BBP). The relationship of basal, casual and mean 24-h non-invasive ambulatory BP (ABP) with echo findings, blood chemistries and body fatness was evaluated. Subjects with mean BBP on the 4 years above the 85th percentile showed significantly higher blood levels of urea and glucose and of body fat than subjects below this BP level. Left ventricular echo measurements did not differ in the two groups. Left ventricular diameters and volumes were not correlated with basal, casual or ambulatory BP. Interventricular septum (IVS), LV posterior wall (LVPW) and LV mass were correlated with ambulatory systolic but not with basal or casual BP. A significant increase of wall thickness and LV mass was associated with a mean 24-h ambulatory systolic BP (ASBP) above 129 mmHg. It is concluded that random BP and ABP tend to identify hypertensive subjects with different features.