Dimitri Tsialtas

Abnormal ventricular repolarization mimicking myocardial infarction after heterocyclic antidepressant overdose.

In 2 young adult women who experienced acute heterocyclic antidepressant intoxication, we found a quite unusual electrocardiographic pattern characterized by abnormal ST-tract elevation in the right precordial leads associated with a marked QRS widening (right bundle branch block and left anterior fascicular block type). Because serum electrolyte imbalance and acute myocardial ischemic events were excluded, the mechanism by which antidepressant overdose may produce such elevation of the ST tract remains unclear.

Marked sinus bradycardia and QT prolongation in a diabetic patient with severe hypoglycemia.

We report an uncommon case of an insulin-treated diabetic patient, presenting severe hypoglycemia, coma, marked sinus bradycardia and QT prolongation. Intravenous administration of glucose and atropine awaked the patient and increased heart rate but did not affect QT prolongation. Basal and exercise electrocardiogram excluded primary diseases associated with QT prolongation. Pathophysiologic aspects of electrocardiographic and clinical findings occurring in the hypoglycemic patients are briefly discussed.

Stented versus stentless bioprostheses in aortic valve stenosis: effect on left ventricular remodelling.

BACKGROUND Whether the use of stentless aortic bioprostheses improves hemodynamics more than stented bioprostheses in the small aortic root is still a matter of debate. METHODS Early- and mid-term effects were compared between 2 different types of stentless bioprotheses and 1 type of stented bioprosthesis for left ventricular remodelling. The effects of the bioprotheses were studied by echocardiography in 68 patients (age, 74 +/- 7 years) with aortic annulus diameter < or =23 mm who were undergoing prosthesis implantation due to aortic isolated stenosis. Stented bioprostheses (Carpentier-Edwards Perimount [CEP]) were implanted in 36 subjects and stentless bioprostheses (18 Toronto SPV and 14 Shelhigh Super Stentless) were implanted in 32 subjects. RESULTS A progressive and similar decrease in left ventricular mass of 30% was observed in both stented and stentless bioprostheses at 12 months. A progressive increase in transprosthetic effective orifice area and a decrease in transprothetic pressure gradient were observed at 3, 6, and 12 months in the Toronto group, but these variables showed improvement only at 3 months in the CEP and Shelhigh groups. No mortality occurred during surgery or during the 1-year follow-up period. CONCLUSIONS Our results confirmed good feasibility of aortic stented and stentless bioprostheses implantation in the elderly population. A 30% decrease in left ventricular mass occurred in the early- and mid-term (12 months) periods after surgery with all 3 types of bioprostheses. Advantages consisting of a progressive increase in transprosthetic effective orifice area and a decrease of the transprosthetic pressure gradient were observed in the Toronto group in comparison to the CEP and Shelhigh groups. These observations may help surgeons in choosing bioprostheses.

Surgical coronary revascularization with or without mitral valve repair of severe ischemic dilated cardiomyopathy.

BACKGROUND Because patients with dilated cardiomyopathy tend to have a poor prognosis with medical therapy, surgery with coronary bypass alone or associated with mitral valve repair should be a promising feasible therapeutic option. We evaluated the early effects of surgical coronary revascularization with or without mitral valve repair in patients with severe dilated ischemic cardiomyopathy. METHODS The study group consisted of 38 patients aged 65 +/- 8 years with severe dilated ischemic cardiomyopathy, chest pain, and heart failure. Twenty-four patients were in a New York Heart Association (NYHA) class > or =3, and 14 patients were in class 2. Twenty patients had a degree of mitral regurgitation defined as an effective regurgitant orifice > or =20 mm2. The mean values (+/-SD) of the EuroSCORE, which evaluates operative risk, were 5 +/- 2.2. Clinical and echocardiographic reevaluation followed at 6 months. RESULTS All patients underwent coronary artery bypass surgery with a mean of 2.3 +/- 0.8 grafts, and mitral valve repair with annuloplasty and Cosgrove ring insertion were performed in 20 patients. No deaths occurred during the operative period. Ten patients could not be reevaluated at 6 months, and 3 patients died (7.9% mortality). At 6 months, the end-systolic volumes in 15 patients who underwent coronary bypass plus mitral valve repair (group A) and in 13 patients who underwent coronary bypass alone (group B) decreased, respectively, from 139 +/- 56 mL to 121 +/- 94 mL and from 122 +/- 48 mL to 96 +/- 36 mL (P < .05). The wall motion score index also decreased from 1.9 +/- 0.3 to 1.4 +/- 0.4 and from 2.1 +/- 0.3 to 1.8 +/- 0.2, respectively. The mean values of the ejection fraction, the peak early mitral inflow velocity, and the ratio of the peak early mitral inflow velocity to the peak late mitral inflow velocity increased significantly in both groups (P < .001, P < .01, and P < .05, respectively). The mean NYHA functional class significantly improved in both groups (P < .0001). CONCLUSIONS In patients with severe ischemic dilated cardiomyopathy, surgical coronary revascularization can be safely carried out during the operative and early postoperative periods with low mortality rates. This procedure decreased left ventricular end-systolic volume, consistently increased contractility, and subsequently ameliorated the ejection fraction to produce improvements in clinical condition according to the NYHA functional class. Similar results have been obtained in patients who have undergone coronary bypass surgery and mitral valve repair, despite a higher operative risk and longer cardiopulmonary bypass circulation and aortic cross-clamping times.

Clinical, electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization.

BACKGROUND Preoperative cardiac assessment may essentially contribute to estimate the operative risk in vascular surgery.This study was undertaken to depict the clinical conditions and cardiac status in patients before elective major vascular surgery. PATIENTS AND METHODS 143 patients with asymptomatic critical aortic abdominal aneurysm, 119 with high-grade carotid stenosis, and 138 with advanced symptomatic ischemia due to peripheral artery disease were assigned to surgical revascularization. Preoperatively, all subjects completed detailed medical history, physical and laboratory examinations, electrocardiogram, and transthoracic echocardiography. RESULTS In patients with peripheral artery disease we identified more smokers (p < 0.05), diabetes (p < 0.01), hypertriglyceridemia (p < 0.05), previous myocardial infarction (p < 0.01); the asymptomatic aortic abdominal aneurysm group had a higher body mass index (p < 0.05), diastolic hypertension (p < 0.05), and most had left ventricular anterior hemiblocks (p < 0.001). Patients with critical carotid stenosis were older (p < 0.01), with greater systolic hypertension (p < 0.01), and with a less compromised left ventricular systolic function. CONCLUSIONS Patients with peripheral artery disease were mostly affected by severe metabolic diseases and by worst cardiac conditions; patients with asymptomatic abdominal aortic aneurysms were of robust physique, and often had left ventricular anterior hemiblocks. Patients with critical carotid stenosis were older and had less cardiomyopathies.

Diagnosis of an Aorto-Caval Fistula by Echo 2D Color Doppler Flow Imaging and Echocardiographic Probe

We describe a clinical case presenting two unusual features. The first was a spontaneous aorto-caval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second uncommon feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-Doppler color flow (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination revealed an aneurysm of the abdominal aorta that communicated with a dilated inferior vena cava. Furthermore, flow study with pulsed color Doppler revealed a continuous turbolent, mixed (arterial and venous) blood flow into the vena cava.

Acute heart failure due to neoplastic invasion of ventricular myocardium by relapsing thymoma.

Malignant thymomas are the most frequent type of w x tumours of anterior mediastinum 1 . They may be found incidentally on routine chest radiography; in other cases they may be manifested as paraneoplastic w x syndromes 1,2 . Cardiac involvement by malignant thymomas is due to pericardial invasion from the thymic region with clinical signs of cardiac tampoŽ . nade, compression or less commonly invasion of the mediastinic great veins resembling the ‘superior ̈ena w x ca ̈a syndrome’ 2]4 . The most common location of secondary intramyocardial neoplasms is the left ventricular free wall w x and the ventricular septum 5 . Although malignant thymomas rarely result in intra-myocardial metastases w x 4 , a few, and small, intra-myocardial lesions have w x been reported 6 .

Left-ventricular outflow tract obstruction by mitral valve ring calcification and proximal septal hypertrophy in elderly patients. Presentation of 2 clinical cases.

The pathophysiology, clinical presentation and prognosis of left-ventricular obstruction still represent an important cardiological problem. Various anatomical and/or functional mechanisms can cause this phenomenon. This report concerns 2 patients over 75 years old in whom the simultaneous presence of localized proximal septal hypertrophy and massive calcification in the anterior portion of the mitral valve ring provoked significant systolic intraventricular gradients. Cardiac rhythm disturbances and consequent variability of R-R intervals, found in both subjects, appear fundamental in determining the value of such gradients. Occasionally an anterior mitral ring calcification may bring about left-ventricular outflow tract obstruction in aged hearts where localized hypertrophy of the proximal portion of the intraventricular septum is present.

Evidence ef compensatory preload adjustment on early filling phase in patients with stable angina pectoris and good left ventricular systolic function

Abstract The normal mitral flow pattern seen in our patients with stable angina and good systolic function is related to an increase in atria1 pressure; this increase maintains normal stroke volume despite impaired relaxation and a moderate increase in the minimum LV diastolic pressure (a finding that confirms a computer-simulation hypothesis by Thomas et al 13 ).

Digitalis and heart failure: Does digitalis really produce beneficial effects through a positive inotropic action?

SummaryAlthough digitalis was introduced to medicine long ago, the drug is still extensively used in clinical practice today. Opinions on its mechanism of action have undergone much change in the course of time, and the way in which cardiovascular effects are produced is still not completely clear. Limitations and contraindications for the use of digitalis substances are reported, especially in the treatment of ischemic heart disease. Preliminary data regarding the effects of digitalis on the diastolic phase are unfavorable, although the relationship between digitalis and diastolic function ought to be studied in greater depth in various clinical conditions. In spite of many recent trials, the old question of the usefulness of digitalis in the chronic treatment of patients in sinus rhythm and heart failure is still debated. An important clinical benefit in the chronic use of digitalis appears restricted to a relatively small proportion of patients with severe congestive heart failure, while in the majority of chronically treated subjects the effects of the drug are scanty or insignificant. The beneficial effect of digitalis used chronically is essentially believed to be due to its positive inotropic action. Since the vagomimetic and the antiadrenergic effects of digitalis have been demonstrated to be independent from its inotropic action, they could be considered determinants of the clinical benefits of digitalis. These indirect effects may be useful in the control of the negative neuroendocrine response developing during congestive heart failure. Thus the statement that digitalis is essentially an inotropic agent seems restrictive; its definition should reflect the favorable effects obtained in some cases of congestive heart failure rather than its various and contrasting underlying mechanisms of action.