[Planar determination of the aortic valve area with transesophageal echocardiography with multiplanar probe in patients with aortic stenosis and insufficiency. Comparison with transthoracic Doppler echocardiography]

BACKGROUND

The simple determination of transaortic pressure gradient does not accurately assess the severity of an aortic valve stenosis. Thus, estimating the aortic valve area (AVA) is vital for clinical decision-making. Cardiac catheterization has been considered the "gold-standard" for the quantification of the stenotic valve area, but this technique may underestimate the actual valve area when aortic regurgitation is associated. Doppler transthoracic echocardiography (TTE) with the continuity equation method is usually employed for AVA estimation. Recently, in pure aortic stenosis, transesophageal echocardiography (TEE) has provided AVA values well-correlated to hemodynamic invasive results.

METHODS

In this study, we correlated AVA values by TTE and multiplane TEE in 18 patients with combined aortic valve stenosis and regurgitation.

RESULTS

The mean values of AVA by TEE and TTE were 0.74 +/- 0.12 and 0.68 +/- 0.55 cm2, respectively (p = NS). TEE-derived AVA correlated well to TTE-derived AVA (r = 0.816; p < 0.0001). Critical aortic stenosis was predicted by TEE with 100% sensitivity and specificity. Total time of examination was significantly longer for TTE (p < 0.00001).

CONCLUSIONS

In conclusion, direct planimetry by multiplane TEE is a reliable method for AVA determination in aortic stenoinsufficiency. For this purpose, when the technical quality of TTE study is poor or when the patient is critically ill and does not tolerate a longer lasting TTE, multiplane TEE should be considered.

Atrial septal aneurysm and cardiac arrhythmias

Atrial septal aneurysm has been associated with thromboembolic events, interatrial shunting, mitral valve prolapse, and systolic click. An association between atrial septal aneurysm and cardiac arrhythmias has been also described. Twenty patients with atrial septal aneurysm and 19 control subjects performed 24-h Holter monitoring. Frequent (> 10/h) atrial premature beats were observed in seven patients vs. none of the controls (P = 0.008). The mean number of episodes of supraventricular tachycardia and the prevalence of ventricular tachycardia were also higher in the atrial septal aneurysm group (P = 0.044 and P = 0.046, respectively). Left atrial enlargement, mitral valve prolapse and left ventricular hypertrophy were more frequent than in the normal subjects. In conclusion, atrial and ventricular 'complex' arrhythmias occurred more frequently in patients with atrial septal aneurysm than in normal subjects. Further studies in patients with atrial septal aneurysm without other associated echocardiographic abnormalities need to be done to ascertain a potential arrhythmogenicity of this condition.

[Infective endocarditis. Recent progress in its epidemiology, clinical picture and therapy. Comments on cases]

Infective endocarditis (IE) may be considered as a disease in evolution because of changes occurred in the last decades in epidemiologic and clinical aspects. M-mode, two-dimensional, Doppler and color Doppler echocardiography allowed major advances in diagnosis and management of patients with IE. More recently, transesophageal echocardiography has been introduced in clinical practice with excellent results, because of unsurpassed quality of images able to early recognize small vegetations and complications of infective process. The authors report 13 cases of IE observed from March 1991 to March 1993. Streptococcus viridans was detected in 46% of cases and enterococcus species in 23%. Culture negative endocarditis represented 31% of total cases. Mitral valve was most frequently involved (67% of cases of native valves), followed by aortic valve (22%) and tricuspid valve (11%). In 30% of cases a prosthetic valve was involved. A presumed portal of entry has been identified, in 69% of cases, in oral cavity during dental procedures; in 2 cases an asymptomatic colonic carcinoma was detected. Diagnostic sensitivity of transesophageal echocardiography was 100%. Only 1 patient died during hospitalization. Cardiac surgery was performed in 4 patients (33%). The antibiotic drug teicoplanine has been successfully employed in 54% of cases.

1,25(OH)2-vitamin D3 signal transduction in chick myoblasts involves phosphatidylcholine hydrolysis

1,25-Dihydroxyvitamin D3 (1,25(OH)2D3) rapidly stimulates the biphasic formation of diacylglycerol (DAG) in chick myoblasts. Neomycin (0.5 mM), an inhibitor of phosphoinositide hydrolysis, abolished the first phase (1 min) but had no effect on the second 1,25(OH)2D3-induced DAG peak (5 min). In myoblasts prelabeled with [3H]choline, 1,25(OH)2D3 increased the release of [3H]choline (maximally at 5 min), with a concomitant decrease in phosphatidylcholine and the absence of significant changes in phosphocholine. 1,25(OH)2D3 caused a significant increase in phosphatidylethanol (PEt) formation in myoblasts in the presence of 1.5% ethanol. The effects of 1,25(OH)2D3 were time- and dose-dependent (10(-11) to 10(-8) M) and specific as 25OHD3 and 24,25(OH)2D3 failed to accumulate PEt. 12-O-Tetradecanoylphorbol-13-acetate failed to accumulate PEt. 12-O-Tetradecanoylphorbol-13-acetate also stimulated PEt formation. The combination of 1,25(OH)2D3 and 12-O-tetradecanoylphorbol-13- acetate was more effective than either compound alone. Neither the PKC inhibitor H7 nor PKC down-regulation blocked the hormone-induced increase in PEt. The effects of 1,25(OH)2D3 were, however, inhibited in the absence of extracellular Ca2+ (+EGTA) and by nifedipine and verapamil, whereas the Ca2+ ionophore A23187 also increased PEt generation. The data support the notion that 1,25(OH)2D3 triggers the hydrolysis of phosphatidylcholine in myoblasts through a Ca(2+)-dependent, PKC-independent, phospholipase D-catalyzed mechanism.

Stem cell factor improvement of proliferation and maintenance of hemopoietic progenitors in myelodysplastic syndromes

Human recombinant stem cell factor (rSCF) was tested for its capability of improving the defective growth of hemopoietic progenitors in 28 cases of myelodysplastic syndromes (MDS). In vitro growth and response to rSCF were quite variable. However, in most cases, rSCF stimulated CFU-GM growth induced by rG-CSF, rGM-CSF, rIL-3, 5637 conditioned medium (50-1400% enhancement). rSCF effect was slightly more evident on day 14 CFU-GM and in the presence of rIL-3. BFU-E growth induced by rEPO or rIL-3 + rEPO was enhanced by rSCF in about 50% of cases, in linear correlation with the levels of patients' hemoglobin. rSCF did not increase CFU-E growth, whereas it slightly stimulated CFU-Mk in 33% of the cases. EPO, SCF and, particularly, their combination, enhanced the recovery of normal CFU-E and BFU-E after 7 days of liquid culture. This was less evident in cultures of MDS patients. Conversely, CFU-GM generation in long term liquid cultures, although highly variable, was stimulated by rSCF and, above all, by rSCF + rG-CSF, similarly to what was observed with normal bone marrow samples. SCF seems to enhance in vitro erythropoiesis only in MDS cases presenting without severe anemia. It has little effect on megakaryocytopoiesis, while it seems to be more active on CFU-GM growth and maintenance.

Pulmonary arterial hypertension responsive to immunosuppressive therapy in systemic lupus erythematosus

Two female patients with recent diagnosis of systemic lupus erythematosus (SLE) are reported. Pulmonary arterial hypertension was diagnosed by Doppler echocardiography. Immunosuppressive therapy was started at the time of diagnosis of SLE. After 2 months of therapy, Doppler echocardiography was repeated and the estimated pulmonary artery systolic pressure was substantially decreased from 78 to 42 mmHg and from 67 to 42 mmHg, respectively, along with significant improvement of the clinical conditions.

Interleukin-3 in vivo: kinetic of response of target cells

Human recombinant interleukin-3 (IL-3; Sandoz AG, Basel, Switzerland) was administered for 7 days to patients with neoplastic disease and normal hematopoiesis. The purpose of the study was to assess IL-3 toxicity, to identify target cells, to define their kinetics of response at different dose levels, and to determine if IL-3 in vivo increased the sensitivity of bone marrow (BM) progenitors to the action of other hematopoietic growth factors. A total of 21 patients entered the study; the dosage ranged from 0.25 to 10 micrograms/kg/d. The effect on peripheral blood cells during treatment showed no significant changes in the number of platelets, erythrocytes, neutrophils, or lymphocytes (and their subsets). A mild monocytosis and basophilia occurred. Eosinopenia, present in the first hours of treatment, was followed by a dose-and time-dependent eosinophilia. IL-3 treatment affected BM cell proliferation by increasing the percentage of BM progenitors engaged in the S-phase of the cell cycle. The effect was dose dependent, with the various progenitors showing different degrees of sensitivity. The most sensitive progenitors were the megakaryocyte progenitors (colony-forming unit-megakaryocyte), then the erythroid progenitors (burst-forming unit-erythroid), and finally the granulo-monocyte progenitors (colony-forming unit-granulocyte-macrophage) whose proliferative activity was stimulated at the higher doses of IL-3. Only a slight increase in the proliferative activity of myeloblasts, promyelocytes, and myelocytes was observed, whereas the activity of erythroblasts was unchanged. The priming effect was such that BM progenitors, purified from patients treated with IL-3, produced more colonies in vitro in the presence of granulocyte colony-stimulating factor (G-CSF; granulocyte colonies), IL-5 (eosinophil colonies), and granulocyte-macrophage CSF (GM-CSF; predominantly eosinophil colonies). These data indicate that even in vivo IL-3 acts essentially as a primer for the action of other cytokines. Therefore, optimum stimulus of myelopoiesis will require either endogenous or exogenous late-acting cytokines such as G-CSF, erythropoietin, GM-CSF, and IL-6 for achieving fully mature cells in peripheral blood. If exogenous cytokines are used with IL-3, it is likely that G-CSF will yield more neutrophils, whereas GM-CSF may enhance eosinophils, monocytes, and neutrophils. Attention to the clinical relevance of each cell type will be necessary and should determine the selection of the combination of cytokines.

[Pulmonary hypertension and systemic sclerosis]

BACKGROUND

Pulmonary involvement in systemic sclerosis (SS) is a frequent complication and is associated with a poor prognosis. Pulmonary hypertension may or may not develop, however, its recognition is usually possible only in advanced stages.

METHODS

In this study we noninvasively evaluated the pulmonary artery systolic pressure in 31 patients with SS using Doppler echocardiography. Pulmonary hypertension was detected in 48.4% of the patients.

RESULTS

The prevalence of pulmonary hypertension was similar in patients with limited SS and diffuse SS (42.9% and 52.9%, respectively; p = NS). No differences were observed in pulmonary artery systolic pressure between patients with limited or diffuse SS and pulmonary hypertension. Pulmonary hypertension was usually mild, and only in two cases was pulmonary systolic pressure higher than 50 mmHg (63 and 107 mmHg, respectively).

CONCLUSIONS

Pulmonary hypertension is frequently observed in patients with SS. The patients with diffuse or limited SS are equally affected by this complication. Doppler echocardiography has proved to be the technique of choice for the evaluation of pulmonary involvement in patients with SS because it is noninvasive, inexpensive and allows serial examinations. Early recognition of pulmonary hypertension may favor the use of therapeutical strategies to prevent the progression to advanced forms.

Granulocyte-macrophage colony stimulating factor and interleukin 3: target cells and kinetics of response in vivo

Granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin 3 (IL-3) target cells have been studied in vivo in subjects with normal hemopoiesis. GM-CSF administration elicits a rapid and sustained neutrophilia, monocytosis and eosinophilia due to a direct proliferative stimulus on all progenitors and precursors of the granulomonopoietic lineage. GM-CSF is also a powerful stimulator of erythroid burst forming unit (BFU-E) and megakaryocyte colony forming unit (CFU-MK) proliferation. Its action, however, does not extend to more mature erythroid and megakaryocyte cells suggesting the need for combined treatment with lineage-specific growth factors such as erythropoietin (Epo) or IL-6 to obtain a complete myeloid stimulation. When GM-CSF is discontinued, its action rapidly vanishes, and a rapid decline in the proliferative rate of target cells to values below the initial ones occurs. The potential clinical usefulness of this phenomenon in regard to cancer chemotherapy is discussed. IL-3 treatment induces only a rapid and marked eosinophilia. Chronic IL-3 administration, however, increases the proliferation of all myelopoietic progenitors and primes CFU-GM to become more sensitive in vitro to the action of granulocyte CSF (G-CSF), GM-CSF and IL-5. Whereas an increased IL-5 sensitivity seems devoid of therapeutic potential, the priming of G-CSF and GM-CSF action suggests rational scheduling for a combined treatment of IL-3 with other hemopoietic growth factors.

Oligonucleotide degradation contributes to resistance to antisense compounds

A subline of the human B cell lymphoma DHL-4, grown in the artificial serum-free medium HB101, displayed a resistant phenotype to the activity of an antisense oligodeoxynucleotide (aODN) effective on the parental DHL-4 line. It was found that the cellular uptake of the 18mer aODN in the two cell lines was almost the same. In contrast, the unresponsive subline DHL-4r degraded the aODN very efficiently, in contrast to the stability of aODN inside cells of the parental DHL-4 line. Activation of the degrading 'machinery' combined with selective properties of the artificial medium may be responsible for the loss of responsiveness to aODN.

Generation of inositol phosphates, diacylglycerol and calcium fluxes in myoblasts treated with 1,25-dihydroxyvitamin D3

We have examined the effects of the seco-steroid hormone 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] on membrane phosphoinositide metabolism, protein kinase C (PKC) activation and influx of extracellular Ca2+ in chick-embryo muscle-cell (myoblast) cultures. At physiological concentrations, the hormone induces a rapid (15 s) and transient release of inositol triphosphate (InsP3) and diacylglycerol (DAG). InsP3 release is maximal at 60 s (80% above controls) and then declines. The effects of 1,25(OH)2D3 on InsP3 production exhibited specificity, as 25-hydroxy-vitamin D3 and 24,25-dihydroxy-vitamin D3 did not alter myoblast InsP3 levels. The stimulation of DAG is biphasic, with peaks at 60 s (+105%) and 5 min (+700%). The second phase of DAG release is not associated with changes in InsP3. 1,25(OH)2D3 induces a rapid (within 60 s) accumulation of InsP2, and its effect on InsP is delayed (120 s). The hormone rapidly activates myoblast PKC, with maximal translocation of activity from the cytosol to the cell membrane occurring at 60 s. Myoblast 45Ca uptake significantly increases within 30 s of exposure to 1,25(OH)2D3. The response is time- (0.5-10 min) and dose- (1 pM-10 nM) dependent. The effects of the hormone are mimicked by the Ca(2+)-channel agonist Bay K 8644 and are effectively suppressed by nifedipine and extracellular EGTA. The results suggest that the rapid non-genomic actions of 1,25(OH)2D3 in myoblasts involve second-messenger systems associated with the generation of InsP3 and DAG and regulation of Ca2+ fluxes through voltage-operated channels.

Evidence for the participation of protein kinase C and 3',5'-cyclic AMP-dependent protein kinase in the stimulation of muscle cell proliferation by 1,25-dihydroxy-vitamin D3

Treatment with 1,25-dihydroxy-vitamin D3 (1,25(OH)2D3) (1-12 h, 10(-10) M) stimulates DNA synthesis in proliferating myoblasts, with an early response at 2-4 h of treatment followed by a maximal effect at 10 h. To investigate the mechanism involved in the mitogenic action of the hormone we studied the possible activation of intracellular messengers by 1,25(OH)2D3. The initial phase of stimulation of [3H]thymidine incorporation into DNA by the sterol was mimicked by the protein kinase C activator tetradecanoylphorbol acetate (TPA) in a manner which was dose dependent and specific as the inactive analog 4 alpha-phorbol was without effect. Maximal responses to TPA (100 nM) were obtained at 4 h. Staurosporine, a protein kinase C inhibitor, blocked the effect of 1,25(OH)2D3 on myoblast proliferation at 4 h. In addition, a fast (1-5 min) elevation of diacylglycerol levels and membrane-associated protein kinase C activity was observed in response to 1,25(OH)2D3. The adenylate cyclase activator forskolin (20 microM) and dibutyryl-cAMP (50 microM) increased DNA synthesis reproducing the second 1,25(OH)2D3-dependent stimulatory phase at 10 h. Inhibitors of protein kinase A blocked the increase in muscle cell DNA synthesis induced by 1,25(OH)2D3 at 10 h. Significant increases in cyclic AMP levels were detected in myoblasts treated with the sterol for 1-10 h. The calcium channel antagonist nifedipine (5-10 microM) abolished both the effects of 4-h treatment with 1,25(OH)2D3 or TPA and 10-h treatment with 1,25(OH)2D3 or dibutyryl-cAMP. Similar to the calcium channel agonist Bay K8644, 1,25(OH)2D3 stimulated myoblast 45Ca uptake and its effects were blocked by nifedipine.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced release of atrial natriuretic factor during exercise-induced myocardial ischaemia in patients after acute myocardial infarction

To determine whether acute myocardial ischaemia induced by dynamic exercise can lead to changes in plasma levels of atrial natriuretic factor, we performed symptom-limited bicycle electrocardiographic tests in 20 males with recent acute myocardial infarction and in 8 control males. Ten patients developed exercise-induced myocardial ischaemia and 10 patients did not. There were no significant differences between the two groups with regard to age, site of myocardial infarction, urinary sodium, atrial sizes, radionuclide left ventricular ejection fraction, workload, baseline and peak-exercise heart rate, baseline and peak-exercise rate-pressure product, duration of exercise. Also baseline atrial natriuretic factor concentrations were similar in both groups (ischaemic patients: 34.51 +/- 15.73 pg/ml; nonischaemic patients: 27.17 +/- 8.74 pg/ml, NS), while peak-exercise atrial natriuretic factor concentrations were higher in patients with exercise-induced myocardial ischaemia (112.31 +/- 35.5 pg/ml) than in the others (80.46 +/- 23.43 pg/ml) (P less than 0.05). After 15 minutes of recovery, plasma atrial natriuretic factor levels were still raised only in the ischaemic patients (63.3 +/- 15.44 pg/ml, P less than 0.01), returning to baseline after 30 minutes in both groups. In control subjects, the behaviour of atrial natriuretic factor resembled that of the patients without exercise-induced ischaemia, with a significant increase at peak-exercise (from baseline levels of 23.1 +/- 10.5 pg/ml to peak-exercise levels of 91.3 +/- 14.5 pg/ml, P less than 0.0005) and a rapid return to baseline levels after 15 minutes of recovery (28.5 +/- 10.6 pg/ml, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in the atrial natriuretic factor and the renin-angiotensin-aldosterone axis induced by maximum exertion in subjects with a recent myocardial infarct]

To examine the effect of exercise-induced myocardial ischemia (EIMI) on atrial natriuretic factor (ANF), plasma renin activity (PRA) and aldosterone (PA), a maximal exercise test in 12 patients with recent acute myocardial infarction (AM) was performed. ANF, PRA and PA were measured by radioimmunoassay at baseline, peak-exercise and at 15 min after recovery. Four patients developed EIMI (group I) and 8 patients did not (group II). ANF increased in all patients from baseline to peak-exercise (27.7 +/- 9.5 pg/mL vs 92.7 +/- 26.7 pg/mL, p less than 0.0005) and it was still elevated 15 min after recovery. Baseline ANF was similar in both groups while at peak-exercise it was higher in group. I than in group II (112 +/- 15 pg/mL vs 82 +/- 26 pg/mL p less than 0.05). After 15 min of recovery, ANF was higher in group I than in group II (67 +/- 20 pg/mL vs 32 +/- 10 pg/mL, p less than 0.01), resulting higher than at baseline only in group I (p less than 0.05). PRA and PA also increased during exercise but their values rose more slowly and were the same in both groups. Thus, ANF, PRA and PA increase during exercise in patients after AMI, and EIMI is associated with higher ANF plasma levels.

In vivo effect of human granulocyte-macrophage colony-stimulating factor on megakaryocytopoiesis

The effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on megakaryocytopoiesis and platelet production was investigated in patients with normal hematopoiesis. Three findings indicated that GM-CSF plays a role in megakaryocytopoiesis. During treatment with GM-CSF (recombinant mammalian, glycosylated; Sandoz/Schering-Plough, 5.5 micrograms protein/kg/d, subcutaneously for 3 days) the percentage of megakaryocyte progenitors (megakaryocyte colony forming unit [CFU-Mk]) in S phase (evaluated by the suicide technique with high 3H-Tdr doses) increased from 31% +/- 16% to 88% +/- 11%; and the maturation profile of megakaryocytes was modified, with a relative increase in more immature stage I-III forms. Moreover, by autoradiography (after incubation of marrow cells with 125I-labeled GM-CSF) specific GM-CSF receptors were detectable on megakaryocytes. Nevertheless, the proliferative stimulus induced on the progenitors was not accompanied by enhanced platelet production (by contrast with the marked granulomonocytosis). It may be suggested that other cytokines are involved in the regulation of the intermediate and terminal stages of megakaryocytopoiesis in vivo and that their intervention is an essential prerequisite to turn the GM-CSF-induced proliferative stimulus into enhanced platelet production.

[Effects of flecainide in patients with non-sustained ventricular tachycardia and impaired left ventricular function]

Anti-arrythmia efficacy and effects on left ventricular function of flecainide have been evaluated in 9 patients with symptomatic non sustained ventricular tachycardia (NSVT) and left ventricular ejection fraction (LVEF) lower than 30%, respectively detected by Holter monitoring and radionuclide angiocardiography in basal conditions. Seven to eleven days after starting flecainide therapy (100 mg b.i.d.), Holter and radionuclide angiocardiography were repeated. In 56% of patients a ventricular premature beats (VPB) reduction more than 70% was obtained and total VPB suppression was achieved in 33% of patients. Total suppression of NSVT was obtained in 67% of patients; LVEF did not show significant changes. Thus, antiarrhythmic efficacy of flecainide resulted in agreement with the previous reports, whereas no patient developed signs or symptoms of heart failure or pro-arrhythmia.

Early hepatitis during intravenous amiodarone administration

Two patients with acute changes suggesting acute hepatitis after parenteral amiodarone administration are described. No other explanation for liver damage was found in these patients. Normalization of liver function in spite of continuation of drug infusion was observed.

Opposite effect of tumor necrosis factor alpha on granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor-dependent growth of normal and leukemic hemopoietic progenitors

The effect of recombinant human tumor necrosis factor alpha (TNF-alpha) on normal and chronic myeloid leukemia granulocyte-macrophage progenitors (CFU-GM) growing in semisolid agar cultures in the presence of recombinant granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor was studied. Granulocyte-macrophage colony-stimulating factor-dependent growth of normal and chronic myeloid leukemia bone marrow CFU-GM was greatly enhanced by TNF-alpha at doses of 0.1 to 100 units/ml. Growth enhancement included neutrophil, eosinophil, and monocyte-macrophage colonies and clusters at 7 and 14 days of culture. Since similar results were achieved with highly enriched progenitor cell populations, devoid of accessory cells, an indirect effect on CFU-GM growth through the release by accessory cells of other cytokines upon TNF-alpha stimulation was thus ruled out. By contrast, the same doses of TNF-alpha inhibited the growth of normal CFU-GM in granulocyte colony-stimulating factor-dependent cultures. Taken together, our findings indicate that the final effect of TNF-alpha on normal bone marrow granulocyte-macrophage progenitor growth is dependent on the specific growth factor interacting with it, and that both normal and chronic myeloid leukemia CFU-GM are equally responsive to the combined effects of TNF-alpha and a given colony-stimulating factor.

[Monitoring of respiratory exchange during ergometric test in patients with heart failure: current aspects and prospects]

The current techniques of respiratory gas-exchange monitoring during stress testing in patients with congestive heart failure have provided new physiopathologic and clinical data. The "breath-by-breath" measurement of oxygen consumption and carbon dioxide production and the evaluation of the relationship between these parameters and respiratory volumes, allow to determine both ventilatory and metabolic responses during exercise, thus giving a precise estimate of the effective cardiopulmonary functional capacity. The demonstration of peripheral vascular and metabolic abnormalities by these techniques have provided new insights into the mechanism of dyspnea and fatigue in patients with heart failure. Although the relationship between respiratory and metabolic parameters and hemodynamics has been extensively studied, its mechanisms are still unclear. Moreover, controversy still exists as to the link between functional capacity and prognosis. Finally, recent studies on the cardiopulmonary adaptations to exercise training in patients with left ventricular dysfunction, have clearly demonstrated clinical and hemodynamic improvement after conditioning. These data, if confirmed, may provide a new approach in the management of patients with this disorder.

[Holiday heart syndrome: spontaneous reversibility of the electrocardiographic and echocardiographic alterations]

The holiday heart syndrome is characterized by symptomatic arrhythmias more often supraventricular, elicited by alcohol ingestion, typically during the week-end period. After admission, electrocardiographic changes, which disappear in few days, are often reported. A case of an alcoholic with syncopal episodes related to alcohol ingestion is described. In this patient, remarkable changes of ventricular repolarization on the electrocardiogram associated with impairment of ventricular diastolic function on the Doppler echocardiographic study are showed. ECG and echo-Doppler data reversed to normality after few days of alcohol withdrawal.