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Background and Methods: We analyzed the complications of 1729 pacemakers implants (from October 1980 to December 1992) divided according to the way of leads insertion. The approaches from the subclavian vein was used in 1220 cases, the cephalic vein was used in 431 implants and the external jugular vein in 78., Results: Major complications were: pocket bleeding (108 cases), pocket erosion (15 cases), infection (2 cases), lead fracture (5 cases), lead dislodgement (20 cases), pneumothorax (4 cases, only for subclavian puncture). There were no significative differences in the complications between the three approaches. On the other hand, the subclavian puncture reduces the time of the procedure, is less traumatic and allows to insert and to position several leads., Conclusions: We suggest to use the subclavian vein approach as first choice to implant one or more leads, being this way safe and fast.

The purpose of this study was to evaluate the hemodynamic benefits of atrioventricular (A-V) sequential pacing. 30 pts implanted with DDD pacemakers underwent M-mode, B-mode and Doppler echocardiography. In each patient, left ventricular (LV) stroke volume was assessed by measuring the time-velocity integral of mitral inflow in the following modes and rates: VOO at 70 ppm or at the minimum stimulation rate and at 120 ppm; DOO at the same rates with different A-V delay (100, 150, 200, 250 and, whenever possible, 300 msec). The increase in stroke volume obtained with dual chamber pacing at the optimal A-V delay was 45 +/- 25% at 75 ppm and 29 +/- 14% at 120 ppm (p less than 0.05 75 vs 120 ppm). This increase was significantly higher in pts with than in pts without LV hypertrophy (respectively: 51.9 +/- 20.4 vs 36.9 +/- 20.8% at 75 ppm, p less than 0.05 and 33 +/- 13.4 vs 25.4 +/- 14.5% at 120 ppm, p = 0.08). Concerning the A-V delay, we noted that at 75 ppm stroke volume was significantly higher in DOO than in VOO with any A-V delay ranging +/- 100 msec from the optimal one; at 120 ppm the hemodynamic benefit of DOO pacing was observed only when the programmed A-V delay was the optimal one or very near to it. In conclusion, atrio-ventricular sequential pacing allows a significant increase in LV stroke volume over single chamber ventricular pacing both at 75 and 120 ppm. Programming the optimal A-V delay is absolutely necessary to obtain this hemodynamic benefit at the higher stimulation rate.

Five patients affected by angina pectoris showed a spontaneous attack of myocardial ischemia in the course of coronary arteriography examination. During the ischemic episode it was shown a severe coronary arterial spasm promptly relieved by nitroglycerin. In these patients the administration of ergonovine maleate induced the same clinical, electrocardiographic and coronariographic patterns of spontaneous ischemic episodes. These data support the hypotesis that the ergonovine maleate administration is a suitable test for detection of the vasospastic pathogenesis in acute myocardial ischemia.

Left ventricular contractile function was evaluated in twenty patients with coronary artery disease before and during handgrip by use of Vpm, VCEIO and Vmax (obtained with a simplified calculation) from high-fidelity pressure measurements. In eight patients the response to handgrip was characterized by an increase of the contractile indices accompanied by small changes of left ventricular end-diastolic pressure (not exceeding + 4 mm Hg) and was considered normal. Twelve patients who showed abnormal or pathologic reaction to isometric exercise repeated handgrip after administration of 0.4 mg of spray nitroglycerin. Thus eight patients normalized their response to exercise, while in four we observed again a pathologic reaction to handgrip. It is concluded that is a useful and simple manoeuvre for a better evaluation of left centricular function in patients with coronary artery disease; the repetition of the test after administration of nitroglycerin can be useful in identifying those patients with greatest contractile reserve.

Screening of patients with precordial symptoms is a mayor social problem. Holter monitoring is easy to use because it ambulatory, non invasive, can be repeated without harm, has no contraindications and permits prolonged monitoring. Therefore, it seemed necessary to determine the "role" of this test. We examined all of the Holter monitorings performed in Dynamic electrocardiographic laboratory of the S. Matteo Polyclinic from 1983 to 1986. 480 of the 3365 patients visited, presented precordial symptoms. 162 patients (group A) had established ischemic heart disease (old myocardial infarction and/or coronary arteriography). 318 patients (group B) had no definite diagnosis. 71 subjects from group A and 140 from group B presented a typical symptomatology. Group A showed a 31.48% positivity during the test with 165 ischemic attacks. Group B had 25.15% positivity with 397 ischemic attacks. 51 symptomatic attacks (30%) were recorded for group B. Therefore, there was a mayor incidence of silent ischemic heart disease in both groups. Results obtained comparing Holter monitoring to the bicycle ergometry exercise test and to functional test, were comparable in 56.91% (sensibility 41.71% and specificity 78.62%) in the first case and 61.38% (sensibility 42.50% and sensitivity 73.77%) in the latter. In conclusion, we believe that Holter monitoring is useful in mass screening because it permits monitoring of most ischemic attacks, whether under stress or at rest, symptomatic or silent.

Four cases of subjects with implanted pacemakers are reported. The patients temporarily presented suspected symptoms of altered activity of the pacemakers. On the other hand usual tests demonstrated a regular activity of the pacemakers. The dynamic electrocardiography, by a regular registration during 24/48 hours and during usual working, documented; once a partial hole in the circuits of the generator, twice a partial break of the catheter, once a displacement. It is underlined the importance of dynamic electrocardiography to identify temporarily altered activity of pacemakers, undiagnosticable by disposable usual tests.

In 6 patients affected by spontaneous angina with S-T elevation and coronariographic findings of obstruction, intravenous administration of ergonovine maleate determined the same clinical and ECG patterns of spontaneous episodes. The coronary arteriography during pain showed a marked spasm with occlusion of a large coronary vessel in four patients. In 2 patients with atypical chest pain and normal coronariogram, E.M. did not induce pain, ECG abnormality or coronariographic alterations. The role of spasm in spontaneous angina is discussed.

Based on classifications proposed by Anglosaxon and French authors who were the first to become interested in the so-called cardiomyopathies of unknown origins, 41 cases clinically classified as hypotrophic-hypokinetic (congestive) cardiomyopathies are presented. After a period of clinical observation, 21 cases were studied hemodynamically, with ventriculography and coronaryarteriography, with phonocardiography (35 cases) and follow-up from some months to 6 years. Post mortem studies were performed in 6 patients, five of whom died of congestive heart failure or thromboembolism and one of sudden death. It was concluded that these entities are hypotrophic-hypokinetic cardiomyopathies with a clinical pattern of congestive heart failure and with unknown aethiologic factors. Treatment as far as indications and efficacy are discussed.