[Twiddler's syndrome in a patient with implantable cardioverter defibrillator: an avoidable complication?]

The Twiddler's syndrome is an uncommon, but potentially life-threatening complication in patients with an implantable cardioverter-defibrillator. Early identification of repetitive vicious attitudes and a periodic radiological follow-up in predisposed patients, may be useful in the primary prevention of this syndrome.

[Fibrinolytic treatment for patients with prosthesis thrombosis and high surgical risk]

We retrospectively analyzed the response to fibrinolytic treatment in a group of 5 patients with prosthetic thrombosis, one of whom was a pregnant woman. All the patients were in functional class IV (NYHA), and the risk of surgery was considered very high for the following reasons: cardiogenic shock in 2 cases, severe depression of ventricular function in 1 case, and 3 and 4 prior interventions in 2 patients. The treatment was effective in 4 cases and the fifth patient died in cardiogenic shock. There were no major hemorrhagic complications and one case of peripheral embolism was detected. The treatment was effective and no obstetric or fetal complications were observed in the pregnant woman. We believe that fibrinolytic treatment is a good alternative for patients with prosthetic thrombosis and very high surgical risk and it may even be effective during pregnancy.

[Prognostic value of cardiac perfusion scintigraphy associated with the dobutamine test in acute coronary syndromes]

OBJECTIVES

This study aimed to establish the value of myocardial ischemia induced by the dobutamine infusion test associated to 99m technetium isonitrile single photon emission computed tomography in patients with unstable angina or non Q-wave infarction during the first days in the Coronary Care Unit.

METHODS

Fifty three patients with unstable coronary syndromes and common medical treatment were studied with a moderate-dose dobutamine test (5 to 20 microgram/Kg/min) using a 99mTc-MIBI SPECT. The results were correlated with the incidence of recurrent angina, infarction, death or revascularization.

RESULTS

The dobutamine test induced a reversible perfusion defect in 36 patients (68%) and angina in 12 of them (12/36, 33%). However, the patients who had a positive test had a similar incidence of events as those with a negative test (58% vs 59%). Thus, while the sensitivity of the dobutamine test to identify patients at risk was relatively high (68%), its specificity (32%) and its negative predictive value (41%) were low. The patients with dobutamine-induced angina, however, had a higher scintigraphy score (3.0 +/- 1,7 vs 1.6 +/- 1.8, p < 0.02) and a higher incidence of recurrent angina (8/12, 67% vs 13/41, 31%, p < 0.04) than those without, at a comparable double product.

CONCLUSIONS

In conventionally treated patients with unstable coronary syndromes, the specificity of the inducible scintigraphic ischemia with moderate dose of dobutamine performed during the first days is too low to be used as a marker for in-hospital events. However, inducible angina with dobutamine suggests an extensive jeopardized area and/or a particularly reduced ischemic threshold.

[Pericardial effusion in the elderly: A different disease?]

INTRODUCTION AND OBJECTIVES

The aim of the present study was to assess possible differences in etiologic spectrum and clinical course of pericardial effusion in elderly patients, as has been previously suggested, and therefore determine whether clinical, management should be based on patient age.

METHODS

All echocardiograms performed in our hospital from 1990 to 1996 were screened for pericardial effusion, and those with moderate or large effusions were selected. Patients under 66 years of age were included in group I, and those above 65 years were assigned to group II.

RESULTS

We selected 322 patients with moderate (122) or with large (200) effusions. 221 patients being included in group I (aged 15-65, mean 47) and 101 in group II (aged 66-88, mean 72.5). Effusion was large in 60% of group I and in 66% of group II (p = NS), and tamponade occurred in 36% and 38.6%, respectively (p = NS). Specific pericardial infections (tuberculous and purulent pericarditis) were more frequent in group I (5.9 versus 0.9%; p < 0.05). No significant differences were found in incidence of idiopathic (33 vs 38%) or neoplastic (14.4 vs 10.8%) etiologies. During follow-up (96% of the patients, median time of 11 months, range 1-58 months) the mortality (24 vs 30%) and evolution to cardiac constriction (4 vs 2%) were similar in the two groups, but persistence of effusion was more common in group II (6.3 vs 14%; p < 0.05).

CONCLUSIONS

Our study suggests that etiology, clinical course and prognosis of moderate and large pericardial effusion are, in general, similar in elderly and younger patients. Thus, management should be similar in the different age groups, and no etiologic form of pericardial disease should be ruled out because of patient's age when considering the differential diagnosis.

[Diagnostic accuracy of tomographic myocardial imaging for evaluation of aortocoronary graft patency]

INTRODUCTION AND OBJECTIVES

Conventional ergometry has limitations in the evaluation of coronary artery bypass graft patency. The aim of the present study was to determine the efficacy of exercise single photon emission tomography with 99mTc-compounds for the diagnosis of coronary artery bypass grafts disease.

PATIENTS AND METHODS

The state of sixty-seven coronary artery bypass grafts (31 with mammary artery, 36 with safein vein; 35 to left descending anterior artery, 15 to circumflex and 17 to right coronary artery) were analyzed retrospectively in 38 patients (mean age 63+/-8.7; 35 men). The time that elapsed between the coronary surgery and the exercise tomography was 9,7 years. In 16 cases, exercise tomography was performed with 99mTc-MIBI and in the 22 remaining with 99mTc-tetrofosmin. In 6 cases, dipiridamol was administred simultaneously during an insufficient exercise test.

RESULTS

Sensitivity (73.1%), specificity (93%), positive predictive value (86.3%), negative predictive value (84.4%), global value (85%), positive likelihood ratio (10.4) and negative likelihood ratio (0.29) of exercise tomography were significantly (p<0.01) better than those obtained with the exercise test alone (53.8%, 43.6%, 38.9%, 58. 6%, 47.7%, 0.95 and 1.06, respectively).

CONCLUSIONS

Exercise tomography with 99mTc-compounds is a highly effective for the detection of coronary artery bypass grafts disease.

[Patients with acute coronary syndrome: therapeutic approach (management patterns) and 1-year prognosis in a tertiary general hospital]

BACKGROUND

To assess the determinants of short-term and one-year prognosis of all patients with suspected acute coronary syndrome seen by the cardiologist on duty in the Emergency Service of a tertiary hospital during a six month period.

PATIENTS AND METHODS

153 consecutive patients with a diagnosis of acute myocardial infarction, 225 with a diagnosis of unstable angina and 89 with a diagnosis of atypical chest pain were identified and their in-hospital characteristics and one-year prognosis were prospectively assessed.

RESULTS

Age was higher than 65 years in 53% of acute myocardial infarction and in 54% of unstable angina patients. Only 3 patients were lost to follow-up. 35% of acute myocardial infarction patients had died or had reinfarction after one year and 16% of unstable angina patients had died or had suffered acute myocardial infarction. Baseline features, management patterns and prognosis of patients admitted with acute myocardial infarction to the Cardiology Service, to other hospital areas or to other hospitals were markedly different, and admission in areas other than the Cardiology Service was an independent mortality predictor. In unstable angina, complications happened in patients older than 75 years, those with previous revascularization procedures, those undergoing revascularization or those with lesions not deemed revascularizeable.

CONCLUSIONS

a) In the study population there was a predominance of elderly patients; the proportion of patients with poor prognosis was considerably high; b) a sizeable proportion of patients with severe complications was scarcely represented in the major clinical trials; c) the possibility arises of a distribution of care resources tending to concentrate the greater therapeutic efforts in the patients with good prognosis.

[Refractory angina caused by steal phenomenon in internal mammary artery resolved with embolization]

We report a patient with refractory angina in the postoperative period of a coronary artery bypass grafting. Ischemia was due to a large side branch of the left internal mammary artery causing steal phenomenon that was treated with transcatheter coil embolization.

Heart failure after aortic valve replacement for aortic regurgitation: prospective 20-year study

BACKGROUND

The objective of this study was to assess the probability of development of heart failure during a long-term follow-up in patients submitted for aortic valve replacement for aortic regurgitation on the basis of preoperative findings.

METHODS AND RESULTS

Eighty-seven consecutive patients with pure aortic regurgitation and normal coronary arteries were submitted for aortic valve replacement and prospectively followed up. Clinical examination, echocardiography, and radionuclide ejection fraction were performed before surgery and at 1, 2, 5, and 10 years after surgery. Operative mortality rate was 2.2% (2 patients). The follow-up period was 1 to 12 years (mean 6 years). Overall survival rate was 87% at 5 years and 81% at 10 years. During follow-up, 19 patients had heart failure develop, and there were 14 deaths (6 caused by heart failure). Probability of heart failure was 16% at 5 years and 24% at 10 years. Age was the single independent preoperative predictor of both death and heart failure. Age >50 years (relative risk [RR] 10.4), preoperative ejection fraction <40% (RR 10.6), and end-systolic diameter >50 mm (RR 74) were independently related to the postoperative development of heart failure.

CONCLUSIONS

Aortic valve replacement can be performed safely in patients with severe aortic regurgitation by following current recommendations. Age >50, end-systolic diameter >50 mm, and radionuclide ejection fraction <40% were independent preoperative predictors of postoperative heart failure. The only independent predictor of both postoperative death and heart failure was age >50 years.

[Natural history and prognosis in infective endocarditis]

The natural history and prognosis of native valve infective endocarditis, prosthetic endocarditis and right sided endocarditis in drug addicts is analyzed. In native endocarditis mortality during the active phase is 12% and survival at 10 years 81%. Early prosthetic endocarditis has a worse prognosis. In late prosthetic valve endocarditis prognosis depends on the infective organism: mortality is less than 10% in estreptococcal infections and higher than 50% in staphylococcal infections. Right sided endocarditis in intravenous drug addicts has a relatively benign prognosis and seldom requires surgical treatment.

[Quantification of myocardial ischemia in regions dependent on occluded coronary arteries in patients without previous infarction]

INTRODUCTION AND OBJECTIVES

The aim of this study is to assess myocardial ischemia in regions with no infarction dependent occluded coronary arteries.

PATIENTS AND METHODS

149 patients with proved coronary artery disease and without previous myocardial infarction were studied by 99mTc-MIBI SPECT (long protocol) and coronary angiography. The extent of the uptake reversibility was quantified in 3 regions (antero-septal, inferior and lateral) of the polar maps, assessing the percentage of each region that had a > 10% difference resulting from the rest uptake minus the stress uptake. The regions dependent on one occluded artery were compared to those dependent on non-occluded arteries. In the regions dependent on one occluded artery a comparison was also made between those which had a good collateral circulation and those which did not.

RESULTS

Fifty-four out of 149 patients (36%) had at least one occluded coronary artery (20 anterior descending, 22 right and 27 circumflex coronary arteries). In the visual analysis, reversible defects were observed in all patients with occlusion of the anterior descending and the right coronary artery, but only in half of the occlusions of the circumflex coronary artery. The extent of this reversibility was significantly higher in the regions dependent on occluded arteries and was highly variable, though lower when good collateral circulation was present.

CONCLUSIONS

Reversible defects were always observed in the occlusions of the left anterior descending and right coronary arteries, but only in half of those of the circumflex artery. The extent of the ischemia was higher in the regions dependent on one occluded coronary artery, mainly when there was an absence of good collateral circulation.

[Pathology of diseases of extracardiac origin. VI. Disease of the connective tissue and heart]

Connective tissue diseases encompass a wide group of nosologic entities of unknown etiology, characterized by multisystemic organ involvement, sharing an immunologic pathogenetic mechanism, producing a variety of inflammatory manifestations, and whose primary lesion is always a diffuse vasculitis. Any part of the cardiovascular system may be involved, including the pericardium, the myocardium, the endocardium and valves, the coronary arteries, the aorta, the pulmonary vasculature, the peripheral arteries, veins, arterioles, venules, and the capillary beds of almost every organ subsystem. Pathologic studies disclose a high prevalence of heart involvement, but the presence and extent of pathologic findings correlate poorly with clinical manifestations. With the advent of echocardiography-Doppler, milder and earlier cases are now recognized. Although these patients continue under the care of rheumatologists and internists, when cardiac involvement arises, cardiologists must be aware of the characteristics, outcome and management of connective tissue diseases.

[Prognostic value of pre-discharge exertion echocardiography after acute myocardial infarct]

OBJECTIVE

The aim of the present work was to ascertain the usefulness of exercise echocardiography performed prior to discharge following acute non-complicated myocardial infarction in the prognosis and detection of multi-vessel disease.

PATIENTS AND METHODS

Sixty-five consecutive patients with primary episode of acute non-complicated myocardial infarction, with normal or slightly depressed ventricular function, were studied. Submaximal exercise test including echocardiogram pre- and immediately post-exercise were performed 7 to 10 days after infarction. Mean follow-up was 15 +/- 8 months; 15 patients presented angina, 9 revascularization and 1 died.

RESULTS

Electrocardiographic ischaemia had low sensitivity and negative predictive value regarding complications (44% and 73% respectively); however, its specificity and positive predictive values were high (97% and 92%). In contrast, echocardiography-detected ischaemia showed much better sensitivity and negative predictive values (72% and 83%), with a slight decrease in specificity and positive predictive values (87% and 78%). Both remote ischaemia and the increase in global score > 0.25 during exercise were of high prognostic value (p < 0.001). Remote echocardiographic ischaemia yielded the diagnosis of multi-vessel disease with greater sensitivity than electrocardiographic ischaemia (84% vs 41%).

CONCLUSIONS

Exercise echocardiography is highly useful in the prognostic assessment of patients prior to discharge following acute non-complicated myocardial infarction. The ischaemia detected on sub-maximal exercise and assessed by echocardiography was much more sensitive than that detected by electrocardiography in the prediction of new coronary events and multi-vessel disease.

[De-novo reversible stenoses in tortuous arteries during coronary angioplasty due to the accordion effect. A clinical case and review of the literature]

During the performance of PTCA, the operator must be able to differentiate true complications from pseudocomplications. Mechanical coronary shortening and vessel wall invagination due to accordion effect, "pseudo-transection", dissection, coronary spasm, and localized thrombosis are sources of iatrogenic obstruction during angioplasty. We report a case in which straightening of a right tortuous coronary artery during angioplasty produced an iatrogenic lesion that has a typical invaginate appearance. Conservative management is indicated in the absence of definitive angiographic aspect of vessel trauma, because they disappear after withdrawal of angioplasty equipment or adequate management of the guidewire.

[Stress myocardial gammatomography in the diagnosis of multivessel coronary disease]

OBJECTIVE

The aim of the study was to evaluate the diagnostic yield of 99m-Technetium-methoxy-isobutyl-isonitrile (MIBI) SPET for identification of individual coronary artery disease and in the prediction of multivessel involvement.

METHODS

Stress/rest myocardial SPET and coronary arteriography were evaluated in 231 consecutive patients (age 58 +/- 10 years, 26% women) without prior myocardial infarction. 149 patients had coronary narrowing > 50%: 104 with multivessel disease and 45 with one vessel disease. Tomographic stress defect score was obtained by semiquantitative analysis (maximal score 65). Univariate and multivariate analysis was performed to identify discriminant parameters between one vessel and multivessel patients.

RESULTS

The sensitivity and specificity for the identification of individual artery disease was 74% and 85% for left anterior descending artery, 79% and 85% for right coronary and 45% and 96% for circumflex artery. In the prediction of multivessel involvement the sensitivity was 65%, specificity 87%, positive predictive value 81% and negative predictive value 76%. In the bivariate analysis, four parameters differed significantly between one vessel and multivessel disease patients: ST downslope > 1 mm (p = 0.01), ST downslope/heart rate corrected (p = 0.005), reversible defects in two or more regions (p = 0.009) and SPET score (p = 0.002). In the multivariate analysis the probability of multivessel disease was 90% when ST depression > 1 mm and SPET score > 20 were associated and the probability was lowered to 16% when these criteria were not present.

CONCLUSION

Myocardial SPET with MIBI offers an accurate localization of individual coronary artery disease, mainly in left anterior descending artery and right coronary artery lesions. Combined evaluation of ST depression and extension of myocardial stress defects improved prediction of multivessel involvement.

[The use of transesophageal echocardiography in the diagnosis of aortic hematoma after an aortic recoarctation angioplasty]

Transesophageal echocardiography is a very useful technique in studying thoracic aorta diseases, particularly aortic dissection and aortic intramural hematoma. In this report, we describe a case of aortic intramural hematoma after balloon angioplasty of a recoarctation. This case illustrates the importance of transesophageal echocardiography in the diagnosis and subsequent management of possible complications following this technique.

[Assessment of quality of life related to health 2 years after coronary surgery]

BACKGROUND

The determinants of quality of life after coronary artery surgery in well defined health care populations are still incompletely understood. The aim of the present study was to assess the health related quality of life associated with coronary artery bypass surgery as performed in a tertiary public hospital, and also to investigate its association with clinical variables.

PATIENTS AND METHODS

All survivors of a first coronary artery bypass grafting operation performed during a calendar year in a single center (100 patients) were included for assessment two years after surgery. Assessment included a review of the clinical records, a structured clinical interview and the administration of three questionnaires of perceived health (Nottingham Health Profile, Duke Activity Status Index and SF-36 Health Survey).

RESULTS

The mean scores of the administered questionnaires corresponded to a moderate overall impairment of perceived health, with wide individual variations. Chronic stable postoperative angina pectoris (28% of patients), worse clinical functional grade (either due to angina or to others causes), comorbidity (51% of patients) and female sex were significantly associated with worse scores.

CONCLUSIONS

In the study population, postoperative angina, impairment of the clinical functional grade (due to angina or to other conditions), and female gender were the major determinants of impaired health related quality of life after coronary artery bypass surgery. As such determinants are associated with anatomoclinical variables in the population undergoing coronary bypass surgery and also with perioperative variables, appropriate effectively studies appear to be indicated for the assessment of this surgical procedure.

[Neurohormonal factors in heart failure (and III)]

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these system, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. II]

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as "compensators", which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatments for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Neurohormonal factors in heart failure. I]

Heart failure is a physiopathological condition, with an increasing incidence and prevalence, involving the action of a series of mechanisms known as 'compensators', which are phylogenetically ready to normalize minute volume and blood pressure. These mechanisms include the activation of a series of neurohormonal systems: the sympathetic nervous system, the aldosterone renin-angiotensin system, vasopressin arginine, endothelin, which are basically vasoconstrictors, with the counterpoint of other vasodilator systems, such as the endothelial relaxation factor, certain prostaglandins and the bradykinin-kallikrein system, which modulate global response. The authors review the physiopathology of each of these systems, as well as their significance in the diagnosis and prognostic evaluation of heart failure. We analyze the possible deleterious effects of neurohormonal activation, anatomically and at the cardiovascular function level, and try to determine if they are capable of explaining the evolution and progression of heart failure, in a truly vicious circle, up until the irreversible heart failure phase. We review the current importance of the inhibition of the aldosterone renin-angiotensin system in the prophylaxis and treatment of heart failure. Furthermore, we describe the present-day value of the inhibition of the sympathetic nervous system in some forms of heart failure. We also analyze the different pharmacological treatment for heart failure: diuretics, inotropic agents, vasodilators (in their different pharmacological types), paying particular attention to their action on neurohormonal systems and their implications in the prognosis and evolution of heart failure.

[Rupture of type A aortic dissection into right cardiac cavities]

We present three cases of communication between the false channel of an ascending aortic dissection and a right cardiac chamber in three patients that had previously been operated on for aortic valve replacement. In two cases there already was a degree of aortic dissection at the moment of surgery. Diagnosis was confirmed by transesophageal echocardiography and/or aortography. Two patients developed severe cardiac failure and underwent surgery, while the other one is surviving with medical treatment.

Myocardial segment shrinkage during coronary reperfusion in situ. Relation to hypercontracture and myocardial necrosis

We have investigated the changes in myocardial segment length induced by reperfusion, and their relation to myocyte hypercontracture and contraction band necrosis. Regional wall function was monitored by ultrasonic gauges in 39 pigs submitted to 48-min occlusion of the left anterior descending coronary artery (LAD) and 6h of reperfusion. Infarct size (triphenyltetrazolium reaction), the extent of contraction band necrosis (quantitative histology) and myocardial water content (desiccation) were measured. Reperfusion induced a marked reduction in end-diastolic length of the LAD segment in all animals, maximal within 15 min after reflow. After 30 min of reperfusion, end-diastolic length of the LAD segment remained below the basal value in 15 animals. The 15 animals that showed shrinkage of the reperfused segment did not differ from the remaining animals in heart rate, aortic pressure, or control segment variables, but had larger infarcts (mean +/- SEM: 32.1 +/- 5.4 vs 12.1 +/- 3.2% of the area at risk, P = 0.003). There was an inverse correlation between end-diastolic length of the LAD segment after 30 min of reperfusion and infarct percentage (r = -0.72) or the extent of contraction band necrosis (r = -0.71). End-diastolic length reduction was more pronounced in larger infarcts despite a more severe myocardial oedema. Neither systolic shortening of the LAD segment nor end-diastolic length or systolic shortening of the control segment, or haemodynamic variables after 30 min of reperfusion correlated to infarct percentage or to the extent of contraction band necrosis. It is concluded that myocardial segment shrinkage during reperfusion reflects myocyte hypercontracture leading to contraction band necrosis.

Previous aspirin use may attenuate the severity of the manifestation of acute ischemic syndromes

BACKGROUND

The present study was designed to investigate whether the prior use of aspirin could influence the severity of the manifestation of acute coronary artery syndromes, given the well-documented observations that aspirin can prevent myocardial infarction, stroke, and death in cardiovascular disease.

METHODS AND RESULTS

A series of 539 consecutive patients admitted to the Coronary Care Unit of a General Hospital was carefully characterized in a study with an ambidirectional design, with regard to previous medical history, aspirin use, and subsequent hospital diagnosis. Among the 214 patients previously taking aspirin, the hospital diagnosis was myocardial infarction in 24% and unstable angina in 76% compared with 54% and 46%, respectively, among the 325 not taking aspirin (P < .0001), for a reduction in the odds ratio of myocardial infarction with aspirin of 72% (95% CI, 59% to 90%). The decrease in odds was homogeneous in all subsets studied and independent of age, sex, previous angina, or previous myocardial infarction. The myocardial infarction was of a Q-wave type in 62% of aspirin users compared with 76% of nonusers (P < .05). By multivariate analysis, previous aspirin use was a strong predictor of unstable angina versus myocardial infarction and the only independent predictor of non-Q-wave versus Q-wave myocardial infarction.

CONCLUSIONS

This study, thus, suggests a shift to less severe manifestation of acute coronary syndromes with aspirin use, implying that the failure of the drug in many patients with an acute coronary syndrome is only partial and that aspirin has the potential of attenuating the severity of the underlying acute thrombotic disease process.

[Prosthesis-related thrombosis cleared with fibrinolysis. Usefulness of transesophageal echocardiography]

Thrombosis is an infrequent complication in mechanical valve prostheses carrying a vital risk for the patient. The performance of transesophageal echocardiography (TEE) is high in differentiating the thrombosis from other causes of flow obstruction and is fundamental for establishing treatment. Fibrinolysis is an effective alternative treatment to surgery when the latter carries a high risk. In the case herein reported TEE provided a rapid and precise diagnosis and allowed to prove the resolution of the prosthetic thrombosis following fibrinolytic treatment.

[ST segment elevation during exercise test and perfusion scintigraphy in patients without infarction]

BACKGROUND

The features of perfusion scintigraphy in patients who show exercise-induced ST-segment elevation in the absence of previous infarction have been assessed in only a few reports. Therefore, we have evaluated our experience in a wide review of exercise 201-thallium scintigraphies.

METHODS

16,620 exercise 201-thallium scintigraphies, carried out between 1986 and 1993, have been retrospectively reviewed. Fourteen patients (0.8/1000) without previous infarction who were evaluated for chest pain showed ST-segment elevation. In all patients coronary arteriography was also available.

RESULTS

Five patients were free from significant coronary artery stenoses, 6 had one-vessel disease, 2 had two-vessel disease, and the remaining patient had three-vessel disease. In 8 patients ST-segment elevation (up to 3-24 mm) was inferior, in 5 anterior and in 1 lateral. The radionuclide was injected during ST-segment elevation in 10 cases and before such elevation (which developed in the postexercise phase) in 4. In 3 out of these 4, which had angiographically normal coronary arteries, the scintigraphy was negative. In all cases where thallium-201 was injected during ST elevation, severe perfusion defects were detected corresponding to the localization of ST elevation. In the 4 patients with critical coronary stenoses, thallium-201 redistribution after 3 hours was partial.

CONCLUSIONS

In patients without previous infarction and with exercise-induced ST-segment elevation, very severe perfusion defects are detected when the radionuclide has been injected during the crisis. Thallium-201 redistribution after 3 hours was not total in patients with fixed critical stenoses. When radionuclide injection preceded the crisis, the result of the scintigraphy was in agreement with the coronary anatomy.

[Pericardial constriction with predominant involvement of the left heart chambers]

Constrictive pericarditis is a common complication of purulent pericarditis and it can evolve to hemodynamic patterns different from the classical one. We report a patient that after purulent pericarditis, his clinical and hemodynamic features suggest isolated constriction of the left ventricle.

[The long-term efficacy of fibrinolytic treatment in the acute phase of a myocardial infarct. A comparison with a control group]

BACKGROUND

The follow-up of patients with an acute myocardial infarction treated with fibrinolysis and that of patients treated with conventional therapy was analyzed.

PATIENTS AND METHODS

The study cohort included: 1) 214 patients with a first acute infarction of < or = 4 hours and with < or = 70 years of age who participated in a randomized study comparing the effects of streptokinase (SK, n: 110) vs conventional treatment (control, n: 104), and 2) a total of 361 patients with a myocardial infarction of < or = 6 hours and < or = 75 years old treated with fibrinolytic agents.

RESULTS

In-hospital mortality in the randomized study was 11% for the control group and 7% for the SK group, and 8.8% for the rest of patients treated with fibrinolysis. Mortality during follow-up in the randomized study (7.0 +/- 1.5 years) was 10.7% for the SK group and 19.3% for the control group. Ejection fraction was significantly lower in non survivors than in survivors (36.7% vs 50.8%, (p < 0.0001) and among patients with an ejection fraction < 50%, follow-up mortality was significantly lower in those with a complete recanalization (TIMI 3) than in those with an absent or incomplete recanalization (TIMI 0-2) (98% vs 22%). Follow-up mortality for the rest of patients treated with fibrinolysis (2.6 +/- 1.6 years) was 9%.

CONCLUSIONS

1) The reduction of in-hospital mortality by fibrinolysis appears to increase in the long-term follow-up, and 2) the long-term survival seems to be related not only to the left ventricular function but also to the extent of angiographic recanalization.

[The postinfarct prognostic value of right ventricular systolic function]

BACKGROUND

Right ventricular extension of inferior myocardial infarction has been shown to be a predictor of poor prognosis during the acute phase. However, it is not known whether right ventricular dysfunction predicts long term complications. The aim of the present study was to assess whether right ventricular ejection fraction is also a predictor of poor prognosis during the first five follow-up years.

METHODS

Ninety-eight consecutive patients (age < or = 65 years) with acute noncomplicated myocardial infarction (49 anterior and 49 inferior) were evaluated before hospital discharge. In all of them the ejection fraction of both ventricles was evaluated with radionuclide ventriculography at rest and during submaximal exercise. All patients were clinically followed up for at least 5 years. The prognostic relevance of right and left ventricular function for the prediction of all complications and severe complications was assessed using univariate and multivariate analysis.

RESULTS

After 5 years, 66 patients had 94 complications (angina in 44, heart failure in 21, reinfarction in 10, revascularization procedures in 11, death in 6). In the univariate analysis, resting right ventricular ejection fraction was significantly lower in patients with inferior infarction and severe complications at one year (32 +/- 12% vs 38 +/- 6%, p = 0.03). However, in multivariate analysis only resting left ventricular ejection fraction was predictive of complications at 5 years (odds ratio 5.93, 95% confidence interval = 1.32-26.6). Statistical results did not change when the ejection fraction of both ventricles during submaximal exercise was considered.

CONCLUSIONS

Although right ventricular ejection fraction, measured before hospital discharge, is predictive of complications at five years in inferior infarctions, multivariate analysis shows that it does not add prognostic information to the measurement of left ventricular ejection fraction in patients with uncomplicated acute myocardial infarction, either anterior or inferior.

[Acute myocardial infarct and Friedreich's disease]

The association between Friedreich's ataxia and heart disease is well known. Microvascular disease and spasm of coronary arteries have been reported. We report now a patient with the association between this disease and acute myocardial infarction, which raises the hypothesis that it may be related with the already known cardiac abnormalities in this disease.

[Perfusion tomographic scintigraphy and coronary angiography as complementary studies for the therapy decision for patients with ischemic cardiopathy]

BACKGROUND

The aim of the present study was to assess the value of tomographic perfusion scintigraphy as a complement to coronary arteriography in the therapeutic management of patients admitted to the hospital for treatment of unstable ischaemic heart disease.

METHODS

A review was carried out of the discharge report of 100 consecutive patients (mean age 58 years, 19 females) in which there was a mention of having taken a therapeutic decision on the basis of coronary angiography and tomographic perfusion scintigraphy with 99m-technetium isonitriles under exercise and/or dipyridamole. In 90% of instances the study was performed during drug therapy after the patient had remained stable for at least 3 days. The indication of the studies and the type of therapy was made by the attending physician. Concordance between both studies was said to exist when both pointed to the same type of therapeutic approach, either medical treatment (nonsevere stenosis on coronary arteriography with mild ischaemia on scintigraphy) or revascularization (severe stenosis with moderate or severe ischaemia in tomographic scintigraphy). Discordance was said to be present when ischaemia was mild with severe stenosis on coronary angiography.

RESULTS

In 80 patients there was concordance between both studies regarding the subsequent therapeutic approach (medical treatment in 32 and revascularization in 48 [25 coronary angioplasty and 23 bypass surgery]). In the patients with discordance (n:20) medical treatment was decided in 14 patients on the basis of mild ischaemia with significant angiographic stenosis, and in only 6 patients revascularization (angioplasty in 5 and bypass surgery in 1) was indicated, based on the severity of coronary stenosis even if the ischaemia apparent on the scintigraphy was mild.

CONCLUSIONS

Therefore, in 80% of patients admitted for unstable coronary artery disease there was a concordance between the results of tomographic scintigraphy and coronary angiography, when both studies were indicated to select the most appropriate therapeutic modality. In the 20% of discordant cases the attending physician decided on a conservative strategy in most cases, as no significant enough perfusion defect was shown on scintigraphy in spite of severe coronary artery stenosis.

[Extrinsic compression of the pulmonary artery by a mediastinal lymphoma. Diagnosis by Doppler echocardiography]

A patient with an anterior mediastinal tumor and cardiomegaly observed by plain chest roentgenogram is presented. The echocardiographic-Doppler examination showed massive pericardial efussion with hemodynamic compromise, and external compression of the right atrium and pulmonary artery. A pericardiocentesis was performed, and a mediastinoscopy with biopsy was diagnostic of lymphoblastic lymphoma.

[Treatment of hypertrophic obstructive cardiomyopathy with dual chamber pacing. Use of isoproterenol in determining the optimal AV interval]

Dual chamber pacing may be used as an alternative in the treatment of selected patients who are refractory to conventional medical treatment of hypertrophic obstructive cardiomyopathy. When programming the pacemaker it is essential to know the value of the atrio-ventricular interval which is able to cause the greatest reduction in the left ventricle outflow tract pressure gradient. We have used isoproterenol to calculate the parameter mentioned above. This allowed us to know the optimum value, not only in non-active conditions, but also reproducing the changes in the pressure gradient in different physiological situations.

[Coronary thrombosis as the manifestation of the antiphospholipid syndrome]

We present 3 cases of antiphospholipid syndrome with thrombosis in the coronary circulation. Two of them presented an acute myocardial infarction, whereas the third one showed thrombosis in the coronary microcirculation together with aortic valve disease.

[A cost-effectiveness analysis of prognostic studies in acute uncomplicated myocardial infarct]

INTRODUCTION AND OBJECTIVES

The prognostic assessment of the acute myocardial infarction may be obtained through clinical criteria, particularly in patients who are symptomatic during admission, or with several studies in patients without complications. The "effectiveness" of such investigations has been long studied, but not so their "efficiency", which analyses the relationships between costs and outcomes. The goal of the present study is to report the results of a cost-effectiveness analysis of various combinations of diagnostic tests.

METHODS

One hundred and fifteen patients (age < 65) with uncomplicated first acute myocardial infarction were evaluated. In all patients exercise test, two-dimensional echocardiogram thallium-201 scintigraphy, radionuclide ventriculography, Holter monitoring and cardiac catheterization were performed. The effectiveness was calculated as the "global value" (rate of correctly diagnosed patients: complications prediction during the first year follow-up) of every of such tests combinations. We have used the direct differential costs estimated following the "Colegio Oficial de Médicos de Barcelona" standards. The index used in the cost-effectiveness analysis was the medium cost person/global value. The lowest index corresponded to the most efficient test combination.

RESULTS

The highest effectiveness was found for the exercise test plus bidimensional echocardiography combination (global value = 0.64). At the same time it was the less expensive combination (medium cost = 14.444 ptas); therefore, its index was the lowest (21.724 ptas/patient).

CONCLUSIONS

In patients with a first uncomplicated myocardial infarction, the performance of exercise test and echocardiogram is the less costly and most effective combination of studies for one year prognosis. In these patients, routine cardiac catheterization does not improve the results.

[The usefulness of transesophageal echocardiography in assessing mechanical mitral prostheses. A comparison with transthoracic echocardiography]

One hundred and sixty mechanical mitral prostheses were studied by transoesophageal echocardiography to ascertain the role of this technique in their functional assessment. All patients underwent transoesophageal echocardiogram, and, in 83, transthoracic Doppler-echocardiogram had already been performed immediately prior to transoesophageal echocardiogram. Prostheses presenting structural anomaly on bidimensional image and/or areas of regurgitation with predominantly turbulent flow on colour Doppler were considered to be dysfunctional. Of the 160 prostheses, 115 were considered normofunctional, and regurgitation was detected in 85 (94%) by transoesophageal echocardiogram and 10 (9%) by transthoracic echocardiogram; haemodynamic and/or surgical confirmation was obtained in 6 of these prostheses and all proved to be functioning normally. Of the 45 remaining prostheses considered to be dysfunctional, haemodynamic and/or surgical confirmation was obtained in 21 (the non-confirmed 24 were excluded from the study). Seventeen of the dysfunctional prostheses presented with areas of regurgitation of 3.9-24 cm2 (mean: 9.21 + 5.36); in one case, the degree of regurgitation with respect haemodynamic study was over-assessed; transthoracic echocardiogram detected only periprosthetic leaks in 38% of cases, with areas of regurgitation of 1.8-6.3 cm2 (mean: 1.87 + 2.02). The other 4 dysfunctional prostheses presented dysfunction due to thrombosis; all 4 were diagnosed by both transthoracic and transoesophageal echocardiogram. Transoesophageal echocardiogram detected 12 structural anomalies (1 vegetations, 4 thromboses and 7 dehiscencies), whereas transthoracic echocardiogram only detected these anomalies in five of the cases (1 vegetations and 4 thromboses). Transoesophageal echocardiography surpasses transthoracic echocardiography in the assessment of mechanical mitral prostheses and dysfunction diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[An analysis of the responses to the tilt-table test depending on the clinical characteristics of the syncopal episodes in patients without apparent cardiopathy]

Seventy-six consecutive patients were evaluated to assess whether the response to head-up tilt test was related to the type of clinical presentation in patients with syncope of unknown origin and free from heart disease. The syncopal attacks were clinically characterized in a prospective fashion before the tilt test. In 44 patients (group I) syncope had been preceded by autonomic symptoms or was associated with recent or static sustained orthostatism. In 32 patients (group II), syncope had been sudden, without prodromal or autonomic symptoms. Mean age was 49 +/- 17 years in group I patients and 47 +/- 17 years in group II patients (NS). The degree of tilt was 75 degrees. During 30 min no drugs were administered, and then isoproterenol was infused for an additional 20 min (1-5 micrograms/min until a maximal heart rate of 140 bpm was achieved). Tilt test was considered as positive when the patient developed syncope or presyncope with hypotension. Tilt test was positive in 33 patients from group I (75%) and 12 from group II (37.5%)(p = 0.001). The positive response developed within the 30 initial min of the test (without isoproterenol infusion) in 19 of 33 patients from group I (57%) and in 3 of 12 patients from group II (25%) (p = 0.053). It is concluded that the response to tilt test is related to the clinical features of syncopal attacks.

[The diagnosis of ventricular pseudoaneurysms. The complementary role of echocardiography, isotopic ventriculography and contrast ventriculography]

The diagnostic yield of echocardiography, radionuclide ventriculography (first pass and multiple gated) and contrast ventriculography was evaluated in 11 patients in whom a diagnosis of left ventricular pseudoaneurysm had been made during the last ten years. The diagnosis was made by two dimensional echocardiography (associated with Doppler in the last 5 patients) in 8 of 11 patients (sensitivity: 73%). The major limitation of the technique, in addition to the impossibility of an adequate recording due to a suboptimal acoustic window, is the poor definition of the neck of the pseudoaneurysm, particularly in the inferior localization. By contrast, echocardiography is the only technique which permits the direct visualization of thrombi within the pseudoaneurysm. Multiple gated radionuclide ventriculography was diagnostic in 7 of 10 patients (sensitivity: 70%). Its major limitations are the poorer spatial resolution to visualize the pseudoaneurysm neck and the thrombi within the cavity. First pass radionuclide ventriculography was diagnostic in 4 of 6 patients (sensitivity: 67%). In one of them it improved on the diagnostic yield of the multiple gated technique. Contrast ventriculography was diagnostic in 5 of 7 patients (sensitivity: 71%). The diagnosis was missed due to technical problems in one patient and to significant thrombosis within the pseudoaneurysm in another. Thus, none of the imaging studies has optimal sensitivity. Therefore, all play a complementary role in the diagnosis of ventricular pseudoaneurysm.

[The detection of acute myocardial infarct without a Q wave; indium-111-labelled antimyosin antibodies versus technetium-99m-labelled radiophosphates]

In order to ascertain whether antimyosin myocardial imaging is superior to the more conventional cardiac radiophosphate scanning for the diagnosis of non Q wave acute myocardial infarction (AMI), we conducted a comparative study with the contemporary use of both tracers. Forty eight patients admitted to the coronary care unit of our centre because of non Q AMI, were included. Between two and seven days after onset, cardiac scintigraphy was performed both using 99mTc labelled diphosphonic-propane-dicarboxylic acid (99mTc-DPD) and 111indium labelled antimyosin (111In-AAM). In addition to planar imaging, tomoscintigraphy (SPECT) with 99mTc-DPD was obtained in 12 patients. 99mTc-DPD imaging was positive for AMI in 44% of the cases, while 111In-AAM in 52% (NS). In most positive cases (more than 85%) myocardial necrosis was localised in the posterolateral wall. In the subgroup of SPECT imaged patients, the percentage of positive findings was the same as the percentage using planar 111In-AAM imaging (58%). We conclude that the apparent efficacy of antimyosin for the diagnosis of non Q AMI is similar to that of 99mTc-DPD imaging. We feel that owing to its higher cost, such procedure should be saved for those cases were standard 99mTc-DPD imaging fails to detect the infarcted myocardium.

[Intraventricular transient obstruction related to bronchodilator treatment]

A 66-year-old woman with a previous history of chronic lung disease, without evidence of heart disease and without signs of left ventricular hypertrophy developed a dynamic intraventricular obstruction documented by a Doppler-derived gradient of 25 mmHg and by physical signs consisting of a brisk carotid pulse and a harsh systolic murmur while she was on treatment with theophylline and hexoprenaline. Both physical signs and Doppler-derived gradient disappeared after withdrawal of bronchodilator drugs.

[Electrical cardioversion after quinidine administration]

The aim of the present study was to investigate the influence of quinidine on the effectiveness of electrical cardioversion (CV) for the reversion of supraventricular arrhythmias, the amount of electrical energy necessary for the CV and the possible complications of electrical CV. Initially, 100 CV procedures were allocated to the control group (patients free from the action of any antiarrhythmic drug), and 50 CV to the quinidine group. Quinidine was given as dihydroquinidine C1H at a dose of 500 mg/12 hours since the day before CV. In the last group, 6 (12%) patients reverted to normal sinus rhythm before electrical CV. At the time of electrical CV (100 procedures in the control group and 44 in the quinidine group), the patients who received quinidine required a lower amount of electrical energy, and showed a lower incidence of atrial premature beats as compared with the control group (11.3% versus 28%, p less than 0.05). A similar proportion of patients reverted to sinus rhythm in both groups. We conclude that the administration of quinidine before electrical CV has the following advantages: 1) 12% of patients reverted to normal sinus rhythm before electrical CV; 2) quinidine reduced the amount of electrical energy necessary for the CV, and 3) quinidine reduced the incidence of atrial premature beats after electrical CV. On the other hand, quinidine had no influence on the incidence of ventricular arrhythmias after electrical CV.

[Myocardial damage caused by electrical cardioversion]

The possible myocardial injury induced by electrical cardioversion in the treatment of supraventricular arrhythmias was analyzed after 45 countershocks of 200 joules and after 6 of 600 joules (total accumulated energy). In all patients myocardial injury was evaluated by serial CK, CK-Mb, and myoglobin determinations and in 48 cases a cardiac gammagraphy with technetium pyrophosphate was also performed. Significant increases in total CK and myoglobin were observed in 2 (4%) patients treated with 200 joules and in 3 (50%) patients receiving 600 joules. CK-Mb was also increased in one patient receiving 200 joules (13.5 U/I) and in one patient treated with 600 joules (27.8 U/I). In all cases technetium gammagraphy was negative.

[Spontaneous echocardiographic contrast in the left ventricle related to aortic insufficiency]

A case of spontaneous echocardiographic contrast in the left ventricle of a patient with severe aortic insufficiency is presented. This contrast appeared through the mitral valve which opened mainly during tele-diastole. Pulsed Doppler showed the blood flow responsible was laminar and of normal velocity. The mechanism of spontaneous intraventricular contrast cannot be attributed to poor left ventricle function or to high-velocity turbulent flow. We believe that spontaneous contrast was triggered by the decrease in proto-diastolic mitral flow secondary to aortic insufficiency. Transient stagnation of blood in the left atrium might modify the echogenic characteristics of the blood which persist during the passage of the flow through the left ventricle.

[Echocardiographic manifestations in patients with hypereosinophilia]

In order to assess the degree and type of cardiac involvement in patients with sustained hypereosinophilia, we studied by two-dimensional, M-mode echocardiography and Doppler (4 cases) 20 patients distributed into 2 groups. Group I: 10 patients with the idiopathic hypereosinophilic syndrome. Group II: 10 patients with secondary hypereosinophilia. In group I, 6 patients (60%) had echocardiographic abnormalities consistent with the endomyocardial disease: four apical obliteration of right ventricle, three apical obliteration of left ventricle, three endocardial thickening of the left ventricle, three endocardial thickening of the left ventricle posterior wall, one endocardial thickening of the right ventricle free wall, three subvalvular mitral thickening, three subvalvular tricuspid thickening, two pericardial effusion and two protodiastolic septal notch. These corresponded to 2 cases of endomyocardial fibrosis and restriction, as shown by pathological and hemodynamic study. In only 1 patient from group II echocardiographic abnormalities consistent with right apical occupation and tricuspid subvalvular thickening, with mild regurgitation detected by Doppler, were found. It was concluded that echocardiographic abnormalities are common in patients with idiopathic hypereosinophilic syndrome, even in the absence of clinical features. The development of echocardiographic abnormalities in patients with sustained secondary hypereosinophilia is exceptional and is probably related to duration of eosinophilia. Therefore, we think that echo-Doppler is a fundamental investigation for the diagnosis and follow-up of these patients.

[Severe bradycardia and arterial hypotension following the administration of sublingual nitroglycerin]

Two patients with coronary artery disease who developed severe bradycardia (less than 40 beats/min) and hypotension (less than 65/...mmHg) in supine position following the administration of sublingual nitroglycerin in the course of an anginal pain are reported. The administration of intravenous atropine sulfate (1-1.5 mg) readily reverted both hypotension and bradycardia. In one patient this complication was observed three times; in this patient sublingual nifedipine (10 mg) was successfully used to treat subsequent anginal crisis.

[Coronarography using high-flow 5F catheters. Percutaneous technic using the femoral and brachial routes]

In order to validate 5F catheters for assessing ischemic heart disease either by the femoral and the right brachial approaches, we prospectively studied with these catheters 125 patients by means of left ventriculogram and coronary artery angiograms. Twenty-five patients were studied with pigtail and Amplatz catheters using the right brachial approach (group I) and 100 patients were studied by the femoral route with pigtail and Judkins catheters (group II). Results were compared to those obtained in a control group of 100 patients prospectively studied by the femoral route with 8F catheters (group III). The following parameters were analyzed: need to change the initially elected catheter diameter or/and artery approach; technical difficulty for obtaining left ventriculogram, left coronary artery, and right coronary artery angiograms; total time of X-ray exposure; quality image of left ventriculograms; incidence of arterial puncture related hematomas or total arterial occlusion; and duration of local compression after sheath removal. There were no differences between groups I and II except for the arterial compression time (p less than 0.0001), and the X-ray exposure time (p = 0.02); both were longer in patients studied by the brachial approach (group I). Whatever the route used, 5F showed a mild increased difficulty (brachial p = 0.001; femoral p = 0.01), and a mild decreased quality image for left coronary artery (brachial p = 0.006; femoral p less than 0.05). Among patients studied by the femoral route a reduction in mild hematomas (p less than 0.05) and in the arterial compression time (p less than 0.0001) were observed in those studied with 5F catheters.(ABSTRACT TRUNCATED AT 250 WORDS)