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Aims Transthoracic (TTE), transesophageal echocardiography (TEE), and cardiac Magnetic Resonance Imaging (MRI) are usually the mainstay for diagnosis of cardiac myxomas (MYX). It has been reported that three dimensional (3D) TEE has an additional value in describing the anatomical features. MYX are classified in two types: solid (with a round shape and a non-mobile surface) and papillary (asymmetrical shape with an irregular surface). Even though embolic events are linked to thrombus formation in both types, the latter are more frequently source of embolism. The detection of the attachment of the peduncle and a detailed assessment of the echotexture and of the surface characteristics of the tumour is not always possible by 2D TTE and TEE, therefore MRI is considered the gold standard for diagnosing cardiac tumours and myxomas. Our study aim to determine the accuracy of 3D echocardiographic techniques in the detection of the following anatomical features of the MYX: site of attachment (mid atrial septum, other locations), modality of attachment (pedunculated or sessile), echotexture, surface characteristics in comparison with MRI, and histological findings. Methods and results We retrospectively reviewed 11 cases of the confirmed myxomas by histology that underwent 2D, 3D TEE, and MRI (6 cases) in the past 6 years in order to assess the ability of the imaging techniques in identifying the anatomical features. Pathology samples were analysed in all patients. Differences in parameters were collected. Our study group is comprised by 10 patients (one recurrence), 8 female, mean age 45.6 ± 14.6 years with 15 myxomas; 11 located in the left atrium [one in left atrial appendage (LAA), one on the mitral valve annulus, 9 near the fossa ovalis], 3 in the right atrium, and 1 on the left ventricular outflow tract (LVOT). Seven were pedunculated, 8 sessile. 2D TEE was not able to diagnose two myxomas. There was an agreement between 2D TEE and 3D TEE in detecting the peduncle except in three patients (only seen by 3D TEE): in the first patient the peduncle was in the atrial septum close to the opening of the left upper pulmonary vein; in the second it was close to the LAA and in the last it was in the LVOT. 3D TEE echotexture analysis matched the pathology in all cases, also in one case of solid tumour with fimbriated edges on a one side which was found to have a clot formation at surgery. There was an excellent matching between the 3D TEE and the MRI in all cases. In our cohort 3DE was able to detect all the morphologic features of the MYX including the site and the type of attachment, the echotexture, and the surface characteristics. The above results led to predict the histologic type, solid, or papillary and there was a correlation with embolism (three patients) and papillary tumours (two patients). Conclusions 3D TEE and MRI are reliable in assessing the anatomical features of myxomas. The described additional features (peduncle, echotexture, and surface characteristics) seen by these two methods could predict the histological type and have an additional value in the work up of the myxomas leading to correct diagnosis and evaluation of possible complications such as embolic risk. This is helpful to suggest in the management (antiplatelet vs. anticoagulation) and has a pivotal role in programming surgery.

SummaryWe present a 74-year-old male with a chondrosarcoma, who presented with chest pain. The history, electrocardiogram (ECG), and biomarkers established the diagnosis of myocardial infarction (MI); angiography did not show coronary atherosclerosis and, both initial transthoracic echocardiogram and chest computed tomography (CT), did not demonstrate any cardiac abnormalities. A second echocardiogram following a routine ECG showed presence of a mass involving the right ventricle and the cardiac apex that was confirmed by chest CT scan. We underline the importance of considering cardiac tumors in the clinical arena of MI management.Learning pointsCardiac tumors cause ECG changes similar to ischemic heart diseases.Keep in mind cardiac tumors when performing transthoracic echocardiogram (TTE) in the setting of suspected MI.TTE is the technique of choice in detecting cardiac tumors.

Our objective was to retrospectively evaluate the ability of multidetector-row computed tomography (MDCT) to detect previous myocardial infarctions (MIs) and to correlate necrosis with the status of coronary arteries supplying the infarcted territory. After having clinically evaluated 187 patients referred for ECG-gated MDCT of the coronary arteries, 30 previous MIs were identified in 29 patients (9 recent and 21 chronic). MDCT data were evaluated qualitatively and quantitatively by measuring attenuation values and wall thickness within the infarcted region and normal adjacent myocardium. Each MI was also assigned to the distribution territory of a coronary vessel, and morphological data were combined with MDCT angiographic findings. MDCT was able to detect 25/30 MIs showing an overall sensitivity and specificity of 83 and 91%, respectively. Quantitative analysis revealed a statistically significant difference in attenuation values between normal and infarcted regions (38.9+/-14 HU vs. 104.0+/-16 HU). Regional wall thinning was observed in chronic MIs (4.1+/-2 mm vs. 10.5+/-3.8 mm), and not in patients with recent event (7.9+/-1.6 mm vs 9.1+/-4 mm). In 22/25 cases, MDCT angiographic findings showed the presence of suspicious critical lumen narrowing (n=3), previous coronary stenting (n=14) and surgical revascularization (n=5) in the infarct-related coronary. During a single examination, MDCT might provide comprehensive imaging of MI offering a combined morphological and angiographic assessment.

During the 18th century in Naples, Raimondo di Sangro, Prince of Sansevero, gave definitive form to the family chapel, the so-called “Cappella San Severo”. The chapel houses not only extraordinarily beautiful and spectacularly detailed statues but also two human skeletons known as anatomical machines (“Macchine Anatomiche”) in the basement. These two skeletons, a man and a pregnant woman, are entirely surrounded by their own circulatory system, just as they were suddenly and mysteriously, fixed. Legend, believed as truth until few years ago, tells that Prince Raimondo had prepared and injected an unknown embalming substance in their blood vessels convicting them to eternal fixity. Most recent investigations, however, demonstrated that while the bones are authentic, the blood vessels are actually an extraordinary artifact, even though the perfect reproduction of the coronary vascular tree, including congenital malformations in detail, raises some doubts about the technique used by the Prince. The dreadful aspect of these two skeletons appears to be in strident contrast with the classic beauty of the statues, which glorifies and celebrates the ideal of morphology. Conversely, the two “Anatomical Machines”, protagonists of legends and superstitions since centuries, represent a marvelous example of science and art.

The aim of our study was the evaluation of the effects of cigarette smoking on ambulatory blood pressure (ABP) in normotensive subjects participating to a cardiovascular prevention program. All subjects were followed up for an average time of 97+/-42 months to assess the event of hypertension development. Prevalence of hypertension development was higher in smokers even if regression logistic analysis was not able to predict hypertension development.

The 64-slice multidetector-row computed tomography (MDCT) is an accurate noninvasive technique for assessing the degree of luminal narrowing in coronary arteries of patients with chronic ischemic disease. Aim of this study was to determine the value of MDCT in comparison to invasive coronary angiography (ICA) for detecting the presence and extent of coronary atherosclerotic plaques in a population of asymptomatic, hypertensive patients considered to be at high risk for cardiovascular events.We studied 67 asymptomatic, hypertensive patients at high-risk (Euro Score5%). All patients had negative or nondiagnostic findings at exercise stress testing and therefore underwent both MDCT and ICA.In the per-patient analysis, MDCT correctly identified 16/17 (94%) patients with significant coronary artery disease involving at least 1 vessel and 48/50 (96%) normal subjects. In the per-segment analysis, MDCT correctly detected 21/22 (95%) coronary segments with a stenosisor=50% and 856/868 (98%) normal segments, with a high negative predictivity of normal scans (100%). There was a good concordance between MDCT and ICA, with a high Pearson correlation coefficient between the coronary narrowings with the two techniques (r=0.84, p0.01). Mean coronary calcium score was higher for the 17 patients with significant coronary artery disease on ICA than in the 50 patients without (422+/-223 HU vs 72+/-21 HU p0.001). The ROC curves identified 160 as the best calcium volumetric score cut-off value able to identifyor=1 significant coronary stenosis with sensitivity 88% and specificity 85%.MDCT is an excellent noninvasive technique for early identification of significant coronary stenoses in high risk asymptomatic hypertensive patients and might provide unique information for the screening of this broad population.

Background— The sequence of left ventricular (LV) systolic emptying is not completely understood. Using real-time 3-dimensional echocardiography, we investigated this sequence and LV synchronicity in physiological and pathological conditions. Methods and Results— The study population consisted of 116 healthy volunteers, 20 top-level athletes, 35 patients with LV dysfunction, and 84 patients with LV dysfunction and left bundle-branch block (LBBB). We subdivided the LV into 16 volumetric segments for regional analysis and into apical, middle, and basal regions to calculate the mean of end-systolic times and the time to minimum systolic volume of each region. In healthy volunteers and in top-level athletes, the emptying systolic times increased smoothly from apex to base. These differences determined an apex-to-base time gradient in the LV emptying sequence. In patients with LV dysfunction and without LBBB, this gradient was maintained with a relatively higher LV dyssynchrony. However, in patients with LV dysfunction and LBBB, there was no clear sequence in LV emptying volumes, and this group had the highest LV dyssynchrony. Conclusions— Real-time 3-dimensional echocardiography tomographic slicing of the LV enables accurate analysis of LV emptying in physiological conditions and in conditions of LV dysfunction with and without electrical dyssynchrony. Progressive dilation of LV produces deterioration in LV synchronicity. However, it is the presence of LV dysfunction in combination with LBBB that determines the loss of the apex-to-base time gradient in LV emptying.

Left atrial (LA) enlargement is a negative prognostic factor for survival in patients with stroke, congestive heart failure, and myocardial infarction. In the absence of mitral valvular disease it is also a marker of chronic elevated left ventricular filling pressures. The aim of our study was to examine whether the currently considered factors such as demographic, clinical, and Doppler parameters fully correspond to LA maximal volume measured by real time three-dimensional echocardiography (RT3DE). Two-hundred-twenty-four patients (age 58+/-12 years) were studied. Of these, 66 were healthy volunteers and 158 were patients with more than 2 cardiovascular risk factors (109), documented coronary heart disease (CHD) and normal LV function (33), and patients with (10) and without (6) IHD and LV systolic dysfunction. Two-dimensional Doppler and tissue Doppler (TDI) echocardiographic parameters and LA maximal volume, assessed by RT3DE were analyzed. LA maximal volume values were positively and highly significantly associated, after adjustment for age and sex, with LV mass, mitral flow peak E velocity and E/A ratio, TDI E'/A' ratio and E/e' ratio (P0.001). There were highly significant inverse associations of LA maximal volume and ejection fraction and peak A' velocity detected by TDI (P0.0001). LA maximal volume was significantly correlated with the progression of diastolic dysfunction from normal to grade III. In particular, there was a clear difference between the normal and pseudonormal filling patterns (p0.001) in terms of LA maximal volume. In conclusion, progressive LA volume increase is directly correlated with age, LV mass, and LV diastolic dysfunction, and inversely correlated with LV systolic function.

Are recommended indications for ambulatory blood pressure monitoring followed in clinical practice?

This study was performed to evaluate the ability of 64-slice multidetector computed tomography (MDCT) to detect previous myocardial infarctions (MIs) in patients referred for the assessment of the coronary arteries. In patients with regional changes of left ventricular wall myocardial density, the territory-dependent coronary vessel status was examined.We retrospectively assessed 202 consecutive patients referred for 64-slice MDCT of the coronary arteries. In all cases, detailed, clinical, serological and electrocardiograph (ECG) data were collected to identify patients with a previous diagnosis of MI. An initial qualitative evaluation of MDCT images was performed in all patients to identify areas of suspected myocardial necrosis, which were defined as regions of lower density within normally enhanced left ventricular myocardium. Thereafter, in all patients with suspected MIs, attenuation values and left ventricular wall thickness were also measured at the level of the normal myocardium and within the hypodense regions. Each MI was also assigned to the distribution territory of a coronary vessel, and morphological data were combined with MDCT angiographic findings.After clinical assessment, MI was found in 27 patients (six acute).; 64-slice MDCT was able to detect the presence of MI in 24/27 cases, showing sensitivity and specificity of 89% and 95%, respectively, and an overall diagnostic accuracy of 95%. Quantitative analysis showed a significant difference (p0.01) between attenuation values of normal vs. infarcted myocardium (124.5+/-19 HU vs. 56.1+/-23 HU, respectively); wall thinning was exclusively observed in chronic MIs (p0.01). In 23/24 detected cases, analysis of territory-dependent arteries showed findings compatible with presence of MI.The presence of MI is well depicted with retrospective 64-slice MDCT. The main advantage of 64-slice MDCT is that it allows to evaluate and relate the status of a vessel and its dependent myocardial region in a single exam.

Being usually asymptomatic, anomalous coronary arteries (ACAs) are discovered in adulthood using invasive coronary angiography (CA) performed for suspected coronary artery disease. However, if only based on CA, the correct diagnosis is not easily made. We report on the importance of integrated data obtained by using multidetector computed tomography, and perfusional myocardial scintigraphy as alternative non-invasive imaging techniques in evaluating the exact course and the functional importance of usually considered "benign" ACAs in three symptomatic subjects, and of the development of official recommendations for the practitioners in the management of such patients.

High normal blood pressure (HNBP), i.e. blood pressure (BP)or = 130/85 mmHg and140/90 mmHg, is an important predictor of progression to established hypertension.The purpose of this retrospective study was the evaluation of the predictive value of ambulatory blood pressure monitoring (ABPM) for the development of drug-treated hypertension in subjects with HNBP and other risk factors.We studied 127 subjects (69 M, 58 F, age 50 +/- 14 years): 59 subjects had normal BP (NBP:130/85 mmHg), 68 subjects had systolic and/or diastolic HNBP. All the subjects underwent ABPM. There were 21/68 (30.9%) subjects in the HNBP group vs. 1/59 (1.7%) in the NBP group with an elevated (135/85 mmHg) daytime ambulatory blood pressure (ABP) (p0.01).After an average follow-up of 103 +/- 28 months, 27 subjects (39.7%) in the HNBP group and 4 subjects (6.8%) in the NBP group developed drug-treated hypertension (p0.01). An elevated daytime ABP correctly predicted development of drug-treated hypertension in 17/21 subjects (81%) of the HNBP group and in the only subject of the NBP group. Development of drug-treated hypertension was associated with higher office and ambulatory BP (p0.01) and pulse pressures (p0.05), longer follow-up (p0.05) and higher prevalence of hypercholesterolaemia and smoking (p0.01).We conclude that ABPM correctly predicts development of drug-treated hypertension in most subjects who were identified early as having a daytime mean ABP135/85 mmHg. ABPM appears to be a useful clinical tool in the early diagnosis of hypertension in subjects with metabolic risk factors and smoking.

Immigration has increased drastically to the point of becoming an ordinary structure of our society. Once in Italy, the immigrant's health is compromised rapidly due to a series of conditions and illnesses that exist in our country: lack of work, inadequate salary, inappropriate residence, lacking family support, climate changes, nutritional differences. Cardiovascular illnesses represent 7.6% of the diseases of the immigrants, and cause 36.6% of deaths. The risk factors that affect the genesis of cardiovascular diseases include: subjective factors (age, ethnic group), environmental, nutritional and pathological (arterial hypertension, AIDS, tuberculosis, alcohol). The challenge for our time is to design a new solidarity model to promote cultural and social integration in order to meet the multiethnical and multiracial needs of western society. This model should permit reconsideration of doctor-patient relationship in order to build a real intercultural society.

Coronary angiography is presently considered the gold standard test for the assessment of coronary artery disease. However, owing to the exposure to ionizing radiations, the invasiveness, and the incidence of major complications (0.3-1.1%), investigators are attempting to develop safer, non-invasive techniques. Cardiovascular magnetic resonance proved to be an extremely safe tool with a wide range of clinical applications. Its flexibility and non-invasiveness allow the evaluation of the heart and coronary arteries in one single setting, with the possibility of quantifying several cardiac physiological parameters. Multiple techniques have been applied to overcome the substantial difficulties in coronary artery imaging: respiration artifacts are suppressed by breath-holding or respiratory gating, cardiac motion artifacts are reduced by diastolic gating with ultra fast sequences and the signal-to-noise ratio can be increased with contrast agents. In several clinical trials, magnetic resonance coronary angiography has been successfully used to assess coronary artery stenoses, coronary artery bypass grafts and anomalous coronary artery origins and course. Considering the continuing developments in magnet coils, in software technology and in innovative imaging approaches, it is likely that magnetic resonance coronary angiography will in the future play an important role in the evaluation of coronary artery disease.

Objectifs Etudier les variations du rehaussement arteriel en fonction de la teneur en iode de l’agent de contraste au cours de l’exploration des arteres coronaires par MDCT. Materiels et methodes Cinquante patients suspects de pathologie coronarienne ont beneficie d’une exploration arterielle coronaire par MDCT couplee a l’ECG. Chaque patient a recu selon randomisation, une dose de Iomeron ® -300 (groupe A) ou Iomeron ® -400 (groupe B), correspondant a 56 g d’iode, administre a la vitesse 4 mL/s et pousse par un bolus de solution saline. Les images ont ete reconstruites a 40 %, 50 %, 60 % et 70 % de l’intervalle R-R et l’evaluation a porte sur les images comportant le moins d’artefacts de mouvement. Le rehaussement a ete mesure sur 15 segments coronaires et dans le ventricule gauche. La visualisation de chaque segment coronaire a ete evaluee par deux radiologues. Resultats Un total de 750 segments coronaires a ete evalue. Les valeurs d’attenuation etaient significativement superieures avec Iomeron ® -400 (p ® -400) par rapport au groupe A (Iomeron ® -300). Conclusion Ces resultats preliminaires montrent qu’un produit a forte concentration d’iode augmente le rehaussement arteriel et ameliore la visualisation des arteres coronaires.

P-56 Key Words: Ambulatory Blood Pressure Monitoring, Recommended Indications, Cost-Effectiveness

Incubation of isolated rat hepatocytes with cytotoxic concentrations of menadione resulted in inhibition of plasma membrane Ca2+-ATPase activity. This could be restored by subsequent treatment with either dithiothreitol or reduced glutathione, suggesting that the inhibition by menadione was due to oxidation of sulfhydryl groups critical for Ca2+-ATPase activity.

The ATP-dependent sequestration of Ca2+ by the plasma membrane fraction from rat liver is stimulated by reduced glutathione and dithiothreitol and inhibited by diamide and t-butyl hydroperoxide. The inhibitory effect on Ca2+ sequestration by the oxidizing agents is prevented in the presence of the thiols. Our results therefore suggest that free sulfhydryl group(s) may be critical for the activity of hepatic plasma membrane Ca2+ translocase, and that inhibition of this activity by the oxidation of such group(s) may contribute to the perturbation of Ca2+ homeostasis during oxidative stress.

The incubation of isolated rat hepatocytes with extracellular adenosine 5′-trihosphate (ATP) resulted in an inhibition of Ca2+ efflux. The ATP-induced Ca2+ accumulation as determined by the increase in phosphorylase a activity and the Ca2+ -sensitive fluorescent indicator (2-[(2-bis-[carboxymethyl]-amino-5-methylphenoxy)-methyl]-6-methoxy-8-bis-[carboxymethyl] aminoquinoline-tetrakis-[acetoxymethyl]ester) (Quin 2-AM) was associated with both the hydrolysis of ATP and the phosphorylation of a 110 kDa protein. No significant alteration in the intracellular ATP level was observed. The appearance of surface blebs and cytotoxicity followed the rise in cytosolic Ca2+, suggesting that the increased free Ca2+ may be responsible for the loss of viability. When a calmodulin inhibitor, 1-[bis(4-chlorophenyl)methyl]-3-[2-(2,4-dichlorophenyl)-2-[(2,4-dichlorophenyl)methoxy] ethyl]-1H-imidazolium chloride (calmidazolium), was included in the medium prior to ATP addition, bleb formation was reduced and the loss of viability was completely prevented, indicating that a Ca2+ -calmodulin process may be involved in the initiation of cytotoxicity.