An atypical case of pulmonary embolism from a jugular vein.

Neck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation. Learning points: Internal jugular venous malformations, such as aneurisms or hypoplasia, could be associated with an increased risk of thrombosis and major embolic events. Systemic thrombolysis can be an efficient solution in cases of pulmonary embolism with right heart thrombosis. Multimodality imaging is greatly valuable in clarifying the diagnosis of atypical cases.

Evaluation of right ventricular function performed by 3D-echocardiography in scleroderma patients.

The impairment of the right ventricle (RV) in systemic sclerosis (SSc) is usually related to pulmonary arterial hypertension (PAH). New echocardiographic techniques, such as 3-dimensional echocardiography (3DE) and 2-dimensional speckle tracking (2DSTE), allow an accurate evaluation of the RV function. The aim of this study was to evaluate the RV function using 3DE and 2DSTE in SSc patients with no history of heart disease and no PAH. Forty-five SSc patients, 42 females and 3 males, 28 with limited cutaneous SSc (lcSSc) and 17 with diffuse cutaneous SSc (dcSSc), were studied. Forty-three age- and gender-matched healthy subjects were enrolled as controls. All of them underwent a 3DE and 2DSTE ecocardiographic evaluation of the RV function. Systolic pulmonary arterial pressure (sPAP) and total pulmonary vascular resistance (tPVR) were also estimated by power doppler. RV echocardiographic parameters were compared in the different subsets of SSc patients. A statistical analysis was performed by t-test, ANOVA and multiple logistic regression. RV areas in 2DSTE and volumes in 3DE were higher and RV function parameters were reduced in SSc patients compared with controls. Also sPAP and tVPR were higher, but they did not reach pathological values. Echocardiographic alterations were more pronounced in patients with lcSSc. 3DE and 2DSTE echocardiography allowed us to detect morphological and functional alterations of the RV in a group of SSc patients with no clinical signs of heart disease and no PAH. These patients had significantly higher sPAP and tPVR than healthy controls without reporting values compatible with PAH. These data suggest that RV alterations are related to a pressure overload rather than to an intrinsic myocardial involvement in SSc.

Ultrasound and radiology surrogate endpoints in pharmacological studies.

Cardiovascular studies investigating therapeutic intervention with clinical endpoints are costly due to the need for considerable duration and large number of patients, or both. Therefore, for evaluation of novel cardiovascular drug efficacy, surrogate endpoints are used. Cardiovascular imaging endpoints have proven their worth. Sometimes the relevance of imaging is questioned and other methods are suggested instead. There is also some confusion about the strengths of imaging endpoints. The aim of the present paper is to review ultrasound and radiology imaging techniques as surrogate endpoints in pharmacological trials.

Acute thrombosis of mechanical mitral valve prosthesis: echo-Doppler diagnosis and successful treatment with systemic thrombolysis.

The case of a 72-year old patient with acute heart failure due to thrombosis of the mechanical mitral prosthesis is presented. The diagnosis was made by transthoracic echocardiography. The patient refused reoperation, and systemic thrombolysis was administered. After thrombolytic infusion we observe the disappearance of the echocardiographic signs of thrombosis, with concomitant improvement of symptoms.

Feasibility and clinical value of "intelligent" compression and digital storage of transthoracic echocardiograms in day-to-day practice.

BACKGROUND: The aim of this study was to assess the clinical concordance of expert cardiologists' interpretation of echocardiographic studies recorded on Super-VHS videotape or stored in magneto-optical disk, as well as the feasibility and clinical value of intelligent compression and digital storage of echocardiographic data as cine-loops and still-frames for interpretation of transthoracic echocardiographic images in clinical practice. METHODS: All clinical cardiologists experienced in echocardiography in our department (n = 10) reported on a standardized worksheet checklist the echocardiographic data of 7 consecutive patients (140 reports), and recorded them on videotape or magneto-optical disks to compare the interpretation of videotaped studies, acquired in the usual way, with clinically compressed studies stored to magneto-optical disks using a standard (Italian Society of Echocardiography) image acquisition protocol. RESULTS: The time interval between analog and digital study readings was 50 +/- 15 days. Except for tricuspid valve regurgitation grading (k = 0.28) and for left ventricular global hypokinesia (k = 0.32), the intraobserver agreement in the interpretation of the 3290 cardiovascular morphological and functional findings found on analog and digitally stored images was good (k value ranging from 0.66 to 1.00). The wall motion score index was 1.56 +/- 0.53 when interpreting analog studies, and 1.52 +/- 0.54 on digital studies (p = 0.35). Conversely, the interobserver variability of the wall motion score index (Gini index ranging from 0 to 0.80) was significantly lower when interpreting studies stored digitally than when analog ones were examined (0.48 +/- 0.021 and 0.52 +/- 0.023 respectively, p = 0.006). In comparison to videotape recordings, digital storage of echocardiographic studies significantly shortened the time to image access for study review (327 +/- 62 and 30 +/- 4 s, respectively, p < 0.0001) and the reading time (600 +/- 300 and 540 +/- 300 s respectively, p = 0.034), rendered study accessibility easier (difficult or good: 73 vs 43% of observers, fast or optimal: 27 vs 57% of observers respectively, p = 0.0011) and improved the recorded image quality perception (poor: 25 vs 10% of observers, sufficient or good: 75 vs 90% of observers respectively, p = 0.022), without loss of study completeness (insufficient: 18 vs 17% of observers, adequate or complete: 82 vs 83% of observers, respectively; p = NS). Finally, from September 1, 1999, digital storage has become routine practice for patients admitted to our Department. By December 31, 1999, 411 echo studies had been stored: 7 +/- 3 cine-loop/study, 32 +/- 18 frames/cine-loop, and 3 +/- 2 still-frames/study. The average amount of memory needed for storage was 18.6 +/- 11.9 MB/study. CONCLUSIONS: Clinical compression of echocardiographic studies seems to be an accurate summary of the complete examination recorded to videotape for the assessment of patients admitted in the coronary care unit. In addition, digitally stored studies allow a significant improvement in the interobserver reproducibility of wall motion score assessment.

[Reporting echocardiography exams with the G8-Cardio ANMCO software]. / Refertazione dell'esame ecocardiografico con il software G8-Cardio ANMCO.

BACKGROUND: The availability of a common computerized program for echocardiographic study archiving and reporting at national and/or international level could make it possible to standardize the echo reports of different echocardiographic laboratories, and to use the wealth of data thus obtainable with echocardiography, and to exploit its capillary territorial distribution, with the aim of collecting echocardiographic data in a standard format for epidemiological, scientific and administrative purposes. METHODS: To develop such a software, an ad hoc joint National Association of Hospital Cardiologists and Italian Society of Echocardiography task force worked in conjunction with the Italian Branch of Agilent Technologies to standardize the phraseology of accepted echocardiographic terms and of the quantitative parameters derived from transthoracic and transesophageal echocardiographic examination at rest as well as during exercise and pharmacological stress, and to develop an ad hoc software. This echocardiographic study archiving and reporting program is part of the whole G8-Cardio ANMCO software developed to computerize the whole cardiological chart. The software has been developed by Agilent Technologies to provide a fast, easy-access and easy to use report generator for the non-computer specialist using DBMS Oracle 7.3 database and Power Builder 5.0 to develop a user-friendly interface. RESULTS: The number of qualitative and quantitative variables contained in the program is 733 for echocardiography at rest, while it depends on the stressor and on the length of the examination for the stress echo (dipyridamole 214-384, dobutamine 236-406, exercise 198-392). The program was tested and refined in our laboratory between November 1999 and May 2000. During this time period, 291 resting and 56 stress echocardiographic studies were reported and recorded in a database. On average, each resting echocardiographic study lasting 10 +/- 4 (range 5-17) min was recorded using 50 +/- 11 (range 33-67) variables and 41,566 bytes of hard-disk memory space. Stress echocardiographic studies, each lasting 7 +/- 5 (range 5-21) min, were recorded using 143 +/- 74 (range 38-194) variables and 38,531 bytes of hard-disk memory space. CONCLUSIONS: To our knowledge this software represents the first experience of a common computerized program for echo archiving and reporting carried out at national level.

Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Oucome dello Scompenso Cardiaco in relazione all'Utilizzo delle Risore.

AIMS: This study was designed to identify potential specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for congestive heart failure in departments of cardiology or internal medicine. METHODS AND RESULTS: From 1 July to 31 December 1998, we prospectively recorded epidemiological and clinical data from patients with congestive heart failure consecutively admitted to 11 departments of cardiology and 12 departments of internal medicine in Liguria, a northern area of Italy. The overall study population included 749 patients; 22% were treated by cardiologists and 78% by internists (P<0.0001). Patients managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%) and exercise stress testing (20% vs 0.5%) than those managed by internists (P=0.001). At discharge, patients treated by cardiologists were more likely to be prescribed beta-blockers (41% to 4%) and ACE inhibitors (100% to 74%) than those treated by internists (P<0.0001), and the latter medication at higher dosages by cardiologists than internists. In addition, patients followed by cardiologists were younger (70+/-9 to 79+/-1 years;P<0.0001), more likely to be male (61% to 50%;P=0.011) and to have coronary artery disease (57% to 45%;P<0.006) than those followed by internists. Conversely, patients followed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation and renal failure (P<0.03). In the overall study population, 53 patients (7%) died during hospitalization. Patients treated by cardiologists had a mortality not significantly different from that of patients treated by internists (10% and 6%, respectively;P=0.067), although congestive heart failure was more severe on admission in patients treated by cardiologists. CONCLUSION: Cardiologists follow published guidelines for congestive heart failure more strictly than internists, but treat a smaller number of patients who are younger, have more severe congestive heart failure and fewer co-morbidities than those managed by internists.

Dynamic left ventricular outflow tract obstruction: an unusual mechanism mimicking anterior myocardial infarction with cardiogenic shock.

Cardiogenic shock is a frequent and threatening complication in the course of acute myocardial infarction. Besides the well known causes (left ventricular failure, acquired interventricular defect, papillary muscle rupture, free wall rupture) other less frequent mechanisms recognize a functional substrate. The recognition of such mechanisms makes us to revert to the treatments with completely different prognostic implications. In our Coronary Care Unit we encountered, in a period of 12 months, 4 patients who presented clinical, electrocardiographic and/or echographic signs and symptoms of acute myocardial infarction, with different degrees of heart failure up to cardiogenic shock. Only 1 patient showed a severe stenosis of the left anterior descending coronary artery and a significant creatine kinase reduction. Left ventriculography, performed at admission, was unable to disclose the true mechanism of clinical presentation. Only a thorough echographic examination disclosed the presence of a dynamic left ventricular outflow tract obstruction as the cause of heart failure culminating in cardiogenic shock. Once recognized, pathophysiological treatment (administration of beta-blockers and withdrawal of vasodilators, inotropic drugs and intra-aortic balloon pump) led to a dramatic improvement, with an almost complete left ventricular function recovery. Left ventricular outflow tract obstruction is a mechanism that can lead to severe heart failure as a complication of an acute myocardial infarction. Conversely such a mechanism can be precipitated by other causes (hypotension, hypovolemia, especially in hypertensive patients) and can mimic an acute myocardial infarction. Its incidence is not negligible: in our Coronary Care Unit it accounted for about 15% of all cases of myocardial infarction requiring inotropic support. An accurate echocardiographic examination is mandatory even after coronary angiography, and always permits the physician to select the appropriate therapy.

[The SCOOP II trial in heart failure]. / Lo studio SCOOP II (Scompenso nell'Ospedalizzazione Pubblica): proposta di un modello.

BACKGROUND: The aim of this study was to evaluate the effectiveness of a health education intervention aimed at improving therapeutic compliance and quality of life of patients with chronic heart failure (CHF). In this 1100 bed Community hospital 97% of patients with CHF admitted to the Internal Medicine Unit have a high rate of readmission, mortality and negative quality of life. METHODS: Two hundred patients (123 males, 77 females, mean age 75 years) were enrolled and randomized. CHF patients admitted to the Internal Medicine Unit were randomly assigned to usual care (n=100) or intervention group (n=100), which consisted of a nurse-guided education program, facilitated telephone communication and regularly scheduled follow-up visits with an internist. The primary endpoints were quality of life and quality of service improvement, and improved compliance with the heart failure guidelines. All patients were submitted to echocardiography. RESULTS: Ejection fraction is available for 87% of them. Baseline quality of life is similar in both groups. Final data will be available after April 2001.

[Is a more efficient operative strategy feasible for the emergency management of the patient with acute chest pain?]. / E realizzabile una strategia operativa più efficace per la gestione in urgenza del paziente con dolore toracico acuto?

Patients with acute chest pain are a common problem and a difficult challenge for clinicians. In the United States more than 5 million patients are examined in the emergency department on a yearly basis, at a cost of 6 billion dollars. In the CHEPER registry the prevalence of patients with chest pain in the Emergency Department was 5.3%. Similarly, in 1997 at our institution the prevalence was 4.8%. Only 50% of the patients are subsequently found to have cardiac ischemia as the cause of their symptoms and 50-60% of them showed a non-diagnostic electrocardiogram (ECG). Twenty-five-50% of chest pain patients are not appropriately admitted to the hospital and despite this conservative approach, acute myocardial infarction is misdiagnosed up to 8% of patients with acute chest pain who are released from the emergency department without further evaluation, accounting for approximately 20% of emergency department malpractice in the United States. Important diagnostic information is covered by the patient's medical history, physical examination, and ECG, but often this approach is inadequate for a definitive diagnosis. Creatine kinase (CK) and CK isoenzyme--cardiac muscle subunit (CK-MB)--are traditionally obtained in the emergency department in patients admitted for suspected acute coronary syndrome. Mass measurements of CK-MB have improved sensitivity and specificity, and to date this is the gold standard test for diagnosis of acute myocardial infarction. CK-MB, however, is not a perfect marker because it is not totally cardiac specific and does not identify patients with unstable angina and minimal myocardial damage. There are no controlled clinical impact trials showing that these tests are effective in deciding whether to discharge or to appropriately admit the patient with suspected acute coronary syndrome. Relevant investigative interest has recently been focused on new markers for myocardial injury, including myoglobin, cardiac troponins T and I. Myoglobin, a sensitive but not specific marker for cardiac damage, increases earlier than CK-MB and cardiac troponins. It should be used early after symptom onset and in conjunction with a more specific marker of myocardial damage. Cardiac troponins T and I are highly specific markers for cardiac damage, rise parallel to CK-MB and remain elevated longer, up to 5 to 9 days. They are useful for detection of less severe degrees of myocardial injury, which may occur in several patients with unstable angina who are at higher risk of cardiac events. Recent studies suggest that cardiac troponins have good diagnostic performance and prognostic value in the heterogeneous population of patients seen in the Emergency Department with acute chest pain. Despite these promising data, several analytical and interpretative problems in the routine use of cardiac troponins must be solved. Incremental value of echocardiography in acute chest pain patients is still uncertain. Echocardiography can be recommended as an adjunctive test if readily available during acute chest pain or prolonged pain, especially in patients without previous myocardial infarction. Rest myocardial radionuclide imaging has been studied in the emergency department setting and although the overall diagnostic performance and prognostic value of sestamibi has been found to be promising, it is not suitable, in our country, for extensive clinical use. ECG exercise stress test in the emergency department population has been shown to be safe and it has a good negative predictive value for cardiac events. It should be recommended that any institution identify specific and shared protocol and strategies for management of patients with chest pain. These should include basal clinical evaluation, serial ECG and the use of specific and sensitive myocardial markers. Adjunctive tests, such as echocardiography, nuclear studies and stress tests should be employed when indicated taking into account local facilities.

[Digital revolution in the echocardiography laboratory. Current status and future perspectives] . / La rivoluzione digitale nel laboratorio di ecocardiografia. Stato attuale e prospettive future.

Echocardiography is changing from an operative modality in which most images are stored in analog fashion on videotape into one with most data stored digitally. This transition is accelerating today, fueled by several factors. First, there is widespread recognition of the value of digital storage of echocardiograms, including random access to studies as well as to images within a study, side-by-side comparison with prior studies, easier quantification, and multiplication and remote transmission of images without degradation. Second, continuous improvement of the cost/performance ratio of modern computers makes routine digital echocardiography both feasible and affordable. Finally, the formulation and acceptance within the industry of the DICOM image formatting standard for echocardiography. The acceptance of this standard allows the echo-labs around the world to be free to choose individual echo-machines on the basis of their individual merits for their laboratories with the assurance that these machines will be able to communicate with each other by an internationally agreed upon standard. Advantages of digital echocardiography are overwhelming and there is little doubt that this approach will be essential for the proper utilization of this technique. The technology will undoubtedly continue to change. Those who are waiting for it to be perfected may be waiting for a long time.

ASSENCE (assessment of cost-effectiveness of several strategies of early diagnosis in patients with acute chest pain and non-conclusive electrocardiogram).

Clinical, economical, organizative, and medico-legal issues raised by management of citizens who come to Emergency Department with acute chest pain and non diagnostic electrocardiogram are well known. Data from the Italian Health Ministry show that, in 1996, 37,444 patients had been discharged from Italian hospitals with the main diagnosis of chest pain. To obtain this "non-diagnosis", it was needed a mean hospital stay of 4.2 days with estimated costs close to $57,000,000. The ASSENCE study is a randomized, multicenter, international trial aimed at comparing three strategies of handling citizens presenting to emergency department for unexplained chest pain in terms of cost/effectiveness ratio and quality of patients' life. The three strategies that will be compared are: 1. current clinical protocols, prescribing an in-hospital observation period and discharge after several hours/days; 2. performing a dobutamine-atropine stress echocardiography between 0 and 18 hours after randomization (at 6 hours after index chest pain onset) and discharging the patients (if negative) immediately thereafter; 3. performing an electrocardiographic exercise stress test between 0 and 18 hours after randomization and discharging the patients (if negative) immediately thereafter. The main ASSENCE study end-point will be assessment of cost/effectiveness of the 3 strategies tested. Costs will be assessed taking into account: hospital stay length, performed diagnostic procedures and treatments during index admission, in-hospital and 2-month follow-up events (cardiac death, myocardial infarction, definite unstable angina, coronary angioplasty, by-pass surgery, re-admission to hospital for chest-pain). A secondary ASSENCE study end-point will be to assess the effect on patient quality of life of the use of the 3 strategies tested. Sample size estimation calculated in order to detect an absolute difference of at least 10% and based on a 30% expected rate of events, was of 186 patients for each strategy tested.

Use of a common computerized program for echocardiogram archiving and reporting over a regional territory: feasibility and clinical and research impact during a 5-year experience.

The aims of this study were to optimize interlaboratory standardization of echocardiographic reporting (qualitative terms and quantitative parameters) and to evaluate the feasibility and clinical and research impact of collecting echocardiographic data in a standard computerized format over a geographical territory. In April 1992, a computer program of echocardiogram archiving and reporting (ARCE) was distributed at no cost to the 23 hospital echocardiographic laboratories operating in our region (Liguria). In April 1993 (1-year survey), 16 (70%) of the 23 hospital echo laboratories operating in our region were routinely using ARCE. In April 1997 (4-year survey ), 21 (87%) of the 24 echo laboratories were routinely using the system and 128,642 echocardiograms had been databased. ARCE is a powerful tool both for education and training in cardiac ultrasound and for undertaking multicenter studies by 95% of the users. Regarding the quality improvement process, we achieved 3 main goals: (1) a unique report format from 87% of Ligurian echo laboratories, which improved the communication between echocardiographers and other physicians; (2) development of specific, Ligurian population-based reference limits for M-mode and 2-dimensional quantitative parameters; and (3) interlaboratory comparison and standardization of both quantitative and semiquantitative evaluation of heart valve disease, left ventricular systolic and diastolic function, valve prosthesis function, and left ventricular hypertrophy. Regarding the scientific activity in Liguria, 9 multicenter studies in which 15 Ligurian echo laboratories took part were organized and completed in 5 years. Our 5-year experience shows that it is possible to create a large database of echocardiographic data that uses a fast, easy-access, and easy-to-use program of echo archiving and reporting that contains standardized variables. The use of this program on a regional territory scale appeared feasible and useful both for educational and training purposes. In addition, it stimulated the quality improvement process in echocardiography as well as performance of epidemiologic and clinical multicenter studies.