Pietro Pugliatti

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.

Contrast-enhancing right atrial thrombus in cancer patient

The progress in cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–11]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care. Increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention [12,13] as well as the role of the thromboembolism prophylaxis [14–24]. The increased thromboembolism risk in cancer patients [19,20] is influenced by the type of cancer, its stage and histology, the presence of thrombophilia, concomitant and previous treatments, metastatic-stage malignancy [25], vascular catheter presence [15], and paraneoplastic hypercoagulability [17,18,20,25]. Patient-, cancer-, and treatment-related factors should be taken under consideration in the assessment of individual venous thromboembolism risk [25]. We present a case of a right atrial mass in a 57-year-old Italian woman. She reported a history of diabetes mellitus, a history of smoking, a sotalol treatment and a lymphoma chemotherapy treatment. Echocardiographic evaluation revealed a right atrial mass (Fig. 1) [26,27]. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network [26]. Cardiac magnetic resonance [27,28] identified right atrial mass as an atrial thrombus

Cardioinhibitory vasovagal syncope in a cancer patient

The progress in cancer knowledge and treatment has led to a new frontier: cardio-oncology [1–27]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care [1,12,17]. We present a case of a 57year-old Italian man complaining about episodes of cardioinhibitory vasovagal syncope [28–30]. He reported a history of atrial fibrillation, diabetes mellitus, smoking, a sotalol treatment, a chemotherapy treatment and a laryngeal tracheostomy for laryngeal cancer. Echocardiographic evaluation revealed a biatrial dilatation, a fibrocalcification of a three-leaflet aortic valve with a severe aortic stenosis [AVA = 0.8 cm, transvalvular mean gradient = 51 mm Hg] [Fig. 1] and a moderate aortic regurgitation [PHT= 415ms], and amildmitral regurgitation. Results of a 24-hour Holter monitoring showed several pauses of at least 1.5 s and up to 2.5 s, and 68 pauses of longer than 2.5 s (max pause of 3360 ms). Computer tomography imaging showed progressive stenosis of the left internal carotid artery and the total occlusion of the left jugular vein due to neck neoplastic mass [Fig. 2]. A pacemaker implantation was successfully performed.

The chance finding of echocardiographic complications of infective endocarditis

Fig. 1. Biatrial dilatation, a left ventricular dilatation, an interventricular septal hypertrophy, an anterior mitral leaflet abscess/perforation complication of infective endocarditis. Despite the progress in its knowledge and treatment, infective endocarditis [1–17] remains a therapeutic challenge [17]. We present a case of an infective endocarditis in a 62-year-old Italian man. A 62-year-old Italian man was admitted to the Cardiology Unit for a pre-operative cardiac risk assessment in colon cancer surgery. He reported a streptococcal infection two years ago. Echocardiographic evaluation revealed a biatrial dilatation and a left ventricular dilatationwith an interventricular septal hypertrophy. The semilunar aortic valves were markedly thickened with retraction of left and right cusps. A moderate–severe mitral regurgitation, a severe aortic regurgitation, a mild tricuspidal regurgitation, and an anterior mitral leaflet abscess/perforation complication of infective endocarditis were also observed. Also this case focuses attention on infective endocarditis.

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.

Interplay between arterial stiffness and diastolic function: a marker of ventricular-vascular coupling.

Aims We evaluated the interplay between left ventricular diastolic function and large-artery stiffness in asymptomatic patients at increased risk of heart failure and no structural heart disease (Stage A). Methods We divided 127 consecutive patients (mean age 49 ± 17 years) with risk factors for heart failure who were referred to our laboratory to rule out structural heart disease into two groups according to presence (Group 1, n = 35) or absence (Group 2, n = 92) of grade I left ventricular diastolic dysfunction. Doppler imaging with high-resolution echo-tracking software was used to measure intima-media thickness (IMT) and stiffness of carotid arteries. Results Group 1 had significantly higher mean age, blood pressure, left ventricular mass index, carotid IMT and arterial stiffness than Group 2 (P < 0.05). Overall, carotid stiffness indices (&bgr;-stiffness index, augmentation index and elastic modulus) and ‘one-point’ pulse wave velocity each showed inverse correlation with E-wave velocity, E′ velocity and E/A ratio, and direct correlation with A-wave velocity, E-wave deceleration time and E/E′ ratio (P < 0.05). Arterial compliance showed negative correlations with the echocardiographic indices of left ventricular diastolic function (P < 0.05). On logistic regression analysis, age, hypertension, SBP, pulse pressure, left ventricular mass index, carotid IMT and stiffness parameters were associated with grade I left ventricular diastolic dysfunction (P < 0.05 for each). However, on multivariate logistic analysis, only ‘one-point’ pulse wave velocity and age were independent predictors (P = 0.038 and P = 0.016, respectively). Conclusion An independent association between grade I left ventricular diastolic dysfunction and increased arterial stiffness is demonstrated at the earliest stage of heart failure. Hence, assessment of vascular function, beyond cardiac function, should be included in a comprehensive clinical evaluation of these patients.

Arterial stiffness changes in patients with cardiovascular risk factors but normal carotid intima-media thickness.

Aims We aimed to evaluate, through an Echotracking system, the functional changes of carotid arteries with relation to the amount of cardiovascular risk factors in patients without structural atherosclerotic damage. Methods From a series of 260 asymptomatic consecutive patients we selected 75 patients (mean age: 47 ± 8 years) with normal intima–media thickness (IMT) and without atherosclerotic plaques. In these patients, local arterial stiffness parameters were evaluated using a simple Echotracking system. Patients were divided in three groups: group 1 (n = 25 patients without risk factors), group 2 (n = 23 patients with one risk factor) and group 3 (n = 27 patients with two or more risk factors). Results Carotid IMT was similar in all groups (P = ns). On the contrary, stiffness parameters progressively increased according to the number of risk factors [pulse wave velocity (PWV) = 5.8 ± 1.1 m/s, 6.4 ± 1.2 m/s and 6.7 ± 1.4 m/s in Group 1, 2 and 3, respectively, P = 0.002; &bgr;-index = 7.5 ± 3.4, 8.5 ± 3.2 and 9.5 ± 4.7 in Group 1, 2 and 3, respectively, P = 0.047]. Furthermore, on multivariate linear regression analysis, PWV and &bgr;-index significantly correlated (P = 0.002 and P = 0.048, respectively) with the number of risk factors even when adjusted for age, gender and current therapy. Conclusion In a population with normal carotid IMT and without plaques, changes in arterial stiffness are significantly related to the number of risk factors. This information could be relevant for a more tailored primary prevention in patients with risk factors even in absence of structural atherosclerotic abnormalities.

A massive pericardial effusion in a cancer patient

The progress in the cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–22]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists for the optimal effective patients care [1–24]. Moreover oncosurgery represents a challenge for cardiologist [23] and preoperative cardiological assessment is the cornerstone of the modern oncosurgery as well as efficacious anesthesiological evaluation [23–25]. In the emerging scenario of concomitant problems and diseases [23–38], physicians should be familiar with available drugs, environmental epidemiology and patient factors [23–34] as well as with new emerging findings regarding use of cardiovascular drugs [26,27,30–33,39]. The pericardium is involved in a large number of systemic disorders includingneoplastic pathologies [40–73]. We present a case of massive pericardial effusion in a 66-yearold Italian man suffering from a haematological cancer. Echocardiographic evaluation revealed a massive pericardial effusion with initial signs of atrial collapse (Fig. 1). Post-contrast CT images show a massive pericardial effusion (white asterisks), with left hilar lymphadenopathies, malignant lung nodules associated with mild pleural thickening and effusion (Fig. 2 Panel A) and abdominal voluminous lymphadenopathy (Fig. 2 Panel B). Also this case is illustrative of the benefit resulting from an open dialogue between both cardiologists and oncologists for the optimal effective patients care.

Extrinsic pulmonary stenosis in primary mediastinal B-cellular lymphoma

We describe the case of a 34‐year‐old man with a history of asthenia and excessive fatigability. Transthoracic echocardiography showed a mass in the right ventricular outflow tract with a peak systolic gradient of 52 mmHg. Contrast‐enhanced CT confirmed the presence of a lobulated mass, which extensively filled the anterior mediastinum, infiltrating the pulmonary artery trunk up to occupying the right ventricular outflow tract. CT‐guided biopsy revealed primary mediastinal B‐cellular lymphoma. The patient underwent chemotherapy, achieving complete remission of the disease at the 12‐month follow‐up, while the gradient across the pulmonary artery dropped from 52 mmHg to 14 mmHg.

Myocardial bridging in a young patient with left ventricular hypertrophy: a combined approach with CT scan and color Doppler echocardiography.

In this report the authors deal with the combined approach of last generation computed tomography and color Doppler echocardiography to make a diagnosis of myocardial coronary bridging in a young patient with left ventricular hypertrophy. Double-source tomographic scan precisely identified the tunnelled segment of the left descending coronary artery (the first diagonal branch), whereas echocardiography allowed recognising diastolic and systolic velocity just in this vessel. Coronary velocity throughout the bridged artery was not particularly increased at rest and late after exercise, even if the patient had ST-T changes during cycling test. These findings likely support a benign pathophysiological significance of isolated bridging of secondary coronary branches.