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In a relatively large population of patients with treated systemic hypertension and normal left ventricular systolic function, prevalence of abnormalities of left ventricular diastolic function, as assessed by Doppler echocardiographic study of mitral and pulmonary vein flow, was high, with 51% of patients showing indirect signs of increased left ventricular end-diastolic pressure. Furthermore, our data documented that a "normal" mitral flow profile does not exclude the presence of an abnormality of left ventricular filling, which could be otherwise identified by combined analysis of a pulmonary vein flow profile. [ABSTRACT FROM AUTHOR]

Background: Left ventricular obstruction (LVO) is an infrequent complication following transcatheter aortic valve replacement (TAVR) that can lead to severe hemodynamic decompensation. Previous studies have analyzed the pathophysiology of this clinical entity; however, little is known about the anatomical characteristics as assessed by computational tomography (CT) of patients at risk., Methods: Data from 349 patients were retrospectively analyzed from a single center registry of patients undergoing TAVR at San Raffaele Hospital, Milan, Italy, between January 2020 and December 2021. All patients with aortic valve stenosis and available pre-procedural CT data were included. Patients with previous heart valve surgery/interventions were excluded., Results: Post-procedurally, a total of 57 patients (16.3 %) developed LVO. They were more frequently older (83.2 vs 81.4, p = 0.04), females (67 % vs. 47 %, p < 0.05) and had smaller body surface areas and weight. CT analysis between the two groups demonstrated an acuter aorto-mitral angle (107 vs 114°, p < 0.001), shorter interventricular septum to leaflet coaptation distance (SLCL, 22.1 vs 28.1 mm, p < 0.001), smaller telo-systolic left ventricular areas (267 vs 714 mm2) and smaller LVOT area (404 vs 470 mm2, p < 0.001) in patients with LVO. Multivariate regression analysis identified as parameters able to predict the occurrence of LVO the telo-systolic LV area (OR, 0.998; 95 % CI 0.996-0.999; p = 0.001) and the anatomical distance between the interventricular septum and the point of leaflet coaptation (OR, 0.92; 95 % CI 0.86-0.99; p = 0.02)., Conclusion: This is the first study identifying pre-procedural CT imaging predictors of patients at risk for LVO following TAVR. Further multicenter studies with systematic follow up will be needed to confirm these findings., Competing Interests: Declaration of competing interest Prof M Montorfano received consultant fees from Abbott, Boston, Kardia and Medtronic. Dr. Ancona received consultant fees from Abbott and Abiomed. Dr. Papageorgiou has received a fellowship grant from EAPCI/Abiomed. Other authors have no relationships relevant to the contents of thispaper to disclose., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Background: Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) disease is still burdened by a non-negligible rate of stroke and permanent pacemaker implantation (PPI). These suboptimal results, possibly related to the unique BAV anatomy, may suggest the use of a different sizing method in this setting. The aim of our study is to evaluate whether the application of the supra-annular LIRA method may improve clinical outcomes in this population., Methods: In this single-center retrospective study, we enrolled consecutive patients with severe aortic stenosis and raphe-type BAV undergone TAVR with the implantation of supra-annular self-expanding prostheses sized according to the LIRA method. The primary endpoint was the device success. Secondary endpoints were in-hospital and 30-day safety outcomes and 1-year clinical efficacy. All study endpoints were adjudicated according to Valve Academic Research Consortium 3 criteria., Results: A total of 104 patients (mean age, 79.8 ± 5.83 years) were enrolled in our study. The mean Society of Thoracic Surgeons score was 4.96 ± 4.73%. Use of the LIRA method led to prosthesis downsizing in 85.6% of patients. Device success was 94.2%. All-cause death was 0%, conversion to surgery was 0%, and an extremely low rate of stroke (1.9%) and PPI (9.6%) was observed. The intended performance of the valve was 96.1% and it was maintained at 1-year follow-up. Clinical efficacy at 1 year was reached in 90.6% of patients., Conclusions: The LIRA method represents an alternative option for prosthesis sizing in patients with type 1 and type 2 BAV undergoing TAVR with promising early and midterm outcomes., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Recently, an increase in the number of patients with severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) has been observed worldwide. In order to reduce waiting lists, provide to all patients referred to us equal access to care and to further improve the collaboration with spoke centers, we developed a specific Hub & Spoke specific protocol for TAVI. According to our protocol, a clinical selection (with echo and computed tomography scan) is done by Spoke centers, the case is discussed with a multidisciplinary team online and the procedure is planned (access, valve type size). At day 0, the patient is admitted in Spoke centers where blood samples are taken; at day 1, the patient is transferred to a Hub center for the TAVI procedure and after 2 h of observation, if no adverse events are registered, the patient is transferred back to the Spoke center. Since 2019, an agreement among our center and two hospitals has been signed. According to this Hub & Spoke model, a total of 72 patients with aortic stenosis were treated with TAVI (mean age 83 years, 48.6% female, median Society of Thoracic Surgeons risk 2.4 ± 1.1%, left ventricular ejection fraction 58.0 ± 7.75%). More frequently CoreValve Evolut R (47.2%) was used. Only 2 patients had a prolonged admission at Hub and were not transferred at day 1 (1 vascular complication and 1 intra-procedural resuscitated cardiac arrest). This Hub & Spoke model guaranteed shortening of waiting lists, more effective turnover of bed, equal access to care to patients referred to our center. In addition, it helped also to increase Awareness and education as well as appropriate training of the teams from spoke facilities.

Background: Ischemia with non-obstructive coronary artery (INOCA) disease is being progressively acknowledged as one of the pathophysiological mechanisms of chronic coronary syndrome (CCS) in an increasingly wide range of clinical pictures. Although the research has already begun to move towards a defined diagnostic pathway and a specific medical therapy for this disease, at present it remains a clinical challenge, especially if not thoroughly investigated., Methods and Results: The INOCA IT Multicenter Registry RF-2019-12369486 is a prospective, multicentric, non-randomized, single-arm, open label clinical study which aims to evaluate the efficacy of a stratified diagnostic and therapeutic approach on adverse events prevention and symptom relief in Italian patients with INOCA disease. The study population includes patients with a clinical presentation of CCS for angina and/or positive stress test for myocardial ischemia and evidence of non-obstructive coronary artery disease (CAD) at coronary angiography. In these patients a complete invasive coronary physiology assessment is performed with the guidewire-based measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), followed by acetylcholine (ACh) spasm provocation test. On the basis of the results of coronary function testing, patients are stratified into different INOCA endotypes (coronary microvascular disease, vasospastic angina, microvascular spasm, non-cardiac chest pain) and given a tailored medical therapy in accordance with the latest scientific evidence. At one year follow-up the impact of such a target therapy on angina class and quality of life, as well as on cardiovascular adverse events (hospitalization and coronary revascularization) is evaluated., Conclusions: The INOCA-IT Multicenter Registry will inform clinicians on sex-specific prevalence of INOCA in Italy and will show the impact of a stratified diagnostic and therapeutic approach on symptoms burden and prognosis of INOCA patients., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing., Competing Interests: Declaration of competing interest Prof M Montorfano receive consultant fees from Abbott, Boston, Kardia and Medtronic. Prof A Chieffo received speaker/consultant fees from Abiomed, Boston Scientific, Medtronic, Menarini, Shockwave Medical. Dr. Ancona received consultant fees from Abbott and Abiomed. Other authors have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Chest pain affects more than 100 million people globally, however up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease and ischemia with non-obstructive coronary artery disease (INOCA) is often a cause of the clinical picture. The symptoms reported by INOCA patients are very heterogeneous and often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. The underlying pathophysiological mechanisms of INOCA are multiple and include coronary vasospasm and microvascular dysfunction. Most importantly, this condition must not be considered benign: compared to asymptomatic individuals, INOCA patients present an increased incidence of cardiovascular events, rehospitalizations, as well as impaired quality of life, with increasing costs for healthcare systems. The aims of this review are to describe the pathophysiological and clinical characteristics of INOCA and to provide guidance to the medical community on the diagnostic approaches and management of INOCA, also via a series of clinical case reports.

Ischemia with no obstructive coronary artery disease (INOCA) is not an uncommon diagnosis in patients presenting with chest pain who undergo clinically indicated coronary angiography. However, the symptoms reported by patients with INOCA may be heterogeneous, leading to misdiagnosis and undertreatment. Herein we report 3 clinical cases of INOCA misdiagnosis and describe how the cases were reinvestigated following the appropriate diagnostic pathway. ( Level of Difficulty: Advanced. )., Competing Interests: Dr Ghizzoni has received a grant from Italian MoH within INOCA-IT Multicenter Registry RF-2019-12369486. Dr Chieffo has received speaker and/or consultation fees from Abiomed, Boston Scientific, Biosensor, Menarini, Medtronic, and Shock Wave Medical. Dr Montorfano has received consultant fees from Abbott, Boston, Kardia, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2023 The Authors.)

Aim: To evaluate short-term changes in tricuspid regurgitation (TR) after transcatheter edge-to-edge mitral valve repair (M-TEER) in secondary mitral regurgitation (SMR), their predictors and impact on mortality., Methods and Results: This is a retrospective analysis of SMR patients undergoing successful M-TEER (post-procedural mitral regurgitation ≤2+) at 13 European centres. Among 503 patients evaluated 79 (interquartile range [IQR] 40-152) days after M-TEER, 173 (35%) showed ≥1 degree of TR improvement, 97 (19%) had worsening of TR, and 233 (46%) remained unchanged. Smaller baseline left atrial diameter and residual mitral regurgitation 0/1+ were independent predictors of TR ≤2+ after M-TEER. There was a significant association between TR changes and New York Heart Association class and pulmonary artery systolic pressure decrease at echocardiographic re-assessment. At a median follow-up of 590 (IQR 209-1103) days from short-term echocardiographic re-assessment, all-cause mortality was lower in patients with improved compared to those with unchanged/worsened TR (29.6% vs. 42.3% at 3 years; log-rank p = 0.034). Baseline TR severity was not associated with mortality, whereas TR 0/1+ and 2+ at short-term follow-up was associated with lower all-cause mortality compared to TR 3/4+ (30.6% and 35.6% vs. 55.6% at 3 years; p < 0.001). A TR ≤2+ after M-TEER was independently associated with a 42% decreased risk of mortality (p = 0.011)., Conclusion: More than one third of patients with SMR undergoing successful M-TEER experienced an improvement in TR. Pre-procedural TR was not associated with outcome, but a TR ≤2+ at short-term follow-up was independently associated with long-term mortality. Optimal M-TEER result and a small left atrium were associated with a higher likelihood of TR ≤2+ after M-TEER., (© 2022 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Competing Interests: M. Montorfano and F. Russo received consultancy fees from Boston Scientific. The other authors have no conflicts of interest to declare.

Competing Interests: Funding Support and Author Disclosures Dr Ancona has received consultant fees from Abbott and Abiomed. Dr Montorfano is a proctor for Edwards Lifesciences, Boston Scientific, and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Purpose: The persistent left superior vena cava (PLSVC) is usually asymptomatic and creates a challenge when detected incidentally during cardiac resynchronization therapy defibrillator (CRT-D) implantation. The purpose of our cases is to show different anatomical variables of PLSVC and different strategies used for CRT-D implantation., Methods: Four cases of PLSVC were presented. Pre-procedural bilateral venography was done to define anatomical variant of PLSVC. The side of approach and vein of approach were chosen according to the anatomical variant. Major challenges, electrical parameters, procedural times, long-term follow up, and complications were addressed., Results: Two cases were de novo CRT-D implantation. One case was an extraction/re-implantation of the coil lead, and one case was an upgrading. In one case, CRT-D implantation was followed by AVN ablation. All cases had successful devices implantation. Two cases had isolated PLSVC: one of them had right approach and the other had left approach. One case had double SVC with no connecting brachiocephalic veins and underwent a left-sided approach. One case had double SVC with a small connecting brachiocephalic vein and had a left approach for implantation with using the small brachiocephalic vein for the RV lead. Electrical parameters were acceptable for all leads implanted. Long-term follow-up was done for 6 months to 5 years. One complication occurred (acute atrial lead dislodgement)., Conclusions: In our case series, the presence of PLSVC did not preclude successful placement of pacemaker/defibrillator leads using standard tools. Bilateral venography helped to decide the side and vein of lead insertion., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Theleadless pacemaker (LLPM) therapy has been developed in recent years to overcome the transvenous lead and device pocket-related complications. The LLPMs now available are self-contained right ventricular pacemakers and are limited to single-chamber ventricular pacing modality. This literature review deals with the current status of LLPM technology and current areas of clinical applicability. The safety and efficacy outcomes published from randomized clinical trials and real world registries are analyzed and compared with historical conventional transvenous pacemaker data. Furthermore, new pacing modalities and future perspectives to broaden the clinical use and cover most of pacing indications are discussed. Due to the overall safe and effective profile in the short term and intermediate term, also in fragile patients, the LLPM use is constantly growing in daily clinical practice. Actually, it can be considered a landmark innovation, through which a new era of cardiac pacing has begun., (© 2020 Wiley Periodicals LLC.)

Wellens' syndrome is a pattern of electrocardiographic T-wave changes seen in the precordial leads in patients with unstable angina. Two different patterns have been described. Type A presents with biphasic T-waves in V2-V3 and type B presents with symmetrical deep T-wave inversions in V2-V3. The etiology is related to a critical stenosis in the proximal left anterior descending artery (LAD). We describe a patient who presented at our emergency department with intermittent chest pain and showing Wellens' pattern T-wave inversions in the precordial leads of the electrocardiogram. She was found to have 95% stenosis in mid LAD.

We report five cases of stress related cardiomyopathies that occurred in post-menopausal women (age range from 49 to 90) consecutively admitted to our Department in the last year in different clinical settings: typical anginal pain, carotid endarterectomy, pulmonary edema, cardiogenic shock, and severe asthenia. Apical left ventricular involvement was observed in three patients in conjunction with ECG mild ST segment elevation in anterior precordial leads resembling acute anterior myocardial infarction; isolated mid ventricular dysfunction was present in two patients in conjunction with ST segment depression in the anterior precordial leads. The ECG evolved showing T wave inversion in four cases and normalized in one. In all cases, blood chemistry showed mild elevation of CK-MB and TN. The observed wall motion abnormalities were reversible in four of five cases during hospital stay. Stress echocardiography was performed in two patients (dobutamine in the patient with persistent mid-ventricular hypokinesis, exercise in another case) and correctly predicted the absence of coronary artery disease. We conclude that wall motion analysis at echocardiography combined with ECG ST segment changes and serum markers of myocardial necrosis (CK-MB and TN) may allow recognition of stress cardiomyopathies in different clinical settings. Echo stress may be proposed in those patients in whom some suspicion of coronary artery disease persists.

We report the case of a 71-year-old woman with previous coronary angioplasty, ovarian cancer with multiple metastases and allergy to iodinated contrast media, who developed vasospastic angina after several treatments with cisplatin and cyclophosphamide, so that we considered this as a case of "allergic angina" or Kounis syndrome (type II variant). The patient underwent standard anti-ischemic therapy with nitrates, calcium blocking agents and enoxaparin so having an uneventful outcome., (Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.)

We describe a 47-year-old man with a history of malignant melanoma, starting with a resection from his left thigh and followed, 4 years later, by a metastatic melanoma in the right ventricle. Within a few days, hemodynamic compromise occurred combined with evidence of an impressive intracavitary growth of the tumor causing obstruction of the right ventricular inflow and outflow tract. Echocardiography was valuable in the assessment of neoplastic cardiac involvement and was useful in detecting rapid right ventricular cavity obliteration by the expansion of the metastatic mass.

The aim of this study was to evaluate echographically anatomic and functional features of the left ventricle in adult patients with valvular aortic stenosis according to the presence or absence of congestive heart failure and the level of ventricular performance. Fifty-six adult patients with moderate-to-severe aortic stenosis underwent echocardiographic Doppler examination in order to evaluate left ventricular mass and dimensions, systolic function and filling dynamics. Twenty-seven patients had no heart failure and were symptomatic for angina (5), syncope (4) or were symptom-free (group I); the other 29 had heart failure (group II): 16 with normal left ventricular systolic performance (fractional shortening > 25%, group IIa) and 13 with systolic dysfunction (fractional shortening < or = 25%, group IIb). Despite a similar left ventricular mass, compared to group IIa, group IIb showed a significant left ventricular dilatation (end-diastolic diameter: 61 +/- 6.5 vs. 45.5 +/- 6.1 mm, p < 0.001) and mild or no increase in wall thickness (11.5 +/- 1.6 vs. 14.9 +/- 2 mm, p < 0.001). Indices of left ventricular filling on Doppler transmitral flow were also significantly different between the two groups, with a higher early-to-late filling ratio and a shorter deceleration time of early filling in group IIb (2.8 +/- 1.9 vs. 1.2 +/- 0.85, p < 0.01, and 122 +/- 66 vs. 190 +/- 87 ms, p < 0.05, respectively), both indirectly indicating higher left atrial pressure. Finally, heart failure was generally more severe in group IIb patients. In some patients with aortic stenosis, symptoms of heart failure may be present despite a normal left ventricular systolic function and seem to depend on abnormalities of diastolic function. The presence of systolic or isolated diastolic dysfunction appears to be related to a different geometric adaptation of the left ventricle to chronic pressure overload.

The aim of this study was to analyze the left ventricular (LV) geometric changes occurring in chronic pressure overload due to valvular aortic stenosis (AS). Fifty-six adult patients (30 women, 26 men, mean age seventy-two +/- nine years, range forty-five to eighty-five years) with isolated AS (mean valve area by Doppler = 0.6 +/- 0.2 cm2) underwent a complete Doppler echocardiographic examination. According to the value of relative wall thickness (RWT = 2 x posterior wall thickness/LV end-diastolic diameter) and LV mass index (LVMI) in normal subjects (RWT < or = 0.44, LVMI < or = 125 gr/m2) AS patients were subdivided into four groups: Normal: no patients; Concentric Remodeling RWT > 0.44, LVMI < or = 125 gr/m2): 4 patients (7%); Concentric Hypertrophy (RWT > 0.44, LVMI > 125 gr/m2): 39 patients (70%); and Eccentric Hypertrophy (RWT < or = 0.44, LVMI > 125 gr/m2): 13 patients [23%]. Eccentric hypertrophy patients had, as compared with those with concentric hypertrophy, a larger left ventricle (61 +/- 6.5 mm vs 47.6 +/- 6 mm, P < or = 0.001), a smaller mean wall thickness (11.3 +/- 1.2 vs 14.7 +/- 1.7 mm, P < 0.001) and reduced LV fractional shortening (FS% = 22.9 +/- 11 vs 42.6 +/- 8.7%, P < 0.001). Furthermore, most patients (11/13) of the former group had heart failure due to LV systolic dysfunction, while only 16 of 39 patients of the latter group had heart failure and all but 2 had normal LV systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular (LV) response to chronic pressure overload of aortic stenosis (AS) is usually characterized by an increase of wall thickness without cavity enlargement ("concentric hypertrophy"). During follow-up, two patients with AS developed relevant structural and functional changes of the left ventricle, ie, progressive LV dilatation, wall thinning, and reduction of systolic performance. At the same time, the patients had clinical symptoms of congestive heart failure. The pathophysiologic relevance of this form of LV remodeling in AS is discussed.

It is a common opinion that nitrate therapy may have a harmful effect on cardiac output in patients with congestive heart failure when left ventricular filling pressure is markedly reduced. In this study, we evaluated, using hemodynamic monitoring with Swan-Ganz catheterization, the effects on cardiac output and filling pressures of high-dose intravenous nitroglycerin in 8 patients with dilated cardiomyopathy and severe heart failure. At maximal doses of nitroglycerin utilized (350 +/- 220 micrograms/m, range 100-800), a significant reduction in right atrial pressure (from 4 +/- 3.5 to -1 +/- 4 mm Hg, p < 0.001) and pulmonary capillary wedge pressure (from 16 +/- 5 to 7 +/- 3 mm Hg, p < 0.001) was observed. Furthermore, we found neither a significant reduction in systemic vascular resistances (from 1,500 +/- 329 to 1,320 +/- 330 dynes/s/cm-5) nor changes in heart rate or blood pressure. Finally, stroke volume and cardiac index increased slightly although not significantly (from 62 +/- 18 to 70 +/- 16 ml and from 2.3 +/- 0.45 to 2.65 +/- 0.4 l/m/m2). The preservation of stroke volume despite a marked reduction in left ventricular filling pressure can be explained by a reduction in pericardial constraint and of mitral regurgitation induced by nitroglycerin. The clinical implications of these hemodynamic results are discussed with emphasis on the short- and long-term use of nitrates in congestive heart failure.

We report the case of a 52-year-old man admitted to our Hospital for a massive pericardial effusion already discovered at an X-ray examination of the chest more than one year before, but never submitted to further investigation. Four months after a first surgical intervention of "pericardial windowing" and a drainage of 1700 ml of clear pericardial fluid, the patient was again hospitalized because of cardiac tamponade and underwent open pericardial drainage. At inspection, the pericardium and the myocardial muscle were fused in a single mass that at histological examination was discovered to be a primary mesothelioma of the pericardium, epithelial type. We discuss the clinical course and review the scientific literature inherent in these rare cases of primary neoplastic diseases of the heart.

We examined 38 patients discovered to be affected by an atrial septal aneurysm (ASA) during 4014 consecutive echocardiographic examinations on an adult population in an eighteen-month period. ASA is often associated with other abnormalities, mainly mitral valve prolapse (23%), followed by aortic or pulmonary regurgitation, interatrial septal defect, tricuspid valve prolapse. It has been hypothesized that ASA could be a trigger for cardiac arrhythmias or a source of emboli to various districts. However, in our population we were not able to find any patient complaining of significant ASA-related cardiac symptoms nor affected by complications such as cardiac arrhythmias or embolic phenomena. Therefore, in our opinion this entity could be defined as quite benign neither requiring pharmacological therapy nor anticoagulant prophylaxis unless such treatments are indicated by an associated pathology.

Several epidemiological and clinical studies have underlined the close relationship between hypercholesterolemia and risk of coronary heart disease suggesting the opportunity of treating hypercholesterolemic patients according to their associated risk factors. Simvastatin, a drug for the treatment of hypercholesterolemia, is a competitive inhibitor of 3-Hydroxy-Methyl-Glutaryl-CoA reductase, the rate limiting enzyme in cholesterol biosynthesis. In the present study we have assessed the efficacy, safety and tolerability of simvastatin (10-20 mg) administered once daily for a period of 12 months to 50 patients with coronary heart disease (CHD) or at high risk for CHD according to the National Cholesterol Education Program. All patients underwent complete physical examination and laboratory safety tests (including blood cell count, liver function tests, creatine kinase and lipid profile) at baseline and every 6 weeks during treatment. Simvastatin was highly effective in reducing total and LDL cholesterol (-25% and -35% respectively). No significant effect on HDL cholesterol or triglycerides was obtained. Two patients were excluded after 6 weeks of treatment because of a serum creatine kinase increase (more than twice normal values). This was the only drug related side effect. In conclusion our data show that: a) simvastatin treatment is well accepted and compliance is good; b) the effect of simvastatin is evident after the first 6 weeks of treatment and is maintained during the whole treatment time; c) simvastatin is highly effective in lowering total and LDL cholesterol. When considering a patient who has had an atherosclerotic event the best deterrent to the occurrence of a subsequent event (secondary prevention) could be reduction of serum total and LDL cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

In a group of 13 patients with severe heart failure, both forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) significantly improved after intensive medical therapy (FVC: from 77 +/- 17 to 92 +/- 20%, p < 0.001; FEV1: from 65 +/- 15 to 81 +/- 15%, p < 0.001) in the absence of change in M-mode echo cardiac dimension and left ventricular systolic function; on the other hand, a change of indices of left ventricular filling by Doppler transmitral flow was documented (E/A ratio: from 3.6 +/- 1.2 to 1.65 +/- 1.5, p < 0.01; early filling deceleration time: from 94 +/- 39 to 178 +/- 78 ms, p < 0.01), indicating a reduction of pulmonary capillary pressure; this probably positively affected pulmonary interstitial edema and bronchial wall congestion, thus enhancing pulmonary function.

We report the case of an 80-year-old man affected by hypertensive cardiomyopathy and already admitted to our Division for recurrent episodes of heart failure. He was eventually hospitalized for septic shock secondary to disseminated pneumonia with concomitant left pleural effusion. At 2D-echo examination, a highly echo-reflectant mass was detected in the retrocardiac space. As the patient died notwithstanding the intensive pharmacological care, an autoptic procedure was performed which showed a massive thrombosis of the right atrial appendage. We discuss the 2D-echo imaging and advance a pathogenetic hypothesis after a review of the current literature.

Until recently the hemodynamic severity of valvular aortic stenosis (AS) was evaluated only by cardiac catheterization. Now, Doppler echocardiography allows a noninvasive and accurate assessment of AS severity and can be used to study its progression with time. The progression of AS was assessed during a follow-up period of 6 to 45 months (mean 18) by serial Doppler examinations in 45 adult patients (21 men and 24 women, mean age 72 +/- 10 years) with isolated AS. The following parameters were serially measured: left ventricular outflow tract diameter and velocity by pulsed Doppler, peak velocity of aortic flow by continuous-wave Doppler, to calculate peak gradient by the modified Bernoulli equation, and aortic valvular area by the continuity equation. At the initial observation, 13 of 45 patients (29%) were symptomatic (1 angina, 1 syncope and 11 dyspnea); during follow-up, 25 (55%) developed new symptoms or worsening of the previous ones (5 angina, 3 syncope and 17 dyspnea); 11 underwent aortic valve replacement and 3 died from cardiac events. Baseline peak velocity and gradient ranged between 2.5 and 6.6 m/s, and 25 and 174 mm Hg, respectively; aortic area ranged between 0.35 and 1.6 cm2. With time, mean peak velocity and gradient increased significantly from 4 +/- 0.7 to 4.7 +/- 0.8 m/s (p less than 0.01), and 64 +/- 30 to 88 +/- 30 mm Hg (p less than 0.01), respectively. A concomitant reduction in mean aortic area occurred (0.75 +/- 0.3 to 0.6 +/- 0.15 cm2; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

A 60-year-old man with atypical chest pain not submitted to adequate diagnostic procedures was treated on an empirical basis with nifedipine 20 mg b.i.d. The patient was referred to our institution where a first symptom-limited exercise stress-test during treatment was performed; neither S-T alterations nor clinical symptoms were induced at the maximal tolerated work load. Therefore we suggested a short period of hospital stay to repeat the stress-test after a progressive tapering off of the drug with the aim of obtaining a more definite diagnosis. However the patient refused and an at-home nifedipine withdrawal was planned. Some days later a second test showed marked S-T segment elevation in leads V4 to V6; concomitant high-grade ventricular arrhythmias and anginal pain occurred. Both the ECG alterations and the clinical symptom promptly regressed interrupting the test and administering sublingual isosorbide dinitrate. A coronary angiography performed few days later showed only a single and no significant stenosis of the left anterior descending artery (60%). The clinical and electrocardiographic pictures were therefore attributed to stress-induced vasospastic ischemia. A week later a third maximal stress-test during further treatment with nifedipine was totally negative. The pathophysiological mechanisms of rest and stress-induced vasospastic angina and the usefulness of Ca-blocking agents are discussed.

High blood cholesterol levels are associated with an increased risk of coronary heart disease. Guidelines for the detection and treatment of patients with hypercholesterolaemia have been developed in the United States and in Europe. The causes of secondary hyperlipidaemia are generally well known, but not always diagnosed. A wide variety of drugs cause secondary hyperlipidaemia but the incidence of this event is infrequently recognised. This article focuses on those drugs that are known to have an adverse effect on the serum lipid profile and the clinical significance of this effect.