Left ventricular outflow tract shape after aortic valve replacement with St. Jude Trifecta prosthesis.

BACKGROUND: Aortic prosthesis area (EOA) is computed by continuity equation from left ventricular (LV) stroke volume (SV) derived from LV outflow tract diameter (LVOTD ) or, when unmeasurable, from LV volumes (SVV ). There is evidence to suggest LVOT ellipticity and recommend 3D LVOT area (LVOTCSA ) adoption in aortic stenosis. We sought to evaluate if the same concept applies to supra-annular aortic prosthesis comparing SV and EOA derived from LVOTD (EOAD ) and from LVOTCSA (EOACSA ). EOA computed from SVV (EAOV ) accuracy was evaluated in this setting. Patient-prosthesis mismatch (PPM) was compared among different EOA computations. METHODS: A consecutive series of 202 patients (aged 81 ± 4 years, 43% males) underwent St.Jude Trifecta aortic valve replacement (AVR) and were followed up with echocardiography at one-year (335 ± 31 days). All measurements followed the EACVI or ASE guidelines, 3D X-plane modality was used to compute SVv and measure LVOTCSA ; SV was calculated from LVOTD (SVD ) and LVOTCSA (SVCSA ). PPM was indexed EOA <0.65 cm²/m². RESULTS: LVOT showed a significant ellipticity index (1.17 ± .27), independent of prosthesis size. EOAD (1.70 ± 0.55 cm²) was less than EOACSA (1.95 ± 0.62 cm²) (P < .0001). SVV was significantly lower than SVD and SVCSA . Bland-Altman analysis showed a significant correlation between SVV and SVD or SVCSA although with large bias and imprecision. The correlations improved reducing bias and imprecision when LVOT time-velocity integral was <20 cm. PPM incidence was higher in EOAV (15.6%) compared to EOAD (P = .04) or EOACSA (P < .001). CONCLUSIONS: In supra-annular AVR, LVOT retains its elliptical shape and LVOTCSA yielded larger prosthesis EOA with lower PPM incidence. PPM may be overestimated by EOAV .

Abnormal coronary reserve and left ventricular wall motion during cold pressor test in patients with previous left ventricular ballooning syndrome.

AIMS: To investigate whether and how cold pressor test (CPT) could affect myocardial perfusion and left ventricular (LV) function in patients with previous LV ballooning syndrome (LVBS). METHODS AND RESULTS: Cold pressor test (3 min hand immersion in ice-water) was performed in 17 women with previous LVBS and in 7 age- and risk factor-matched women with chest pain and normal coronary arteries. At baseline and peak CPT, global and regional LV function, and myocardial perfusion were quantitatively assessed by real-time three-dimensional echocardiography (RT3DE) and myocardial contrast (SonoVue, Bracco) 2D echocardiography (MCE), respectively (Philips iE33 machine, X3-1 and S5-1 probes). Data were analysed off-line (QLab 6.0 software). Peripheral venous catecholamines were assayed by high performance liquid chromatography with electrochemical detection. Cold pressor test induced similar haemodynamic changes and catecholamine increase in controls and LVBS patients. Left ventricular ejection fraction decreased and transient new mid-ventricular and apical motion abnormalities developed in LVBS patients only (quantitative RT3D analysis), without corresponding perfusion defects (MCE). At peak CPT, coronary blood flow and velocity increased (quantitative MCE analysis) in control subjects only. CONCLUSION: Cold pressor test induced LV wall motion abnormalities unmatched to regional coronary flow reduction in LVBS patients only. The reduced coronary reserve in response to CPT suggests microvascular dysfunction in LVBS patients.

Results of comprehensive cardiovascular diagnostic work-up in HIV positive patients.

Cardiovascular disease (CVD) in the HIV population accounts for a large proportion of morbidity and mortality and, with the increased life expectancy, the burden of CVD is expected to rise. Inflammation, immune dysfunction, side effects of HIV medications, high prevalence of other risk factors are the likely pathogenic mechanisms for accelerated atherosclerosis. We aimed to evaluate the diagnostic yield of a cardiovascular multimodality diagnostic work-up in a contemporary cohort of HIV-infected patients. From November 2017 to October 2019, HIV infected patients were screened in a cardiovascular diagnostic work-up program including clinical history, physical examination, arterial blood pressure measurement, 12-lead ECG, and Transthoracic Echocardiogram (TTE). Advanced non-invasive cardiovascular imaging tests, like Coronary Computed Tomography Angiography (CCTA), stress-echocardiography, Cardiac Magnetic Resonance (CMR), were performed in patients with suspicion of chronic coronary syndrome (CCS) or non-ischemic heart disease (NIHD). 117 HIV-infected consecutive patients underwent this cardiovascular diagnostic work-up and were included in our study. Fifty-two patients (45%) had evidence of CVD. Of them, 22 presented Coronary Artery Disease (CAD), whereas 47 cases showed NIHD. In 17 cases both conditions were present. Among patients with CAD, 8 showed critical coronary stenosis; among them, 5 were treated with percutaneous coronary intervention, 2 with Aorto-Coronary By-Pass Grafting (CABG), and one with medical therapy. Hypertension and diabetes were significantly associated with the development of CVD (respectively p<0.001 and p< 0.05), while current smoking (p<0.02) and hypertension (p<0.007) were positively associated to CAD. A comprehensive cardiovascular diagnostic work-up including advanced multimodality diagnostic imaging modalities led to early detection of CVD in nearly half of an HIV population with immediate interventions required in 6.8% of them, and aggressive prevention treatment started in the remaining HIV patients.

Myocardial infarction redefined: impact on case-load and outcome of patients with suspected acute coronary syndrome and nondiagnostic ECG at presentation.

Risk stratification of chest pain (CP) is still debated. Objective of this study was to evaluate the performance of a risk stratification model for patients with suspected acute coronary syndrome (ACS) and nondiagnostic ECG at presentation, in whom the occurrence of myocardial infarction was either diagnosed following traditional (t-MI) or the recently redefined (r-MI) criteria. First-line 6-h work-up categorized 3068 patients with suspected ACS and nondiagnostic ECG into low-risk for short-term coronary events, intermediate-risk who entered second-line work-up, and high-risk. Intermediate-risk patients with positive second-line work-up and high-risk patients were considered for urgent coronary angiography. Angina, non-fatal MI, sudden death, and revascularization constituted composite end-point (CE) for in-hospital and 6-month outcome. ACS incidence was 16%; r-MI increased by 62% the diagnosis of MI over t-MI. Among 2024 discharged low-risk patients, 12 (0.6%) had non-fatal CE at 6 months. ACS was diagnosed in 19% of 503 intermediate-risk and 96% of 389 high-risk patients. Among ACS patients, in-hospital CE occurred in 14% of t-MI, 7% of r-MI, and 9% of unstable angina (UA) patients (t-MI vs. r-MI and t-MI vs. UA: p<0.05, for both); 6-month CE occurred in 23%, 16% and 12% of t-MI, r-MI and UA, respectively (t-MI vs. UA: p<005). Sensitivity, specificity and accuracy were high both for diagnostic (97%, 98%, 99%, respectively) and treatment (83%, 98%, 97%, respectively) strategy. Risk stratification, and categorization according to traditional or redefined MI and UA criteria allow safe allocation of resources in CP patients with suspected ACS and nondiagnostic ECG at presentation because outcome is accurately predicted.

Multiparametric electrocardiographic evaluation of left ventricular hypertrophy in idiopathic and hypertensive cardiomyopathy.

BACKGROUND: Electrophysiological abnormalities underlying the increased arrhythmogenicity of left ventricular hypertrophy (LVH) are still under investigation. The aim of this study was to assess non-invasively the electrophysiologic alterations in two different types of LVH, METHODS: Multiparametric non-invasive ECG analysis (R-R interval, QRS and QT intervals, QT dispersion, T-wave complexity, activation-recovery interval [ARI] dispersion, standard deviation of RR intervals [SDNN], filtered QRS duration [fQRS], root-mean-square voltage of the terminal 40 ms of the fQRS [RMS40] and low amplitude signal duration (< 40 microV) in the terminal portion of the fQRS [LAS]) was performed in 57 patients with hypertensive LVH and hypertrophic cardiomyopathy (HCM), and in 105 healthy subjects. RESULTS: The R-R interval and SDNN were similar in hypertrophic patients and controls. QRS and QT intervals were longer in hypertrophic patients without any differences between hypertensive LVH and HCM. QT dispersion, T-wave complexity and fQRS were greater in hypertrophic patients; QT dispersion was the greatest in HCM. ARI dispersion was lesser in hypertrophic patients without any differences between subgroups of LVH. fQRS showed a trend toward higher values in hypertensive patients. LAS at 25 Hz had a trend toward lower values in HCM patients, while LAS at 40 Hz and RMS40 showed no difference between controls and hypertrophic patients. Left ventricular mass index was not correlated with any of the above-mentioned parameters. CONCLUSIONS: The QT interval and dispersion did not identify the type of hypertrophy. Similarly, ARI dispersion which explores local variations of repolarization duration, and T-wave complexity could not distinguish patients with hypertensive LVH from those with HCM indicating that multiparametric ECG data are affected more by the presence of LVH, than by its type.

Hypertrophic cardiomyopathy: electrical abnormalities detected by the extended-length ECG and their relation to syncope.

BACKGROUND: Ventricular repolarization abnormalities can represent a trigger for lethal arrhythmias in hypertrophic cardiomyopathy (HCM). We sought to assess whether multiparametric computerized surface ECG analysis identifies repolarization abnormalities in HCM patients, and whether this approach allows identification of patients with syncope. METHODS: In 28 HCM patients and 102 healthy subjects (14 and 51 males, mean age 44 +/- 15 and 41 +/- 14 years, respectively), 8-lead ECG (I, II, V1-V6) was recorded for 5 min, acquired in digital format and analyzed. Heart-rate corrected QT (QTc) and T wave complexity index (TWCc), QT dispersion, activation-recovery interval (ARI) and its dispersion, signal duration in the terminal portion of the filtered QRS at 25 Hz (LAS(25 Hz)) were analyzed among other parameters. RESULTS: Compared to healthy subjects, HCM patients exhibited longer QRS, filtered QRS, QTc and QTd, greater TWCc, minor ARId and LA(25 Hz). QRS duration and maximal septum thickness were linearly correlated (r=0.231 p<0.001). ARId shortening depended on ARI shortening in lead V1 (241 +/- 51 vs. 287 +/- 45, HCM vs. healthy subjects, p<0.0001) and lengthening in V6 (257 +/- 42 vs. 209 +/- 34, HCM vs. healthy subjects, p<0.0001). Significant factors for syncope at Wilks' stepwise discriminant analysis were TWCc, QRSd and LAS(25 Hz) (F=14.394, 10.098 and 9.226, respectively) with 92.3% positive predictive accuracy. CONCLUSIONS: In HCM, longer QRS and QT intervals are consequences of increased left ventricular mass, while ARI seems to reflect myocardial activation rather than inhomogeneity of recovery. The simultaneous evaluation of TWC, QRSd and LAS(25 Hz), unable by itself to hold a predictive value, yielded high accuracy in predicting cardiogenic syncope.

Simultaneous assessment of electrocardiographic parameters for risk stratification: validation in healthy subjects.

BACKGROUND: Sudden cardiac death represents a major public health problem, but in the general population the identification of those subjects at very high risk remains poor. Simultaneous multiparametric ECG analysis can improve the identification of high-risk patients. METHODS: Five-min ECG recordings at a 5 MHz sampling rate (extended length-XL-ECG, Mortara Instruments, Milwaukee, WI, USA) were acquired in 105 healthy subjects (age range 21 to 80 years), equally distributed for age decades and sex, and three additional recordings, 30 min apart, were repeated in 30 subjects on the second day. The following parameters were recorded and analyzed: the RR interval, QRS duration, QT interval corrected according to the Bazett and Fridericia formulae, QT dispersion, T wave complexity, activation-recovery interval dispersion, standard deviation of the RR intervals, filtered QRS duration, the square root of the mean voltage of the last 40 ms of the filtered QRS, and the length of time that the terminal vector magnitude complex remains < 40 microV. RESULTS: QRS duration, activation-recovery interval dispersion, and filtered QRS differed in the two sexes. The standard deviation of the RR intervals, T wave complexity and QT dispersion were significantly correlated with age. The reproducibility was good for each parameter. CONCLUSIONS: The XL-ECG allows the simultaneous calculation of eight adequately reproducible different parameters the values of which are in agreement with those of the literature. Thus, XL-ECG is a reliable time- and cost-saving tool.

Favorable short-term outcome of transplanted hearts selected from marginal donors by pharmacological stress echocardiography.

BACKGROUND: Because of the shortage of donor hearts, the criteria for acceptance have been considerably expanded. Abnormal results on pharmacologic stress echocardiography are associated with significant coronary artery disease and/or occult cardiomyopathy on verification by cardiac autopsy. The aim of this study was to establish the feasibility of an approach based on pharmacologic stress echocardiography as a gatekeeper for extended heart donor criteria. METHODS: From April 2005 to April 2010, 39 "marginal" candidate donors (mean age, 56 ± 6 years; 21 men) were initially enrolled. After legal declaration of brain death, marginal donors underwent rest echocardiography, and if the results were normal, dipyridamole (0.84 mg/kg over 6 min, n = 25) or dobutamine (up to 40 µg/kg/min, n = 3) stress echocardiography. RESULTS: A total of 19 eligible hearts were found with normal findings. Of these, three were not transplanted because of the lack of a matching recipient, and verification by cardiac autopsy showed absence of significant coronary artery disease or cardiomyopathy abnormalities. The remaining 16 eligible hearts were uneventfully transplanted in marginal emergency recipients. All showed normal (n = 14) or nearly normal (minor single-vessel disease in two) angiographic, intravascular ultrasound, hemodynamic and ventriculographic findings at 1 month. At follow-up (median, 14 months; interquartile range, 4-31 months), 14 patients survived and two had died, one at 2 months from general sepsis and one at 32 months from allograft vasculopathy in recurrent multiple myeloma. CONCLUSIONS: Pharmacologic stress echocardiography can safely be performed in candidate heart donors with brain death and shows potential for extending donor criteria in heart transplantation.

Elevated plasma levels of urotensin II do not correlate with systemic haemodynamics in patients with cirrhosis.

BACKGROUND: The hyperdynamic circulation of hepatic cirrhosis is related to decreased systemic vascular resistance due to arterial vasodilation. Urotensin II plasma levels are increased in cirrhotic patients, and have been suggested to play a role in the pathogenesis of systemic haemodynamic alterations. AIM: To evaluate the relationships between systemic haemodynamics and urotensin II plasma levels. METHODS: Thirty-six consecutive in-patients with cirrhosis and no alteration of plasma creatinine, and 20 age- and gender-matched healthy volunteers underwent noninvasive assessment of systemic haemodynamics and measurement of urotensin II plasma levels. RESULTS: In comparison to healthy controls, cirrhotic patients had signs of hyperdynamic circulation and higher plasma urotensin II levels. Plasma urotensin II was neither significantly different amongst patients with different severity of cirrhosis nor between patients with or without ascites. Both in controls and cirrhotic patients no significant correlations were found between parameters of systemic haemodynamics and plasma urotensin II levels. CONCLUSIONS: In patients with cirrhosis and hyperdynamic circulation, but with normal serum creatinine, urotensin II is higher than in healthy subjects. However, no correlation with cardiac index or other haemodynamic parameters was observed, indicating that other mechanisms prevail.

Left ventricular shape and function in primary coronary angioplasty.

OBJECTIVES: To evaluate the effects of primary coronary angioplasty (PCA) on regional left ventricular (LV) contractile dysfunction and deformation, and on global remodeling. METHODS: In 99 consecutive patients (81 males, aged 61+/-11 years) who underwent successful PCA of left anterior descending (LAD) and right coronary (RCA) arteries for treatment of first myocardial infarction and completed a hemodynamic follow-up at 1 and 6 months, LV eccentricity and circularity indexes, centreline wall motion and regional curvature were analyzed. Asynergy and akinesia were defined as centreline impairment -1 standard deviation) at 6 months was used to categorize the outcome as improved. RESULTS: Systolic deformation and impairment of regional LV function soon after LAD and RCA occlusion closely resembled those of the chronic myocardial infarction. PCA improved regional contractility in all patients, due to early salvage of the epicardial injured myocardium, and at least in two fifths of patients the injury area magnitude reduced by improvement of the ischemic boundaries of the infarct. Irrespective of either persistently impaired or normalized regional contractility, LV shape remained abnormal. In contract to the persistence of local deformation, global remodeling was observed in patients categorized as the highest end-diastolic volume quartile at presentation who had greater myocardial damage. CONCLUSION: Regional contractility impairment induced by acute myocardial infarction can be reverted by PCA, but systolic shape deformation persists over time.

Preoperative and late postoperative mitral regurgitation in ventricular reconstruction: role of local left ventricular deformation.

BACKGROUND: We sought to analyze the characteristics of local left ventricular deformation related to functional mitral regurgitation (MR) in post-anterior myocardial infarction scar, and to evaluate how local remodeling contributes to late development of MR after surgical ventricular reconstruction by endoventricular circular patch plasty repair. METHODS: Two hundred twenty-one consecutive patients (aged 60 +/- 9 years; 193 males) with previous transmural anterior infarction underwent heart catheterization both before and 1 year after endoventricular circular patch plasty repair. Preoperative global left ventricular shape determinants (eccentricity and circularity indexes), regional curvature and wall motion (centerline), and both preoperative and 1-year postoperative hemodynamic parameters (volumes, ejection fraction, capillary wedge and pulmonary artery pressures) were calculated. RESULTS: Forty-eight patients had (MR patients), and 173 did not have (NoMR patients) angiographic MR grade 2 or more preoperatively; at follow-up, 30 NoMR patients had MR (late MR [LMR]). Before surgery, MR patients had larger left ventricular volumes, higher capillary wedge and mean pulmonary artery pressures, and lower ejection fraction and cardiac index. The LMR patients had similarly high capillary wedge and pulmonary artery pressures as MR patients; otherwise, they did not differ from NoMR patients. Mitral regurgitation patients had wider lateral wall akinesia and greater inferior wall asynergy; the inferobasal region was hypokinetic in LMR patients. In MR patients, inferior wall systolic curvature was less negative; the inferobasal region had a more positive curvature in LMR patients. CONCLUSIONS: Local deformation of the inferior wall with loss of systolic inward bending is associated with functional MR, while asynergy and systolic deformation of the inferobasal region and high capillary wedge pressure are prognostic signs of MR development late after endoventricular circular patch plasty repair.

Cardiovascular effects of canrenone in patients with preascitic cirrhosis.

In patients with cirrhosis and portal hypertension, standing induces a reduction in cardiac index (CI) and an increase in systemic vascular resistance index. Our previous studies indicate that this abnormal hemodynamic response to standing is due to an altered myocardial function, because cirrhotic patients are unable to compensate for the reduced preload with an increase in left ventricular (LV) ejection fraction (EF) and stroke volume. To evaluate whether the cardiac dysfunction in cirrhosis is influenced by canrenone, an aldosterone antagonist, 8 patients with preascitic, nonalcoholic cirrhosis, and portal hypertension underwent echocardiographic assessment of LV function and systemic hemodynamics and determinations of plasma volume, urinary sodium excretion, and plasma renin activity (PRA), aldosterone (PAC), and norepinephrine (PNE) when on a 150-mmol/d-sodium diet (baseline), after 1 month on canrenone (100 mg/d) plus a 40-mmol/d-sodium diet and after 1 month on canrenone plus a 150-mmol/d-sodium diet. Echocardiographic evaluation was performed with the patient in the supine position and during active standing. At baseline, patients had high plasma volume and normal renal function, PRA, PAC, and PNE. CI, LVEF, and stroke volume index were also normal. Standing caused a significant reduction in CI and LVEF. After canrenone and either sodium diet, CI significantly decreased, and PRA and PNE increased in the supine position. On standing, LVEF and CI did not decrease further. Plasma volume significantly decreased only after low-sodium diet plus canrenone. In conclusion, canrenone normalizes the cardiac response to the postural challenge in patients with preascitic cirrhosis.