Domenico Zanuttini

PAIMS 2: Alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2

BACKGROUND The effect of alteplase versus heparin in pulmonary embolism has not been studied extensively with serial pulmonary angiograms. OBJECTIVES The aim of this randomized, open trial was to evaluate the efficacy and safety of alteplase followed by heparin, versus heparin alone, in 36 patients with angiographically documented pulmonary embolism. METHODS Twenty patients were allocated randomly to a 2-h infusion of alteplase (10 mg bolus, then 90 mg over 2 h) followed by heparin; the other 16 patients were given intravenous heparin at a continuous infusion rate of 1,750 IU/h. RESULTS The vascular obstruction, assessed by the Miller index at pulmonary angiography, decreased significantly in alteplase-treated patients (p less than 0.01) from a baseline of 28.3 +/- 2.9 to a value of 24.8 +/- 5.2 2 h after the start of infusion; in the heparin group there was no change (from 25.3 +/- 5.3 to 25.2 +/- 5.4). Mean pulmonary artery pressure decreased significantly from a baseline of 30.2 +/- 7.8 mm Hg to 21.4 +/- 6.7 in the alteplase group and increased in the heparin group (from 22.3 +/- 10.5 to 24.8 +/- 11.2 mm Hg). For a subset of patients, lung scans were performed at baseline and on days 7 and 30. There were no differences between the two groups in the follow-up lung scans, but there were significant decreases from the baseline values. Bleeding occurred in 14 of 20 alteplase-treated patients and in 6 of 16 in the heparin group (p = NS). There were three major bleeding episodes in the alteplase group and two in the heparin group. Two patients died after fibrinolysis (one of acute renal failure after cardiac tamponade and one of cardiac arrest after cerebral hemorrhage) and one patient in the heparin group died of recurrent pulmonary embolism. CONCLUSIONS Alteplase resulted in a greater and faster improvement of the angiographic and hemodynamic variables compared with heparin. However, the high frequency of bleeding observed with alteplase in this trial suggests that patients should be carefully selected before thrombolytic therapy is given.

Relation of right ventricular morphology and function in pectus excavatum to the severity of the chest wall deformity

Although pectus excavatum (PE) is thought to impair right ventricular (RV) performance, the degree of RV dysfunction, if any, produced by this chest wall deformity remains controversial. To address this issue, we performed 2-dimensional echocardiography and chest wall radiography in 28 subjects with mild-to-severe degrees of PE to assess RV morphology and function in relation to the degree of the chest wall deformity. Measurements of RV anatomy and function obtained in these patients were compared to those of 24 normal control subjects of similar age and sex. In subjects with PE, mean RV outflow tract diameter at the aortic root level was narrower (1.4 +/- 0.3 cm/m2) and end-diastolic (10 +/- 2.3 cm2/m2) and end-systolic (5.8 +/- 1.4 cm2/m2) areas were larger than those in normal controls (1.6 +/- 0.3, 8.6 +/- 1.7, and 4.5 +/- 1.2 cm2/m2, respectively; p < 0.013). The magnitude of these abnormalities was related to the degree of the chest wall deformity evaluated on the chest radiogram (r = 0.54, 0.51, and 0.49, respectively). RV planar emptying fraction, an index of RV systolic function, was reduced in subjects with PE (42 +/- 10%) compared to the normal controls (48 +/- 10%; p = 0.047). No relation could be found, however, between this index and the severity of the chest wall deformity.(ABSTRACT TRUNCATED AT 250 WORDS)

Sodium-lithium countertransport and cardiorenal abnormalities in essential hypertension.

The rate of red blood cell sodium-lithium countertransport is elevated only in a subgroup of patients with essential hypertension. We have therefore compared renal and cardiac function and morphology in two groups of hypertensive patients with high (n=23) or normal (n=22) sodium-lithium countertransport (mean±SEM: 0.61±0.10 versus 0.29±0.07 mmol/l red blood cells - hr). The two groups were similar in age, sex distribution, body mass index, smoking habit, duration of hypertension, and actual levels of untreated blood pressure. Hypertensive patients with elevated sodium-lithium countertransport activity showed elevated glomenilar filtration rate (118±2 versus 109±2 ml/min • 1.73 m2;p<0.001), albumin excretion rate (23±3 versus 14±2 /ug/min; p<0.001), larger kidney volume (250±15 versus 203±13 ml • 1.73 m2; p<0.01), lower lithium clearance rate (26.7±03 versus 28.9±03 ml/min • 1.73 m2;p<0.01), and higher total body exchangeable sodium (2,716±33 versus 2,485±41 mmol • 1.73 m2; p<0.01). Left ventricular mass index (139±6 versus 119±6 g/m2; p<0.05), relative wall thickness (0J9±0.05 versus 0.29±0.04 cm;p<0.001), and left posterior wall plus intravenrricular septum thickness (2.02±0.04 versus 1.76±0.03 cm; p<0.05) were also higher in patients with high sodium-lithium countertransport Hypertensive patients with normal sodium-lithium countertransport had renal and cardiac parameters similar to those of a normotensive control group (n=21) except for a higher glomenilar filtration rate and left ventricular mass index. Finally hypertensive patients with elevated rates of sodium-lithium countertransport had significantly higher plasma triglyceride levels and lower plasma concentrations of high density lipoprotein cholesterol. Thus renal and cardiac hypertrophy, lipid abnormalities, and altered kidney function are prominent features of hypertensive patients with higher sodium-lithium countertransport

Usefulness of transesophageal echocardiography in evaluation of paracardiac neoplastic masses

Mediastinal paracardiac tumors may cause both cardiovascular complications and problems in differential diagnosis of cardiac diseases. Transesophageal echocardiography (TEE) may give an additional new window to mediastinal neoplasms, but only a few studies have been reported. TEE was performed in 70 patients with paracardiac neoplastic masses. The procedure was indicated to solve particular clinical problems in 20 patients, and as a prospective study on 50 unselected patients with mediastinal neoplasms. Twenty-three patients underwent follow-up studies; a total of 101 echocardiograms were recorded. The procedure was tolerated well or very well by most patients, and provided additional anatomic or hemodynamic data in every patient in group a and in 45 of 50 in group b. The additional data were relevant for clinical management in 14 of 20 patients in group a, and in 3 of 45 in group b. Based on the results of this study, TEE is useful in association with other radiologic techniques in patients with paracardiac neoplasms. As an imaging technique, it may represent a reliable alternative to computed tomography whenever the latter is not feasible.

Secondary Neoplastic Infiltration of the Myocardium Diagnosed by Two-Dimensional Echocardiography in Seven Cases With Anatomic Confirmation

In seven patients with different types of neoplasm, secondary myocardial infiltration was diagnosed in vivo by two-dimensional echocardiography and confirmed by direct inspection. In all patients, clinical and electrocardiographic findings were suggestive but nonspecific for myocardial involvement. Two patients had cardiac tamponade and three had pericardial effusion. In three patients, the echocardiographic diagnosis made it possible to plan specific therapy. Clinical, electrocardiographic and echocardiographic aspects are discussed. A two-dimensional echocardiographic examination should be performed in all patients when cardiac metastatic involvement is suspected from clinical electrocardiographic findings, because the in vivo diagnosis of such a condition may have important therapeutic implications for such patients.

Role of Transesophageal Echocardiography in Evaluation of Pulmonary Venous Obstruction by Paracardiac Neoplastic Masses

From 71 consecutive patients with paracardiac neoplastic masses who underwent transesophageal echocardiography (TEE), obstruction of individual right upper pulmonary venous flow by compression by contiguous mass was detected by TEE in 4 patients before and disappeared after anti-neoplastic treatments. Pulmonary vein, contiguous neoplastic mass and their relation could be clearly visualized and assessed by TEE. Pulmonary venous obstruction was assessed as moderate degree by combination of Doppler flow characteristics and diameter of pulmonary vein. Before therapy, peak velocities and time-velocity integrals in obstructed right upper pulmonary venous flow were increased, whereas deceleration times of systolic flow were prolonged. After therapy, peak velocities and time-velocity integrals were reduced and deceleration times of systolic flow were shortened, with normalization of the diameter of the right upper pulmonary veins. Thus, TEE may be used to detect and evaluate pulmonary venous obstruction by neoplastic masses and its changes after antineoplastic treatments.

Direct Demonstration of an Air-Fluid Interface by Two-Dimensional Echocardiography: A New Diagnostic Sign of Hydropneumopericardium

Hydropneumopericardium is an uncommon condition that requires prompt diagnosis and treatment if hemodynamic compromise is present. Chest roentgenography, computerized tomography, and echocardiography provide important information for the diagnosis. In this article a new distinctive echocardiographic sign of hydropneumopericardium is described: the direct demonstration of the air-fluid interface in the long-axis precordial view.

Echocardiography in pulmonary embolism disease

Pulmonary embolism is a very common disease often misdiagnosed, because of variable and nonspecific clinical manifestations. Therefore it has a burden of high mortality, particularly in nonrecognized cases. Pulmonary angiography, which is usually considered the gold standard, and ventilation/perfusion pulmonary scan have shown good results in this field, but the first is costly and invasive, and both are not easily and rapidly available in all centers. Echocardiography can be helpful in the diagnosis of pulmonary embolism; transthoracic echo in particular is able to recognize indirect signs of the disease, due to acute pressure right overload; it is also possible to evaluate pulmonary artery systolic pressure by continuous wave Doppler. Transthoracic echocardiography can be negative in cases of small pulmonary embolism, in which the pressure overload and therefore haemodynamic impairment is trivial. The sensitivity and specificity of transthoracic echo is low, but its role in the diagnosis and management of pulmonary embolism may be important, because it can easily and rapidly show the presence and degree of right ventricular pressure overload and therefore it can help in addressing therapy and prognosis. Transesophageal echo may directly demonstrate thrombotic masses in the main pulmonary arteries or, less often, floating intracavitary thrombi. In this field it is showing promising results.

Relation Between Three-Dimensional Geometry of the Inflow Tract to the Orifice and the Area, Shape, and Velocity of Regurgitant Color Doppler Jets: An In Vitro Study

The relation between three-dimensional geometry of the inflow tract to the orifice and the area, shape, and velocity of regurgitant jets was studied in a pulsatile in vitro color Doppler flow model. A 2.5 MHz transducer connected to a diagnostic ultrasound machine was placed in a water tank facing pulsatile jets (duration, 0.5 second) obtained by a calibrated injector. Flow rate from 6 to 52 ml/sec were tested through a 5 mm diameter circular orifice. Four different three-dimensional inflow tract geometries were compared: (A) sharp-edged, (B) Venturi (funnel), (C) converging conical, and (D) diverging conical. Mean velocities of jets were measured by continuous-wave Doppler echocardiography. Driving pressures were also measured by means of a fluid-filled catheter. Two observers independently digitized contours of maximal color jet areas by computer system from two separate sets of experiments. Results are given as the mean values of the four measurements for each parameter. Jet areas were correlated to flow rate, with no difference from A through D. The shape (eccentricity) of jets was different between A and B (p less than 0.05), between B and D (p less than 0.01), and between C and D (p less than 0.01). The shape of jets was correlated with flow rate, continuous-wave velocity, and pressure gradient in B, C, and D but not in A. Measured pressure gradients and estimated gradients by continuous-wave Doppler echocardiography were similarly correlated from A through D.(ABSTRACT TRUNCATED AT 250 WORDS)

Limitations in the assessment of changes of cardiac output by Doppler echocardiography under various hemodynamic conditions

Abstract Several groups have reported successful estimation of cardiac output (CO) by the Doppler echocardiography volume flow method. 1–3 Recently, considerable effort was directed toward the use of the Doppler method for the evaluation of changes in CO during pharmacologic or stress intervention. 4–6 However, these measurements still rely on a combination of 2-dimensional imaging and Doppler flow data, both of which have several inherent sources of error. The purpose of this study was to (1) test whether the Doppler volume flow method through the aortic annulus is suitable for detecting rapid changes in CO during subsequent modifications of hemodynamic conditions (baseline, during intravenous nitroglycerin, and immediately after ventriculography and aortography) compared with simultaneous measurements by the thermodilution technique, and (2) assess the degree of agreement between the 2 techniques by both correlation and Bland-Altaian statistical methods. 7