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We describe a case of a 56 year-old man with a history of chest pain. No evidence of myocardial ischemia or arrhytmias was observed. Echocardiographic examination in Emergency Department evidenced aortic root dilatation. Angio CT excluded aortic dissection. Trans esophageous Echocardiography (TEE) correctly identified an arterial fistula between the right coronary artery and superior vena cava, confirmed by angio CT 3-D reconstruction and coronarography. The definitive diagnosis was made after integrated approach (using TTE, TEE, CT, coronarography). The anatomic features of the fistula and the aortic root were examinated. Actually the patient is being followed with serial clinical and echocardiography examination for monitoring hemodynamic overload by fistula and size of aortic root for potential surgical correction. Current literature for incidence, diagnosis and the treatment of coronary fistulas is discussed.

Pulmonary arterial hypertension frequently develops after a thromboembolic pulmonary event. The difference in degree of pulmonary artery pressure depends mainly on the size and location of the pulmonary embolus and presence of pre-existing cardiopulmonary diseases. Right ventricle (RV) afterloading from an acute obstruction of the pulmonary vasculature causes an increase of RV volume and dysfunction of right heart cavities, the varying levels of severity of which explain the multiple clinical expression of pulmonary embolism (PE). While the diagnostic approach, therapeutic management and prognostic evaluation are now well defined, the natural progression of PE is still not completely understood. In particular, insufficient data exist on the rate, timing and modalities of development of chronic thromboembolic pulmonary hypertension (CTPH). The aim of this review is to evaluate the role of echocardiography in detecting patients with CTPH, and in assessing hemodynamic consequences on RV and related prognostic implications.

IntroduzioneL'ischemia cerebrale è tra le principali cause di mortalità e morbilità nei paesi industrializzati, essendo responsabile del 10-12% di tutti i decessi e di un elevato numero di invalidità permanenti [1]. Le forme cardioemboliche, secondarie a fibrillazione atriale (FA), cardiopatia ischemica, valvulopatia reumatica, protesi valvolari, cardiopatie congenite ed endocarditi sarebbero responsabili di circa il 30-35% delle sindromi cerebrovascolari acute [2]. Tuttavia in una significativa percentuale dei casi, soprattutto nei giovani, gli episodi ischemici cerebrali non sono riconducibili a nessuna di tali alterazioni: si parla in questi casi di Stroke / TIA criptogenici [3]. In tali pazienti sono state frequentemente segnalate anomalie cardiache rappresentate dall'aneurisma del setto interatriale (ASA) e dal forame ovale pervio (FOP) [4]. L'ASA è un'alterazione costituita da un'abnorme estroflessione del setto interatriale che coinvolge prevalentemente la regione della fossa ovale, ma che può interessare anche tutto il setto, con diversa morfologia in relazione al variare delle pressioni esistenti nelle cavità atriali, potendosi mostrare come una sacculazione sinistra o destra concava fissa o più frequentemente fasicamente mobile [5][6].L'ASA è un'entità ad oggi ancora non ben definita: non univoci ne sono i criteri diagnostici, incerta ne è la prevalenza in popolazioni non selezionate, non definitivamente chiarito è il suo ruolo nelle sindromi ischemiche cerebrali/sistemiche, nella sua Cerebral ischemia is among the principal causes of mortality and morbidity in industrialized countries being responsible of 10-12% of all deaths and of an elevated number of permanent disability. The cardioembolic forms may be responsible of the 30-35% of cerebrovascular acute syndrome, nevertheless in a significant percentage of cases, especially among young people, cerebral ischemic episodes are not induced by these cardiembolic forms: these cases are defined as cryptogenetic stroke/TIA. In these patients cardiac abnormalities represented by an aneurysm of the interatrial septum (ASA) and by a patent foramen ovale (PFO) have been frequently observed. The purpose of our prospective study was to evaluate, through transthoracic ecocardiography and tissue harmonic imaging (ETT-THI), the prevalence of ASA in the general population (group A) and the prevalence of ASA-FOP in a subgroup of patients with recent episode of cryptogenetic ischemic stroke/TIA (group B). We studied in a prospective manner from January 1 2003 to October 31t 2004 n. 5.631 patients. The presence of ASA was found in 3,2% of patients of group A, while in patients of group B we identifyed an ASA in 32% and a POF in 42% of the cases. Using a ETT-THI, our study shows in a wide range of a non selected population a prevalence of ASA greater than in previous studies. Such high prevalence in the general population of patients submitted to echocardiography and the higher frequency in subjects with recent cryptogenetic stroke, suggests to search carefully these ab...