Abstract: Blunt abdominal aortic trauma is a rare but potentially lethal event. It is commonly associated with high-speed motor vehicle accidents. Intimal flap, thrombosis, and pseudoaneurysm of the abdominal aorta are the more common findings. We present a case of blunt abdominal aortic trauma in which CT disclosed free aortic rupture with intraabdominal bleeding and a huge retroperitoneal hematoma, an extremely rare finding among patients reaching the hospital alive, due to its high and immediate mortality rate.
Abstract: OBJECTIVES: Left atrial size has shown prognostic importance in a variety of cardiac conditions. Diameters, area, and volume derived from M-mode and two-dimensional (2D) echocardiography are commonly used to estimate left atrial size. However, M-mode and 2D measures of left atrial size rely on various geometrical assumptions and their accuracy remains to be determined. To address this issue, we compared M-mode and 2D parameters routinely used to estimate left atrial size with three-dimensional (3D) echo measured left atrial volume (LAV) as a reference standard. METHODS: We studied 104 patients (55% males, 62 +/- 15 years, range 10-87 years), presenting for a routine echocardiographic evaluation. RESULTS: The mean 3D LAV for the study population was 90 +/- 68 ml (range 24-458 ml). We found highly significant (P < 0.0001) correlations between 3D LAV and left atrial anterior-posterior (r = 0.78, 95% CI = 0.69-0.85), superior-inferior (r = 0.74, 95% CI = 0.63-0.81) and medial-lateral (r = 0.91, 95% CI = 0.86-0.93) diameters. A highly significant correlation was also found between 3D LAV and left atrial area (r = 0.94, 95% CI = 0.91-0.96). However, using M-mode anterior-posterior diameter or left atrial area would have misclassified 57% and 70% of our study patients, respectively, regarding the degree of left atrial dilatation. Closer correlations and narrower confidence intervals were found between 3D LAV and single-plane (r = 0.98; 95% CI = 0.94-0.97) and biplane (r = 0.97; 95% CI = 0.96-0.98) 2D LAVs. CONCLUSION: Left atrial diameters and area measurements were poor predictors of 3D LAV, especially in the enlarged left atria. Therefore, these parameters can be misleading in assessing the severity of left atrial dilatation. Two-dimensional LAVs are accurate in estimating 3D LAV. The small additional accuracy obtained by using the biplane instead of the single-plane area-length method, and the fact that the biplane method is more technically demanding and time consuming, may allow the use of the area-length for routine clinical use.
Abstract: Quadricuspid aortic valve is a rare congenital abnormality; it is usually an isolated lesion, but several concomitant congenital abnormalities have been described. We report a case of congenital quadricuspid aortic valve associated with obstructive hypertrophic cardiomyopathy. Two-dimensional (2D) transthoracic and transesophageal echocardiography and real-time three-dimensional (3D) echocardiography clarified the morphological and functional status of the aortic valve. To our knowledge, the association between quadricuspid aortic valve and obstructive hypertrophic cardiomyopathy has never been described before.
Abstract: Arrhythmogenic right ventricular dysplasia/cardiomyopathy is a rarely described cause of sudden death among infants. We report the case of a 4-month-old male infant who died suddenly in his sleep. Postmortem examination revealed the presence of arrhythmogenic right ventricular dysplasia/cardiomyopathy.
Abstract: Pacemaker leads may impair tricuspid valve coaptation and they are a well-known cause of mild tricuspid regurgitation. Occasionally, right ventricular leads worsen tricuspid regurgitation over time and patients develop late-onset symptoms of right-sided heart failure. The exact mechanism of this clinical entity is rarely identifiable by 2D-echocardiography only. This case report details a patient with severe tricuspid regurgitation secondary to immobilization of the anterior leaflet of the tricuspid valve by a permanent ventricular pacing lead. The mechanism of regurgitation was clarified by real time three-dimensional echocardiography that showed the location of the ventricular lead and its interference with the tricuspid valve.
Abstract: Radiofrequency ablation of atrioventricular junction plus pacing therapy ("ablate and pace") is an effective non-pharmacological therapy in patients with medically refractory permanent atrial fibrillation and heart failure. However, the chronic right ventricular pacing may result in regional wall motion abnormalities and adverse hemodynamic effects. These findings imply that patients with permanent atrial fibrillation who undergo "ablate and pace" may benefit from cardiac resynchronization therapy. The review of both observational and randomized studies suggests an important role of biventricular pacing combined with atrioventricular junction ablation only in patients with severe reduction of left ventricular ejection fraction and advanced heart failure. In all other patients with permanent atrial fibrillation, the comparison of conventional right ventricular pacing with respect to cardiac resynchronization therapy showed conflicting results. The assessment of cardiac dyssynchrony by means of new echocardiographic technology, including three-dimensional analysis, may improve the selection of the best pacing modality in patients undergoing "ablate and pace" for drug refractory permanent atrial fibrillation.
Abstract: A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.
Abstract: Transesophageal echocardiography (TEE) is the most common imaging modality for the detection of acute aortic syndromes. However anomalous anatomic structures may be occasionally misunderstood as pathologic due of lack of familiarity with anatomical variations; false-positive diagnosis can result, potentially leading to unnecessary surgical intervention. It is crucial for echocardiographers to be aware of possible pitfalls which may create false positive findings, since the complementary use of other imaging modalities, such as multislice spiral computed tomography (MSCT), could improve the diagnostic accuracy of TEE. We report a case in which an image resembling an acute aortic dissection (AAD) on transthoracic (TTE) and transesophageal echocardiography was found in a patient with acute chest pain; MSCT detected an anomalous origin of the right coronary artery as cause of false aortic dissection image at echocardiography.
Abstract: Infective endocarditis (IE) in chronic haemodialysis (HD) is significantly more common and causes greater morbidity and mortality than in the general population, being second only to cardiovascular disease as the leading cause of death in this group of patients. Because of the peculiarity of this group of patients, it has been recently proposed to add a fifth category (health-care associated and HD-associated IE) in the actually four categories classification of IE (namely, native valve IE, prosthetic valve IE, IE in e.v. drug users, and nosocomial IE). Given that rates of acceptance into HD are increasing (including a higher proportion of older patients in whom valvular calcification is virtually ubiquitous), and along with improved survival in HD patients, the incidence of IE in this subset of patients will probably increase with significant diagnostic and therapeutic implications. In particular cardiac, diagnostic, echocardiographic, and surgical expertises are required to correctly identify patients at higher risk and who may benefit from surgical treatment. The aim of this review is to clarify the peculiar features of chronic HD patients with regard to pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE.
Abstract: OBJECTIVES: The American College of Cardiology (ACC) and the American Heart Association (AHA) provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery. Even if previously validated as safe and effective in risk stratification, there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines. We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic. METHODS: One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation (from September 2004 to May 2005) were enrolled in the study and compared with a historical group of 166 patients operated from April 2002 to September 2002. Preoperative resources utilization (cardiologic consultations, non-invasive diagnostic tests, coronary angiograms, coronary revascularizations) and clinical events [all-cause death, acute myocardial infarction (AMI) and acute myocardial ischaemia] occurring within 30 days after surgical procedure were compared. RESULTS: Guidelines implementation reduced preoperative cardiologic consultations by 21% (P < 0.001) and preoperative non-invasive diagnostic testing by 11% (P = 0.01), and increased utilization of preoperative beta-blockers by 13% (P = 0.01). Preoperative coronary angiograms (2% versus 4%) and coronary revascularizations (3% versus 2%) and all-cause death (1% versus 2%), AMI (2% versus 1%) and acute myocardial ischaemia (4% versus 2%) during follow-up were similar in both groups. CONCLUSIONS: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization, improved medical treatment and preserved a low rate of perioperative cardiac complications.
Abstract: AIM: To study frequency and incremental prognostic value of restrictive filling pattern (RFP) in hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS: Eighty seven consecutive HCM patients (64% men, mean age 45+/-19 years) underwent physical and Doppler echocardiographic evaluation at our centre from March 1993 to February 2001. Mean length of follow-up was 96+/-54 months. RFP was found in 14 patients (16%) at index evaluation. Patients with RFP had higher NYHA class, more frequent signs of heart failure and lower left ventricular ejection fraction (p=0.018, p=0.002 and p=0.001, respectively). During follow-up, cardiac death plus heart transplantation was significantly higher in HCM patients with RFP than in those without RFP (p=0.0001). NYHA class (HR=5.95, 95% CI: 1.34-26.38, p=0.019), indexed left atrial diameter (HR=1.68, 95% CI: 1.01-2.82, p=0.047) and RFP (HR=2.94, 95% CI: 1.25-6.88, p=0.01) were selected as predictors of cardiac death or heart transplantation in a multivariate proportional hazard model. The AUC of ROC curve from multivariate regression models for predicting adverse outcome significantly improved from 0.76 considering only NYHA class to 0.84 after inclusion of RFP and indexed left atrial diameter (p=0.01). CONCLUSIONS: RFP is rare, but not exceptional, in HCM. Echo-Doppler evaluation of filling pattern confers additional prognostic power to clinical stratification.
Abstract: Fat embolism syndrome (FES) is a common complication of fractures, usually of the long bones and pelvis. Common computed tomography findings of pulmonary FES include areas of consolidation, ground-glass opacities, and small nodules of various sizes, whereas filling defects in pulmonary arteries are rarely described in nonfulminant syndromes. We present an unusual case of nonfulminant pulmonary FES in which computed tomography disclosed multiple macroscopic pulmonary fat emboli associated to diffuse ground-glass attenuation in both lungs.
Abstract: We report the case of a 39-year-old woman who developed worsening dyspnea and abdominal pain 4 days after subtotal gastroresection. She underwent thoracic computed tomography scan and lung scintigraphy and was diagnosed with pulmonary embolism. Despite the fact that she was feverish, she was treated by the insertion of a vena cava filter and transferred to our Emergency Department. Twelve hours later, a beta-haemolytic Streptococcus agalactiae was reported to be growing in both bottles of blood cultures that had been taken. The patient underwent transthoracic two- and three-dimensional echocardiography, which showed a large pulmonary valve vegetation prolapsing into the main and right pulmonary artery during systole.
Abstract: This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.
Abstract: OBJECTIVE: Heart failure (HF) is a major health problem resulting in a high financial burden for the healthcare system. Many previous HF management programmes reduced adverse clinical outcomes and costs, but they usually involved several professional figures as well as huge investments, requiring resources and budgets not often available in our healthcare system. We evaluated the effects of our HF management programme, which included patient education and regular outpatient contact with the HF team, on re-hospitalisation and death, optimising the few resources already available at our hospital. METHODS: Two hundred consecutive patients admitted to the internal medicine department with a diagnosis of HF were randomised to the intervention group (nurse-led education programme, facilitated telephone communication and follow-up visits with an internist at 15 days, 1 and 6 months) or to the usual care group (follow-up by their primary care physician). The primary endpoints were all-cause readmissions and all-cause deaths during the 6-month post-discharge period. RESULTS: There were 81 all-cause hospital readmissions in the intervention group and 82 in the control group (P = NS). Fourteen patients (14%) in the intervention group and eight patients (8%) in the control group died during the study period (P = NS). Unplanned outpatient visits were less frequent in the intervention group than in the control group (39 [28%] versus 99 [72%], P < 0.001). CONCLUSIONS: The present low-cost HF management programme reduced unplanned outpatient visits but proved ineffective in reducing subsequent readmissions and in improving clinical status. More intense follow-up monitoring and more resources are needed to achieve better results.
Abstract: Disulfiram is a drug used since 1940 in the treatment of alcohol dependence. However, it is not a completely safe drug; there are in the literature some case reports of more severe reaction than the usual "acetaldehyde syndrome" secondary to ingestion of disulfiram and alcohol. We describe a case of a 45-year-old, chronic alcoholic man in treatment with disulfiram, who suffered an acute anterior myocardial infarction, successfully treated with thrombolysis. The possible factors precipitating acute myocardial infarction in this patient are discussed.
