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Objective: Pulmonary arterial hypertension (PAH) is a rare but severe complication of connective tissue diseases (CTD), with a negative impact on patients survival. Bosentan, a receptor antagonist of endothelin, has been proved effective for the treatment of PAH. The aim of this study was to evaluate the effects and the safety of bosentan administered for 2 years in a group of patients with PAH related to CTD. Methods: Twelve patients with PAH related to systemic sclerosis (8 cases), SLE (2 cases), mixed connective tissue disease (1 case) and polymyositis (1 case) attending the Rheumatology Unit of Padova University were treated with bosentan for two years. Distance walked in 6 minutes, right ventricular systolic pressure and mean pulmonary artery pressure estimated by doppler echocardiography were evaluated at baseline and after 6, 12, 18 and 24 months of treatment. Safety was assessed by laboratory tests performed every two months. Results: During bosentan treatment, a significant decrease of right ventricular systolic pressure was observed after 6, 12, 18 and 24 months in comparison to baseline, whereas pulmonary artery mean pressure remained unchanged. Distance walked in 6 minutes slightly increased after 6 and 12 months, but significantly decreased after 18 and 24 months, mostly because complications of CTD which compromised the ability to walk arose in 4 patients. Adverse events related to bosentan were observed in 2 cases. Conclusions: Bosentan has been demonstrated effective in reducing pulmonary arterial pressure in a two-year period of treatment. Exercise capacity improved only in the first year of therapy and worsened thereafter, suggesting the opportunity of a combination therapy for a long-term treatment of PAH related to CTD.

Speckle tracking echocardiography (STE) has recently emerged as a quantitative technique to accurately estimate myocardial function. By the analysis of the motion of speckles in the two-dimensional ultrasonic image, this technique allows a non-Doppler angle-independent objective analysis of myocardial deformation, with the possibility to quantify thickening, shortening and rotation dynamics of cardiac function. Since this technique does not require Doppler imaging, the analysis is relatively angle-independent and is marginally affected by cardiac in-plane motion artifacts. Data regarding feasibility, reproducibility and diagnostic accuracy appear to be optimal in several clinical contexts. This review describes the fundamental concepts of deformation imaging, explains how to obtain myocardial deformation measurements in clinical practice and highlights current clinical applications of STE. In addition, in relation with the recent extension of STE to three-dimensional echocardiography with the potential for a more comprehensive analysis of global and segmental myocardial function, a window is also opened on the perspectives of three-dimensional STE.

Pulmonary embolism is a major health problem. Clinical presentation may vary from cardiovascular emergency with high mortality risk to mild or atypical illness, and the diagnosis is not always easy. However, the timeliness of diagnosis and prognostic stratification are crucial because immediate treatment and thromboembolic prophylaxis are highly effective. Echocardiography can play a key role in pulmonary embolism regarding different aspects: diagnosis, risk stratification, and follow-up but sometimes it is not properly used. Therefore, it is important for a physician to know exactly how to utilize echocardiography in pulmonary embolism. The purpose of this paper is to review the role of echocardiography as part of the diagnosis, management and follow-up of acute pulmonary embolism in the light of current literature.

Atrial fibrillation is the most common arrhythmia encountered in clinical practice. Cardiologists are often called upon to manage atrial fibrillation both in the acute urgent setting for the presence of hemodynamic compromise and electively for rhythm and/or heart rate control as well as for anti-remodeling strategies. In all these cases echocardiography is generally used. In particular, different echocardiographic techniques (transthoracic, transesophageal) and modalities (two-dimensional, three-dimensional, speckle tracking) can be indicated depending on the stage of the arrhythmia management and the need for cardioversion or interventional procedures. The purpose of this review is to clarify the current role of echocardiography, including specific techniques and modalities, in the managing process of atrial fibrillation.

The objective of this review was to explore the clinical relevance of Doppler echocardiographic techniques in the evaluation of right and left ventricular function. It is well known that echocardiographic and Doppler analysis are able to provide information about several hemodynamic parameters, such as cardiac output, diastolic filling pressure, vascular resistances and pulmonary arterial pressures. This integrated approach, completely reliable and non-invasive, could allow to obtain useful information not only from a diagnostic and prognostic point of view but also for a potential therapeutic management, either pharmacological or surgical. This review summarizes the current knowledge and the emerging applications of echocardiographic and Doppler techniques focusing on the close correlation between Doppler-derived data and those coming from invasive techniques. On the basis of these evidences, the importance, even in daily clinical practice, of a non-invasive catheterization laboratory is clear and able to supply key information about ventricular function and, at the same time, to avoid expensive and unpleasant invasive procedures for patients.

The possibilities of applying the laws of dynamics to the study of myocardial mechanics are remarkable and to some extent neglected to characterize ventricular performance by the imaging techniques. There are potentially useful applications derived from the analyses of Doppler flow velocity profiles of left ventricular outflow to be applied to the study of cardiovascular dynamics. They include ejection force, pressure-volume work and ventricular power. All these variables require measurements that are easy to obtain even during a standard examination, like stroke volume, ventricular outflow velocity, and the velocity-time integral.

In cardiology, ventricular function has extensively been studied, whereas atrial function received less attention. For such a reason atrial function is less known. The aim of this review was to summarize the role of atrial function and to explain how echocardiography and new echocardiographic-derived techniques may be of help to better study atrial function.

Tissue Doppler is an ultrasound tool representing a useful completion of standard Doppler echocardiographic examination, The placement of pulsed tissue Doppler sample volume at the level of the different sites of the mitral annulus allows to obtain information on left ventricular global longitudinal (systolic and diastolic) function, whereas the sampling of tricuspid lateral annulus gives similar information on the right ventricular chamber. Myocardial early diastolic velocity (Em) is a marker of ventricular diastolic relaxation and the ratio obtainable between transmitral (or transtricuspid) E velocity and annular Em (E/Em ratio) is an accurate index of the level of filling pressure of the assessed ventricular chamber. Myocardial systolic velocity (Sm) as well as the frequency of acceleration of presystolic velocity, occurring during isovolumic contraction time, are indexes of systolic performance and their reduction is evident in several cardiac pathologies. Tissue Doppler-derived systolic and diastolic indexes have a recognized prognostic value in heart failure and after acute myocardial infarction. In these conditions they are able to predict both left ventricular remodeling and mortality.

Background: It has been observed that in patients with ST-elevation myocardial infarction (STEMI) the presence of ST-segment depression (ST) in heterozonal electrocardiographic leads (remote STI) worsens the patient's prognosis. The aim of this study was to observe in an unselected population with a first STEMI the incidence of remote STI and the risk factors related to this condition., Methods: We evaluated retrospectively 350 patients with a first STEMI; we excluded from our analysis 139 patients because no data about their coronary anatomy was available. ST-segment depression in the heterozonal myocardium was considered significant if > 0.1 mV at 60 ms from the J point, in at least two electrocardiographic leads., Results: Patients were classified according to the presence (group 1, 117 patients) or absence (group II, 94 patients) of remote ST. The two groups did not differ for age, sex and coronary anatomy. In group I we found more heterozonal wall motion abnormalities than group II (32 vs. 18%, p = 0.018). In this group there was a higher incidence of smokers (56 vs. 33%, p = 0.025) and less patients were treated with statins when the STEMI occurred (6 vs. 14%, p = 0.047). Patients with remote ST had higher total cholesterol (214.6 +/- 48.9 vs. 192.3 +/- 29.8 mg/dl, p < 0.001) and low-density lipoprotein cholesterol (138.7 +/- 40.7 vs. 123.2 +/- 22.9 mg/dl, p < 0.0001) levels. Conclusions. In patients with STEMI the presence of remote ST is rather frequent, and seems to indicate a real heterozonal ischemia, independently of an epicardial coronary stenosis of the non-infarct-related artery. Remote ST. is associated with a higher incidence of risk factors related to microcirculatory dysfunction, such as cigarette smoking, a worse lipid profile and less protective factors, such as the use of statins prior to acute myocardial infarction.

The authors' aim is to outline some of the main medico-legal problems in cardiology, especially those regarding the premature hospital discharge of patients with undefined chest pain and/or with acute myocardial infarction. After a brief overview on the etiology and clinical definition of chest pain and myocardial infarction, premature hospital discharge is defined and the incidental medico-legal risks that physicians operating in such situations are exposed to are pointed out. Next, the profiles regarding both the positive and negative views of professional medical responsibility are described. In the negative frame, the authors outline the most frequent civil and penal aspects of the unpremeditated responsibility. Then the physician's error, in both qualitative (generic or specific guilt) and quantitative (degree) terms, is considered; particularly, negligence, imprudence and inexperience, as qualitatively accepted meanings of generic guilt, are dealt with by adopting illustrative cases settled in the light of the right legal interpretation. The phases of the diagnostic or prognostic error are evaluated, and clinical protocols, as a reference parameter for the identification of error, are considered. Lastly, the problem of causality, essential condition for the judgment about the professional responsibility, and the problem of the patient's consent, including an evaluation of the legal capability or incapability about the declaration of consent, are examined closely.

The Authors report the results of a study on 204 patients anesthetized with epidural administration of buprenorphine with bupivacaine. The data obtained were compared with a sample of 236 patients treated with local anesthetic alone. On the whole, the first group of patients presented better anesthesia, with a significantly longer anesthetic effect and more effective sedative and postoperative analgesic effects. Side effects observed were of acceptable entity and incidence.