P223 THYROTOXIC DILATED CARDIOMYOPATHY

Hyperthyroidism can strongly impact cardiac function. Thyrotoxicosis enhances myocardiocytes metabolism and it can be responsible for hyperdynamic circulation state leading to heart failure with preserved ejection fraction, but also left ventricle dilatation and severe contractile function impairment. It can furthermore provoke arrhythmias, mostly atrial fibrillation, but, as we are going to discuss in this case, even ventricular arrhythmias. A 40–year–old woman came to our emergency department for chest pain. ECG showed reduced R waves voltage in precordial leads and troponin I values were normal. The echocardiogram showed severe left ventricle disfunction with global hypokinesia (EF 35%) and enlarged left ventricle (LVEDD 65 mm). Blood tests revealed severe hyperthyroidism with extremely low level of TSH, FT3 13,45 pg/ml, FT4 3,4 ng/ml and thyroid echography documented multiple solid nodular formations with hypo–isoechogenic signal. She underwent a coronary angiography that showed patent coronary arteries, and a cardiac magnetic resonance confirming severe contractile impairment and hypertrabeculation of the apex and lateral wall. On the assumption of a dilated cardiomyopathy secondary to hyperthyroidism, we started treatment with methimazole, ACE inhibitors and propranolol. During hospitalization, continuous ECG monitoring recorded several episodes of non–sustained ventricular tachycardia, the longest lasting 22 seconds, so the patient was discharged with a wearable cardioverter–defibrillator. It did not record any arrhythmias and it was dismissed a month later. After almost two months of therapy, the echocardiogram showed mild left ventricular contractility improvement (EF 45%), and blood tests documented partial reduction of hyperthyroidism. A 24–hour ECG Holter did not record any arrhythmias and the patient remained asymptomatic during all the period after discharge. Even if rare, scientific literature confirms that dilated cardiomyopathy with reduced ejection fraction can occur as a complication of hyperthyroidism. After the exclusion of an ischemic cause, we underline the need for adequate initiation of treatments for thyrotoxicosis and heart failure, in order to improve chance of left ventricular function recovery. In the case discussed, after two months of therapy, EF was still not completely restored but improved from 35% to 45%, and concurrently arrhythmic risk did clearly decrease.

[Endovascular laser treatment of lower limbs varicose veins: results of a three-years experience]

The aim of this work is to report our three-years experience in the endovascular laser treatment of lower limbs varicose veins. After the evaluation of results after a middle-term follow-up, Authors discuss about an enlargement of indications to this method, and suggest some original technical details.

[Epidemiological study on pathology and abnormalities of the external male genitalia]

The Authors report the outcomes of an epidemiology study concerning the external genital pathologies, carried out on 2400 young males, ranging between 18 and 22 years who underwent the medical inspection for admission to the Air Force Academy. Basing on an andrologic clinical and anamnestic protocol, 229 cases with genital abnormalities, and among them 171 cases of varicocele (8.16%), were detected. The presence of varicocele in all the selected cases was confirmed with proper instrumental investigations (CW Doppler, ecocolorDoppler, telethermography). A randomized sample of 240 out of the 2400 young males, underwent the same investigations as a routine. These investigations enhanced the accuracy in detecting the varicocele, and allowed to identify 3 new cases, all classified as 1st type, in addition to the 19 previously correctly detected by the clinical and anamnestic examination.

[Pre- and postoperative external biliary drainage in patients with obstructive jaundice caused by neoplasm of the pancreatic head]

The external biliary drainage in severe jaundice secondary to pancreatic carcinoma acts differently in pre, intra, and postoperative period. In the preoperative period the drainage enables to lower the direct bilirubinemia and the intrahepatic biliary stasis and consequently the complications linked to the impaired hepatic and renal function. During the operation the catheter acts as a guide in performing the biliodigestive anastomosis. In the postoperative period the external drainage of most of daily biliary secretion protects the biliodigestive anastomosis during the postoperative paralytic ileus, and prevents the fistula development along the pancreatic jejunal anastomosis.

[Gastrointestinal stromal tumors: a case with mixed muscular-neuronal origin]

GIST have still today controversial aspects of their histogenesis that are reflected on the classification and prognosis. It's showed a particular case with mixed muscular-neuronal histogenesis that supposes totipotent cell origin of these neoplasms. Diagnosis, classification and prognosis are very difficult to evaluate; surgery at the moment is the only useful treatment modality.

[Role of embryogenesis of the left renal vein and spermatic veins in etiopathogenesis of idiopathic varicocele]

The aim of this work was to clearly illustrate that the haemodynamic pathogenesis of the varicocele can be a consequence of a retrograde flux along the internal spermatic vein. The reflux is due to the use of a different path of drainage along the internal spermatic vein, which uses some collateral routes of the vessel, and mainly the nephrogenital branch. The diminishing pressure in the final segment of the internal spermatic vein is the focal points of the pathogenesis of the disease. The ontogenetic processes that lead to the formation of the left renal vein help in explaining the almost general one-sidedness of the disorder, its frequency and the fact that it is mostly the young who are affected by it. In fact, the variability of the timing and of the extension of the involution of the primitive venous system and of the processes of evolution which lead to the morphological definition of the tracts of the genital flow down, lead to the various manifestations of the idiopathic varicocele. This theory which also takes into account the physiological mechanisms of the venous drainage to the testicle in an anti-gravitation sense is part of the patterns that, under the diaphragm, rule the entire venous return of the blood toward to the heart.

[Structure of the venous wall of the pampiniform plexus in idiopathic varicocele]

The Authors discuss about some histologic patterns observed in 100 pampiniform plexus specimens of patients who underwent direct scrotal surgery for idiopathic varicocele. Tunica media was involved in all of 81 specimens in which Authors observed a vascular wall thickening. Out of these, localized hypertrophic phenomena, leading to segmental vascular obliteration, prevailed (74%) on widespread forms (26%). In advanced focal localizations subintimal fibrous pads were demonstrated. In 96% of cases hypertrophy affected the muscular layer too, respectively in focal (41%) and diffuse (59%) way. In 85% of cases fragmentation of lamina elastica interna was associated to media hypertrophy. In 69%, venous lumen was dilated, frequently in association with wall thickening, while only in 12 specimens all vascular layers were reduced. Occlusive endoluminal thrombi were evident in 12%. At last the Authors underline how the wall pathologic modifications do not involve all the veins within the same plexus, and stress on the possible physiopathologic relationships between this fact and different haemodynamic and clinic conditions.

[Bilateral hernioplasty: sonographic study of prosthetic integration as a function of fixation to the hernia opening]

The Authors report in this paper the outcomes of a post-operative study based on echo and echo-color imaging in 10 patients who underwent surgery for bilateral groin hernia. On both sides the operation was performed with a "patch and plug" implantation, according to the Rutkow technique. On right sides the polypropilene mesh was fixed to the inguinal orifice with cardinal stitches, while on left sides the mesh was shaped and spreaded on the orifice without any fixation. The U.S. postoperative pictures, performed up to 30 th p.o. day, showed a better stretching of the unfixed meshs, probably owed to a better adapting capability of the free mesh inside the tissues in standing position. The Authors consider significative the correlation between images showing in 7 patient's right sides little irregularities in mesh display, with presence of thin liquid filled spaces, and the moderate postoperative pain, that occurred in the same side in 6 of them.

[Experimental studies on the role of suture materials in the healing of anastomoses of the colon. Mechanical and histological study]

The relation between suture material and consolidation and healing in operations on the colon was investigated by using silk and catgut in one group of disinfected stray dogs subjected to right or left hemicolectomy and resection of the transverse portion, and a synthetic reabsorbable material (polyglycolic acid) in another. The following parameters were assessed following removal of the segment containing the anastomosis after various periods of time: resistance to biomechanical tests, stenosis of the lumen, extent and duration of inflammation and regeneration at the edge. Reabsorbable material was associated with less overall inflammation and healing was more rapid. Consolidation of the suture was not significantly different in the two groups.