Francesco Luzza

Prevalence of Atrial Septal Aneurysm in Patients With Migraine: An Echocardiographic Study

Objective.—To evaluate the prevalence of atrial septal aneurysm in patients with migraine.

Anatomical M-Mode: An Old–New Technique

The M‐mode (motion mode) technique has improved the diagnostic possibilities of echocardiography due to its high temporal resolution. The use of a two‐dimensional (2D) image as a basis for M‐mode analysis at a defined line, independent of the transducer orientation, namely the anatomic M‐mode (AMM), has been proposed from the beginning of 2D echocardiography. For several years, however, this could not be accomplished due to several reasons including the limited digital memory, the relatively rough pixels of 2D images, and the low temporal resolution of the screen. The AMM has been improved by the “fully digital” machines. These are able to provide a series of digital data (direction, position, and timing) relative to any single echo received from any point of the tissue. AMM analysis, thus, can be performed in any direction, as a “normal” monodimensional echocardiogram. With respect to traditional M‐mode, AMM permits a more detailed analysis of cardiac chambers diameters obtained by linear measurements, regional wall motion of the left ventricle (both at rest and during stress), and location of accessory pathways. In particular, the assessment of left ventricular regional wall motion represents the most important goal of this new technique, which results in marked reduction or even elimination of the limitations due to the subjective character of wall motion evaluation with 2D echocardiography. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Atrial flutter, ventricular tachycardia and changing axis deviation associated with scleroderma

Rhythm disturbances have been described in immunological and connective diseases. Scleroderma is a fibrotic condition characterized by immunological abnormalities, vascular injury and increased accumulation of extracellular matrix proteins. The heart is one of the major organs involved in scleroderma, the involvement of which can be manifested by myocardial disease, conduction system abnormalities, arrhythmias, or pericardial disease. Additionally, scleroderma renal crisis and pulmonary hypertension lead to significant cardiac dysfunction secondary to damage in the kidney and lung. Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. We present a case of atrial flutter, ventricular tachycardia and changing axis deviation in a 61-year-old Italian woman with scleroderma. This case focuses attention on changing axis deviation and on the presentation of arrhythmias in scleroderma. The underlying arrhythmogenic mechanisms are probably multiple and intriguing, even though the myocardial fibrosis and immunological autoantibody-mediated mechanisms seem to play a pivotal role.

Syncope of psychiatric origin.

Abstract.Background:A well-defined relationship between transient loss of consciousness and a psychiatric disorder has not yet been established.Review summary:In the past, psychiatric origin of syncope was considered to be uncommon, occurring only in 1–7% of patients with syncope. Recently, a much higher incidence ranging from 20 % to 81 % has been reported. One main difficulty may be an incorrect approach to the problem. Authors generally defined syncope as every loss of consciousness without regard to the specific pathophysiology of the symptom. Moreover, identification of psychiatric origin of transient unconsciousness may be very difficult. Some clinical features can suggest the diagnosis; none of them, however, is an identification mark. Thus, in most cases, the diagnosis may be certain only when direct observation of the clinical event occurs. A transient loss of consciousness may be related to a psychiatric disorder when the symptom ensues in the presence of normal values of both blood pressure and heart rate. The phenomenon resembles syncope and has been defined as “pseudosyncope”. Unfortunately, direct observation of a spontaneous event is very uncommon. Recently, few cases of pseudosyncope induced by Tilting test (HUTT) have been reported. In these patients, HUTT revealed a previously unknown psychiatric disorder. In our experience, pseudosyncope represented an uncommon HUTT outcome in all patients referring for unexplained syncope; in selected patients, however, HUTT may be useful in the early identification of psychiatric syncope.Conclusions:Prospective researches are needed to assess HUTT utility in evaluating patients whose clinical features suggest psychiatric origin of transient loss of consciousness.

Verapamil-induced electrical and cycle length alternans during supraventricular tachycardia: what is the mechanism?

The tracing shown in Figure 1, which was recorded from a 55-year-old man with frequent episodes of paroxysmal tachycardia, shows a narrow QRS complex tachycardia (QRS duration 0.10 sec) at a rate of 186/min. A 5-mg bolus of verapamil was injected intravenously in 2 minutes. During injection, the rate of tachycardia was reduced to 175/min, and an electrical alternans that was very clear in lead V2 ensued, associated

Supernormal Conduction in the Left Bundle Branch Unmasked by the Linking Phenomenon

This presentation reflects a case of phase‐3 left bundle branch block (LBBB). Analysis reveals that relatively early QRS complexes are wide, whereas beats occurring later than a critical time are narrow. There are, however, two unexpected phenomena: (1) an overlap occurs between the range of R‐R intervals resulting in normal intraventricular conduction and the range of R‐R intervals resulting in LBBB pattern. Complexes that follow a wide beat are often wide although they are associated with relatively long R‐R intervals, whereas complexes that follow a normal beat tend to be normal even after relatively short R‐R cycles. This is due to concealed retrograde penetration of the bundle branch that is blocked in anterograde direction (the so‐called linking phenomenon). (2) Some early supraventricular impulses, paradoxically, resulted in normal intraventricular conduction. The phenomenon is a manifestation of supernormal LBB conduction, and only occurs following a wide QRS complex associated with retrograde activation of the LBB. The linking phenomenon reveals or unmasks the supernormal phase of LBB conduction. Following a retrograde and delayed activation of the LBB, the refractory period of the bundle branch is postponed, in such a way that a supraventricular impulse is allowed to occur during the early phase of supernormal conduction.

Supraventricular Tachycardia in Infants: Epidemiology and Clinical Management

Supraventricular tachycardias (SVTs) are observed in 0,1-0,4% of the paediatric population and represent an important clinical problem with related significant health and social issues. Most tachycardias are paroxysmal, being associated with sudden onset and termination, and only a relatively small number of them is permanent, namely chronic. Paroxysmal tachycardias, in addition, can be either sustained (lasting > 30 seconds) or non-sustained whenever their duration is less. Most SVTs are due to re-entry, and only atrial tachycardia and and junctional ectopic tachycardia are caused by enhanced automaticity. Atrial tachycardia, however, can also be due, although rarely, to re-entry or to triggered activity. A prompt recognition of these arrthmias in children by pediatric cardiologist is essential for a correct clinical managemet of the patients. In this review, the epidemiologic data regarding the SVTs in pediatric age are reported along with the description of the pathophysiological mechanisms and the analysis of electrocardiographic findings to be considered for a correct clinical diagnosis and a rational therapeutic approach to these arrhythmias.

Spontaneous termination of ventricular fibrillation

A 65 year old woman with hypertension and permanent atrial fibrillation had suffered two brief syncopal episodes. She was on losartan, digoxin, and aspirin. The ECG showed atrial fibrillation and incomplete left bundle branch block; the QT interval was 0.36 s and the QTc 0.414 s. The echocardiogram revealed mild dilatation and dysfunction of …

Torsades de pointes in congenital long qt syndrome following low‐dose orphenadrine

We report the case of a woman, affected by congenital long QT syndrome (LQTS), who experienced three syncopal episodes shortly after the assumption of a low dose of orphenadrine. The ECG revealed a QT interval of 600 ms, and the corrected QT interval (QTc) was 537 ms. No structural cardiac disease was demonstrated by echocardiography. Orphenadrine treatment was discontinued. During the first 12 h of monitoring, three short‐lasting, asymptomatic episodes of torsades de pointes occurred. No other sustained ventricular arrhythmia was revealed at Holter monitoring in the following days. During the ensuing 6 months, the patient remained asymptomatic, and the QTc did not change. Orphenadrine is an analogue of diphenhydramine, an antihistaminic drug that produces sodium channel blockade similar to that caused by quinidine and other Class Ia antiarrhythmic drugs. Our case rises the suspicion that orphenadrine could cause life‐threatening arrhythmias in LQTS even at a low dose, and independently from concomitant assumption of potentially QT‐prolonging drugs.

Concealed ventricular quadrigeminy linked to atrial quadrigeminy: A manifestation of modulated parasystole

Analysis of a long electrocardiographic recording including many atrial and ventricular extrasystoles shows that when atrial extrasystoles are in a quadrigeminal distribution, the ventricular extrasystoles also manifest a quadrigeminal distribution or reflect a distributional pattern of concealed quadrigeminy. Conversely, when atrial extrasystoles are other than in a quadrigeminal distribution, the ventricular extrasystoles do not occur in a quadrigeminal or concealed quadrigeminal distribution. This pattern is explained on the basis of modulated parasystole. A biphasic phase-response curve explains the observed phenomena on the basis of variations of the parasystolic cycle length due to the modulating effect of supraventricular beats.