Introduction: Stepping has been one of the first proposed exercise tests but is not been adequately studied regarding cardiopulmonary parameters. Aims and objectives: Measuring cardiopulmonary and metabolic exercise indices in a 6-MST. Methods: Healthy volunteers were included in the study. Exercise protocol imposed ascending and descending a single step 23cm high with a rate of at least 20steps/minute and 3-minute recovery period. Blood pressure, ECG and expired gases were measured. Subjects were considered to have achieved maxVO2 when respiratory quotient (RQ)u003e1.1 or the 90% of individual9s estimated max heart rate. Results: Twenty two subjects (13 males/9 females) aged 38,64±6,22years old were included in the study. All of them achieved RQu003e1.1 but only 7 out of 22 the estimated maxHRu003e90% (mean value 84,53%±8,54). They ascended and descended 158,27±21,76steps, producing 177,54±31,06Joules/step and a total mechanical work of 27.800±6960Joules with a power of 77,22±19,33Watts. PeakVO2 was measured 1.756,00±414,67mL/min or 21,75±2,97mL/Kg/min equivalent with 6,21±0,85METS. Expired VCO2 at peak exercise was measured 1.846,22 ±443,50mL/min. Anaerobic Threshold (AT) occurred at 57,29%±14,50 of the predicted peakVO2. We found that for every 1mL/min of peakVO2 uptake a mechanical work of 0,06±0,008Joules was produced. PeakVO2 was found to be statistically correlated with measured peakVCO2, AT, estimated maxHR, maxVE, maxVT, VD/VT and total mechanical work (p Conclusions: 6-MST seems to be a reliable submaximal exercise test which could be applied in everyday clinical practice, provided that it needs cheaper equipment compared to conventional exercise tests.

Sustained ventricular tachycardia during dobutamine stress echocardiography is a rare complication of dobutamine stress echocardiography. It may be related to reduced left ventricular function and prior myocardial infarction but cannot be used as a sensitive or specific sign for myocardial ischemia. The clinical significance of dobutamine stress echocardiography-induced sustained ventricular tachycardia is uncertain, and this condition probably does not represent an adverse prognostic sign.

60-year-old woman, with a historyof hysterectomy for leiomyomatwo years earlier, was admitted toour department because of deterioratingfatigue and dyspnoea on exertion, pedaloedema, and a recent episode of syncope.Physical examination revealed an early di-astolic plop associated with a rumblingmurmur in the left parasternal region, he-patomegaly, ascites and severe oedema ofthe lower extremities. Transthoracic echocardiography re-vealed mild right ventricular dilatationwith preserved systolic function (S-wavevelocity measured with pulsed tissue Dop-pler in the basal free wall of the right ven-tricle >13 cm/s). In addition, a mass ofmoderate echogenicity was identified in-side the right ventricle in the long left pa-rasternal view (Figure 1A, arrow), as wellas in a modified apical 4-chamber view(Figure 1B, arrow). Partial obliteration ofthe flow of the inferior

The clinical and radiographic presentation of a child with spastic tetraplegia, anticonvulsant drug-induced rickets, borderline hypothyroidism and multiple slipped epiphyses is described. While the metabolic abnormalities were being treated, the parents denied surgical treatment and have been non-compliant with bracing of the wrist, ankle and knee deformities.By two years of medical treatment, rickets had resolved and the growth plates of the lower limbs' joints had closed. Non weight-bearing, gentle physiotherapy and bracing led to good results in the hip, ankle and wrist joints and to unacceptable residual valgus angular and rotational deformity of the right knee.Severely handicapped paediatric patients with metabolic bone disorders, non-compliant with bracing and with co-existent soft tissue contractures, are probably not good candidates for conservative treatment of severe angular limb deformities. However, non-operative treatment of minimal or moderate slippage of the proximal femoral epiphysis (as well as other major epiphyses) can lead to good results.

We present a case of a 75-year-old male with a worsening dyspnea during the last month. Transthoracic echocardiography revealed a severe mitral regurgitation. Transesophageal echocardiography was evident of a 6 mm defect of the mitral anterior leaflet at the region of the anteromedial A1 and medial A2 scallops probably due to perforation, which caused a significant regurgitant jet as documented by the presence of a convergence flow over the 'hole'. As the patient had a prolonged fever of undetermined origin one and a half months ago, perforation of the mitral anterior leaflet must at least be considered to be of an infective origin.

Aims: Aim of the study was to determine the effect of dobutamine stress echocardiography (DSE)-induced ischemia on circulating levels of N-terminal fragment of B-type natriuretic peptide (NT-pro-BNP).Methods and results: One hundred and twenty-eight patients underwent DSE for the evaluation of known or suspected coronary artery disease. NT-pro-BNP levels were measured before and 1 h after completion of DSE. NT-pro-BNP levels were similar before and after DSE regardless of whether patients had (123 +/- 101.8 vs. 124.2 +/- 108.3, p = NS) or did not have inducible ischemia (96.5 +/- 70.5 vs. 100.5 +/- 71.1, p = NS). Patients with inducible myocardial ischemia had no different NT-pro-BNP levels compared to patients without inducible ischemia both before (123 +/- 101.8 vs. 96.5 +/- 70 pg/ml, p = 0.37) and after DSE (124.2 +/- 108.3 vs. 100.5 +/- 71.1 pg/ml, p = 0.55). Patients with severe inducible ischemia had significantly higher NT-pro-BNP levels compared to patients with mild or moderate inducible ischemia and patients without inducible ischemia, both before (208.5 +/- 125.5 vs. 96 +/- 78.9 vs. 96.5 +/- 70 pg/ml, p = 0.017 and p = 0.025, respectively) and after DSE (212.5 +/- 138.1 vs. 94.8 +/- 81.1 vs. 100. 5 +/- 71.1 pg/ml, p = 0.015 and p = 0.023, respectively). NT-pro-BNP levels before DSE could be independently predicted by age (p < 0.0001), presence of diabetes mellitus (p = 0.002), and ejection fraction (p = 0.005), but not DSE inducible ischemia.Conclusion: NT-pro-BNP is not affected by DSE-induced ischemia and cannot be used in clinical practice to improve diagnostic accuracy of DSE. (C) 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

We report on a case of Inoue balloon mitral valvotomy in a patient with low echo score that was complicated by papillary muscle rupture 36 h after the successful procedure. Our case highlights the importance of close follow-up of patients undergoing percutaneous mitral valvotomy even following a successful procedure on pliable non-calcified valves. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

Recent studies have shown that enoxaparin may be equally as safe and effective as unfractionated heparin during a coronary angioplasty procedure. The aim of this study was to investigate whether enoxaparin can be used effectively and safely in place of unfractionated heparin in patients undergoing emergency or programmed coronary angioplasty, regardless of the use of platelet glycoprotein IIb/IIIa inhibitors.We compared two series of consecutive patients, who received unfractionated heparin (n = 217) or enoxaparin (n = 116) during emergency or programmed angioplasty, regardless of age, weight, renal function and the coadministration of platelet glycoprotein IIb/IIIa inhibitors. In the patients who received enoxaparin the arterial sheaths were removed immediately after the procedure.There were no significant differences between the two groups as regards clinical characteristics or risk factors for coronary artery disease. During a 30-day follow up no major adverse cardiac events were observed (death, myocardial infarction, target vessel revascularisation). Multivariate logistic regression analysis showed no correlation between the anticoagulant used and the occurrence of major cardiac events in the two groups of patients (log odds ratio = -9.46, p = 0.89), after controlling for age, sex, administration of platelet glycoprotein IIb/IIIa inhibitors, number of coronary lesions, number of stents used, clinical picture and risk factors for coronary artery disease. As regards the development of haematoma in the groin, the only significant independent predictive factor for this was the coadministration of platelet glycoprotein IIb/IIIa inhibitors.The use of enoxaparin in coronary angioplasty is safe, effective and allows faster removal of sheaths and mobilisation of the patient.

Introduction: Dobutamine stress echocardiography (DSE) represents an important diagnostic modality for the evaluation of coronary artery disease (CAD). The aim of this study was to present our experience from the application of the method in routine clinical practice. Methods: Eight hundred two DSE studies were performed in 418 patients (group A) with chest pain without a positive history of CAD and in 384 patients (group B) with a known history of CAD. Results: Two hundred sixty six studies were diagnostic of reversible myocardial ischemia. In group A, 119 patients had evidence of reversible ischemia and underwent coronary angiography, whereas 147 patients in group B had evidence of inducible ischemia and 94 of them underwent coronary angiography. Sensitivity and specificity of the method were from 82% to 100%, and 80% to 100%, respectively, for the detection of significant disease in the main left coronary artery or left anterior descending artery, and for 2- or 3-vessel disease. In group A, patients with no inducible ischemia had clinical follow-up over 1-21 months. During the study period one patient developed an acute myocardial infarction, 5 patients experienced an episode of sustained ventricular tachycardia, and 6 patients had an episode of supraventricular tachycardia. Other adverse effects included nausea (21%) and discomfort (31%). Conclusions: DSE is a reliable and safe method for the detection of myocardial ischemia.