Italian heart journal : official journal of the Italian Federation of Cardiology最新文献

Background: The aim of this study was to assess the long-term predictive values of supine bicycle exercise stress echocardiography (ESE), and the ESE additional role compared to other traditional clinical and rest echocardiographic variables, in 607 patients with low, intermediate and high pretest risk of cardiac events.

Methods: Clinical status and long-term outcome were assessed for a mean period of 46 months (range 12-60 months). ESE was performed for the diagnosis of suspected coronary artery disease (CAD) in 267 patients (43.9%), and for risk stratification of known CAD in 340 patients (56.1%). At baseline, the mean value of wall motion score index (WMSI) was 1.22 +/- 0.36, and the mean left ventricular ejection fraction was 58.5 +/- 10.9%.

Results: ESE was positive for ischemia in 210 patients (34.9%), while ECG was suggestive for ischemia in 157 patients (25.8%). During the test only 97 patients (15.9%) experienced angina. At peak effort, the mean WMSI was 1.38 +/- 0.46. A low workload was achieved by 158 patients (26.1%). During the follow-up period there were 222 events, including 82 hard events (36.9%), 48 deaths (21.6%) and 34 acute non-fatal myocardial infarction (15.3%). At stepwise multivariate model, cigarette smoking (p < 0.01), peak WMSI (p < 0.001), ESE positive for ischemia (p < 0.001) and low workload (p < 0.01) were the only independent predictors of cardiac death, while positive ESE, peak WMSI, angina during the test and hypercholesterolemia were the only independent determinants of hard cardiac events. The cumulative 5-year mean survival rate according to ESE response was 95.9% in patients with negative ESE, and 83.7% in patients with positive ESE (log rank 13.6; p < 0.00001).

Conclusions: ESE yields prognostic information in known or suspected CAD, especially in patients with intermediate pretest risk level. The combined evaluation of clinical variables and other ESE variables, such as peak WMSI and exercise capacity, may further select patients at greatest risk of cardiac death in the overall population.

Patients with suspected coronary artery disease often undergo coronary angiography without prior non-invasive functional stress testing, mainly because of logistic reasons, shortcomings of the non-invasive tests, and a more widespread confidence in invasive techniques. The availability in the catheterization laboratory of the pressure-derived fractional flow reserve (FFR) has provided the interventional cardiologist with the ideal tool for appropriate decision-making based on the functional significance of the coronary stenosis detected at the angiogram. In fact, FFR allows a more refined and individualized understanding of the true severity of coronary artery disease, and, therefore, a more appropriate selection of the epicardial lesions to be treated, especially in patients with dubious lesions and complex disease. A clinical decision-making based on coronary pressure measurement results in a more effective strategy than placing stents on a "trial and error" basis. This is particularly true in case of drug-eluting stents where an approach based on an indiscriminate multi-stenting will annihilate the benefits of these new stents and be unacceptably expensive. In addition, many angiographically mild stenoses happen to be hemodynamically significant and, therefore, deserve revascularization, especially in the drug-eluting stent era.

Background: Ostial radiofrequency catheter ablation (RFCA) of pulmonary veins (PVs) is a promising invasive approach for the non-pharmacologic treatment of atrial fibrillation, but PV stenosis has been reported as a possible complication of this intervention. The aim of this study was to assess PV anatomy and stenosis (i.e. number and progression) by means of transesophageal echocardiography (TEE) during the follow-up of patients undergoing RFCA.

Methods: Twenty-three consecutive patients with refractory and highly symptomatic atrial fibrillation underwent ostial radiofrequency isolation of arrhythmogenic triggers/foci, localized into the PVs, by an electroanatomic approach (CARTO system) or circular mapping with a multipolar catheter (LASSO) placed under radioscopic guidance. All patients were investigated using TEE and magnetic resonance angiography before radiofrequency application to evaluate PV anatomy. TEE examination was repeated after 2 months of follow-up and, in the presence of a stenosis, 1 year later.

Results: TEE allowed to identify 100% of the left and right superior PVs, 96% of right inferior PVs, and 74% of the left inferior PVs. Anatomic variants were detected at TEE in 33% of patients against 37% at magnetic resonance angiography (95% of concordance). After ostial RFCA, TEE disclosed a significant reduction in the mean diameters of the left superior PV (14.1 +/- 3.2 vs 12.0 +/- 2.7 mm, p < 0.01), left inferior PV (11.2 +/- 2.3 vs 9.8 +/- 2.2 mm, p = 0.05) and right superior PV (14.2 +/- 2.6 vs 12.9 +/- 2.7 mm, p < 0.05), and an increase in the mean peak velocities of the left superior PV (69.8 +/- 14.8 vs 91 +/- 42.4 cm/s, p < 0.05) and left inferior PV (59.2 +/- 18.1 vs 79.3 +/- 40.5 cm/s, p < 0.05). From a total of 88 PVs treated, 7 (7.9%) showed a higher significant stenosis in patients treated using the LASSO than the CARTO system (31.3 vs 2.8% respectively, p < 0.01). After 1-year follow-up there was no progression of PV stenosis.

Conclusions: TEE was successful to evaluate PV anatomy and stenosis of patients undergoing ostial RFCA for atrial fibrillation. This complication is not rare and seems to be strictly related to the method of ablation, in particular when circular mapping and disconnection of triggers/foci was carried out by only a circular multipolar catheter without an electroanatomic approach.

The authors report a very unusual case of non-invasive diagnosis of acute ischemic bowel disease detected as hepatic portal venous gas during intra-aortic balloon percutaneous counterpulsation. A 64-year-old man with acute ST-elevation myocardial infarction complicated by cardiogenic shock was treated with percutaneous angioplasty and intra-aortic balloon percutaneous counterpulsation. The post-procedural period was complicated by severe abdominal pain. Abdominal computed tomography revealed hepatic portal venous gas. Multiple kidney and splenic ischemic areas were also identified. Colonoscopy showed signs referring to acute ischemic colitis. Computed tomography detection of hepatic portal venous gas has permitted the non-invasive diagnosis of bowel necrosis.

Unlabelled: BACKGROUND; Heart failure (HF) represents an important health issue in western countries, especially for the elderly, frail population. A number of HF patients must usually be assisted at home. No information is available about the usual care of HF patients in Italy. The aim of this study was to describe the characteristics of HF patients receiving homecare in the Italian general practice.

Methods: A questionnaire was sent to 320 general practitioners (GPs) involved in the Health Search project. Among these, 148 (46.2%) answered and 376 home-ridden HF patients (60.3% women, median age 85 years) were identified.

Results: 257 (57%) patients were in NYHA class III or IV. Multiple relevant concomitant diseases occurred in 326 (86.7%) subjects. Only 140 (37.2%) patients were able to take their pills without any help; caregivers, mainly family members, were required 24 hours a day in 78.7% of cases. The length of homecare was > 1 year in 84.5% of cases.

Conclusions: According to our data, thousands of HF patients are usually assisted at home for long periods in Italy. This is a very old group of subjects with heavy co-morbidity and a high need for continuous, prolonged assistance. Studies specifically aimed at the care of HF patients are needed.

Background: Catheter ablation of typical atrial flutter (AFL) occurring in patients who take antiarrhythmic drugs for atrial fibrillation (AF) has been proposed as a curative approach for AF. The aim of this study was to evaluate the efficacy of this technique.

Methods: Forty-six consecutive patients (30 males, 16 females, mean age 67 +/- 9 years) with paroxysmal or persistent AF were submitted to right atrial isthmus ablation: 1) 33 patients (group 1) in whom typical AFL spontaneously occurred during oral treatment with propafenone (n = 19), flecainide (n = 9) or amiodarone (n = 6); 2) 13 patients (group 2) submitted to electrophysiological study while taking oral propafenone (n = 3), flecainide (n = 8) or amiodarone (n = 1), in whom sustained AFL was induced (n = 9) or AF was induced and AFL was obtained by intravenous administration of class IC drugs (n = 4). The same antiarrhythmic drug which induced the conversion of AF into AFL was administered after ablation.

Results: During a follow-up of 20 +/- 18 months (range 1-78 months), 23 patients (50%) remained asymptomatic and free from AF recurrences. Fifteen patients (33%) with AF recurrences reported a reduction in arrhythmia-related symptoms. Eight patients (17%) did not show symptomatic improvement. These results did not significantly differ between group 1 and group 2. The duration of follow-up was significantly longer in patients with AF recurrence. Among several clinical, echocardiographic and electrophysiological parameters, only atrial enlargement and the absence of structural heart disease were independently associated with AF recurrence.

Conclusions: In selected patients with AF and drug-induced AFL, right atrial isthmus ablation and prosecution of the drug treatment is a safe and feasible approach, which totally eliminates or reduces symptomatic AF recurrences in one half and one third of patients, respectively. However, the number of AF-free patients tends to decrease over time.

A patient implanted with a cardioverter-defibrillator for symptomatic Brugada syndrome was referred to our hospital 17 months later because of recurrent shocks due to ventricular fibrillation (VF). Isoprenaline was intravenously infused and prevented VF episodes, but VF recurred after every attempt of drug discontinuation. A total of 34 shocks were recorded over 25 days. Subsequently, we treated the patient with oral quinidine and the drug suppressed the electrical storm and prevented VF episodes during a follow-up period of 3 years. This case report, together with few others reported in the literature, suggests a role of oral quinidine in the treatment of electrical storm in Brugada syndrome.

Because of their potent hemodynamic effects, organic nitrates have been introduced in the cardiovascular pharmacopoeia since more than a century in the treatment of coronary artery disease and congestive heart failure. Today, nitroglycerin is the most commonly prescribed generic drug in Italy. While their hemodynamic effects and some of their side effects (e.g. nitrate tolerance, the rebound phenomenon) are at least in part known, little is known regarding other effects of nitrates, for instance their antiaggregant, preconditioning-mimetic, and antiatherosclerotic properties. These effects might have tremendous importance in the treatment of cardiovascular patients. At the same time, the effects of nitrate-derived oxygen free radical species require further investigation. This review provides an update on recent findings in this field.

Infection is a serious complication following pacemaker implantation. Usually it results from normal flora of the skin or from Enterobacteriaceae, Pseudomonas aeruginosa, Streptococcus spp., Enterococcus spp. We report here a case suggesting that Brucella melitensis is able to persist around pacemaker device being a cause of relapsing brucellosis.