Safety of heart radiotherapy for malignant cardiac tumors: a short and long term study

Background

Radiotherapy (RT) may be used as a complementary or palliative treatment for selected cases of malignant cardiac tumors, and improves the overall and relapse-free survival in cardiac sarcomas (1–3). Its use is limited by the risk of radiation injury on the cardiac structures (4). Only few data about the safety of cardiac RT are available.

Purpose

This study aimed to assess the short and long term adverse cardiac effects in a cohort of patients with cardiac malignancies treated with RT directly on the heart.

Methods

We reviewed the clinical and echocardiographic data of 25 patients (pts) treated with cardiac RT from 2002 to 2021, using Intensity Modulated RT or Tomotherapy at doses of 25–59 Gy over 5–25 fractions for primary or metastatic tumors (21 sarcomas). The patients had ECG and echocardiogram (ECHO) before RT and weekly during the treatment. After RT, the cardiac surveillance included a visit with ECG and ECHO every 3 months for the first 2 years, every 6 months for 3 years, and yearly thereafter. We compared the left ventricular ejection fraction (LVEF) before RT and at the last available follow-up for all patients; for 12 pts whose radiation field included the right chambers, we analyzed also the right ventricular shortening fraction (RVSF) at the last available follow-up.

Results

The pts were 14 males, 11 females, aged 22 to 75 (median 54) when treated. The intent was adiuvant after R1 surgery in 12 pts, preoperative in 3, palliative or curative for metastatic or unresectable tumors or in patients refusing redo surgery or chemotherapy (10 pts). Anthracyclines chemotherapy was used in 19 pts. The radiation field included the left atrium and/or ventricle in 11 pts, the right heart in 9, both left and right structures in 3. Two pts were lost to follow-up after 36 and 50 months; 17 died, 3 to 175 months after RT (median 12), all for non-cardiac causes; 6 are alive (with complete local remission) 15 to 126 months (median 79) after completing RT. Acute toxicities were: atrial fibrillation in 2 pts, pericarditis in 2 (both reverted in one week with medical therapy) and temporary worsening of ventricular arrhythmias in one pt with myocardial metastases. At last follow-up no significant valvular or pericardial disease was evident; the LVEF was >50% in all pts (5–10% decreased -compared to baseline- in 2 pts, improved in 3, stable in the others) and the RVSF was >35%.

Conclusions

In our experience, RT may be used in the treatment of cardiac malignancies with little adverse effects both on short term and at a median follow-up of 13 months (and lasting up to >10 years).

Funding Acknowledgement

Type of funding sources: None.

P4656Short- and long-term evaluation of safety of cardiac sarcomas radiotherapy

Background

Primary cardiac sarcomas (PCS) have a dismal prognosis (a reported median survival of 17 months). Complete surgical resection is the mainstay of treatment, but the resection may be incomplete or impossible because of the local extension. Multimodal treatment (MMT) with chemotherapy and radiotherapy (RT) is widely used in soft tissue sarcomas of the extremities, improving survival, and could be considered for PCS. A consequence of the inclusion of the heart in a radiation field, is acute and chronic radiation-induced heart disease (RIHD). New RT techniques, as Intensity Modulated Radiotherapy (IMRT) reduce the risk, focusing the radiation burden to the target neoplasm and limiting the involvement of the cardiac structures. Nevertheless, RT is rarely used in PCS, because the target lesion is inside the heart, and the heart's movement make difficult to avoid the irradiation of the surrounding structures.

Purpose

Our aim was to report the short and long term clinical and echocardiographic changes in patients (pts) with cardiac sarcomas treated with IMRT.

Methods

Amongst a group of 33 with PCS seen in our hospitals, we reviewed the data of 20 pts (12 males, 8 females) with PCS treated with local RT. The tumors were left-sided in 10 pts, right-sided in 8 and involved both right and left chambers in 2; fifteen patients had received also anthracyclines chemotherapy (CT). For every patient, we reviewed the clinical data and the echocardiograms performed (as for protocol) before and after CT, before starting RT, weekly during RT and at follow-up (FU), performed every 3 months for 2 years, every 6 months for 3 more years, then yearly. The mean age at diagnosis was 48 years (range 22–72). The FU lasted 2 to 131 months (mean 31, median 14). Five pts are alive 29–85 months (mean 57), after ending therapies, the others died of non-cardiac causes.

Results

At the end of RT 3 pts had atrial fibrillation (AF), which was cardioverted with Amiodarone, and one had acute pericarditis, treated with non-steroidal anti-inflammatory drugs for one week. Long-term therapy was not needed. The left ventricular ejection fraction (LVEF) was 52% to 70%, decreased by −1% to −10% in 10 pts. At last FU, LVEF ranged from 52 to 75%; it decreased (compared to baseline) by >11% in 1 pt only; global longitudinal LV strain (GLS), available in 8 pts only, was −17%. Amongst the pts with IMRT on the right heart, right ventricular function (evaluated by tricuspid annulus excursion, and right ventricular area shortening fraction) was within normal limits in all both at short and long term FU. There were no cases of constrictive pericarditis or of valvular disease.

Conclusion

In our experience IMRT for heart sarcomas seems to be relatively safe using modern RT techniques, without evident RIHD at long term follow-up. Larger studies are necessary to further evaluate the safety of RT in the multimodal treatment of cardiac sarcomas.

Adjuvant trastuzumab cardiotoxicity in patients over 60 years of age with early breast cancer: a multicenter cohort analysis

BACKGROUND

Adjuvant Trastuzumab with chemotherapy is the gold standard for human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (HER2+ EBC). Older patients have been largely under-represented in clinical trials, and few data on Trastuzumab cardiotoxicity have been reported in this subgroup.

PATIENTS AND METHODS

Four hundred and ninety-nine consecutive HER2+ EBC patients were treated with adjuvant trastuzumab and chemotherapy (aTrastC) at 10 Italian institutions. We evaluated disease prevalence and patient characteristics in the patients older than 60 years of age (over-60), prevalence of aTrastC cardiotoxicity and risk factors.

RESULTS

There were 160 'over-60' patients (32%), in whom a higher prevalence of hypertension, diabetes, renal dysfunction, dyslipidemia and treatment with ACEi (40 versus 8%) and beta blockers (20 versus 8%) was found than in the younger patients (339 = 68%). Clinical heart failure occurred in 6% of the 'over-60' and in 2% of the younger patients. A reduction in left ventricular ejection fraction of >10 points was detected in 33% of the 'over-60' and in 23% of the younger patients (all P < 0.05). aTrastC was discontinued in 10% of the 'over-60' and in 4% of the younger patients (P = 0.003), restarted in 44% of the 'over-60' and in 58% of the younger women (P = ns).

CONCLUSION

In clinical practice, 32% of HER2+ EBC patients treated with aTrastC are 'over-60'. These patients have an increased cardiovascular risk profile and develop aTrastC cardiotoxicity commonly.

Safety of adjuvant trastuzumab (T) in elderly patients with breast cancer

282

Background: T is a mainstay in adjuvant therapy for HER2+ breast cancer (BC) patients (pts). Safety and efficacy of T in elderly patients are largely unknown. In HERA trial, NSABP B-31, NCCTG N9831 only 16% of pts were older than 60 years. Risk factors for T related cardiotoxicity are age (>50 y/o), hypertension, baseline LVEF (left ventricular ejection fraction <55%), previous antracycline therapy and BMI.

Methods: Charts of pts >65 y/o with early HER2+ BC treated with T as adjuvant or neoadjuvant therapy at our institution were retrospectively reviewed. Primary endpoint was the evaluation of T cardiac toxicity and safety.

Results: 22 elderly out of 172 pts (12%) were identified: 19 pts were treated only with surgery and adjuvant chemotherapy with concomitant or sequential T, 3 more pts also received neoadjuvant chemotherapy concomitant with T. According to Balducci’s criteria, fit, vulnerable and frail pts were 20, 2, 0 respectively. Median age was 69 y/o (range 65-76). Hormonal status was negative in 10/22 (45%). 21/22 were histologic grade 3. Median follow-up was 33 months. Baseline comorbidities were the following: hypertension (G2-3) in 17 pts, diabetes mellitus in 1, supra/infraventricular arrhythmia (G1-2) in 3 and 1 pts. Antracyclines were administered in 16 pts (liposomal-doxorubicin in 5 pts), a sequential taxane-regimen was used in 3 more pts. Neoadjuvant weekly Paclitaxel and concomitant T was used in 3 pts. Median basal LVEF was 65% (range 59-74%). 2 pts developed an asymptomatic 10% LVEF drop from baseline (left ventricular systolic dysfunction G1) during T treatment. Known cardiac risk factors were hypertension in 1 pt and previous antracycline based chemotherapy in both. They recovered within 9 months. One minor adverse event was atrial fibrillation (G2) during T treatment.

Conclusions: T was well tolerated in elderly pts. More data are needed in order to understand the correlations between T related toxicity and cardiovascular risk factors. Long term safety of T treatment should verify the reversibility of cardiac T related toxicity on elderly pts.

Innovative schedule of oral idarubicin in elderly patients with metastatic breast cancer: comprehensive results of a phase II multi-institutional study with pharmacokinetic drug monitoring

BACKGROUND

To determine if protracted low-dose oral idarubicin (IDA), feasible in a previous dose-finding study, would result in similar activity and a better toxicity profile in patients with metastatic breast cancer.

PATIENTS AND METHODS

Elderly women (> or=65 years) with metastatic breast carcinoma were treated with 7.5 mg/day for 21 consecutive days, every 4 weeks. After the first fourteen patients, due to excessive toxicity, the protocol was amended to 5 mg/day. IDA and Idarubicinol (IDOL) plasma concentrations (C(trough)) were investigated in all patients.

RESULTS

Between April 1999 and June 2004, 47 elderly patients were accrued in this two-part study (14 and 33 patients respectively). The median age was 74 and 75 years respectively. Visceral involvement was present in most patients. A partial response was noted in 7/31 patients (22%; 95% CI, 9.6-41.1%). Eleven patients had stable disease (33%). At the dose of 5 mg/day the treatment was well tolerated. Neutropenia grade 4 was present in only 6% of patients; alopecia > grade 1 and cardiotoxicity did not occur. The median time to progression was 3 months and the median overall survival was 17 months. IDA C(trough) and IDOL C(trough) levels were significantly associated with haematologic toxicity.

CONCLUSION

This study shows that idarubicin at the dose of 5 mg/day for 21 consecutive days is feasible and effective in elderly breast cancer patients but do not demonstrate an improvement in efficacy. A determination of the IDA and IDOL plasma levels (C(trough)) is predictive for toxicity.

Left atrial invasion by lung carcinoma through a pulmonary vein

We describe a rare case of small-cell lung carcinoma invading the left atrium through a pulmonary vein. Echocardiography was particularly useful in this case in assessing the intracavitary extension of the tumor and the outcome of therapy. Echocardiography is a low-cost, easy imaging tool, complementary to radiological techniques and useful in evaluating thoracic tumors involving the cardiovascular structures.

Pharmacokinetic and pharmacodynamic effects of high-dose continuous intravenous verapamil infusion: clinical experience in the intensive care unit

OBJECTIVE

Our study aimed at evaluating the pharmacokinetic, cardiovascular, and metabolic effects of high-dose verapamil continuous intravenous infusion in cancer patients.

DESIGN

Prospective clinical and pharmacokinetic study.

SETTING

Intensive care unit of a Cancer Research Institute.

PATIENTS

Nine patients (age range 31 to 57 yrs) with progressive cancer disease and without cardiovascular, renal, or hepatic dysfunctions.

INTERVENTIONS

After a loading dose (0.15 mg/kg followed by 12 hrs of continuous intravenous infusion at 0.20 mg/kg/hr), the infusion rate of verapamil was increased every 24 hrs (0.25, 0.30, 0.35, and 0.40 mg/kg/hr). The highest rate was maintained for 48 hrs. Doxorubicin was given from the 60 th to the 108 th hr. Hydrochlorothiazide (25 mg/day) and potassium (36 mmol/day) were given orally. Altogether, 17 courses were completed.

MEASUREMENTS AND MAIN RESULTS

Steady state concentration (C(SS) and systemic clearance of verapamil and nor-verapamil (active metabolite) for each infusion rate were calculated. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), PR, QT and QTc intervals, and left ventricular ejection fraction (LVEF) were measured, as well as daily body weight, blood glucose and potassium. C(SS) of verapamil and nor-verapamil increased more than proportionally to the infusion rate (p<.001). Systemic clearance of verapamil decreased over the range of the infusion rate (p<.005). MAP and HR decreased at the 12th hr (p<.001) and then plateaued. CVP increased (p<.01). The relationship between MAP, HR, CVP, and verapamil plasma concentrations was significant (r2 = .25, .14, and .35, respectively; p<.0001). LVEF did not change. Six patients (11 courses) developed junctional rhythm. Three patients (six courses) showed a PR interval increase (p<.05). Patients with junctional rhythm had higher Css of verapamil (p<.009). Overall, QT and QTc intervals increased (p<.01). A linear relationship was observed between verapamil plasma concentrations and QT intervals (r2 = .09, p<.01). Cardiovascular side effects did not determine treatment withdrawal in any patient. Body weight, blood glucose, and potassium did not show significant changes.

CONCLUSIONS

Our data suggest a capacity-limited clearance of high-dose verapamil. In the absence of heart disease, following a step by step increase of the dosage, the high plasma verapamil concentrations (617 to 2970 ng/mL) produce frequent but well tolerated hemodynamic and electrocardiogram changes.

Relation of right ventricular morphology and function in pectus excavatum to the severity of the chest wall deformity

Although pectus excavatum (PE) is thought to impair right ventricular (RV) performance, the degree of RV dysfunction, if any, produced by this chest wall deformity remains controversial. To address this issue, we performed 2-dimensional echocardiography and chest wall radiography in 28 subjects with mild-to-severe degrees of PE to assess RV morphology and function in relation to the degree of the chest wall deformity. Measurements of RV anatomy and function obtained in these patients were compared to those of 24 normal control subjects of similar age and sex. In subjects with PE, mean RV outflow tract diameter at the aortic root level was narrower (1.4 +/- 0.3 cm/m2) and end-diastolic (10 +/- 2.3 cm2/m2) and end-systolic (5.8 +/- 1.4 cm2/m2) areas were larger than those in normal controls (1.6 +/- 0.3, 8.6 +/- 1.7, and 4.5 +/- 1.2 cm2/m2, respectively; p < 0.013). The magnitude of these abnormalities was related to the degree of the chest wall deformity evaluated on the chest radiogram (r = 0.54, 0.51, and 0.49, respectively). RV planar emptying fraction, an index of RV systolic function, was reduced in subjects with PE (42 +/- 10%) compared to the normal controls (48 +/- 10%; p = 0.047). No relation could be found, however, between this index and the severity of the chest wall deformity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Normalization of left ventricular function and subsequent recurrence of dilatation and pump failure in a patient with hypertensive heart disease in dilated phase after treatment with anthracycline]

A 71 years old man, ex-smoker, moderate drinker, with a history of diabetes mellitus (type II), moderate arterial hypertension, mild aortic stenosis and moderate uniform left ventricular hypertrophy echographically documented, developed a non Hodgkin low malignancy cavum lymphoma. He has underwent chemotherapy for two years (adriamycin and other chemotherapy drugs) at moderate dosages. A complete remission of the lymphoma followed the treatment, but an initial deterioration of left ventricular function, with heart dilatation and congestive heart failure, was found. The patient improved by medical treatment, returning to the previously stable clinical condition. However a ventricular dilatation reoccurred and a paroxysmal complete atrio-ventricular block developed, necessitating the implantation of a pace maker. The patient died suddenly, during sleep, at home. This is a unique case, because of the numerous cardiac factors associated (chemotherapy and clinical findings). More probably the combination of these multiple factors and their interrelationship could explain the unique non-linear evolution of the left ventricular hypertrophy. In conclusion in these patients a very strict clinical and pharmacological follow up with serial echocardiographical examinations is fundamental and highly recommended.

Effect of atrial fibrillation on pulmonary venous flow patterns: transoesophageal pulsed Doppler echocardiographic study

The effect of atrial fibrillation on pulmonary venous flow patterns is still not well known. Twenty-four patients in atrial fibrillation and 21 patients in sinus rhythm were studied by transoesophageal echocardiography. In ninety-five percent (20/21) of sinus rhythm patients, the early systolic wave due to atrial relaxation or reverse wave due to atrial contraction could be distinguished on pulsed Doppler tracings by transoesophageal echocardiography. However, there was no early systolic wave and/or reverse at the end of diastole in any atrial fibrillation patients. In atrial fibrillation patients without mitral regurgitation (n = 14), the onset of systolic flow was delayed (165 +/- 38 vs 50 +/- 46 ms, P < 0.05), and systolic peak velocities, time-velocity integrals and systolic fractions were reduced (31 +/- 13 vs 54 +/- 17 cm.s-1, P < 0.05; 5 +/- 2 vs 13 +/- 6 cm, P < 0.05 and 36 +/- 8 vs 61 +/- 15%, P < 0.05, respectively) as compared to those in sinus rhythm. Significant mitral regurgitation (n = 10) reduced systolic velocity parameters considerably in atrial fibrillation patients but the diastolic flow parameters were not significantly different between sinus rhythm and atrial fibrillation patients. Stepwise multiple regression analysis identified atrial fibrillation as an important independent predictor for changes in systolic flow parameters. The R-R interval is also an important factor for diastolic flow parameters. Thus, the present study demonstrates that atrial fibrillation significantly modifies pulmonary venous flow pattern and is an important factor for systolic flow parameters. Significant mitral regurgitation can further modify systolic flow pattern in atrial fibrillation patients.

Diagnosis of heart tumours by transoesophageal echocardiography: a multicentre study in 154 patients. European Cooperative Study Group

In a retrospective multicentre study, the diagnostic potential of transoesophageal 2D-echocardiography (TEE) as compared to precordial 2D-echocardiography (TTE) was determined in 154 patients with primary or secondary tumours of the heart. Additionally, the value of standard diagnostic parameters, such as symptoms, X-ray of the chest and electrocardiogram were evaluated. In 84 patients (24 male, 60 female; age 20-85, mean 56.6 years) intracardial tumours were present, and 70 patients (37 male, 33 female; age 18-79, mean 44.3 years) presented with peri- or paracardial tumours. The main symptoms of patients with intracardial tumours were dyspnoea (60.7%), vena cava syndrome (22.2%) and chest pain (20.2%). Embolization was found in 11.9%. Left or right atrial enlargement was observed on chest X-ray in 23 patients, and echocardiographic abnormalities in 17 cases. The patients with peri- or paracardial tumours presented with dyspnoea in 51.4% of cases, loss in body weight in 20.0% and with vena cava syndrome and chest pain in 17.1%. The chest X-ray was abnormal in 56 patients. Unspecific ST segment changes in the electrocardiogram were observed in five, and arrhythmias in seven cases. Diagnosis of atrial myxomas was achieved by TTE in 95.2%, by TEE in 100%, by angiography in 78.4%, by computed tomography (CT) or magnetic resonance tomography (NMR) in 70%. Identification of the attachment point was made by angiography in 8.1%, by TTE in 64.5% and by TEE in 95.2%. In 22 patients with intracardial tumours (myxomas excepted) diagnosis was achieved by TTE in 90.9%, by TEE in 100%, by CT or NMR in 88.9% and by angiography in 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic prediction of the final event in patients dying of acute myocardial infarction

From an autopsy series of 346 patients who died of acute myocardial infarction, we selected 36 cases for whom echocardiographic data preceding death were available: 17 cases died from a rupture of the left ventricular free wall (group A) and 19 from pump failure (group B). Our aim was to investigate whether any echocardiographic parameter could predict the final event. The total wall motion score, regional wall motion score index and percent of abnormally contracting myocardium were calculated. Diastolic and systolic volumes, ejection fraction and the eccentricity index, as a rough indicator of the left ventricular shape, were also estimated. Interventricular septum and posterior wall thicknesses were also measured. All measured parameters were similar in both groups except posterior wall thickness. Even though an unavoidable selection bias is present in our series, we failed to identify any echocardiographic predictor of the final event in this patient group.

Role of transesophageal echocardiography in evaluation of pulmonary venous obstruction by paracardiac neoplastic masses

From 71 consecutive patients with paracardiac neoplastic masses who underwent transesophageal echocardiography (TEE), obstruction of individual right upper pulmonary venous flow by compression by contiguous mass was detected by TEE in 4 patients before and disappeared after anti-neoplastic treatments. Pulmonary vein, contiguous neoplastic mass and their relation could be clearly visualized and assessed by TEE. Pulmonary venous obstruction was assessed as moderate degree by combination of Doppler flow characteristics and diameter of pulmonary vein. Before therapy, peak velocities and time-velocity integrals in obstructed right upper pulmonary venous flow were increased, whereas deceleration times of systolic flow were prolonged. After therapy, peak velocities and time-velocity integrals were reduced and deceleration times of systolic flow were shortened, with normalization of the diameter of the right upper pulmonary veins. Thus, TEE may be used to detect and evaluate pulmonary venous obstruction by neoplastic masses and its changes after antineoplastic treatments.

Usefulness of transesophageal echocardiography in evaluation of paracardiac neoplastic masses

Mediastinal paracardiac tumors may cause both cardiovascular complications and problems in differential diagnosis of cardiac diseases. Transesophageal echocardiography (TEE) may give an additional new window to mediastinal neoplasms, but only a few studies have been reported. TEE was performed in 70 patients with paracardiac neoplastic masses. The procedure was indicated to solve particular clinical problems in 20 patients, and as a prospective study on 50 unselected patients with mediastinal neoplasms. Twenty-three patients underwent follow-up studies; a total of 101 echocardiograms were recorded. The procedure was tolerated well or very well by most patients, and provided additional anatomic or hemodynamic data in every patient in group a and in 45 of 50 in group b. The additional data were relevant for clinical management in 14 of 20 patients in group a, and in 3 of 45 in group b. Based on the results of this study, TEE is useful in association with other radiologic techniques in patients with paracardiac neoplasms. As an imaging technique, it may represent a reliable alternative to computed tomography whenever the latter is not feasible.

Familial dilated cardiomyopathy: a transverse and longitudinal clinical and echocardiographic study

The familial occurrence of hypertrophic cardiomyopathy is well known; familial dilated cardiomyopathy has so far received less attention. Ten families with two or more members affected by dilated cardiomyopathy were studied by echocardiography. In 3 out of 10 families, a transverse study extended to even apparently healthy subjects was carried out, which included a total of 45 subjects. In 19 out of the 45, dilated cardiomyopathy (either symptomatic or asymptomatic) was diagnosed at echocardiography. Three more relatives, already dead of the disease, were identified through hospital records. A clinical and echocardiographic longitudinal study, lasting up to 11 years, was carried out in 5 of the 10 families. During the follow-up, 8 out of 19 patients who, at first examination were affected by dilated cardiomyopathy, died, one improved, 3 remained in stable condition and 7 were lost at follow-up. One of two patients who presented echocardiographic findings suggestive of border-line dilated cardiomyopathy returned to normality and the other developed dilated cardiomyopathy. The clinical and echocardiographic findings in our patients, and in their relatives, suggest the possibility that idiopathic dilated cardiomyopathy may be a multifactorial disease in which genetic factors might play a variable role.

Quantification of mitral regurgitation: comparison between transthoracic and transesophageal color Doppler flow mapping

We reviewed transthoracic (TTE) and transesophageal (TEE) echocardiograms of 100 consecutive patients: 63 male, 37 female, mean age 50 years (range 16-83 years), 32 with neoplastic disease, 18 aortic disease, 28 mitral valve disease, and 22 with other diseases. Absence or presence of mitral regurgitation (defined as mild, moderate, or severe) was assessed. TEE showed mild mitral regurgitation in 26 patients where TTE was negative. The overall estimate of regurgitant lesion severity was concordant at TEE and TTE in 64% of cases. The overall estimate of regurgitant lesion severity was also greater by one grade in 1% of cases at TTE, and in 35% of cases at TEE. Maximal digitized jet areas were 3.60 +/- 6.35 cm 2 at TTE and 3.04 +/- 3.79 cm 2 at TEE (P = NS). Correlation was r = 0.69 (TEE = 0.41 TTE + 1.55; P less than 0.001). TEE yielded a higher prevalence of mitral regurgitation than TTE with a trend toward greater overall estimate of mitral regurgitation at the semi-quantitative analysis. TTE and TEE showed similar mean results at the quantitative assessment of maximal jet areas. However, a highly significant random variability was observed in quantifying mitral regurgitation at TEE.

[Evolving electrocardiographic changes in massive neoplastic infiltration of the right ventricle. Description of a case and review of the literature]

We report a case of metastasis of lung carcinoma infiltrating the inferior left ventricular wall, the interventricular septum and the right ventricle. The metastatic invasion of the heart caused the appearance of pseudoischemic electrocardiographic changes, arrhythmias and eventually a conduction disturbances. The relevance of electrocardiographic changes as an indicator of cardiac metastasis in neoplastic patients is discussed.

[Apical hypertrophic cardiomyopathy: variability of bidimensional echocardiographic and electrocardiographic expression]

Apical hypertrophic cardiomyopathy is characterized by primary hypertrophy of the myocardium which is localized exclusively at the apex of the left ventricle. Previous studies have indicated that apical hypertrophic cardiomyopathy is characterized by a unique combination of cross-sectional echocardiographic and ECG findings ("giant" T wave inversion and high R wave voltage in the precordial leads). The aim of this study was to evaluate the possible relation between apical hypertrophy, quantitatively defined by cross-sectional echocardiography, and ECG findings in patients with apical hypertrophic cardiomyopathy. We studied 13 pts with apical hypertrophic cardiomyopathy, 10 men and 3 women (aged between 11 and 73 years, mean age 47). Apical hypertrophy was assessed quantitatively by determinating the muscle cross-sectional area in the apical region. From the end-diastolic apical 4 chamber view, endocardial and epicardial contours were digitized in order to obtain the muscle cross-sectional area of the left ventricle. The walls of the left ventricle were then divided into 3 regions (basal, mid-ventricular, apical). Final values of planimetered muscle areas are given as the average of the calculations obtained blindly and independently by 4 observers. The comparison between cross-sectional echocardiographic and electrocardiographic findings showed that patients with giant T wave inversion (T wave greater than 10 mm) and high R wave voltages (R greater than wave 25 mm) had a more severe degree of apical hypertrophy. However there was no complete agreement between cross-sectional echocardiographic and electrocardiographic findings. This study in fact demonstrates a wide variation in the degree of severity of apical hypertrophy among patients with apical hypertrophic cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation

We evaluated the correlations between electrocardiographic ST-T changes (negative T waves, ST segment elevation) and echocardiographic diagnosis of neoplastic infiltration of the myocardium in 95 patients with neoplastic masses in contact with the heart. We compared echocardiographic results to computed tomography, nuclear magnetic resonance, surgery or autopsy data in 49 patients: the concordance was 86 percent. Significant ST-T changes were present in 77.7 percent of the patients with myocardial infiltration at echocardiography. The "false negatives" (normal ECG, nonspecific changes) were mainly related to infiltration limited to the right side of the heart; in some of these cases, the appearance of right bundle branch block was observed. The "false positives" (ST-T changes without echocardiographic signs of infiltration) were observed in the older patients and in those with pericardial effusion or other heart diseases. The ST segment elevation was a more specific sign of myocardial infiltration as compared to negative T waves (86 vs 47 percent). A progression or the disappearance of electrocardiographic and echocardiographic abnormalities was observed during follow-up in 24 cases. Serial electrocardiograms are useful for screening in clinical settings in neoplastic patients; the appearance of ST-T changes or of conduction disturbances should suggest the need for two-dimensional echocardiography in order to define the diagnosis.

Echocardiographic findings of left ventricular hypertrophy and normalization of parameters of left ventricular function in patients with previous evidence of dilated and poorly contracting left ventricle and coexisting systemic hypertension

We report 6 cases of dilated left ventricle with poor left ventricular function and coexisting systemic hypertension in whom left ventricular hypertrophy and normalization of left ventricular function and dimensions have been subsequently documented by M-mode and two-dimensional echocardiographic follow-up studies. Four patients were in New York Heart Association functional Class IV, one in Class III, and one in Class II when first seen. Normalization of left ventricular function and dimensions and features of left ventricular hypertrophy (fractional shortening from 15.0 +/- 5.2 to 39.7 +/- 5.4, left ventricular end-diastolic diameter from 6.6 +/- 0.6 to 4.6 +/- 0.6 cm, left ventricular end-systolic diameter from 5.6 +/- 0.8 to 2.8 +/- 0.6 cm, left ventricular end-diastolic radius/posterior wall thickness from 3.1 +/- 0.5 to 2.0 +/- 0.4, interventricular septum thickness from 1.2 +/- 0.3 to 1.5 +/- 0.3 cm, left atrium from 4.6 +/- 0.6 to 3.5 +/- 0.9 cm) were achieved after adequate medical treatment at the end of the follow-up (11-39 months). It appears from this study that normalization of left ventricular dimensions and function with features of left ventricular hypertrophy can occur after adequate treatment in patients with echocardiographic findings of dilated and poorly contracting left ventricle and coexisting systemic hypertension. It is conceivable, in such cases, to classify the dilatation of the left ventricle as secondary and to suggest the hypothesis of a cause-effect relationship between therapy and normalization of left ventricular parameters with findings of left ventricular hypertrophy. Further studies are needed to clarify this phenomenon.

[Normally functioning mitral prosthesis: visualization and characterization of the trans-valvular flow using color-coded Doppler]

Color flow imaging (CFI) allows real time visualization of intracardiac and transvalvular blood flow, superimposed on two-dimensional echocardiographic images. Therefore it can be useful in the identification and characterization of spatial configuration of jets through valve prosthesis. The aim of this study was to define the transvalvular flow pattern of jet in 54 patients (pts) with mitral valve prosthesis which were functioning well. Thirty-six of these pts were females and 18 males; their ages ranged from 40 to 73 years, mean age: 58. Prosthetic mitral inflow was evaluated utilizing the parasternal long axis, apical long axis and apical 4 chamber views; in addition ("off axis") intermediate sections were used when needed. Adequate CFI for detailed frame by frame analysis was obtained in 50 pts (92%). Fourteen pts had biological prosthesis (9 Hancock, 4 Carpentier-Edwards, 1 Ionescu-Shiley). Thirty-six pts had mechanical prosthesis: 13 Björk-Shiley, 8 Starr-Edwards, 9 Sorin, 5 Lillehey-Kaster, 1 Smeloff-Cutter. Variable jet configurations were identified, which were related to the type of prosthetic valve. Bioprosthetic valve characteristically had a wide, homogeneous transvalvular flow, directed towards the interventricular septum. Björk-Shiley prosthesis presented typically a jet with two components. Trans-prosthetic flow was dependent on the spatial position of the prosthesis and on the orientation of the tilting disc. Thus, the main jet, coming from the major orifice, could be directed towards the apex, flowing parallel to the left ventricular postero-lateral wall while the jet coming from the minor orifice was thin and directed towards the interventricular septum.(ABSTRACT TRUNCATED AT 250 WORDS)

[Visualization and characterization of the transvalvular jet in mitral stenosis using color-coded Doppler]

Two-dimensional Color Doppler flow imaging is a new non-invasive technique which allows real-time visualization of intracardiac blood flow and provides informations about its direction, velocity and presence of turbulence. As a consequence the identification of jets configuration across stenotic valve orifices is now possible by Color flow imaging. This non invasive tool may be particularly helpful in patients with rheumatic mitral valve disease in whom distortion of mitral valve apparatus is often present, determining a non uniform and variable appearance of jets. Therefore the aim of this study was to describe our initial experience with color flow imaging in the visualization of transtenotic mitral jets in order to characterize different spatial configurations. We studied 45 patients with clinical and echocardiographic diagnosis of mitral stenosis. The mean age of these patients was 59 years (range from 36 to 72 years), 34 were women and 11 men. The different types of transmitral jets were characterized by real time and frame by frame analysis. The following characteristics of transmitral jets have been evaluated: A) appearance ("Candle flame", "Mushroom", "Scimitar"-shaped, "Double-jets"); B) direction (centrally directed or eccentric); C) extension into the left ventricle (basal, mid-ventricular and apical); D) persistence of turbulent flow during diastole (early-, mid-, late diastole). Mitral valve area was calculated from the velocity tracings obtained by continuous wave Doppler, applying the pressure half-time method. Color flow imaging of good quality for analysis was obtained in 41 of 45 patients (91%). In the other 4 patients the quality of color flow images was suboptimal however the direction and configuration of the jets could still be visualised.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal myocardial texture demonstrated by ultrasound in two patients with idiopathic haemochromatosis

We studied by cross-sectional echocardiography seven patients affected by idiopathic haemochromatosis without clinical signs of heart failure. In two patients the heart muscle showed a peculiar echocardiographic texture at the level of the endocardium. No differences were noticed in clinical and haematological findings of the patients with and without abnormal texture. Increased echogenicity of the subendocardial myocardium should be looked for in patients with idiopathic haemochromatosis.

Heterogeneity of left ventricular wall dynamics in normal hearts and in chronic aortic regurgitation. A two-dimensional echocardiographic study

The variation in shape, in the global and regional function of the left ventricle (LV) was quantitated by using Two-Dimensional Echocardiography (TDE) in 20 normal subjects (N) (17 males, 3 females, with a mean age of 21.2 years, age range 15 to 34) and compared to 20 patients with aortic regurgitation (AR) (14 males, 6 females with a mean age of 31 years, age range 16 to 51). The left ventricle was subdivided into two TDE short axis cross-sections at the papillary muscle (PM) and at the mitral valve (MV) level. Wall motion was assessed by the following indices; endocardial systolic fractional area change (FAC), wall thickening (Wth) and circumferential fiber shortening (S). The ejection fraction (EF), the diastolic (EID) and systolic eccentricity index (EIS), the end-diastolic volume (EDV), the end systolic volume (ESV) and the LV mass (M) were estimated using a 4 chamber apical view. Measurements of sectional cavity areas, muscle areas and endocardial perimeters were obtained twice independently by two observers using a computer aided system, to achieve the final results as the mean of the 4 measurements. Paired t-test showed a statistically significant variation between PM and MV for FAC in N (p less than 0.001). A statistically significant difference (p less than 0.01) was found for EID between N and AR. The EIS was not significantly different in the two groups. In AR a significant difference was found between EID and EIS (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Normalization of variables of left ventricular function in patients with alcoholic cardiomyopathy after cessation of excessive alcohol intake: an echocardiographic study

An excessive alcohol intake has been reported as one of the possible causes or risk factors of 'alcoholic cardiomyopathy'. The possibility that this cardiomyopathy may improve or even reverse if the alcohol abuse has been terminated has been suggested, but unequivocal echocardiographic documentation of this improvement has never been described. This study reports the normalization of cardiac chamber dimensions and of variables of left ventricular function documented by M-mode and cross-sectional echocardiographic follow-up studies, after cessation of excessive consumption of alcohol, in three cases of alcoholic cardiomyopathy.

Secondary neoplastic infiltration of the myocardium diagnosed by two-dimensional echocardiography in seven cases with anatomic confirmation

In seven patients with different types of neoplasm, secondary myocardial infiltration was diagnosed in vivo by two-dimensional echocardiography and confirmed by direct inspection. In all patients, clinical and electrocardiographic findings were suggestive but nonspecific for myocardial involvement. Two patients had cardiac tamponade and three had pericardial effusion. In three patients, the echocardiographic diagnosis made it possible to plan specific therapy. Clinical, electrocardiographic and echocardiographic aspects are discussed. A two-dimensional echocardiographic examination should be performed in all patients when cardiac metastatic involvement is suspected from clinical electrocardiographic findings, because the in vivo diagnosis of such a condition may have important therapeutic implications for such patients.

Pharmacokinetics of VM 26 given intrapericardially or intravenously in patients with malignant pericardial effusion

Three patients with lung cancer (1 SCLC, 2 NSCLC) and pericardial malignant effusion received 100 mg/m2 Teniposide (VM 26) i.v. and, 1 week later, 50 mg/m2 intrapericardially. Plasma, pericardial, and urine levels of the drug were measured in all patients after the two treatments by a HPLC assay. After intrapericardial administration, a high VM 26 concentration was found in the pericardial cavity and slow systemic drug absorption was observed. Since the drug AUC after intrapericardial administration was approximately 15-21 times that after i.v. administration, it could be that this treatment is more effective against neoplastic deposits localized in the pericardium. Even though this small series does not permit conclusions to be drawn on the efficacy of VM 26 given intrapericardially, the lack of local toxicity, minimal systemic toxicity, and the response observed in two out of three patients given intrapericardial VM 26 suggest that further investigation should be carried out on this method of VM 26 administration.

[Electrocardiographic changes and echocardiography variations in ventricular morphology in left ventricular overload]

In order to compare the ECG patterns to several echocardiographic morphological indexes in different left ventricular overloadings, 15 cases of systolic left ventricular overloading (SLVO) and 17 cases of diastolic left ventricular overloading (DLVO) were analyzed. The current ECG changes of left ventricular hypertrophy and some original parameters of ventricular repolarization have been correlated with volumes, ejection fraction and mass of the left ventricle (calculated by Reichek's formula) and with left ventricular diastolic and systolic eccentricity indexes, derived by the application of Fishl's formula to the 2D echocardiographic four or two chamber apical view. In both SLVO and DLVO we found a correlation between the left ventricular mass and Romhilt-Estes point score system (p = 0.02) as well as the degree of ventricular repolarization abnormalities (p = 0.01). In SLVO we found a direct correlation between negative P wave deflection on lead V1 and diastolic as well as systolic eccentricity index: that is, the more negative P wave the more elongated left ventricular geometry. Moreover, in SLVO we found an interesting apposite correlation, compared with DLVO, between the systolic eccentricity index and the degree of ventricular repolarization abnormalities: in SLVO ST depression or T wave inversion on left limb or left precordial leads was associated with the maintenance of an elongated shape of left ventricle, while in DLVO the same ventricular repolarization abnormalities were associated with the loss of the elongated geometry of left ventricle which became spheric. Thus ECG correlates with echocardiographic left ventricular mass if poliparametric voltage indexes are considered.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study of the intracardiac flow by real-time bidimensional color-coded Doppler echocardiography. Preliminary experience]

The new technique of real-time two-dimensional color Doppler echocardiography has been recently developed to allow visualization of the blood flow inside the cardiac chambers. The blood flow informations are color coded and displayed in real-time into the two-dimensional echocardiographic images of the cardiac structures. The flow informations which are given are velocity, direction and variance, calculated from the Doppler signals obtained from all the sample points. Flow directed toward the transducer is coded in red; flow away from the transducer is coded in blue, while the echoes from the cardiac structures are imaged in gray scale. The magnitude of the velocity of flow is represented by the brightness of the color, with an 8-steps scale of brightness, beginning from the lowest grade, which is not colored on the screen. To represent the velocity spectrum variance, green is added to each color in proportion to the extent of turbulence. We report our preliminary experience with this technique in 91 subjects by using an Aloka SSD 880 commercial equipment (age range 18 days-82 years): 5 were normal, 15 had cardiomyopathy, 21 had congenital, 40 valvular, 6 ischemic and 4 other forms of heart disease. Color display of intracavitary flow allowed to identify normal and abnormal patterns. Valvular regurgitation and abnormal intracavitary shunts were easy to identify, suggesting the possibility of a semiquantitative assessment of the lesions. The possibility of a quantitative approach should be further investigated in the future.(ABSTRACT TRUNCATED AT 250 WORDS)

[Possibilities and difficulties of differential diagnosis by 2-dimensional echocardiography of mobile masses inside the right atrium. Apropos of a case]

A peculiar case of mobile right atrial mass thrombotic in origin identified by two-dimensional echocardiography is reported. By the characteristics of the mass and the negative history for SBE and malignant neoplasm, the possibilities of tricuspid vegetations or infiltration by an extracardiac tumor could be reasonably ruled out. On the other hand, a myxomatous mass could not be excluded in this case. The thrombotic nature of the mass was recognized at autopsy. The possibility to identify by two-dimensional echocardiography right atrial masses together with the difficulties in certain particular cases to recognize their nature are discussed.

[Role of bidimensional echocardiography in the study of aneurysms of a membranous septum associated with defects of the intraventricular septum of perimembranous type]

Spontaneous closure of ventricular septal defects (V.S.D.) is frequently associated with aneurysm of the membranous septum (A.M.S.). However, the presence of A.M.S. may not be always indicative of closure or diminution of the size of V.S.D.. The purpose of this paper is to present the role of two-dimensional echocardiography (2D E) in the identification and assessment of A.M.S.. The dimensions, morphology and motion of A.M.S. during the cardiac cycle was also analyzed frame by frame by the 2D E technique. 20 cases of A.M.S. associated with perimembranous V.S.D. are included in this study. The most useful echocardiographic section in the assessment of A.M.S. was the apical four-chamber view with slight cranial angulation (sensitivity = 100%). The frame-by-frame analysis of A.M.S. motion during the cardiac cycle may give useful informations concerning the hemodynamic and physiopathologic abnormalities associated with the underlying congenital heart diseases. We conclude the 2D E seems to be useful in the identification and assessment of A.M.S. associated with perimembranous V.S.D.

[2-dimensional echocardiography in the evaluation of pericardial pathology: new prospects for its differential diagnosis]

We examined retrospectively the M-mode and two-dimensional echocardiograms performed in our laboratory on 227 patients with pericardial diseases, in order to assess the capabilities and limits of echocardiography in this field. We observed 4 patients with congenital absence of the pericardium, 10 with of constrictive or infiltrative-adhesive pericarditis, 213 pericardial effusions, associated with left pleural effusion in 36 cases and with different kinds of intrapericardial masses in 33 cases. Through qualitative analysis of the echogenicity of such masses some aspects were singled out which may prove useful in identifying intrapericardial fat, as well as tumors. We also suggest new ways of using specific echocardiographic sections to differentiate left pleural effusions from pericardial effusions, and to identify very small pericardial effusions.

Prospective identification of patients with amyloid heart disease by two-dimensional echocardiography

The purpose of this study was to determine whether changes in myocardial wall echogenicity that suggest amyloid disease could be prospectively identified by a qualitative analysis of two-dimensional echocardiographic images. Two thousand seventy-eight consecutive echocardiograms obtained over a 14 month period were prospectively analyzed. The myocardial walls of 30 patients showed multiple, discrete, small highly refractive echoes; amyloid disease was not known or suspected in any of them. It was recommended that all 30 patients undergo gingival biopsy to confirm the diagnosis and biopsy was performed in 15 patients. The recommendation for biopsy was made only on the basis of two-dimensional echocardiographic images and was independent of findings regarding thickness of the walls or the dimensions of the cardiac chambers. Results of biopsy were positive in 11 patients and negative in four. We conclude that qualitative evaluation of two-dimensional echocardiographic images can identify changes in myocardial wall echogenicity that correlate with a result of gingival biopsy positive for amyloidosis. In patients who have a typical myocardial texture by two-dimensional echocardiography and a positive gingival biopsy result, cardiac amyloidosis should be strongly suspected.

In vivo and in vitro evaluation of left ventricular thrombi by two-dimensional echocardiography. Comparison with cineventriculography

The purpose of this study was to assess the capability of two-dimensional echocardiography to identify left ventricular thrombi as compared to standard single plane cineventriculography in 284 patients, who underwent both procedures within 24 hours for diagnostic purposes. In order to obtain informations about the degree of thrombus organization and diagnostic accuracy of the echocardiographic technique, two-dimensional echocardiographic examinations were also performed in 31 thrombi from 16 autopsy specimens. In 249 cases the results were negative and in 14 cases positive by both techniques. Seven cases were positive by cineventriculography but negative by 2D-echocardiography. In seven cases the findings were equivocal by two-dimensional echocardiography; three of them were negative, two positive, and two equivocal by cineventriculography. In two cases the results were negative by two-dimensional echocardiography but equivocal by cineventriculography. Finally five cases were diagnosed to have a thrombus but two-dimensional echocardiography but not by cineventriculography. In two patients, positive by two-dimensional echocardiography, who were on anticoagulant therapy, follow-up studies showed the disappearance of left ventricular thrombi. In all of them the thrombi showed tissue characteristics similar to those of fresh thrombi examined in vitro. Two-dimensional echocardiography seems to be more reliable than cineventriculography for assessing the presence, extension, number, and morphology of left ventricular thrombi. In vitro studies suggest that two-dimensional echocardiography cannot visualize small thrombi, that fibrotic areas may simulate a thrombus and that in some cases under or overestimation is possible.