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

Early after the beginning of the pacemaker era, endocardial right ventricular apex has been the most extensively used site for cardiac pacing because it was easily accessible and reliable in a long-term perspective. However many data have demonstrated that this kind of pacing is suboptimal from a physiologic point of view because it causes several adverse effects such as altered ventricular contraction geometry, mitral regurgitation, perfusion alterations and interference with myocardial ion channels which determine a worsening of left ventricular function. Several strategies have been proposed to solve these problems (alternative pacing sites, specific algorithms able to reduce the percentage of ventricular pacing) which are still under evaluation. In this review we analyzed the effects of right apical ventricular pacing and its possible alternatives.

Background: Elderly subjects frequently experience a decline in function following hospitalization and surgery. Specific changes in the provision of acute hospital care can improve the ability of acutely ill older patients to perform activities of daily living at the time of discharge and the quality of life. The aim of this study was to investigate outcomes of older (age > or =80 years) cardiac surgery patients managed with multicomponent intervention.

Methods: Between 1998 and 2004, we studied records of 193 octogenarian patients who underwent cardiac surgery and were treated with a multicomponent intervention that included: specially designed environment, patient-centered care, planning for patient discharge at home, and an interdisciplinary approach that incorporates in- and out-of-hospital health professionals.

Results: Mean follow-up was 26.4 months and 100% complete. Mean age of patients was 82.3 +/- 2 years. Eighty-nine patients had myocardial revascularization (CABG), 40 aortic valve replacement (AVR), 34 AVR + CABG, 8 mitral valve replacement (MVR), 11 MVR + CABG and 11 other interventions. Rates of hospital death, major complications and prolonged stay (> 14 days) were as follows: CABG 4 (4.4%), 3 (3.3%), 6 (6.4%); AVR 1 (2.5%), 3 (7.5%), 2 (5%); AVR + CABG 1 (2.9%), 2 (5.8%), 4 (11.7%); MVR 0 (0%), 0 (0%), 1 (12.5%); MVR + CABG 2 (18.1%), 2 (18.1%), 3 (27.2%). Multivariate predictors of hospital deaths were NYHA class, cardiopulmonary bypass and cross-clamping time, urgent procedure and ischemic mitral valve procedures. The actuarial 6-year survival was as follows: CABG 91%,AVR 92.5%, AVR + CABG 88.2%, MVR + CABG 81.8%. Total survival rate, free from rehospitalization and redo surgery, was 89.7, 69.8 and 99% respectively. Multivariate predictors of late death were urgent procedure and ischemic mitral valve procedures. At follow-up NYHA classification had improved a median of two classes. Global patients' satisfaction was excellent in 76.7% of survivors; 95.7% were autonomous, 40.5% live at home, 64% had a light-moderate physical activity, and 70% of patients had good social relationships and quality of life. Medical therapy was reduced in 29.3% and level of anxiety improved in 76%.

Conclusions: An interdisciplinary approach and multicomponent intervention with an appropriate postoperative care, provides beneficial effects on outcome in geriatric cardiac surgery patients.

Isolated left ventricular noncompaction is a genetically heterogeneous congenital disorder characterized by an altered structure of the myocardial wall. This cardiomyopathy is thought to be due to an arrest of intrauterine compaction of the myocardial fibers in the absence of any other structural heart disease. Noncompaction of the left ventricular myocardium is an uncommon finding and remains frequently overlooked even by experienced echocardiographers. However, a correct diagnosis of noncompaction has important implications due to the possible association with other cardiac abnormalities and/or muscle disorders, progressive left ventricular dysfunction, risk of thromboembolism, and life-threatening arrhythmias. Furthermore, because of the familial association described with ventricular noncompaction, screening with echocardiography of first relatives is recommended. Since echocardiography is the diagnostic technique of choice, missed diagnoses may be due to nonoptimal imaging of the lateral and apical myocardium, and/or insufficient disease awareness by echocardiographers. To increase awareness of left ventricular noncompaction, the present paper reviews embryology, genetics, clinical features and pathophysiology, diagnosis, treatment and prognosis of patients affected by isolated left ventricular noncompaction.

The incidence of sudden cardiac death ranges from 0.4 to 1.28 every 1000 inhabitants per year. Sudden cardiac death is responsible for about 10% of all deaths in Italy in 2000. It is unpredictable and is related to malignant ventricular arrhythmias that may be interrupted in more than 70% of cases. Survival rates generally do not exceed 5% in out-of-hospital cardiac arrest, but, as previously reported, early defibrillation may increase survival rate by 3 times. The Italian law of April 3, 2001, and its recent amendments authorized healthcare providers and trained lay rescuers to use automated external defibrillators either for in-hospital or out-of-hospital settings. We planned a program for early defibrillation in ASL 3 in four outpatient clinics where a transit of 300,000 patients was expected in 2004. Defibrillators were placed in wall-mounted boxes. Opening of these boxes enable an automatic calling to the 118 emergency service that is able to dispatch an advanced cardiac life support team to the pertinent outpatient clinic. The system of wall-mounted boxes automatically communicates by modem with a programmable rate, the state of repair and efficiency of the single boxes, in order to simplify the control of the whole system of defibrillators. This plan of Turin ASL 3 is innovative in the metropolitan area and emphasizes the central role of the 118 emergency system in the management of out-of-hospital cardiac arrest, even in hospital settings such as outpatient clinics with a high number of old users at higher risk of cardiac events. This plan with the availability of automatic calling of the 118 emergency service will be proposed to remaining local hospital utilities for their outpatient settings as well as to other public utilities such as general stores, drugstores, airports where a significant transit mat be expected. The plan will include a specific training for the use of automated external defibrillators by first responders.

Background: As a consequence of prolonged life expectancy the number of older patients with symptomatic coronary artery disease is constantly increasing. The aim of the study was to evaluate procedural success, immediate and long-term outcomes and the predictive factors of prognosis in patients aged > 80 years with high-risk coronary artery disease treated with coronary angioplasty.

Methods: In this retrospective study, we report the diagnostic and therapeutic strategies adopted in patients aged > 80 years admitted to our institution for acute coronary syndrome with or without ST-segment elevation or disabling angina (CCS class 3-4) and the immediate and long-term results of patients treated with coronary angioplasty.

Results: A conservative approach was adopted in 180 patients (33%, group 1) out of the total number of 545 patients, while 365 patients (67%, group 2) underwent coronary angiography. Among these, 85% underwent revascularization. Relevant comorbidities were significantly higher in group 1 (59 vs 16%, p < 0.001) while a clinical presentation with ST-elevation myocardial infarction was prevalent in group 2 (15 vs 6%, p = 0.007). The in-hospital mortality was 19% in group 1 and 7.9% in group 2 (p = 0.001). Among 198 patients treated with angioplasty, procedural success was achieved in 93% of cases, with 8% in-hospital mortality. Periprocedural myocardial infarction occurred in 3.3% and major bleeding in 5.6% of patients. At multivariate analysis ST-elevation myocardial infarction and cardiogenic shock were significantly related to the in-hospital mortality. At follow-up (mean 25 +/- 13 months) 13 patients died, 9 from cardiac causes and 4 from noncardiac events. Recurrence of ischemia requiring revascularization occurred in 15.9% of cases. Cumulative survival at follow-up was respectively 86% at 1 year and 83% at 5 years, while the event-free survival at 5 years was 59% in the entire group, without any significant difference among patients with multivessel disease in whom a complete vs an incomplete revascularization was performed. The presence of severe comorbidities appeared to be the only predictive factor of unfavorable outcome at long-term follow-up at multivariate analysis.

Conclusions: In patients aged > 80 years with symptomatic ischemic heart disease at high risk, the invasive approach was prevalent. Higher mortality rates were found in patients in whom coronary angiography was not performed. Comorbidities represent an important negative prognostic factor, impairing both the possibility of an invasive approach and conditioning an unfavorable outcome of revascularized patients. Coronary angioplasty can be successfully performed even in elderly patients. The in-hospital mortality turns out significantly higher in the setting of an acute ST-elevation myocardial infarction or in cardiogenic shock patients. For patients overcoming the acute phas

Myocardial injury during coronary intervention occurs in 10-40% of cases and is often characterized by a slight increase in the markers of myocardial necrosis, without symptoms, electrocardiographic changes or impairment of cardiac function. However, even small increases in creatine kinase (CK)-MB levels are an expression of a true and detectable infarction and may be associated with a higher follow-up mortality. The cause of CK-MB elevation in case of procedural complications is obvious; however, most cases of minor CK-MB elevation occur in patients with uncomplicated procedures with excellent final angiographic results. It has been suggested that the main mechanism explaining the occurrence of myocardial necrosis during otherwise successful coronary intervention may be distal microembolization of plaque components, an enhanced inflammatory state or total plaque burden and/or instability. Different treatments have been proposed to prevent myocardial injury during coronary intervention, including nitrate infusion, intracoronary beta-blockers, adenosine and IIb/IIa inhibitors, but none of these (apart from the use of IIb/IIIa inhibitors) have been routinely introduced into clinical practice. Previous observational studies suggested a beneficial effect of pre-treatment with statins in this setting; the ARMYDA (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) trial is the first prospective, randomized, placebo-controlled study, evaluating the effects of 7-day therapy with 40 mg/day of atorvastatin on post-procedural release of markers of myocardial damage in patients with stable angina undergoing percutaneous intervention. In this study therapy with atorvastatin was associated with an 80% risk reduction in the occurrence of periprocedural myocardial infarction, as well as with a significant reduction in post-intervention peak levels of all markers of myocardial damage. The mechanisms underlying the beneficial effects of atorvastatin may be an inflammatory action reducing myocardial injury necrosis due to microembolization, an improvement in endothelial function on microcirculation, and direct myocardial protection.

Coronary artery calcifications seem to be correlated with a high risk of coronary heart disease. Computed tomography has been shown to be capable of providing accurate, non-invasive measurements of coronary artery calcifications. Coronary calcium is a recognized marker of atherosclerosis. Atherosclerotic burden of coronary arteries correlates strongly with the amount of coronary artery calcifications measured by computed tomography. The presence and extent of breast arterial calcifications detected at mammography has been associated with diabetes and hypertension and it seems to be correlated with the extent of coronary atherosclerosis. This review analyzes the relationship between coronary artery calcifications, breast arterial calcifications and the increased risk of subsequent cardiovascular events.

Background: Strain rate (SR) is considered as an accurate index of myocardial contractility, capable of differentiating regional myocardial contractions from hypokinetic ones. It is not dependent on adjacent myocardial motion or heart translation. Clinical studies proved this method to be useful in case of heart disease but detailed analyses, homogeneous normal reference parameters, and studies about atrial myocardium are still scanty. The aim of this study was to evaluate longitudinal SR of the left myocardial ventricle and atrium in normal subjects.

Methods: Nineteen normal subjects were examined with tissue Doppler imaging; SR values were obtained off-line on images stored by internal software using the curved M-mode of the left ventricle and atrium. Mean SR values were obtained at the distal, mid, and basal left ventricular segments of the septum and lateral wall, and at the basal and distal left atrial segments of the septum and lateral wall.

Results: Ventricular SR values showed a negative systolic peak, two positive peaks at rapid filling and one at late filling. In the distal segments systolic SR values were lower and that of rapid filling were higher. Systolic events showed a progression from the base to the apex; the diastolic ones had an opposite trend. SR values of the closest atrial segments to the annulus showed the same progression as the ventricular ones; in the distal segments systolic SR was positive and diastolic SR was negative. The atrioventricular sequence of the cardiac cycle is identified.

Conclusions: The method to obtain SR is semiautomatic and objective; image acquisition at a frame rate > 100/s identifies accurately the components of the SR curves. The analysis of the progression of events can allow to study ventricular and atrial synchronization of contraction, relaxation, and compliance.

Sinus of Valsalva aneurysms are extremely rare with a predominance in the Asian population. The clinical presentation may be ambiguous, depending on which sinus is affected and on the conditions of the lesion. We report a case of a 33-year-old patient with Down syndrome. Ambulatory transthoracic and transesophageal echocardiography both show a mass located in the right atrium presumed to be of mixomatous nature. Intraoperative transesophageal echocardiography and surgical exploration lead to the diagnosis of sinus of Valsalva aneurysm.