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Coronary artery perforation is a rare but potentially fatal complication. Therefore, it is crucial for interventional cardiologists to have knowledge of this condition and what management strategies are available, particularly in the case of procedures with a high level of complexity. Notwithstanding this, even simple procedures are not immune to serious complications, as described in this case report where coronary angioplasty was complicated by left anterior descending artery perforation with cardiac tamponade, giving rise to multiple complications of difficult management. The case presented here also provides the opportunity to investigate the optimal duration of dual antiplatelet therapy after implantation of drug-eluting stents, a topic much debated in recent years.

Patients treated with oral anticoagulant therapy (OAT) represent an issue to the dentist, as an increasing number of people are using anticoagulant drugs for cardiovascular disease. The choice of an eventual suspension or continuation of anticoagulant therapy is important when considering an efficient management of the patient. Patients in anticoagulant therapy and requiring dental procedures sometimes represent therapeutic concerns especially concerning the suspension of the anticoagulant treatment. At the moment there is no consensus among international experts of a possible discontinuation of therapy before invasive dental procedures. In this paper, the authors try to focus on this topic through a critical review of the literature. Most of the studies suggest the continuation of the anticoagulant treatment with heparin before invasive oral surgical interventions. Based on the data of the literature, two rules must be adopted in clinical practice: 1) maintenance of anticoagulation related to the international normalized ratio (INR); 2) local application of antifibrinolytic agents to ensure a proper hemostatic process. Given the widespread use of anticoagulant drugs in cardiovascular disease, dentists must often face the problem of the therapy and, since there is no consensus on the management of these patients, the authors propose, after a thorough critical review of the literature, the implementation of a multiphase protocol of surgical approach to be implemented with safety in daily clinical practice.

Systemic thrombolysis is a well known treatment for massive pulmonary embolism (PE) but it remains often underutilized in clinical practice because of the risk of major bleeding, especially intracranial hemorrhage. Recently, the use of safe-dose recombinant tissue-type plasminogen activator (rTPA) has been proposed for the treatment of moderate PE demonstrating to be safe and more effective than standard anticoagulation. We report the case of an 83-year-old male patient affected by massive PE associated with high bleeding risk, and treated with half-dose of rTPA that resulted in rapid clinical improvement. This clinical experience led us to focus on the role of reduced doses of rTPA to decrease bleeding risk in patients with PE. We conclude that the new concept of "safe-dose thrombolysis" with rTPA may be considered a reasonable and interesting option in high-bleeding risk patients with massive PE.

Anticoagulation of the extracorporeal circuit, necessary for the correct management of renal replacement treatment in acute renal failure, is essential. There is a high risk of bleeding secondary to the presence of complex platelet and coagulation abnormalities, the effect of uremia, recent surgery or a state of sepsis. This requires careful evaluation of the type of anticoagulation to be used to prevent blood clotting of the circuit, maintain filter efficiency, and minimize the risk of bleeding. In critically ill patients with no risk of bleeding, heparin is still the anticoagulant treatment of choice. With an increased bleeding risk or in particular situations such as HIT-II, dermatan sulfate can be safely used as an alternative to dilution driven. A valid additional resource in case of a high risk of bleeding is citrate, the use of which - thanks to its effectiveness and ease of use - is becoming more widespread. Citrate is able to provide regional anticoagulation without any interference with the patient. This makes it increasingly feasible to continue replacement therapy, allowing a sufficient number of hours to obtain the correct dialysis dose in critically ill patients with acute renal failure.

The efficacy of reperfusion therapy, both pharmacological and mechanical, in patients with ST-elevation myocardial infarction (STEMI) is time-dependent. The relation is closer the earlier we are from symptom onset and is valid for thrombolysis within 6h and for primary angioplasty till to at least the twelfth hour. Benefits of reperfusion bring to an advantage both in terms of myocardial salvage and left ventricular systolic function and in terms of quality of life and long-term survival. Although mortality and morbidity of STEMI patients have been greatly reduced in the last 20 years, the need for guideline revision and implementation remains urgent, mostly because mortality of real-world STEMI patients keeps to be always much higher compared to what reported in big randomized controlled trials. The most important indications from big trials and guidelines regarding both pharmacological and non-pharmacological reperfusion strategy in STEMI patients are discussed.

Introduction: Peripheral venous catheters (PVC) may cause complications, specifically local. Their management varies across health care workers and wards, and guidelines recommendations are often weak and based on experts' opinion., Aim: To measure the incidence of PVCs phlebitis, occlusions, accidental removal and infiltrations and their predictive factors in an orthopedic population., Methods: From may 4 2009 to 30, in an orthopedic hospital, data on patients to whom a PVC was inserted were collected: patient's and PVC characteristics, management and securing strategies, until one of the following outcomes: phlebitis, occlusion, accidental removal, infiltration or end of treatment., Results: Overall, 873 patients were recruited and 139 PVCs. The following complications occurred: phlebitis 10.9%; occlusions 16.8%; accidental removals 5.8%, local infiltrations 14.4%; 648 PVCs (46.5%) were removed without complications. The risk for all complications (multivariate analysis) increased with age and for the other complications also with the administration of blood transfusions thorough PVC, irritant drugs and use >3 times/day for phlebitis; small gauge, not using PVC and surgical site infections for occlusions; positioning the PVC in the hand and fixing the PVC with the Chevron method for accidental removals; and female sex, transfusions and thromboembolic therapy for infiltrations., Conclusions: The incidence of phlebitis is high compared to the gold standard of 5%. Knowing the incidence of main complications is a requirement for any improvement strategy and may favor the abandonment of useless or dangerous practices.

Purpose: It is often difficult to diagnose cerebral venous thrombosis (CVT), an uncommon condition that more frequently affects young subjects, is responsible for 1%-2% of strokes in adults and has a subtle clinic onset. The aim of this study was to evaluate the role of computed tomography (CT), magnetic resonance imaging (MRI) and MR venography in the emergency setting and to discuss the risk factors, clinical presentation, outcome and follow-up of this disease., Materials and Methods: We retrospectively studied 40 patients with CVT admitted to the emergency department between 1996 and 2006 and examined with unenhanced CT, MRI and MR venography. Fourteen patients also underwent digital subtraction angiography (DSA)., Results: Headache was the most common presenting feature (60%). Unenhanced CT showed typical signs (cord or empty delta sign) in 11 cases and nonspecific signs in the other cases. The diagnosis was achieved with MRI and MR venography in 38/40 cases (95%) and with DSA in 2/40 cases. All patients were treated with heparin. Five patients died, and only one of the remaining patients developed serious disability., Conclusions: Knowledge of the CT, MRI and MR-venography signs of CVT is crucial and enables an early diagnosis and timely treatment with heparin in the majority of cases. DSA should be reserved for doubtful cases only.

Pulmonary embolism is high letal risk pathology often misdiagnosed, up to 70% cases, more frequent in hospitalized subjects, i. e. geriatric patients with chronic respiratory and circulatory diseases, or orthopaedic, neurosurgical, or neoplastic ones and trombophylic predisposing conditions. Medical pharmacological strategies include anticoagulative regimens (heparines, fibrinolitic drugs), either for prolonged therapeutical schedules or for prophylactic ones; within 30% of timely acquired diagnoses, compared to 70% non diagnosed cases, survival rates is directly related to the first approach, ranging from 60% after 7 days, to 48% survival during the first year, 39% and 34% after five and eight years respectively, considering the progressive relapsing risk. Radiological invasive devices such as caval filters or percutaneous trombolysis and reolysis are recommended for non responder subjects, in which medical programs failed. Time from diagnosis is infact the most important parameter conditioning therapeutic approach, that can rely on open surgery only in selected patients and in very specialized centers. The poor surgical prognosis is due infact to the cardiocirculatory emergency of patients that couldn't take advantage from any other therapeutical strategy.

Little evidence exists about the risk of venous thromboembolism after coronary artery bypass graft (CABG) surgery. According to available studies, about one fifth of CABG patients develop symptomatic or asymptomatic deep vein thrombosis, whereas less than 1% of patients suffer from clinically evident pulmonary embolism. Deep vein thrombosis and pulmonary embolism may influence the outcome of coronary revascularization in terms of morbidity and mortality in the short and medium-term, but unfortunately no clear consensus still exists regarding proper thromboprophylaxis measures. As the incidence of deep vein thrombosis and pulmonary embolism after CABG is similar to the incidence in patients undergoing general surgery, heparin prophylaxis could be considered targeted on patients' individual prothrombotic risk.

Venous thromboembolism is one of the main causes of morbidity and mortality in many diseases, either in medical or in surgical wards. The aim of this study is to determine its frequency in a medical ward and to find all the patients who need a prophylaxys. We examined all the inpatients admitted in our Department during a period of three years, selecting all subjects affected by venous thromboembolism. Patients affected by metastatic cancer, namely pancreatic one, or congestive heart failure showed higher risk to develope venous thromboembolism. A prompt heparinic prophylaxys could reduce thromboembolic events. Male gender could be a further risk factor.

Background: In many sports (such as rock-climbing and caving) and working activities (e.g., construction and maintenance of buildings, pruning of lung-trunked trees, abseiling in wells) people run the risk of falling from a height. To prevent the effects of any potential fall, personalprotection devices consisting of at least a body holding device (i.e. a harness of some type), a lanyard and a reliable anchor are used., Objectives: Reporting on the occurrence of vascular thrombosis in subjects undergoing prolonged hanging in a harness, either for work or recreation., Methods: We investigated patients treated for vascular thrombosis in our hospital in the last 5 years to identify subjects with frequent use of a harness., Results: We identified a 36-year-old rock-climber who developed pulmonary thrombo-embolism and infarction 5 days after he had been wearing a harness for 12 hours consecutively, and a 32 year-old worker who often used a harness to fix wire-nettings to prevent rocks falling from steep places and suffered thrombosis of the left superficial femoral artery. A feature of both cases was the considerable length of time spent hanging in the harness and the absence of alternative risk factors for thrombosis., Conclusions: Prolonged hanging in a harness can be dangerous in itself because it can produce vascular thrombosis. Reduction of intravascular blood flow (stasis) and compression of the femoral veins by harness groin straps were the likely pathogenetic mechanisms of the described diseases. The importance is stressed of prevention, which must be based on planned regular breaks in the hanging position, checking on the fit and comfort level of the harness before it is first used, as well as medical surveillance of the subjects who spend prolonged periods in a harness for work or recreation.

Heparin is currently the most popular anticoagulant for extracorporeal circuits in ICUs. Yet, heparin may also be considered as an invasive procedure possibly complicated by bleeding in post-surgical patients who are often septic and with largely exposed skin areas. Over time many alternatives in anticoagulation have been suggested and applied with varying outcomes, including both systemic (heparinoids, thrombin inhibitors, nafamostat, prostacyclin) and regional (saline flushes, protamin coupled heparin, cit-rate). Among all, citrate is emerging as the most promising method with regard to efficacy, safety and feasibility, beside its being more and more used, particularly in North America and northern European countries. Many reasons could explain this success, such as low costs, uncomplicated technology, easy handling and complete reversibility of its anticoagulant activity. Above all, the main advantage of citrate is its capacity to provide anticoagulation specific to the extracorporeal circuit with-out involving the patient. In critically ill patients the bleeding rate is more frequent in continuous than in intermittent treatments, and the bleeding risk is often per se the main factor hindering the practical feasibility of ''continuous'' treatment.

Critically ill patients with acute renal failure, and especially those with sepsis, may have increased coagulation changes as well as a high incidence of hemorrhagic complications. Thus, in this clinical condition, the use of renal replacement therapies (RRT) can be frequently complicated both by high rates of extracorporeal circuit coagulation, resulting in a reduced treatment efficacy, and by increased incidence of bleeding. Heparin is the most commonly used RRT anticoagulant, even if several alternative options have been proposed, aiming at obtaining regional anticoagulation (i.e., limited to the extracorporeal circuit). This review analyses modern strategies for RRT anticoagulation and evaluates safety and efficacy parameters of each method. In this regard, no definite recommendations can be made based on the available evidence further randomised controlled trials are needed in this field, with a clear endpoint definition.

The association between cancer and thromboembolic disease is a well-known phenomenon and can contribute significantly to the morbidity and mortality of cancer patients. Recent studies evidenced that malignant growth has also been linked to activity of heparin-like glycosoaminoglycans, to neoangiogenesis, to protease activity, to immune function and gene expression in addition with activation of coagulation and fibrinolysis. These evidences suggest that antithrombotic drugs may play an additional role in tumour cell growth and in cancer dissemination. The spectrum of thromboembolic manifestations in cancer patients includes deep vein thrombosis, pulmonary embolism, but also intravascular disseminated coagulation and abnormalities in the clotting system in the absence of clinical manifestations. Antithrombotic drugs such as unfractioned heparin (UFH) and, particularly, low molecular weight heparins (LMWH) in addition with dicumaroids, are widely used for the prevention and treatment of thromboembolic manifestations that commonly accompanies malignancies. The aims of the study are to review the pathogenetic mechanisms of thromboembolic disease in cancer patients, the efficiency of antithrombotic drugs in preventing and treating of cancer related thromboembolic complications and review the thromboprophylaxis strategies to prevent thromboembolic complications of cancer patients. Meta-analyses comparing UFH and LMWH for the treatment of deep vein thrombosis have shown better outcome with reduction of major bleeding complications in patients treated with LMWH. Many studies have demonstrated the efficiency and the safeness of antithrombotic agents in the prophylaxis and in the treatment of thromboembolic complication that accompanies malignancies. Many experimental studies, reviewed in this paper, support the hypothesis that antithrombotic agents, but especially heparins can affect cancer progression in many of the different steps of cancer biology. First of all, due to their anticoagulant effect, antithrombotic agents may interfere with thrombin generation and with fibrin formation induced by cancer cells, thus inhibiting the mechanism of metastasis.

Total hip replacement surgery carries the risk of thromboembolic complications, which could be fatal. Over the last three decades however, the risk has decreased considerably thanks to progress made in the understanding of the physiopathogenetic mechanism of thromboembolic disease and perioperative prophylaxis. It is the purpose of this study to discuss the main medical and surgical preventive measures that must be carried out before, during and immediately after surgery. The old concept of deciding thromboembolic prophylaxis after surgery is now obsolete.

Patients with heart valve prostheses carry a higher risk of thromboembolic events compared to the normal population. In many cases anticoagulation is required after heart valve replacement. Thromboembolic risk is related to valve prosthesis design, patient own characteristics and adequacy of anticoagulation. Recent advance in the understanding of the pathophysiology of thrombus formation and pharmacological characteristics of most used anticoagulants are discussed. Suggestions for anticoagulation regimen are given according to recent randomised clinical trials based on prosthesis type, site of implant and patients clinical characteristics. Emphasis is given for cumbersome situations such as pregnancy and major hemorrhage in which anticoagulation has to be interrupted.

Except for selected patients requiring aggressive therapies, the large majority of patients with acute venous thromboembolism are currently treated with full doses of unfractionated or low-molecular-weight heparins (LMWH) followed by oral anticoagulants for variable periods of time. LMWHs present a number of potential advantages over unfractionated heparin: a longer plasma half-life, improved subcutaneous bioavailability, and a more predictable dose-response relationship. As a result of these pharmacokinetic properties, these compounds have the potential to greatly simplify the initial treatment of venous thromboembolism, making the treatment of suitable patients feasible in an outpatient setting with considerable saving in costs and improvement in patients' quality of life. The use of unfractionated heparin is still desirable in the initial treatment of acute pulmonary embolism in non-critically ill patients. The use of heparin protocols assures that virtually all patients will promptly achieve the therapeutic range for the activated partial thromboplastin time. Although the optimal duration of anticoagulation in patients suffering an episode of venous thromboembolism is presently unknown, it seems reasonable to administer a short-term course of coumarin drugs to patients with thrombosis associated with transient risk factors, while a longer course should be considered in patients with idiopathic thrombosis and in those with permanent risk factors. At present, indefinite anticoagulant therapy remains a clinical judgment in the individual patient. The efficacy and safety of emerging drugs (pentasaccharide, ximelagatran) in the treatment and secondary prevention of venous thromboembolic disorders is currently under investigation.

Left atrial myxoma is a benign tumor but it has a high prevalence of important complications. We report a case of a 73-year-old man affected by hypertension and chronic atrial fibrillation admitted to our hospital for pulmonary embolism, that resulted associated with a proximal deep venous thrombosis of the right leg and with an unknown left atrial myxoma.

Venous thromboembolism encompasses deep venous thrombosis (DVT) and pulmonary embolism (PE), which represent different manifestations of the same disease process. Recent epidemiological studies confirm that DVT is a major health problem and that survival after pulmonary embolism is much worse than previously thought. Our understanding of the risk factors and natural history of DVT has undergone considerable evolution in recent years, influencing the clinical management of this epidemic disease. Known risk factors for DVT have been focused on hospitalised patients so that they have about 100-fold higher risk of developing DVT compared with non hospitalised people. So it is crucial for every hospital to develop its own strategy for prevention, diagnosis, treatment and follow-up of patients with DVT. It is now recognised that DVT is a chronic disease, given the high percentage of recurrences after the initial event. The possible modality to decrease the morbidity and mortality following DVT are: a) To develop prevention modalities that have been demonstrated efficacious by clinical evidence; b) To improve the diagnosis of DVT, emphasizing the crucial role of clinical suspicion in patients at high risk; c) To optimize the therapeutic management and follow-up of this chronic disease, with clinical and instrumental tools for monitoring patients during the follow-up and early recognizing the those at risk of recurrences and/or complications.

Background: The purpose of the present is to assess the effectiveness of pulmonary embolism prevention using temporary or permanent vena cava filters in deep venous thromboses of the lower extremities with a discussion of indications and complications., Methods: In the period between 1989 and 1998 we observed 46 patients (33 m, 13 f) suffering from deep venous thrombosis of the lower extremities., Results: The cases treated with cava filter showed an improvement in clinical conditions in 15-19 cases with 4/19 cases of complications: filter ascent, lipothymia, one case of pneumothorax and one case of filter ascent with thrombosis of the contralateral venous axis. All complications were solved without further sequelae. After catheterisation of the femoral vein, the thrombosis of the contralateral venous axis in patients with caval filter was a frequently observed event (in 75% of cases). In the cases without filter, an evident improvement was observed in 22/27 cases, a slight improvement in 2/27 cases, with 3/27 cases of complications: two cases of cardiocirculatory arrest and one case of severe dyspnea with suspected pulmonary embolism which survived the event., Conclusions: From our experience, the use of caval filters is unquestionably useful for the prevention of pulmonary embolism, but is not wholly free from complications.

Low molecular weight heparins (LMWH) have become the reference drugs for the prevention and treatment of venous thromboembolism. Among the newer antithrombotic agents, the pentasaccharide is the most advanced and promising alternative of low molecular weight heparins. The pentasaccharide is a synthetic and specific inhibitor of activated coagulation factor X (factor Xa). The pentasaccharide is identical to the active sequence of heparin which is present in about a third of commercially available heparin mixtures. The pentasaccharide binds specifically to antithrombin III (ATIII) thus potentiating its inhibitory activity on factor Xa. As a result, thrombin generation and the formation of fibrin and thus of thrombi is inhibited. After a large phase II dose finding clinical trial, four large clinical trials with pentasaccharide in the prevention of venous thromboembolism in hip or knee surgery have been conducted in Europe and North America. The results of these trials show that pentasaccharide prevents venous thromboembolism to a larger extent than enoxaparine with an overall risk reduction of 50% and no significant increase in bleeding. Among newer antithrombotic drugs, an oral, direct thrombin inhibitor, ximelagatran, has been developed and evaluated in the prophylaxis of venous thromboembolism in hip or knee surgery in comparison with enoxaparine with promising RESULTS. Oral direct thrombin inhibitors have the advantage of predictable dose response with the possibility of oral administration without laboratory monitoring.

Unlabelled: Recently, evidence-based guidelines for the prevention and therapy of venous thromboembolism have been published. Prophylaxis: in General Surgery patients with moderate to severe risk need to be treated with unfractioned (UFH) or low molecular weight (LMWH) heparin. Non pharmacological methods must be reserved to patients with high hemorrhagic risk and in association to heparin to patients with particularly high thromboembolic risk. In high risk Ortopedic Surgery prophylaxis with high doses LMWH or oral anticoagulants (OA) is indicated. Il Neurosurgical Surgery and in politraumatized patients prophylaxis must be individualized taking account of hemorrhagic risk; patients with acute medullary lesion with paraplegia must be treated with LMWH. In Internal Medicine conditions which determine prolonged bed rest need prophylaxis with UFH or LMWH. In pregnancy, pharmacological prophylaxis is indicated only in cases of preceding thrombotic events or documented congenital risk factors., Therapy: deep venous thrombosis or sub-massive pulmonary embolism must be treated with anticoagulant doses of UFH or LMWH (100 U antiXa/Kg twice daily). OA must be continued for a time identifiable on the basis of underlying disease. In massive or sub-massive pulmonary embolism with hemodynamic instability thrombolysis is indicated. In heparin induced thrombocytopenia alternative antithrombotic treatments must be employed.

The main aim of the treatment of deep venous thrombosis (DVT) is to prevent the onset of the main complications: embolism (acute) and post-phlebothrombotic syndrome-PPS--(late complication). If not treated, during the acute phase DVT presents extension and/or embolism in 60% of cases and pulmonary embolism is potentially fatal in 5-10%. PPS is the most frequent complication (up to 70% of cases). The treatment of acute DVT has been based for over thirty years on heparin and oral anticoagulants: thrombolytic agents and low molecular weight (LMWH) heparins have been introduced more recently. Anticoagulants treatment is continued for 3-6 months (or longer in the event of recidivation or thrombophilia). LMWH have proved more effective and easier to manage than non-fractioned heparin. The association of thrombolytic and heparin presents no advantages compared to the use of heparin alone. It is currently reserved for cases of venous gangrene and acute massive pulmonary embolism. The possibility of surgical embolectomy or the use of catheters should only be considered in treatment is ineffective or contraindicated. The aim of this paper is to analyse the treatment of DVT and the diagnostic, clinical, laboratory and instrumental procedures used, and to describe the most up-to-date indications for its diagnosis and treatment.

Thrombophlebitis of the superficial veins (SVT) of the leg is usually regarded as a mild and uncomplicated disease. Although this is generally true for acute thrombosis of the branches of the saphenous vein, the natural history of SVT involving the main trunk may not be as benign. The association of SVT with deep venous thrombosis (DVT) has been reported to range from 17 to 40%; the progression of the thrombotic process from the greater saphenous vein into the deep venous system has been reported in 8.6% of the cases. For this reason, even if symptoms of DVT are lacking, it is necessary to use duplex ultrasonography to be certain that DVT does not exist concurrently with SVT. In a recent study we found that saphenous-vein thrombi embolize even when no femoral-vein involvement is evident. Of 21 patients included in the study, findings compatible with a high probability of pulmonary embolism were detected in 7 (33.3%, 95% CI, 14.6 to 57.0), although clinical symptoms were present only in 1. The risk of pulmonary embolism is similarly high in patients with and without thrombosis at the sapheno-femoral junction. These patients presumably would benefit from anticoagulation, but such a benefit remains to be proven. Superficial thrombophlebitis, in the absence of DVT proven by duplex ultrasonography, is generally treated with nonsteroidal anti-inflammatory agents. A prospective randomized study is being carried out at our Institution evaluating therapeutic doses of anticoagulant drugs in SVT. Interim report suggests that, in thrombophlebitis of the thigh, high fixed doses of unfractioned heparin are more effective than low doses for the prevention of early and late venous thromboembolic complications and are not associated with an appreciable bleeding risk.

Approximately 20 years ago a new family of antithrombotic compounds started to be investigated: the low-molecular weight heparins (LMWH). The rationale for their use was based on the evidence that the inhibition of the Factor Xa of blood coagulation was less marked than that of Factor IIa when using the LMWHs as compared to unfractioned heparin (HF). This particular mechanism of action was considered to be of advantage regarding the safety profile (the pro-haemorrhagic effect) compared to HF. Today we know that the real advantage of LMWHs is due to their high bioavailability which makes safe and reliable their subcutaneous administration without laboratory monitoring. The LMWHs are equally effective than HF for the treatment of acute Deep Vein Thrombosis. For the prophylaxis of Venous Thromboembolism, LMWHs are indicated as first choice in high-risk patients such as those undergoing major orthopaedic surgery. The future development of this family of drugs encompasses the launch of the pentasaccharide which is a pure anti-/Xa inhibitor.

Pulmonary embolism (PE) represents the third more frequent cardiovascular disease following the acute coronary artery disease and stroke. The most important predisposing clinical condition for PE is represented by the deep-vein thrombosis. The clinical diagnosis of PE has a very low accuracy; so the clinical suspect has to be necessarily directed towards the performance of diagnostic procedures. Among the most used procedures, the echocardiography has a diagnostic role but also a prognostic one. Moreover, it offers precious informations useful to perform the most suitable treatment. The echocardiography features which suggest the presence of pulmonary embolism are: right ventricle and atrium dilatation, right ventricular hypokinesia, systolic flattening of the interventricular septum, tricuspid regurgitation, pulmonary artery dilatation, disappearance or reduction of the inspiratory collapse of the inferior vena cava and presence of eventual embolic sources. According to the involvement degree of right ventricular function, it is generally possible to identify a different survival. The subgroup of patients with moderate or severe right ventricular dysfunction shows a high in hospital and within 1 year death rate. For this reason the right ventricular dysfunction degree together with the hemodynamic stability, are the most important parameters in the therapeutic choice. If there is no right ventricular dysfunction a treatment with heparin is indicated. In presence of right ventricular dysfunction and hemodynamic instability, the thrombolytic treatment is necessary. If the patient is hemodynamically stable, a transesophageal echocardiography is recommended; in case of central thrombosis the thrombolytic therapy or surgery are needed, while if no embolic material is shown the heparin treatment is advisable.

The most frequent complications of deep venous thrombosis (DVT) are post-thrombotic syndrome (PTS) and pulmonary embolism (PE); the main purpose of DVT therapy is to prevent their onset. A range of treatment is now available, including physical, medical and surgical forms. Physical: elastic compression mobilization postural therapy. Medical: anticoagulants (heparin, LMW heparins, oral anticoagulants), thrombolytic agents. Surgical: if DVT is diagnosed at an early stage, anticoagulant treatment may be accompanied by attempted surgical deobstruction, above all if DVT is localised at the popliteal and femoral confluents (greater risk of evolution towards severe "ischemic" forms potential cause of venous gangrene). These treatments include locoregional endogenous thrombolysis followed after phlebography, by surgical thrombectomy in the event of thrombotic residue, enabling the possible embolization of the pulmonary district using a caval filter. The combined medical and surgical approach reduces the long-term incidence of PTS. Temporary caval filters are also available. In short, a modern approach to the clinical problem of DVT now takes the form of early diagnosis and combined thrombolysis-surgery, which appears to be the most appropriate choice, ensuring the best form of venous functional recovery. However, this requires hospitalization in specialist units and multidisciplinary skills (hematological, medical, radiological and surgical) to ensure the best results.

Background: Neurohormonal and metabolic responses to acute ischemic events associated with thrombolysis and heparin induce substantial changes in the lipid profile (acute phase response). The aim of this study was to assess changes in total cholesterol and triglycerides in patients with acute coronary syndrome, admitted to our Intensive Coronary Care Unit (ICCU)., Methods: The study included 1051 consecutive patients, 316 with unstable angina, 583 with Q wave acute myocardial infarction (AMI) and 152 with non-Q wave AMI. Total cholesterol and triglycerides were measured in all patients at time 0 (admission), at time 1 (the morning following admission), at time 2 (the morning after discontinuation of heparin treatment)., Results: The mean value of total cholesterol at admission was 235, 210 and 197 mg% at admission, time 1 and time 2, respectively. Triglyceride levels were 234, 178 and 189 mg%, respectively. In the subgroup of thrombolized AMI the reduction in total cholesterol at time 1 and time 2 resulted similar in comparison with non-thrombolized AMI (p = NS). The decrease in triglycerides showed a similar pattern in the different subgroups. Comparison was also done according to sex, age, and complications., Conclusions: These data confirm that mean total cholesterol and triglycerides at admission are sharply higher than values considered normal in the literature. Within 24 hours of admission there is a 10.7% drop in total cholesterol which increases to 16.2% after a few days (mean 3.4 days). Total cholesterol determination upon admission in patients with acute coronary syndromes is necessary in order to know the true concomitant lipid profile during the precipitating ischemic events. The decision of initiating early therapy with statins would then appear more justified.

Echocardiographic demonstration of right ventricular thrombosis is relatively common in pulmonary embolism. There are also reports of right ventricular thrombi in patients affected by right myocardial infarction or dilated cardiomyopathy. In arrhythmogenic right ventricular cardiomyopathy single or multiple aneurysms are often present in the right ventricular free wall. These hypoakinetic areas represent a site for potential development of thrombi especially in advanced disease states. In the literature a single case of a patient affected by arrhythmogenic right ventricular cardiomyopathy with right heart failure and atrial and ventricular thrombi is reported. We report a case of arrhythmogenic right ventricular cardiomyopathy with a right ventricular thrombus located inside a single apical aneurysm in the presence of normal right ventricular systolic function.

Background: Evaluation of influence of pre-op continuous e.v. heparin infusion in patients undergoing urgent myocardial surgical revascularization, on the anticoagulation threshold needed for cardiopulmonary bypass. Analysis of the efficacy of ATIII substitutional therapy to allow best ACT values during extracorporeal circulation, and to reduce intra and post-op bleeding and need for homologus transfusion., Setting: Operative room and ICU of a cardiac surgery unit in a regional hospital., Methods: Two groups of coronary patients in preoperative treatment with heparin were randomized in a prospective double blind study for an intraoperative treatment with heparin and ATIII (Group A) and heparin plus placebo (Group B). An investigation was made on the influence of preoperative heparin treatment regarding extracorporeal circulation, the variation of the coagulation parameters in CEC with substitutive therapy of ATIII and the reduction of the therapeutic strength of heparin during perfusion, the problem of bleeding and the incidence of blood transfusions and lastly the economic questions of the two procedures., Results: The study showed the necessity of repeated bolus of heparin during CEC and the rapid loss of its effect in the group not subjected ATIII therapy. A less incidence of bleeding in Group A was observed; for this reason the patients received significantly less packed red cells and FFP and a discrete number of patients of this group were not transfused. Surely the method of using the ATIII is much more expensive from the economic point of view, but the benefits of avoiding the problems of a blood transfusion (infections, immunodepression etc.), of the reduced stay in the Intensive Care Unit, of the riduced risk involved with problems of bleeding and the need of repeated operative procedures make this method fundamental in patients with reduced plasma levels of ATIII such as coronary patients who are under heparin treatment for several days., Conclusions: Intraoperative administration of ATIII can reduce most problems due to heparinization of the extracorporeal circuit, such as onset of fibrinolysis, CID and platelets depletion or inactivation causing intra and post-op massive bleeding.

Unlabelled: The cardioversion of atrial fibrillation is linked to a substantial risk of systemic embolization. In an effort to reduce it, the American College of Chest Physicians (ACCP) periodically publishes guidelines for the use of anticoagulation in the conversion of atrial fibrillation., Objective: Determination of the physician's compliance with the recommendations of the "Fourth ACCP Consensus Conference on Antithrombotic Therapy"., Methods: The charts of people admitted to a community hospital in 1998 with a diagnosis of atrial fibrillation (n = 202) were evaluated retrospectively. Consideration was given to the ACCP's recommendation to give anticoagulants 3 weeks before and 4 weeks after elective cardioversion to patients who had been in atrial fibrillation for more than 2 days., Results: Ninety-one of the 202 patients admitted with atrial fibrillation reported the onset of arrhythmia more than 48 hours before. Thirty-four of them underwent elective cardioversion and 13 cases (33%) went without anticoagulation in the preceding 2 weeks. Of these 13 cases, 8 were patients aged over 75 (range 78-88, mean 84). After sinus rhythm had been restored in 30 people (spontaneously in 5 of them), the anticoagulant therapy was not administered during the 4 recommended weeks in 10 people (33%), all of them over 75 (range 77.94, mean 84)., Conclusions: Anticoagulation for cardioversion of atrial fibrillation is underused, especially among elderly patients. In order not to let age itself be an obstacle to the correct treatment of patients with high embolic risk, our efforts must be improved in order to identify the correct therapeutic choice in each particular case. Initiatives aimed at identifying and removing any impediment to the application of guidelines may contribute to stimulating physicians in the process of evaluating the quality of hospital treatment.

Background: Pulmonary embolism is one of the most frequent cardiopulmonary diseases, but it is often under- or misdiagnosed. In order to address this issue and to identify flow charts that are commonly used in pulmonary embolism diagnosis and treatment, 191 clinical wards of internal medicine, cardiology, geriatrics, pneumology and intensive care units, located in the Veneto Region, were surveyed., Methods: An anonymous questionnaire was mailed to each ward in order to collect clinical diagnostic information on all pulmonary embolisms which occurred during 1993. Among the returned questionnaires, 114 (59.6%) had usable information for the analysis., Results: The vast majority of participating centers reported in 1993 less than 10 pulmonary embolism events. No significant differences were observed between internal medicine, geriatrics, pneumology wards and intensive care units. The reported events, however, were slightly higher in the divisions of cardiology with an annual average of 12 events per center. First level diagnostic procedures, such as ECG, chest X-ray and arterial blood gas analysis were chosen and performed in all patients. Interestingly, Doppler echocardiography, which is often not included in official guidelines for pulmonary embolism diagnosis, was performed in 56% of the participating centers. On the contrary, ventilation-perfusion lung scanning, which is considered highly predictive in many diagnostic algorithms, was underutilized (35% perfusion scan, 20% ventilation scan). This underuse was probably due to technical and organizational difficulties. Pulmonary angiography, the most accurate procedure for the diagnosis of pulmonary embolism, was performed in 28% of the patients. During the acute phase, intravenous heparin was commonly used; 91% of patients received the infusion continuously, 4% intermittently. Thrombolysis was performed in 25% of the patients. The preferred drugs were recombinant tissue-plasminogen activator (67%), followed by urokinase (20%) and streptokinase (13%). To start thrombolytic therapy, 20% of the interviewed clinicians considered sufficient the evidence of clinical manifestations of pulmonary embolism confirmed by echocardiographic data. At discharge, prescription of oral anticoagulant drugs was common (78%) for at least 6 months (47%). Standardized procedures for the diagnosis and treatment of pulmonary embolism were already implemented in 13% of the participating centers., Conclusions: These data suggest a common effort to define unanimous conventional protocols in the management of pulmonary embolism. It should be underlined, however, that a particular attention to the clinical manifestations and a productive collaboration among clinicians with different expertise are required to improve the diagnosis and treatment of pulmonary embolism.

Background: The most important problem with which doctors have to deal every day in their practice, is occlusive vascular disease, at the basis of which there is commonly a process of thrombosis. For this reason, it is very important to define early the subjects at thrombosis risk and an appropriate therapeutic strategy., Methods: We considered 13 inpatients at thrombosis risk, c/o sezione di Clinica Medica I, dipartimento di Medicina Interna e Terapia Medica, Università di Pavia, IRCCS Policlinico S. Matteo, and 12 healthy volunteers, between March and June 1998, evaluating age, sex, weight, diseases and ongoing therapy, hemocytological, hemocoagulational and hemorheological tests before and after heparinic therapy., Results: General blood viscosity, measured by the rotational and double-filtration method, presented no significant changes; on the contrary, capillary blood viscosity and erythrocyte deformability, measured by our new double-filtration method, showed respectively an increase and a decrease., Conclusions: Calcium heparin is the most frequently used antithrombotic drug in thrombotic diseases and their prevention, but its action on the hemorheological profile is not clear. This study showed that it increases erythrocyte aggregation rate and decreases erythrocyte deformability, having a negative effect on the microcirculation.

The incidence of DVT in axillo-subclavian district is rather low. Up-to-date reports show however it is progressively increasing, owing to the widespread diffusion of intravenous prosthetic devices. While the opportunities of a correct diagnosis are becoming various, particularly because of the development of echo color-Doppler and imaging techniques, there is indecision for the treatment: the question is about a medical and a surgical therapy. Neither the former nor the latter are well established. This case report is about a 61-year-old woman affected by a recurrent DVT of the subclavian and axillary veins, who never underwent operation and/or handling of the venous district. Clinical tests didn't show any well determinate cause of thrombosis. It was decided not to treat the patient surgically, so a medical therapy was undertaken. Now she is completely recovered.

Background: Venous thromboembolic disease is a recurring reason for death, it is often well-known but sometimes misunderstood. The right treatment for this pathology should not follow one approach only, but several strategies with respect to the seriousness and extension of the several clinical pictures. In particular the pharmacological therapy tries to find the balance between risks and benefits. It is well-known that a weak treatment may cause an increase in the risk of the pathology extension or of recurrence; on the other hand, a therapy exceeding the well known ranges exposes to important hemorrhagic risk., Methods: This work presents the personal seven years' experience in patients affected by limb venous thrombosis, in some cases combined with pulmonary embolism. For all patients the pathology seriousness has been assessed by echoduplex scanner and angio-CT, and routine serum electrolite and enzymes analysis and blood counts have been carried out. Different therapies have been investigated, their evolution over the years (on the basis of international and personal experience) and the follow-ups., Results and Conclusions: The foudamental implications of this experience are: the more remarkable use of vena cava filters do not improve clinical findings' follow-up. On the contrary, it can cause the extension of pathology; heparin therapy must start early and the therapeutic range must be reached as soon as possible. Any delay, together with immobilization, can cause the extension of the pathology; diagnosis research cannot stop at the acuity moment but it should study also the etiopathogenetic picture. This affects the future therapeutic strategy in the follow-up; fibrinolitic therapy, once recommended for extended femoral-iliac thrombosis, should be used for serious levels of the same pathology and only for patients with low haemorrhage risk, or for patients affected by periodic pulmonary thromboembolism which may compromise haemodynamic system.