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The electric treatment of cardiac bradyarrhythmias by an implanted pacemaker is mandatory whenever the reduction in ventricular rate results in a functional impairment affecting health, safety, and quality of life [1]. Nevertheless, it is well-known that electrical stimulation of the heart may have disadvantages and drawbacks, which have been progressively identified and brought to attention as a consequence of increasing clinical experience and medical knowledge. Parallel improvements in pacing technology have allowed many essential issues to be addressed and solved, such as the prevention of competitive pacing and synchronization of atrial and ventricular stimulation to maintain physiological sequential activation. In the last decade, the increasing use of biventricular pacing in the therapy of heart failure has underlined the relevance of interventricular and intraventricular synchronization for effective pump function. However, conventional singlesite pacing in the right ventricular apex (RVA) necessarily implies myocardial conduction of the evoked action potential, resulting in deep modification of the ventricular activation pattern and delayed contraction of the left ventricle (LV), as indicated by the altered axis and increased duration of the QRS complex and confirmed by echocardiographic observation. The shortand long-term impacts of RVA pacing on cardiac hemodynamics have therefore become major concerns in the care of patients presenting with bradycardia [2].

The aim of this study was to evaluate the safety and efficacy of ambulatory external cardioversion (EC) by means of monophasic and biphasic shock in patients with persistent atrial fibrillation (AF).One hundred and twenty-seven consecutive patients with AF were submitted to EC, preceded by short general anesthesia with propofol, after pretreatment with oral anticoagulants for at least 3 weeks and, if not contraindicated, with amiodarone. In 87 of these patients we used monophasic shock and in 40 patients we used biphasic shock. Our protocol provided for up to 3 shocks delivered at an energy level ranging between 200 and 360 J for monophasic and from 70 to 175 J for biphasic shock. The patients were discharged after 4 hours of ECG monitoring and following a determination of serum CK-MB at the fourth hour.The mean age of the patients submitted to EC with monophasic and biphasic shock (65 +/- 9 vs 67 +/- 7 years) and the duration of AF (34 +/- 22 vs 32 +/- 25 days) were similar. The efficacy of EC with monophasic shock was 85% and the mean energy delivered was 266 +/- 81.5 J. The efficacy of the EC with biphasic shock was 98% and the mean energy delivered was 127 +/- 40 J. The difference between the percentage of efficacy and the number of joules delivered was statistically significant (p0.05). The mean value of the CK-MB after 4 hours following delivery of the shock was not significantly different: 2.5 ng/ml for monophasic vs 1.7 ng/ml for biphasic shock (p = NS).In our patients, ambulatory EC of persistent AF is safe and feasible; biphasic shock is more efficacious and requires less energy with respect to monophasic shock.

Bacterial endocarditis in pregnancy is uncommon. We described two cases: the first case of endocarditis, caused by staphylococcus epidermidis (at the 35th week of pregnancy) was complicated by severe aortic valvular insufficiency; the second case, endocarditis caused by streptococcus alpha hemolytic (at the 32nd week of pregnancy) was complicated by severe mitral valvular insufficiency associated with multiple systemic emboli. Therapy consisted, in the first case of partum-induction followed by antibiotic therapy; in the second case it consisted of specific antibiotic therapy followed by gestation. There was no maternal or fetal mortality in the two cases.

Giant cell arteritis is a disease of the elderly of unknown origin. It involves large, medium and small sized arteries. The extracranial arteries, especially the aorta and its main branches, are rarely involved. The typical histologic features are fibrous intimal proliferation, the disruption of the internal elastic lamina, the presence of mixed cellular infiltrate, plasma cells and histiocytes and giant cells. We report the case of a 78-year-old patient, who died of acute myocardial infarction. The autopsy unexpectedly revealed giant cell arteritis involving the coronary arteries and other systemic arteries.

Left ventricular false tendons (or anomalous bands) have been described in several anatomic studies. Recently the echocardiographic features of such false tendons have been reported also. We have found a prevalence of 36 cases in 1,600 consecutive patients examined (2.2%). False tendons represent a rather common and benign phenomenon. Echocardiography is the most useful tool in the detection of false tendons.