Annalisa Lamari

Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine.

Objective: The aim of this study was to compare transthoracic echocardiography (TTE) and transcranial Doppler ultrasonography (TCD) with transesophageal echocardiography (TEE) in order to define the best clinical approach to patent foramen ovale (PFO) detection. Methods: In total, 72 consecutive patients (33 men) with a mean age of 49 ± 13 years were prospectively enrolled. The TEE indication was cryptogenic stroke (36 patients) or migraine (36 patients, 22 with aura). All patients underwent standard TTE, TCD, and TEE examination. For any study, a contrast test was carried on using an agitated saline solution mixed with urea‐linked gelatine (Haemaccel), injected as a rapid bolus via a right antecubital vein. A prolonged Valsalva maneuver was performed to improve test sensitivity. Results: TEE identified a PFO in 65% of the whole population: 56.5% in the migraine cohort and 43.5% in the cryptogenic stroke cohort. TTE was able to detect a PFO in 55% of patients positive at TEE (54% negative predictive value, 100% positive predictive value, 55% sensitivity, and 100% specificity). TCD was able to identify a PFO in 97% of patients positive at TEE (89% negative predictive value, 98% positive predictive value, 94% sensitivity, and 96% specificity). Conclusions: In patients with cryptogenic stroke and migraine, there is a fair concordance (k = 0.89) between TCD and TEE in PFO recognition. Accordingly, TCD should be recommended as a simple, noninvasive, and reliable technique, whereas TEE indication should be restricted to selected patients. TTE is a very specific technique, whose major advantage is the ability to detect a large right‐to‐left shunt, particularly if associated with an atrial septal aneurysm.

[Correlation between insulin resistance and endothelial dysfunction assessed by flow-mediated dilation].

Insulin resistance and endothelial dysfunction are major cardiovascular risk factors. The purpose of this study was to determine whether only patients with insulin resistance also have an alteration of endothelial function assessed by ultrasound flow-mediated (FMD). In a population of 165 patients, 30 subjects had only a family history of diabetes and/or sporadic findings of hypoglycemia, and they were assessed for FMD, the glucose and insulin curve. Of these 30 subjects, 20 patients had an alteration of the parameters measured and were related with 20 healthy patients. The study group and the control group showed a markedly significant statistical difference in the performance of the curve insulin, in the calculation of FMD and HOMA. FMD allows to study populations with no apparent cardiovascular risk and to monitor the effectiveness of possible endothelial protective therapy.

The chance finding at multislice computed tomography coronary angiography of an ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva

Anomalous coronary arteries occur in less than 2% of the general population. Most coronary anomalies are clinically asymptomatic. However some of them may present with chest pain, syncope, heart failure and sudden death. Acute myocardial infarction has been also described. Extravascular coronary compression results in dynamic obstruction which can cause effort angina as well as syncope and anomalous coronary arteries with an inter-arterial course are associated with sudden cardiac death. Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is thought to be of little clinical significance without the presence of severe narrowing of the vessel. Adequate visualization of the anomaly is essential for proper patient management. It has reported the full capability and accuracy of computed tomography coronary angiography in the identification and evaluation of the ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva, displaying accurately the origin, size, course, and relationship of the anomalous vessel with respect to surrounding structures. We report a case of chance finding at multislice computed tomography coronary angiography of an ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva. Also this case focuses attention on the anomalous origin of the circumflex coronary artery from the right sinus of Valsalva and confirms the full capability and accuracy of computed tomography coronary angiography in its adequate visualization.

Interatrial defect, ventricular septal defect and patent ductus arteriosus in a 2-day-old newborn infant

Interatrial defects, ventricular septal defects, and patent ductus arteriosus can occur as part of more congenital cardiac malformations or as an isolate finding. We present a case of interatrial defect associated with ventricular septal defect and patent ductus arteriosus in a 2-day-old newborn infant.

Valutazione eco-Doppler dell'insufficienza venosa cronica di recente insorgenza in soggetti anziani: il cuore potrebbe avere un ruolo?

Riassunto. L’insorgenza in eta avanzata dei segni clinici di insufficienza venosa cronica (IVC), senza precedente storia di patologia venosa degli arti inferiori, pone degli interro gativi sulla causa eziologica. Nel nostro studio abbiamo va lutato le possibili cause indagando il sistema venoso degli arti inferiori e la funzione cardiaca destra in soggetti anzia ni con segni di IVC. Le alterazioni rilevate hanno riguardato la riduzione del TAPSE, un indice di massa corporea significativamente piu alto e una ridotta capacita deambulatoria rispetto al gruppo di controllo. Le differenze potrebbero es sere alla base dell’edema e delle alterazioni cutanee di re cente insorgenza. Se si tratta di IVC di tipo funzionale o di scompenso cardiaco congestizio in fase preclinica sara chia rito solo da adeguati follow-up. Parole chiave. Insufficienza venosa, scompenso destro, TAPSE. Echo-Doppler evaluation of recent onset chronic venous in sufficiency in elderly patients: does the heart have a role? Summary. The onset in elderly subjects of clinical signs of chronic venous insufficiency (CVI), without a previous history of venous disease of the lower limbs, raises questions about the etiology. In our study we evaluated the possible causes investigating the venous system of the lower limbs and right heart function in elderly subjects with signs of CVI. The alter ations found were on the reduction of TAPSE, a significantly higher body mass index and a reduced ability to walk com pared to the control group. The differences described could explain edema and skin changes of recent onset. If it is CVI functional type or of congestive heart failure in the preclinical stage will be clarified only by adequate follow-up.

Treatment failure of low molecular weight heparin in a patient with an aortic mechanical prosthesis

After mechanical heart valve replacement use of unfractionated heparin is sometimes required because vitamin K antagonists are temporarily contraindicated or to prevent valve-associated thromboembolism until oral vitamin K antagonists take effect. Bridging therapy with a standardized low molecular weight heparin-based regimen has been reported effective and relatively safe in a large cohort of patients with mechanical heart valves. Many cases with mitral mechanical valve prostheses and treatment failure of low molecular weight heparin have also been reported as well as prosthetic valve thrombosis has been reported with adequate anticoagulation. A case has also been reported of well functioning Starr-Edwards aortic prosthesis without anticoagulation. We present a case of cardioembolic stroke in a patient with an aortic mechanical prosthesis in bridging therapy with a standardized low molecular weight heparin-based regimen. This case is illustrative of treatment failure of low molecular weight heparin in a patient with an aortic mechanical prosthesis.

2-Dimensional Strain echocardiography and early detection of myocardial ischemia

Echocardiographic strain with strain rate imaging is a new technology enabling more reliable and comprehensive assessment of myocardial function. The spectrum of potential clinical applications is very wide due to its ability to differentiate between active and passive movement of myocardial segments, to quantify intraventricular dyssynchrony and to evaluate components of myocardial function, such as longitudinal myocardial shortening, that are not visually assessable. In-vivo and in-vitro validation of 2D-strain imaging technique have been undertaken and reached a point where it is considered ready for more widespread investigations into clinical utility, e.g. regarding myocarditis, arrhythmogenic right ventricular dysplasia/cardiomyopathy and regional ischemia. Moreover, longitudinal LV strain is closely related to log plasma brain-type natriuretic peptide levels in patients with congestive heart failure, both in patients with systolic and diastolic heart failure. We present a case of detection of coronary artery disease in a 55-year-old Italian man. This case focuses attention on the higher sensibility of the 2-Dimensional Strain echocardiography the diagnosis of myocardial ischemia in patients with coronary artery disease.

Handgrip exercise associated with dobutamine stress echocardiography

BACKGROUND Stress echocardiography is today the best possible imaging choice in the field of noninvasive diagnosis of coronary artery disease. Dobutamine stress echocardiography (DSE) and Dobutamine-atropine stress echocardiography (DASE) have been studied. Handgrip (HG) exercise has been rarely studied in stress echocardiography. Aim of the study was to investigate the safe, feasibility and efficacy of use of HG associated with DSE and if it may lead to improved diagnostic capacity of the test. METHODS DSE was performed in 96 consecutive patients. Seventy-seven patients reached their target heart rate age-adjusted and were excluded. To 19 patients who have not reached their target hr age-adjusted, HG at 50% maximum effort was applied for a minute and 16 patients reached the maximum heart rate. RESULTS Of these 16 patients, 8 were positive for myocardial ischemia induced. Of the 3 other patients, 2 were positive for myocardial ischemia before reaching the target hr. One patient, without reaching the max hr and without being positive for myocardial ischemia, refused other investigations. Therefore, a total of 10 patients presented an inducible myocardial ischemia. Coronary angiography revealed a significant coronary artery disease in all these 10 patients (10/10 patients, 100%). DISCUSSION Our study concludes for the safe, feasibility and efficacy of use of HG with DSE and that it may lead to improved diagnostic capacity of the test. Large studies need to be done to confirm these preliminary results but our study is very encouraging for the application and validity of this type of test mixture.

Perinatal asphyxia and cardiac abnormalities

The most common etiologies of myocardial infarction in the perinatal period are congenital heart disease, coronary artery lesions, thromboembolism and perinatal asphyxia. Cardiac abnormalities in perinatal asphyxia include tricuspid regurgitation and mitral regurgitation associated with transient myocardial ischemia of the newborn. Patent foramen ovale is a frequent remnant of the fetal circulation. Persistent hypoxia sometimes causes pulmonary arterial hypertension with consequent right to left shunt across patent ductus arteriosus and foramen ovale. We describe a case of tricuspid regurgitation, mitral regurgitation, and patent foramen ovale in a 15-day-old newborn male infant with a history of perinatal asphyxia. Also this case focuses attention on the perinatal asphyxia.

The chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old child with a ventricular septal defect and a pericardial effusion

Ventricular septal defects can occur as part of other congenital cardiac malformations or as an isolated finding. Aneurysms of the sinus of Valsalva are rare, most commonly involving the right or noncoronary sinuses. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-exist with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. More commonly, sinus of Valsalva aneurysms are diagnosed after the clinical sequelae of rupture. Several etiologic factors may lead to the development of pathologic pericardial effusion and the detection of pericardial effusion was one of the first applications of echocardiography to gain widespread acceptance. We present a case of a chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old Italian child with a ventricular septal defect and a pericardial effusion.