[Significance of hypotension and vasovagal reflex during echo-stress using high doses of dobutamine]

Coronary artery disease (CAD) is one of the main causes of cardiovascular morbility and mortality. Actual research lines are directed towards the discovery of silent CAD before hard events as myocardial infarction and sudden death. Dobutamine stress echocardiography is an useful method to assess patients with suspected CAD who, are not able to stand an effort because of physical reasons. During the test, hypotension and/or bradycardia may occur and may cause interruption of the test. The aim of our study was to consider prevalence, meaning and clinical implications of hypotensive, sometimes associated to bradycardia, during dobutamine stress echocardiography. From April 1994 to June 1996, 363 consecutive patients (267 men and 96 women with an average age of 59.3 +/- 10 year) were examined because of suspected or known ischemic cardiopathy. All patients underwent dobutamine stress echocardiography and coronary arteriography. Neither hypotension nor bradycardia was noted in 285 of our patients (78.51%), while in the remaining 78 patients (21.48%) there was a pressure drop > or = 20 mmHg; bradycardia appeared in 6 patients. The study shows that it does not exist a statistically significant difference between the percentage of the patients with CAD of the control group and those of the hypotensive group (91.9 vs 83.3%, NS). As for the changes in well motion score index, there was not a statistically significant difference between patients improved score index in the control group and in the hypotensive group (80 vs 74.3%, NS). The 6 patients with hypotension and bradycardia had normal coronary arteries. In the light of these results hypotension, alone or associated with bradycardia, should not be considered as a negative prognostic factor and should not induce to the interruption of the dobutamine stress echocardiography.

[Single-center experience with the Palmaz-Schatz intracoronary stent: the immediate results and medium- and long-term follow-up]

The recent implantation of intravascular devices (stents), during percutaneous transluminal coronary angioplasty (PTCA), has shown favourable results, decreasing acute occlusion and restenosis during follow-up as compared to PTCA alone. The aim of the study was to assess in a single center the efficacy of the implantation of a Palmaz-Schatz stent in a homogeneous group of patients and to assess the incidence of angiographic restenosis. Fifty-four consecutive patients (mean age 57 +/- 12 years) with single vessel coronary disease at angiography and with objective evidence of myocardial ischemia were studied. According to the duration of angiographic follow-up, patients were divided into two groups: Group I (mean 6 +/- 3 months) and Group II (mean 29 +/- 5 months). Stent implantation was performed electively in 43 patients (80%) while in the remaining 11 (20%) as "bail out" in a failed PTCA. Sixty-five stents were implanted in 54 patients of whom 1 stent in 47 patients (87%), 2 stents in 3 patients (6%) and 3 stents in the remaining 4 patients (7%). The stents were placed in the anterior descending of the left coronary artery in 32 patients (59%), left circumflex coronary artery in 8 patients (15%) and right coronary artery in 14 patients (26%). Mean diameter stenosis before stent implantation was 88 +/- 6% and decreased significantly to 4 +/- 7% after stent implantation (p < 0.0001). No major complications such as death, Q wave myocardial infarction, emergency coronary artery bypass graft or stroke occurred during the procedure. Minor complications such as wrong positioning of the stent, non occlusive acute thrombosis, non Q wave myocardial infarction and transient vessel occlusion occurred in 9% of treated patients. At follow-up, in Group I, 8 patient of 43 (18%) showed a > or = 50% restenosis and 10 patients < 50% restenosis; in the remaining 25 patients no variations in the caliber of the vessel were observed. In Group II, 2 patients of 11 (18%) showed a > or = 50% restenosis and 1 patient < 50% restenosis; in the remaining 8 patients no variations in the caliber of the vessel were observed. Complications during medium and long-term follow-up included total vessel occlusion in 1 patient. In conclusion, these data confirm that the Palmaz-Schatz stent may be implanted with high success and low complication rate. The percentage of restenosis, occurring in near 20% of the cases, remains an unresolved problem, despite the implantation of such intravascular devices.

[The immediate and midterm results of percutaneous mitral valvuloplasty in subjects over 60]

We have analyzed the immediate and mid-term (1 and 2 years) results of percutaneous mitral valvuloplasty (PMV) by Inoue's catheter in 97 patients < 60 years (Group A) compared with 34 patients > 60 years (Group B). In 61% Group A the patients were in NYHA functional class II, 36% in III, and 3% in I; in Group B, 56% of the patients were in NYHA functional class III, 38% in II, and 6% in IV. Mean mitral valve area was 1.1 cm2 before dilatation in both groups, and a significant (p < 0.0001) increase was obtained in both Group A (0.9 +/- 0.3 cm2) and Group B (0.8 +/- 0.3 cm2). No significant differences were observed between the two groups. Mean transvalvular gradient decreased significantly (p < 0.0001) from 13.6 +/- 5.7 to 7.2 +/- 3.1 mmHg in Group A, and from 9.9 +/- 4 to 6.5 +/- 2.3 mmHg in Group B (A vs B: p < 0.02). Optimal result was obtained in 94% and 88% of Group A and Group B patients, respectively. Suboptimal result was obtained in 2% and 6% of Group A and Group B patients, respectively. These differences were not significant. Failure of PMV occurred in 4% and 6%, respectively. At 1-year follow-up Group A 7 patients and 5 Group B patients showed restenosis; at 2-year follow-up one more restenosis was present in Group A (A vs B at 1 and 2 years: NS). We conclude that PMV is a safe and effective technique in young patients and in patients > 60 years.

[Percutaneous mitral valvuloplasty in patients who have undergone surgical commissurotomy]

Percutaneous mitral valvuloplasty (PMV) was performed with Inoue's catheter, by anterograde approach, in 19 patients (2 males and 17 females, mean age of 56 +/- 13 years) with restenosis after surgical commissurotomy. Mean valvular area increased from 1.2 +/- 0.2 to 1.9 +/- 0.2 cm2 while mean transvalvular gradient decreased from 13 +/- 6 to 7 +/- 4 mmHg. All but 2 patients reached optimal results; one had a suboptimal result (final valvular area > 1.5 cm2, percentage of increase less than 25%), and 1 was sent to the surgeon for a significant increase in mitral regurgitation ( ). At 1 year follow-up, (available for 11 patients), mean valvular area was 1.7 +/- 0.3 cm2 and transmitral gradient was of 5.4 +/- 2 mmHg. Four patients showed a restenosis; 1 of them underwent surgical mitral valve replacement after a second unsuccessful PMV; 2 showed good clinical conditions, while the fourth patient was sent to the surgeon for the high echocardiographic score. At 2-year follow-up, available for 4 patients, the mean gradient was of 5.5 +/- 2.5 mmHg and the mitral valve area was 1.8 +/- 0.2 cm2. NYHA functional class progressively improved after the procedure in all patients but those undergoing mitral valve replacement. In conclusion, despite the occurrence of restenosis, PMV seems to be feasible in patients who already underwent surgical commissurotomy; this procedure can avoid the risks of a second surgery, and should be considered the first choice treatment in these patients.

Prevalence and risk factors for micro- and macroalbuminuria in an Italian population-based cohort of NIDDM subjects

OBJECTIVE

To determine the prevalence of micro- and macroalbuminuria in NIDDM and their relationship with some known and putative risk factors.

RESEARCH DESIGN AND METHODS

Out of a population-based cohort of 1,967 NIDDM subjects, 1,574 were investigated (80%). Albumin excretion rate (AER) was evaluated on an overnight urine collection, and plasma and urine determinations were centralized.

RESULTS

The prevalences of microalbuminuria (AER 20-200 micrograms/min), macroalbuminuria (AER > 200 micrograms/min), and hypertension were 32.1% (95% CI 29.8-34.4), 17.6% (15.7-19.5), and 67% (64.6-69.3), respectively. Apart from prevalence of hypertension, which after adjustment for age, BMI, and duration of diabetes was 2.3 times higher in women, rates were higher in men (odds ratio [OR] 1.31, 95% CI 1.04-1.66 for microalbuminuria and OR 1.63, 1.22-2.17 for macroalbuminuria). In comparison with normoalbuminuric subjects, both micro- and macroalbuminuric diabetic subjects had significantly longer duration of diabetes, higher levels of systolic blood pressure, fasting plasma glucose, HbA1c, triglycerides, and uric acid; in macroalbuminuric subjects only, levels of apolipoprotein B and HDL cholesterol were, respectively, higher and lower than in normo- and microalbuminuric subjects. In logistic regression, variables independently related to both micro- and macroalbuminuria were age, HbA1c, cigarette smoking habits, plasma uric acid, and diastolic blood pressure, after adjustment for plasma creatinine and diabetic treatment. In addition, duration of diabetes and HDL cholesterol levels were associated with macroalbuminuria.

CONCLUSIONS

This population-based study showed high prevalence of micro- and macroalbuminuria in NIDDM subjects, who were characterized by a more adverse pattern of cardiovascular risk factors.

[Value of intraoperative transesophageal echocardiography during repair of thoracic aorta dissection]

The study was designed to assess the diagnostic accuracy and usefulness of intraoperative transesophageal echocardiography (TEE) during repair of aortic dissection. To this end, 32 patients with ascending aortic dissection, undergoing replacement of the ascending aorta, were examined. The diagnosis was validated in each case by intraoperative and/or autopsy findings. The accuracy of TEE was studied in three different periods of surgical operation: before cardiopulmonary bypass (TEE pre-CPB), during CPB (TEE-CPB) and after CPB (TEE post-CPB). In comparison with TEE performed in the intensive care unit 70 +/- 40 min before surgery, TEE pre-CPB showed a higher diagnostic accuracy (100 vs 96%) in classification of the dissection type, a higher sensibility in the identification of intimal tears (83 vs 75%), involvement of the coronary arteries (71 vs 62%) and of aortic arch branches (81 vs 71%); there was no statistically significant difference in the detection of the aortic valve involvement (100 vs 100%). TEE-CPB showed normal perfusion of the true lumen in all but one patient, in whom TEE-CPB showed retrograde perfusion of the false lumen, promptly resolved by fenestration of the false lumen. TEE post-CPB showed persistence of the intimal flap in non repaired segments in all the patients with type I aortic dissection: in 60% of them there was no communication between the true and false lumen; in 40% of them there was a communication between the two lumina, which was proximal in 25% and distal in 15%; all patients did not show thrombosis of the false lumen. TEE post-CPB allowed also the evaluation of flow in left aortic arch branch vessels in 77% of the patients and in the coronary arteries in 70%, and showed well functioning prosthesis in all patients. In each case aortic regurgitation was mild; however, one case had severe insufficiency which was corrected at the time of surgery with annuloplasty. Ejection fraction was normal in 45% of the patients, whereas it was decreased in the remaining patients. Intraoperative TEE during repair of aortic dissection is accurate and useful: it allows improvement in preoperative diagnosis just before CPB, optimizing surgical technique; it gives also important information for the management of patients immediately after CPB and for the follow-up.

Cardiac iron overload in thalassemic patients: an endomyocardial biopsy study

Secondary heart failure induced by organ siderosis is the main cause of death in patients affected by thalassemia major. At present it cannot be predicted whether heart siderosis is correlated with iron overload and little is known about the real cardiac histological pattern of post transfusional hemochromatosis in patients with thalassemia major and intermedia. The study aim was to evaluate cardiac iron overload by non invasive and invasive techniques. Fifteen thalassemic patients were investigated and endomyocardial biopsy performed in ten revealed different grades of endomyocardial iron overload with histochemical positivity. Non invasive techniques are not able to furnish an exact picture of the cardiac hemochromatosis. There was a significant correlation between serum ferritin and myocardial iron grade. Patients with elevated ferritin levels and poor compliance to chelating therapy are at high risk of severe heart hemochromatosis. It was seen that endomyocardial biopsy is a useful tool in studying myocardial iron.

[Diagnostic accuracy of transesophageal echocardiography in the diagnosis of aortic dissection: comparison with computerized axial tomography]

This study was designed to assess the sensibility, specificity and diagnostic accuracy of transesophageal echocardiography (TEE) and X-ray contrast enhanced computed tomography (CT) in the diagnosis of aortic dissection and its complications. Fifty patients with clinically suspected aortic dissection were examined. Imaging results were validated in each case by intraoperative and/or autopsy findings and/or the results of cineangiography. The Stanford and DeBakey classifications were used to differentiate the dissection type; the patients were also subdivided by TEE according to a modified DeBakey classification. The sensibility of TEE to detect aortic dissection was 100%, significantly higher (p < 0.05) than that of CT for type A dissections (77.2%). The two imaging procedures did not statistically differ (NS) in the detection of type B dissection (CT sensibility 87.5%). The specificity of TEE for the detection of type A aortic dissection was 94%; it was not significantly higher (NS) than that of CT (CT specificity 86.6%). Both TEE and CT had no false negative findings in the diagnosis of type B aortic dissection (100%; TEE vs CT, NS). TEE was reliable in the correct identification of the primary entry site in the ascending aorta (80%), the arch (62.5%) and descending aorta (71.4%), and also in the involvement of coronary arteries (62.5%), and aortic arch branch vessels (71.4%); CT scanning was not effective in detecting any of these complications. Aortic regurgitation was accurately identified by TEE in each case. Both TEE and CT scanning correctly identified thrombosis of the false lumen and pericardial effusion. Intraoperative TEE documented in all patients postrepair persistence of the intimal flap in aortic segments that were not operated; flow in the false lumen was detected in 46.6% of the patients; in 26.6% of them secondary tears, not seen before surgical treatment, were detected. In conclusion, TEE allows a bedside, safe and accurate diagnosis and classification of aortic dissection. It also provides the diagnostic information necessary for the therapeutical decision making. Intraoperative TEE allows improvement in preoperatory diagnosis and gives important information for the management of the patient immediately after cardiopulmonary bypass and in the follow-up.

[Coronary recanalization in acute myocardial infarction: early coronary angiography]

In acute myocardial infarction the early patency of the infarct-related artery is positively correlated with improved left ventricular function and survival. Coronary artery reperfusion is commonly achieved by intravenous administration of thrombolytic agents. Methods of mechanical recanalization, mainly percutaneous transluminal coronary angioplasty (PTCA), have been proposed and tested as alternative or adjunctive ways to thrombolysis. Early coronary angiography provides reliable and irreplaceable information concerning mechanical intervention utility and feasibility. Therefore, it is incorporated in the mechanical revascularization strategies at various stages in the setting of acute myocardial infarction. In the primary, direct PTCA strategy early coronary arteriography is done for planning and carrying out mechanical revascularization as an alternative to intravenous thrombolytic therapy. This strategy may be particularly effective in patients presenting with cardiogenic shock, large infarctions, contraindications to thrombolytic therapy, and prior bypass surgery. Coronary angiography in evolving myocardial infarction has also been proposed to set the stage for rescue PTCA when thrombolysis has proved to be ineffective. Nevertheless, there are currently no unequivocal data to judge the value of the rescue PTCA strategy. After unsuccessful thrombolysis, this approach should be considered in patients with a large infarction, with cardiogenic shock, with left ventricular dysfunction and with refractory ischemia. Early, routine coronary angiography after lytic recanalization is not recommended. In fact, the strategy of immediate arteriography plus PTCA after thrombolytic therapy does not improve outcome but leads to several deleterious effects.

[Echocardiography in the early diagnosis of acute rejection in patients with heart transplant]

The aim of our study was to assess the sensibility and specificity of Doppler echocardiographic evaluation of left ventricular diastolic function during acute cardiac rejection. We studied 34 patients who had undergone a recent heart transplant and compared the echocardiographic results with the histologic findings. We considered the following parameters of left ventricular filling: early peak of mitral flow velocity; pressure half-time (PHT); isovolumic relaxation time (IVRT). We divided the patients into two groups according to the histologic findings: Group I (25 patients who had at least 1 episode of mild-moderate rejection), Group II (6 patients without documented rejection after at least three consecutive biopsies). Three patients with clinically evident rejection were excluded from the analysis. In Group I cardiac rejection was associated with a statistically significant decrease in IVRT (p < 0.0005), without significant changes in heart rate and in the early peak of mitral flow velocity. In Group II Doppler parameters remained unchanged. These variations were not associated with changes in echocardiographic morphologic parameters and in parameters of ventricular systolic function. IVRT and PHT returned to normal values after adequate immunosuppressive treatment. Considering variations of IVRT and PHT of at least 20%, we obtained a sensibility of 88% for isolated variations of PHT and a specificity of 93% for consensual variations of PHT and IVRT. Therefore, the assessment of the left ventricular diastolic function by Doppler echocardiography represents a safe and non-invasive method for an early detection of acute cardiac rejection.

[Imaging in atherosclerosis: coronary arteriography]

Arteriography is still today the best imaging technique to evaluate coronary atherosclerosis. Some limitations have nonetheless been documented by pathologic studies (underestimated lesions), and by physiologic studies (poor correlation between stenosis and coronary flow reserve). Such limitations are due to the nature of the technique, as it provides the "silhouette" of the artery lumen, but does not provide any information on the artery wall, where the atherosclerotic plaque is located. Moreover, very often the vessel segment used as reference for stenosis calculation could also be affected by atherosclerosis; this occurrence plagues measurement of percent stenosis. On the other hand, a better usage of radiological techniques has also allowed a better assessment of certain stenosis shapes, such as eccentric or slit-like lesions. The introduction of quantitative coronary arteriography has overcome the problems related to visual assessment, such as the inter and intra observer variability. Furthermore, the recognized value of morphology analysis allows today a better characterization of the lesion. Coronary arteriography remains today a non-replaceable technique with regard to the choice of the most suitable revascularization procedures (coronary artery bypass graft, percutaneous transluminal coronary angioplasty) and supplies fundamental information for the interventional procedures.

[Mitral valvuloplasty: immediate results and 2-year follow-up]

Since May 1991 to July 1993, 121 patients (mean age 50 +/- 13 years, 23 males and 98 females) underwent 122 percutaneous mitral valvuloplasty according to Inoue's technique. Following Wilkins criteria the indications for the procedure were given on the basis of the echo-score (ideal cases with score < or = 8). Echo-score was > 8 in 59 patients (49%), and < or = 8 in 62 (51%); 19 patients (16%) had previous surgical mitral commissurotomy and 36 (30%) had previous embolic events. All patients were successfully treated except for 5 who developed mitral regurgitation 3+/4+. In 1 patient the procedure was unsuccessfully performed for the low increase in mitral valve area. All these patients except 1 were referred to elective surgery. Mitral valve area increased from 1.1 +/- 0.2 to 2.1 +/- 0.4 cm2 (p < 0.001) and transvalvular gradient fell from 15 +/- 6 to 6 +/- 3 mmHg (p < 0.001). Patients with previous surgical commissurotomy had a lower increase in the mitral valve area than patients without previous surgery (p < 0.006). Patients with echo-score > 8 presented a lower, but not significant, increase in mitral valve area after valvuloplasty; patients with mono-commissural calcifications had worse results than those without calcifications (p < 0.03). At 12 and 24 month follow-up 9 and 3 restenosis respectively occurred, but in 10 of these cases the residual valvular area was > 1.5 cm2. The Authors conclude that in patients with good anatomy percutaneous mitral valvuloplasty is an effective and safe treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous valvuloplasty in mitral stenosis]

Since May 1991 to July 1992, 83 patients (mean age 49 +/- 13 years, 17 males and 66 females) underwent percutaneous mitral valvuloplasty according to Inoue's technique. Following Wilkins' criteria echo-score was < or = 8 in 46 patients and mono-commissural calcifications were present in 8 cases. Sixteen (19%) patients had previous surgical mitral commissurotomy and 15 (18%) had previous embolic events. The indications for the procedure were given on the basis of the echo-score (ideal cases with score < or = 8). All patients but 2 were successfully treated. Two patients who developed mitral regurgitation grade 3+/4+ were referred to elective surgery. Mitral valve area increased from 1.1 +/- 0.2 to 2 +/- 0.3 cm2 (p < 0.001) and transvalvular pressure gradient fell from 16 +/- 5 to 6 +/- 3 mmHg (p < 0.001). Patients with previous surgical commissurotomy had a lower increase in mitral valve area than patients without previous surgery (p < 0.02). Patients with echo-score > 8 presented a more evident increase in mitral regurgitation than patients with good valvular anatomy, even if this difference was not significant. At 6 and 12 month follow-up respectively 2 and 1 restenosis occurred, but in 1 of these cases the residual valvular area was > 1.5 cm2. The authors conclude that in selected patients with mitral stenosis percutaneous mitral valvuloplasty seems to be an effective and safe treatment. Furthermore, immediate and middle-term results show that this technique can be performed without adjunctive risks and with satisfactory results also in cases of no ideal clinical and/or valvular conditions (echo-score > 8, previous surgical commissurotomy, history of embolism, mono-commissural calcifications).

[Silent ischemic cardiopathy: a study with dynamic electrocardiogram and ergometric test]

Ninety-two patients with effort angina were retrospectively studied to define the prevalence, the daily distribution and the prognostic value of silent ischemic attacks. All patients had positive Holter monitoring and exercise test; coronary angiography, performed in 75/92 patients, showed 1, 2 or 3-vessels disease. Six hundred ninety-three ischemic episodes, 481 (69.5%) silent and 212 (30.5%) symptomatic, were recorded by Holter monitoring, with the highest incidence in the morning; 74/92 patients (80%) showed silent ischemic attacks. Mean duration of the symptomatic and silent ischemic attacks was respectively 9.8 +/- 5.2 and 6.4 +/- 4.2 min (p less than 0.0001); mean ST-segment depression was respectively 2.8 +/- 1.2 and 2.3 +/- 0.8 mm (p less than 0.0001). During exercise testing 86 patients (93%) had both chest pain and ST-segment changes, 2 patients (2%) only angina and 4 patients (5%) only ST-segment depression. Mean heart rate at onset of ischemia was higher during exercise testing compared with Holter monitoring (119 +/- 20 vs 95 +/- 22 b/min; p less than 0.0001). No significant difference was shown between patients with and without silent ischemia about the prevalence of 1, 2 and 3-vessels disease; 1-year cardiovascular mortality in the 2 groups of patients was respectively 6.8% and 5.5% (p:NS). In patients with effort angina, silent ischemia has not a poor prognostic value; Holter monitoring is very useful to the correct assessment of these patients.

[Bolus nicardipine in the hemodynamic assessment for heart transplantation of patients with severe failure of ischemic origin and high pulmonary resistance]

Nicardipine i.v. bolus (5 mg/5 min) was administered in the pulmonary artery trunk in 13 patients (2 f, 11 m), mean age 48 +/- 8 yrs, affected by ischemia congestive heart failure, with pulmonary hypertension (pulmonary vascular resistances greater than 6 U.W. and/or systolic pulmonary artery blood pressure greater than or equal to 60 mmHg). The vasodilatation induced by nicardipine caused a rapid improvement of all hemodynamic parameters, with a significant reduction of systemic and pulmonary pressures and resistances; in addition, cardiac output increased significantly. Even if heart rate decreased and mean right atrial pressure fell, their variation did not reach statistical significance. These beneficial effects are attributable to the vasodilator action of nicardipine on the systemic and pulmonary vascular districts. Therefore, in the hemodynamic evaluation of patients with ischemic cardiomyopathy proposed for heart transplantation, we propose the employment of nicardipine in testing the vascular reactivity in cases with secondary pulmonary hypertension.

Isolated, anomalous origin of the left anterior descending coronary artery from the right coronary artery with angina pectoris

The case of a 51-year-old woman with exertional angina pectoris and isolated anomalous origin of the left anterior descending coronary artery from the right coronary artery is reported. This anomalous artery was not narrowed, coursed in front of the pulmonary artery and did not present either anatomical derangement at the take off or intramyocardial course. The mechanism of ischaemia could not be identified.

[Value of coronary angiography in the diagnosis of left atrial thrombosis in mitral valve disease]

Arteriographic findings of neovascularity and fistula formation between coronary arteries and left atrium have occasionally been described in association with left atrial thrombosis in patients with mitral valve disease. The validity of these coronary arteriographic findings in diagnosis of atrial thrombi has been evaluated in 164 patients with mitral valve disease. Comparison was made with surgery. The study provided these diagnostic values: sensitivity 65%, specificity 85%, positive predictive value 72%. Even if this angiographic finding is complementary in diagnosis of atrial thrombosis, its identification during coronary arteriography in patients with mitral valve disease is useful. Its detection could improve diagnostic prediction of thrombosis especially in patients without previous embolic events or where echocardiography failed to show thrombi.

Diagnosis of left atrial thrombi in mitral valve disease by coronary arteriography

Arteriographic findings of neovascularity and fistula formation between coronary arteries and left atrium have occasionally been described in association with left atrial thrombosis in patients with mitral valve disease. The validity of these coronary arteriographic findings in diagnosis of atrial thrombi has been evaluated in 112 patients with mitral valve disease. Comparison was made with surgery. The study furnished these diagnostic values: sensitivity 70%, specificity 85%, positive predictive value 72%. Even if this angiographic finding is complementary in diagnosis of atrial thrombosis, its identification during coronary arteriography in patients with mitral valve disease is useful. Its detection could improve diagnostic prediction of thrombosis, especially in patients without previous embolic events or where echocardiography failed to reveal thrombi.

[Multiple coronary-pulmonary fistulas: description of a case]

An uncommon case of multiple coronary artery-pulmonary artery fistulas, associated with a mitral valve disease, is reported. The coronary fistulas presence was suspected on the ground of Doppler-echocardiography and the diagnosis was subsequently defined by coronary angiography. The utility of Doppler-echocardiography in the differential diagnosis from patent ductus arteriosus is discussed.

Intravenous propafenone reduces energy requirements for defibrillation in pigs

The effect of antiarrhythmic drugs on defibrillation threshold have become an important issue with the increasing use of the automatic implantable cardioverter defibrillator (AICD). In several reports antiarrhythmic therapy has been found to affect the energy required for defibrillation; the present study examined the effects of intravenous propafenone on defibrillation threshold in open chest, anesthetized pigs. Twenty health pigs were studied; 10 pigs free from any drugs (Group 1) and 10 pigs after a constant iv infusion of 0.04 mg/kg/min of propafenone (Group 2). Defibrillation threshold was 21 +/- 5, 20 +/- 5, 21 +/- 6, 19 +/- 4 and 19 +/- 6 J in Group 1 and 20 +/- 7, 18 +/- 9, 15 +/- 5, 14 +/- 7, 9 +/- 6 J in Group 2, respectively at 20, 40, 60, 80 min (p value respectively NS, NS, less than 0.05, less than 0.01, less than 0.001). We conclude that intravenous propafenone reduces the energy requirements for defibrillation in experimental animals.

Opposite effects of propafenone and flecainide in a patient with reciprocating supraventricular tachycardia

A 46 year-old woman with Wolff-Parkinson-White syndrome (postero-septal accessory pathway), symptomatic for recurrent episodes of nonsustained paroxismal supraventricular tachycardia (PSVT), was empirically treated with propafenone (600 mg/day). After a week of therapy the patient returned to the hospital after an episode of syncope. She referred a significant increase in duration and frequency of "palpitations". Under treatment with propafenone a sustained PSVT could be induced during transesophageal testing. During the electrophysiologic study performed off drugs, only a nonsustained PSVT could be induced. After flecainide infusion (1 mg/kg) anterograde block of the accessory pathway was observed and only few beats (less than 8) of PSVT could be induced. The patient was discharged on flecainide (200 mg/day) and 1 month later a transesophageal testing was repeated showing an anterograde block of the accessory pathway at a pacing cycle length of 500 ms; no arrhythmias were induced. The patient has been asymptomatic on chronic oral therapy with flecainide during a follow-up period of 8 months. This case shows that 2 1c class antiarrhythmic drugs may have opposite effects (proarrhythmic and antiarrhythmic). Failure, or even the proarrhythmic effect of one drug, does not necessarily exclude the efficacy of another drug of the same subclass in preventing recurrence of PSVT.