Graduated with full marks and honours in 1987 (PAVIA Italy) Postgraduate School in Haematology (PAVIA Italy) Postgraduate School in Cardiology (MILAN Italy)
Abstract: Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.
Abstract: BACKGROUND: The continuity equation (CE) represents the 'gold standard' for the evaluation of aortic valve area in patients with aortic stenosis, but it is time-consuming and subject to error, and can be technically demanding. Recently, a new echocardiographic nonflow corrected index was introduced and demonstrated excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bioprostheses. This new index, the ejection fraction (EF)-velocity ratio (EFVR), is obtained by dividing the percentage left ventricular EF by the maximum aortic gradient. OBJECTIVE: To assess the usefulness of this echocardiographic index for quantifying the EOA in patients with aortic bioprosthesis and left ventricular dysfunction. METHODS: A total of 70 patients (25 women and 45 men) with aortic bioprosthesis and left ventricular dysfunction (EF of 49% or less) were studied. The mean (+/- SD) age of the study population was 71.4+/-9 years. The EOA was evaluated, both by the CE and by the EFVR. RESULTS: A significant linear correlation between the CE and the EFVR was found (r=0.80; P<0.0001). The receiver operating characteristic curve analysis showed good agreement between the CE and the EFVR. An EFVR value of 1.15 or less was found to have a good sensitivity (89%) and good specificity (91%) in identifying patients with an EOA of 1.0 cm2 or smaller, with positive and negative predictive values of 79% and 95%, respectively. CONCLUSIONS: The EFVR, a simple index that is less time-consuming than the CE, allows the identification of patients with aortic bioprosthesis stenosis with excellent sensitivity and specificity. It may be taken into consideration in clinical practice for the evaluation of patients with aortic bioprosthesis stenosis and left ventricular dysfunction.
Abstract: Background:Altitude-induced sympathetic hyperactivity can elicit rhythm disturbances in healthy subjects, in particular during exercise. Aim:To asses the real susceptibility of healthy myocardium to malignant ventricular arrhythmias during exercise at high altitude using microvolt T-wave alternans (MTWA). Methods:We evaluated eight healthy trained participants (one female, 42 +/- 9 years) during a mountain climbing expedition on Gashembrum II (Pakistan, 8,150 m). MTWA and heart rate variability (HRV) were measured in each subject at sea level and at high altitude, both under rest conditions and during exercise. MTWA was determined with the modified moving average method. HRV was expressed as root mean square of successive differences. Results:Rest HRV at high altitude was significantly lower compared to rest HRV at sea level (36 +/- 5 vs 56 +/- 9 ms, P = 0.003). HRV during exercise was significantly lower with respect to rest condition both in normoxia (46 +/- 7 vs 56 +/- 9 ms, P = 0.0001) and hypoxia (27 +/- 4 vs 36 +/- 5 ms, P = 0.005). Moreover, HRV was significantly lower during exercise at high altitude compared to exercise at sea level (27 +/- 4 vs 46 +/- 7 ms, P = 0.0002) and arrhythmias were more frequent during exercise in hypoxia. Nevertheless, MTWA was absent under rest conditions both at sea level and at high altitude and minimally evoked during exercise in both conditions (22 +/- 3 muV and 23 +/- 3 muV, respectively, P = 0.2). Conclusions:In spite of an enhanced sympathetic activity, MTWA testing during exercise at high altitude was negative in all participants. Healthy trained subjects during exercise under hypoxia seem to be at low risk for dangerous arrhythmias.
Abstract: We describe a rare case of superior vena cava syndrome that occurred a few hours after insertion of an implantable cardioverter defibrillator through the right subclavian vein in a patient with previous dual chamber DDD pacemaker. The patient was successfully treated with anticoagulant therapy showing a fast clinical and instrumental improvement.
Abstract: Guillain-Barrè syndrome (GBS) is an acute, inflammatory, demyelinating polyneuropathy that nowadays represents the most common cause of flaccid paralysis. GBS is considered a reactive, autoimmune disease preceded by a triggering event, such as a respiratory infection or gastroenteritis. Campylobacter jejuni, Mycoplasma pneumoniae, Cytomegalovirus and Ebstein Barr Virus are the most frequent antecedent pathogens isolated in GBS; nevertheless recent reports suggest that pathogens related to infective endocarditis may be the triggers of this generalized polyneuropathy. We discuss the likely pathogenesis of this rare association and review the pertinent literature.
Abstract: Left ventricular apical ballooning, also named tako-tsubo cardiomyopathy, is a syndrome characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes mimicking an acute myocardial infarction without significant stenosis on the coronary angiogram. Although the aetiology remains unknown, several reports have found that preceding psychological stress could act as a trigger. This report describes a case of tako-tsubo-like left ventricular apical ballooning in a patient with "soft" atherosclerotic plaque at the middle portion of the left anterior descending coronary artery.
Abstract: BACKGROUND: Prior studies demonstrated that kinetics of oxygen uptake (KVO(2)) at the onset of exercise is delayed in patients with ischemic left ventricular dysfunction (LVD), since it reflects a slower cardiac output increase. Given the myocardial contractile reserve elicited by endogenous catecholamines during exercise, it may be speculated that patients with a significant amount of myocardial viability (MV) could show a faster KVO(2) at the onset of exercise attributable to a faster increase in stroke volume compared to patients without MV. OBJECTIVES: To demonstrate a relationship between contractile reserve detected by low-dose dobutamine Echocardiography (LDDE) and KVO(2) obtained during cardiopulmonary testing in patients with ischemic LVD. METHODS: Forty-one consecutive patients (62.5+/-10.1 years) with ischemic LVD underwent LDDE and constant work rate exercise with KVO(2) determination. The time constant for VO(2) (tau) was determined by a curve fitting breath-by-breath data. Ten healthy subjects served as control group (59.5+/-13.4 years). RESULTS: LDDE identified contractile reserve in 20 (48%) subjects. Patients without MV detected by LDDE showed a significantly longer tau compared to patients with MV and to healthy subjects (p=0.03 and p=0.01, respectively). Sensitivity, specificity, positive and negative predictive value of tau in detecting MV were 90%, 95%, 95% and 91%, respectively. Moreover, the percentage reduction of LV wall motion score index detected at LDDE was significantly related to KVO(2) (r=0.71, p<0.01) CONCLUSIONS: Our data suggest that KVO(2) represents a reasonable initial approach to estimate presence of MV in patients with ischemic LVD.
Abstract: Guillain-Barrè syndrome (GBS) is the most important cause of acute neuromuscular paralysis in western countries and it is preceded in almost all cases by an infectious disease such as Campylobacter Jejuni or Cytomegalovirus. However, GBS associated with previous bacterial endocarditis is very rare. We report the case of a 74-year-old man with GBS following Staphylococcus Aureus endocarditis affecting aortic valve. Although the absolute incidence of GBS is low, the present case stresses the need to consider GBS in patients developing neurological symptoms following any infectious illness, such as endocarditis, and highlights the challenging problem of rehabilitation and surgical management in these patients.
Abstract: Background Patients with previous myocardial revascularization, even if symptom-free, remain at risk of subsequent cardiac events, so that a non-invasive tool able to stratify this population is wishful. Objectives To assess the prognostic value of dipyridamole stress echocardiography (DipSE) in a population of asymptomatic patients following complete myocardial revascularization, either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Methods We retrospectively evaluated 104 consecutive symptom-free patients (mean age 67 +/- 9.3 years, 75 males) with recent (<12 months) complete myocardial revascularization (48% PCI, 52% CABG) undergoing DipSE. Ischemia was defined as the onset of a new or worsening wall motion abnormality during DipSE. The composite end point of the study was cardiac death and non-fatal acute coronary syndrome. Results Myocardial ischemia was identified in 23 patients (22.1%). During a mean follow up of 21 months, 7 (30.4%) out of these patients suffered cardiac events. Among the remaining 81 patients (77.9%) with negative DipSE results, 7 (8.6%) experienced cardiac events. At multivariable analysis only a positive DipSE (odds ratio 3.9, P = 0.03), wall motion score index at peak of stress (OR 3.6, P = 0.04) and a prior myocardial infarction (odds ratio 3.5, P = 0.04) achieved statistical significance for cardiac events. Moreover, DipSE effectively stratified patients into a high and low risk group according to presence of inducible ischemia (event rate per year 16% vs 4.8%, P = 0.02). Conclusions DipSE yields appropriate risk stratification and provides incremental prognostic value over clinical variables even in asymptomatic patients with prior complete myocardial revascularization. A negative DipSE portends a benign prognosis (<5% event rate/year) in such population.
Abstract: Prolymphocytic leukemia (LPL) is a well defined entity with a relatively low incidence in our country. This disease usually is seen in patients over 50 years of age, and there is a very definite male preponderance. This lymphoproliferative disorder is characterized by very high white cells counts, massive splenomegaly, poor response to therapy and short term survival. The neoplastic cell in prolymphocytic leukemia usually is of B-cell origin (80% of cases). In our patient, affected by B-lineage prolymphocytic leukemia, a acute hepatic failure occurred, leading him to death in a short time. Autoptic findings evidenced a massive leukemic infiltration of the liver with parenchymal necrosis that caused fatal hepatic failure. Autoptic findings did not show histological patterns of acute viral infections or of any other infectious or systemic disease which could have induced a so massive liver injury. In literature there are no evidences of such a massive and lethal involvement of the liver during prolymphocytic leukemia or chronic lymphocytic leukemia and patients affected by LPL generally come to death because of other causes.
