P280 USE OF SYSTEMIC THROMBOLYSIS IN HEMODYNAMICALLY UNSTABLE PULMONARY EMBOLISM PATIENTS WITH AND WITHOUT CARDIAC ARREST: DATA FROM THE IPER REGISTRY

Background

Systemic thrombolysis (ST) remains the treatment of choice in haemodynamically unstable patients with acute pulmonary embolism (PE). However, it remains frequently underused in clinical practice. The purpose of the study is to evaluate the use of ST in hemodynamically unstable PE patients with aand without acute cardiac arrest using the IPER registry.

Materials and Methods

IPER is a multicentre, national, prospective, web–based registry based on 47 Italian hospitals. In this study, the population was divided into two groups: patients with (ACC) and without (No ACC) cardio–circulatory arrest at admission.

Results

Of 1716 patients enrolled between September 2006 and August 2010, 201 (11.7%) [mean age 74 ± 14 years 127 females] were defined as high risk (i.e. haemodynamically unstable). Of these 59 (29.4%, mean age 76.4 ± 13.3 years, 40 females) were admitted with ACC while the remaining 142 (70.6, mean age 73.5 ± 13.7 years, 87 females) without. No differences were observed for venous thromboembolism risk factors, such as immobilization for more than three days, trauma, surgery within the previous 4 weeks, previous venous thromboembolism, history of heart failure, cancer and ischemic heart disease, among the two gropus. Mortality from all causes (62.7% vs 19.0, p < 0.001) and for acute PE (55.9% vs 9.9%, p < 0.001) was higher in ACC patients. Thrombolysis was administered in 82 (40.7%) of haemodynamically unstable patients and more frequently in ACC subjects (55.9% VSA 34.5%, p = 0.005) (Figure 1, panel A). The administration of systemic thrombolysis increased with aging in the No ACC group but showed a significant reduction in over–octogenarian patients (Figure 1, panel B). Major bleeding complications following reperfusive treatment were observed in 8 patients (3.9%); among these, intracranial hemorrhage was registered in 2.4% of cases.

Conclusions

Although systemic thrombolysis remains the first–line treatment in patients with hemodynamically unstable acute PE and is capable of improving both the mortality and morbidity, it continues to be underused in daily clinical practice, often for fear of major bleeding complications.

P285 PROGNOSTIC ROLE OF ELECTROCARDIOGRAPHIC TEMPORAL CHANGES IN PATIENTS WITH ACUTE PULMONARY EMBOLISM. DATA FROM THE ITALIAN PULMONARY EMBOLISM REGISTRY (IPER)

Background

The potential prognostic role of ECG changes during the course of acute pulmonary embolism (PE) has been poorly investigated over the years.

Methods

Data of patients prospectively enrolled in the IPER registry, having three ECGs (the first perfromed on admission, the second after three days of hospitalization and the third at discharge) were extracted and analyzed.

Results

Overall, 687 patients (286 males, mean age 69.0 ± 15.5 years) were included in the study. The negativization of electrocardiographic signs of right ventricualr strain (RVS) (Right bundle branch block –RBBB), S1Q3T3 and negative T waves from V1 to V4) followed the same pattern in both non–high (i.e. hemodynamically stable) and high–risk (i.e. hemodynamically unstable) patients, showing firstly the normalization of the S1QT3 pattern followed by the resolution of the RBBB. Conversely, additional NTWs appeared between the first and second ECGs in about 20% of cases and then partially normalized at discharge. Persistence of RVS at the second ECG was associated with a higher risk of death within 30 days only in high–risk patients [HRa: 2.78 (95% CI: 1.05–7.31. P = 0.03), with a sensitivity, specificity, PPV and PPN of 90.0%, 94.1%, 85.7% and 96.0%, respectively. Furthermore, the lack of normalization of the RBBB [HRa: 2.78 (95% CI: 1.05–7.31, p = 0.003)], of the NTW [HRa: 1.63 (95% CI: 1.04–2.55), p < 0.0001] and of the resolution of qR complex in V1 [HRa: 12.5 (95% CI: 3.39–46.4,) p < 0.0001] were independent predictors of poor prognosis in the short term. High–risk patients showing at the second–ECG the persitence of RBBB and NTWs as well as disappearance of the qR complex in V1 had a higher 30–day increased risk of death [HR: 9.44, (95% CI: 5.22–17.05, p < 0.0001]. The C–statistic confirmed in high–risk subjects an improvement in short–term prognostic power using the persistence of all three ECG signs (0.77, 95% CI: 0.51–0.94) or they single presence (0.61, 95% CI 0.42–0.79; 0.70; 95% CI: 0.52–0.88 and 0.74, 95% CI: 0.56–0.96, RBBB, NTWs and qR in V1, respectively).

Conclusions

The persistence of RBBB, NTWs, and qR pattern in V1 after 3 days from the hospitalization for acute PE represent an independent prognostic factors of death within 30 days in high–risk acute PE patients. In terms of prognostic power, the single evaluation of each ECG sign was lower compared to the overall or combined assessment.

Recurrent pulmonary embolism secondary to popliteal vein aneurysm with intraluminal wall ulcer

The popliteal vein is the most frequent site of venous aneurysm. Surgical treatment is indicated above a 2.5 cm diameter to prevent complications, notably deep venous thrombosis and pulmonary embolism (PE). Here we report a case of recurrent episodes of severe PE, leading to cardio-circulatory shock caused by a popliteal vein aneurysm (PVA) despite oral anticoagulant therapy. When surgical correction of the aneurysm was performed, we found an ulcerative lesion in the inner aspect of the vein that was acting as a 'thrombogenic focus' inside the aneurysm. An accurate inspection of the intimal wall is always important during surgery of PVA, particularly when tangential resection is performed.

[Heart rupture during pre-discharge stress test after myocardial infarction]

A 65-year-old man with a postero-lateral myocardial infarction, complicated by rapid atrial fibrillation was admitted to the Intensive Coronary Care Unit. He received thrombolytic treatment. Electrocardiography and laboratory analysis were suggestive of reperfusion; the rapid atrial fibrillation was converted to sinus rhythm using i.v. amiodarone. Two echocardiograms performed on days 1 and 6 revealed hypokinesis of the postero-lateral wall and a mild reduction in the left ventricular ejection fraction. On day 7, after pharmacological wash-out, he was submitted to a bicycle exercise test: soon after the beginning of the 75 W step, the patient presented cardiac arrest due to electromechanical dissociation and hemopericardium. Despite prolonged cardiopulmonary resuscitation maneuvers and drainage of a few milliliters of pericardial blood, the patient did not survive. At autopsy, a huge clot filling the pericardial space was detected together with two linear 3 cm tears of the left ventricular lateral wall. The authors stress the possibility of unpredictable deaths during a pre-discharge exercise testing; good clinical judgment should therefore be used in deciding which patients should undergo this procedure and appropriate information about its potential risks should be given.

[Acute myocardial damage from a pheochromocytoma]

Cardiac involvement in pheochromocytoma is rare but may be associated with serious clinical deterioration. A 70-year-old woman arrived at our Emergency Department because of chest discomfort, blood pressure lability, mild dyspnea and electrocardiographic signs suggesting an acute myocardial infarction. However two-dimensional echocardiogram did not show any segmental wall motion abnormalities but diffuse and severe left ventricular hypokinesia. The patient was treated with ACE-inhibitors and diuretics and did not receive thrombolytics or beta blocking agents. Creatine kinase-MB and troponin I were normal. Electrocardiogram and echocardiogram completely returned to normal within 1 week and a coronary angiography demonstrated normal coronary arteries. An increase in the catecholamine concentration in a 24-hour urinary sample suggested a pheochromocytoma that was confirmed by abdominal computerized tomography. During surgery, marked hypertension developed treated with sodium nitroprusside and labetalol, and after removal of the tumor severe hypotension required infusion of norepinephrine for several days.

[The cardiologist facing pulmonary embolism. The experience of 160 cases of acute cor pulmonale]

BACKGROUND

The results of recent multicenter studies dealing with pulmonary embolism often reveal remarkable discrepancies in terms of diagnosis, prognosis and treatment, partly due to the heterogeneity of study patients and of evaluation criteria. Our prospective study focused exclusively on patients affected by pulmonary embolism with a hemodynamic pattern of acute cor pulmonale, investigated at a single center. Particular attention was paid to in-hospital mortality, embolic recurrences, major bleeding and underlying pathologies.

METHODS

This study includes 160 cases (103 women with a median age of 71 years and 57 men with a median age of 65 years) in whom the clinical and echocardiographic findings suggestive of acute pulmonary embolism were confirmed by lung perfusion scan, pulmonary angiography, techniques for the detection of deep vein thrombosis and/or autopsy.

RESULTS

The most common clinical manifestations were: dyspnea (92% of cases), tachycardia (80%), syncope (44%), cardiac arrest (22%), and shock (20%). Thoracic pain was present in only 27% of patients. None of the patients showed a normal ECG; a right bundle branch block was found in 47% of cases. T-wave inversion in the precordial leads (32%) was not related to the severity and outcome of pulmonary embolism. Present or previous deep vein thrombosis was found in 53 and 26% of cases, respectively. Only in 2 patients pulmonary embolism was secondary to a deep vein thrombosis of the upper limbs. Intravenous heparin alone was used in 36% of cases, whereas 56% were treated with thrombolytic agents + heparin. Major bleeding occurred in 9% of patients treated with heparin alone, and in 16% of those who received heparin + thrombolytic drugs. Death occurred in 17% of the former, and in 27% of the latter patients. The in-hospital mortality rate was related not only to the presence of cardiac arrest and--to a lower degree--of shock, but also to the recurrence of pulmonary embolism and to the underlying heart disease. No relationship was found between mortality and age, intracardiac thrombi or malignancy. Prognosis was quite different depending on clinical presentation, with a death rate ranging from 11% in the absence of systemic hypertension, and 77% in the presence of cardiac arrest.

CONCLUSIONS

Even the "massive" pulmonary embolism that is observed in a cardiac department represents a true "spectrum" of pathological conditions, a spectrum that should be taken into account not only in order to evaluate prognosis and treatment in a particular case, but also when meta-analyses are performed.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

Hypercoagulability and chronic atrial fibrillation: the role of markers of thrombin generation

BACKGROUND

We have studied 64 patients with congestive heart failure, half of them also with chronic nonvalvular atrial fibrillation (AF). Patients were also stratified according to a history of prior stroke.

METHODS

The generation of thrombin was investigated by means of the molecular markers prothrombin fragment 1 + 2 (F1 + 2) and thrombin-antithrombin III complex (TAT), because AF patients may have a hypercoagulable state. There was only a trend toward higher values of TAT and F1 + 2 for AF patients, while subjects with previous stroke (irrespective of AF) had increased levels of the markers of thrombin generation (TAT stroke+ 18.95 +/- 5.15 vs TAT stroke- 8.34 +/- 2.41; F1 + 2 stroke+ 2.22 +/- 0.29 vs F1 + 2 stroke- 1.32 +/- 0.12). The presence of spontaneous echo contrast (SEC) within left atrium was also investigated in 32 AF patients by transesophageal echocardiography.

RESULTS

TAT were significantly higher in subjects (n = 11) with SEC (TAT sec+ 37.5 +/- 13.41 vs TAT sec- 8.7 +/- 2.51, p = 0.008).

CONCLUSIONS

Finally, when we grouped into 1) those with both AF and stroke, 2) AF alone, 3) stroke alone and 4) sinus rhythm without stroke, levels of F1 + 2 were higher (and marginally higher TAT) in patients with AF and stroke than in those without stroke, revealing that there is a true clotting activation state in these subjects.

Fluvastatin and tissue factor pathway inhibitor in type IIA and IIB hyperlipidemia and in acute myocardial infarction

Tissue factor pathway inhibitor (TFPI) is a serine protease inhibitor that regulates tissue factor-induced blood coagulation. In an open-label 8-week study, 20 hypercholesterolemic patients (10 type IIa and 10 type IIb) were enrolled and given fluvastatin 40 mg once daily at bedtime. At baseline (after a 4-week controlled diet) and at week 8, total cholesterol, total triglycerides and lipoprotein subfractions were assessed. TFPI antigen levels were measured at the same time by ELISA. We also measured TFPI concentrations in 10 control subjects and in 10 patients at the time of and ten days after acute myocardial infarction. In type IIa patients fluvastatin reduced total cholesterol levels by 26% and LDL-cholesterol by 30% (P < 0.001); in type IIb, fluvastatin significantly reduced total cholesterol levels by 24% (P < 0.001). In both dyslipidemic groups the baseline total TFPI levels were significantly higher than in the control group (P < 0.002). The therapeutic lipid-lowering effect was paralleled by a significantly reduction of total TFPI antigen concentrations from 132 +/- 23 to 71 +/- 37 ng/mL (P < 0.001) in type IIa and from 120 +/- 30 to 91 +/- 29 ng/mL (P < 0.05) in type IIb patients; in control subjects total TFPI levels were 81 +/- 22 ng/mL; however the lipoprotein-bound TFPI antigen subfractions did not differ significantly in the treated and control groups. In patients with recent myocardial infarction there was a significant reduction from day 0 to day 10 in total TFPI antigen levels, from 120 +/- 48 ng/mL to 80 +/- 16 ng/mL (P < 0.05). The reported reduction of TFPI antigen levels after fluvastatin treatment could be a sign of normalization of an up-regulated clotting system rather than an unfavourable reduction of a natural anticoagulant.

Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism

The prevalence of right-sided cardiac mobile thrombi, "in transit" from the systemic venous system, was 18% in a series of 130 patients with massive pulmonary embolism referred to early echocardiography and receiving thrombolytic drugs (56%) or intravenous heparin (40%). The mortality rate was lower than previously reported and seemed to be related more to clinical and hemodynamic impairment than to presence of thromboembolus.

Prognostic value of dobutamine-atropine stress echocardiography early after acute myocardial infarction. Echo Dobutamine International Cooperative (EDIC) Study

OBJECTIVES

The aim of this multicenter, multinational, prospective, observational study was to assess the relative value of myocardial viability and induced ischemia early after uncomplicated myocardial infarction.

BACKGROUND

Dobutamine-atropine stress echocardiography allows evaluation of rest function (at baseline), myocardial viability (at low dose) and residual ischemia (peak dose, up to 40 micrograms with atropine up to 1 mg) in one test.

METHODS

Dobutamine-atropine stress echocardiography was performed 12 +/- 5 days (mean +/- SD) after a first uncomplicated acute myocardial infarction in 778 patients (677 men; mean age 58 +/- 10 years) with technically satisfactory rest echocardiographic study results. Patients were followed-up for 9 +/- 7 months.

RESULTS

Dobutamine-atropine stress echocardiographic findings were positive for myocardial ischemia in 436 of patients (56%) and negative in 342 (44%). During follow-up, there were 14 cardiac-related deaths (1.8% of the total cohort), 24 (2.9%) nonfatal myocardial infarctions and 63 (8%) hospital readmissions for unstable angina. One hundred seventy-four patients (22%) underwent coronary revascularization (bypass surgery or coronary angioplasty). Spontaneous events occurred in 61 of 436 patients with positive and 40 of 342 patients with negative findings on dobutamine-atropine stress echocardiography (14% vs. 12%, p = 0.3). When only spontaneously occurring events were considered, the most important predictor was myocardial viability (chi-square 9.7). Using the Cox proportional hazards model, only the presence of myocardial viability (hazard ratio [HR] 2.0, p < 0.002) and age (HR 1.03, p < 0.001) were predictive of spontaneously occurring events. When only hard cardiac events were considered, age was the strongest predictor (chi-square 3.6, p = 0.056), followed by wall motion score index (WMSI) at peak dose (chi-square 3.3, p = 0.06) and remote ischemia (chi-square 2.25, p = 0.1). When cardiac death was considered, WMSI at peak dose was the best predictor (HR 9.2, p < 0.0001).

CONCLUSIONS

During dobutamine stress, echocardiographic recognition of myocardial viability is more prognostically important than echocardiographic recognition of myocardial ischemia for predicting unstable angina, whereas WMSI at peak stress was the best predictor of cardiac-related death. Different events can be recognized with different efficiency by various stress echocardiographic variables.

[Massive pulmonary embolism during the third trimester of pregnancy: effectiveness of thrombolytic treatment with alteplase]

The authors report on a 33-year old woman with massive, life-threatening pulmonary embolism at the third trimester of pregnancy. The diagnosis was rapidly accomplished in the Emergency Department by two dimensional-Doppler echocardiography that showed signs of pulmonary hypertension as well as a large, floating thromboembolus in the right atrium. As the hemodynamic deterioration persisted after treatment with iv heparin, the patient received alteplase 50 mg as a bolus over 5 minutes. About 30 minutes later, a further 50 mg infusion of alteplase was given over 60 minutes because clinical conditions were progressively worsening. After an alteplase dose of 75 mg, the woman showed a definite improvement in clinical-hemodynamic status and echocardiography documented a reduction of right ventricular overload and atrial clot disappearance. Two hours later the patient was submitted to cesarean section, because of the onset of uterine contractions, and delivered a vital baby. The occurrence of uterine bleeding was antagonized by the infusion of fresh-frozen plasma and a moderate anemia was subsequently treated with iron preparations. The mother and her baby were discharged on 16th day in fairly good general conditions. The authors emphasize the leading role of early echocardiography in the clinical decision making and the lifesaving potential of full dose thrombolytic therapy without serious adverse effects.

Pulmonary venous flow velocity patterns in 143 normal subjects aged 20 to 80 years old. An echo 2D colour Doppler cooperative study

In order to find out the normal values and to evaluate the effects of age, heart rate, sex, and haemodynamic and standard echocardiographic parameters on pulmonary venous flow velocity obtained by the transthoracic approach. Doppler pulmonary venous flow parameters were measured in 143 healthy subjects aged from 20 to 80 years. Doppler pulmonary venous flow parameters which had the best correlation with age were: the peak velocity of the systolic wave (r = 0.39) and its integral (r = 0.5), the peak velocity of the diastolic wave (r = -0.6) and its integral (r = -0.44); the systolic (r = 0.68) and diastolic fractions (r = -0.68); the systolic/diastolic peak velocity ratio (r = 0.73) and the systolic/diastolic integral ratio (r = 0.7). The atrial reversal wave did not correlate with age; the atrial reversal wave was more difficult and probably less reliable to measure than the systolic and diastolic waves. The correlations of pulmonary venous flow parameters with mitral flow parameters were also examined. This study showed that, in healthy subjects, despite an increase in the early and atrial waves from the annulus to the tips of the mitral leaflets, there is a similar association between pulmonary venous flow and mitral flow measured at the annulus or at the tips of the mitral leaflets. The intra-observer reproducibility of all the pulmonary venous flow parameters considered were found to be excellent. Moderate inter-observer variability was observed for the systolic, diastolic and atrial reversal wave peak velocities and integrals; however, the systolic/diastolic ratio improved the precision of the measurements. Multivariate analysis showed that age is the principal determinant of the Doppler parameters of pulmonary venous flow: heart rate, sex, body surface area, the size of the left atrium in systole and the left ventricular ejection fraction all influence the Doppler parameters of pulmonary venous flow, even if only slightly.

The varying evolution of Friedreich's ataxia cardiomyopathy

During a mean follow-up period of 8 years, 17% of 66 patients with Friedreich's ataxia developed hypokinetic-dilated cardiomyopathy; most patients originally had a hypertrophic left ventricle. The presence of pathologic Q waves identifies a subgroup of patients with wall motion abnormalities; these patients are more likely to develop a hypokinetic left ventricle, and the prognosis is ostensibly poorer.

The atropine factor in pharmacologic stress echocardiography. Echo Persantine (EPIC) and Echo Dobutamine International Cooperative (EDIC) Study Groups

OBJECTIVES

This study sought to compare, head to head, the two most popular pharmacologic stress echocardiographic tests--dipyridamole and dobutamine--with state of the art protocols in a large multicenter prospective study.

BACKGROUND

In the continuing quest for ideal diagnostic accuracy, pharmacologic stress echocardiography has quickly moved over the years from low to high dose regimens and is currently performed with atropine coadministration.

METHODS

Dobutamine (up to 40 microgram/kg body weight per min) plus atropine (up to 1 mg over 4 h) and dipyridamole (up to 0.84 mg/kg per min over 10 h) plus atropine (up to 1 mg over 4 h) stress echocardiography was performed on different days, in random order and within 1 week in 360 patients with chest pain syndrome. Thirteen different echocardiographic laboratories, all fulfilling quality control criteria for stress echocardiographic reading, contributed to the study.

RESULTS

No major complications occurred during either test. The test was interrupted before achievement of predetermined end points for limiting side effects in 37 dobutamine-atropine and 7 dipyridamole-atropine stress echocardiographic studies (feasibility 90% vs. 98%, p < 0.01). Diagnostic accuracy was assessed in a subset of 110 patients with no obvious rest dyssynergy (akinesia or dyskinesia) who underwent coronary angiography independently of test results and within 1 week of testing. Significant coronary artery disease (> or = 50% diameter reduction in at least one major coronary vessel by quantitative coronary angiography) was found in 92 patients. Sensitivity for detection of coronary artery disease was 84% (77 of 92) for dobutamine-atropine and 82% (75 of 92) for dipyridamole-atropine stress echocardiography (p = NS), with a specificity of 89% (16 of 18) for dobutamine-atropine and 94% (17 of 18) for dipyridamole-atropine stress echocardiography (p = NS). A significant correlation was present between peak wall motion score index during dipyridamole-atropine and dobutamine-atropine stress echocardiography (r = 0.83, p < 0.0001).

CONCLUSIONS

Dobutamine-atropine and dipyridamole-atropine stress echocardiography are safe and feasible, although submaximal studies are more frequent with dobutamine. The two stresses have comparable accuracy in the detection of angiographically assessed coronary artery disease, although dobutamine is marginally more sensitive and dipyridamole marginally more specific. Stratification of the ischemic response in the space domain is also comparable with the two stresses.

[Acute myocardial infarction in bacterial endocarditis]

The authors report on a 47-years old woman with bacterial endocarditis involving both the mitral and aortic valves. At first echocardiographic examination, the mitral vegetation was small, while the aortic one was large highly mobile. Despite adequate antibiotic therapy, the aortic vegetation had become bigger and the valve regurgitation, initially mild to moderate, resulted severe and was associated with left heart failure. While awaiting surgery, the patient sustained an acute non Q wave myocardial infarction with ST segment elevation in inferior and anterolateral leads, complicated by ventricular arrhythmias. Thirty-six hours later, the patient received mitral and aortic valve replacement: at surgical view, the aortic vegetations was found to be very close to the right coronary orifice. After a period of further antibiotic therapy, the woman discharged and at a six months follow-up, she was fairly well. The authors review the mechanisms of acute coronary insufficiency in infective endocarditis and suggest an embolic pathogenesis in the case reported. Taking into account the possible life threatening embolic complications, it seems reasonable not to delay surgery when antibiotic therapy fails to reduce the size and mobility of valve vegetations.

[The new frontier of antithrombotic therapy: ASA + warfarin, the ideal solution?]

In the medical literature reports are accumulating a number of case reports suggesting the potential efficacy and safety of the combination of low-dose aspirin and warfarin to improve the efficacy of antithrombotic therapy in several clinical conditions, ranging from unstable angina to myocardial infarction. The advantages deriving from such a combination have to be considered together with its hemorrhagic risk. Thus the efficacy of such a treatment has to be proved by large clinical trials before the use of this potentially dangerous therapy can be transferred into common clinical practice.

[Dilated cardiomyopathy: a new natural history? The experience of the Italian Multicenter Cardiomyopathy Study (SPIC)]

BACKGROUND

The natural history of idiopathic dilated cardiomyopathy (IDC), once a disease with a dire prognosis, is thought to be changing. Aim of this study was to describe the clinical characteristics, long term course and prognostic factors of IDC patients followed up prospectively since the late eighties.

METHODS

Patients with a diagnosis of IDC confirmed by normal coronary angiography, non specific endomyocardial biopsy findings and a left ventricular ejection fraction below 50% were consecutively enrolled in a multicenter registry and followed up at 6-months intervals.

RESULTS

From January 1986 till January 1994, 441 IDC patients with a mean age of 43 +/- 13 years (range 8-68) entered the registry. Thirty per cent of patients were women and 8% had familial dilated cardiomyopathy. NYHA class was I-II in 77% and 35% of patients were asymptomatic at the time of diagnosis. Treatment included digitalis in 235 patients (53%), diuretics in 239 (54%), angiotensin converting enzyme inhibitors in 269 (61%), betablockers in 108 (24%). Chronic atrial fibrillation was detected in 10% of patients and left bundle branch block in 24%. Mean cardiothoracic ratio was 0.54 +/- 0.06. Mean left ventricular end diastolic dimension was 38 +/- 6 mm/m2; 48% of patients had minimal or mild left ventricular dilatation. Mean left ventricular ejection fraction was 30 +/- 10%. At Holter monitoring 67% of cases had complex ventricular arrhythmias, 37% had ventricular tachycardia and 4% had advanced atrioventricular block. Mean exercise stress test duration was 9 +/- 4 minutes. After a mean follow up of 31 +/- 24 months, 337 patients were alive without transplantation and 5 were lost to follow up; 60 patients (14%) had died of cardiac causes, namely heart failure (6%), sudden death (7%) and pulmonary embolism (< 1%) and 30 had been transplanted (7%), while 4 had died of unclear causes. Survival and transplant-free survival were 94% and 90% at 2 years and 82 and 76% at 5 years, respectively. At multivariate analysis pulmonary capillary wedge pressure (p = 0.0001, odds ratio, for values > 15 mm Hg, 2.05) and betablocker treatment (p = 0.002, odds ratio 0.26) were independent predictors of survival.

CONCLUSIONS

In this large, multicenter prospective study, prognosis of IDC in the eighties appears to be improved. Early diagnosis, together with improved medical treatment, probably bears a causal relation to these changes.

Clinical features of 24 patients on regular hemodialysis treatment (RDT) for 16-23 years in a single unit

Careful investigation of the clinical conditions of patients on maintenance hemodialysis for about 20 years in a single dialysis unit was of great interest for evaluation of the pathological consequences in long-term survivors of insufficient correction of uremia and of the dialysis treatment "per se". We analyzed the outcomes for a cohort of 116 patients who started RDT before 1976 and the clinical conditions of the 24 patients still on RDT in our unit at the end of 1991 (average duration of treatment = 222 +/- 23 months). Actuarial survival was 72% at 10 years and 43% at 20 years. Rehabilitation of the 24 survivors was rather good: 13 were able to work, 8 were retired or unable to work, but able to care for most personal needs. Actual body weight, anthropometric parameters and biochemical parameters revealed a well-preserved nutritional status. Anemia improved from 23 +/- 7 at the start of RDT to 31 +/- 8 in the 21 patients never treated with erythropoietin. Blood pressure was normal without therapy in 18 patients and elevated in 6. Mild-to-moderate left ventricular hypertrophy was present in all the 6 patients with arterial hypertension and in only 6 of the 18 normotensive patients. The ratio of early diastolic filling to filling during atrial contraction (E/A ratio) was < 1 in 16 patients: it was 1.05 +/- 0.43 in 9 patients with stable intradialysis blood pressure and significantly lower (0.73 +/- 0.15) in 12 patients with recurrent intradialysis hypotension. Supraventricular arrhythmias were detected by Holter monitoring in 41% and ventricular arrhythmias in 35% of patients. Extensive vascular calcifications were present (in 100% of patients in the abdominal aorta), but only 4 patients showed clinical signs of peripheral vascular disease. Subperiosteal resorption was detected radiologically in the hands of 59% of patients. Bone histology, interpretable for only 20 patients, revealed no bone lesions in 1 case (5%), mild mixed osteodystrophy in 3 cases (15%), advanced mixed osteodystrophy in 5 cases (25%), osteodystrophy with predominant hyperparathyroidism in 2 cases (10%), osteodystrophy with predominant osteomalacia in 6 cases (30%), and aplastic bone disease in 3 cases (15%). Moderate aluminum staining was found in only 4 patients and was more marked in earlier biopsies taken before withdrawal of the aluminium-containing phosphate-binding drugs.(ABSTRACT TRUNCATED AT 400 WORDS)

Left ventricular diastolic parameters in 288 normal subjects from 20 to 80 years old

Left ventricular diastolic indexes are influenced by several variables. In order to evaluate the relationship of these indexes to age, heart rate, sex and to standard echo parameters, 288 normal subjects aged from 20 to 80 years, divided into six age groups, underwent a two-dimensional colour Doppler examination. Doppler examination was performed from the apical four chamber view to evaluate transmitral flow; isovolumic relaxation time (IVRT) was measured from an apical five chamber view. In order to obtain a sufficient number of subjects for an adequate statistical analysis, seven hospitals were involved in the study. Univariate analysis showed that age influences the peak velocity of the E (r = -0.46) and A waves (r = 0.46), the E/A ratio (peak velocities) (r = -0.69), the A wave integral (r = 0.48) and the E/A integral ratio (r = -0.57), the early and late filling fractions (r = -0.48 and r = 0.51 respectively), and the E wave deceleration (r = -0.43) and deceleration time (r = 0.36). In subjects older than 70 years an inversion of the E/A wave ratio was observed. Multivariate analysis confirmed that age has an important influence on left ventricular diastolic indexes but also demonstrated that heart rate has a significant influence. Sex, ejection fraction (EF), and the dimensions of the mitral annulus and the left ventricular posterior wall had less influence on left ventricular diastolic indexes. The mean values of E and A wave acceleration, deceleration and peak velocity were used to depict left ventricular filling morphology in various age groups for three different heart rate values. The conclusions of the study, are: (1) normal left ventricular diastolic parameters were obtained as mean values at seven different hospitals (2) when evaluating left ventricular diastolic function parameters it is important to take into account age and heart rate; E/A inversion in older subjects should be considered the normal mitral flow pattern.

[Pseudoaneurysm of the right ventricle and rupture of the interventricular septum during the acute phase of myocardial infarct: diagnosis by color Doppler echocardiography]

The authors describe the association of a right ventricular pseudoaneurysm and ventricular septal rupture at the onset of an acute inferior and right myocardial infarction. The patient, a 84-year-old man, presented with cardiogenic shock and died within a few hours with electromechanical dissociation. The diagnosis was made by Echo-color flow mapping and confirmed at autopsy. The authors point out the singleness of such association and the diagnostic value of Echo-Doppler in the early assessment of the mechanical complications of myocardial infarction.

[The early echocardiographic diagnosis of a massive pulmonary embolism]

BACKGROUND

In several cases of clinically suspected massive pulmonary embolism (MPE), a lung perfusion scanning and/or a pulmonary angiography are not quickly available or feasible.

METHODS

Fifty patients admitted to our ICU with a clinically suspected MPE underwent an echocardiographic (Echo) investigation very shortly after onset (within 2 hours in 38 cases, and within 6 hours in 12). An Echo-Doppler study was also performed in 18 patients.

RESULTS

Highly significant differences (p < 0.001) emerged between patients with PE and healthy age-mates for each type of Echo measurement and in all views. The RVDD/LVDD ratio turned out to be the most frequently affected parameter, being altered in 96% of cases. An abnormal diastolic leftward shift of the interventricular septum was detected in 81% of cases. Only one of our 50 patients failed to show any evidence of RV pressure overload; however, this was a patient with a severe dilated cardiomyopathy. In 22 cases in whom hemodynamic monitoring was performed, no significant correlation emerged between RVDD and LVDD, on one hand, mean PAP and cardiac index on the other. All 18 patients examined by Echo-Doppler had mild to moderate tricuspid regurgitation with a peak RV-RA gradient of 38 +/- 7 mm Hg (range 31-53 mm Hg). Seven patients (14%) were found to harbor right heart thrombi when first examined. Overall mortality in this uncommonly high risk population was as high as 28%.

CONCLUSIONS

In a clinical setting suggesting a MPE, an Echo study conducted very shortly after onset may corroborate a tentative diagnosis of PE, thereby permitting timely fibrinolytic therapy pending a lung scan and/or angiography, or in situations where such imaging facilities are not available or readily usable.

Lysosomal glycogen storage with normal acid maltase: a familial study with successful heart transplant

Lysosomal glycogen storage in muscle with normal acid maltase activity is a rare inherited condition characterized by cardiomyopathy, mental retardation and mild myopathy in males, but generally only cardiomyopathy in females. Three cases (index case, his sister and her son) are described in a family with at least two other affected members. The index case underwent a successful heart transplant. The sister has cardiac involvement, myopathic changes and mental impairment--to our knowledge the first report of multisystem involvement in a female. We propose that skeletal muscle should be examined in young patients with hypertrophic cardiomyopathy. Furthermore, female relatives of males with the disease should be investigated for cardiomyopathy; they would be excellent candidates for life-saving heart transplant, since myopathy and mental retardation, if clinically evident, are mild.

[Heart arrest in acute pulmonary embolism. An anatomo-clinical study]

The Authors describe the modalities and mechanisms of cardiac arrest (CA) in the course of acute pulmonary embolism (PE). Clinical data refer to 39 CA episodes occurred in 28 patients with massive or submassive PE; autopsy data are from 26 of 28 patients of the same series. One-third of 39 CAs proved at least momentarily reversible; two-thirds were irreversible. Data analysis showed that most CA episodes, reversible or otherwise, seen in the course of PE were due to electromechanical dissociation (EMD). In fact, EMD was responsible for 12 of 13 reversible CAs and 22 of 26 irreversible arrests. EMD usually follows shock, but may occur unheralded. When EMD-induced CA is at least temporarily reversible, the heart rate is often normal or high and QRS complexes are narrow. In most cases the sudden rise of right ventricular afterload came on top of a pre-existing myocardial damage, for the most part of ischemic, sometimes necrotic, origin. In this series, therefore, it seems quite difficult to tell "primary" from "secondary" forms of EMD. External cardiac massage continued for as long as 40 minutes was associated in some cases with a bolus fibrinolytic infusion within minutes from occurrence of CA. Five of 7 patients so treated made a temporary recovery and two survived; at autopsy, none of the 5 patients who died showed any evidence of bleeding attributable to local injury.

[Early papillary muscle rupture in myocardial infarction, diagnosis with transesophageal echography]

We describe the case of posterior papillary muscle (PPM) rupture with severe mitral regurgitation at the very beginning of an inferior myocardial infarction (MI) in a 79-year-old woman. The diagnosis was made by transesophageal echocardiography (TEE) and confirmed at autopsy. This case confirms the value of TEE in diagnosing PPM rupture and the association of PPM rupture with small posterior myocardial infarction. Moreover the case presents some unusual aspects: the rupture occurred very early; at transthoracic approach, a systolic convergence flow zone was the only sign of mitral regurgitation by color flow mapping; at TEE flail mitral leaflets were absent; in systole, the trunked papillary muscle did not prolapse into the left atrial cavity, but crushed into the atrial side of posterior mitral leaflet, remaining at the atrioventricular level; at autopsy, there was a split PPM with a completely ruptured medial branch. On the atrial side of the posterior mitral leaflet there was an ecchimothic zone, due to the crushing of the PPM.

[Silent myocardial infarction caused by acute carbon monoxide poisoning]

This report describes a 63 year-old man who suffered an acute myocardial infarction after carbon monoxide exposure. When evaluated in the Emergency Room the patient was completely conscious and did not experience any chest pain. The electrocardiogram showed non-specific T wave abnormalities in inferolateral leads. The only sign consistent with a possible myocardial involvement was a slight increase in serum CPK. The electrocardiogram taken 12 hours later revealed a Q-wave inferior myocardial infarction, and CPK levels showed a typical elevation in the following 24 hours. The coronary angiography, performed about two weeks after admission, documented multiple obstructions in the main coronary branches. In the presence of a reduced coronary reserve, the onset of a prolonged myocardial ischemia might have been secondary to a decreased oxygen transport capacity of the blood, which lead to a decreased amount of oxygen available to the tissues. According to their experience, the authors emphasize the importance of a careful electrocardiographic and enzymatic monitoring of all patients in the first hours after CO exposure, because the typical chest pain may be absent.

[Clinical and prognostic significance of echocardiographic parameters in dilated cardiomyopathy: a prospective study on 225 patients. The Italian Multicenter Study of Cardiomyopathies Group]

To assess the prognostic role of echocardiographic indexes and their relation to clinical conditions, 225 patients with dilated cardiomyopathy were studied prospectively. All cases had a normal coronary angiogram and non specific endomyocardial biopsy findings. 163 men (72.4%) and 62 women (27.6%), mean age 41.5 +/- 12.3 (range 8-61), were studied. Clinical, electrocardiographic and echocardiographic parameters, normalized for body surface area, were tested according to NYHA class and presence of segmental or diffuse wall motion abnormalities. One hundred-four patients were in NYHA class I-IIa, 94 were in class IIb-III and 27 were in class IV. Left ventricular end systolic diameter index, right ventricular end diastolic diameter index, left atrial diameter index, left ventricular fractional shortening and ejection fraction, and radius to wall thickness ratio were significantly more impaired in patients with more severe symptoms. Twenty-eight patients (13%) showed segmental wall motion abnormalities and had smaller left ventricular end systolic and left atrial diameter index and higher left ventricular fractional shortening and ejection fraction. During a mean follow up of 23 +/- 15 months (range 1-67 months), 25 patients (11.1%) died from cardiac causes and 16 (7.1%) underwent heart transplant because of refractory heart failure. Prognostic evaluation was performed separately for cardiovascular mortality alone and for cardiac events (cardiovascular mortality and heart transplantation). At Cox multivariate analysis only right ventricular end diastolic diameter index (p < 0.005) predicted cardiovascular mortality, while left atrial diameter index (p < 0.001), right ventricular end diastolic diameter index (p < 0.01) and left ventricular ejection fraction (p < 0.05) were significant independent predictors of cardiac events.

[Pulmonary embolism in the coronary care unit]

Massive pulmonary embolism (MPE), as seen in cardiac care units (CCU), is almost invariably characterized by severe obstruction of the pulmonary vasculature and/or a background of poor cardiorespiratory conditions, all contributing their share to a grave overall situation, often compounded by cardiogenic shock and not exceptionally eventuating in cardiocirculatory arrest (CCA). In such circumstances, echocardiography offers both direct and indirect diagnostic elements that may help, among other things, differentiate pulmonary embolism from acute myocardial infarction--the latter not always easily identified, also in view of its possible occurrence in association with MPE. Conversely, some problems are still open concerning the meaning and treatment of right-sided intracavitary thrombus formations revealed by echocardiography. Among less familiar hemodynamic aspects we must consider right-sided pulsus alternans and the so-called ventricularization of pulmonary pressure curves--a phenomenon to be viewed with caution because of possible modifications imputable to the recording system. Bedside pulmonary angiography, now generally feasible with standard CCU equipment, may readily diagnose or rule out MPE in situations where an angiography room is not available or momentarily not accessible. Numerous personal anatomoclinical observations bear witness to the role of electromechanical dissociation (EMD) as a cause of CCA in patients with MPE. Such dissociation may prove at least temporarily reversible, especially in cases not featuring bradycardia and showing narrow QRS complexes; the concurrent administration of fibrinolytic agents along with cardiopulmonary resuscitation may prove successful while it does not seem to invite important hemorrhagic complications.

Myocardial perfusion in Friedreich's ataxia: assessment by dipyridamole thallium-201 imaging

In order to assess myocardial perfusion in patients with Friedreich's ataxia, we carried out dipyridamole-thallium imaging in 13 cardiologically asymptomatic patients (aged 16 to 39; mean age 24) with various degrees of left ventricular hypertrophy; all showed electrocardiographic ST and/or T wave abnormalities before scintigraphy. After dosing with dipyridamole-201 thallium, we found: a completely reversible perfusion defect in the apical and a partially reversible defect in the posterolateral wall of the left ventricle in 1 case; a partially reversible perfusion defect in the anterior and posterior walls of the left ventricle in 1 case; and a persistent anterolateral perfusion defect in 1 case. The remaining 10 patients showed no scintigraphic abnormalities. The fact that only 1 of our patients showed a completely reversible perfusion defect, possibly consistent with regional myocardial ischemia, suggests that ischemia does not play a major role in the pathogenesis of the cardiac involvement in Friedreich's ataxia.

[Progression of cardiopathology in Friedreich ataxia: clinico-instrumental study]

Clinical, electrocardiographic and echocardiographic 5-year follow-up was performed in our institution on 61 patients with Friedreich's ataxia. Cardiac failure was evident in 5% of the patients, and was the most common cause of death. Cardiac arrhythmias, most commonly supraventricular in origin, usually occurred together with the onset of cardiac failure and in 1 case resulted in sudden death. ST-T abnormalities were present in 91% of the cases, and were independent from other clinical parameters. On the contrary, pseudonecrotic (5%) and right ventricular hypertrophy pattern were associated with a poor prognosis. Left ventricular hypertrophy was evident at the echocardiogram in 75% of cases and remained unchanged throughout the entire follow-up period. In 1 case left ventricular hypertrophy turned to dilative cardiomyopathy. Autopsy was performed in 2 out of 4 decreased patients and revealed massive interstitial fibrosis with cellular degeneration in the absence of coronary lesions.

[Well's syndrome with eosinophilic vasculitis, coronary aneurysms and myocardial infarction]

This report describes a 40-year-old man suffering from Well's syndrome (recurrent granulomatous dermatitis with eosinophilia) who presented an anterior myocardial infarction complicated by shock and 3rd degree A-V block. The patient died within 12 hours of admission to the hospital. At autopsy, both main coronary arteries showed proximal aneurysms occluded by thrombi. On light microscopy, the aneurysmatic coronary walls were infiltrated by numerous eosinophils, lymphocytes and plasma cells. Similar cellulitis, mainly perivascular, was found in kidneys and anterior mediastinum. Because the patient had been treated with large doses of diclofenac and piroxicam owing to painful arthralgias, the Authors discuss the possible allergic pathogenesis of the vasculitis.

[Acoustic, mechanical and electric alternans in heart tamponade. Clinical case and review of the literature]

The uncommon observation of alternation of the first heart sound in intensity, associated with mechanical and electric alternans is reported in a patient with cardiac tamponade due to large hemorrhagic pericardial effusion. Following pericardiocentesis and removal of 400 millilitres of fluid, all alternation phenomena disappeared. The combination of three alternation phenomena may be a helpful physical diagnostic sign of cardiac tamponade. The possible mechanisms of the "alternans" are discussed. It is suggested that variations in ventricular filling and emptying are the relevant pathogenetic factors.

Cardiac transplantation in Becker muscular dystrophy

A 23-year-old man with X-linked Becker type muscular dystrophy underwent cardiac transplantation because of dilated cardiomyopathy which was complicated by terminal heart failure. Impairment of muscle function was mild and slowly progressive, whereas the cardiac disease was severe and rapidly progressive. All four chambers of the removed heart were grossly dilated; microscopically, the myocardial fibres were hypertrophic and pale; the nuclei exhibited pleomorphism with variability in nuclear size, shape, and depth of staining.

Dilated cardiomyopathy and successful cardiac transplantation in Becker's muscular distrophy. Follow-up after two years

A 23 year-old man with x-linked Becker type muscular distrophy underwent cardiac transplantation because of dilated cardiomyopathy complicated by terminal heart failure. The muscular functional impairment was mild and slowly progressive, whereas the cardiac disease was severe and rapidly progressive. The ventricular cavities of the explanted heart were hugely dilated and the left ventricular wall thickness was moderately increased. Microscopically, a diffuse hypertrophy of the myocardial fibers and a widespread interstitial collagenous fibrosis were present. At a follow-up, two years after treatment, the patient is alive and fairly well; the degree of his muscular disability is substantially unchanged.

Progression of hypertrophic into a dilated left ventricle in Friedreich's ataxia

The authors describe the case of a girl who developed Friedreich's ataxia at, approximately, the age of 7, with evidence of cardiac involvement being detected by electrocardiography and echocardiography at a later date. Cardiac function was moderately impaired and remained unchanged for a number of years, during which a picture of hypertrophic left ventricle seemed to be firmly established. Later still, however, the cardiac situation shifted gradually toward a hypokinetic form of the disease, with a progressive thinning of the interventricular septum and posterior wall of the left ventricle, associated enlargement of the ventricular chambers and increasingly severe hypokinesia leading to repeated episodes of heart failure.

Biventricular function in Friedreich's ataxia: a radionuclide angiographic study

The systolic and diastolic function of both ventricles was assessed by radionuclide angiography in 21 patients with Friedreich's ataxia and hypertrophic cardiomyopathy. The indices of systolic function of the two ventricles and those of diastolic function of the right ventricle were generally normal. But in patients with Friedreich's ataxia the time to peak filling rate divided by the diastolic time of the left ventricle was significantly larger than normal. The increase correlated with the heart rate (r = 0.79) and this suggests an alteration in the timing of ventricle filling that is more evident at high heart rates. Movement of the left ventricle was little impaired; however, in 48% of the patients with Friedreich's ataxia the right ventricle showed evidence of hypokinetic segments. Because there is a tendency for congestive heart failure to develop in patients with Friedreich's ataxia, this hypokinesis of the right ventricle should be monitored at follow up.

[Torsade de pointes caused by tricyclic antidepressive agents. Description of a clinical case]

Tricyclic antidepressant drugs are known to cause often electrocardiographic abnormalities and to induce sometimes cardiac rhythm disturbances. We report a case of a patient on antidepressant therapy (Desipramine Hydrochloride, 50 mg/die, and Dothiepin Hydrochloride, 150 mg/die), without any underlaying heart disease, admitted to our Coronary Care Unit for recurrent syncopal episodes. An ECG on admission showed Sinus Tachycardia with Ectopic Ventricular Beats and recurrent runs of Torsade de Pointes, a distinctive form of Ventricular Tachycardia. Lignocaine i.v. was only transiently effective. Both Isoprenaline and Atropine Sulphate i.v. were uneffective. Ventricular Fibrillation occurred and cardioversion was achieved by a single DC shock. Amiodarone i.v. and electrical overdrive only temporarily suppressed ventricular arrhythmias. Magnesium Sulphate i.v. (bolus + infusion) induced a definitive suppression of Torsades de Pointes. One day later no more arrhythmias were present.

[Use of the subclavian vein for permanent cardiac stimulation]

The experience on 101 cases of permanent cardiac stimulation is reported; in all of them, the access was via the subclavian vein. Punction of the subclavian artery, transient injury of the brachial plexus and pneumothorax, were seen in 4.3 and 3% respectively. Early electrode luxation was observed in 5% of the patients. As late complications there where two cases of destruction of the electrode protecting sheet and one electrode rupture. In spite of the potential risks directly related to the vein puncture, the subclavian puncture offers an excellent alternative for placing definitive pacing electrodes.

Echocardiographic evaluation of verapamil in Friedreich's ataxia

Nine patients with hypertrophic cardiomyopathy associated with Friedreich's ataxia were treated with the calcium antagonist verapamil, which is known to reduce myocardial hypertrophy and improve diastolic function in patients with idiopathic hypertrophic cardiomyopathy. Daily oral doses of 7 mg/kg were given for a mean (SD) of 24 (8) months. M mode echocardiography performed at the start of the study and at the end of follow up showed no significant difference between the treated group and an untreated control group of nine patients. Verapamil produced no changes in left ventricular wall thickness, mass index, left ventricular internal diameter, fractional shortening, peak normalised lengthening rate, peak rate of septal and posterior wall thinning, and time from minimum ventricular cavity dimension to mitral valve opening. Myocardial calcium overload has been suggested as a cause of cardiac disease in Friedreich's ataxia; however, verapamil had no beneficial effect on these patients with established myocardial hypertrophy.

Echocardiographic aspects of pulmonary arterial hypertension in chronic lung disease

An echocardiographic M-mode study has been performed on 58 patients with pulmonary arterial hypertension at rest or on exercise, with chronic lung disease, either obstructive (41 cases of COLD) or restrictive (17 cases of interstitial lung disease, ILD) in nature. The average Ppa was practically the same (i.e. 27.3 +/- 11.7 mmHg and 26.0 +/- 8.0 mmHg respectively) in the two groups of patients, even though the COLD patients were older than the ILD patients (58.7 +/- 9.3 vs 38 +/- 11 years). The echo detection of the pulmonary valve was successful in only 35% of COLD patients and in 86% of ILD patients (p less than 0.01). A multiple regression analysis disclosed a rather weak, but nevertheless statistically significant, correlation (p less than 0.01) between 1) Ppa and the ratio of right ventricular to left ventricular end-diastolic volume, and 2) between right ventricular end-diastolic pressure and septal systolic displacement. The standard error of estimated versus actual Ppa taking into account the ventricular and septal echo variables was as high as +/- 7.63 mmHg, thus preventing a reliable prediction of Ppa in individual cases. An echocardiographic pattern of pansystolic mitral valve prolapse was observed in 29% of ILD patients, but never in cases with COLD.

[Cardiologic aspects of Friedreich type heredoataxia]

The authors performed ambulatory electro-vectorcardiography polycardiography and echocardiography in 18 patients with typical Friedreich's disease, and 6 patients with atypical forms of hereditary spino-cerebellar ataxia classified on e basis of the degree of neurological involvement, without clinical signs of cardiocirculatory failure. The ECG and VCG recording commonly showed appearances suggestive of myocardial "necrosis" and were of little value in the differential diagnosis between typical and atypical forms of Friedreich's ataxia. This limitation also applied to the kinetocardiogramme which was sometimes pathological confirming the echocardiographic diagnosis of symmetric LV hypertrophy and of septal hypokinesia despite normal ECG and VCG. The systolic time intervals and echocardiographic parameters of the interventricular septum were more helpful in the differential diagnosis. Hypertrophic cardiomyopathy, usually symmetric, was observed in about 70 p. 100 of typical and only rarely in atypical forms of Friedreich's disease. The symmetric or asymmetric hypertrophy was associated with reduced left ventricular performance in less than 20 p. 100 of typical Friedreich's disease, systolic anterior motion of the mitral valve and other signs of dynamic left ventricular outflow tract obstruction were not observed in any of these patients. The correlations between the degree of neurological disability and the cardiac abnormalities, were, in general, disappointing compared with other reported series. The cardiac investigation of patients with Friedreich's disease remains valuable from the point of view of recent pathological hypotheses of a metabolic abnormality with eventual therapeutic implications.