Arrhythmogenic right ventricular dysplasia/cardiomyopathy: need for an international registry. Study Group on Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy of the Working Groups on Myocardial and Pericardial Disease and Arrhythmias of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the World Heart Federation

Arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C) is a heart muscle disease characterized by peculiar RV involvement and electrical instability that precipitates ventricular arrhythmias and sudden death. The purpose of the present consensus report of the Study Group on ARVD/C of the Working Groups on Myocardial and Pericardial Disease and Arrhythmias of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the World Heart Federation is to review the considerable progress in our understanding of the etiopathogenesis, morbid anatomy, and clinical presentation of ARVD/C since it first was described in 1977. The present article focuses on important but still unanswered issues, mostly regarding risk stratification, clinical outcome, and management of affected patients. Because ARVD/C is relatively uncommon and any one center may have experience with only a few patients, an international registry is being established to accumulate information and enhance the numbers of patients that can be analyzed and thus answer pending questions. The registry also will facilitate pathological, molecular, and genetics research on the causes and pathogenesis of the ARVD/C. Furthermore, availability of an international database will enhance awareness of this largely unrecognized condition among the medical community. Physicians are encouraged to enroll patients in the International Registry of ARVD/C.

Familial effort polymorphic ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy map to chromosome 1q42-43

In the present study we report on another cause of an arrhythmia associated with familial arrhythmogenic right ventricular cardiomyopathy (ARVC), which is linked to chromosome 1q42-43. Two families with 48 subjects were studied with 12-lead electrocardiography, 24-hour ambulatory electrocardiography, chest x-ray, M-mode and 2-dimensional echocardiography, signal-averaging electrocardiography, and exercise stress testing. Six subjects also underwent right and left ventricular angiography and electrophysiologic study. An endomyocardial biopsy was performed in 1 subject. The genetic study included pedigree reconstruction and linkage analysis with polymorphic DNA markers. Five young subjects died suddenly during exercise; autopsy was performed in 3 and showed segmental fibro-fatty replacement of the right ventricle, mostly at the apex. Two of them experienced syncopal attacks during effort. Sixteen living subjects, without arrhythmias at rest had polymorphic ventricular arrhythmias during effort; ARVC was diagnosed in 15, whereas 1 did not have any demonstrable cardiac abnormality. The remaining family members were healthy and did not have arrhythmias. The linkage study assigned the disease locus to chromosome 1q42-q43, in close proximity to the alpha-actinin 2 locus (maximal lod score was 5.754 at theta = 0) with a 95% penetrance. Thus, these data suggest that effort-induced polymorphic ventricular arrhythmias and juvenile sudden death can be due to adrenergic stimulation in a particular genetic group of ARVC patients. In these cases the pathology was segmental, mostly localized to the right ventricular apex. Ventricular arrhythmias that are present in these families differ from the monomorphic ones that are usually seen in patients with ARVC.

Signal-averaged electrocardiogram in patients with arrhythmogenic right ventricular cardiomyopathy and ventricular arrhythmias

OBJECTIVE

The aim of the study was to assess the prevalence, sensitivity, specificity and predictive value of the signal-averaged ECG in patients with arrhythmogenic right ventricular cardiomyopathy and different forms of ventricular arrhythmias.

METHODS

The signal averaged ECG in 138 patients and 146 healthy subjects (control group), using a three bandpass filter system (25-250, 40-250, 80-250 Hz), was considered abnormal when at least two parameters were abnormal at each filter setting. Patients were divided into three groups according to the extent of the right ventricular enlargement (mild, moderate, extensive), and into five groups according to the type of ventricular arrhythmia.

RESULTS

The signal averaged ECG was abnormal in 57% of the patients and in 4% of the healthy subjects. The sensitivity was 57%, specificity 95% and positive predictive value 92%. The signal averaged ECG was abnormal in 94.4% of patients with the extensive form of the disease, in 77.7% of patients with the moderate form and in 31.8% of patients with the minor form, demonstrating good correlation with the extent of the disease. According to the type of ventricular arrhythmia, a higher correlation was found between signal averaged ECG abnormality and sustained ventricular tachycardia with superior axis (94.4%, P<0. 02); the correlation for the other arrhythmias varied from 16.6% to 55.8%.

CONCLUSION

There is a closer correlation between the signal averaged ECG and extent of disease than with the presence of ventricular arrhythmias. The signal averaged ECG is not helpful in diagnosing minor forms of the disease, but since it is a non-invasive method, it may be useful in evaluating progression of the disease.

Vascular endothelial growth factor and hypertrophic osteoarthropathy

OBJECTIVE

Hypertrophic osteoarthropathy (HOA) is characterized by the coexistence of digital clubbing and periosteal proliferation of the tubular bones. Localized vascular proliferation associated with platelet/endothelial cell activation are recognized features of this syndrome. Current knowledge suggests that HOA develops from the presence in the systemic circulation of one or more growth factors that are normally inactivated in the lungs. The nature of these purported growth factors has not yet been identified. Vascular endothelial growth factor (VEGF) has several features that may fit in with the pathogenesis of HOA. The objective of our study was to measure serum and plasma levels of VEGF in different groups of patients with HOA.

METHODS

We studied 24 patients with HOA; of these, in 12 the HOA was secondary to cyanotic congenital heart disease and in 7 to lung cancer, while 5 represented primary cases. As controls we studied 28 individuals without HOA; of these, 12 were apparently healthy individuals, 7 had cyanosis secondary to chronic obstructive pulmonary disease, and 9 had lung cancer. ELISA was used to measure serum and plasma levels of VEGF.

RESULTS

Plasma levels of VEGF were significantly higher in the patients with primary HOA (median 46.2; range 19.4-398.8 pg/ml) and in those with lung cancer-HOA (median 75.5; range 24.6-166.7), compared to healthy controls (median 7.4; range: 0-26.1), p < 0.05. Serum VEGF levels were higher in patients with lung cancer and HOA (median 411.4; range 164.2-959.5 pg/ml) compared with lung cancer patients without HOA (median 74.5; range 13.2-205.4), p < 0.001.

CONCLUSIONS

Patients with primary HOA and those with HOA and lung cancer have increased circulating levels of VEGF. This cytokine may play a role in the pathogenesis of HOA.

Fine mapping and genomic structure of ACTN2, the human gene coding for the sarcomeric isoform of alpha-actinin-2, expressed in skeletal and cardiac muscle

The present paper reports on the fine mapping of the ACTN2 gene and on the reconstruction of its genomic structure. By radiation hybrid mapping, the gene was located about 912 cR from the 1p-telomere. ACTN2 was placed between the marker WI-9317 (alias D1S2421) and the marker AFMA045ZC5, within the chromosomal band 1q43. The gene was detected in YAC 955 c 12. This YAC was used as template DNA for long-distance and Alu-PCR, using a set of putative exonic primers, designed on the cDNA sequence of alpha-actinin-2, in order to characterize the ACTN2 intron-exon boundaries. The entire genomic structure of the gene was reconstructed. The ACTN2 gene contained 21 exons, in a segment spanning about 40 kb of genomic DNA. Only the proximal part of the gene shows a high conservation through evolution, whereas in the remaining part a divergence from the genomic organization of C. elegans and D. melanogaster was noticed. A series of intronic primers was specifically designed and produced, to amplify all the exons of ACTN2, directly from genomic DNA. This will enable mutation screening in patients affected with hereditary diseases linked to the marker CA4F/R, a polymorphism in the last intron of the alpha-actinin-2 gene.

Evaluation of adenosine deaminase activity in the Mycobacterium tuberculosis culture supernatants

BACKGROUND

Adenosine deaminase (ADA) catalyzes hydrolytic and irreversible deamination of deoxyadenosine into deoxyinosine and of adenosine into inosine, and is related to lymphocytic proliferation and differentiation. The measurement of ADA activity in body fluids is a useful tool in the evaluation of mycobacterial infections. Elevated ADA activity has been found in pleural effusions of patients with pleural tuberculosis relative to those from patients with nontuberculous pleural diseases, and is mainly associated with cellular host factors such as monocyte-macrophages or lymphocytes. In contrast, there is little information about ADA activity measurement in mycobacteria culture supernatants.

METHODS

We evaluated ADA activity as described by Giusti in the culture supernatants of eight Mycobacterium tuberculosis isolates.

RESULTS

Mycobacteria culture supernatants did not display any ADA activity.

CONCLUSIONS

This result supports the notion that Mycobacterium tuberculosis is not the source of ADA activity. However, increased ADA activity in biological fluids from tuberculosis patients might be due to the interaction of the mycobacterium with host factors.

Strong association of autoantibodies to human nuclear lamin B1 with lupus anticoagulant antibodies in systemic lupus erythematosus

OBJECTIVE

To determine the frequency and clinical significance of high titers of IgG autoantibodies to nuclear lamin B1 in a large number of unselected and well-characterized systemic lupus erythematosus (SLE) patients, disease controls, and normal healthy controls.

METHODS

A cross-sectional study of anti-lamin B1 autoantibodies, as measured by enzyme-linked immunosorbent assay using human recombinant lamin B1 autoantigen, was performed on serum samples obtained at first evaluation of 238 consecutive French Canadian adults: 61 healthy control subjects, 20 patients with osteoarthritis, 22 with ankylosing spondylitis, 11 with autoimmune hepatitis, 30 with rheumatoid arthritis, and 94 with SLE. SLE patients were studied for 57 disease manifestations. A case-control study was performed to analyze the relationship between anti-lamin B1 status and thrombotic manifestations between SLE onset and last followup.

RESULTS

High titers of anti-lamin B1 were strikingly restricted to a subset of 8 SLE patients (8.5%). The mean anti-lamin B1 titer was higher in this subset than in the other SLE patients or any control group (P<0.001). By univariate analysis and stepwise multiple logistic regression, the most striking association of anti-lamin B1 was with lupus anticoagulant (LAC) antibodies (P = 0.00001). Although LAC were significantly associated with thrombosis in our SLE patients, anti-lamin B1 was not. The frequency of thrombosis in SLE patients expressing both LAC and anti-lamin B1 was similar to that in patients without LAC (P = 1.0). However, patients expressing LAC without anti-lamin B1 had a greater frequency of thrombosis (P = 0.018).

CONCLUSION

High titers of IgG anti-lamin B1 autoantibodies are highly specific for a subset of SLE patients whose clinical characteristics include the presence of LAC and other laboratory manifestations of the antiphospholipid syndrome. The presence of LAC without anti-lamin B1 may define a subset of SLE patients at greater risk for thrombosis.

What is the Brugada syndrome?

In 1992, Brugada and Brugada reported a distinct subgroup of patients with episodes of "idiopathic"polymorphic ventricular tachycardia or ventricular fibrillation characterized by a unique electrocardiographic (ECG) pattern, which consisted of right bundle branch block and ST-segment elevation from V1 to V2-V3. As in patients with long QT syndrome, the ECG changes and the ventricular electrical instability could not be explained by structural heart disease, myocardial ischemia, or electrolyte disturbances. The syndrome can be inherited and predominantly affects males. Clinical presentation includes cardiac arrest or syncope caused by rapid ventricular tachycardia or fibrillation characteristically occurring at rest or during sleep. The clinical outcome of affected patients is poor unless they receive an implantable cardioverter defibrillator. The ECG pattern and the electrical ventricular instability have been explained by the dispersion of repolarization between the right ventricular epicardium and endocardium, which predisposes to local reexcitation of myocytes with different action potential durations. A disease-causing missense mutation in the cardiac sodium channel gene SCN5A has been recently reported in patients with Brugada syndrome. It is mandatory for the clinician to carefully rule out any organic heart disease before suggesting a diagnosis of Brugada syndrome, because the typical ECG pattern with the risk of sudden arrhythmic death is also observed in patients with structural heart diseases in the setting of arrhythmogenic right ventricular cardiomyopathy.

Accuracy of electrocardiographic and echocardiographic indices in predicting life threatening ventricular arrhythmias in patients operated for tetralogy of Fallot

OBJECTIVE

To validate the accuracy of the prognostic significance of non-invasive clinical diagnostic indices as predictors of sustained ventricular tachycardia (sVT) or fibrillation (VF) in patients undergoing repair for tetralogy of Fallot.

METHODS

One way analysis of variance and pairwise comparison of the values with the Bonferroni correction, logistic multivariate analysis, and ordinal logistic analysis were used to study quantitative electrocardiographic and echocardiographic variables in 66 patients who had undergone surgery for tetralogy of Fallot by ventriculotomy at a mean (SD) age of 11.8 (9.5) years. The mean (SD) period of follow up was 16.1 (5.7) years after surgery.

RESULTS

Four groups of patients were identified by ECG and 24 hour Holter monitoring: 19 (28.7%) without ventricular arrhythmias, 34 (51.5%) with minor ventricular arrhythmias, seven (10.6%) with non-sustained ventricular tachycardia (nsVT), and six (9.0%) with sVT or VF. One way analysis indicated significant differences in QT dispersion (QTd) and end diastolic volume of the right ventricle (EDVRV) among the groups. Univariate logistic analysis showed EDVRV, QTd, and QRS duration to be significantly associated with sVT or VF. Stepwise multivariate analysis and ordinal logistic analysis showed QTd to be preferable to QRS duration as an indicator, because it was unrelated to EDVRV, and was capable of separating different probability curves for nsVT as opposed to sVT or VF.

CONCLUSIONS

Stratification of patients undergoing corrective surgery for tetralogy of Fallot and at risk of life threatening arrhythmias is possible by simple and inexpensive means, which provide sensitive and specific indices.

Late potentials and ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy

We studied 38 patients (mean age 32 +/- 14 years) with arrhythmogenic right ventricular cardiomyopathy (ARVC) to evaluate the clinical significance of histologic features on endomyocardial biopsy specimens as related to signal-averaged electrocardiography (SAECG), spontaneous ventricular arrhythmias, and hemodynamic features. Fifteen patients presented with ventricular tachycardia or fibrillation (sustained ventricular arrhythmias), 23 with other minor arrhythmias. SAECG variables and right ventricular ejection fraction (RVEF) were statistically correlated with the extent of myocardial fibrosis on biopsy in ARVC. An increased percentage of fibrous tissue (> or = 30%) was a significant univariate predictor of late potentials (p = 0.004) and reduced RVEF (p = 0.02). The 18 patients with late potentials had an increased percentage of fibrous tissue (p = 0.01), a reduced RVEF (p = 0.0004), and a higher risk for sustained ventricular arrhythmias (p = 0.05) than the 20 patients without late potentials. RVEF was the most powerful predictor of late potentials (p = 0.004) at multivariate analysis. Moreover, RVEF < or = 50% was associated with an increased risk for development of sustained ventricular arrhythmias (p = 0.02). A SAECG parameter, namely the root-mean-square voltage of the terminal 40 ms at 25 Hz, was an independent predictive factor for the occurrence of sustained ventricular arrhythmias (p = 0.02). Although fibrous tissue may contribute to delayed myocardial activation in ARVC, a reduced RVEF plays an essential role for spontaneous manifestation of sustained ventricular arrhythmias.

[Cloacal exstrophy, ultrasonic diagnosis]

This study aims to underline the importance of transvaginal ultrasonography in the first three months of pregnancy. The authors report a case which was referred to their attention for preliminary tests performed prior to amniocentesis, recommended by the general physician because of the mother's age. The primapara woman and father of the fetus were healthy and the family history excluded hereditary diseases or congenital pathologies. Transvaginal ultrasonography permitted the diagnosis at the start of the fourth month of pregnancy of a polymalformed fetus with cloacal exstrophy, sacral myelomeningocele, clubfoot, single umbilical artery. In this case, the mother decided to undergo eugenic abortion in view of the severity of the pathology.

Tolerate, engage or withdraw: a study of the structure of families coping with alcohol and drug problems in south west England and Mexico City

AIMS

To explore the structure underlying individual differences in the ways family members cope with drinking or drug problems.

DESIGN

Cross-sectional interview and questionnaire study of a series of family members in two contrasting socio-cultural groups.

SETTING

Mexico City and South West England.

PARTICIPANTS

Two hundred and seven family members from separate families, three-quarters women, one-quarter men, mostly partners or parents.

DATA

Long semi-structured interviews; the Coping Questionnaire (CQ).

FINDINGS

Factor and subscale analyses of the CQ data and textual analysis of the interview reports were used to test the hypothesis that the underlying structure to coping could be described in terms of eight or nine coherent and distinct ways of coping. Neither form of analysis gave strong support to this hypothesis.

CONCLUSIONS

It is concluded that the structure of coping can best be described in terms of three broad coping positions: tolerating, engaging and withdrawing. These conclusions challenge some previous assumptions about functional and dysfunctional ways of coping with excessive appetitive behaviour in the family.

Radiographic assessment of atrial dipole position in single pass lead VDD and DDD pacing. The Multicenter Study Group

Atrial electrode position was determined by radiographic analysis in 160 patients paced in single-lead VDD for second- or third-degree A-V block, implanted > 1 year with Phymos single pass leads and Phymos 3D pacemakers. The packing lead features an atrial dipole with a 30-mm electrode interspace. In 44% of patients, the upper atrial electrode was positioned within a band of 20 mm centered at the level of the superior vena caval insertion (junctional area) and was in the inferior vena cava or in the atrium in 35% and 21% of cases, respectively. In spite of these different dipole locations, all patients had stable atrium-driven pacing at routine follow-up visits. With the electrode in the junctional area, unipolar stimulation of up to 5 V for 1 ms resulted in stable atrial capture in 63% and 59% of the patients in supine and upright positions, respectively. With the electrode in the atrium, corresponding success rates were 45% and 54%. In the atrium, however, the prevalence of diaphragmatic stimulation was significantly lower than at the junction (10% vs 42% in supine position; 21% vs 47% upright). Though atrial sensing function proved adequate in a wide range of positions, these results suggest that the Phymos lead atrial dipole should be positioned within the atrium, as close as possible to the atrial wall, to maximize the number of VDD patients who might benefit from single-lead DDD pacing.

Cytokines and tear function in ocular surface disease

In summary, tear EGF levels correlate most strongly with tear production in normals, and it is likely that some form of homeostatic mechanism exists to provide a constant supply to the ocular surface. Commercial ELISA kits appear to measure EGF in tears with good consistency and may be useful in the future to improve comparability of data from different studies. In addition, in ocular rosacea, which mimics keratoconjunctivitis sicca in a number of respects, there is a differential increase in the level of the inflammatory cytokine IL-1 alpha in the tear fluid. Much of this elevation appears to be the result of reduced tear turnover, which may form an important positive feedback mechanism encouraging tear stagnation and the perpetuation of ocular surface inflammation.

In vivo evidence of apoptosis in arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a primary heart muscle disease characterized by progressive atrophy of the right ventricular myocardium with fibro-fatty replacement and the risk of electrical instability and sudden death. The disease is often familial and the aetiopathogenesis is still unknown. Recently apoptosis (genetically determined cell death) was postulated to account for progressive loss of myocardium. To establish whether apoptosis is present in ARVC, right ventricular endomyocardial biopsies from 20 patients with clinical and histological diagnosis of ARVC were examined by electron microscopy and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling method (TUNEL). Apoptotic index was calculated as the percentage of positive nuclei in sections stained by TUNEL. Cell proliferation activity was also assessed by argyrophilic staining of the nucleolar organizer region (AgNOR) and MIB-1 antibody analysis. Twenty biopsies taken from patients during monitoring of cardiac transplantation (grade 0 rejection) served as control. Occurrence of apoptosis was correlated with clinical history duration and the presence of acute symptoms and signs like angina, pyrexia, erythrocyte sedimentation rate and creatine phosphokinase elevation, as well as ST segment elevation on basal electrocardiogram. Electron microscopy and TUNEL revealed presence of apoptotic myocytes in seven cases (35%) with a mean apoptotic index of 24.4+/-9.8. The remaining 13 patients and all of the 20 controls were negative both at the electron microscopy and TUNEL. Presence of apoptosis appeared to be significantly related to clinical history duration of less than 6 months (P < 0.001) and presence of acute symptoms and signs (P = 0.007). AgNOR staining and MIB-1 antibody analysis ruled out cell proliferation activity. In conclusion, apoptosis is present in endomyocardial biopsies of patients with ARVC, especially in the early symptomatic phase of disease. Myocardial destruction with replacement by fat may be episodic rather than gradual and continuous.

Incidence of atrial fibrillation in patients with different mode of pacing. Long-term follow-up

We evaluated the incidence of atrial fibrillation in 189 patients (92 males, 97 females, mean age 75 +/- 12 yrs, range 41-100 yrs) with pacemaker, during a mean follow-up of 5.5 yrs (range 1-24 yrs). The indications for implant were: complete AV block (115 pts), second degree Möbitz 2 AV block (51 pts), bifascicular block (5 pts), sick sinus syndrome (14 pts), symptomatic bradycardia (4 pts). The mode of stimulation considered were VVI (105 pt), VVI rate responsive (21 pts), single lead VDD (43 pts), DDD (20 pts). The occurrence of retrograde VA conduction in patients with VVI or VVI rate responsive pacing was also evaluated. Atrial fibrillation occurred in 40 pts (21%). The highest incidence was evidenced in patients with sick sinus syndrome (9 pts, 64%), and in patients with VVI stimulation (28 pts, 27%). On the contrary, the lowest incidence was found in single lead VDD stimulation (4 pts, 9%). The patients with dual chamber pacing showed a relatively high incidence of the arrhythmia (5 pts, 25%). Atrial fibrillation occurred in 9 out of 32 patients with retrograde VA conduction, and in 22 out of 94 patients without retrograde conduction (28% versus 23%, p = NS). In conclusion, it is confirmed that patients with sick sinus syndrome are at high risk for atrial fibrillation. Single lead VDD stimulation seems to be the better mode of pacing in preventing atrial fibrillation, while dual chamber pacing showed minor efficacy. The presence of retrograde VA conduction could not predict the occurrence of the arrhythmia.

Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study

OBJECTIVES

The aim of the present investigation was to redefine the clinicopathologic profile of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC), with special reference to disease progression and left ventricular (LV) involvement.

BACKGROUND

Long-term follow-up data from clinical studies indicate that ARVC is a progressive heart muscle disease that with time may lead to more diffuse right ventricular (RV) involvement and LV abnormalities and culminate in heart failure.

METHODS

Forty-two patients (27 male, 15 female; 9 to 65 years old, mean [+/-SD] age 29.6 +/- 18) from six collaborative medical centers, with a pathologic diagnosis of ARVC at autopsy or heart transplantation, and with the whole heart available, were studied according to a specific clinicomorphologic protocol.

RESULTS

Thirty-four patients died suddenly (16 during effort); 4 underwent heart transplantation; 2 died as a result of advanced heart failure; and 2 died of other causes. Sudden death was the first sign of disease in 12 patients; the other 30 had palpitations, with syncope in 11, heart failure in 8 and stroke in 3. Twenty-seven patients experienced ventricular arrhythmias (ventricular tachycardia in 17), and 5 received a pacemaker. Ten patients had isolated RV involvement (group A); the remaining 32 (76%) also had fibrofatty LV involvement that was observed histologically only in 15 (group B) and histologically and macroscopically in 17 (group C). Patients in group C were significantly older than those in groups A and B (39 +/- 15 years vs. 20 +/- 8.8 and 25 +/- 9.7 years, respectively), had significantly longer clinical follow-up (9.3 +/- 7.3 years vs. 1.2 +/- 2.1 and 3.4 +/- 2.2 years, respectively) and developed heart failure significantly more often (47% vs. 0 and 0, respectively). Patients in groups B and C had warning symptoms (80% and 87%, respectively, vs. 30%) and clinical ventricular arrhythmias (73% and 82%, respectively, vs. 20%) significantly more often than patients in group A. Hearts from patients in group C weighed significantly more than those from patients in groups A and B (500 +/- 150 g vs. 328 +/- 40 and 380 +/- 95 g, respectively), whereas hearts from both group B and C patients had severe RV thinning (87% and 71%, respectively, vs. 20%) and inflammatory infiltrates (73% and 88%, respectively, vs. 30%) significantly more often than those from group A patients.

CONCLUSIONS

LV involvement was found in 76% of hearts with ARVC, was age dependent and was associated with clinical arrhythmic events, more severe cardiomegaly, inflammatory infiltrates and heart failure. ARVC can no longer be regarded as an isolated disease of the right ventricle.

Inflammatory cytokines in the tears of patients with ocular rosacea

OBJECTIVE

The purpose of the study is to compare tear fluid concentrations of interleukin-1alpha (IL-1alpha), tumor necrosis factor-alpha (TNF-alpha), and epidermal growth factor (EGF) in ocular rosacea with those in control subjects and to examine the relation between tear functions, such as production and clearance rate, and the concentrations of cytokines in tear fluid.

PARTICIPANTS AND INTERVENTION

Fourteen patients with severe meibomian gland disease, facial rosacea, and symptoms of ocular irritation were examined for ocular surface disease, tear production, and tear clearance rate (TCR). Twelve control subjects, frequency-matched for age, and 15 ideal normal subjects with no ocular symptoms and normal tear function were assessed using the same parameters. Minimally stimulated tear samples (20 microl) were drawn from each subject and analyzed using a sandwich enzyme-linked immunosorbent assay to detect IL-1alpha, TNF-alpha, and EGF.

RESULTS

Tear IL-1alpha concentration was significantly higher in patients with rosacea than in age-matched (P = 0.003) and ideal control subjects (P < 0.001). Tumor necrosis factor-alpha was not detected in patients or control subjects, indicating levels of less than 10 pg/ml. Epidermal growth factor was not significantly higher in patients with rosacea than in age-matched control subjects. Tear turnover LN(TCR) was lower in patients with rosacea than in both age-matched (P = 0.048) and ideal control subjects (P = 0.002). Schirmer I scores were statistically lower in patients with rosacea than in ideal control subjects (P = 0.013), but not age-matched control subjects. Interleukin-1alpha was correlated inversely with LN(TCR) (r= -0.58, P < 0.0001) and Schirmer I (r = -0.39, P = 0.012).

CONCLUSIONS

Concentrations of IL-1alpha are present in normal tears but are elevated in ocular rosacea, whereas TNF-alpha is not present in either case. The reduced tear turnover, LN(TCR), its inverse correlation with IL-1alpha, and the absence of TNF-alpha in the tears of these patients suggest that the increased concentration of IL-1alpha observed may be largely because of clearance failure of cytokine normally produced at the ocular surface.

Sudden death in young people with apparently isolated mitral valve prolapse

Ventricular electrical instability and sudden death in mitral valve prolapse (MVP) have been related to mitral valve regurgitation and left ventricular dysfunction, autonomic nervous system abnormalities, or underlying cardiomyopathy. The aim of the present study was to assess the frequency, nature and pathophysiologic significance of histologic myocardial abnormalities in young patients with apparently isolated MVP and sudden cardiac death. Among 163 cases of sudden cardiovascular death in young people, MVP was the only cardiac pathology found at postmortem gross examination in 17 (10%) (12 females and 5 males) aged 14 to 35 years, mean 24. In 12 cases sudden death occurred at rest (during pregnancy in 2). MVP was diagnosed during life in 8 patients, 6 of whom had experienced palpitations and/or syncope, and 3 had premature ventricular beats. In every case, postmortem gross examination revealed "floppy" mitral valve leaflets with marked myxoid degeneration, and no other cardiovascular pathology. Cardiomegaly with left chamber enlargement was observed in 5 cases (mild in 3 and moderate in 2). In 12 cases (70%), histopathologic study disclosed myocardial abnormalities which consisted of focal myocardial atrophy and fatty replacement of the right ventricular wall (mostly the outflow tract) in 9 cases, left ventricular myocardial disarray (without hypertrophy) in 2, and lymphocytic infiltrates in one. "Foetal" dispersion of specialized atrioventricular junction and fasciculoventricular Mahaim's fibers were found in 2 cases. In conclusion, apparently isolated MVP was found in nearly 10% of sudden cardiovascular fatalities in young people. Most young sudden death victims with MVP were asymptomatic females without significant mitral valve regurgitation. In more than two-thirds of the cases, histopathologic examination evidenced underlying silent but potentially arrhythmogenic myocardial substrates, mostly consisting of segmental right ventricular cardiomyopathic changes.

ARVD4, a new locus for arrhythmogenic right ventricular cardiomyopathy, maps to chromosome 2 long arm

Autosomal dominant arrhythmogenic right ventricular dysplasia (ARVD; MIM 107970) is a genetically heterogeneous cardiomyopathy, which often causes sudden death in juveniles and athletes. Two disease loci were previously mapped respectively to 14q23-q24 (ARVD1) and to 1q42-q43 (ARVD2). A third possible locus was assigned to 14q12-q22. We report here on a linkage study performed on three independent families with recurrence of ARVD characterized by localized involvement of the left ventricle. In these families the disease appears to be transmitted with three polymorphic DNA markers of the chromosome 2 long arm, showing a maximum lod score of 3.46 at theta = 0 for the marker D2S152. The multipoint linkage analysis suggests that the novel ARVD locus, provisionally named ARVD4, maps to 2q32. 1-q32.3, within the chromosomal region including markers D2S152, D2S103, and D2S389.

On the correct determination of reference values for serum antibodies against pigeon serum antigen using a group of healthy blood donors

An enzymatic immunoassay was developed in order to evaluate the statistical distribution of IgG serum antibodies against pooled pigeon sera antigen in 102 healthy blood donors (HBD). A non-normal distribution was obtained as demonstrated by abnormal values of skewness (2.02) and kurtosis (6.50). A cut-off point (0.120) was determined from the mean plus 2 standard deviations of the optical density values obtained in the HBD group. This value was able to segregate 94% of subjects. However, when calculation of the mean less 2 SD was performed to delimit 95% of the samples, an aberrant negative value was obtained. In contrast, when the nonparametric method of percentile calculation was applied, an optical density value of 0.130 discriminated 97.5% of samples. In addition, the interval between p97.5 and p2.5 delimited 95% of samples. We conclude that when reference values and cut-off point are determined from an enzymatic immunoassay, careful analysis of the statistical distribution of reference values is necessary in order to avoid the inappropriate application of parametric procedures as demonstrated in this study for antibodies against pigeon serum antigens.

The effects of age, gender, and fluid dynamics on the concentration of tear film epidermal growth factor

PURPOSE

To identify the relationship between epidermal growth factor (EGF) concentration in human tears and clinical tear-flow parameters and how these vary with age and gender.

METHODS

Tear samples were collected with minimal stimulation from 68 healthy and asymptomatic adults (33 men, 35 women), aged 21-88 years. EGF concentrations were determined by sandwich enzyme-linked immunosorbent assay (ELISA) in 65 cases. Schirmer tests were performed without anesthesia, and the clearance of fluorescein from the tear film assessed. The Tear Function Index (TFI) was calculated from these values.

RESULTS

There were approximately equal numbers of male and female subjects with a similar age distribution for each gender (48 +/- 3 and 51 +/- 3 years, mean +/- SEM, respectively). Ninety percent of tear EGF concentrations were between 0.75 and 7.1 ng/ml. Tear EGF level correlated significantly with Schirmer I value, but not with age. Schirmer I value correlated with tear clearance [LN(TCR)] but not with age. Tear EGF concentrations were significantly higher for men (3.4 +/- 0.3 ng/ml) than for women (2.4 +/- 0.3 ng/ml; p = 0.043).

CONCLUSIONS

EGF concentrations is tear samples from normal humans were found to correlate with gender and Schirmer I value but not with tear clearance.

Orthostatic sympathetic derangement in subjects with fibromyalgia

OBJECTIVE

To assess the sympathetic-parasympathetic balance in individuals with fibromyalgia (FM), and its response to orthostatic stress, by power spectral analysis of heart rate variability.

METHODS

We studied 19 women with FM and 19 age matched controls. A high resolution electrocardiogram was obtained in supine and standing postures after achieving a stable heart rate. Spectral analysis of R-R intervals was done by the fast Fourier transform algorithm.

RESULTS

Analyses of the different frequency components revealed significant difference between the 2 groups in the low frequency (0.050-0.150 Hz) band, which reflects modulation of the sympathetic nervous system. Controls displayed an increased power spectral density upon standing (+0.081 +/- 0.217 Hz); individuals with FM had a discordant response (-0.057 +/- 0.097 Hz) (p = 0.018).

CONCLUSION

In FM, there is a deranged sympathetic response to orthostatic stress. This abnormality may have implications regarding the pathogenesis of FM.

Spin-echo nuclear magnetic resonance for tissue characterisation in arrhythmogenic right ventricular cardiomyopathy

OBJECTIVE

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a myocardial disorder characterised clinically by ventricular arrhythmias that can cause cardiac arrest and morphologically by fatty or fibro-fatty myocardial atrophy of the right ventricle. In vivo tissue characterisation without endomyocardial biopsy would be useful. The aim of this study was to investigate the diagnostic accuracy of spin-echo nuclear magnetic resonance (NMR) for tissue characterisation in ARVC.

PATIENTS AND METHODS

Twenty three subjects (15 men and eight women, aged 18-49, mean 34) were studied with spin-echo T1-weighted NMR and multislice scan. Fifteen had a clinical diagnosis of ARVC and eight were controls (age and sex matched subjects). Data were independently evaluated by two expert observers.

RESULTS

In the control group NMR was always negative (100% specificity). Ten of the 15 patients with ARVC had an abnormal NMR result (67% sensitivity), with areas that had a signal intensity close to that of pericardial or subcutaneous fat. In the remaining five cases the NMR signal was inadequate. Nine patients underwent both NMR and endomyocardial biopsy; biopsy was positive in eight (89%) and NMR was positive in five (56%).

CONCLUSIONS

NMR is a useful non-invasive diagnostic tool in the evaluation of fatty replacement in ARVC. The technique can be used with other procedures in the initial diagnostic evaluation and is a useful alternative tool in the long term follow up of patients with ARVC.

Upright tilt test: correlation between results and patient clinical features

The aim of our study was to analyze how the clinical history and the main clinical characteristics of patients suffering from loss of consciousness may influence the results of the upright tilt test. A series of 745 patients (333 males, 412 females; mean age 44 +/- 18 years) with recurrent episodes of syncope or presyncope underwent complete clinical and noninvasive laboratory examination, including vagal maneuvers and upright tilt test (60 degrees for 45 min). Cardiological and neurological findings were normal in every case. Upright tilt test was positive in 462 patients (62%). Patients with presyncope showed a lower positivity compared to patients with syncope (70.2% vs 42.9%, P < 0.001). Younger patients (< 25 years) displayed highest upright tilt test positivity (68.5%), while familial occurrence of syncope or presyncope, results of vagal maneuvers, and different gender did not correlate with the results of the test. The time interval between the last syncopal episode and the day of upright tilt test negatively influenced the proportion of positive tests (> 30 days = 45.1% vs < 30 days = 77.2%; P < 0.001). Patients with more than three syncopal episodes in the 2 months preceding the test showed a higher upright tilt test positivity (83.9% vs 64.5%, P < 0.001). In conclusion, upright tilt test seems to be more sensitive in young patients with syncopal episodes during symptomatic periods. These findings suggest both an individual and temporal variability in autonomic nervous system activity, the implication of which are relevant to the indications for testing as well as the analysis of results.

Arrhythmogenic right ventricular cardiomyopathy. Dysplasia, dystrophy, or myocarditis?

BACKGROUND

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a frequent cause of sudden death in young individuals and athletes. Although familial occurrence has been documented and a gene defect was recently localized on chromosome 14q23-q24 the etiopathogenesis of the disease is still obscure.

METHODS AND RESULTS

A pathological study was conducted in 30 hearts with ARVC (age range, 15 to 65 years; mean, 28 years). In the 27 autopsy cases, the mode of death was sudden in 24 and congestive heart failure in 3. ECG, available in 19 cases, showed inverted T waves in the right precordial leads in 15 cases (79%) and ventricular arrhythmias in 15 (79%). Right ventricular aneurysms were present in 15 hearts (50%) and located in the inferior wall in 12. Left ventricle and ventricular septum were involved in 14 (47%) and 6 (20%) cases, respectively. Scattered foci of lymphocytes with myocardial death were observed in 20 cases (67%). Electron microscopy studies, although confirming the myocardial death and lymphocyte infiltrates, did not show any specific ultrastructural substrate. Two pathological patterns, fatty (40%) and fibrofatty (60%), were identified. The fibrofatty pattern was associated with a thinner right ventricular wall (P < .0001) and a higher occurrence of focal myocarditis (P < .001). In sections of right ventricular free wall with maximal fatty infiltration, the mean percentage area of fatty tissue was 35.9 +/- 11.1% in control versus 80.4 +/- 9.6% in the ARVC, fatty variety (P < .00001). Involvement of the left ventricle and/or ventricular septum, right ventricular aneurysms, and inflammation were found almost exclusively in the fibrofatty variety.

CONCLUSIONS

In the fibrofatty variety of ARVC, the myocardial atrophy appears to be the consequence of acquired injury (myocyte death) and repair (fibrofatty replacement), mediated by patchy myocarditis. Whether the inflammation is a primary event or a reaction to spontaneous cell death remains unclear.

Familial cardiomyopathy underlies syndrome of right bundle branch block, ST segment elevation and sudden death

OBJECTIVES

We sought to assess whether structural heart disease underlies the syndrome of right bundle branch block, persistent ST segment elevation and sudden death.

BACKGROUND

Ventricular fibrillation and sudden death may occur in patients with a distinctive electrocardiographic (ECG) pattern of right bundle branch block and persistent ST segment elevation in the right precordial leads.

METHODS

Sixteen members of a family affected by this syndrome underwent noninvasive cardiac evaluation, including electrocardiography, Holter ambulatory ECG monitoring, stress testing, echocardiography and signal-averaged electrocardiography; two patients had electrophysiologic and angiographic study. Endomyocardial biopsy was performed in one living patient, and postmortem examination, including study of the specialized conduction system, was performed in one victim of sudden death.

RESULTS

Five years before a fatal cardiac arrest, the proband had been resuscitated from sudden cardiac arrest due to recorded ventricular fibrillation. Serial ECGs showed a prolonged PR interval, right bundle branch block, left-axis deviation and persistent ST segment elevation in the right precordial leads, in the absence of clinical heart disease. Postmortem investigation disclosed right ventricular dilation and myocardial atrophy with adipose replacement of the right ventricular free wall as well as sclerotic interruption of the right bundle branch. A variable degree of right bundle branch block and upsloping right precordial ST segment was observed in seven family members; four of the seven had structural right ventricular abnormalities on echocardiography and late potentials on signal-averaged electrocardiography. A sib of the proband also had a prolonged HV interval, inducible ventricular tachycardia and fibrofatty replacement on endomyocardial biopsy.

CONCLUSIONS

An autosomal dominant familial cardiomyopathy, mainly involving the right ventricle and the conduction system, accounted for the ECG changes and the electrical instability of the syndrome.

Detection of salivary and seric IgG and IgA antipooled pigeon sera activities in patients with pigeon breeder's disease

Pigeon breeder's disease (PBD) is an interstitial lung disease induced by exposure to pigeon antigens. Search of antipigeon antigen antibodies (APSA) in serum or bronchoalveolar lavage is generally used for auxiliary diagnostic purposes. However, APSA can be present in a number of exposed but asymptomatic individuals as well as in patients with other interstitial lung diseases who live in areas where keeping pigeons is a common domestic habit. In this study, saliva was evaluated as an alternative means to serum for APSA detection by ELISA using pooled pigeon sera as antigen. Serum and saliva samples obtained from 17 patients with PBD, 14 with idiopathic pulmonary fibrosis (IPF), 19 asymptomatic relatives (AR) exposed to pigeon antigens, and 27 clinical healthy voluntary subjects (CHVS) were tested for IgG and IgA APSA. Our results showed that both fluids obtained from PBD patients exhibited a significantly higher specific IgG antibody activity compared to the other groups. Serum optical density (O.D.) values for PBD were 1.187 +/- 0.738 vs. 0.024 +/- 0.033, 0.255 +/- 0.471, and 0.204 +/- 0.346 for CHVS, AR and IPF, respectively (P < 0.05). Salivary O.D. for PBD were 0.801 +/- 0.447 vs 0.010 +/- 0.011, 0.104 +/- 0.151, and 0.22 +/- 0.447 (P < 0.05). In contrast, serum specific IgA did not discriminate between PBD and IPF patients. In addition, although the PBD group exhibited the highest values of IgA salivary APSA, high levels were also observed in saliva specimens from CHVS, a group of normal individuals who deny pigeon exposure. These findings suggest that measurement of IgG salivary APSA can play a role in the evaluation process of patients with pigeon breeder's disease.

Organ-specific circulating heart autoantibodies in Chagas' cardiomyopathy: exploratory study

Chagas' disease can evolve to a chronic phase with cardiomyopathy that may include autoimmune mechanisms, among others. Recently an organ-specific anti-heart muscle antibody was detected in idiopathic cardiomyopathy, using human heart muscle as antigen. We decide to standardize an indirect immunofluorescence assay using rat organs in order to evaluate frequency of organ-specific anti-heart antibodies in chagasic cardiomyopathy. We tested 18 patients with chagasic cardiomyopathy for serum organ-specific anti-heart muscle antibodies. Nine patients were positive for organ-specific anti-heart antibodies (positive in heart muscle but negative in tongue muscle) and one was positive for non-organ-specific anti-heart muscle antibodies (positive in both heart and tongue muscle). We conclude that organ-specific anti-heart muscle antibodies can be detected using rat organs as antigens. Organ-specific anti-heart muscle antibodies are present in patients with chagasic cardiomyopathy.

A new locus for arrhythmogenic right ventricular cardiomyopathy (ARVD2) maps to chromosome 1q42-q43

Autosomal dominant arrhythmogenic right ventricular cardiomyopathy (ARVD, MIM 107970) is one of the major causes of juvenile sudden death. We have previously assigned the disease locus to chromosome 14q23-q24. Here we report on a novel variant of ARVD, which is transmitted associated to 1q42-q43 and is characterized by a concealed form, showing effort-induced polymorphic tachycardias. Since both loci ARVD1 and ARVD2 map in proximity of alpha-actinin genes, the possible implication of these myofibrillar proteins in the pathogenesis of ARVD is discussed. Two additional ARVD families, tested with markers of chromosomes 1q42-q43 and 14q23-q24, failed to show linkage, providing evidence of further genetic heterogeneity.

Antiphospholipid syndrome in patients with cyanotic congenital heart disease

Patients with cyanotic congenital heart disease exhibit an increased incidence of thrombotic episodes and are frequently thrombocytopenic. We studied the sera of 15 patients with this type of heart malformation, searching for anticardiolipin antibodies. 3/15 had positive results. The three of them were adult females; two had thrombotic episodes and a false positive VDRL. Thus, cyanotic congenital heart disease may be another disease entity associated with the antiphospholipid syndrome.

[The prevalence of the Wolff-Parkinson-White syndrome in a population of 116,542 young males]

Since 1988 to 1992 we analyzed 116,452 consecutive 12-lead electrocardiograms belonging to the entire cohort of 18-year old young boys resident in Padova, Treviso, Rovigo, Venezia, Belluno area (2,834,000 inhabitants). We identified 173 cases of overt WPW pattern (short PR interval, delta wave, anomalous configuration of QRS complex) with a calculated incidence of 1.48/1000. Accessory pathway location was: left free wall (70 patients), right free wall (39 patients), postero-septal (37 patients), antero-septal (15 patients) and undetermined (12 patients). Sixty patients (34.6%) complained of different symptoms as palpitations, near syncope and dizziness. Fifty-three patients (30.6%) went in a regular sport activity. Twenty-four hour Holter monitoring (41 patients) and exercise stress test (43 patients) did not show sustained tachyarrhythmias; intermittent preexcitation was recorded in 23 and 32 patients, respectively. Two-dimensional echocardiogram (68 out of 173) was normal in 44 patients, while 24 showed minor cardiac abnormalities with two major disease; mitral valve prolapse was diagnosed in 8 patients. On the basis of transesophageal (24 patients) or intracardiac (5 patients) electrophysiologic study, 11 patients were considered at high risk for sudden death. Eight of them suffered from spontaneous symptoms.

Signal-averaged electrocardiography in familial form of arrhythmogenic right ventricular cardiomyopathy

This study was performed to establish whether signal-averaged electrocardiography can aid in the diagnosis of the familial form of arrhythmogenic right ventricular cardiomyopathy in order to determine the severity of the disease and to predict ventricular arrhythmias. In arrhythmogenic right ventricular cardiomyopathy there is a fatty fibrous substitution of myocardium, which is the substrate for delayed myocardial activation; this is responsible for the abnormalities seen on the signal-averaged electrocardiogram (SAECG). Seventy-five members of 11 families, both healthy and with various forms of the disease, were studied using a signal-averaged electrocardiographic technique. Forty-seven members, 16 with a severe and 31 with a minor form of the disease, were found to be affected. Forty-three subjects had abnormal results on the SAECG; of these, 39 had the disease (100% in patients with widespread disease and 74.1% in patients with a minor form), whereas the other 4 had no sign of the disease. Only 44.1% of the subjects with an abnormal SAECG had ventricular arrhythmias, whereas 76% of the subjects with ventricular arrhythmias had an abnormal SAECG. In contrast, 90.6% of patients with an abnormal SAECG had the disease, and only subjects with arrhythmogenic right ventricular cardiomyopathy had ventricular arrhythmias. The abnormality on the SAECG appears to be correlated with the severity of the disease. Signal-averaged electrocardiography does not seem useful in diagnosing the minor forms of the disease and it does not give precise information about electrical instability in these patients.

The effects of sympathetic stimulation induced by mental stress on signal-averaged electrocardiogram

We evaluated the influence of sympathetic stimulation, induced by mental stress test, on signal-averaged ECG in 30 healthy subjects and in 30 patients with previous myocardial infarction. Both patient and control groups underwent three consecutive signal-averaged ECG: under basal conditions, during a continuous mental stress test, and 5 min after the mental stress test. The signal-averaged ECG parameters, analyzed by mean of a bandpass filter of 25-250 and 40-250 Hz, were: the filtered QRS duration, the duration of the low-amplitude high frequency signals in the terminal portions of the QRS complex below 40 microV (HFLA), and the root mean square voltage in the last 40 ms of the filtered QRS (RMS). The mathematical stress test was considered effective when the heart rate increased by at least 15 beats/min, remaining stable for the total duration of the signal-averaged ECG acquisition. A significant reduction of the filtered QRS duration and HFLA with a simultaneous increase of RMS were found in control group, while no significant changes occurred in patient group. These results indicate that the sympathetic nervous system may affect the results of signal-averaged ECG, probably by influences on intraventricular conduction, in healthy subjects. On the contrary, myocardial alterations in ischemic heart disease induce modification of signal-averaged ECG not influenced by autonomic nervous system activity.

Arrhythmogenic right ventricular cardiomyopathy in young versus adult patients: similarities and differences

OBJECTIVES

This study was designed to evaluate and compare the patterns of arrhythmogenic right ventricular cardiomyopathy in young people and adults.

BACKGROUND

Few data are available on this cardiomyopathy in young people because clinical and morphologic findings considered pathognomonic are normally based on observations in adults. However, a familial occurrence with a probable genetic transmission led to the study of children and to early detection of this disease, in which sudden death has been reported even in young people.

METHODS

Seventeen young patients with arrhythmogenic right ventricular cardiomyopathy diagnosed at a mean age +/- SD of 14.9 +/- 4.9 years were studied. Clinical, electrocardiographic, echocardiographic, cineangiographic and biopsy findings were compared with those of 19 adult patients whose condition was diagnosed at a mean age of 38.1 +/- 13.4 years.

RESULTS

Syncope occurred in 23.5% of the young patients but in none of the adults (odds ratio of familial sudden death 5.54, p = 0.1). Ventricular couplets (odds ratio 16.0, p = 0.004) and subtricuspid bulging on echocardiography (odds ratio 5.95, p = 0.036) were prevalent in the young group. Cineangiographic data in the two groups were similar, except that more hypokinetic areas were found in adults (odds ratio 4.44, p = 0.05). Morphometric analysis of biopsy sections showed a greater amount of fibrous tissue in the young patients (p = 0.04) and a prevalence of fatty tissue in the adults (odds ratio 12, p = 0.005). During an equivalent follow-up time (mean 7 years), two young patients died suddenly, and two had ventricular fibrillation in the absence of antiarrhythmic therapy.

CONCLUSIONS

The pathognomonic criteria for the diagnosis of arrhythmogenic right ventricular cardiomyopathy in adults are also valid for young people. Sudden or aborted death occurred frequently in young untreated patients.

Ocular vaso-occlusive disease in primary antiphospholipid syndrome

PURPOSE

To evaluate the ocular involvement in patients with the primary antiphospholipid syndrome.

METHODS

The authors performed a cross-sectional ophthalmologic study of 17 patients with the primary antiphospholipid syndrome. Retinal fluorangiography was performed in 13 patients.

RESULTS

Visual symptoms were described by ten patients. Visual acuity was markedly decreased in five eyes. Conjunctival telangiectases and microaneurysms, in addition to single instances of bilateral episcleritis and limbal keratitis, were the anterior segment findings. Fundus abnormalities were present in 15 patients. Venous tortuosity was the most common finding but there were instances of optic disc edema, vitreous hemorrhages, cotton-wool spots, vitreous bands, serous detachment of the macula, and retinal capillary abnormalities. Fluorangiography showed vaso-occlusive retinopathy in six eyes (5 patients, 29%). Choriocapillary vessel occlusion was observed in two eyes (1 patient) and binocular reticular degeneration of pigmentary epithelium was present in another case.

CONCLUSION

The eye is frequently involved in the primary antiphospholipid syndrome, and serious ocular damage may occur. Detailed ophthalmologic evaluation is warranted in these patients.

[High-resolution electrocardiography in 102 young healthy subjects]

BACKGROUND

The aim of this study was to evaluate the normal values of the most common indexes used in the analysis of ventricular late potential in 102 young male subjects.

METHODS

The recordings were performed by means of a Marquette electronics Hi-Resolution ECG Mac 15, with filters at 25-250 Hz, 40-250 Hz and 80-250 Hz. The parameters obtained were: filtered QRS duration (QRSD), high-frequency low-amplitude signals duration (HFLA), and the root mean square of the signal expressed in the terminal portion of QRS (RMS). The body surface was also evaluated.

RESULTS

QRSD (121.23 ms-113.9 ms-99.9 ms); RMS (105 uV-42.77 uV-34.3 uV); HFLA (17.5 ms-29.3 ms-29.3 ms). The comparison between our results and those proposed by other authors for normal subjects showed different results, particularly concerning the filtered QRS duration. We suppose that these discrepancies may be due to the different instrumentations used and to the different age and sex of the study population.

CONCLUSIONS

From these results we confirm that a normal range for each index must be done for homogeneous groups of subjects for age and sex, in healthy subjects as well as for different heart disease.

Long-term follow-up of patients with single lead VDD stimulation

The purpose of this study was to assess the long-term results of a single lead VDD pacing system (Phymos MPS) in 85 patients (48 males, 37 females, mean age 74 +/- 9 years). The system, which incorporates two atrial floating electrodes (Phymos 830-S), was implanted for second- or third-degree Mobitz II AV block. The percentage of AV synchronized pacing, the presence of fusion beats due to short AV delay, and the occurrence of supraventricular arrhythmias was evaluated by Holter monitoring at 6-month intervals. Over a mean period of follow-up of 44 months (range 2-56), over 90% of AV synchronized pacing events were noted in 74 patients (87%). The presence of persistent fusion beats was detected in 12 patients (14%). In ten patients the pacemaker was reprogrammed to VVI mode for supraventricular arrhythmias (7 patients, 8.2%) or unsatisfactory atrial sensing (3 patients, 3.5%). One pacemaker was removed for pocket infection and two for battery depletion. These observations support the use of VDD single lead pacing to combine a physiological mode of stimulation with simple implantation techniques.

QT-interval variability in hypertrophic cardiomyopathy patients with cardiac arrest

We studied long-term variability of QT-dispersion in three patients with hypertrophic cardiomyopathy (Maron III) and ventricular fibrillation. Late potentials were absent on signal-averaged electrocardiogram. ST-segment depression was recorded in all three patients at Holter monitoring, and in two during exercise stress testing, nonsustained ventricular tachycardia was present in only one patient. The maximal correct QT-interval and corrected QT-dispersion (QTcd) were measured retrospectively, both off-drug and under treatment with amiodarone and beta-blocker (two patients), or sotalol alone (one patient). Ten age- and sex-matched normal subjects, and 13 hypertrophic cardiomyopathy patients without ventricular arrhythmias formed the control groups. QTcd-values in the control groups never exceeded 80 ms and mean values of 30.1 +/- 10.1 ms and 44.1 +/- 7.9 ms respectively, were found. During long-term follow-up, QTcd increased progressively in two of the three patients with ventricular fibrillation, and at the time of the event all showed a value > 100 ms. Sotalol, but not the amiodarone reduced QTcd. QTcd seems to be a powerful predictor of ventricular electrical instability in the absence of other specific markers, and a promising guide for effective pharmacological therapy.