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

It seems reasonable to suppose that there is some relationship between the fanciful descriptions of arterial pulse dating back to ancient times and the more sophisticated data stemming from the technological advances of recent years. The clinical evidence derived from "the flowing blood" has always been associated with diseases of the heart and vessels and indeed of apparently unrelated organs, as well as with emotional states. Centuries before the Christian era, Chinese and Indian doctors seat great store by the study of the pulse which was described in imaginative terms and considered a clue to a person's character and illnesses. This subject was just as important to Greeks and Romans: to mention just one famous name Galeno, who wrote extensively about pulses. Up to the 18th century many European Universities had chairs entitled: "De pulsibus et urines" and from this time onwards sphygmic doctrine gained an ever-growing space in the scientific literature in the attempt to establish diagnostic and prognostic connections (often rather whimsical ones) between different kinds of pulses and so-called "crises of cerebral, thoracic and abdominal organs". Between the mid 18th century and the end of the 19th century the study of pulses was mainly focused on identifying arrhythmias and valvular defects even though we still find descriptions of "alternating" and "paradoxical" pulses accompanied by somewhat ambiguous explanations. From the second half of the 20th century the possibility of measuring the pulse wave velocity and the "augmentation index" has led to remarkable advances in epidemiological studies of cardiovascular diseases. This work would like to draw the readers' attention to the relevance a simple semeiological practice such as the examination of the pulse still has in the clinical approach to a patient even in these modern times.

Background: Cardiac surgery in octogenarians is increasing in industrialized countries and therefore represents a growing population. The aim of this study was to evaluate characteristics and outcomes of octogenarian patients undergoing cardiac surgery.

Methods: We reviewed all consecutive octogenarians operated on during the last 5 years. Among 1912 patients operated on between April 2000 and December 2004, we identified 223 patients (11.6%) aged > 80 years. Median age was 82.17 +/- 2.11 years, and 52.5% were males. The mean EuroSCORE score was 9.4 +/- 1.8. Among them 43 patients (19.3%) had isolated aortic valve replacement, 127 patients (57%) had isolated coronary artery bypass graft, 40 patients (17.9%) had aortic valve replacement combined with coronary artery bypass graft, 11 patients (4.9%) had mitral valve repair, and 2 patients (0.9%) had ventricular septal rupture repair.

Results: The overall hospital mortality was 5.4%; cumulative actuarial survival at 4 years was 77.6%.

Conclusions: We conclude that for unselected octogenarians the operative mortality is acceptable and only slightly increased than in younger age groups; the late survival rate is good.

The tako-tsubo-like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with a high incidence in the Japanese female population, following an emotional stress. The clinical features (typical chest pain), electrocardiographic (negative T wave and persistent ST-segment elevation in anterior leads), echocardiographic (transient left ventricular apical dysfunction with hyperkinesis of basal segments) are suggestive of an acute anterior myocardial infarction; nevertheless all reports in the literature show coronary arteries without angiographic lesions. We report the case of a 77-year-old female (without cardiovascular risk factors) with two prior episodes of paroxysmal atrial fibrillation, who arrived to the emergency department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, not preceded by any emotional stress. Coronary angiography showed coronary arteries without atherosclerotic lesions; left ventriculography showed an anteroapical dysfunction. The follow-up performed with transthoracic echocardiography (2 months later) showed complete regression of regional wall motion abnormalities. The pathophysiological determinant seems to be related to the release of catecholamines (such as epinephrine and norepinephrine) able to create a transient board of ischemic cardiomyopathy through a direct cellular damage.

Background: Atrial fibrillation (AF) is the most common arrhythmia found in mitral valve (MV) disease, occurring in 30 to 85% of patients. Since 1999, AF has been ablated using monopolar epicardial-endocardial radiofrequency. In this study, we describe our own endocardial experience of using the Cardioablate monopolar radiofrequency irrigated pen for the ablation of AF in patients undergoing MV surgery and an analysis of the short and mid-term results.

Methods: From August 2002 to February 2004, a monopolar radiofrequency pen was used to ablate AF in 29 patients undergoing MV replacement or repair (24 females, 82.7%). Preoperative AF was paroxysmal in 27.6% of the patients, persistent in 13.8%, and permanent in 58.6%. The mean left atrial diameter was 65.8 +/- 11.4 mm (range 40-92 mm). In all the patients the ablation lines were created under conditions of extracorporeal circulation and aortic cross-clamping and carried out according to the Alfieri's set. The left atrial appendage was resected or excluded. Endocardial ablation increased the duration of the operation by a mean time of 14.8 +/- 2.7 min with an average time of 7.3 +/- 1.4 min for radiofrequency application.

Results: All patients left the operating room with ginus rhythm (SR) or with atrioventricular pacing. Perioperative AF was common, affecting 51.7% of patients. Six patients required electrical cardioversion. Both early postoperative death (2 patients, 6.8%) and complications were not procedure-related. At discharge, all patients were in SR. The mean follow-up was 14.8 +/- 5.2 months (range 7-25 months). Only 3 patients (11.1%) lost SR within the first 6 months of follow-up but it was recovered in all cases through the use of electrical cardioversion (2 patients) or antiarrhythmic drugs.

Conclusions: The totally endocardial monopolar radiofrequency pen facilitates a quick and safe AF ablation in patients with MV disease. Its only theoric limitation concerns the transmurality of the lesions. Perioperative AF is common and should be treated aggressively. By 6 months postoperatively, 100% of patients are free of AF or atrial flutter with recovery of normal atrial contraction. More patients and longer follow-up are necessary to document the long-term results of this simple procedure.

Background: The national register is a monitoring surveillance system of fatal and non-fatal events in the general population aged 35-74 years; it was launched in Italy at the end of the 1990's with the aim of estimating the occurrence and fatality of coronary events in different geographical areas of the country.

Methods: Two sources of information were used to assess current events: death certificates and hospital discharge diagnosis registers. Once the events were identified through the International Classification for Diseases-ICD9 codes and the duration of the event, the number of current events in each single area was multiplied for the positive predictive value of each specific mortality or discharge code derived from suspected events validated by applying the MONICA Project diagnostic criteria. The attack rate was calculated as the mean value of a 2-year period, dividing the average number of estimated events by the average resident population; case fatality was calculated at 28 days from admission as fatal to total event ratio.

Results: Attack rates are higher in men than in women: mean age-adjusted (Italian population 1998) attack rate of all areas was 33.9 per 10,000 men and 9.1 per 10,000 women; age-adjusted 28-day case fatality was higher in women (35.5%) than in men (27.3%). Statistically significant geographical differences in comparison with the mean attack rate of all areas were found both in men and women. Case fatality rates result significantly heterogeneous when compared among areas in men but not in women.

Conclusions: Results show that there still exist some differences in the geographic distribution of attack rate and fatality of coronary events which seem to be independent of the North-South gradient. These data show the feasibility of implementing a population-based register, essential for cardiovascular disease surveillance.

Up to now the apical right ventricle one is the best pacemaker implantation. As a matter of fact this site is easily reachable by catheter and dislocations are few. Nevertheless evidence from the literature demonstrates dyssynchrony in myocardial contraction pattern, diastolic dysfunction and mismatch in perfusion and innervation. For this reason alternative sites of stimulation have been tested. One of these is represented by the right ventricular outflow tract. Some studies have compared this site to the apical one, showing a better cardiac index in the former; moreover QRS was narrower and fewer perfusional defects have been found. On the contrary, other studies did not show any significant differences between these two sites of stimulation. In order to obtain cardiac resynchronization, biventricular pacing, has been introduced, consisting in the contemporary stimulation of the lateral wall of both ventricles from a cardiac vein, originating from the coronary sinus. It has been proposed a bifocal stimulation, in which we introduce one catheter into the apex and another one in the right ventricular outflow tract: in this case QRS complex is narrower but cardiac output is not increased. A newer pacing technique is represented by direct His bundle stimulation. We can obtain a narrow QRS complex, like the physiological one. So we might solve problems related to intraventricular dyssynchrony.

Background: The aim of this study was to determine the relationship between coronary flow reserve measurement by transthoracic Doppler echocardiography in recent acute myocardial infarction treated with primary coronary angioplasty (PTCA) and recovery of left ventricular function.

Methods: Forty-one consecutive patients (3 patients excluded for not good quality of the Doppler signal) have been studied with: (1) recent first acute myocardial infarction treated with primary PTCA within 6 hours of pain onset; (2) optimal angioplasty result with stent deployment, anti-IIb/IIIa infusion and TIMI 3 flow; (3) lack of type 1 diabetes and/or hypertension; (4) good tolerance to adenosine. Transthoracic Doppler echocardiography was used to record coronary flow velocities in the distal left anterior descending and posterior descending coronary arteries at rest and after infusion of adenosine. Coronary flow reserve was measured after 11 +/- 1 days from the acute event. The wall motion score index (WMSI) was calculated at baseline, 1 month and 3 months from myocardial infarction.

Results: Patients of group A (n = 29 with coronary flow reserve > or = 1.6) showed a progressive and significant recovery of left ventricular function at follow-up. Patients of group B (n = 9 with coronary flow reserve < 1.6) had persistent left ventricular dysfunction at 3 months (ANOVA, p < 0.0001). WMSI was 1.64 +/- 0.26 in group A and 1.81 +/- 0.16 in group B (p = 0.09) at baseline; 1.30 +/- 0.26 in group A and 1.75 +/- 0.16 in group B (p < 0.0001) at 1 month; and 1.20 +/- 0.25 in group A and 1.73 +/- 0.17 in group B at 3 months. There was an inverse correlation between coronary flow reserve and WMSI at 1 month (r = -0.564, p < 0.0001), and at 3 months (r = -0.583, p < 0.0001). On multivariate analysis baseline WMSI and coronary flow reserve were the only predictors of 1-month WMSI recovery and of WMSI recovery at 3 months.

Conclusions: Coronary flow reserve by transthoracic color Doppler echocardiography is a useful method for predicting left ventricular function recovery in patients after primary PTCA.