Cesare Rusconi

Successful Reduction of Endomyocardial Fibrosis in a Patient with Idiopathic Hypereosinophilic Syndrome A Case Report

A case of endomyocardial fibrosis in a patient with idiopathic hypereosinophilic syndrome is reported and discussed. The authors draw attention to the importance of both echocar diography (two-dimensional and Doppler) and nuclear magnetic resonance in the detection of cardiac involvement due to this rare pathology. Moreover, these imaging techniques appear to be valuable in the evaluation of effects of medical treatment. Therapy with corticosteroids alone has shown no reliable effectiveness in reducing the absolute eosinophil count. A combined immunosuppressive treatment with use of hydrox yurea is required.

Prevalence of late potentials in adult aortic stenosis

Sudden death and syncope are well-recognized clinical manifestations of valvular aortic stenosis (AS). Furthermore, patients with left ventricular hypertrophy due to hypertension have a greater prevalence of late potentials (LP) compared with normal subjects. Chronic pressure overload in AS is frequently characterized by development of left ventricular hypertrophy. The aims of this study were (1) to determine the prevalence of LP in patients with moderate to severe AS, and (2) to investigate the relationship between LP and left ventricular hypertrophy. Signal-averaged electrocardiograms (SAECG) were recorded using a 40 Hz high pass filter in 32 patients (19 M and 13 F), aged 69 +/- 11 years with AS, and in 25 age- and sex-matched controls. QRS duration (QRSD) < 114 ms, low amplitude signal of last 40 ms (LAS40) < 38 ms and root mean square voltage of last 40 ms (RMS40) > 20 microV were considered normal. LP were considered to be present if at least two of the above criteria were abnormal. Each patient underwent a complete echo-Doppler examination and the following parameters were measured; aortic valve area, fractional shortening, left ventricular end-diastolic diameter and mass index. Coronary arteriography was performed in 17 (53%) patients. LP were present in 8 out of 32 (25%) AS patients and in 1 out of 25 controls (4%); this difference was statistically significant (P < 0.006). No difference with regard to age, sex, presence of congestive heart failure, angina, syncope, complex ventricular arrhythmias and coronary artery disease was found in AS patients with and without LP. No correlation was found between indices of left ventricular structure and function and each SAECG parameter. In conclusion, the prevalence of LP in patients with AS is higher than in controls and the presence of LP in AS might be related to factors other than coronary artery disease and left ventricular mass and/or function.

Abnormalities of left ventricular filling in valvular aortic stenosis. Usefulness of combined evaluation of pulmonary veins and mitral flow by means of transthoracic Doppler echocardiography

It has been recently demonstrated that indexes obtained from the study of pulmonary venous flow by Doppler echocardiography are related to left ventricular (LV) pressures during diastole and may improve the assessment of LV filling derived from analysis of mitral flow velocities. In this study we evaluated the pattern of pulmonary venous flow and transmitral flow by means of transthoracic pulsed Doppler echocardiography in 31 adult patients (11 females, 20 males, mean age 72 +/- 10 years) with valvular aortic stenosis (Doppler valve area: 0.77 +/- 0.17 cm2) and in 15 age-matched normal subjects (five females, 10 males, mean age 68 +/- 6 years). Doppler indexes of mitral flow were similar between the two groups; on pulmonary venous flow, peak systolic velocity was lower (46 +/- 13 vs. 63 +/- 17 cm/s, P < 0.01) and both duration of reversal flow during atrial systole and difference between pulmonary atrial reversal flow and mitral A wave duration were longer in aortic stenosis patients compared to normals (148 +/- 21 vs. 111 +/- 16 ms and 6 +/- 27 vs. -26 +/- 21 ms, respectively, P < 0.001). Twenty-two aortic stenosis patients showed an early to late mitral flow ratio (E/A) < or = 1 and the remaining nine patients had a E/A > 1.(ABSTRACT TRUNCATED AT 250 WORDS)

TEE Evidence of Right Atrial Tachycardia with Mechanical Alternans, Interatrial and Atrioventricular 2:1 Block

A 69-year-old patient with paroxismal supraventricular tachyarrhythmias was referred to transesophageal echocardiography to rule out thrombi in the left atrial appendage. The examination was carried out during atriai tachycardia with 2:1 AV hlock on surface ECG (Fig. 1). Biphasic PW-Doppler velocities in right atrial appendage were detected in correspondence of both regularly conducted and blocked P waves (Fig. 2, left). Doppler velocities of the nonconducted P wave were lower, for mechanical right atrial alternans. Conversely, a normal pattern of PW-Doppler velocities was present in the left atrial appendage, corresponding to the conducted P wave only {Fig. 2, right), so suggesting coexistence of interatrial and atrioventricular 2:1 hlock. Figure 1. Electrocardiogram (Vl through V3) showing atrial tachycardia with 2:1 atrioventricular (AV) block.

Congestive Heart Failure in Patients with Valvular Aortic Stenosis

The aim of this study was to evaluate echographically anatomic and functional features of the left ventricle in adult patients with valvular aortic stenosis according to the presence or absence of congestive heart failure and the level of ventricular performance. Fifty-six adult patients with moderate-to-severe aortic stenosis underwent echocardiographic Doppler examination in order to evaluate left ventricular mass and dimensions, systolic function and filling dynamics. Twenty-seven patients had no heart failure and were symptomatic for angina (5), syncope (4) or were symptom-free (group I); the other 29 had heart failure (group II): 16 with normal left ventricular systolic performance (fractional shortening > 25%, group IIa) and 13 with systolic dysfunction (fractional shortening < or = 25%, group IIb). Despite a similar left ventricular mass, compared to group IIa, group IIb showed a significant left ventricular dilatation (end-diastolic diameter: 61 +/- 6.5 vs. 45.5 +/- 6.1 mm, p < 0.001) and mild or no increase in wall thickness (11.5 +/- 1.6 vs. 14.9 +/- 2 mm, p < 0.001). Indices of left ventricular filling on Doppler transmitral flow were also significantly different between the two groups, with a higher early-to-late filling ratio and a shorter deceleration time of early filling in group IIb (2.8 +/- 1.9 vs. 1.2 +/- 0.85, p < 0.01, and 122 +/- 66 vs. 190 +/- 87 ms, p < 0.05, respectively), both indirectly indicating higher left atrial pressure. Finally, heart failure was generally more severe in group IIb patients. In some patients with aortic stenosis, symptoms of heart failure may be present despite a normal left ventricular systolic function and seem to depend on abnormalities of diastolic function. The presence of systolic or isolated diastolic dysfunction appears to be related to a different geometric adaptation of the left ventricle to chronic pressure overload.

Vasospastic Angina in a Patient with Chronic Lead Intoxication: A Possible Cause–Effect Relationship?

Dear Sir, Lead (Pb21) is a constituent of the earth’s crust and is found throughout nature. In the industrial era no population group, even living in remote areas not directly polluted, may be considered not to be exposed to lead. Exposure to lead can cause acute or chronic intoxication (saturnism). Even though the prominent features in lead poisoning generally center on the gastrointestinal, renal, and central nervous systems, myocardial involvement may contribute to or be the principal cause of death in some cases: atrioventricular conduction defects, heart failure, chest pain, and electrocardiographic changes have been reported [1]. Among cardiovascular effects, in acute poisoning some cases of hypertensive crises have been reported, the main pathogenetic mechanism being renal and peripheral vasospasm [2]. However, to our knowledge no cases of myocardial ischemia with a normal coronary tree (or more de~nitely of vasospastic angina) secondary to coronary spasm have yet been described. We report a case of a patient with long-lasting vasospastic angina with normal coronary angiography and chronic lead intoxication.

I NITRATI NELLO SCOMPENSO CARDIACO : EFFETTI EMODINAMICI E IMPLICAZIONI CLINICHE

It is a common opinion that nitrate therapy may have a harmful effect on cardiac output in patients with congestive heart failure when left ventricular filling presssure is markedly reduced. In this study, we evaluated, using hemodynamic monitoring with Swan-Ganz catheterization, the effects on cardiac output and filling pressures of high-dose intravenous nitroglycerin in 8 patients with dilated cardiomyopathy and severe heart failure. At maximal doses of nitroglycerin utilized (350 ± 220 µg/m, range 100-800), a significant reduction in right atrial pressure (from 4 + 3.5 to -1 + 4 mm Hg, p 5) nor changes in heart rate or blood pressure. Finally, stroke volume and cardiac index increased slightly although not significantly (from 62 ± 18 to 70 ± 16 ml and from 2.3 ± 0.45 to 2.65 ± 0.41/m/m2). The preservation of stroke volume despite a marked reduction in left ventricular filling pressure can be explained by a reduction in pericardial constraint and of mitral regurgitation induced by nitroglycerin. The clinical implications of these hemodynamic results are discussed with emphasis on the short- and long-term use of nitrates in congestive heart failure.

Transesophageal echocardiographic evidence of atrial fibrillation with systolic flow in the right atrial appendage and systolic reversal pulmonary flow in a patient with DDD permanent pacing.

We report the case of a patient with atrial fibrillation on standard electrocardiogram who underwent transesophageal echocardiography to rule out presence of thrombi in heart cavities. Pulsed‐wave Doppler investigation revealed multiphasic waves consistent with atrial fibrillation in the left atrial appendage, while in the right atrial appendage, a biphasic flow was registered after QRS depolarization. Some hypotheses are made about the origin of this signal.

Pathophysiology of Diastole and Left Ventricular Filling in Humans: Noninvasive Evaluation

The relationship between cardiac output and filling volume was first recognized by Starling at the beginning of this century and called“the law of heart”(47). According to this law and to the ventricular pressure-volume curve, the functional evaluation of myocardial performance in the clinical setting was initially based on the assessment of left ventricular (LV) filling pressure alone. A higher-than-normal filling pressure was considered an index of LV dilatation and systolic failure. In 1963 Braunwald and Ross (3) highlighted the limitation of using LV filling pressure as index of systolic dysfunction and reflected on the possible role of an impaired diastolic function as a cause of higher than normal LV diastolic pressure. However, until the 1970s, LV diastolic pressure was used as a surrogate for volume in evaluating systolic function (17). In the following years, it was learned from studies in patients that many factors can affect LV relaxation and filling and that diastolic abnormalities appear early in the course of many cardiac diseases independent of systolic function. Left ventricular pressure-volume loops of diastolic and systolic dysfunction were then well characterized and the pathophysiologic differences highlighted. During the past 10 years, experimental research on left ventricular myocardial function and the increasing possibility of its noninvasive evaluation in clinical setting have lead to a remarkable advance in the understanding of LV diastolic function, filling, and failure in man (8,27,53,54).

Failure of low dosage thrombolytic therapy with streptokinase to treat heparin-induced thrombocytopenic-thrombotic syndrome

We report the case of a 58-year-old man affected by thrombocytopenic-thrombotic syndrome induced by therapy with subcutaneous unfractionated heparin for superficial phlebitis of the left inferior limb. Thrombolytic therapy with low-dosage streptokinase, reported as successful in a previous case described by other authors, was inefficacious and the patients outcome was unfavourable. Thrombocytopenic-thrombotic syndrome may be a dreadful and often deadly consequence of heparin therapy, and its treatment needs investigation, owing to currently broadening use of anticoagulant treatment with both unfractionated and low molecular weight heparins.