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Two cases are reported with nonpenetrating chest trauma and involvement of mitral valve in one case and aortic valve cusps in the other, without aortic rupture. In both patients transesophageal echocardiography allowed us an accurate diagnosis, confirmed by surgical findings. In the patient with involvement of the aortic cusps, the regurgitation developed 3 months after the trauma. In conclusion, cardiac valve injuries are rare but not exceptional following nonpenetrating blunt chest trauma. Transesophageal echocardiography is the imaging technique of choice for these patients. The operator performing the study must be aware of the possible coexistence of different cardiac lesions secondary to blunt chest trauma. In the case of valvular regurgitation the accurate definition of the pathophysiological mechanism is mandatory in order to choose the appropriate surgical strategy. In the case of aortic incompetence of unknown origin, a nonpenetrating chest trauma must be searched out during the clinical interview.

Systemic hypertension is associated with an increased risk of cerebrovascular and coronary events. The exact role of antihypertensive therapy in reversing or reducing the incremental risk is still a matter of debate. Stroke in hypertension can be large vessel disease (atherothrombotic ischemic stroke), or small vessel disease resulting in lacunar lesions or an intracerebral haemorrhage. In the major trials evaluating the benefits of antihypertensive therapy the entire excess risk of stroke (35 to 45%) can be reversed in 3-5 years. Data on coronary events are less clearcut but the most recent metanalyses including data from trials in elderly patients show that the reduction in coronary events is larger and more significant than in previous metanalyses (approximately 16%). ACE-inhibitors and calcium channel blockers have many potential advantages over diuretics and beta-blockers. Their role is under investigation in ongoing clinical trials.

The analysis of valvular morphology is important in selecting patients with mitral rheumatic stenosis for percutaneous mitral valvuloplasty. Transthoracic echocardiography definitely plays a major role in this characterization whereas the usefulness of transesophageal echocardiography has not been determined yet. We studied 95 patients (82 females, 13 males, mean age 51 +/- 12 years) undergoing mitral valvuloplasty (Inoue's technique). The two methods were compared for: morphologic mitral score; correlation between score and increase in mitral valve area; ability to predict post valvuloplasty mitral regurgitation; accuracy in detecting atrial thrombosis. A significant linear correlation between transthoracic and transesophageal echocardiographic scores was observed (r = 0.78, p0.001). Transesophageal echocardiographic score was significantly lower (6.8 +/- 1.62 versus 7.17 +/- 1.69, p0.05) due to a lower estimation of the extent of calcifications (0.7 +/- 0.97 versus 1 +/- 1.12, p0.05). Correlation coefficients between increase in mitral valve area and scores obtained with the two methods were similar (0.29 and 0.30). For both echocardiographic techniques 6 was the best cut-off score value. None of the clinical, hemodynamic and echocardiographic variables was able to predict the occurrence of severe mitral regurgitation. Five patients with atrial thrombosis were identified by transesophageal echocardiography but only 1 by transthoracic echocardiography. We conclude that the two echocardiographic methods have complementary roles in the evaluation of patients undergoing mitral balloon valvuloplasty. Mitral valve morphologic score can generally be assessed adequately by transthoracic echocardiography but transesophageal echocardiography is mandatory in order to exclude left atrial thrombi. The occurrence of post valvuloplasty severe mitral regurgitation cannot be reasonably predicted on echocardiographic basis.

The restrictive cardiomyopathies are the least common of the 3 major categories of cardiomyopathic disorders seen in Western countries. According to the report of the WHO/ISFC Task Force the term restrictive cardiomyopathy applies to only 2 conditions: endomyocardial fibrosis and Loeffler endocarditis while many specific myocardial diseases can develop a restrictive pathophysiologic profile along their natural history. During the last decade this topic has received 2 main contributions: the identification of a common pathophysiologic ground linking Loeffler endocarditis and endomyocardial fibrosis and the identification of the so-called idiopathic restrictive cardiomyopathy. This condition, defined as a myocardial disease with restrictive physiology, unknown etiology and without histological evidence of infiltrative or storage diseases, appears to be the single most frequent type of restrictive cardiomyopathy in Western countries. A revision of the current classification of cardiomyopathies and particularly of restrictive myocardial disease is necessary.

Available information on atherosclerosis of thoracic aorta in man is scanty and mostly derived from pathological or surgical series. Transesophageal echocardiography makes a clear definition of the entire thoracic aorta possible and enables large, population based studies. In order to define prevalence, risk factors and clinical implications of aortic atherosclerosis, the echocardiographic recordings of 220 patients suitable for both evaluation of thoracic aorta and risk factors analysis were reviewed. Transesophageal echocardiography has been performed because of valvular diseases (78), suspected aortic aneurysm or trauma (43), evaluation of valve prosthesis (39), previous cerebral or peripheral embolic events (22), infective endocarditis (14), cardiac mass lesions (12) or other indications (12). Age ranged from 5 to 81 years (55 +/- 15), male to female ratio was 0.99. Simple and complex atherosclerotic plaques were identified in 33% and 10% respectively. Complex atheromas were more frequent among patients with previous embolic episodes (6/22, 27% versus 17/198, 8.5%; p = 0.019). The prevalence of any type of atherosclerosis progressively increased from the fourth (8%) to the eighth (88%) decade of age. By univariate analysis age (p0.001), history of hypertension (p0.001), systolic (p0.001) and diastolic (p0.05) pressure, type II diabetes mellitus (p0.01), HDL cholesterol (p0.01), HDL/total cholesterol (p0.01) and uricaemia (p0.05) were associated with aortic atherosclerosis. Discriminant analysis identified 5 independent variables associated with the presence and the extent of atherosclerosis (Wilk's Lambda = 0.43): number of cigarettes per day, age, history of hypertension, systolic pressure and type II diabetes mellitus. This model provided a 63% correct classification rate.(ABSTRACT TRUNCATED AT 250 WORDS)

A 43-year-old hypertensive woman with symptoms of aortic dissection was referred to our hospital 3 days after the initial episode. Transesophageal echocardiography and magnetic resonance showed a large intramural hematoma of the ascending and descending aorta without intimal flap and tears. Aortography confirmed the absence of intimal disruption. Medical therapy with beta and alpha blocking agents was established. After 5 months the patient was asymptomatic. On transesophageal echocardiogram and magnetic resonance, complete reabsorption of the hematoma of descending aorta was evident while a clearly identifiable false lumen and intimal flap (without tear) were present at the aortic arch level. The diagnostic criteria and therapeutic options are discussed and the literature on this topic is reviewed.

Congestive heart failure in patients with prosthetic valves is a complex syndrome which poses difficult clinical and therapeutical problems. In order to identify etiologic factors, pathophysiologic substrates, clinical pictures and natural history we retrospectively evaluated 124 consecutive patients (mean age 61 +/- 11 years) with prosthetic valves, hospitalized during the 1984-1990 period because of congestive heart failure. The following main etiologies were identified: acute prosthetic valve failure (19%), chronic prosthetic failure (15%), preexisting left ventricular dysfunction (9%), newly acquired left ventricular dysfunction (8%), associated valve diseases (15%), chronic constrictive pericarditis (2%), multiple causes (31%). At a mean follow-up of 8.9 +/- 4.5 years, mortality was 8.8%/patients/year in the whole group, 3% in the subgroup with chronic prosthetic failure and 19% among the cases with preexisting left ventricular dysfunction. Among the patients who underwent reoperation because of prosthetic failure, the following were incremental risk factors: mechanical (vs biological) failing prosthetic valve, mitral prosthesis, emergency operations, mitral and or aortic insufficiency as the initial diagnosis. The preliminary knowledge of the possible etiologies and of the pathophysiologic substrates can help the physician while treating the single patient with heart failure after valve replacement. Many implications derived from this kind of patients are also useful in order to select surgical candidates among patients with valve disease.

Cardiac abnormalities are frequently reported in patients with acquired immunodeficiency syndrome (AIDS). Much less is known about the true prevalence of cardiac involvement in patients with human immunodeficiency virus (HIV) infection. We prospectively examined 138 consecutive patients with HIV infection including 41 with AIDS, 49 with AIDS-related complex (ARC), 32 with chronic lymphoadenopathy syndrome (LAS) and 16 with asymptomatic HIV infection. Sixty-one patients had opportunistic infection. The prevalence of cardiac involvement progressively increased from patients with HIV infections or LAS (4%) to ARC (14%) to AIDS (37%). "Major" echocardiographic abnormalities (dilated cardiomyopathy and/or infective endocarditis and/or severe pericardial effusion) were identified in 3 patients (2%), "minor" abnormalities (mild pericardial effusion, hypokinesis of the interventricular septum, mild dilatation of the left ventricle in 21 (15%). Electrocardiographic abnormalities unassociated with echo abnormalities or clinical problems were seen in other 11 patients. End diastolic left ventricular dimension (normalized for body surface area) was higher among AIDS respect to pre-AIDS patients (30.1 +/- 7.1 vs 27.6 +/- 7.5; p less than 0.01) and among patients with respect to patients without opportunistic infections (29.5 +/- 6.5 vs 27.5 +/- 2.4; p less than 0.05). Left ventricular shortening fraction was lower in the subgroup with and absolute CD4 lymphocyte count less than 100/mm3 (31 +/- 7 vs 34 +/- 5; p less than 0.055). In conclusion, in a large, unselected group of patients with HIV infection, echocardiogram discloses cardiac abnormalities in 17% of the cases; their clinical relevance is generally low but in selected patients cardiac tamponade and/or dilated cardiomyopathy (secondary to viral myocarditis) may cause death.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to assess left ventricular diastolic function in elite athletes we studied 24 athletes (mean age 21 +/- 5 years) with the echo-Doppler technique. The control group consisted of 14 healthy males (mean age 24 +/- 6 years) and 99 patients (mean age 50 +/- 14 years) with primary or secondary left ventricular hypertrophy. The following variables were calculated: age, systolic and diastolic blood pressure, septal and posterior wall thickness, left ventricular volume and dimensions, myocardial mass index and mass/volume ratio, left ventricular end-systolic and peak systolic stress, RR interval, isovolumic relaxation time (IVRT), early (E) and late (A) peak flow velocity, E/A ratio, time and rate of deceleration of early diastolic flow. Compared with the normal subjects significant differences were observed with regard to systolic blood pressure, left ventricular wall thickness, myocardial mass, mass/volume ratio and peak systolic stress in the athlete group. In spite of a noticeable increase in myocardial mass indexes, all the diastolic function parameters were normal in the athletes. In this group a linear positive correlation between rapid filling indexes, ventricular mass and mass/volume ratio exists. These correlations are not present in the patients group. Moreover a linear negative correlation between RR interval and late diastolic flow velocity was found. In conclusion, the global diastolic ventricular function, evaluated with the echo-Doppler technique, is normal in athletes in spite of an increase in ventricular mass. Th early diastolic flow velocity is in direct proportion with mass increase and may represent one of the physiological mechanisms of the athlete heart adaptations.

Idiopathic restrictive cardiomyopathy is a rare myocardial disease characterized by restrictive physiology without a specific histologic basis. To assess its clinical, hemodynamic, morphologic and prognostic details we retrospectively evaluated all the patients hospitalized in our Institute from 1974 to 1988. Nine patients, aged 42 +/- 16 years, M/F ratio = 0.29, who represent 64% of all the restrictive myocardial diseases biopsied were identified. Severe cardiac heart failure (3-4 NYHA) and arrhythmias (ventricular and supraventricular) were extremely common. The electrocardiogram showed several non specific signs: low voltage of QRS in peripheral leads (4/7), pseudo-infarctional aspects (3/7), mono or biventricular hypertrophy (3/7) disturbance of ventricular conduction (3/7), aspecific abnormalities of ventricular repolarization (3/7). All patients showed a prolonged QTc. M-mode and 2-dimensional echocardiography demonstrated in 6 cases biatrial enlargement, normal or slightly enlarged ventricles, normal or moderately depressed fractional shortening; biventricular concentric hypertrophy was detected in 3 cases, asymmetrical septal hypertrophy in 1. Five patients showed pericardial effusion. Cardiac catheterization disclosed an increase of left and right ventricular end-diastolic pressures (8/8) with a dip-plateau pattern and/or characteristic W waveform in the atrial pressure tracing (9/9). Passive pulmonary hypertension was detected in 6/9 cases. The cardiac index was decreased in 4/8 cases. Left ventricular angiography showed mitral regurgitation in 5/8 patients, tricuspidal in 5/8. Ejection fraction was decreased in 3/8 cases. Endomyocardial biopsy showed interstitial fibrosis (8/9), cellular hypertrophy and/or nuclear alterations (7/9), slight endocardial thickening (2/9). At a mean follow-up of 22 +/- 15 months 3 patients died and 2 underwent heart transplantation. In conclusion idiopathic restrictive cardiomyopathy is one of the most frequent forms of restrictive myocardial diseases in our geographic area. Severe congestive heart failure and arrhythmias are extremely common. The disease can be suspected by clinical, electrocardiographic and echocardiographic features, but the final diagnosis requires cardiac catheterization and endomyocardial biopsy. Prognosis is severe and heart transplantation must be considered in the cases with severe heart failure.