Usefulness of longitudinal systolic strain and delayed enhancement cardiac magnetic resonance in depicting risk of supraventricular arrythmias in patients with acute myocarditis and preserved left ventricular function.

BACKGROUND: Myocarditis have variable clinical presentation, evolution and prognosis. Aim of our study was to evaluate the value of speckle tracking echocardiography and cardiac magnetic resonance (CMR) in the short-term prediction of supraventricular arrhythmias (SVA) in patients with acute myocarditis. METHODS: Seventy patients (mean age 31±14 years old) with acute myocarditis and preserved left ventricular ejection fraction (LVEF) were enrolled. Longitudinal systolic strain (LS) of the left ventricle (LV), mechanical dispersion (MD) and CMR with quantitative measurement of delayed enhancement (DE) were performed in a subset of 43 patients. Logistic regression and ROC analysis were used to identify predictors of SVA RESULTS: Only LS measured at sup-epicardial, mid-wall and sub-endocardial level of the apical 4-chamber view was significantly lower in patients with SVA, while MD was marginally prolonged in this setting. A value of LS > - 16.1% measured at LV mid-wall in the apical 4-chamber view (ROC-AUC .75, Sensitivity 63%, Specificity 85%) was the most accurate measure to identify patients with SVA. DE mass was also helpful with a ROC-AUC .76; a DE-Mass > 18.9 gr. had a Sensitivity 63% and a Specificity 77%, to identify patients at risk of SVA. CONCLUSIONS: Both DE mass and LS were associated with higher risk of SVA in patients with acute myocarditis and preserved LVEF. However, LS measured at the mid-wall level and limited to LV segments included in the apical 4-chamber view was the most accurate measure and did not show interaction with DE mass.

Prognostic significance of longitudinal strain in dilated cardiomyopathy with recovered ejection fraction.

OBJECTIVE: Patients with non-ischaemic dilated cardiomyopathy (NICM) may experience a normalisation in left ventricular ejection fraction (LVEF). Although this correlates with improved prognosis, it does not correspond to a normalisation in the risk of death during follow-up. Currently, there are no tools to risk stratify this population. We tested the hypothesis that absolute global longitudinal strain (aGLS) is associated with mortality in patients with NICM and recovered ejection fraction (LVEF). METHODS: We designed a retrospective, international, longitudinal cohort study enrolling patients with NICM with LVEF <40% improved to the normal range (>50%). We studied the relationship between aGLS measured at the time of the first recording of a normalised LVEF and all-cause mortality during follow-up. We considered aGLS >18% as normal and aGLS ≥16% as of potential prognostic value. RESULTS: 206 patients met inclusion criteria. Median age was 53.5 years (IQR 44.3-62.8) and 56.6% were males. LVEF at diagnosis was 32.0% (IQR 24.0-38.8). LVEF at the time of recovery was 55.0% (IQR 51.7-60.0). aGLS at the time of LVEF recovery was 13.6%±3.9%. 166 (80%) and 141 (68%) patients had aGLS ≤18% and <16%, respectively. During a follow-up of 5.5±2.8 years, 35 patients (17%) died. aGLS at the time of first recording of a recovered LVEF correlated with mortality during follow-up (HR 0.90, 95% CI 0.91 to 0.99, p=0.048 in adjusted Cox model). No deaths were observed in patients with normal aGLS (>18%). In unadjusted Kaplan-Meier survival analysis, aGLS <16% was associated with higher mortality during follow-up (31 deaths (22%) in patients with GLS <16% vs 4 deaths (6.2%) in patients with GLS ≥16%, HR 3.2, 95% CI 1.1 to 9, p=0.03). CONCLUSIONS: In patients with NICM and normalised LVEF, an impaired aGLS at the time of LVEF recovery is frequent and associated with worse outcomes.

Physiopathology and Diagnosis of Congestive Heart Failure: Consolidated Certainties and New Perspectives.

Volume overload and fluid congestion are a fundamental issue in the assessment and management of patients with heart failure (HF). Recent studies have found that in acute decompensated heart failure (ADHF), right and left-sided pressures generally start to increase before any notable weight changes take place preceding an admission. ADHF may be a problem of volume redistribution among different vascular compartments instead of, or in addition to, fluid shift from the interstitial compartment. Thus, identifying heterogeneity of volume overload would allow guidance of tailored therapy. A comprehensive evaluation of congestive HF needs to take into account myriad parameters, including physical examination, echocardiographic values, and biomarker serum changes. Furthermore, potentially useful diagnostic tools include bioimpedance to measure intercompartmental fluid shifts, and evaluation of ultrasound lung comets to detect extravascular lung water.

[Iron deficiency in heart failure: beyond the anemia.] / Iron deficiency nello scompenso cardiaco: oltre l'anemia.

Iron deficiency in heart failure is a frequent condition and may be a prerequisite for the development of anemia but not necessarily the two conditions coexist. Iron deficiency in itself independently of the presence of anemia, determines a series of alterations of the cellular processes of our body related to the production of energy in the form of ATP, cell proliferation and DNA synthesis. The causes of iron deficiency are several and among the various, the inflammatory state present in chronic heart failure, combined with the absorption deficit seems to play a predominant role. This review aims to cover all the main aspects related to iron deficiency in patients with heart failure starting from aetiology up to the therapeutic implications. In particular, the different causes and the pathophysiological mechanisms that underlie the iron deficiency will be examined, describing what are the consequences on the alterations on the biochemical processes in terms of absorption, transport and use of iron by target cells with particular regard to muscle cells and Erythropoietic line. The meaning, the role and the importance in clinical practice of the different laboratory tests that dose the iron (Ferritin, Serum Iron, Transferrin and Transferrin saturation or TSAT) that allow to identify the presence of absolute or relative iron deficiency will also be underlined. Literature data related to the consequences of iron deficiency and to the alterations concerning its transport on the symptoms and functional capacity of patients with heart failure will be reported as well as their impact on prognosis. A second part of the paper will address the main aspects related to iron therapy. We will discuss the administration of iron per os with regard to the different drugs, to the processes of absorption and to the use of different pharmaceutical formulations with their associated side effects. The scientific evidences on parenteral formulations and in particular on the use of Fe-carboxymaltose will be reported. Finally, we will discuss the role of erythropoietin in the context of heart failure.

[The heart failure management in Sicily: cognitive analysis of clinical features.] / La gestione dello scompenso cardiaco in Sicilia: analisi conoscitiva degli aspetti clinici e organizzativi.

INTRODUCTION: Heart failure (HF) is a main issue of modern healthcare system. Patient affected are continuously growing in number and age; therefore, an integrated management between different parts of healthcare system is crucial to optimize outcome and sustainability. So far, little is known about clinical pathways of HF patients in Sicily. METHODS: On initiative of the Regional HF Group of the Italian Association of Hospital Cardiologists (ANMCO), we decided to census all the Cardiology Unit of Sicily. A simple questionnaire elaborated by the group and exploring clinical and organizational matters of HF was sent to the Units. The answer arrived on a voluntary basis. RESULTS: 41/46 Units sent back the filled questionnaire. Five typologies of units were represented, based on complexity [1. Outpatient units; 2. Units without Intensive Care Unit (ICU); 3. Units with ICU; 4. Units with ICU and Cath Lab; 5. Units with ICU, Cath lab and Cardiac Surgery). A dedicated HF unit is present only in half centers, but it is formally recognized solely in 22% of Units. These Units have scarce dedicated staff and activity is predominantly based on personal initiative. Diagnostic and therapeutic tools are used appropriately in most of them, even though congestion is judged mainly through physical exam and echocardiography. Differently from the indications of the guidelines, post discharge titration of therapy lacks in almost 30% of centers. DISCUSSION AND CONCLUSIONS: In Sicily, HF is managed on a plan mainly based on personal initiative. The quality is sufficiently good but a more appropriate and structured organization in particular of the follow-up seems a necessary and improvable requirement in view of quality measurers and economic sustainability of health care.

The Effects of Sacubitril/Valsartan on Clinical, Biochemical and Echocardiographic Parameters in Patients with Heart Failure with Reduced Ejection Fraction: The "Hemodynamic Recovery".

BACKGROUND: Sacubitril/valsartan has been shown to be superior to enalapril in reducing the risks of death and hospitalization for heart failure (HF). However, knowledge of the impact on cardiac performance remains limited. We sought to evaluate the effects of sacubitril/valsartan on clinical, biochemical and echocardiographic parameters in patients with heart failure and reduced ejection fraction (HFrEF). METHODS: Sacubitril/valsartan was administered to 205 HFrEF patients. RESULTS: Among 230 patients (mean age 59 ± 10 years, 46% with ischemic heart disease) 205 (89%) completed the study. After a follow-up of 10.49 (2.93 ± 18.44) months, the percentage of patients in New York Heart Association (NYHA) class III changed from 40% to 17% (p < 0.001). Median N-Type natriuretic peptide (Nt-proBNP) decreased from 1865 ± 2318 to 1514 ± 2205 pg/mL, (p = 0.01). Furosemide dose reduced from 131.3 ± 154.5 to 120 ± 142.5 (p = 0.047). Ejection fraction (from 27± 5.9% to 30 ± 7.7% (p < 0.001) and E/A ratio (from 1.67 ± 1.21 to 1.42 ± 1.12 (p = 0.002)) improved. Moderate to severe mitral regurgitation (from 30.1% to 17.4%; p = 0.002) and tricuspid velocity decreased from 2.8 ± 0.55 m/sec to 2.64 ± 0.59 m/sec (p < 0.014). CONCLUSIONS: Sacubitril/valsartan induce "hemodynamic recovery" and, consistently with reduction in Nt-proBNP concentrations, improve NYHA class despite diuretic dose reduction.

Anomalous origin of all three coronary arteries from right sinus of Valsalva.

Congenital anomalies of the coronary arteries, although uncommon, have the potential to cause serious myocardial damage, ischemic cardiomyopathy, and sudden cardiac death. We report a rare case of origin of all three coronaries from the right sinus of Valsalva.

[Short-term effects of stimulation in the right ventricular outflow tract]. / Effetti a breve termine della stimolazione in tratto di efflusso del ventricolo destro.

INTRODUCTION: Stimulation in the right ventricular outflow tract (RVOT) showed better clinical and hemodynamic results at short, medium and long term than apical pacing. METHODS: We enrolled 30 patients undergoing pacemaker implantation with positioning of electrocatheters in the high or low RVOT. All patients underwent clinical, echocardiographic and electrocardiographic evaluation after implantation and at 6-month follow-up. RESULTS: After 6 months of pacing, no significant changes in echocardiographic parameters were observed, whereas differences were found between the duration of spontaneous QRS and the duration of QRS stimulated at the time of implantation. Electrocatheter implantation in the high RVOT showed a particular benefit. CONCLUSIONS: Chronic stimulation in RVOT, preferably in the high tract, can be considered a viable alternative to apical pacing in patients with likely high rates of stimulation, especially of young age.

Diagnosis and treatment of asymptomatic left ventricular systolic dysfunction after myocardial infarction.

The increased survival after acute myocardial infarction induced an increase in heart failure with left ventricular systolic dysfunction. Early detection and treatment of asymptomatic left ventricular systolic dysfunction give the chance to improve outcomes and to reduce costs due to the management of patients with overt heart failure.

Heart failure and mechanical circulatory assist devices.

During the last 20 years, the management of heart failure has significantly improved by means of new pharmacotherapies, more timely invasive treatments and device assisted therapies. Indeed, advances in mechanical support, namely with the development of more efficient left ventricular assist devices (LVAD), and the total artificial heart have reduced mortality and morbidity in patients with end-stage heart failure awaiting for transplantation. However, the transplant cannot be the only solution, due to an insufficient number of available donors, but also because of the high number of patients who are not candidates for severe comorbidities or advanced age. New perspectives are emerging in which the VAD is no longer conceived only as a "Bridge to Transplant", but is now seen as a destination therapy. In this review, the main VAD classification, current basic indications, functioning modalities, main limitations of surgical VAD and the total artificial heart development are described.

Relationship between inflammatory markers and new cardiovascular events in patients with acute myocardial infarction who underwent primary angioplasty.

INTRODUCTION: The determination of inflammation markers in circulation has enabled an important improvement in the study of cardiovascular diseases. It was tested the hypothesis that non-specific markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and fibrinogen may provide prognostic information in patients with acute myocardial infarction with persistent ST-segment elevation (STEMI) undergoing primary angioplasty (PCI). PATIENTS: A cohort of 197 consecutive patients with STEMI undergoing primary PCI was enrolled, evaluating during hospitalization, the peak values of the following markers of inflammation: ESR, CRP and fibrinogen. A telephone follow-up has been made in order to investigate any possible new cardiovascular events after hospital discharge and the procedure performed. RESULTS: Higher values of CRP were statistically associated with adverse future events as composite endpoint and with the single endpoint of death. Furthermore, higher age, presence of hypertension, history of previous cardiovascular events, were statistically significantly associated with cardiac events at follow up. In this group were also overrepresented subjects with anterior myocardial infarction in the anterior localization and with an EF ? 35% at discharge. CONCLUSIONS: CRP appears to be a predictor of future cardiovascular events, confirming that a pro-inflammatory state promotes the progression of atherosclerotic disease and its complications.

Chest pain due to late huge coronary pseudoaneurysm following stent implantation.

A 50-year-old man was referred to our hospital because of persistent atypical chest pain. His past medical history was remarkable for a non ST elevation myocardial infarction, treated five months previously with PCI on the right coronary artery. Two months later, for chest pain, he underwent coronary angiography that showed a right coronary artery with slight ectasia near the stent. Five months later for the persistence of atypical chest pain he came to our clinic. Chest CT showed a 31.5 mm hematoma of the right coronary artery. Coronary angiography revealed a giant aneurysm, proximal to the stent. In the light of rapid growth of aneurysm, the risk of rupture and symptoms, we decided to treat the aneurysm with covered stents. The patient underwent successful PCI with regression of symptoms.