Diastolic time intervals before and after nadolol in patients with hypertrophic cardiomyopathy.

In 9 patients with hypertrophic cardiomyopathy, diastolic function was evaluated by noninvasive measurements of diastolic time intervals before and after nadolol administration. No significant variation of the intervals was observed after therapy. The method therefore appears scarcely useful in the evaluation of beta-blocker therapy in these patients.

Occult thyrotoxicosis in patients with chronic and paroxysmal isolated atrial fibrillation.

Thyroid function tests, including thyrotropin releasing hormone administration (TRH), were performed in 40 consecutive patients with isolated atrial fibrillation (IAF) (i.e., without any other evidence of cardiac disease). The arrhythmia was chronic in 5 and paroxysmal in 35 patients. Thyrotoxicosis could not be diagnosed either clinically or by abnormal serum levels of T4, T3, T3 BC, and thyroid stimulating hormone (TSH). Thyroid stimulating hormone response to TRH, which was normal in 35 patients, was absent in 5 (12.5%) who were considered to have occult thyrotoxicosis. One had chronic and the other 4 had paroxysmal IAF. The arrhythmia did not recur after antithyroid treatment in these four patients who were in sinus rhythm after a mean follow-up period of 21 months. Full exploration of the thyroid function therefore seems useful not only in patients with chronic IAF, but also in those affected by the paroxysmal form.

Platelet function and coagulation studies in patients with mitral valve prolapse.

Twenty-eight consecutive patients with mitral valve prolapse (MVP), seven of whom had previous cerebrovascular disorders (CVD), were studied for platelet function and coagulation tests. While platelet function tests were found to be normal with the exception of platelet aggregation rate (PAR), there was a significant rise of factors VIII vWF:Ag (Von Willebrand) and (FPA) fibrinopeptide A. Six cases had high levels of both these factors, suggesting the existence of a particular subset of patients with MVP, with a higher risk of thromboembolic episodes, although only three out of seven patients with previous CVD had either FPA or VIII vWF:Ag levels. The broad spectrum of subjects with MVP probably explains the different results obtained when studying platelet function and coagulation factors. Therefore, larger population studies and prolonged follow-up of cases with either coagulation abnormalities similar to the ones found in the present report and/or altered platelet function tests are suggested to discover if it is possible to detect patients with a potential for thromboembolism.

Spontaneous reversion to normal sinus rhythm after prolonged atrial fibrillation.

Two patients are reported in whom there was a spontaneous reversion to normal sinus rhythm after atrial fibrillation had persisted ten and fourteen years respectively. One of these patients was an exception to the general rule in as much as there was a clinical improvement when sinus rhythm appeared again. The mechanism underlying such changes in rhythm is not yet fully understood.

Two-dimensional echocardiographic findings in a case of massive cardiac involvement by malignant lymphoma.

In a patient affected by malignant mediastinal lymphoma a severe congestive heart failure and the ECG pattern suggested a heart involvement. Two-dimensional echocardiography (2DE) documented the presence of abnormalities suggestive of infiltration: in particular, enormous thickening of the left ventricle, nearly absent wall motion, and "patchy" appearance of the myocardium were seen. Necropsy findings confirmed the presence of a massive lymphomatous infiltration of the heart. 2DE, by its ability to detect abnormalities consistent with heart infiltration, should provide a useful contribution in the staging of lymphomas.

A-V block by an overdose of Clonidine.

The case of a young addict woman, chronically treated with Clonidine, in whom an overdose of the drug determined transient S-A and A-V conduction disturbances is reported. Such effects have been attributed to vagal hyperactivity and must be kept in mind when the drug is administered to patient of old age, with cardiac disease, or in association with digitalis. The treatment of choice is represented by forced diuresis induced either by osmotic diuretics of furosemide.

[Cardiomyopathy in Italy today: extent of the problem]. / Le cardiomiopatie in Italia oggi: dimensioni del problema.

Since the number of patients suffering from cardiomyopathy in Italy is unknown at present, a multicentre survey was carried out in 15 University and Hospital cardiological centres. Each centre was asked to report the number of cases of dilated, hypertrophic or restrictive cardiomyopathy observed between 1970 and 1987. Information was also sought regarding the residence of the patient at the time of diagnosis. Diagnostic criteria for each type of cardiomyopathy, based on those published in the current literature, were sent to the participating centres. For the entire period, a total of 2,229 patients with dilated, 913 with hypertrophic, and 64 with restrictive cardiomyopathy were reported. The number of cases observed between 1980-87 was about four times greater than that observed between 1970-79 for dilated cardiomyopathy and three times greater for hypertrophic cardiomyopathy. In the period 1970-79, a minimal annual incidence of dilated cardiomyopathies was calculated. In the centres this ranged from 0.005 to 1.8 per 100,000 inhabitants, although no systematic evaluation was made. On the contrary, minimal prevalence for hypertrophic cardiomyopathy ranged from 0.4 to 5.6 between 1970-79. These rates increased to 0.09-3.4 for dilated cardiomyopathy and to 1.0-23.0 for hypertrophic cardiomyopathy in the period 1980-87. On the basis of this survey the number of patients with a diagnosis of dilated and hypertrophic cardiomyopathy seems to be on the increase in our country. This increase may be due to the diagnostic facilities available, such as echocardiography, and possibly to a better knowledge and a greater interest in cardiomyopathies.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sarcoidosis with predominant cardiac involvement]. / Sarcoidosi con prevalente interessamento cardiaco.

We present a case of predominantly myocardial sarcoidosis in a 38 year-old man. A second degree atrioventricular block was the clinical presentation, followed 2 years later by sudden cardiac arrest. Autopsy revealed large areas of myocardial scarring in the left ventricular wall unassociated with atherosclerotic coronary lesions; microscopy of these areas disclosed epithelioid granuloma with giant cells embedded in a fibrohyaline tissue. The insidious cardiac involvement in sarcoidosis often hinders an exact diagnosis in life, and prognosis without therapy is severe. Histopathologic diagnosis is made only by exclusion of other systemic granulomatous diseases.

[Late ventricular potentials in patients with dilated cardiomyopathy. Correlations with spontaneous ventricular tachycardia and clinical course]. / Potenziali tardivi ventricolari nei pazienti con cardiomiopatia dilatativa. Correlazione con le tachicardie ventricolari spontanee e decorso clinico.

In a series of 55 patients with dilated cardiomyopathy, the presence of noninvasive recordings of late ventricular potentials (LVP) was correlated to ventricular tachycardia (VT), as detected by a 24-hour Holter monitoring obtained one week within LVP recording. LVPs were found in 12/55 patients (21.8%) and in 2 of a series of 66 normal subjects of the same age and sex. In all patients with LVP either non sustained (11 cases) or sustained (1 case) VT was present at Holter monitoring. In the other 43 patients without LVP only 13 (30%) had non sustained VT (p < 0.01). During the follow-up period (mean 17 months) six patients died suddenly; three of them had LVP and VT (sustained in one); two had non sustained VT, but no LVP; one had neither. This study suggests that the presence of LVP predicts VT recording in ambulatory ECGs. On the contrary, VT may be recorded in patients without LVP. Further studies are necessary to ascertain the value of LVP as a marker of sudden death in patients with dilated cardiomyopathy.

[Oral anticoagulant therapy in dilated cardiomyopathy. Warfarin treatment results in subgroups of patients at risk of embolic complications]. / Terapia anticogulante orale nella cardiomopatia dilatativa. Risultati del trattamento con warfarin in sottogruppi di pazienti a rischio di complicanze emboliche.

BACKGROUND: The aim of the study was to assess the role of oral anticoagulant therapy in patients with dilated cardiomyopathy at risk of embolic complications. METHODS: We studied retrospectively two hundred thirty-six patients with dilated cardiomyopathy; sixty-eight cases, with intracavitary thrombosis at cross-sectional echocardiography (17 patients), embolic episodes (22), N.Y.H.A. functional class IV (38), chronic atrial fibrillation (23) or with a combination of such conditions, were treated with warfarin. The cumulative period of exposure to embolic events during follow-up was 814 years in the whole population in the absence of anticoagulant treatment and 213 years during treatment. RESULTS: The rate of new embolic events was 1.6 and 0 for 100 patients-years for the two periods respectively. The difference was not statistically significant. No clinically relevant haemorrhagic complication was seen during treatment. CONCLUSIONS: Oral anticoagulant therapy may be safely given to subgroups of patients with dilated cardiomyopathy at risk of embolic episodes, following empirical guidelines, provided a careful clinical and laboratory monitoring is carried on, even if no definite conclusion may be obtained about the efficacy of this treatment from a non-randomized study with low rates of new embolic events.

[Correlations between electrocardiographic findings and echocardiographic patterns in 116 patients with hypertrophic cardiomyopathy]. / Correlazione tra reperti elettrocardiografici e quadri ecocardiografici in 116 pazienti con cardiomiopatia ipertrofica.

To evaluate the correlation between electrocardiographic and echocardiographic m-mode (E-TM) and two-dimensional (E-2D) patterns, 116 patients with hypertrophic cardiomyopathy (HCM) were studied by these two methods. Patients were classified into four types, according to Maron et al's E-2D classification of HCM. In addition a subgroup (IIIb) of 15 patients in types III, had typical left ventricular concentric hypertrophy. Twelve per cent of the study patients had a normal ECG, and most often those patients showed types I-II and IIIb. Left ventricular hypertrophy by ECG was most frequent (46%) and was found mostly in type III (P less than 0.02). Abnormal Q waves, suggestive but not diagnostic of HCM, were found in 22 of 116 (18%) patients, and were present in equal proportion in each morphologic type. Isolated ST-T changes were found in the same percentage of patients. Six of 7 patients with giant negative T waves had apical left ventricular hypertrophy, but 4 other patients with apical hypertrophy had no such ECG findings. Mean left atrial dimensions at E-TM, although larger in patients with atrial fibrillation, with statistical significance (P less than 0.001), were not predictive of this arrhythmia. ECG is still useful in the diagnosis of HCM, although there is no abnormal pattern specific for the disease, and even a normal ECG can be found in these patients.

[Usefulness of 2-dimensional echocardiography in emergency surgical treatment. Description of a case of metastatic sarcoma of the right ventricle]. / Utilità dell'ecocardiografia bidimensionale nel trattamento chirurgico d'urgenza. Descrizione di un caso con sarcoma metastatico del ventricolo destro.

A case of metastatic tumor, occupying a large part of right ventricular cavity, is reported. An accurate diagnosis was allowed by 2-D echocardiography and the patient was immediately sent to cardiac surgery. 2-D echo was also useful in the postoperative evaluation of surgical results.

[The evaluation of pulmonary artery pressure by suprasternal notch M-mode echocardiography]. / Valutazione della pressione polmonare mediante ecocardiografia M-Mode per via soprasternale.

Four hundred subjects without any sign of cardiac disease were studied by M-Mode echocardiography both by the parasternal approach, in order to record the pulmonary valve and by the suprasternal approach, in order to visualize the aortic arch and right pulmonary artery. Successful recordings were obtained respectively in 70.2% and 92.7% of the attempts. Furthermore we examined with both approaches, 20 patients (pts) with rheumatic mitral valve disease and mean pulmonary artery pressure (mPAP) greater than 20 mmHg (group A), 20 pts with rheumatic mitral valve disease and mPAP less than or equal to 20 mmHg (group (B) and 20 healthy subjects, homogeneous for age and sex (group C). In group A, the pulmonary valve was well recorded by the parasternal approach in 14 pts (70%). Only 9 (45%) showed a diagnostic pattern of pulmonary hypertension. By suprasternal echocardiography we measured the aortic arch/right pulmonary artery end-diastolic ratio: this index, successfully obtained in all pts of group A, B and C, was significantly (p less than 0.001) lower in group A versus group B and C and was significantly correlated (r = 0.84) with mPAP. We, therefore, conclude that the suprasternal M-Mode echocardiographic evaluation of the pulmonary artery is technically easier than the parasternal visualization of the pulmonary valve. Furthermore, it seems to be able to detect more accurately, at least in a selected population, pts with pulmonary hypertension.

[Evaluation with Doppler echocardiography of the Bjork-Shiley Monostrut prosthesis in the mitral position]. / Valutazione mediante ecocardiografia Doppler della protesi Björk-Shiley Monostrut in posizione mitralica.

The Doppler characteristics of Björk-Shiley Monostrut prostheses in mitral position were studied in 53 patients (35 women; 18 men; mean age 53.8 yrs). Valvular function was considered normal on the basis of clinical and echocardiographic evaluation. Mean follow-up after surgery was 23.9 +/- 12.0 months (range 9-53). M-mode, two-dimensional and colour flow mapping echo were performed in each patient. Transvalvular blood flow characteristics were examined by colour flow imaging whereas peak and mean gradient through the valve, pressure half-time and prosthetic area were calculated using continuous wave Doppler. In 84% of patients, colour flow mapping showed a transprosthetic flow with 2 jets; in 78% the jets were different: the main one was directed towards the free wall of left ventricle in 52% and towards the interventricular septum in 48%. Thus, the main jet direction was dependent on the spatial position of the prostheses and the orientation of the disc. In 16% a single jet flow was present during the whole diastole. CW Doppler showed the following parameters: peak velocity 1.6 +/- 0.3 m/s; peak gradient 10.7 +/- 3.9 mmHg; mean gradient 3.8 +/- 2.3 mmHg; pressure half-time 83.3 +/- 16.6 msec; prosthetic area 2.7 +/- 0.51 cm2. No statistically significant difference was found between different size prostheses. Our data show the excellent long term hemodynamic parameters of Björk-Shiley Monostrut mitral prosthesis and confirm the value of colour flow mapping in identifying normal transprosthetic flow profile.

[Alcoholic cardiomyopathy in the preclinical stage: non-invasive clinico-instrumental research study on 112 chronic alcoholics]. / Cardiomiopatia alcoolica in fase preclinica: studio mediante indagini clinico-strumentali non invasive in 112 alcoolisti cronici.

112 consecutive asymptomatic patients who assumed alcohol in excess (1-2 g/kg/die) for 5 years or more were admitted to our hospital for detoxication. They were examined both clinically and with chest x-rays, ecg, phonocardiography, external pulse recording, and M-mode/2-D echocardiography to detect myocardial involvement. Heart disease not related to alcohol abuse was found in 6 cases. In the remaining 106/112 patients electrocardiographic abnormalities (aspecific ST-T changes, left bundle branch block, intraventricular conduction defects, left ventricular strain pattern and atrial fibrillation) were present in 18 per cent of cases. PEP, LVET intervals and PEP/LVET, were calculated only in 39/106 patients and did not differ significantly from the control group. The echocardiographic study showed hypokinesis and left ventricular dilatation in 9/106 patients. In other 5 cases echocardiographic findings were at upper limits of normal for left ventricular dimension and motility. Therefore in 13 per cent of cases a dilated cardiomyopathy was revealed by the echocardiographic study. In 6 of these 13/106 patients ecg was either normal or showed only aspecific ST-T changes. Echocardiography failed to confirm augmented left ventricular thickness and mass as reported in asymptomatic alcoholic patients in the literature. Probably several factors (different interval of time between the interruption of the alcoholic abuse and the time of examination, the quantity of alcohol in excess and the echocardiographic technique) may influence the results of such studies. The present report nevertheless points out to the validity of the echocardiographic study in the detection of subclinical myocardial involvement in alcoholic patients and should be performed in such cases.

Nonsustained ventricular tachycardia as a predictor for sudden death in patients with idiopathic dilated cardiomyopathy. The role of amiodarone treatment.

BACKGROUND: Sudden death frequently occurs in patients with idiopathic dilated cardiomyopathy. Ventricular arrhythmias are encountered in almost all cases. The prognostic significance of life-threatening arrhythmias such as successfully resuscitated ventricular fibrillation and sustained ventricular tachycardia is well known, while it is controversial for ventricular arrhythmias of a lower degree. Amiodarone has been used widely in these patients but its value in preventing sudden death is still uncertain. The aim of this study was to evaluate the prognostic significance of runs of nonsustained ventricular tachycardia (NSVT) as a hallmark for sudden death and the efficacy of amiodarone in preventing sudden death and reducing overall mortality in a large series of patients with dilated cardiomyopathy. METHODS: Over the period between 1983 and 1994, a series of 151 consecutive patients with idiopathic dilated cardiomyopathy underwent ambulatory electrocardiographic monitoring for a mean period of 191 hours/patient. Seventy-nine patients (56 male, mean age 50.7 +/- 13.1 years) (group A) had ventricular arrhythmias of Lown class < or = 4A, while 72 (53 male, mean age 48.6 +/- 12.8 years) (group B) had one or more NSVT runs. The two groups were well matched in terms of clinical features. Mean follow-up period was 86.8 +/- 38.7 and 74.7 +/- 39.5 months, respectively. In group A no antiarrhythmic drug was administered, while in group B 54/72 patients were treated with amiodarone (mean dosage 300 mg/day) for a mean period of 69.7 +/- 37.8 months (group B1). The remaining 18 patients received class I antiarrhythmic drugs, mexiletine (12) and propaphenone (6) for a mean period of 46.1 +/- 29.4 months, because amiodarone was contraindicated (3) or serious side-effects occurred during amiodarone treatment (15), which was discontinued after a mean period of 3.8 +/- 3.1 months (group B2). RESULTS: The cumulative survival probability in the whole population was 86.6% at two years and 65.6% at five years. The rate of sudden death was 6.0% at two years and 18.3% at five years. No statistically significant difference was observed in terms of all-cause mortality or sudden death in the three groups (A, B1, B2). In group B1, amiodarone determined the disappearance of NSVT at Holter monitoring in 50% of patients (27), with no significant difference in the rate of sudden death between the two subgroups. CONCLUSIONS: In unselected patients with idiopathic dilated cardiomyopathy, cardiovascular mortality does not differ between those with NSVT on chronic amiodarone treatment and those without NSVT who have not undergone antiarrhythmic therapy. There was a trend towards a higher overall and sudden mortality rate in patients with NSVT treated with other antiarrhythmic drugs vs patients with NSVT treated with amiodarone, but due to the small size of the first group no significant difference could be calculated. Assuming NSVT as a potential prognostic marker for sudden death, amiodarone treatment may have exerted a beneficial effect in these patients, but this statement is only a presumption due to the limitations of our study. The disappearance of NSVT during amiodarone treatment is not predictive of a reduced rate in sudden death, so that the potential effect of the drug does not appear to be related to the suppression of NSVT at Holter monitoring.

[Pulmonary atelectasis and massive pleural effusion. Echocardiography]. / Atelettasia polmonare e versamento pleurico massivo. Aspetti ecocardiografici.

Pulmonary atelectasis can be detected by Two Dimensional Echocardiography (2D-E) when massive pleural effusion is present. A triangular mass, base toward the mediastinum and apex moving freely in the pleural cavity, is shown by 2D-E either in an apical modified view in left pleural effusions or in a subcostal modified view in right pleural effusions. The texture of the mass is liver-like. Three cases are reported by way of example. Differential diagnosis with other masses, such as pleural or pericardial metastasis, is discussed.

[Mitral valve prolapse. A prevalence study using bidimensional echocardiography in a young population]. / II prolasso della valvola mitrale. Studio della prevalenza mediante ecocardiografia bidimensionale in una popolazione giovanile.

The results of many studies on the prevalence of mitral valve prolapse have been greatly influenced by the diagnostic methods and criteria adopted as well as by population selection. The method of choice today is 2d-echocardiography because of its ability to highlight both movement anomaly (i.e. functional prolapse) and any eventual morphological variations of the mitral valve (i.e. anatomic prolapse). The latter (chordae lengthening, thickening and overabundance of the leaflets, dilation of the valvular ring) are, nowadays, considered especially important even as predictive factors of complications. Therefore we studied the prevalence of these two types of prolapse in a population of 420 university students. Functional mitral valve prolapse was found in 27/420 (6.4%) and anatomical prolapse in 2 cases (0.5%). No auscultatory finding was present in 24/27 patients with functional prolapse. There was no correlation between the two types of mitral valve prolapse and the body mass index, the fractional shortening of the left ventricle and symptoms (dyspnea, palpitations, precordial pain, dizziness). We think that the distinction between the two types of mitral valve prolapse should prove very useful for the comparison of results in future epidemiological studies. Follow-up of both groups of patients will hopefully clarify the usefulness of such distinction from the clinical point of view.

Lack of correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy.

The correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic embolism was studied in 126 consecutive patients with idiopathic dilated cardiomyopathy who were examined from January 1980 to September 1987. A total of 1041 serial echocardiograms were obtained with 3.5 and 5 MHz transducers. The mean follow up period was 41.2 months. The survival rate was 88% at two years and 56% at five years. Echocardiography showed intracavitary thrombi in 14 (11.1%) patients; 13 were mural and 11 were localised at the apex of the left ventricle. Twelve patients (8.4%) had systemic emboli; this corresponded to an incidence of new embolic events of 1.4 for 100 patient-years. Patients with intracavitary thrombi or systemic emboli were treated with oral anticoagulants, as were nine in functional class IV of the New York Heart Association, for 61 patient-years. The cumulative observation period for the whole population study was 418 patient-years. None of the patients with intracavitary thrombosis had embolic complications and none of those with embolism had intracavitary thrombi. Rates of intracavitary thrombosis and systemic embolism in this series were low and there was no overlap between the two events. This may have been because the patients did not have severe dilated cardiomyopathy, because echocardiography did not detect all the thrombi, or because patients were treated with oral anticoagulants. The presence of intracardiac thrombosis detected by cross sectional echocardiography is not predictive of systemic embolism in patients with idiopathic dilated cardiomyopathy. Criteria for the use of the anticoagulant treatment remain largely empirical in these cases.