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This case report describes the outcome of straight endograft placement for treating a large para-anastomotic aortic aneurysm (PAA). A 43-year-old woman was admitted to the emergency department because of a vast PAA (8.7 cm in maximum transverse diameter). Since 1983, she has undergone multiple vascular operations for arterial occlusive disease. In 1990, an aortobifemoral bypass operation was performed. In this most recent intervention, we implanted three tube Excluder® endografts. The procedure was uneventful. Considering the size of the aneurysm sac, particular attention was paid to possible sequelae during the over 4-year follow-up period. No complications developed and the last computed tomography (CT) scan showed a remarkable decrease of 50 mm in aneurysm size. In conclusion, the use of straight endografts seems to be effective and lasting, even in large para-anastomotic aneurysmatic lesions.

The aim of this study is to assess safety, reliability, ease of use and usefulness of filter protection devices during angioplasty and stenting of stenotic lesions of the cervical carotid bifurcation. Over a period of 42 months, 53 patients harboring a cervical carotid bifurcation stenotic lesion were treated, by angioplasty and/or stenting using filter protection devices of different kinds. The stenosis was atherosclerotic in 48 cases, post-surgical in four and post-radiation in one case. In all cases, the treatment was successful, with good restoration of the luminal diameter. There were three major strokes (5.6%) and one minor stroke (1.9%). Two of these (one major, one minor) occurred a few hours after the stenting procedure and both seemed by all evidence due to a hemorrhagic hyperperfusion syndrome. One hemiparesis and dysphasia occurred two days after the procedure, secondary to subacute thrombosis with occlusion of the stent. One patient complained of three episodes of decrease in visual acuity of the eye ipsilateral to the stenting in the two weeks following treatment. In conclusion, in our experience, use of the devices adds only few minutes to the procedure time; direct lesions of the arterial wall, such as dissections or intraluminal thrombi, related to the use of filters were never observed, and spasm of the distal I.C.A. also proved rapidly regressive. The content of all filters, if any, was histologically examined, but plaque material was found only in one case, probably owing to our primary stenting technique without use of pre-dilation. The major technical drawback is in-filter coagulation, which occurred in 16 cases, occluding the membrane of the filter and thus slowing or blocking intracranial flow. Such an event can be counteracted by a more aggressive anti-coagulation protocol, which could, however, be responsible for the two complications with hemorrhagic brain infarction. Furthermore, we observed two other major neurological events, which bring the incidence of neurological complications in this series as high as 7.5%. Therefore, it is our opinion that safety of filters is not yet proven, and consequently great care must be taken in their use.

Since the exclusion of somatic causes is necessary for somatoform disorders (SMD) to be diagnosed, there is little information on the prevalence of such disorders in the community. As the method we have previously developed [general practitioners (GPs) with psychiatric training who interview samples representative of the general population] seemed to be appropriate to deal with the problem, we carried out a community survey focused on somatoform disorders. The prevalence rates of DSM-III-R somatoform disorders were studied in two wards of the city of Florence. In order to be representative of the general population, 673 subjects randomly selected were interviewed by their own GP. Four GPs, all with specific training in psychiatry, participated in the interviewing process. The 1-year prevalence figures were as follows: 0.7% body dysmorphic disorder; 4.5% hypochondriasis; 0.6% somatoform pain disorder; 0.3% conversion disorder; 0.7% somatization disorder; 13.8% undifferentiated somatoform disorder. No specific comorbidity was found between somatoform disorders and mood or anxiety disorders. Although the sample investigated was small, this study may be seen as one of the first in an area where knowledge is still scant. The prevalence rates of somatoform disorders were generally found to be slightly lower than expected.

Fifteen cases of coronary aneurysms are reported. Coronary arterio graphy demonstrated saccular aneurysms in 2 patients and fusiform, not poststenotic aneurysms in the others. Four patients underwent successful bypass surgery.

Thirty-four patients with right bundle-branch block (RBBB) and coronary artery disease (CAD) (RBBB was not pre-existent to clinical development of CAD) and 52 consecutive CAD patients without conduction disturbances were studied and compared to verify whether the presence of RBBB implies more severe and extensive left ventricular myocardial damage as well as more severe CAD. The two groups did not differ either in age or in New York Heart Association functional class. The incidence or location of previous myocardial infarction (MI) was not different in the two groups. No significant differences were found in left ventricular volumes or ejection fraction. Higher end-diastolic left ventricular pressure and more severe and diffuse left ventricular wall asynergy were present in RBBB patients. At coronary arteriography, more severe involvement of the right coronary artery in CAD patients without conduction disturbances was the only significant finding. The group of patients with CAD and RBBB without MI showed significantly less involvement of the left anterior descending coronary artery and significantly more severe damage of the inferior wall of the left ventricle than the group with CAD without RBBB and MI. Patients with inferior wall MI and RBBB had more severe asynergy of the posterobasal region of the left ventricle than did patients with inferior wall MI without RBBB. The group of patients with anterior wall MI and RBBB had a higher left ventricular end-diastolic pressure, a lower left ventricular ejection fraction, and a greater extent of myocardial damage compared to similar patients of the control group. The groups with MI and RBBB had the same Gensini's score as similar groups without RBBB. (ABSTRACT TRUNCATED AT 250 WORDS)

19 patients affected by discrete subvalvular aortic stenosis were studied by M-mode echocardiography. The diagnosis was confirmed by cardiac catheterism and angiocardiography and by anatomic evidence in operative room. The most frequent echocardiographic pattern was the abnormal protosystolic movement of aortic valve leaflets, that was found in all the patients. A discrete linear echo in the outflow tract of the left ventricle was observed in almost half of the cases. In 40% of the cases the left ventricular outflow tract was narrowed. The relations between these echocardiographic patterns and the anatomical kinds of discrete subaortic stenosis are discussed. No correlations were found between echocardiographic patterns and severity of the subaortic stenosis.

The case of a 59-year-old man with corrected transposition of the great arteries (CTGA) is reported. This anomaly is rare in adult patients, uncommon in patients over 50. Most of the cases with CTGA are diagnosed in childhood because of associated cardiac abnormalities. When isolated or complicated by other mild anomalies, CTGA can cause no symptoms until adult life or can even go unrecognized. However, most of these patients present with congestive heart failure when they are 40 or 50 years old. Our patient was admitted to the hospital because of heart failure. Cardiac catheterization and selective angiography demonstrated a CTGA associated with severe pulmonary valve stenosis. The case here reported shows that CTGA even when associated with other cardiac abnormalities, can be a relatively benign lesion, and can be revealed in adult life by signs of cardiac failure.

Left cardiac catheterisation, selective coronarography and ventriculography were employed in a study of 89 patients with left bundle-branch block. Three subjects presented normal haemodynamic and cineangiographic data, 16 displayed valve defects, usually of the aorta, 34 had ischaemic heart disease, and 36 cardiomyopathy mostly of a congestive type. Deviation of the axis in excess of--30 degrees on the frontal plane appeared to be more frequently accompanied by ischaemia, though this finding was not prognostic from the haemodynamic standpoint. A prolonged QRS (over 0.15") was more frequent in valvular heart disease and accompanied by more evident left valve dysfunction. Comparison between the 34 ischaemic patients and 317 coronary patients without left bundle-branch block showed that the former has a higher frequency of leftness in the distribution of their coronary circulation, and more extensive impairment of the coronary arteries, especially the ramus interventricularis anterior. Changes in left ventricle kinetics and serious hypokinesia and/or akinesia appear to be due to the heart disease responsible of the block. The series examined did not make it clear whether this intraventricular conduction defect can cause albeit slight alterations in left ventricle wall motility.

Coronary angiography, left ventriculography, and hemodynamic data were evaluated in 34 patients with coronary artery disease and left bundle branch block. Left axis deviation (mean frontal axis greater than —30°) was correlated with hemodynamic and angiographic findings. The patients with left bundle branch block and coronary artery disease were compared with 98 subjects with ischemic heart disease without conduction disturbances. Left axis deviation, which is common in subjects with coronary artery disease and left bundle branch block, had no prognostic hemodynamic significance. Left bundle branch block associated with coronary artery disease did not imply more severe or more extensive coronary atherosclerosis, even though it revealed a higher frequency of lesions of the left main coronary artery and more severe myocardial dysfunction, with asynergy especially involving the anterior areas of the left ventricle.

A case of left atrial Myxoma shown on an equilibrium radionuclide ventriculography is presented. The finding were consistent with the ecocardiographic patterns and the gross anatomy of the tumour. The analysis of various parameters obtained with gated radionuclide cardiac blood pool scan shows that the Fourier phase image is another method to detect and study this disease.

One hundred-five patients (median age 14 months) in whom a PTFE prosthesis was used to create a systemic-pulmonary artery shunt were studied between 1978 and 1980. The prosthesis was mainly used to create a modified Blalock-Taussig anastomosis. Nine patients died in hospital (8.5%, 70% confidence limits: 5.7% to 12.3%). The clinical condition did not appear to be an incremental risk factor, while the young age and the underlying type of disease accounted for the hospital mortality to a large extent. All 96 survivals were available for follow-up information. One graft, which was damaged intraoperatively, occluded 3 months later. The remaining patients have a patent graft 3 months to 36 months (mean 24 months) postoperatively. In 6 patients the patency was assessed angiographically and no damages of the pulmonary artery were observed, therefore this type of palliation is advisable for any patient, particularly in the first year of life.

In 96 patients with coronary artery disease a coronary arteriography was performed twice at least with some months' interval, in order to establish the rate of progression of coronary atherosclerosis and the factors which could affect this progression. It was possible to select patients with progression of the coronary arteria lesions from patients with no increase of coronary stenosis. From the angiographic point of view, the progression of angina and the appearance of myocardial infarction are connected with a general progression of arterial lesions on all main coronary branches. As to the electrocardiographic aspects, the ECG at rest give no informations about the evolution of the coronary disease. Among the risk factors the smoking only has some importance in order to predict the progression of the coronary atherosclerosis.

The surgical management of tetralogy of Fallot (TF) may be complicated by anomalies in the course and distribution of coronary arteries. Selective coronary angiography was performed in 119 cases of TF in order to prevent injury of aberrant vessels. In 11 patients, anomalies in the origin of coronary branches were revealed (five patients with a single coronary ostium, five with the anterior descending coronary artery arising from the right coronary artery or right sinus of Valsalva, and one with the circumflex artery arising from the right coronary artery). Other findings include anastomoses between coronary and bronchial arteries, small fistulas between coronary arteries and the pulmonary artery or right atrium, and hypoplasia of the coronary tree. The onset of left anterior hemiblock after total correction of TF could possibly be explained, in cases with a dominant left pattern, by injury to the coronary system after closure of the interventricular septal defect, rather than by injury to the conduction system.

The effect of glucose-1-phosphate, administered in a single dose (5 g by slow intravenous route), on myocardial contractility was evaluated in a group of patients undergoing diagnostic cardiac catheterization. The study of the hemodynamic values observed demonstrated that glucose-1-phosphate has positive inotropic action and is able to strengthen the effect of the cardioactive glucosides.

A between-patients trial between a new anti-hypertensive drug (Guanabenz) and methyldopa in subjects with essential hypertension showed the new preparation to be active and endowed with a satisfactory therapeutic index.

An inverse relationship between alpha-cholesterol and coronary atherosclerosis was observed in 200 male patients given coronographies. Specifically the lowest alpha-cholesterol levels were observed in patients with the most serious and widespread atherosclerotic lesions. This inverse correlation was maintained at the same level in all age groups.

77 patients with aortic valve disease have undergone heart catheterization in prevision of valve replacement: in this group the incidence of angina pectoris and the incidence of coronary artery disease associated with the valvular disease have been evaluated. The most important data resulting from out study are: 1) High frequency of angina pectoris both aortic stenosis and in aortic regurgitation: respectively about 60% and 50%. 2) The frequency of coronary atherosclerosis associated with aortic valve disease is much higher in aortic stenosis than in aortic regurgitation: respectively 35% versus 15%. 3) Coronary atherosclerosis associated with aortic stenosis frequently occurs (about 30%) also in young-aged patients (under 40 years). On the contrary in case of aortic regurgitation it occurs much more frequently in elderly patients. 4) The absence of angina both in aortic stenosis and in aortic regurgitation virtually excludes the presence of associated coronary atherosclerosis. 5) The presence of angina in aortic stenosis indicated either severe valvular stenosis or associated coronary artery disease (in this case the valvular stenosis is mild or moderate). The presence of angina in aortic regurgitation indicates either severe impairment of left ventricular performance or associated coronary atherosclerosis.

Nine patients with dissecting aneurysm of the ascending aorta (type A dissection) were operated upon. Six cases had an acute dissection, whereas three cases had a chronic type of dissection. The ascending aorta was replaced with a Dacron tubular prosthesis after solidification of the external and the internal layers of the two aortic stumps using a G.R.F. biological glue. Early and late results as well as the possible complications during the post-operative course are reported. Furthermore the advantages in using the G.R.F. glue are discussed in details. They are mainly represented by the excellent solidification of the aortic stumps, by the possibility to correct the aortic regurgitation without valve replacement and particularly by a good hemostasis of the surgical sutures.

Anomalies in the course and distribution of coronary arteries may complicate the surgical correction of tetralogy of Fallot (TF). With the aim of preventing possible serious, and even lethal, cardiac events caused by the injury of aberrant vessels, 119 patients with TF were subjected to selective coronary angiography. Apart from demonstrating anastomoses between the coronary and bronchial arteries in 31 cases, small fistulas between the coronary arteries and pulmonary artery (in 14 cases) and hypoplasia of the entire coronary tree in 1 case, this investigation revealed anomalies in the origin of coronary branches in 11 cases. In some cases the first septal branch was absent and the diagonal branches were poorly developed. An injury to the coronary system, following the closure of the interventricular septal defect, may possibly explain the onset of a "left anterior hemiblock" after total correction of TF. Selective coronary angiography in small children presents no riskes provided it is correctly performed. In our cases no complications arose.

The Authors have taken into account 21 patients who complained of myocardial infarction before they were 30 years old. We performed coronary angiography, left ventriculography and left cardiac catheterization in all the patients. In 20 cases we found atherosclerotic alterations (50 or greater obstruction) at least in one of the three main braches of coronary tree. The coronary angiography in one patient showed a picture of dissection of right coronary. The alterations are localized more frequently on the anterior descending branch than on the right coronary. On the contrary we found very seldom atherosclerotic lesions on the circumflex artery. Monovascular alterations were more frequent than plurivascular alterations (more than 40% of the total). Left ventricular function was out of order in almost all cases. In summary the important differences between young patients with myocardial infarction and older patients are the following: 1) from the clinical point of view the sudden onset of myocardial infarction without previous symptoms of angina pectoris; 2) from the angiography point of view high incidence of monovascular alterations and low incidence of collateral circulations.

Radiological ventriculographic findings of twenty-three patients with left bundle branch block (LBBB) without valvular heart disease and without evident coronarographic lesions are studied by means of six differents methods for quantitative evaluation of wall motion analysis. The patients are subdivided into two subgroups on the basis of hemodynamic criteria, but the results of wall motion studies are similar in both, if the values obtained are normalized for election fraction (EF). End-diastolic images of left ventricle are similar in both subgroups too, but very different from those of normals because apical region is characterized by rounded contour of images. The modes of contractility in LBBB patients evidence, after normalization by the same EF, hypercinetic motility of anterior wall. The patterns of contractility, shaped by progressive simulated EF, show that low EF are obtained through contraction of anterior wall. Greater EF are obtained by further uniform contraction of all the explored regions. The apical zone in LBBB patients is affected by persistent hypokinesis.