Cardiac CT perfusion and FFRCTA: pathophysiological features in ischemic heart disease.

Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFRCTA), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future.

CT Myocardial Perfusion Imaging: A New Frontier in Cardiac Imaging.

The past two decades have witnessed rapid and remarkable technical improvement of multidetector computed tomography (CT) in both image quality and diagnostic accuracy. These improvements include higher temporal resolution, high-definition and wider detectors, the introduction of dual-source and dual-energy scanners, and advanced postprocessing. Current new generation multidetector row (≥64 slices) CT systems allow an accurate and reliable assessment of both coronary epicardial stenosis and myocardial CT perfusion (CTP) imaging at rest and during pharmacologic stress in the same examination. This novel application makes CT the unique noninvasive "one-stop-shop" method for a comprehensive assessment of both anatomical coronary atherosclerosis and its physiological consequences. Myocardial CTP imaging can be performed with different approaches such as static arterial first-pass imaging, and dynamic CTP imaging, with their own advantages and disadvantages. Static CTP can be performed using single-energy or dual-energy CT, employing qualitative or semiquantitative analysis. In addition, dynamic CTP can obtain quantitative data of myocardial blood flow and coronary flow reserve. The purpose of this review was to summarize all available evidence about the emerging role of myocardial CTP to identify ischemia-associated lesions, focusing on technical considerations, clinical applications, strengths, limitations, and the more promising future fields of interest in the broad spectra of ischemic heart disease.

Anterior Mitral Valve Aneurysm Is an Uncommon Complication of Aortic Valve Infective Endocarditis: A Case Report.

BACKGROUND Mitral valve aneurysms (MVAs) are uncommon conditions frequently associated with aortic valve endocarditis. They may be complicated by perforation and severe mitral regurgitation (MR). Optimal treatment of MVA, and in particular the best timing for surgery, are uncertain. CASE REPORT A 62-year-old man with a recent history of dental surgery presented to the Emergency Department complaining relapsing fever. A first echocardiogram demonstrated infective endocarditis of the aortic valve. The patient was primarily managed with specific antibiotic therapy. Despite this, a few days later he suffered from splenic embolization and an MVA with MR was detected. Surgical replacement of the mitral and aortic valves was therefore performed. CONCLUSIONS MVAs are infrequent but potentially severe complications of AV endocarditis. In the absence of definite treatment indication, the correct time for surgery should depend on concomitant clinical and infective features.

Sudden death after valve-in-valve procedure due to delayed coronary obstruction: a case report.

BACKGROUND: Valve-in-valve transcatheter aortic valve implantation for degenerated aortic bioprostheses is an effective option for patients at high risk for redo surgery, even if it may be burdened by complications more common in specific settings, such as, coronary artery obstruction. CASE PRESENTATION: We present the case of a Caucasic 84-year-old woman with degeneration of a previously implanted aortic Mitroflow bioprosthesis. She underwent a valve-in-valve transcatheter aortic valve implantation with a CoreValve® bioprosthesis. End-procedure coronary angiography demonstrated maintained perfusion of both coronary arteries. However, few hours later, she experienced sudden cardiac death. An autopsy showed that Mitroflow prosthesis leaflets were higher than the left main coronary ostium, and no other possible cause for the sudden death. Fatality was thus ascribed to left main coronary ostium obstruction due to apposition of the Mitroflow leaflet pushed upward by the late expansion of CoreValve®. CONCLUSIONS: Coronary artery obstruction is a frequently fatal complication which usually presents just after valve implantation, but, as reported in our case, it may also have a delayed presentation. Accurate patient's selection and intraoperative preventive measures can reduce this eventuality.

One-year GH replacement therapy reduces early cardiac target organ damage (TOD) in adult GHD patients.

Hypopituitarism reduces life expectancy and increases the risk of cardiovascular and cerebrovascular diseases, as well as death. Abnormalities in the cardiovascular system may be independently related to GH deficiency (GHD). The aim of this study was to prospectively investigate coronary flow reserve and diastolic function in GHD adult patients at diagnosis and after 1 year of GH replacement therapy. As control group, an age- and sex-matched population was chosen. All patients and controls were non-smokers, non-diabetic, and normotensive, with no history of vascular disease. 14 patients with adult-onset GHD and 17 controls represent the two study groups. Anthropometric data, blood pressure, lipid profile, glycosylated hemoglobin (HbA1c) and IGF-I plasma levels, coronary flow reserve (CFR), and LV diastolic function (evaluated by E/A) were collected in all subjects before and after 12 months of GH replacement therapy. Compared with controls, systolic and diastolic blood pressure and LDL cholesterol levels were significantly higher at baseline and return, comparable to controls after 1 year of GH replacement (GHRT). GHD patients showed a blunted CFR at baseline (P < 0.001) and a significant improvement after GHRT, returning to values comparable with those recorded in the control group. In addition, after therapy a significant (P < 0.001) improvement in E/A was recorded. One year of GH therapy improves CFR and E/A in the patient population analyzed, thereby encouraging the early start of GHRT.

Comparison of coronary flow reserve estimated by dynamic radionuclide SPECT and multi-detector x-ray CT.

BACKGROUND: Recent technical advances in multi-detector computed tomography (MDCT) allow for assessment of coronary flow reserve (CFR). We compared regional CFR by dynamic SPECT and by dynamic MDCT in patients with suspected or known coronary artery disease (CAD). METHODS: Thirty-five patients, (29 males, mean age 69 years) with greater than average Framingham risk of CAD, underwent dipyridamole vasodilator stress imaging. CFR was estimated using dynamic SPECT and dynamic MDCT imaging in the same patients. Myocardial perfusion findings were correlated with obstructive CAD (≥50% luminal narrowing) on CT coronary angiography (CA). RESULTS: Mean CFR estimated by SPECT and MDCT in 595 myocardial segments was not different (1.51 ± 0.46 vs. 1.50 ± 0.37, p = NS). Correlation of segmental CFR by SPECT and MDCT was fair (r 2 = 0.39, p < 0.001). Bland-Altman analysis revealed that MDCT in comparison to SPECT systematically underestimated CFR in higher CFR ranges. By CTCA, 12 patients had normal CA, 11 had non-obstructive, and 12 had obstructive CAD. CFR by both techniques was significantly higher in territories of normal CA than in territories subtended by non-obstructive or obstructive CAD. SPECT CFR was also significantly different in territories subtended by non-obstructive and obstructive CAD, whereas MDCT CFR was not. CONCLUSION: Despite relative underestimation of high CFR values, MDCT CFR shows promise for assessing the pathophysiological significance of anatomic CAD.

Detection of the "Crossed Aorta Sign" during Echocardiography before Angiography.

We report the case of an anomalous circumflex (Cx) origin from the right sinus of Valsalva with retroaortic course observed in a modified apical four-chamber view during transthoracic study (TTE). This finding is known as the "crossed aorta sign." Usually, the diagnosis of this congenital anomaly of coronary circulation is established during coronary angiography. In this case, the diagnosis was performed by echocardiography before angiography. We believe that recent improvements in echocardiography increase the potential of this imaging technology also in the diagnosis of coronary artery anomalies.

Beneficial effects of long-term treatment with bosentan on the development of pulmonary arterial hypertension in patients with systemic sclerosis.

OBJECTIVE: To investigate the effects of long-term treatment with bosentan on pulmonary arterial hypertension (PAH) in patients with systemic sclerosis. METHODS: Patients with systemic sclerosis were followed between 2003 and 2014; those who developed digital ulcers were treated with standard regimens of bosentan. Patients were assessed at baseline and every 12 months using transthoracic Doppler echocardiography, 6-min walking distance test, Borg dyspnoea index and monitoring of plasma levels of 76-amino-acid N-terminal probrain natriuretic peptide. Patients who developed PAH underwent right heart catheterization to confirm the diagnosis. RESULTS: Sixty-nine patients with systemic sclerosis were enrolled in the study. Of these, 25 developed digital ulcers and received treatment with bosentan; the remaining 44 comprised the control group. None of the patients treated with bosentan developed PAH during the follow-up period. Furthermore, in these patients the mean ± SD systolic pulmonary arterial pressure significantly decreased from 33.64 ± 2.91 mmHg at baseline to 26.20 ± 1.78 mmHg at the end of the follow-up period. In contrast, in the control group, seven patients developed PAH during the follow-up period, with the mean ± SD systolic pulmonary arterial pressure significantly increasing from 33.57 ± 2.75 mmHg at baseline to 39.41 ± 4.11 mmHg at the end of the follow-up period. CONCLUSION: Long-term treatment with bosentan reduces the risk of developing PAH in patients with systemic sclerosis.

Testosterone Antagonizes Doxorubicin-Induced Senescence of Cardiomyocytes.

BACKGROUND: Chronic cardiotoxicity is less common in male than in female patients receiving doxorubicin and other anthracyclines at puberty and adolescence. We hypothesized that this sex difference might be secondary to distinct activities of sex hormones on cardiomyocyte senescence, which is thought to be central to the development of long-term anthracycline cardiomyopathy. METHODS AND RESULTS: H9c2 cells and neonatal mouse cardiomyocytes were exposed to doxorubicin with or without prior incubation with testosterone or 17ß-estradiol, the main androgen and estrogen, respectively. Testosterone, but not 17ß-estradiol, counteracted doxorubicin-elicited senescence. Downregulation of telomere binding factor 2, which has been pinpointed previously as being pivotal to doxorubicin-induced senescence, was also prevented by testosterone, as were p53 phosphorylation and accumulation. Pretreatment with the androgen receptor antagonist flutamide, the phosphatidylinositol 3 kinase inhibitor LY294002, and the nitric oxide synthase inhibitor L-NG-nitroarginine methyl ester abrogated the reduction in senescence and the normalization of telomere binding factor 2 levels attained by testosterone. Consistently, testosterone enhanced the phosphorylation of AKT and nitric oxide synthase 3. In H9c2 cells, doxorubicin-stimulated senescence was still observed up to 21 days after treatment and increased further when cells were rechallenged with doxorubicin 14 days after the first exposure to mimic the schedule of anthracycline-containing chemotherapy. Remarkably, these effects were also inhibited by testosterone. CONCLUSIONS: Testosterone protects cardiomyocytes against senescence caused by doxorubicin at least in part by modulating telomere binding factor 2 via a pathway involving the androgen receptor, phosphatidylinositol 3 kinase, AKT, and nitric oxide synthase 3. This is a potential mechanism by which pubescent and adolescent boys are less prone to chronic anthracycline cardiotoxicity than girls.

Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

BACKGROUND: To evaluate the impact of patient-prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients. METHODS: Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21 mm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85 cm/m. Median age was 82 years (range 75-93 years). Mean follow-up was 56 months (range 1-82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed. RESULTS: Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75 cm/m and 17 less than 0.65 cm/m (11.7%). Overall survival at 5 years was 78 ±â€Š4.5% and was not influenced by PPM (P = NS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (P < 0.001). QoL (physical functioning 45.18 ±â€Š11.35, energy/fatigue 49.36 ±â€Š8.64, emotional well being 58.84 ±â€Š15.44, social functioning 61.29 ±â€Š6.15) was similar to that of no-PPM patients (P = NS). CONCLUSION: PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.

Recurrent and Residual Shunts After Patent Foramen Ovale Closure: Results From a Long-Term Transcranial Doppler Study.

OBJECTIVES: Assess the evolution of right-to-left shunt (RLS) after transcatheter patent foramen ovale (PFO) closure. BACKGROUND: Despite the high number of interventional procedures performed worldwide, limited systematic data on the long-term abolition of RLS after percutaneous closure are available. METHODS: All patients treated at our Institution between February 2001 and July 2009 were included in this single center, prospective study, and were asked to repeat late contrast transcranial Doppler (cTCD). Rate of complete closure, residual RLS (i.e., a shunt that persists after closure), and recurrent RLS (i.e., a shunt that reappears after a previous negative cTCD) was assessed. RESULTS: Long-term follow-up was completed in 120 patients (56% male). RLS was still detectable 4.9 ± 2.3 years (range 1.3-10.3) after the procedure in 55 patients; 20 (17%) had residual RLS and 35 (29%) had recurrent RLS. Multivariate analysis revealed that significant predictors of residual RLS included post-procedural shunt at transesophageal echocardiography (OR 3.07, 95%CI 0.97-9.7), use of a bigger device (35 vs 25 mm, OR 3.85, 95%CI 1.22-12.2) and length of follow-up (OR 0.75, 95%CI 0.57-0.98), while only length of follow-up (OR 0.77, 95%CI 0.62-0.95) was associated with recurrent RLS. Neurological recurrences (1 stroke, 6 transient ischemic attacks) were equally distributed between the groups. CONCLUSION: A significant number of recurrent and residual shunts may be observed by cTCD up to 5 years after PFO closure. Management of late RLSs includes periodic re-evaluation, exclusion of device-induced complications or secondary sources of RLS, and optimization of antithrombotic treatment with or without a second intervention.

Aberrant right subclavian artery (arteria lusoria) challenging 4-French homolateral transradial coronary catheterisation in adulthood.

We report a case of an accidental finding of an aberrant right subclavian artery diagnosed in an adult man during a 4-French coronary angiography performed by right transradial access, then confirmed by multi-slice computed tomography. Tips and tricks have been suggested to complete the 4-French procedure avoiding changing the vascular access.

Left ventricular dilatation and subclinical renal damage in primary hypertension.

OBJECTIVE: A new classification of left ventricular geometry based on left ventricular dilatation and concentricity has recently been developed. This classification identifies subgroups differing with regard to systemic haemodynamics, left ventricular function and cardiovascular prognosis. We investigated the relationship between the new classification of left ventricular geometry and subclinical renal damage, namely urine albumin excretion and early intrarenal vascular changes in primary hypertensive patients. METHODS: A total of 449 untreated hypertensive patients were studied. Four different patterns of left ventricular hypertrophy (eccentric nondilated, eccentric dilated, concentric nondilated and concentric dilated hypertrophy) were identified by echocardiography. Albuminuria was measured as the albumin-to-creatinine ratio. Early intrarenal vascular changes, expressed as the renal volume to resistive index ratio, were evaluated by ultrasound and Doppler scan. RESULTS: Patients with concentric dilated left ventricular hypertrophy had higher albumin excretion rates (P = 0.0258) and prevalence of microalbuminuria (P < 0.0001) and lower renal volume to resistive index ratio than patients with concentric nondilated hypertrophy (P = 0.0093). Patients with eccentric dilated hypertrophy showed a higher prevalence of microalbuminuria than patients with eccentric nondilated hypertrophy (P < 0.0001). Moreover, patients with chamber dilatation showed a higher prevalence of microalbuminuria (P = 0.0002) and lower renal volume to resistive index ratio (P = 0.0107) than patients without chamber dilatation. After adjusting for potentially confounding variables, left ventricular chamber dilatation was an independent predictor of subclinical renal damage. CONCLUSION: Left ventricular dilatation is associated with subclinical renal damage in hypertension. These findings extend previous reports and provide a pathophysiological rationale for the observed unfavourable prognosis in patients with left ventricular dilatation.

Transient left ventricular and stomach apical ballooning syndromes: when the trigger is also a clinical emergency.

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of "apical stomach ballooning." Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.

[Postoperative atrial fibrillation in noncardiac thoracic surgery]. / Fibrillazione atriale postoperatoria nella chirurgia toracica non cardiaca.

Atrial fibrillation is the most common arrhythmia in clinical practice. Although postoperative atrial fibrillation occurs in a small percentage of the total number of cases, it is associated with increased mortality, longer hospital stay and higher hospitalization costs, making this issue of particular relevance. The aim of this literature review is to describe the risk profile of this patient subset and to focus on the current knowledge of available prophylactic and therapeutic strategies.

Functional tricuspid regurgitation: an underestimated issue.

This review article focuses on functional tricuspid regurgitation (FTR) that has long been a neglected and underestimated entity. FTR is defined as leakage of the tricuspid valve during systole in the presence of structurally normal leaflets and chordae. FTR may be secondary to several heart diseases, more commonly mitral valve disease, pulmonary hypertension, atrial fibrillation, cardiomyopathies, right ventricular dysplasia, and idiopathic annular dilatation. The reported prevalence of moderate or greater FTR is roughly 16%, but it rises up to 89% when considering FTR of any grade. According to the recommendations of the European Association of Echocardiography, two-dimensional transthoracic echocardiography (TTE) is the first-line imaging modality for the assessment of valvular regurgitation, whereas three-dimensional TTE may provide additional information in patients with complex valve lesions. Transesophageal echocardiography may be used when TTE results are inconclusive. The natural history of FTR is unfavorable, even in less than severe tricuspid regurgitation. Data from the literature suggest that moderate or greater FTR is a risk factor for worse survival. In addition, FTR of any grade may worsen over time, which makes it reasonable to consider the correction of FTR at an early stage, preferably at the time of mitral valve surgery. Tricuspid valve annuloplasty is the gold standard surgical treatment for FTR and is associated with a recurrence rate, defined as postoperative moderate or severe FTR, ranging from 2.5 to 5.5% at 1-year follow-up.