First results of an eye lens dosimetry survey in an interventional cardiology department.

The eye lens annual dose limit for exposed personnel to ionizing radiation has recently been revised by the ICRP--International Commission on Radiological Protection and the proposed new limit has been accepted by European legislation through the Council Directive 2013/59/EURATOM 2013. Among medical exposed personnel, the staff performing interventional cardiology are usually affected by relevant doses. For this reason a survey, employing dosemeters characterized in terms of H(p)(3), was performed in order to get the order of magnitude of the doses received by the eye lens, at least as a first guess.The survey showed that the annual dose limit can easily be reached if a proper radiation protection approach is not implemented.

[Nutritional and Functional assessment of peritoneal dialysis patients in the clinical practice: Report from MITO-DP Group]. / Valutazione Nutrizionale e Funzionale dei pazienti in dialisi peritoneale nella pratica clinica: l'esperienza del Gruppo Medico-Infermieristico Toscano di Dialisi Peritoneale (M.I.TO.-DP).

Nutritional abnormalities and physical inactivity are risk factors of increased morbidity and mortality in patients with ESRD. Identify and define malnutrition, in particular protein-energy depletion (PEW), is an important task in the management of renal patients. The aim of this multicenter observational study was to implement the assessment of nutritional status and functional capacity in patients on peritoneal dialysis, including tests and validated methods which are relatively easy to apply in daily clinical practice. The study includes all the 133 prevalent patients (80 m, 53 f, age 65 14 years), in peritoneal dialysis treatment (vintage 26 19 months) in 9 centers in Tuscany. We performed anthropometry, bioimpedance (BIA), clinical biochemistry, evaluation of habitual physical activity (RAPA tests) and performance (Sit-To-Stand test), appetite-evaluation questionnaire, and indices including the Malnutrition Inflammation Score (MIS), Geriatric Nutrition Risk Index (GNRI), Charlson comorbidity index, Barthel and Karnowsky index. The latter showed a condition of dependence in 7.2% and 19.7% of cases, respectively. Poor appetite was recorded in 48.2%. The majority of patients fell within the overweight / obesity range (51%) with waist circumference values associated with increased cardiovascular risk in 51% of males and 60% of females. At the BIA analysis, a BCMI <8 kg/m2 was detected in 39% of patients; an estimated protein intake <1.0 g / kg/d was found in 59% of cases; 34% of patients had serum albumin <3.5 g / dl; control of acidosis was good (bicarbonate 25.4 3.8 mM) but hyperphosphatemia was present in 64.6% of patients. A condition of sedentary or light physical activity was reported by 65.1% of patients, vigorous activity only by 11.9%. The 86.5% of patients able to perform the Sit-to-stand test reported a lower than the reference values for age and sex. A diagnosis of PEW was possible in 8% of our series, while a MIS score> 11, indicative of PEW, took place in 12.7% of cases. The values of the MIS correlated directly with age and the degree of comorbidity and inversely with the sit-to-stand test, RAPA tests and appetite level. The data in this study show that single tests indicative of malnutrition disorders are frequent to be found in our series of peritoneal dialysis patients. However, a diagnosis of PEW is quite infrequent. A large percentage of patients are overweight with increased abdominal adiposity, and reduced cell mass and protein intake below recommended levels; the level of habitual physical activity is low, and the level of physical capability is scarce. Therefore it is conceivable a nutritional counseling intervention to increase the intake of proteins, limiting the phosphorus and (when indicated) energy intake and to stimulating spontaneous physical activity or arranging assisted programs for functional rehabilitation. Close monitoring of the nutritional status and implementation of programs of adapted physical activity should have a prominent role in the clinical management of patients on peritoneal dialysis.

Results of coronary stenting for unstable versus stable angina pectoris.

Coronary artery stenting has been shown to improve the short- and long-term results of coronary angioplasty in mainly stable patients with 1-vessel disease, but it is uncertain whether its use in an unstable clinical setting may be safe and useful. To evaluate the stenting efficacy in patients with unstable angina, we retrospectively examined our experience with the Palmaz-Schatz balloon expandable stent in 231 consecutive patients. Patients were divided into 2 groups on the basis of symptoms at the time of stent implantation: group U (132 patients) had unstable angina, and group S (99 patients) had stable angina. After stent insertion, patients were treated with anticoagulant or combined antiplatelet therapy. Baseline characteristics of the 2 groups were comparable with the exception of age (higher in the unstable group) and angiographic characteristics of the target lesions (more unfavorable in unstable patients). In both groups, coronary stenting presented a high procedural success rate. Major in-hospital complications occurred in 9 unstable (6.8%) and in 2 stable (2%) patients (p = NS) and were mainly related to subacute stent thrombosis. In both groups, subacute stent thrombosis mostly occurred in patients treated with anticoagulant therapy (7 of 9 unstable patients, 2 of 2 stable patients). At 6-month follow-up, unstable and stable patients had a similar incidence of death (0%), Q-wave myocardial infarction (0%), and need of coronary artery bypass graft (3.2% vs 4%, p = NS), but coronary angioplasty repetition (4.8% vs 14%, p = 0.027) and target vessel revascularization (6.3% vs 17%, p = 0.019) rates were lower in the unstable group. In conclusion, stent insertion increases the short- and midterm coronary angioplasty effectiveness in unstable angina, making it possible to achieve outcomes quite comparable to stable angina. Compared with conventional anticoagulant regimen, combined antiplatelet therapy after placement of coronary stents seems to reduce the incidence of subacute thrombosis also in this clinical setting.

An unusual marrow transplant complication: cardiac myxoma.

We report a right atrial myxoma which suddenly developed in a thalassemic patient after allogeneic bone marrow transplantation. The tumor was first detected by echocardiography on day +47 after transplant and the patient underwent surgical removal of the myxoma on day +103. The post-operative course was uneventful, and at more than 3 years from the event, he is alive and well, cured from his congenital disease, with no detectable intra-cardiac tumor. The onset of the myxoma in the early post-transplant period and the extremely high velocity of growth suggest a possible relationship of this condition with the immunosuppressive status.

Coronary stenting for unstable angina: predictors of 30-day and long-term clinical outcome.

BACKGROUND: Unstable angina is usually caused by acute thrombosis superimposed on a fissured plaque. Coronary artery stenting has been shown to improve short- and long-term results of coronary angioplasty in mainly stable patients with one-vessel disease, but it is uncertain whether its use in an unstable clinical setting can be safe and useful. This study sought to evaluate the results of coronary stenting in unstable angina and to determine patient, lesion and procedure-related predictors of 30-day and long-term ischemic events. METHODS: We studied 266 consecutive patients (mean age 62 +/- 9 years) with unstable angina who underwent coronary artery stenting. The procedure was performed electively in 24%, in bailout situations in 11% and for a suboptimal result of conventional angioplasty in 65%. After stent implantation, patients were treated with anticoagulation (61) on combined antiplatelet therapy (200). Multivariate logistic regression analyses were performed to determine 30-day and long-term predictive factors of ischemic complications. RESULTS: Procedural success was obtained in 261 patients (98.1%). During the first 30 days after stenting, one patient died from cardiogenic shock (0.3%) and six (22%) suffered a non-fatal Q-wave myocardial infarction. Patients with combined antiplatelet therapy had a significantly lower stent thrombosis rate (1.5% versus 11.4%, P = 0.002) than those treated with anticoagulant regimen. At long-term follow-up (17.7 +/- 9.4 months) cardiac mortality myocardial infarction and target-vessel revascularization rates were 0.4%, 1.5% and 9.3%, respectively. In multivessel and diabetic patients, a worse long-term event-free survival was observed. Logistic multivariate analysis revealed bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm as predictors of 30-day ischemic events. In addition, multivessel coronary artery disease and stent application with balloon size of less than 3 mm were predictive of long-term ischemic events. CONCLUSIONS: This study demonstrates that, either electively or after failure of conventional angioplasty, coronary stenting represents an effective therapy for patients with unstable angina. In the same clinical setting, combined antiplatelet therapy is associated with a lower 30-day stent thrombosis rate than anticoagulant therapy. Bailout stenting, anticoagulant therapy, implantation of stents longer than 15 mm were shown to be predictors of 30-day ischemic events, whereas multivessel coronary artery disease and stent application with small balloon size were predictive of long-term ischemic events.

Percutaneous transluminal coronary angioplasty of the very proximal left anterior descending artery lesions: immediate results and follow-up.

In order to assess the results of percutaneous transluminal coronary angioplasty of the proximal (before the first septal branch) left anterior descending artery lesions, we analyzed the results in 206 consecutive patients, aged 56 +/- 12 years. The distance of the lesion from the origin of the left anterior descending artery was measured in the right oblique angiogram. The location of the lesions proved to be very proximal (less than 0.5 cm from the origin) in 22 patients, intermediate (0.5-1 cm from the origin) in 26 patients and distal (greater than 1 cm from the origin) in 158 patients. The initial angiographic success rate was similar among the 3 groups of patients: 95.8% in those with very proximal and intermediate lesions and 98.1% in those with distal lesions. Occlusive dissection of the left anterior descending artery without involvement of the mainstem occurred in 3.8% of the patients with intermediate lesions and in 1.9% of those with distal lesions. No complications occurred in any patient with very proximal lesions. The clinical follow-up was 25.2 +/- 12 months; angina recurred in 15.5% (31 out of 206 patients). Coronary angiography was performed in 103 patients. Restenosis occurred in 42.3% of the patients with very proximal and intermediate lesions (11 out of 26) and 31.2% of those with distal lesions (24 out of 77). In conclusion, in most patients with very proximal and intermediate lesions of left anterior descending artery, coronary angioplasty can be performed with low risk. The location of the lesion in the proximal portion of left anterior descending artery does not affect the overall success rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Adjustment of pulmonary capillary wedge pressure for wave delay increases the accuracy of mitral valve area measurement.

Pulmonary capillary wedge pressure, currently accepted as an approximation of left atrial pressure, leads to underestimation of mitral valve area calculated with the Gorlin formula. Wave delay has been pointed out as a major source of the underestimation. The aim of this study was to increase the accuracy of pulmonary artery wedge pressure-based measurements through a correction for time delay. Electrocardiogram, pulmonary capillary wedge, left atrial and left ventricular pressures were recorded simultaneously at high paper speed in 18 patients with mitral stenosis who underwent transseptal left atrial catheterization prior to mitral valvulotomy. Heart rate and wedge pressure wave delay were closely correlated (r = 0.78, p < 0.001). Linear regression equation (y = 1.1x + 8) was then applied in order to adjust the pulmonary capillary wedge pressure for time delay in every complex. Relative to mitral area measured with left atrial pressure, areas calculated using wedge pressure with and without correction were, respectively, 5 +/- 6% and 16 +/- 7% (p < 0.001) lower. Both methods showed a close correlation (r > 0.95) with measurements obtained using left atrial pressure; plotting the standard deviation against the mean, the correction of capillary wedge pressure significantly (p < 0.001) increased the accuracy of area measurement. In conclusion, pulmonary wedge pressure, properly obtained and adjusted for time delay, allows a more reliable measurement of the mitral area.

Quality criteria for cardiac images in diagnostic and interventional cardiology.

The quality of cardiac imaging plays a pivotal role in clinical decision-making and depends mainly on the technical performance of the imaging system and on angiographic technique. The Italian Society of Invasive Cardiology and The Italian Society of Physics in Medicine have set quality criteria giving precise guidelines regarding how an angiogram should appear provided that good equipment and correct angiographic technique are used. The criteria have been reviewed by the European Concerted Action DIMOND Cardiology group and are reported here to provide a reference standard for images for the most common procedures in daily practice.

Iomeprol and iopamidol in cardiac angiography: a randomised, double-blind, parallel-group comparison.

During cardiac angiography, hemodynamic alterations and surface electrocardiographic changes are common, predictable and dose-related adverse reactions to radiocontrast media. High osmolality, inadequate sodium content and local transient hypocalcemia are thought to be the main mechanisms responsible for these untoward cardiovascular effects. The purpose of this double-blind, parallel-group trial was to compare the hemodynamic and electrocardiographic responses to cardiac and selective coronary artery injection of iomeprol 400 (400 mgI/ml) and iopamidol 370 (370 mgI/ml). One-hundred consenting adult inpatients were randomised to receive iomeprol 400 (41 males, nine females; mean age, 56.6 years) or iopamidol 370 (46 males, four females; mean age, 57.6 years). Both agents produced minor and transient hemodynamic and electrophysiological effects. Following left ventriculography, iopamidol 370 produced a significantly greater increase in LVEDP than iomeprol 400 (mean increases after first and second left ventriculogram: 2.5 and 4.6 mmHg with iomeprol 400, 3.3 and 9.9 mmHg with iopamidol 370, P = 0.027). The QT-interval was more affected by iopamidol 370 than by iomeprol 400. However, post-contrast prolongation of the QT-interval was not significant with either agent, nor were there any significant T-wave, ST-segment or RR-interval changes associated with the injection of the test compounds. No serious adverse events occurred throughout the study. Mild pain was complained by only one patient, while most patients reported mild to moderate sensation of heat. Image quality of the vast majority of the procedures was rated as good or excellent in both patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The esophagus as a possible cause of chest pain in patients with and without angina pectoris.

In a series of 18 patients with angina pectoris, in whom treatment over at least 3 years with nitroderivatives and Ca-antagonists had become partially ineffective on chest pain, and in 18 patients with angina-like non-cardiac chest pain, the following examinations were carried out: upper gut x-ray and endoscopy, acid perfusion test, esophageal manometry, 24-hour esophageal pH monitoring associated with Holter recording. The presence or absence of coronary insufficiency was established by means of scintigraphic and ECG tests, Holter monitoring and coronary arteriography. In both groups the majority of patients had abnormal esophageal function, but in patients with angina pectoris treated for a long period of time the motility changes were prevalently reflux-related. With respect to the origin of chest pain, the esophagus was found to be the likely cause in 4 patients with angina pectoris, and the probable cause in another 10 of the same group; it was the likely cause in 7 patients without angina pectoris, and the probable cause in another 7 of the same group. As nitroderivatives and Ca-antagonists decrease the LES tone and the amplitude of esophageal pressure waves, long-term treatment with these drugs may be taken into account in the genesis of gastro-esophageal reflux and related changes, including esophageal pain.

Nifedipine compared with verapamil in unstable angina pectoris.

A randomized trial was performed in 22 patients with unstable angina to compare the efficacy of oral verapamil with nifedipine in reducing symptomatic ischaemic episodes. The trial consisted of a 48 h control period, a 96 h treatment period with nifedipine (20 mg every 6 h) or verapamil (120 mg every 6 h), and a follow-up period. Patients who had a minimum of four symptomatic ischaemic episodes during the control period were entered into the trial. Asymptomatic ischaemic episodes were evaluated by Holter monitoring. Coronary angiography was performed at the end of the treatment period. Both nifedipine and verapamil significantly reduced the mean number of daily symptomatic ischaemic episodes (p less than 0.01) and the total number of ischaemic episodes (p less than 0.03). This study confirmed the high degree of efficacy of both nifedipine and verapamil in reducing the number of ischaemic episodes during short-term treatment of unstable angina. Nevertheless, a significant number of myocardial infarctions occurred in these patients, and some required subsequent coronary bypass graft operations.

Ultrasound-assisted stent implantation in small size coronary arteries: a pilot study.

BACKGROUND: Many studies have indicated that a small lumen size is one of the most important predictors of acute events and of late restenosis after balloon angioplasty or stent implantation. In the last few years many studies have shown that intravascular ultrasound (IVUS) guidance makes it possible to optimize stent implantation. The aim of this pilot study was to evaluate the feasibility and safety of IVUS imaging of small vessels. Secondary endpoints were the immediate and long-term results of IVUS-guided elective BeStent implantation in small vessels. METHODS: Fourteen symptomatic patients with small coronary vessel (mean angiographic reference diameter 2.3 +/- 0.2 mm) disease underwent IVUS-guided BeStent implantation. IVUS success was defined as the achievement of a final minimal intrastent cross-sectional area (CSA) > 90% of the smaller reference lumen CSA. RESULTS: IVUS evaluation was feasible in all patients without any clinical or angiographic adverse events. Procedural success was achieved in all patients with implantation of a BeStent 15 mm. No major complication (death, myocardial infarction, stent acute or subacute thrombosis, coronary artery bypass, re-coronary angioplasty) occurred during the in-hospital phase. Two non-flow-limiting, asymptomatic coronary dissections were detected after stent expansion. The post-stenting lesion stenosis rate decreased from 72.9 +/- 12.9% to 0.75 +/- 11.7% with an acute gain of 1.8 +/- 0.4 mm. The final IVUS minimal stent CSA was 5.6 +/- 1.1 mm2. The IVUS criteria of adequate stent expansion were reached in 11 (78.6%) patients. At 6 months of follow-up, the rate of angiographically diagnosed in-stent restenosis was 30.7%; the 6-month late loss in stent diameter was 1.1 +/- 0.6 mm. No patient died or presented with a myocardial infarction. The target lesion revascularization rate was 30.7%. CONCLUSIONS: Coronary IVUS-guided stenting can be performed in small vessels with a high success rate and low incidence of in-hospital complications. However, despite these encouraging short-term results, the long-term clinical and angiographic outcome is less favorable. Further larger and randomized IVUS studies, probably employing more aggressive IVUS criteria, are needed to clarify the true role of IVUS guidance in this particular field.

[Percutaneous aortic valvuloplasty in the adult. When and why is now useful?]. / La valvuloplastica aortica percutanea nell'adulto. Quando e per chi è ancora utile?.

Percutaneous aortic valvuloplasty was introduced into clinical practice in 1986 and widely applied in elderly patients with symptomatic aortic stenosis. Nevertheless its results have been unsatisfactory over the mid to long term due to a high incidence of restenosis after 6-12 months. At the same time, patients over 70 years are more frequently undergoing surgical aortic valve replacement with low immediate postoperative mortality and good long term results. Although randomized trials are not available, aortic valve replacement seems to be a definitive therapeutic treatment when compared to the palliative result of aortic percutaneous valvuloplasty. However, since the complication rate of valvuloplasty carried out in cardiological centers with experienced personnel is low, this procedure is still indicated in selected patients. The very old (> 80 years) patients with associated systemic disease, and candidates for major surgery are referred for this procedure. Another indication for aortic valvuloplasty is severe aortic stenosis with cardiogenic shock; in this case, valve dilatation improves clinical status and acts as a "bridge" to surgery, enabling surgical intervention to be carried out at a later date. Nowadays, aortic percutaneous valvuloplasty is a possible alternative to surgical treatment in patients with an absolute surgical contraindication and in those who are in such poor clinical condition that they cannot be immediately referred to surgery. It is also useful for patients requiring urgent non-cardiac surgery (e.g., subjects with gastrointestinal bleeding). We discuss our results with this procedure which concord with those presented in the literature.

[Need and quality assurance: can the introduction of the new generation mobile systems change the reference standards?]. / Fabbisogno e VRQ: l'introduzione dei sistemi portatili di nuova generazione può modificare i parametri di riferimento?

The new generation of radiological mobile systems, by lowering the installation and depreciation expenses, has led to start new low volume catheterization laboratories. These equipments allow to obtain good quality images, but they are not so reliable for extended performances, so that they are not suitable for interventional procedures. On the other hand, the extension of the indications to coronary angiography and angioplasty, with the related increase in the population needs, leads the resetting of the reference areas to start new catheterization laboratories. Anyhow lowering of expenses and of the extension of the reference areas does not change the need for maintaining high activity levels of centers and first operators in order to guarantee the quality of diagnostic and interventional procedures. The optimal levels of centers in national standards are 800 coronary angiographies and 400 coronary angioplasties per year: these numbers indicate the experience necessary to warrant the quality of procedures, with optimal results and low rate of complications, therefore they should not be changed. The spreading of laboratories due to the new low cost radiological equipments leads to an increase in inappropriate procedures and in the total expenses for the management of cardiac patients, without a proportional advantage in prognosis and quality of life. In order to ensure a quick diagnostic and therapeutic process to all the patients who need invasive procedures, instead of starting new centers, it is worthwhile to perfect the efficiency of links among small and main centers following shared pathways.

Optimisation of therapeutic strategies for ST-segment elevation acute myocardial infarction: the impact of a territorial network on reperfusion therapy and mortality.

OBJECTIVE: To assess the clinical impact of a regional network for the treatment of ST-segment elevation myocardial infarction (STEMI). METHODS: All patients with STEMI (n = 1823) admitted to any of the hospitals of an area with one million inhabitants during the year 2002 (n = 858)-that is, before the network was implemented, and in 2004 (n = 965), the year of full implementation of the network, were enrolled in this study. The primary evaluation was in-hospital mortality. Secondary outcomes included the incidence of major adverse cardiac and cerebrovascular events (MACCE), defined as death, myocardial infarction, stroke and coronary revascularisation procedures over 1-year follow-up. RESULTS: Between 2002 and 2004, there was a major change in reperfusion strategy: primary angioplasty increased from 20.2% to 65.6% (p<0.001), fibrinolytic therapy decreased from 38.2% to 10.7% (p<0.001) and the rate of patients not undergoing reperfusion was reduced from 41.6% to 23.7% (p<0.001). In-hospital mortality decreased from 17.0% to 12.3% (p = 0.005), and this reduction was sustained at 1-year follow-up (23.9% in 2002 and 18.8% in 2004, p = 0.009). Similarly, the 1-year incidence of all MACCE was reduced from 39.5% in 2002 to 34.3% in 2004 (p = 0.01). CONCLUSIONS: Organisation of a territorial network for STEMI is associated with increased rates of reperfusion therapy and reduction of in-hospital and 1-year mortality.

Clinical value of multidetector CT coronary angiography as a preoperative screening test before non-coronary cardiac surgery.

OBJECTIVE: Myocardial scintigraphy and/or conventional angiography (CA) are often performed before cardiac surgery in an attempt to identify unsuspected coronary artery disease which might result in significant cardiac morbidity and mortality. Multidetector CT coronary angiography (MDCTCA) has a recognised high negative predictive value and may provide a non-invasive alternative in this subset of patients. The aim of this study was to evaluate the clinical value of MDCTCA as a preoperative screening test in candidates for non-coronary cardiac surgery. METHODS: 132 patients underwent MDCTCA (Somatom Sensation 16 Cardiac, Siemens) in the assessment of the cardiac risk profile before surgery. Coronary arteries were screened for > or = 50% stenosis. Patients without significant stenosis (Group 1) underwent surgery without any adjunctive screening tests while all patients with coronary lesions > or = 50% at MDCTCA (Group 2) underwent CA. RESULTS: 16 patients (12.1%) were excluded due to poor image quality. 72 patients without significant coronary stenosis at MDCTCA were submitted to surgery. 30 out of 36 patients with significant (> or = 50%) coronary stenosis at MDCTCA and CA underwent adjunctive bypass surgery or coronary angioplasty. In 8 patients, MDCTCA overestimated the severity of the coronary lesions (> 50% MDCTCA, < 50% CA). No severe cardiovascular perioperative events such as myocardial ischaemia, myocardial infarction or cardiac failure occurred in any patient in Group 1. CONCLUSIONS: MDCTCA seems to be effective as a preoperative screening test prior to non-coronary cardiac surgery. In this era of cost containment and optimal care of patients, MDCTCA is able to provide coronary vessel and ventricular function evaluation and may become the method of choice for the assessment of a cardiovascular risk profile prior to major surgery.

[Electrocardiogram in pulmonary embolism]. / L'elettrocardiogramma nell'embolia polmonare.

The Authors are examining the electrogenetic and vectorial alterations during pulmonary embolism and the consequent more frequent electrocardiographic patterns according to the literature data. The analysis of the electrocardiograms of 37 patients with proved pulmonary embolism confirms that ECG is not of absolute diagnostic value but may be extremely useful especially if subsequent records are compared.