Pulmonary transit time as a marker of diastolic dysfunction in Takotsubo syndrome.

AIM: To evaluate the pulmonary transit time (PTT) and its derived parameters using cardiac magnetic resonance imaging (CMRI) as markers of diastolic dysfunction in Takotsubo syndrome (TS) and its relationship with transthoracic echocardiography and CMRI parameters. MATERIALS AND METHODS: Twenty-two patients with TS, who exhibited diastolic dysfunction as assessed by transthoracic echocardiography, were enrolled retrospectively and the PTT, pulmonary transit time index (PTTI), and pulmonary blood volume index (PBVI) were evaluated using first-pass CMRI. PTT was calculated as the number of cardiac cycles required for a bolus of contrast agent to move from the right ventricle (RV) to the left ventricle (LV), whereas PTTI represents the PTT interval corrected for the heart rate. Finally, PBVI was calculated as the product of PTTI, and RV stroke volume indexed for body surface area. Normal references of PTT, PTTI, and PBVI were evaluated in a cohort of 20 age- and sex-matched healthy controls. RESULTS: Compared with healthy subjects, TS patients showed significantly higher PTT, PTTI, and PBVI (p=0.0001, p=0.0001, and p=0.002, respectively). Using multivariable logistic regression, PBVI provided the best differentiation between TS and controls (AUC 0.84). PBVI was significantly associated with the index of diastolic dysfunction and left atrial strain parameters. In addition, PBVI demonstrated a significant correlation with global T2 mapping (r=0,520, p=0,019). CONCLUSION: PTT and the derived parameters, as assessed using first-pass CMRI, are potential tools for assessing LV diastolic dysfunction in patients with TS.

Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Perioperative dental screening and treatment in patients undergoing cardio-thoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections, and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients had never been defined. Following the systematic review several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently and then a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions, and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus can become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

CT Attenuation Analysis of Carotid Intraplaque Hemorrhage.

BACKGROUND AND PURPOSE: Intraplaque hemorrhage is considered a leading parameter of carotid plaque vulnerability. Our purpose was to assess the CT characteristics of intraplaque hemorrhage with histopathologic correlation to identify features that allow for confirming or ruling out the intraplaque hemorrhage. MATERIALS AND METHODS: This retrospective study included 91 patients (67 men; median age, 65 ± 7 years; age range, 41-83 years) who underwent CT angiography and carotid endarterectomy from March 2010 to May 2013. Histopathologic analysis was performed for the tissue characterization and identification of intraplaque hemorrhage. Two observers assessed the plaque's attenuation values by using an ROI (≥ 1 and ≤2 mm2). Receiver operating characteristic curve, Mann-Whitney, and Wilcoxon analyses were performed. RESULTS: A total of 169 slices were assessed (59 intraplaque hemorrhage, 63 lipid-rich necrotic core, and 47 fibrous); the average values of the intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue were 17.475 Hounsfield units (HU) and 18.407 HU, 39.476 HU and 48.048 HU, and 91.66 HU and 93.128 HU, respectively, before and after the administration of contrast medium. The Mann-Whitney test showed a statistically significant difference of HU values both in basal and after the administration of contrast material phase. Receiver operating characteristic analysis showed a statistical association between intraplaque hemorrhage and low HU values, and a threshold of 25 HU demonstrated the presence of intraplaque hemorrhage with a sensitivity and specificity of 93.22% and 92.73%, respectively. The Wilcoxon test showed that the attenuation of the plaque before and after administration of contrast material is different (intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue had P values of .006, .0001, and .018, respectively). CONCLUSIONS: The results of this preliminary study suggest that CT can be used to identify the presence of intraplaque hemorrhage according to the attenuation. A threshold of 25 HU in the volume acquired after the administration of contrast medium is associated with an optimal sensitivity and specificity. Special care should be given to the correct identification of the ROI.

Epicardial fat thickness, an emerging cardiometabolic risk factor, is increased in young adults born preterm.

Preterm birth and epicardial fat thickness (EFT) constitute novel risk factors for the onset of future adverse cardiovascular events. In total, 30 ex-extremely low birth weight (ex-ELBW) subjects (10 males, 20 females, aged 17-28) were enrolled and compared with 30 healthy peers. EFT was significantly higher (8.7±0.7 mm v. 5.6±0.9 mm; P<0.001) in ex-ELBW than in controls and was correlated with birth weight (r=-0.47, P=0.0009), gestational age (r=-0.39, P=0.03) and cardiac left ventricular mass (r=0.51, P=0.004). When excluding the influence of body mass index, birth weight was the sole remaining determinant of EFT, irrespective of gestational age (r=-0.37, P=0.04). The same findings when excluding the possible influence of blood pressure values on the cardiac structures (r=-0.40, P=0.028). In conclusion, EFT is significantly higher in former preterm subjects and is likewise associated with an increase in left ventricular mass. In view of the acknowledged correlation between the latter and an increased incidence of cardiovascular diseases, EFT appears to be an easy-to-measure tool capable of predicting the likely development of future adverse cardiovascular events in these subjects.

Factors influencing adaptation and performance at physical exercise in complex congenital heart diseases after surgical repair.

In the last thirty years, steady progress in the diagnostic tools and care of subjects affected by congenital heart diseases (CHD) has resulted in a significant increase in their survival to adulthood, even for those affected by complex CHD. Based on these premises, a number of teenagers and adults affected by corrected (surgically or through interventional techniques) CHD ask to be allowed to undertake sporting activities, both at a recreational and competitive level. The purpose of this review is to examine the mechanisms influencing the adaptation at physical exercise of patients suffering from complex CHD. The conclusion is that even if there are some modest risks with exercise, they should be seen in perspective, and the life-long benefits of regular exercise on general health, mood, and well-being should be emphasized.

Antihypertensive therapy in children: differences in medical approach between the United States and Europe.

Similarly to a series of chronic diseases, essential arterial hypertension (HTN) may be manifested during childhood as a blood pressure (BP) reading which repeatedly rises above the 95(th) percentile of population-specific standards. Since BP tends to track along the same percentiles throughout life, children with higher BPs are more likely to become hypertensive adults. When healthy measures aimed at reducing BP (i.e. body weight reduction, aerobic physical exercise, low sodium intake) have failed, pharmacological treatment is usually required. This paper aims to undertake a review of antihypertensive pharmacological therapy in children, examining the drugs used in chronic treatment as well as those administered to treat hypertensive crisis (i.e. a BP major than 99(th) percentile of paediatric normograms). Moreover, several important differences registered in the therapeutic approach to paediatric HTN between US and European Guidelines will be underlined.

Advanced intrauterine growth restriction is associated with reduced excretion of asymmetric dimethylarginine.

BACKGROUND: High blood levels of asymmetric dimethylarginine (ADMA) are associated with future development of adverse cardiovascular events. The ADMA/symmetric dimethylarginine (SDMA) ratio is a marker of ADMA catabolism, with a high ADMA/SDMA ratio being suggestive of reduced ADMA excretion. AIMS: This study aimed a) to verify the presence of a statistically significant difference between ADMA/SDMA ratio levels in a group of young adult subjects who were born preterm with an extremely low birth weight (ex-ELBW) and a group of healthy adults born at term and b) to seek correlations between ADMA/SDMA ratio levels in ex-ELBW and anthropometric and clinical parameters (gender, chronological age, gestational age, birth weight, and length of stay in the Neonatal Intensive Care Unit). SUBJECTS, STUDY DESIGN, OUTCOME MEASURES: Thirty-seven ex-ELBW subjects (11 males [M] and 26 females [F], aged 17-28 years, mean age: 22.2 ± 1.8 years) were compared with 37 controls (11 M and 26 F). ADMA/SDMA ratio levels were assessed for each patient included in the study. RESULTS: ADMA/SDMA ratio in ex-ELBW subjects was higher compared to controls (1.42 ± 0.31 vs 0.95 ± 0.14, p<0.002) and inversely correlated with birth weight (r=-0.68, p<0.0001) and gestational age (r=-0.54, p<0.0005). CONCLUSIONS: ADMA catabolism is significantly decreased in ex-ELBW subjects compared to controls, underlining a probable correlation with restriction of intrauterine growth. These results suggest the onset of early circulatory dysfunction predictive of increased cardiovascular risk in ex-ELBW.

Clinical metabolomics and hematic ADMA predict the future onset of cardiorenal syndrome in young grown-up subjects who were born preterm.

OBJECTIVES: To look for differences in the urinary metabolic profile and in the hematic asymmetric dimethylarginine (ADMA) levels between a group of young adults born preterm with an extremely low birthweight (<1000 g; ex-ELBW; n=19) and a control group of subjects born at term with a weight appropriate for their gestational age (AGA; n=13); and to look for a possible correlation between the urinary metabolic profile in ex-ELBW and their hematic levels of ADMA. DESIGN AND METHODS: Urine samples were analyzed by (1)H nuclear magnetic resonance spectroscopy, and then submitted to unsupervised and supervised multivariate analysis. Samples of blood were collected and ADMA concentration was assessed by high-performance liquid chromatography. RESULTS: Using supervised PLS-DA (partial least squares discriminant analysis) model, the authors were able to discriminate between ex-ELBW and AGA. Statistically significant differences were detected in the ADMA levels between ex-ELBW and AGA (p<0.02). Ex-ELBW metabolic profile correlated with ADMA concentrations (r=0.456, p<0.05). Conversely, ADMA levels in AGA did not correlated with their metabolic profiles. CONCLUSIONS: This study demonstrates the relevance of the metabolomic technique as a predictive tool of the metabolic status in ex-ELBW. The relationship between ex-ELBW urinary metabolic profile and their blood ADMA levels suggests the presence of a subclinical cardio-renal involvement in these subjects.

Drugs in newborn resuscitation: the more we learn the least we use.

Temperature control, airway management and support of circulation remain the gold-standards for the majority of neonates requiring resuscitation at birth. For the minority of neonates in which the basic steps of resuscitation fail to reverse an adverse situation, drug administration is justifiable. The 2010 International Liaison Committee on Resuscitation (ILCOR) guidelines for newborn resuscitation state: "Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually caused by inadequate lung inflation or profound hypoxia, and establishing adequate ventilation is the most important step to correct it. However, if the HR remains less than 60 min-1 despite adequate ventilation and chest compressions, it is reasonable to consider the use of drugs. These are best given via an umbilical venous catheter". Even though drugs have been used in neonatal resuscitation for long, their doses, order and route of administration have been issues of debate among neonatologists, mainly due to the lack of data in human studies. This review will examine existing evidence behind the medications currently used in neonatal resuscitation.

Could ADMA levels in young adults born preterm predict an early endothelial dysfunction?

BACKGROUND: Sporadic data present in literature report how preterm birth and low birth weight are risk factors for the development of cardiovascular diseases in later life. High levels of asymmetric dimethylarginine (ADMA), a strong inhibitor of nitric oxide synthesis, are associated with the future development of adverse cardiovascular events and cardiac death. AIMS: 1) to verify the presence of a statistically significant difference between ADMA levels in young adults born preterm at extremely low birth weight (<1000 g; ex-ELBW) and those of a control group of healthy adults born at term (C) and 2) to seek correlations between ADMA levels in ex-ELBW and anthropometric and clinical parameters (gender, chronological age, gestational age, birth weight, and duration of stay in Neonatal Intensive Care Unit). METHODS: Thirty-two ex-ELBW subjects (11 males [M] and 21 females [F], aged 17-29years, mean age 22.2 ± 2.3 years) were compared with 25 C (7 M and 18F). ADMA levels were assessed by high-performance liquid chromatography with highly sensitive laser fluorescent detection. RESULTS: ADMA levels were reduced in ex-ELBW subjects compared to C (0.606+0.095 vs 0.562+0.101 µmol/L, p<0.05), and significantly correlated inversely with gestational age (r=-0.61, p<0.00001) and birth weight (r=-0.57, p<0.0002). CONCLUSIONS: Our findings reveal a significant decrease in ADMA levels of ex-ELBW subjects compared to C, underlining a probable correlation with preterm birth and low birth weight. Taken together, these results may underlie the onset of early circulatory dysfunction predictive of increased cardiovascular risk.

Supraventricular tachycardia in neonates: antiarrhythmic drug choice dilemma.

Supraventricular tachycardia (SVT), being atrioventricular reentry the underlying mechanism, is the most frequently tachyarrhythmia requiring a medical treatment in infants with no cardiac disease. The acute treatment of a single episode of SVT has generally an excellent prognosis. An antiarrhythmic prophylaxis of SVT recurrences is usually recommended during the first year of life. Although many efficient drugs are available for the SVT treatment, a careful risk-benefit analysis of each single case should suggest the correct drug choice.

Counseling and informed consent: the experience in a pediatric cardiology unit. How to communicate a pathological diagnosis.

The aim of our study was to create an operative scheme for conveying a pathological diagnosis with emphasis on communication strategies. In order to check the validity of the scheme, parents of 122 of our patients were contacted by an outside observer and were asked to answer anonymously to a questionnaire concerning their experience in our unit. The questionnaire has been structured in three parts in order to verify (1) the quality of the communication of the diagnosis, (2) the team-patient relationship and (3) the comparison between our unit and the others. 87% of parents declared the language used in the communication clear and comprehensible and the time dedicated to the explanations sufficient (p<.01). They judged the quality of the information received as excellent (50%) or good (50%) (p<.01). Eightyfour % of them thought that the information given was sufficient and there was no need for any more details (p<.01). 92% perceived a comfortable atmosphere, they felt involved in the communication and encouraged to ask questions (p<.01). 91% described the behaviour of the team as helpful and warm without differences between the different figures of the unit (p<.01). In regard to the psychological support 70% of parents found it essential, 30% found it very useful (p<.05). These results show that our operative scheme is functional to the communication and to the team-patient relationship. It permits an "informed consent" as an aware choice of the parents and consequently a better way of management of the congenital heart disease.

Reduced brachial flow-mediated vasodilation in young adult ex extremely low birth weight preterm: a condition predictive of increased cardiovascular risk?

BACKGROUND: Sporadic data present in literature report how preterm birth and low birth weight constitute the risk factors for the development of cardiovascular diseases in later life. AIM: To assess the presence of potential alterations to endothelial function in young adults born preterm at extremely low birth weight (<1000 g; ex ELBW). METHOD: Thirty-two ex-ELBW subjects (10 males [M] and 22 females [F], aged 17-28 years, mean [+/- DS] 20.1 +/- 2.5 years) were compared with 32 healthy, age-matched subjects born at term (C, 9 M and 23 F). EXCLUSION CRITERIA: 1) pathological conditions known to affect endothelial function; 2) administration of drugs known to affect endothelial function. Endothelial function was assessed by non-invasive finger plethysmography, previously validated by the US Food and Drug Administration (Endopath; Itamar Medical Ltd., Cesarea, Israel). RESULTS: Endothelial function was significantly reduced in ex-ELBW subjects compared to C (1.94 +/- 0.37 vs. 2.68 +/- 0.41, p < 0.0001). Moreover, this function correlated significantly with gestational age (r = 0.56, p < 0.0009) and birth weight (r = 0.63, p < 0.0001). CONCLUSIONS: The results obtained reveal a significant decrease in endothelial function of ex-ELBW subjects compared to controls, underlining a probable correlation with preterm birth and low birth weight. Taken together, these results suggest that an ELBW may underlie the onset of early circulatory dysfunction predictive of increased cardiovascular risk.