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The article presents a case study of a 67-year-old man with acute heart failure caused by neoplastic invasion of ventricular myocardium by thymoma relapse. Clinical history of patient includes surgical treatment of radical thymus tumour excision dignosed as atypical thymic carcinoid tumour. It mentions that mild pericardial effusion was present, likewise pulmonary oedema.

This report describes a case in which serial cross-sectional echocardiographic examinations allowed us to make the diagnosis and to follow anatomical evolution of pulmonary thromboemboli. Frequent (three times a day for seven days) echocardiographic surveillance of thromboemboli allowed us to assess the effectiveness of the therapeutic approach. [ABSTRACT FROM PUBLISHER]

Background: We aimed to depict the electrocardiographic and echocardiographic aspects in patients before elective major vascular surgery. Methods: We evaluated through standard 12 lead electrocardiography and transthoracic echocardiography 469 patients with asymptomatic large abdominal aortic aneurysm (AAA), 334 with critical carotid stenosis (CAS), and 238 with advanced peripheral artery disease (PAD) before surgical revascularization. Results: Patients with AAA were predominantly males ( p  < .001) with normal sinus rhythm ( p  = .026), were more affected by atrioventricular block ( p  = .033) and left anterior fascicular block ( p  < .001). They also presented larger aortic root size ( p  < .001) and septal hypertrophy ( p  = .036), in addition, atrial fibrillation was less frequent in the same group ( p  = .023). Patients with CAS were of older age ( p  < .001) with a substantial number of females ( p  < .001). They presented less left ventricular segmental kinetic disorders and fewer dilated ventricles ( p  = .004 and p  < .001 respectively). Finally, those with PAD had reduced septal and posterior wall thickness ( p  < .01, p  = .009 respectively), greater mitral and aortic annular calcification ( p  < .001), and were more affected by previous myocardial infarction ( p  < .001). The PR interval, left anterior fascicular block and aortic root size were independently associated with aneurysm, previous myocardial infarction with PAD, while smaller left ventricular end systolic volumes with carotid artery stenosis. Conclusions: Patients with AAA were mostly affected by cardiac conduction disorders, septal hypertrophy, aortic root dilation and less affected by atrial fibrillation. Patients with CAS were older with more normal sized ventricles, whereas, previous myocardial infarction was most common amongst patients with peripheral artery disease.

Objectives: We investigated the clinical, electrocardiographic, and echocardiographic determinants of the cardiac status in nonagenarian patients., Methods: We consecutively examined 654 Caucasian patients (232 males and 422 females) aged ≥90 years. All patients underwent clinical examination, ECG, and transthoracic echocardiography., Results: Their average age was 92.5 ± 2.5 years. Patients were predominately female of older age (p < 0.0001 and p = 0.02, respectively). A history of cardiovascular disease was present in 78.4% of the participants. One third of the patients was hospitalized for cardiovascular causes, with females being twice as many (p < 0.0001). Females showed higher levels of serum cholesterol, triglycerides, and glycemia (p < 0.0001, p< 0.0001, and p = 0.04 respectively). Sinus rhythm was detected in 65%, and atrial fibrillation in 31% of the overall population. Heart rate, PR and corrected QT (QTc) intervals, right bundle branch block (RBBB) and RBBB associated with left anterior fascicular block (LAFB) were higher in males (p < 0.0001, p = 0.036, p = 0.009, p = 0.001, and p = 0.004, respectively). Aortic root dimension, left ventricular (LV) mass index, and indexed LV systolic-diastolic volumes were higher in males (p < 0.001, p < 0.0001, p < 0.001, and p < 0.0001, respectively). Women showed fewer LV segmental kinetic disorders (p = 0009) and higher LV ejection fraction (LVEF; p< 0.0001). Hyperuricemia was positively associated with a history of cardiovascular disease (r = 0.15), glycemia (r = 19), creatininemia (r = 0.50), uremia (r = 0.51), triglycerides (r = 0.19), PR interval (r = 0.14), and left bundle branch block (r = 0.11), and inversely associated with sinus rhythm (r = -0.14) and LVEF (r = -0.17). Diabetes was positively correlated with PR and QTc intervals (r = 0.14 and r = 0.10, respectively), and RBBB with LFAB (r = 0.10), and inversely correlated with LVEF (r = -0.10)., Conclusions: We found a remarkable presence of cardiovascular risk factors, ECG, and structural alterations in hospitalized nonagenarians, which presents more commonly in males., (© 2019 S. Karger AG, Basel.)

Objectives The purpose of this study was to investigate whether there are differences among clinical conditions and traditional atherosclerotic risk factors between patients with large abdominal aortic aneurysm and those with occlusive non-coronary arterial disease. Methods We clinically examined 519 patients with asymptomatic abdominal aortic aneurysm and 672 with severe obstructive arterial diseases before surgical repair. Results In patients with abdominal aortic aneurysm, we identified a clear predominance of males ( p < 0.001), more alcohol consumers ( p < 0.05), higher values of diastolic blood pressure ( p < 0.05), higher values of serum creatinine ( p < 0.005), more hyperuricemic patients ( p < 0.005) and less diabetics ( p < 0.001). In patients with occlusive atherosclerotic vasculopathies, we observed more smokers ( p < 0.05), higher systolic blood pressure and more hypertensives ( p < 0.05 respectively) and a prevalence of hypertriglyceridemia ( p < 0.05). Conclusions Patients with abdominal aortic aneurysm were mostly males with diastolic hypertension, impaired renal function and less diabetics, while patients with occlusive arteriopathy were more smokers, hypertensives and more hypertriglyceridemics.

Background: Preoperative cardiac assessment may essentially contribute to estimate the operative risk in vascular surgery.This study was undertaken to depict the clinical conditions and cardiac status in patients before elective major vascular surgery., Patients and Methods: 143 patients with asymptomatic critical aortic abdominal aneurysm, 119 with high-grade carotid stenosis, and 138 with advanced symptomatic ischemia due to peripheral artery disease were assigned to surgical revascularization. Preoperatively, all subjects completed detailed medical history, physical and laboratory examinations, electrocardiogram, and transthoracic echocardiography., Results: In patients with peripheral artery disease we identified more smokers (p < 0.05), diabetes (p < 0.01), hypertriglyceridemia (p < 0.05), previous myocardial infarction (p < 0.01); the asymptomatic aortic abdominal aneurysm group had a higher body mass index (p < 0.05), diastolic hypertension (p < 0.05), and most had left ventricular anterior hemiblocks (p < 0.001). Patients with critical carotid stenosis were older (p < 0.01), with greater systolic hypertension (p < 0.01), and with a less compromised left ventricular systolic function., Conclusions: Patients with peripheral artery disease were mostly affected by severe metabolic diseases and by worst cardiac conditions; patients with asymptomatic abdominal aortic aneurysms were of robust physique, and often had left ventricular anterior hemiblocks. Patients with critical carotid stenosis were older and had less cardiomyopathies.

We report an uncommon case of an insulin-treated diabetic patient, presenting severe hypoglycemia, coma, marked sinus bradycardia and QT prolongation. Intravenous administration of glucose and atropine awaked the patient and increased heart rate but did not affect QT prolongation. Basal and exercise electrocardiogram excluded primary diseases associated with QT prolongation. Pathophysiologic aspects of electrocardiographic and clinical findings occurring in the hypoglycemic patients are briefly discussed., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Whether the use of stentless aortic bioprostheses improves hemodynamics more than stented bioprostheses in the small aortic root is still a matter of debate., Methods: Early- and mid-term effects were compared between 2 different types of stentless bioprotheses and 1 type of stented bioprosthesis for left ventricular remodelling. The effects of the bioprotheses were studied by echocardiography in 68 patients (age, 74 +/- 7 years) with aortic annulus diameter < or =23 mm who were undergoing prosthesis implantation due to aortic isolated stenosis. Stented bioprostheses (Carpentier-Edwards Perimount [CEP]) were implanted in 36 subjects and stentless bioprostheses (18 Toronto SPV and 14 Shelhigh Super Stentless) were implanted in 32 subjects., Results: A progressive and similar decrease in left ventricular mass of 30% was observed in both stented and stentless bioprostheses at 12 months. A progressive increase in transprosthetic effective orifice area and a decrease in transprothetic pressure gradient were observed at 3, 6, and 12 months in the Toronto group, but these variables showed improvement only at 3 months in the CEP and Shelhigh groups. No mortality occurred during surgery or during the 1-year follow-up period., Conclusions: Our results confirmed good feasibility of aortic stented and stentless bioprostheses implantation in the elderly population. A 30% decrease in left ventricular mass occurred in the early- and mid-term (12 months) periods after surgery with all 3 types of bioprostheses. Advantages consisting of a progressive increase in transprosthetic effective orifice area and a decrease of the transprosthetic pressure gradient were observed in the Toronto group in comparison to the CEP and Shelhigh groups. These observations may help surgeons in choosing bioprostheses.

Background: Because patients with dilated cardiomyopathy tend to have a poor prognosis with medical therapy, surgery with coronary bypass alone or associated with mitral valve repair should be a promising feasible therapeutic option. We evaluated the early effects of surgical coronary revascularization with or without mitral valve repair in patients with severe dilated ischemic cardiomyopathy., Methods: The study group consisted of 38 patients aged 65 +/- 8 years with severe dilated ischemic cardiomyopathy, chest pain, and heart failure. Twenty-four patients were in a New York Heart Association (NYHA) class > or =3, and 14 patients were in class 2. Twenty patients had a degree of mitral regurgitation defined as an effective regurgitant orifice > or =20 mm2. The mean values (+/-SD) of the EuroSCORE, which evaluates operative risk, were 5 +/- 2.2. Clinical and echocardiographic reevaluation followed at 6 months., Results: All patients underwent coronary artery bypass surgery with a mean of 2.3 +/- 0.8 grafts, and mitral valve repair with annuloplasty and Cosgrove ring insertion were performed in 20 patients. No deaths occurred during the operative period. Ten patients could not be reevaluated at 6 months, and 3 patients died (7.9% mortality). At 6 months, the end-systolic volumes in 15 patients who underwent coronary bypass plus mitral valve repair (group A) and in 13 patients who underwent coronary bypass alone (group B) decreased, respectively, from 139 +/- 56 mL to 121 +/- 94 mL and from 122 +/- 48 mL to 96 +/- 36 mL (P < .05). The wall motion score index also decreased from 1.9 +/- 0.3 to 1.4 +/- 0.4 and from 2.1 +/- 0.3 to 1.8 +/- 0.2, respectively. The mean values of the ejection fraction, the peak early mitral inflow velocity, and the ratio of the peak early mitral inflow velocity to the peak late mitral inflow velocity increased significantly in both groups (P < .001, P < .01, and P < .05, respectively). The mean NYHA functional class significantly improved in both groups (P < .0001)., Conclusions: In patients with severe ischemic dilated cardiomyopathy, surgical coronary revascularization can be safely carried out during the operative and early postoperative periods with low mortality rates. This procedure decreased left ventricular end-systolic volume, consistently increased contractility, and subsequently ameliorated the ejection fraction to produce improvements in clinical condition according to the NYHA functional class. Similar results have been obtained in patients who have undergone coronary bypass surgery and mitral valve repair, despite a higher operative risk and longer cardiopulmonary bypass circulation and aortic cross-clamping times.

We have investigated the possibility of detecting early abnormalities of left ventricular function at the initial phase of ischemic cardiomyopathy. Sixteen normotensive patients with coronary artery disease and normal left ventricular ejection fraction and 6 control patients were studied by invasive hemodynamic techniques in combination with transmitral Doppler flow or with echo-tissue Doppler imaging. The extent of the percentage of left ventricular longitudinal shortening and the systolic peak velocity at echo-tissue Doppler were significantly higher in the control patients than in patients with ischemic cardiomyopathy (P <.01). Left ventricular end-diastolic pressure was higher (P <.05), whereas mean values of isovolumic contraction and relaxation indexes (dP/dt/P: P <.05; +dP/dt: P <.05; -dP/dt: P <.01) were lower in patients with ischemic cardiomyopathy. Tau was significantly longer in ischemic patients (42.7 +/- 8.8 versus 34.5 +/- 3.7 ms, P <.05). In the control patients, the aortic valve closure to peak E interval by transmitral Doppler flow was significantly longer than that measured by echo-tissue Doppler (P <.001), whereas in patients with ischemic cardiomyopathy, this interval difference was still present and significantly shorter (P <.05). In patients with coronary artery disease and normal ejection fraction, minor and early abnormalities of left ventricular function related to isovolumic contraction and relaxation as well as to longitudinal shortening could be detected. In addition, a suction-like effect, detected during early filling evaluation with echo-tissue Doppler, is significantly decreased but not abolished during the early stages of coronary artery disease.

Aortic intramural hematoma (IMH) is a rarely diagnosed pathological condition that is not well characterized to date. We diagnosed IMH in 4 of 31 patients with suspected aortic dissection admitted to our coronary care unit from 1992 to 1995. In all 4 cases, IMH was located in the ascending aorta. At the time of hospitalization, all patients showed tachycardia, hypotension and pericardial effusion. Diagnosis of IMH was made by transesophageal echocardiography and computed tomography. We performed aortography in 2 patients, but it was non-diagnostic in both of them. One patient died before surgery. Autopsy confirmed the diagnosis of IMH and showed severe pericardial effusion. In another patient, the diagnosis was confirmed during successful surgery, while the remaining 2 patients recovered after medical therapy. The 3 surviving patients are still under follow-up control 12, 16 and 20 months after the initial acute event. We briefly discuss the epidemiological, clinical, diagnostic, therapeutic and prognostic aspects of IMH.

In 2 young adult women who experienced acute heterocyclic antidepressant intoxication, we found a quite unusual electrocardiographic pattern characterized by abnormal ST-tract elevation in the right precordial leads associated with a marked QRS widening (right bundle branch block and left anterior fascicular block type). Because serum electrolyte imbalance and acute myocardial ischemic events were excluded, the mechanism by which antidepressant overdose may produce such elevation of the ST tract remains unclear.

Although digitalis was introduced to medicine long ago, the drug is still extensively used in clinical practice today. Opinions on its mechanism of action have undergone much change in the course of time, and the way in which cardiovascular effects are produced is still not completely clear. Limitations and contraindications for the use of digitalis substances are reported, especially in the treatment of ischemic heart disease. Preliminary data regarding the effects of digitalis on the diastolic phase are unfavorable, although the relationship between digitalis and diastolic function ought to be studied in greater depth in various clinical conditions. In spite of many recent trials, the old question of the usefulness of digitalis in the chronic treatment of patients in sinus rhythm and heart failure is still debated. An important clinical benefit in the chronic use of digitalis appears restricted to a relatively small proportion of patients with severe congestive heart failure, while in the majority of chronically treated subjects the effects of the drug are scanty or insignificant. The beneficial effect of digitalis used chronically is essentially believed to be due to its positive inotropic action. Since the vagomimetic and the antiadrenergic effects of digitalis have been demonstrated to be independent from its inotropic action, they could be considered determinants of the clinical benefits of digitalis. These indirect effects may be useful in the control of the negative neuroendocrine response developing during congestive heart failure. Thus the statement that digitalis is essentially an inotropic agent seems restrictive; its definition should reflect the favorable effects obtained in some cases of congestive heart failure rather than its various and contrasting underlying mechanisms of action.

We describe a clinical case presenting 2 rare features. The first was a spontaneous aortocaval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second infrequent feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-color Doppler flow imaging (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination showed an aneurysm of the descending aorta that communicated to a dilated inferior vena cava. Furthermore, flow study with color Doppler showed a continuous turbulent, mixed (arterial and venous) blood flow into the inferior vena cava.

We describe a clinical case presenting two unusual features. The first was a spontaneous aorto-caval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second uncommon feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-Doppler color flow (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination revealed an aneurysm of the abdominal aorta that communicated with a dilated inferior vena cava. Furthermore, flow study with pulsed color Doppler revealed a continuous turbolent, mixed (arterial and venous) blood flow into the vena cava.

The availability of i.v. nicardipine has urged us to prove this drug in the treatment of hypertensive attacks (SAP greater than or equal to 210 mmHg and/or DAP greater than or equal to 110 mmHg). Two groups of patients (each made up of ten subjects) were treated with 2 mg and 5 mg respectively of i.v. nicardipine injected for 4 min while mean systolic and diastolic arterial pressure and heart rate were registered until three hours. I.V. nicardipine administration induced in both groups of patients a decrease in systolic pressure from 20 to 30% while diastolic arterial pressure decreased from 15 to 18% in the first group and from 20 to 25% in the second one. Heart rate showed an initial mild increase following arterial vasodilator action of nicardipine whereas it decreased significantly from 120 min in the presence of an unchanged hypotensive effect of the drug. One patient did not respond to nicardipine while another felt chest pain and palpitations. In conclusion our results are satisfactory and argue for the inclusion of nicardipine among the drugs that may be considered useful for the treatment of hypertensive attacks.

The case presented is a 47-year-old woman with left-ventricular outflow tract obstruction which was the late complication of mitral valve replacement (4 years later). The diagnosis was made using two-dimensional Doppler echocardiography (echo-2D Doppler) and confirmed by cardiac catheterization. Protrusion of the prosthetic ring towards the intraventricular septum reducing the diameter of the outflow tract to 7-8 mm and creating a dynamic obstruction (30 mm Hg on cardiac catheterization, and 44 and 75 mm Hg on echo-2D Doppler basally and after isoamyl nitrite inhalation, respectively) was recorded. The echo-2D Doppler technique appears to be useful in detecting this postsurgical mitral complication.

Acute thrombotic obstruction of disc valve prosthesis is a rare but catastrophic event without an immediate correct diagnosis and precocious treatment (Amman et al., 1984; Assanelli et al., 1986; Copans et al., 1980; Mann et al., 1986; Gibson et al., 1974; Johnson et al., 1973; Ledain et al., 1986). That is the main reason it is important to consider each helpful sign in order to recognize such a situation. We detected an important dilatation of the right ventricle in two patients with different stages of thrombosis of mitral Björk, the first one had also a chronic dilatation of the right ventricle due to tricuspid regurgitation. The clinical and pathophysiological aspects of these unusual situations are described in this article.

A female patient with recurrent "torsades de pointes" and a long QT interval was successfully treated with i.v. magnesium sulfate. This work provides further support of the use of magnesium sulfate in this particular arrhythmia.

Muscular exercise is the most common stress imposed on the cardiovascular system and, in hypertensive patients, it causes an exaggerated increase in the already elevated blood pressure. The evaluation of any antihypertensive drug must, therefore, include an investigation of its effects on the haemodynamic response to exercise. For this reason the effects of celiprolol and enalapril were studied in hypertensive patients, both at rest and during an exercise stress test performed on a bicycle ergometer. The haemodynamic changes observed were very similar at rest: both drugs consistently reduced blood pressure without impairing either myocardial geometry or function. The only between drug difference found at rest was slight bradycardia with celiprolol, whereas heart rate was unaffected by enalapril. By contrast, there was a marked difference in the effect on the blood pressure increase caused by muscular exercise: 24 h after dosing, celiprolol continued to attenuate the hypertensive response to exercise while enalapril failed to show any significant antihypertensive effect possibly because after this time there was a reduction in angiotensin converting enzyme inhibiting activity. Thus, celiprolol and enalapril are both effective once-a-day antihypertensive agents, but celiprolol provides a longer lasting protection from hypertensive peaks caused by exercise.

The obstruction of the left ventricular tract outflow following mitral valve surgery, as a late complication, is rarely reported in the literature. The case of a 47-yr-old woman, who, after mitral valve surgery, developed dynamic left ventricular tract outflow obstruction four years later is reported. This alteration was detected by 2D echo-Doppler. The echocardiographic findings were: 1) Normal function of the mitral prosthesis. 2) An equal pressure-gradient of 44 mmHg at rest and of 75 mmHg after amyl nitrite at three examined levels: below, above and at the level of the aortic valve. 3) A hyper-echo image in the peri-annular region, probably representing fibrous degeneration around the valve ring, which was the likely cause of the obstruction. Th data were confirmed by cardiac catheterization. The echocardiographic technique appears to be a useful tool to detect and study this complication of mitral valve surgery.

Intravenous flecainide (2 mg/Kg for 15 min) was used in 30 patients (18 men and 12 women aged 23 to 85 years: mean 62) with recent or paroxysmal atrial fibrillation: 5 patients returned to sinus rhythm during flecainide administration while other 23 patients did it not later than 2 hours. Treatment with intravenous flecainide proved to be safe without significant side effects. Further investigations are required to define the effects of flecainide in the treatment of atrial fibrillation; at the moment it must be admitted that flecainide acetate is a useful, safe, fast acting drug for the conversion of paroxysmal or recent atrial fibrillation to sinus rhythm.

To assess the diagnostic value of continuous ambulatory ECG in exercise angina pectoris, 49 males (mean age 52, 1 years), with exercise ischemic ECG changes and positive coronary angiography were evaluated. Ischemic ST-changes were detected by ambulatory ECG in 47% of those patients; most of these ST segment displacements were asymptomatic and a lot of them occurred at rest. In order to assess the specificity of ambulatory ECG, 90 healthy subjects (47 males and 43 females, mean age 43,6 years), were also evaluated 8.9% of these subjects developed ischemia like episodes of ST segment deviation. We conclude that in exercise angina pectoris the ambulatory ECG allows to recording silent ST segment changes, in spite of a poor diagnostic sensitivity. The low specificity of ST segment depression recorded by ambulatory ECG must be also emphasized.