T wave normalization in infarct-related electrocardiographic leads during exercise testing for detection of residual viability: comparison with positron emission tomography.

OBJECTIVES: We investigated the sensitivity and specificity of exercise-induced T wave normalization (TWN) in infarct-related electrocardiographic leads (IRLs) for detection of residual viability in the infarct area. BACKGROUND: The meaning of exercise-induced TWN on IRLs is not yet well understood. Recent reports suggest that TWN during dobutamine echocardiography could indicate the presence of viable myocardium. METHODS: We evaluated 40 consecutive patients with a recent acute myocardial infarction and negative T waves in at least two IRLs. All patients underwent exercise testing; positron emission tomography (PET) with nitrogen-13 ammonia and fluorine-18 fluorodeoxyglucose; and coronary angiography. RESULTS: Twenty-four patients showed exercise-induced TWN: 18 at a work load < or =50 W (group la) and 6 at a work load > or =75 W (group 1b); 16 patients did not show TWN (group 2). On the PET study, viability in the infarct area was present in 17 patients (94%) from group la, in only 1 (16%) from group 1b and in 4 (25%) from group 2 (p < 0.0001). The sensitivity, specificity and diagnostic accuracy of exercise-induced TWN, in comparison with residual viability, were, respectively, 82%, 67%, 75% for TWN at every work load and 77%, 94%, 85% for TWN at a work load < or =50 W. Moreover, the sensitivity and diagnostic accuracy of TWN at the low work load were higher for anterior infarctions (87% and 88%, respectively). CONCLUSIONS: Exercise-induced TWN on IRLs at low work loads is a sensitive and specific index for the presence of residual viability in the infarct area. Sensitivity and diagnostic accuracy of this sign are higher for anterior infarctions.

Effects of left bundle branch block on myocardial FDG PET in patients without significant coronary artery stenoses.

UNLABELLED: Cardiac PET studies in patients with left bundle branch block (LBBB) are few, and the results are conflicting. In particular, even if a reduced uptake of FDG is reported, confirmation in a large group of patients and exact understanding of the underlying cause are lacking. METHODS: We selected 29 consecutive patients who had complete LBBB and no significant stenosis on coronary angiography scheduled for FDG and 13N-NH3 PET for myocardial viability evaluation at our center. Wall motion was evaluated using 2-dimensional echocardiography. Ten volunteers without coronary stenosis or LBBB served as a control group. RESULTS: All LBBB patients had a reverse mismatch in the septum, defined as reduced uptake of FDG in comparison with 13N-NH3. The mismatch extended to the anterior and inferior walls in 17 patients. The mean (+/-SD) septal-to-lateral ratio was 0.57 +/- 0.11 for FDG (range, 0.28-0.76) and 0.99 +/- 0.12 for 13N-NH3 (range, 0.75-1.18), with P < 0.0001. In contrast, no significant differences in uptake were seen in the control group, which had a septal-to-lateral ratio of 0.95 +/- 0.13 for FDG (range, 0.78-1.15; P < 0.01 with respect to LBBB patients) and 0.94 +/- 0.11 (range, 0.85-1.20) for 13N-NH3. CONCLUSION: Our study suggests that in LBBB patients without significant coronary stenosis, FDG uptake in the septum changes without a correlating change in perfusion. To avoid possible overestimation of necrosis, especially in the LAD territory, this phenomenon must be considered in evaluations of myocardial viability using FDG images.

[Post-infarction rupture of the interventricular septum. A report on 2 cases studied by color-coded Doppler]. / Rottura post-infartuale del setto interventricolare. Descrizione di due casi studiati con Doppler a codice di colori.

Rupture of interventricular septum is an infrequent but serious complication of acute myocardial infarction. We report the cases of two patients admitted to our department for acute myocardial infarction whose clinical course was complicated by rupture of the interventricular septum. They died from cardiogenic shock on the 13th and 6th days. Two dimensional and color coded echocardiography correctly detected the presence and the site of the rupture.

[Long-term evaluation of a new single lead VDD pacemaker]. / Valutazione a lungo termine di un nuovo pacemaker VDD monocatetere.

Since June 1988 we have implanted 36 VDD pacemakers with single lead catheter which has floating differential sensing (Phymos). The patients were affected by 2nd and 3rd degree AV block with normal sinus node function. The reliability of the pacing system was assessed acutely and after 1 and 3 months and then every six months with ECG, Holter 24 hours monitoring, exercise stress test and nifedipine test. Two patients died during the follow-up period and two had atrial fibrillation. In the remaining patients an AV synchronization between 95 and 100% was demonstrated.

[Endocarditis at risk of embolism. An indication for prophylactic surgical treatment?]. / Endocardite a rischio embolico. Indicazione al trattamento chirurgico profilattico?

Two cases of embolic infective endocarditis on bicuspid aortic valve are described. The trans-thoracic and trans-esophageal echocardiographic aspect could leave easily suppose the possibility of embolism. The prophylactic surgical treatment, during the active phase, also if the indication is debated, could have probably avoided the serious consequences of embolism.

[Floating thromboembolism of the right atrium in pulmonary embolism. Effectiveness of treatment with rTPA]. / Tromboembolo fluttuante nelle cavità cardiache destre in corso di embolia polmonare. Efficacia del trattamento con rTPA.

We describe a case od echocardiographic visualisation of right atrial thrombus in a patient affected by pulmonary embolism. The thrombus had the characteristic aspect of embolus with venous origin. The litic treatment with rTPA, during echocardiographic monitoring, was effective with disappearance of the thrombus and quick improvement of symptoms.

[Role of transesophageal echocardiography in the diagnosis of obstructive hypertrophic myocardiopathy. Report of 2 cases and review of the literature]. / Ruolo dell'ecocardiografia transesofagea nella diagnosi di miocardiopatia ipertrofica ostruttiva. Descrizione di due casi e revisione della letteratura.

Two cases of obstructive hypertrophic cardiomyopathy, in which the transthoracic echocardiography was not enough to reach the right diagnosis, are reported. The transesophageal echocardiography revealed to be the most useful technique to reach the exact diagnosis and more information about the mechanism of the left ventricular outflow tract obstruction. Moreover, this technique could be useful to direct to a surgical treatment and to monitorize the mitral valve function and the possible complications during operation.

[Micro-Ebstein. Presentation of 3 cases and analysis of the literature]. / Micro-Ebstein. Presentazione di tre casi e analisi della letteratura.

The authors describe three cases of micro-Ebstein diagnosed using 2D-echocardiography in patients affected by extrasystolic cardiopalm. The most important echocardiographic criterion for diagnosis was an apical displacement of the septal cusp of the tricuspid valve of at least 8 mm/m2 BA. It is generally reported that the severity of arrhythmias is independent of the degree of tricuspid malformation. The anatomical substrates of arrhythmias are persistent anomalous muscular by-passes between the atrium and the ventricles, and intrinsic anomaly of the right ventricular myocardium. For these reasons, it is necessary to follow-up patients and monitor arrhythmias using Holter-ECG. Echocardiography is now recognised as being the most important tool for the identification of this anomaly.

[Anomalous muscle band of the left heart ventricle and negative anterior T wave in young men]. / Banda muscolare anomala del ventricolo sinistro e T negative in sede anteriore nel giovane.

Two cases of left ventricular bands, detected by two-dimensional echocardiography, in two young men are described. In both cases anterior negative T waves were present. Therefore, the possible presence of these structures should always be investigated, by two-dimensional echocardiography, when anterior negative T waves are present in normal young people.

[Cardiac echinococcosis. Description of a case with cysts localized in the free wall of the left ventricle]. / Echinococcosi cardiaca. Descrizione di un caso con cisti localizzata nella parete libera del ventricolo sinistro.

A case of isolated cardiac echinococcosis is reported. A 19-year-old man was hospitalized for chest pain with electrocardiographic pathological Q waves in D1, aVL, V5, V6. Two-dimensional echocardiography and chest computed tomography documented pericardial effusion and an intramyocardial cyst. Casoni's reaction and immunological tests completed the diagnosis of cardiac hydatidosis. The localization and the etiology of the cyst were confirmed during cardiac surgery.

[Electrocardiography and myocardial viability]. / Elettrocardiografia e vitalità miocardica.

After an acute myocardial infarction, the cardiologist cannot discard data regarding myocardial viability. The most frequently used diagnostic methods for this are echocardiographic or scintigraphic techniques; unfortunately, these techniques are operator sensitive or expensive. However, also by simple electrocardiography is it possible to obtain important information about myocardial viability, in an objective and economic way. There are three electrocardiographic modifications potentially related to myocardial viability: 1) spontaneous modifications after an acute myocardial infarction: early or late T wave normalization, and Q wave regression; 2) exercise-induced modifications: ST segment elevation, T wave normalization, ventricular arrhythmias; 3) dobutamine-induced modifications: ST segment elevation and T wave normalization. In this editorial, the authors report the literature data on the various electrocardiographic signs and analyze their accuracy and utility in myocardial viability assessment.

[Large thrombus in non-aneurysmal descending aorta and peripheral embolism: report of a case and review of the literature]. / Voluminoso trombo in aorta discendente non aneurismatica ed embolia periferica: descrizione di un caso e revisione della letteratura.

We describe the case of a middle-aged woman with massive thrombosis of the aortic bifurcation, treated with emergency surgery. The patient was later evaluated by transthoracic echocardiography, which resulted normal, and by transesophageal echocardiography, which demonstrated a huge thrombus in the lumen of the descending thoracic aorta, in the absence of gross vessel wall abnormalities. Thus, the patient underwent a second surgical intervention and the thrombus was successfully removed. The episode led us to review the medical literature about cases of thrombosis and embolization originating from macroscopically normal aortas. This review underscores the diagnostic yield of the transesophageal study of the aorta in patients with systemic embolization (particularly in the presence of risk factors for atherosclerosis) and supports a wider indication of transesophageal echocardiography in the evaluation of systemic embolizating syndromes.

Cost finding in the diagnostic imaging service.

The experience with control and reporting system at the "Policlinico A. Gemelli" based on the integrated use of cost and service information drawn from all applications of Hospital Information System, are described. Cost accounting for services based on about 500 operating units and monthly reporting system, inclusive of all management information communicated to all managers, is analyzed. The system design, based on the specific features of Diagnostic Imaging Service especially for internal handling, staff of operating rooms and of emergency service, is described.

Implementation of a management information system for hospital use at the Policlinico Universitario A. Gemelli.

First, the experience with the implementation of HISs at the "Policlinico Gemelli", is reported. They were adopted since long for management support. In fact, they are playing an increasingly relevant role in health care facilities. Subsequently, operational applications are described with particular reference to the most recent ones, implemented within European projects with partial EEC financing. They are very useful to the medical and nursing personnel and for patient data management during treatment. Finally, the accounting system for cost centers, using, processing and integrating data of all used information systems, is described. It affords a low cost aggregation of all information about costs and services required for the management of four-hundred elementary operating units which constitute the structure. This system is representative of all managerial information of the "Policlinico" which is included in monthly reports, also described. They are sent to the Direction and managers of the organizational units. The system is a strategic tool of the utmost importance for rapid and effective management.

[Hemopericardium caused by cardiac perforation during anticoagulation therapy. Description of 2 cases]. / Emopericardio da perforazione cardiaca in corso di terapia anticoagulante. Descrizione di due casi.

We describe two cases of cardiac tamponade following a right ventricular wall perforation, due to temporary stimulating catheter, during acute myocardial infarction. The pericardial effusion, which occurred after the catheter remotion, could have been favoured by the anticoagulant treatment.

[Effects on myocardial perfusion of epidural spinal cord stimulation in refractory angina. Description of a case studied with positron emission tomography]. / Effetti sulla perfusione miocardica della stimolazione spinale epidurale nell'angina refrattaria. Descrizione di un caso studiato con tomografia ad emissione di positroni.

We describe a case of patient with severe angina pectoris unresponsive to medical therapy who was treated with spinal cord stimulation. The patient was studied by dynamic positron emission tomography (PET) (13-N ammonia) and with heart rate variability. Spinal cord stimulation was effective in reducing anginal attacks and PET documented an enhancement of myocardial perfusion when spinal stimulator was activated. Heart rate variability did not change during spinal cord stimulation.

[Left cor triatriatum in a man over 60]. / Cuore triatriato sinistro in uomo ultrasessantenne.

A case of cor triatriatum in a 66-year-old man is reported. The patient died of pneumonia; ante mortem diagnosis was made with both transthoracic and transesophageal echocardiography. Autopsy finding showed a very good correlation between anatomical and echocardiographic abnormalities. Cor triatriatum is amenable to surgical correction and echocardiography is extremely helpful in the diagnosis.

[Cardiac metastasis of Grawitz tumor: transesophageal monitoring of the effectiveness of antineoplastic therapy]. / Metastasi cardiache di tumore di Grawitz: monitoraggio con ecocardiografia transesofagea dell'efficacia del trattamento antiblastico.

A patient with carcinoma of the kidney and right heart metastasis is reported. Transesophageal echocardiography allowed to detect the cardiac metastasis and to control the efficacy of antineoplastic therapy. The surgical resection of the primitive tumor was subsequently possible.

[Traumatic rupture of the chordae tendineae in acute tricuspid insufficiency. Early detection with transesophageal echocardiography]. / Rottura traumatica di corde tendinee con insufficienza tricuspidale acuta. Diagnosi precoce con ecocardiografia transesofagea.

An uncommon case of traumatic rupture of chordae tendineae with tricuspid regurgitation is described. The early diagnosis, in a patient with polydistrectual injuries, was done by transesophageal echocardiography. This technique allowed accurate diagnosis of the type of lesion suggesting the opportunity to perform an echocardiogram, possibly transesophageal, in all patients with blunt thoracic trauma, even in the absence or with subtle clinical manifestations of cardiovascular involvement.

[Thrombosis on a mitral valve prosthesis: treatment with urokinase and color-Doppler monitoring]. / Trombosi su protesi valvolare mitralica: trattamento con urokinasi e monitorizzazione con color-Doppler.

A case of thrombolytic treatment with urokinase on a Sorin mitral prosthesis is described. Thrombolytic therapy, that is an alternative to valvular replacement was effective. Color-Doppler showed as a reliable method to monitor therapy effectiveness. However, a serious complication was cerebral embolism.