Coronary microvascular dysfunction is associated with impaired cognitive function: the Cerebral-Coronary Connection study (C3 study).

BACKGROUND: It remains unknown whether the presence of coronary microcirculatory dysfunction (CMD) correlates with its equivalent condition in the brain, cerebral small vessel disease (CSVD). The cerebral-coronary connection (C3), a prospective blinded study, investigated the prevalence of CMD in patients with coronary artery disease (CAD) and its association with CSVD and cognitive function. METHODS AND RESULTS: Patients with documented CAD fulfilling inclusion criteria underwent physiological assessment of epicardial vessels and the microcirculation using intracoronary pressure and Doppler. Coronary microcirculation-related indices included coronary flow reserve (CFR) and hyperaemic microvascular resistance. Brain magnetic resonance imaging, transcranial Doppler (TCD), and neurocognitive examination were performed. Overall, 67 patients were included in the study (mean age 66 years, 73% female). Patients with abnormal CFR (<2.0) (55.2%) showed higher burden of white-matter hyperintensities: 43.2 vs. 20.0% (P = 0.044). After statistical adjustment, low CFR was associated with lower grey matter volume (P = 0.024) and with parameters of white-matter microstructural damage in diffusion-tensor imaging (lower fractional anisotropy and higher mean diffusivity, P = 0.029 and P = 0.032, respectively). Low CFR was associated with higher resistive (P = 0.027) and pulsatility (P = 0.043) values on TCD, and worse neurocognitive test scores (lower mini mental state examination, P = 0.025, and slower Trail Making Test A, P = 0.034). CONCLUSIONS: Coronary microcirculatory dysfunction is frequent in patients with CAD and correlates with CSVD, abnormal cerebral flow haemodynamics, and significant cognitive impairment. These findings support the hypothesis that microvascular dysfunction in the heart and the brain are part of a single pathological process affecting microcirculation in patients with CAD. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT04131075.

Tricuspid annular plane systolic excursion inaccuracy to assess right ventricular function in patients with previous tricuspid annulopasty.

OBJETIVES: The clinical and prognostic usefulness of tricuspid annular plane systolic excursion (TAPSE) is well established. However, the ability of TAPSE to assess right ventricular (RV) function in patients with previous tricuspid valve annulopasty is controversial. This study examined the TAPSE suitability in patients with previous tricuspid valve annuloplasty using right ventricular fractional area change (RVFAC) as reference method. METHODS: We retrospectively analyzed 53 patients who underwent tricuspid valve annuloplasty at our hospital between 2013 and 2016. TAPSE and RVFAC were obtained in preoperative and postoperative periods using standard methodology. RESULTS: Mean age was 68±12years and 34 patients (64.1%) were women. TAPSE decreased significantly after surgery in comparison with pre-surgical values (17±4.2 Vs 12.9±4.1mm, p<0.001). On the contrary, RVFAC did not change significantly after surgery (37±9.2 Vs 36.2.9, p=0.25). The correlation between RVFAC and TAPSE was better in the preoperative (r=0.63, p<0.0001) than in the postoperative period (r=0.38, P=0.005). Good intra- and interobserver agreement for TAPSE and RVFAC was obtained, with intraclass correlation coefficients of 0.97 and 0.92 for TAPSE; and 0.90 and 0.85 for RVFAC, respectively. CONCLUSIONS: These findings suggest that TAPSE is not suitable after tricuspid valve annuloplasty and it leads to an underestimation of RV systolic function. It seems to be appropriate to rely on echocardiographic parameters of global RV function such as RVFAC in this context.

M-mode apical systolic excursion: A new and simple method to evaluate global left ventricular longitudinal strain.

INTRODUCTION: Since M-mode measurements can assess deformation of specific regions of the left ventricle, we hypothesized that M-mode measurements like M-mode apical systolic excursion (MMASE) and mitral annular plane systolic excursion (MAPSE) may be correlated with left ventricular longitudinal strain (LVLS). METHODS: All subjects of the study underwent a full echocardiographic evaluation and MMASE and MAPSE measurement. Three-dimensional wall motion tracking (3D-WMT) was performed. RESULTS: Thirty-one patients were evaluated. Significant correlations between MAPSE and LVLS (-0.372; p=0.04) and between MMASE and LVLS (-0.398; p=0.027) were found. LVLS was linearly related to MAPSE and MMASE (in mm) as follows: ST=-10.6 -0.4 * MAPSE (r2=0.14) and ST=-13.1 -0.5 * MMASE (r2=0.16). CONCLUSIONS: Our results demonstrate that simpler and faster methods than strain based on complex speckle analysis can also have a role in predicting subclinical left ventricular systolic dysfunction.

Giant and thrombosed left ventricular aneurysm.

Left ventricular aneurysms are a frequent complication of acute extensive myocardial infarction and are most commonly located at the ventricular apex. A timely diagnosis is vital due to the serious complications that can occur, including heart failure, thromboembolism, or tachyarrhythmias. We report the case of a 78-year-old male with history of previous anterior myocardial infarction and currently under evaluation by chronic heart failure. Transthoracic echocardiogram revealed a huge thrombosed and calcified anteroapical left ventricular aneurysm. Coronary angiography demonstrated that the left anterior descending artery was chronically occluded, and revealed a big and spherical mass with calcified borders in the left hemithorax. Left ventriculogram confirmed that this spherical mass was a giant calcified left ventricular aneurysm, causing very severe left ventricular systolic dysfunction. The patient underwent cardioverter-defibrillator implantation for primary prevention.

Efficacy and learning curve of a hand-held echocardiography device in an oncology outpatient clinic: Expanding the use of echoscopic heart examination beyond cardiology.

Certain chemotherapy drugs for breast cancer may induce cardiotoxicity and these patients should be echocardiographically monitored. The performance of a focused echocardiographic evaluation (echoscopy) at the patient's location by a non-cardiologist appears to be feasible. The aim of the present study was to assess the accuracy of echoscopy performed by medical oncologists in an outpatient clinic using hand-held echocardiography devices. The study cohort comprised consecutive unselected patients who attended an oncology outpatient clinic. Two medical oncologists attended a one-week training period, which included theoretical and practical teaching by an expert cardiologist. Every subject underwent two echo examinations. The first examination was performed by an oncologist using a hand-held echo device and the second was performed by a cardiologist using a 'premium' device. Out of the 101 enrolled patients, 32 were men (31.7%) and the mean age was 56.03±16.88 years. There was a good global agreement [intra-class correlation coefficient (ICC): 0.65 for left ventricular ejection fraction (LVEF)]. When the results were analyzed depending on the period of time when the echo studies were performed, a clear and short learning curve was observed: LVEF started at ICC=0.58 and increased to 0.66 and 0.77 in the second and third period, respectively. There were extremely few clinically significant differences and a learning curve was also evident. In conclusion, cardiac echoscopy performed by an oncologist with a hand-held device may lead to a similar clinical management as a study performed by an expert cardiologist with a 'premium' system in patients under chemotherapy following a short training period.

Isolated noncompaction of the ventricular myocardium: infrequent because of missed diagnosis?

Isolated noncompaction of the ventricular myocardium is frequently mistaken for other cardiomyopathies. We report a case of a 49-year-old woman admitted to hospital for heart failure and initially given the diagnosis of apical hypertrophic cardiomyopathy. In this case, myocardial contrast echocardiography and magnetic resonance imaging played a pivotal role in establishing the diagnosis of isolated noncompaction of the ventricular myocardium.

Doppler Tissue Imaging positive preejection velocity wave is a sign of non-transmural necrosis: comparison with delayed-enhancement cardiac magnetic resonance.

AIMS: Our purpose was to test the hypothesis that Tissue Doppler Imaging (TDI)-derived positive preejection velocity (PPV) is associated with transmural extent of necrosis in delayed-enhancement cardio-magnetic resonance (DE-CMR) in patients with reperfused myocardial infarction (MI). METHODS AND RESULTS: Longitudinal myocardial velocities were recorded by TDI in 24 patients with MI reperfused with primary angioplasty, using an Acuson-Sequoia equipment. The same day a CMR study was performed, including cine images in short axis and long axis views and DE images in the same views using a 3D-T1-Turbo-field-echo sequence, 15 min after administration of gadodiamide. Transmural extent of hyperenhancement in each segment was compared to presence or absence of PPV wave. A total of 384 segments were evaluated. Normo-hypokinetic segments (100%) showed a PPV wave, whereas it was only present in 53% of akinetic-dyskinetic segments (p=0.0005). One hundred percent of the segments with absent-mild DE showed a PPV wave; this percentage was lower in segments with intermediate and transmural DE (63 and 10%, p=0.001). The presence of PPV wave in an akinetic segment ruled out transmural necrosis with 97% sensitivity and 90% specificity. CONCLUSIONS: The absence of PPV is strongly associated to transmural necrosis in MI and therefore to absence of viability.