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Incessant ventricular tachycardia is an arrhythmia refractory to conventional antiarrhythmic treatment. We describe the case of 55-year-old man who presented incessant ventricular tachycardia in the early post-acute phase of myocardial infarction. Optimal coronary revascularization was not effective, but radiofrequency catheter ablation was able to eliminate the anatomic substrate and clinical arrhythmic recurrence.

Background: Although a large number of studies have investigated the relationship between atrial natriuretic peptide (ANP) concentrations and circulatory abnormalities, it is presently unsettled as to whether this parameter provides valuable information in unselected patients with heart disease of different etiologies regardless of the presence of left ventricular dysfunction or heart failure., Aim of the Study: The aim was to evaluate the correlation between ANP, hemodynamics and parameters of ventricular function in a large series of consecutive patients and to define the predictive value of ANP for the identification of specific circulatory abnormalities., Methods: Cardiac catheterization was performed in 167 consecutive patients (62% males; mean age 62 yrs; range 18-85) and ANP serum levels were determined concomitantly by single antibody immune assay. Underlying etiology was: ischemic (67), valvular (72), idiopathic (12) and miscellaneous (16). Data management included: comparison of patients according to ANP values > or < 50% percentile of the cumulative distribution curve (i.e. 140 pg/ml); analysis of ANP concentrations according to the presence of normal or abnormal ventricular filling pressures; correlation between hemodynamic parameters and ANP concentrations; correlation of ANP with ventricular function in the whole population and in subgroups; calculation of sensitivity and specificity of ANP for the identification of abnormal filling pressures., Results: Mean ANP concentration was 181 +/- 139 pg/ml. Patients with ANP < 140 had significantly lower right-sided pressures but similar ventricular volumes and ejection fractions. By multivariate analysis, the single independent predictor of ANP was wedge pressure (p < 0.0001). Regarding etiology, severe mitral regurgitation was associated with the highest ANP levels (259 +/- 122 pg/ml), although the difference was not significant. The presence of abnormal left and right ventricular filling pressures was associated with significantly higher levels of ANP (p < 0.0001). A level of 125 pg/ml proved to be fairly sensitive (79%) but poorly specific (66%) for the detection of an abnormal wedge pressure. ANP was related to ventricular function only in the small subgroup of patients with dilated cardiomyopathy, where a significant negative correlation was found with both left ventricular (r = -0.72; p = 0.008) and right ventricular ejection fraction (-0.71; p = 0.01)., Conclusions: In unselected cardiac patients, ANP is confirmed to be a marker of left ventricular filling pressure in spite of poor specificity. Ventricular function appears to be related to ANP concentrations only in the subgroup of patients with pure heart-muscle disease.

Background: Right ventricular (RV) function and morphometric quantitation of interstitial fibrosis in idiopathic dilated cardiomyopathy (IDC) have not been the subject of specifically designed clinical observations. In particular, their role in routine assessment and prognostic evaluation of patients (pts) with IDC remains to be settled., Methods: Eighty-one consecutive IDC patients (63 M, 18 F; mean age 52 +/- 11 yrs) with left ventricular (LV) systolic dysfunction (angiographic ejection fraction - EF - < 55%), normal coronary arteries and no histologic evidence of myocarditis were studied. Cardiac catheterization and endomyocardial biopsy (EMB) were routinely performed in all cases. RV volumes and EF were obtained by angiography according to Ferlinz' method and interstitial fibrosis was quantitated by computer-assisted morphometric analysis. These data were analyzed in order to study correlations with hemodynamic parameters and to assess their prognostic value in a long-term follow-up., Results: In the study population, right ventricular EF was significantly lower than in normal controls (35 +/- 11% vs 53 +/- 6%, p < 0.0001) and showed a significant positive correlation with LV EF (r = 0.54; p < 0.0001), and a weak but significant negative correlation with fibrosis (r = -0.29; p = 0.03). RV volumes, but not EF, were significantly related to mean pulmonary pressure. At multivariate analysis, RV end-diastolic volume (EDV) and EF were the two independent predictors of severe heart failure (NYHA class III-IV). After a mean follow-up of 64 +/- 36 months, 20 pts died and 9 had heart transplantation, for a 63% transplant-free survival rate (TFS). Multivariate analysis identified three independent predictors of TFS: LV stroke work index (p < 0.0001), RV stroke work index (p = 0.02) and RV EDV (p = 0.03). Fibrosis was predictive of survival only in the subgroup with LV EF < 20%., Conclusions: Assessment of RV function provides useful information in the evaluation of hemodynamic profile and prognosis of pts with IDC. Quantitation of interstitial fibrosis by morphometry provides little additional data.

As a part of the "Hypertension Management Audit Project" a random sample of 4070 subjects was drawn from the population aged 35-64 living in the city of Vicenza, in order to assess the prevalence and the level of control of hypertension in the community. 2854 (70.1%) were screened in the first step of the survey. Two blood pressure (BP) reading, height and weight measurements were performed and a short questionnaire filled in. Systolic BP (SBP) and diastolic BP (DBP) were (mean and 95% confidence interval) 143.7 (142.6-144.7) and 88.3 (87.7-88.8) mmHg in males; 137.8 (136.8-138.8) and 84.9 (84.5-85.5) mmHg in females, respectively. The BP value corresponding to the 95 degrees percentile of the cumulative distribution of BP was 180 mmHg for SBP and 105 mmHg for DBP in males; 173 mmHg for SBP and 100 mmHg for DBP in females. Systo-diastolic hypertension was present in 12.3% of the screened population; isolated diastolic hypertension in 9.1%; isolated systolic hypertension in 5.3%; borderline hypertension in 31.6%; severe hypertension (DBP > or = 115 mmHg) was present in 1.9% of females and in 2.2% of males. Prevalence in males was significantly higher with respect to females in all three categories of defined hypertension, but not in borderline hypertension. The second step of the survey involved 849 subjects (29.7% of the screened population) who completed two re-examinations because at the screening they had: 1) history of high BP; 2) BP > or = 160/95 mmHg; 3) ongoing antihypertensive treatment. At the end of the survey, 772 of these subjects (91%) were confirmed as hypertensives (mean BP of six readings > or = 140/90 mmHg and/or taking antihypertensive drugs). Patients aware of their high BP were 78.8%; aware and treated 51.0%; treated and controlled (BP < 140/90 mmHg) 19.1%. All indices of control were significantly higher in female with respect to male patients. Treated patients were significantly older than untreated patients; treated females had significantly lower BP than treated males, whereas no difference was detected between untreated patients; patients unaware of high BP had the highest BP values if compared to treated and untreated patients. This survey reveals a high prevalence of hypertension in the adult population of the city of Vicenza; quality of control shows a moderate improvement if compared to previous studies carried out in our country.

The authors report the case of an 84-year-old man with mild aortic valvular disease and arterial hypertension who developed marked QT interval prolongation and several lipotimic and syncopal attacks after 3 months of treatment with ketanserin (40 mg/day). The correlation between ketanserin, QT prolongation and symptoms was assessed by withdrawal and subsequent re-administration of the drug. Continuous ECG monitoring revealed the occurrence of QT prolongation and symptomatic runs of torsade de pointes ventricular tachycardia. The Authors suggest that treatment with ketanserin needs careful patients selection and follow-up.

The Authors report a case of incessant torsade de pointes, associated with QT prolongation, due to the proarrhythmic effect of quinidine, which was successfully treated with i.v. verapamil. The arrhythmia occurred after oral administration of quinidine polygalacturonate (550 mg + 275 mg + 275 mg over a 4-hour period) for the conversion of atrial fibrillation in a 41-year-old woman with mild mitral stenosis and regurgitation. Verapamil was administered as an i.v. bolus (5 mg at a rate of 1 mg/min) and with in four minutes the arrhythmia disappeared. The electrophysiological mechanisms of torsade de pointes and the potential role of Ca+(+)-channel-blocking agents in its treatment are briefly discussed.

Transcatheter direct-current ablation of the atrio-ventricular junction is a recently developed technique in the treatment of medically refractory supraventricular tachycardia. Twenty patients underwent this procedure between July 1987 and May 1989 and were followed-up for a mean period of 8.3 +/- 6 months (range 1-23). Indication for ablation included atrial flutter in 4 patients, atrial fibrillation in 8, atrial tachycardia in 1, atrio-ventricular nodal re-entrant tachycardia in 4, atrioventricular re-entrant tachycardia (concealed pathway) in 2, permanent junctional reciprocating tachycardia in 1. These arrhythmias were resistant to a mean of 3.3 +/- 1.7 antiarrhythmic drugs. A mean of 1.4 +/- 0.59 (range 1-3) electrical shocks, with a mean energy of 285 +/- 135J (range 200-700), were delivered during 1-2 sessions. In all patients a persistent complete atrio-ventricular block was achieved. Immediate complications included transient hypotension in 2 pts, acute pulmonary edema in 1, premature ventricular complexes in 4, non sustained ventricular tachycardia in 4, sustained ventricular tachycardia in 1. Late complications included thrombophlebitis of the right femoral vein in 2 pts; one of them died suddenly as a result of massive pulmonary embolism 10 days after the procedure. Follow-up evaluation reveals chronic complete atrio-ventricular block in all patients. Symptoms related to pre-existing arrhythmia are absent in all pts and none of them is currently taking antiarrhythmic drugs. Two patients with DDD pacing had pacemaker mediated re-entrant tachycardia and 1 patient with VVIR pacing developed a pacemaker syndrome. This experience confirms that transcatheter fulguration of atrio-ventricular junction is an effective technique. However, possible severe complications related to the procedure suggest this approach be restricted to patients with very symptomatic and drug-refractory supraventricular tachyarrhythmias.

28 subjects with atherosclerotic lesions of coronary arteries were studied by means of cineventriculography both before and after IV administration of verapamil Regional wall motion has been analyzed by means of two different methods. Imporvement of regional wall motion has been demonstrated in about 65% of cases. No significant result has been achieved in segments corresponding to previous infarctions. Such a response does not differ substantially from that evoked by nitroglycerin or other calcium antagonist drugs.

The case of a patient with angiosarcoma of the right atrium is described with respect to clinical presentation, hemodynamic and angiographic findings and post-mortem examination. The need of a high index of suspicion when dealing with patients who show evidence of systemic venous congestion is stressed.

We describe the case of a diastolic mitral and tricuspid regurgitation in a patient affected by acute myocardial infarction Ecg showed inferior myocardial infarction complicated by atrioventricular block and a junctional rhythm with frequent premature ventricular beats; the mean heart rate was of about 60 per minute. 2D echocardiogram disclosed akinesia of the apical segments of the inferior septum and anterior and infero-lateral walls. Pulsed and continuous wave Doppler showed mild to moderate mitral and tricuspid systolic regurgitation and diastolic regurgitation through both atrioventricular valves. The diastolic regurgitation always occurred during prolonged diastoles, soon after the blocked P waves. The possible mechanism of this finding and its clinical significance are discussed, drawing the conclusion that the atrioventricular diastolic regurgitation is not diagnostic of a specific valvular disease but can be secondary to other conditions, especially the atrioventricular block.

The intravenous dipyridamole test is considered a safe procedure with a very low incidence of severe cardiac effects and is routinely used in the diagnosis and prognosis of coronary artery disease. We report the case of a 63-year-old female with negative exercise stress test who developed prolonged and extensive myocardial ischemia after the high-dose intravenous dipyridamole echocardiography test. Aminophylline and nitroglycerin were employed but were ineffective and the patient was successfully treated with systemic thrombolysis. At coronary angiography, 48 hours later, a 50% stenosis in the proximal LAD was documented. We stress that high-dose intravenous dipyridamole can induce a severe ischemic response whose occurrence is unpredictable according to the pre-test clinical features.

We describe the case of a patient with massive pulmonary embolism, in which two-dimensional echocardiography demonstrated the presence of a free-floating mass in the right atrial cavity. The patient was urgently and successfully operated on. We describe the echocardiographic findings and emphasize the value of two dimensional echocardiography in detecting right-sided intracavitary thromboemboli, a condition in which immediate surgical treatment is mandatory.

We describe the cases of two neonates affected by the syndrome of pulmonary valve agenesis, in whom non-invasive diagnosis was possible by two dimensional echocardiography. The echocardiographic features we describe are the following: enlargement of the right ventricle in association with ventricular septal defect, malalignment type, dilatation of the right ventricular outflow tract, massive dilation of the main and branch pulmonary arteries, annular pulmonary stenosis. At the expected site of the pulmonary valve two ridges were seen, which did not have the typical motion of a fully developed valve. The ventricular septal motion was paradoxical in both cases. The diagnosis was confirmed at cardiac catheterization and the two neonates underwent operation unsuccessfully. The anatomic post-mortem examination confirmed the echocardiographic and angiographic findings. As successful treatment of this syndrome is difficult, we believe that a non-invasive echocardiographic diagnosis is very useful in order to avoid or, at least, delay a high risk cardiac catheterization.

The aim of this work is to demonstrate the possibility to identify persistent right sinus venous valve and to differentiate it from other right sided heart pathology by two dimensional echocardiography. We report the echocardiographic findings observed in three out of 215 paediatric patients we examined for clinically suspected congenital heart disease in 12 months period. The first patient was a 24 hours old newborn with transient pulmonary hypertension; the second one was a 6 months old child with pulmonary atresia, severe right ventricular hypertrophy, atrial septal defect and patent ductus arteriosus; the third patient, aged 6 months, had atrial septal defect and mild pulmonary stenosis. In all three patients a particular linear structure was seen, as a membrane that crossed the right atrium from the orifice of the inferior vena cava towards the atrial septum. This structure was identified as persistent right sinus venosus valve according to its morphology, its position into the right atrium and its connection to the atrial septum. The incidence of this echocardiographic finding was 1.4% in our series. In the first case contrast echocardiography from the inferior vena cava demonstrated the deviation of blood flow caused by the persistent sinus valve, although no intra-atrial pressure gradient was shown at cardiac catheterization. In the second patient who died during the operative procedure for making a systemic-pulmonary anastomosis, post mortem examination showed a membranous structure connecting the orifice of the inferior vena cava to the atrial septum.(ABSTRACT TRUNCATED AT 250 WORDS)

Four cases of cardiac arrest occurred during Holter monitoring are described. All patients had sustained an acute myocardial infarction thirteen-fourteen days prior to recording and were fully mobilized. In all of them the fatal arrhythmic event was ventricular fibrillation (VF). ECG analysis revealed an increase in heart rate before initiation of VF in one patient only. Warning ventricular arrhythmias were present in two patients. Transient ST segment changes during monitoring were noted in all patients. In three cases the arrhythmia was initiated by an ectopic ventricular beat (EVB) with R-on-T phenomenon; in two of them the EVB occurred after a sinus beat following a long post-ectopic pause. The different electrical events able to induce VF showed a variable and unpredictable pattern of occurrence and association in different patients and at different times in the same patient. Therefore, no specific "trigger" of the fatal arrhythmia could be identified.

We have performed a multi-centre study with 47 outpatients in order to evaluate the efficacy of Verapamil (V) in the treatment of stable effort angina, and to compare the effect of two different doses of the drug (240 and 360 mg/die). The protocol consisted of a first period of Placebo, followed by the double-blind randomized cross-over administration of Placebo (P) and Verapamil (V) in doses of 240 and 360 mg/die. The symptomatology, the consumption of TNG, the ECG pattern at rest and during exercise, the maximum exercise tolerance during exercise and the rate of recovery were evaluated at the end of each 1 month period. V. provided a significant reduction of the number of angina attacks and of the consumption of TNG pills with improvement of symptomatology. The maximum exercise performance improved without changes in maximum rate pressure double product. A decrease of double product was observed at rest and during the recovery period. The higher dose of V. (360 mg/die) provides a better improvement in the number of angina attacks, in the symptomatology, in the double product at rest, and in the rate of recovery than the lower dose (240 mg/die). Thus these data indicate that V. provides anti-anginal efficacy by reducing myocardial oxygen demand, and increases exercise tolerance in effort angina patients.

In order to compare the effectiveness of different therapeutic regimens in reducing infarct size serial determinations of CPK activity (at 4 hourly intervals in the first 48 hours from the admission to CCU, at the 72th and at 120th hours) were performed in 100 patients with transmural AMI (53 anterior and 47 inferior) with no obvious evidence of LV failure and basal CPK levels lower than 50 U/L. 20 patients (control group) have been treated with glucose-insulin-potassium (GIK). 20 patients have been treated with GIK plus Verapamil (GIK + V). Verapamil was administered at the dose of 50 mg in continuous drip. 20 patients received GIK plus digoxin at the dose of 0.25 mg b.i.d. (GIK + D). 40 patients received GIK, Verapamil and digoxin at the above doses (GIK + V + D). Different values of CKr and infarct size (IS.) show a statistically significant difference between the various regimens, which is more evident if we consider the whole series. Infarct size was greater in patients treated with digoxin with respect to controls, while it was smaller in patients treated with Verapamil. Combined Verapamil-digoxin therapy is associated to an enzymatic behaviour not different from controls. Authors emphasize that in uncomplicated AMI digoxin causes an increase in infarct size while Verapamil reduces significantly it. Association of Verapamil allows the use of digoxin, if clinically justified, without increase in infarct size.

We describe the case of a patient 4 months old transferred to our hospital for evaluation of occasionally detected cardiac alterations: ecg showed abnormal Q and negative T waves in D1 - aVL leads and chest x-ray was consistent with enlargement of the left ventricular cavity. After admission, 2D echocardiographic examination disclosed, in the left ventricular cavity, a large mass extending from the papillary muscles to the outflow tract. The mass was of uniform density and easily recognizable as a tumor. Although asymptomatic, the patient underwent operation 10 months later because of the risk of occurrence of severe conduction disturbances or arrhythmias. Histological examination demonstrated that the mass was a fibroma. At post-op echocardiographic and angiographic evaluation the left ventricle appeared abnormally dilated with a large aneurysm of the lateral wall and very poor pump function. Nevertheless the patient did well in the following months until a ventricular fibrillation occurred at home. He was immediately brought to hospital and resuscitation was attempted unsuccessfully. We discuss the role of 2D echocardiography in the diagnosis of cardiac tumors, the indication of the early surgical removal and the possible limitations of the technique we used in this case.

A case of right atrium aneurysm (diverticulum) detected in an asymptomatic 61-year-old woman is described. Diagnosis was made according to echocardiographic and echocontrastographic findings and was confirmed by both angiographic data and surgical pathology. The rarity of this finding and the possibility of a correct non-invasive assessment can be considered the two most peculiar features of this case.

A case of mitral valvular disease in which spontaneous return of sinus rhythm occurred after 12 years of atrial fibrillation is reported. The course of the disease, complicated by A.V. and intraventricular conduction disturbances which made the insertion of a pacemaker necessary, suggests that return to sinus rhythm should not be considered necessarily an improvement in the clinical picture and in the prognosis in such patients.

The behaviour of some serum enzymes (CPK, LDH, alpha HBDH, SGOT) in 50 patients after permanent pacemaker implantation is outlined. Changes of each enzyme were analyzed statistically by applying Student's t test. Most significant changes are represented by the increase in CPK serum concentrations (19 cases). In 14 of them LDH isoenzymes were evaluated and in 4 patients alteration of LDH1/LDH2 ratio suggestive of cardiac "injury" were observed.

The Authors describe two cases of double mitral valve orifice associated with complete atrioventricular canal. The first patient, 10 month-old male, affected by type A complete atrioventricular canal, underwent surgical repair which was performed in association with division of the tissue bridge between the two orifices. The patient died the day after because of severe mitral insufficiency and pulmonary oedema. The second patient, 3.5 year-old female, affected by type A complete atrioventricular canal with pulmonary banding, underwent a surgical procedure without division of the tissue bridge. In the postoperative period a suture dehiscence occurred which caused severe mitral regurgitation, and another intervention had to be performed; subsequently the patient did well and was discharged in good condition. The Authors discuss the possible role of two dimensional and Doppler echocardiography in the diagnosis of this uncommon condition; they also discuss the related surgical problems and stress the necessity to repair with a proper compromise between residual mitral insufficiency and a mitral stenosis.