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Oropharyngeal dysphagia has an incidence of between 30-47% in patients affected by cerebral stroke outcomes: it is, therefore, necessary to implement an early rehabilitation treatment. The subject of this study is the effect of this treatment on the outcome of a group of patients with dysphagia secondary to stroke. [ABSTRACT FROM AUTHOR]

Lung cancer is one of the leading causes of death in Europe. More and more efforts are being made to research in new diagnostic and stadiative tools for this lethal disease: the transesophageal approach for sampling the mediastinal lymphonodes or masses plays a very important role. Here we describe two cases taken from our daily experience, where the introduction of the echobronchoscope in the esophagus (EUS-B) secured the correct sampling of mediastinal lesions. [ABSTRACT FROM AUTHOR]

Atrial fibrillation is the most common cardiac arrhythmia and the most frequent cause of hospitalization and utilization expense among all heart diseases. Taking into account persistent atrial fibrillation we know that, in order to cardiovert persistent atrial fibrillation, external direct current cardioversion is the method most frequently used to restore sinus rhythm. But external cardioversion has also some limitations: it requires high energy direct current shocks so that patients have to be anaesthetised, which means a dedicated apparatus and place to adequately assist the patients. The oesophageal cardioversion is an alternative method to restore sinus rhythm, which could obviate some of these limitations of external cardioversion. Compared to external cardioversion oesophageal one has lower defibrillation impedance and requires lower energies to restore sinus rhythm, increasing for the same energy level, success rate. Using low energy shocks, a mild sedation is sufficient to make the procedure well tolerated by most of patients. Other 2 important advantages coming from low energy shocks are the safety in patients with pacemaker or implantable cardioverter-defibrillator and the availability of a back up atrial pacing. Oesophageal cardioversion is not indeed a new technique. Looking at literature, studies in animals and in humans have been performed since the 60s, assessing feasibility, effectiveness and safety of such a procedure. The oesophageal-precordial cardioversion is usually performed on an outpatient regimen, resulting in a very cost-effective method to cardiovert patients with persistent atrial fibrillation, which may definitely represent a real alternative technique to external cardioversion.

From June 1987 to April 2000, 167 (74%) of 223 patients suspected of swallowing foreign bodies were treated. Hundred-sixty-three were successfully treated endoscopically. The surgery rate was 2.4%. There was failure to remove a tablespoon, a tooth-brush, a dental prostheses with metallic hook, a knitting-needle. The sharp and pointed foreign bodies were 35 (20.9%). Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract can be very difficult to manage. The Authors report iatrogenic perforation of esophagus-gastric-fundus in a patient with hiatus hernia who ingested a big knitting-needle in order to suicide. They think that it is absolutely necessary to use special endoscopic equipment during the taking out of foreign-body procedure, especially when pointed and sharp-edge shaped bodies are involved and when there is high risk of iatrogenic lesions.

The Authors report a clinical case of a patient endoscopically treated for recurrent oesophageal obstruction by a foreign body. A review of the recent medical literature confirms that immediate endoscopic treatment is the best approach in the oesophageal retention of foreign bodies.

Background: The management of patients with paroxysmal atrial fibrillation (AF) is unsuccessful, because AF recurs in about 50% of patients despite an antiarrhythmic treatment. Usefulness of non-pharmacological strategies is available in a limited subset of patients and it does not present a global solution to the problem. At present, treatment with antiarrhythmic agents is the only available tool in patients with AF recurrence. The aim of this study was to assess the predictive value of the electropharmacological transesophageal (TE) test in the management of patients with paroxysmal AF treated by flecainide., Methods: In 32 patients, ranging in age from 38 to 70 years (mean: 59 +/- 12 years), with documented episodes of paroxysmal AF (mean: 5.6 +/- 3.7 episodes/last year), we performed an electrophysiological transesophageal (TE) test following pharmacological wash-out. An aggressive protocol was used: step A: 10 sec atrial burst at Wenckebach point + 10 bpm, 200 and 250 bpm; step B: 10 sec atrial bursts at 300, 400, 500 and 600 bpm; step C: 8 sec increasing rate burst from 200 to 800 bpm. Induction of sustained AF (> 1 min) was considered the end-point. Patients were treated with flecainide 100 mg bid and a second TE test was performed at the steady-state, with an identical induction protocol and end-point. Based on the response of the second test, patients were divided into responders (R Group: non-inducible AF) and non-responders (NR Group: inducible, sustained AF). Patients were followed-up by periodical controls and contacted by telephone to confirm their clinical status., Results: Sustained AF was induced in 30 patients (94%) at the first TE study. Eight of them dropped-out at the time of the second TE test (6 patients for lack of consent, 1 patient for side-effects and another one for proarrhythmic effects). In the mean follow-up of 15 +/- 6 months, among patients who underwent a second TE test, AF recurrence was documented in 2 out of 14 patients from the R Group and in 7 out of 10 patients from the NR Group (p < 0.01). There were 4 AF episodes in the R Group and 19 in the NR Group (p < 0.001). We did not find significant statistical differences between the two groups in terms of age, sex, body weight, AF episodes/past year, P-wave duration, left atrial dimension, structural heart disease, AF duration at the first TE test and follow-up duration. In five patients from the NR Group with induced AF lasting > 5 min, the percentage of recurrence was 100% and there were 16 AF episodes. Global percentage of patients with recurrence was 37%., Conclusions: Flecainide is effective in reducing the incidence of AF and results are similar to other antiarrhythmic agents generally used. The electropharmacological TE test might be a useful tool to predict the response to an antiarrhythmic treatment.

Transesophageal atrial pacing is a diagnostic and therapeutic tool in patients with supraventricular reciprocating tachycardia (SVRT). The aim of the present study was to evaluate the effectiveness of transesophageal atrial pacing in the selection of the chronic treatment of SVRT. Between June 1993 and March 1995 we have performed transesophageal atrial pacing in 44 patients affected by atrioventricular nodal reentry tachycardia (AVNRT: n = 28) or atrioventricular reentrant tachycardia (AVRT) using a concealed or manifest bypass tract (n = 16). After a basal (free drug state) transesophageal atrial pacing, we performed serial electropharmacological tests during chronic treatment with sotalol (160 mg/die), flecainide (200 mg/die) and propafenone (450 mg/die). At the end of these tests, the patients were finally discharged with the drug that allowed a more difficult induction or a wider cycle length, and that showed a better clinical tolerance. At the end of the electropharmacological tests 53.6% of the patients affected by AVNRT were discharged with sotalol, 17.8% with propafenone and 28.6% with flecainide. The follow-up of these 28 patients is 11.4 +/- 1.7 months. In the 79.2% of the patients the drug is still effective (absence of whatever episode of SVRT in the follow-up period). In the AVRT group, at the end of the electropharmacological tests, 25% of the patients were discharged with sotalol, 6.25% with propafenone, and 68.75% with flecainide. The follow-up of these 16 patients is 11.7 +/- 1.8 months. In the 78.6% of the patients the drug is still effective (absence of episode of SVRT in the follow-up period).

Transesophageal atrial pacing is effective in the interruption of atrial flutter, and being simple and minimally invasive, is easily performed even on outpatients. The influence of antiarrhythmic drugs on this procedure is controversial. We investigated whether the administration of oral propafenone may facilitate the procedure. Thirty patients with type I atrial flutter were randomized into two groups in which transesophageal pacing was attempted, respectively, without treatment (Group A) and after oral administration of propafenone 600 mg (Group B). Transesophageal pacing was effective in interrupting atrial flutter in 53% (8/15) of patients in Group A and in 85% (13/15) of patients in Group B. A significant lengthening of the flutter cycle was observed in patients treated with propafenone (261 +/- 23 vs 217 +/- 25 ms, p < 0.01). Sinus rhythm resumed at a shorter paced cycle in patients of Group A (166 +/- 13 vs 187 +/- 14 ms, p < 0.01). The transesophageal threshold for stable atrial capture was significantly lower in Group A (20.5 +/- 0.2 vs 23.3 +/- 1.2 mA, p < 0.01). In no patient the threshold for atrial capture was higher than the pain threshold. We did not observe abrupt enhancement of atrioventricular conduction. We can conclude that propafenone is effective and safe when used with transesophageal pacing in the termination of atrial flutter. The depressing effect of the drug on intraatrial conduction and the possible stabilizing effect on the reentry circuit appear to be outweighed by the positive effect of propafenone on the excitable gap of the circuit, facilitating its capture and account for the beneficial effect of the drug on arrhythmia termination.

Background: Over the last two decades several new surgical methods for repairing a regurgitant mitral valve have been proposed. Unfortunately, early applications of such techniques were not always encouraging because the evaluation in the operating room led to false optimism due to a marked difference between static and functional anatomy of the repaired valve. By means of intraoperative echocardiography, be it transesophageal or epicardial, it is now possible to assess the functional result immediately after valvuloplasty and to decide about further surgery, right at the operating table., Materials and Methods: Thirty-six patients (mean age 61.8 years) who underwent mitral valve repair were studied; all underwent preoperative transthoracic echocardiography in the week preceding surgery, and intraoperative transesophageal echo before cardiopulmonary bypass. The surgical results were evaluated by epicardial and/or transesophageal echocardiography in the operating room, and by transthoracic and/or transesophageal approach during follow-up., Results: In 5 patients with intraoperative echocardiography done before valve repair, leaflets pathology and subvalvular apparatus were better evaluated. Besides, in 3 patients the more evident calcification of the leaflets led the surgeon to decide on direct replacement rather the reconstruction of the valve. The postoperative assessment has shown an unsatisfactory correction in 8 patients (24%). In 4 of these patients an important mitral regurgitation was reported and in 2 there was a moderate regurgitation. In the last 2, a iatrogenic stenosis had resulted. Of these 8 patients, 6 underwent valve replacement using an artificial valve. The other 2 patients (one with moderate stenosis and the other with moderate regurgitation) did not undergo a second operation because of the excessive operating time taken for valvuloplasty and the advanced age of the patients. During follow-up, from 6 to 54 months, a remarkable mitral regurgitation was present in 4 patients, one being severe and the other moderate. A persistence of ventricular dilatation was present only in these patients, while in the remainder the left ventricular diameters were normal. Finally, the mitral valve area after six months was between 1.5 an d4 cm2., Conclusions: Intraoperative echocardiography, both transesophageal and epicardial, can help the surgeon by giving him useful diagnostic information, if carried out before reconstructing the mitral valve with regurgitation. Its application is even more useful if applied straight after the surgical intervention. Unsatisfactory results may be evidenced at once and the operating team will decide right at the table for further repair or replacement, thus avoiding a second operation and the relevant risks.

Introduction: The aim of the study was the evaluation of the usefulness of transesophageal atrial pacing in predicting chronic oral treatment efficacy of symptomatic reciprocating supraventricular tachycardia in infants and in avoiding the risk of very dangerous recurrences at home., Methods: We studied 13 infants (11 males, 2 females, mean age 43 +/- 31 days) with symptomatic reciprocating supraventricular tachycardia and no structural heart disease. All patients had chronic oral therapy, using the drug effective in acute i.v. somministration. Each patient was discharged when supraventricular tachycardia was not inducible with transesophageal atrial pacing after 5 half-lives of the drug used in chronic oral treatment. All patients, every 6 months, were retested with transesophageal atrial pacing alternatively during chronic oral therapy and after complete wash out. Oral therapy was stopped in each patient when supraventricular tachycardia was not inducible after the wash out., Results: The number of oral treatments tested for each patient were 2 +/- 1 (range 1-5). The number of transesophageal studies performed for each patient were 4 +/- 2 (range 3-7). No patient had symptomatic episodes of supraventricular tachycardia or needed to change therapy during the follow-up. The oral treatment was stopped after the twelfth month of life in 8 patients and after the twenty-fourth in 2 others without recurrences., Conclusion: Transesophageal atrial pacing seems to be useful in predicting accurately and rapidly the oral treatment efficacy of supraventricular tachycardia in infants. Our protocol seems to be effective to avoid dangerous recurrences of tachycardia and to decide when we can stop therapy without risk.

The presence of gastroesophageal reflux (GER) was studied, by computerized 24 hours intraesophageal pH monitoring, in 27 asthmatic children (16 M - 11 F; mean age 75.04 months) without allergy and in absence of medical treatment for at least ten days. Patient were divided in 3 groups: Group A (11 cases): subjects with Reflux Index (R.I. = percentage of time pH < 4) more than 4.2% and with GER percentage of time in standing position > supine position (p < 0.001). Group B (6 cases): subjects with R.I. more than 4.2% and with GER percentage of time in standing position < supine position (p = 0.05). Group C (10 cases): subjects with R.I. less than 4.2%. A group D (10 cases): normal children considered as control. The group A ("daily refluxes") resulted as the most numerous, in contrast to the studies up to now followed. The total number of refluxes resulted with no significant difference in groups A, B and C, but a significant prevalence of this number was noted in the group C against group D. Therefore, the parameter "Total number of refluxes in 24 hours" characterizes in our opinion, on the pH monitoring, children with bronchial asthma and without allergy.

Cor triatriatum (CT) is a rare malformation consisting of a fibromuscolar membrane that subdivides the left atrium in a postero-superior (or accessory) chamber and an antero-inferior chamber (true left atrium, containing the left atrial appendage). In its classic form, the accessory chamber receives the pulmonary veins and communication with the left atrium is accomplished by way of one or more fenestrations in the membrane. The malformation is usually isolated, but in about one in four patients is associated with other congenital defects of a complex nature. We describe a case of CT associated with atrial septal defect, in which transthoracic echocardiography failed to document the existence of CT membrane, while this abnormality was clearly seen and defined by use of transesophageal echocardiography. The patient was a 26 year-old girl, presented at our outpatient clinic after an episode of palpitations and dyspnea, which lasted for two hours. She suffered of mild dyspnea on exertion during the last three months. Physical examination revealed the typical findings of an atrial septal defect (ASD), and the electrocardiogram revealed right bundle branch block. The two-dimensional echocardiography disclosed an ostium secundum ASD with left to right shunt; dilatation of the right cavities; paradoxical movement of the interventricular septum. A small linear echo originating from the lateral wall of the left atrium, with no evidence of turbulent flow on pulsed wave Doppler and color flow examination, was interpreted as an artifact. Transesophageal echocardiography clearly visualized a tense, bulging membrane separating left atrium into two chambers.(ABSTRACT TRUNCATED AT 250 WORDS)

In patients with depressed left ventricular function, the normal precautions during transesophageal atrial pacing may not be sufficient to prevent life threatening arrhythmias. In this article two cases of ventricular fibrillation induced during this technique, aimed at treating atrial flutter, are described.

The aim of this study was to detect by dopamine echocardiography dysfunctioning but viable myocardial segments. We have studied 19 patients with 3-vessel disease and chronic, stable angina pectoris. Patients were studied by intraoperative transesophageal echocardiography during coronary artery bypass surgery. The analysis of regional systolic function was performed utilizing the transgastric short-axis view at papillary muscle level and dividing the left ventricle in 8 segments, according to the recommendations of the American Society of Echocardiography. A total of 152 myocardial segments were analyzed. Percent systolic wall thickening was calculated in each segment at baseline (early after pericardiectomy), during dopamine infusion (5 mcg/kg/min) and 30 min after separation from cardiopulmonary bypass (after protamine administration). The administration of vasodilatory or inotropic drugs was avoided. The echocardiographic images were recorded on videotape and analyzed off-line by 2 independent observers. Segments showing at baseline percent systolic wall thickening < 30% were considered dysfunctional (134/152 = 88%). Eighty-four (63%) of these segments, increasing during dopamine infusion percent systolic wall thickening > 10% (from 12.9 +/- 3.5 to 20.7 +/- 5.4%; p < 0.05) were considered responder. On the other hand, 50 segments (37%) showing during dopamine an increment in percent systolic wall thickening < 10%, were considered non-responder. After coronary surgery, responder segments showed a significant increase in percent systolic wall thickening in comparison with baseline values (from 12.9 +/- 3.5 to 22.1 +/- 4.3%; p < 0.05). Segments non-responding to dopamine showed no significant changes in percent systolic wall thickening after myocardial revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors examined a series of 231 patients suffering from unoperable neoplastic dysphagia of the esophagus and treated using prevalently palliative endoscopic methods (photocoagulation and/or intubation) during the period 1980-1991. They draw the following conclusions: a) endoscopic methods are better than surgical techniques; b) there are a greater number of indications for endoscopic intubation than for photocoagulation (approximately 2 to 1); c) some situation which are indicated for photocoagulation are not contraindicated for intubation; d) the sole contraindication for intubation is stenosis in which the proximal limit is less than 2 cm from the upper esophageal sphincter; e) contraindications for photocoagulation are long stenoses and/or those of the infiltrating type, and/or involving the upper third of the esophagus; f) sometimes the two methods may be complementary in the sense that intubation may be preceded by a few photocoagulation sessions in order to necrotize the vegetating portion of an infiltrating tumour; g) it is best to choose intubation wherever possible since this technique is less expensive and the quality of remaining life better, even if the percentage of severe and generally fatal complications (perforation) is still too high; h) the possible introduction of expandable metal prostheses might increase indications for intubation and reduce the number of severe complication.

Objectives: The aim of this study was to evaluate the usefulness of transesophageal echocardiography (TEE) for the diagnosis of arrhythmogenic right ventricle cardiomyopathy (ARVC)., Patients: Using TEE and the standard transthoracic echocardiography (TTE), we studied 19 patients affected with hyperkinetic ventricular arrhythmias with a LBBB pattern, as well as 10 normal control subjects (C)., Methods: We calculated the following parameters: the fractional area change (FAC) of the end-diastolic right ventricule (RV) area; the global wall motion score (WMS) by the algebraic sum of the score of each of the 9 wall segments including the inflow, outflow and apex of RV; the asynergy index (AI) by the percentage of the 9 segments with a score > or = 2; the average thickness of moderator band and papillar muscles (ATMP); the echo reflectivity score (ERS) and the structural abnormalities score (SAS) of RV. The diagnosis of ARVC was proposed when RV segmental wall motion abnormalities were visualized, or when a decrease of the ventricular FAC and dysmorphic aspects were contemporaneously present. The results of the two echocardiographic approaches were compared, and in arrhythmic patients (A) echocardiographic results were compared with those obtained by cineventriculography (CVG), which we had adopted as the reference diagnostic method., Results: The comparison between A and C showed significant differences for all parameters if calculated by the TEE (p < 0.003-0.0001), except for ATMP if calculated by TTE (p < 0.003-0.0001). The comparison between TEE and TTE approaches did not show any difference in the C group while in the A group only FAC and ERS resulted similar; the values of the remaining parameters were significantly greater if calculated by TEE than by TTE (WMS = 7.3 +/- 4.1 vs 4.3 +/- 2.3: p < 0.01; AI = 22.6 +/- 18.5 vs 11.6 +/- 10.3: p < 0.05; ATMP = 6.1 +/- 0.9 vs 5 +/- 1.2 mm: p < 0.04; SAS = 2.2 +/- 0.8 vs 1.4 +/- 0.7: p < 0.002). In 17 of the 19 patients who were clinically suspected to be affected with ARVC the diagnosis was confirmed by CVG; 12 of them (70%) were correctly identified by TTE and 17 (100%) by TEE. One of the two negative patients was erroneously considered positive both by TTE and TEE., Conclusions: TEE is a usefull diagnostic tool for ARVC and is more accurate than TTE for the identification of the concealed or dubitative forms of the disease.

We describe a case of a man with acute myocardial infarction of the inferior wall complicated by cardiogenic shock due to acute mitral regurgitation. Transesophageal echocardiography showed the rupture of the posteromedial papillary muscle. The examination (otherwise difficult) was facilitated by the mechanical ventilation by means of an endotracheal intubation.

Background: P-wave signal averaged ECG has recently been proposed in the evaluation of patients with Paroxysmal Atrial Fibrillation (PAF). The aim of this study was to verify the utility of this method in the characterisation of these patients utilizing a transoesophageal signal., Methods: The study population consisted of two groups of subjects: Group A, 34 consecutive patients (16 males; 57 +/- 9 yrs) with a documented PAF and without any underlying heart disease, and Group B, normal controls (9 males; 44 +/- 6 yrs). A signal-averaged ECG, triggered with the oesophageal P-wave, obtained from an X, Y, Z lead system was recorded in each patient, utilizing the AEROTEL HIPEC 200 system. The three orthogonal averaged ECGs were band-pass filtered (non-recursive filter, 40-250 Hz) and combined into a spatial vector magnitudo. We evaluated the filtered P-wave duration (Ad, msec) and the Root Mean Square (RMS) voltages of the last 10, 20, and 30 msec of the P vector magnitudo (RMS 10, 20, 30; mcV)., Results: The patients with PAF presented with a significantly longer Ad duration (A 126.6 +/- 12.4 vs B 96.8 +/- 12.5 msec, < 0.001), and lower amplitudes of RMS 10, 20, 30 (RMS 10 A 4.8 +/- vs B 9 +/- 2.7 p < 0.005; RMS 20 A 6.9 +/- 2.3 vs B 15.7 +/- 7.3 p < 0.005; RMS30 A 12.1 +/- 5.1 vs B 25.3 +/- 11.5 p < 0.005). An Ad > or = 100 msec, a value of RMS 10 < or = 6.5, RMS 20 < or = 9 and RMS 30 < or = 12.5 mcV showed high values of sensitivity, specificity and positive predictive value (Ad 85%, 100%, 100%, RMS10 93%, 80%, 90%, RMS20 84%, 90%, 96%, RMS30 72%, 90%, 72%). The combined duration/voltage criteria (Ad +/- 110 msec and RMS10 < or = 6.5 mcV or RMS20 < or = 9 mcV) showed a sensitivity of 80% and 76% with a specificity and positive predictive value of 100%., Conclusions: The P-wave triggered transoesophageal atrial signal averaged ECG appears able to identify patients with PAF; however, prospective studies must investigate the possible clinical use of these findings.

Pulmonary venous flow (PVF) pattern can be easily recorded by using transesophageal Doppler echocardiography. Recent reports suggest that the analysis of PVF pattern could be useful to better understand the role of atrial contraction on left ventricular filling. In order to evaluate the effect of loss of atrial contraction, we studied 50 consecutive patients with atrial fibrillation. We then compared the PVF pattern of atrial fibrillation with the normal pattern obtained from 20 healthy subjects. The reversal flow (A wave) resulting from atrial contraction was lost in patients with atrial fibrillation. The systolic flow was composed by 1 wave in almost all the patients and the peak velocity was reduced compared to normal sinus rhythm. On the contrary, the diastolic flow was increased comparing to normal subjects. In atrial fibrillation the flow shifted from systolic to diastolic filling. The restore of sinus rhythm induced a normalization of PVF pattern.

Evaluation of mediastinal lymph nodes in patients with lung cancer is fundamental for their treatment and prognosis. Chest computed tomography (CT) is presently the most utilized diagnostic modality. In recent years endoscopic ultrasound (EUS) is being employed for this purpose. We retrospectively compared the results of CT and EUS staging of 35 selected patients with postsurgical stage. A total of 175 lymph node sites were examined. Results CT vs EUS were as follows: specificity 92% vs 98%, sensitivity 88% vs 84%, positive predicted accuracy 80% vs 96%, negative predicted accuracy 95% vs 94%, overall accuracy 92% vs 95%. The region most accessible by EUS evaluation were the paraesophageal lymph nodes; the most difficult were the right superior mediastinal nodes which cannot be imaged for anatomic reasons. EUS not only allows one to arrive at correct diagnosis with less false positive results, but also permits evaluation of lymph nodes which are not enlarged. We think that EUS, in combination with CT, is an appropriate modality for staging of mediastinal lymph nodes in patients with lung cancer.