Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction.

Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.

[Paradoxical low flow-low gradient aortic stenosis: lights and shadows]. / Stenosi aortica "paradoxical low flow-low gradient": luci ed ombre.

Paradoxical low flow-low gradient aortic valve stenosis (AVS) is an increasing phenotype in the general population, particularly after the seventh decade of life. It is an AVS in which, despite the preserved ejection fraction, the mean transvalvular gradient is not suggestive of severe AVS (<40 mmHg). The pathophysiology is often intertwined with conditions resulting in heart failure with preserved ejection fraction, such as arterial hypertension and cardiac amyloidosis. Its management is rather controversial about the diagnosis and therapeutic management. The aims of this focus are: to clarify the role and reliability of the main available diagnostic methods, the efficacy of surgical and percutaneous treatments, and to develop a diagnostic-therapeutic algorithm for managing this condition in clinical practice. This algorithm will involve a multi-parametric evaluation, integrating standard echocardiographic assessment with three-dimensional planimetric valve area calculation, determination of the energy loss index), and calcium score calculation by computed tomography scan. This approach aims to ascertain the severity of the stenosis and determine the appropriate therapeutic management.

[Atrial cardiomyopathy as a link between atrial fibrillation and stroke. Clinical implications and future diagnostic-therapeutic implications]. / La cardiomiopatia atriale come legame tra fibrillazione atriale e ictus. Implicazioni cliniche e implicazioni diagnostico-terapeutiche future.

Atrial myopathy is characterized by atrial fibrotic remodeling, together with electrical, mechanic and autonomic remodeling. Methods to identify atrial myopathy include atrial electrograms, tissue biopsy, cardiac imaging, and serum biomarkers. Accumulating data show that individuals with markers of atrial myopathy have an increased risk of developing both atrial fibrillation and strokes. The aim of the present review is to present atrial myopathy as a pathophysiologic and clinical entity, to describe methods for its detection and the possible implications on management and therapy in selected group of patients.

[Barlow's disease with arrhythmic phenotype: a case report]. / Un caso di malattia di Barlow a fenotipo aritmico.

Barlow disease represents the extreme form of the degenerative mitral valve spectrum described by Carpentier. The myxoid degeneration of the mitral valve may result in a billowing leaflet or in a prolapse and myxomatous degeneration of the mitral leaflets. There are increasing evidences of the association between Barlow disease and sudden cardiac death. It is common in young women. Symptoms include anxiety, chest pain and palpitation. In this case report, the markers of risk for sudden death such as typical ECG changes, complex ventricular ectopy, a spiked configuration of the lateral annular velocities, mitral annular disjunction and evidence of myocardial fibrosis were assessed.

Unveiling the Hidden Chamber: Exploring the Importance of Left Atrial Function and Filling Pressure in Cardiovascular Health.

The left atrium (LA) is a vital component of the cardiovascular system, playing a crucial role in cardiac function. It acts as a reservoir, conduit, and contractile chamber, contributing to optimal left ventricle (LV) filling and cardiac output. Abnormalities in LA function have been associated with various cardiovascular conditions, including heart failure, atrial fibrillation, valvular heart disease, and hypertension. Elevated left ventricular filling pressures resulting from impaired LA function can lead to diastolic dysfunction and increase the risk of adverse cardiovascular events. Understanding the relationship between LA function and LV filling pressures is crucial for comprehending the pathophysiology of cardiovascular diseases and guiding clinical management strategies. This article provides an overview of the anatomy and physiology of the LA, discusses the role of LA mechanics in maintaining normal cardiac function, highlights the clinical implications of elevated filling pressures, and explores diagnostic methods for assessing LA function and filling pressures. Furthermore, it discusses the prognostic implications and potential therapeutic approaches for managing patients with abnormal LA function and elevated filling pressure. Continued research and clinical focus on left atrial function are necessary to improve diagnostic accuracy, prognostic assessment, and treatment strategies in cardiovascular diseases. It will explore the importance of assessing LA function as a marker of cardiac performance and evaluate its implications for clinical practice. In accordance with rigorous scientific methodology, our search encompassed PubMed database. We selected articles deemed pertinent to our subject matter. Subsequently, we extracted and synthesized the salient contents, capturing the essence of each selected article.

[Ten questions on cardiac magnetic resonance in patients with heart failure: from etiological diagnosis to prognostic stratification]. / Dieci quesiti in tema di risonanza magnetica cardiaca nel paziente con scompenso cardiaco: dalla diagnosi eziologica alla stratificazione prognostica.

Cardiac magnetic resonance (CMR) imaging has progressively become part of the imaging methods recommended in patients with heart failure. CMR represents the gold standard for assessing volumes, function, biventricular kinetics and providing tissue characterization through scans with and without contrast medium. In patients with heart failure with reduced ejection fraction (HFrEF) and ischemic dilated cardiomyopathy, CMR allows to search for viability, accurately estimate volumes and ejection fraction. It can assess scar extent for predicting response to cardiac resynchronization therapy and for establishing an indication for implanting a defibrillator in borderline cases. In patients with HFrEF and non-ischemic dilated cardiomyopathy, CMR helps to identify specific etiological subgroups and to estimate the arrhythmic risk beyond ejection fraction. In patients with heart failure with preserved ejection fraction, CMR offers the possibility of diagnosing specific phenotypes, including sarcomeric hypertrophic cardiomyopathy, amyloidosis or Fabry disease, and adds prognostic information. Both clinical and scientific interest in this imaging method is constantly expanding; the clinicians dealing with heart failure cannot fail to know the technique, the indications and all the potential that CMR can offer.

[Role of nuclear cardiology in clinical practice: state of art]. / Ruolo della cardiologia nucleare nella pratica clinica: stato dell'arte.

Nuclear imaging plays a pivotal role not only in in the evaluation of myocardial ischemia, but also in the evaluation of cardiac infectious, inflammatory, infiltrative and innervation disorders. Myocardial ischemia and viability, cardiac amyloidosis, sarcoidosis, large vessel vasculitis, infective endocarditis, infected cardiac implantable electronic devices, vascular graft infection, and myocardial innervation dysfunction are the main indications for the use of nuclear medicine procedures in both diagnosis and response assessment. With this summarized paper we share a comprehensive review of the role and the use of nuclear cardiology in different cardiac diseases.

[Transcranial color Doppler ultrasonography: methodology and usefulness for the study of patent foramen ovale in cryptogenic stroke]. / Eco-color Doppler transcranico: metodologia e utilità nello studio del forame ovale pervio nell'ictus criptogenetico.

Non-invasive Doppler ultrasonographic study of cerebral arteries (transcranial Doppler, TCD) has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays a valid indication for TCD in the outpatient setting is the research of right-to-left shunting, responsible for the so-called "paradoxical embolism", most often due to patency of foramen ovale, which is responsible for the majority of cryptogenic strokes occurring in patients younger than 55 years. TCD also allows to classify the grade of severity of such shunts using the so-called "microembolic signal grading score". Therefore, TCD is an essential cardiological exam for the detection of patent foramen ovale, assuming an important role as a first-level examination to guide the subsequent diagnostic-therapeutic management. In addition, TCD has found many useful applications in neurocritical care practice. It is useful for the identification of intracranial vascular stenosis and for the assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury and brain stem death. It is also used to evaluate cerebral hemodynamic changes after stroke, to investigate cerebral pressure autoregulation, and for the clinical evaluation of cerebral vasomotor reactivity.

[Lung ultrasonography: what the cardiologist should know]. / Ecografia del polmone: quello che il cardiologo dovrebbe conoscere.

In recent years, lung ultrasonography has acquired an important role as a valuable diagnostic tool in clinical practice. The lung is usually poorly explorable, but it provides more acoustic information in pathological conditions that modify the relationship between air, water and tissues. The different acoustic impedance of all these components makes the chest wall a powerful ultrasound reflector: this is responsible for the creation of several artifacts providing valuable information about lung pathophysiology. Lung ultrasonography helps in the diagnostic process of parenchymal and pleural pathologies, in the differential diagnosis of dyspnea and in the clinical and prognostic evaluation of the SARS-CoV-2 infection.

[Non-ischemic ventricular dysfunction in COVID-19 patients: characteristics and implications for cardiac imaging on the basis of current evidence]. / La disfunzione ventricolare non ischemica nei pazienti con COVID-19: caratteristiche e implicazioni per l'imaging cardiaco in base alle attuali evidenze scientifiche.

Coronavirus 2019 disease (COVID-19), caused by SARS-CoV-2, can lead to cardiac impairment with various types of clinical manifestations, including heart failure and cardiogenic shock. A possible expression of cardiac impairment is non-ischemic ventricular dysfunction, which can be related to different pathological conditions, such as myocarditis, stress and cytokine-related ventricular dysfunction. The diagnosis of these pathological conditions can be challenging during COVID-19; furthermore, their prevalence and prognostic significance have not been elucidated yet. The purpose of this review is to take stock of the various aspects of non-ischemic ventricular dysfunction that may occur during COVID-19 and of the diagnostic implications related to the use of cardiac imaging techniques.

[Grey zones in cardiovascular adaptations to physical exercise: how to navigate in the echocardiographic evaluation of the athlete's heart]. / Le "zone grigie" degli adattamenti cardiovascolari all'esercizio fisico: come orientarsi nella valutazione ecocardiografica del cuore d'atleta.

"Athlete's heart" represents a series of mechanisms through which cardiac chambers can adapt to physical activity. Echocardiography has a major role in sports cardiology and it can help physicians to investigate the so-called "grey zones", defined as diagnostic overlaps between athlete's heart and several cardiac diseases: wall thickness and left ventricular size in hypertrophic and dilated cardiomyopathy, ventricular trabeculations in left ventricular non-compaction cardiomyopathy, left atrial size and atrial fibrillation, right ventricular systolic dysfunction in arrhythmogenic right ventricular cardiomyopathy. The use of advanced ultrasound methods such as tissue Doppler and two-dimensional strain can be added to the classic echocardiographic assessment to complete a multi-parametric evaluation, guiding the sports physician and cardiologist in the correct framing of these patients.

[Imaging in acute aortic syndrome: not just dissection]. / L'imaging nella sindrome aortica acuta: non solo dissezione.

Acute aortic syndrome includes three main pathological conditions: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU). These are life-threatening conditions, therefore early diagnosis and interventional/surgical treatment are fundamental for the survival of affected individuals. While anatomical findings of classical AD provided by imaging techniques are known to all cardiologists, imaging findings of IMH and PAU are less known, as are their prognostic implications and consequences on management and treatment strategies. This review aims to describe and discuss findings and role of imaging techniques in patients with IMH and PAU.

[The role of multimodality imaging in COVID-19 patients: from diagnosis to clinical monitoring and prognosis]. / L'imaging integrato nel percorso del paziente con COVID-19: dalla diagnosi, al monitoraggio clinico, alla prognosi.

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, monitoring and evaluation of the patient's therapy in COVID-19 pneumonia. The ideal imaging strategy in this setting is not yet well defined. Bedside pulmonary ultrasound presents an undeniable series of advantages in patients at high risk of infection, and can provide incremental data in the respiratory intensive care for the serial control of the individual patient, as well as for home delivery of stabilized patients. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. Pulmonary computed tomography shows high sensitivity but should not be routinely performed in all patients, because in the first 48 h it can be absolutely negative, and in the late phase imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability.

[ANMCO/SICI-GISE/SIC/SIECVI/SIRM Consensus document: Appropriateness of multimodality imaging in cardiovascular disease]. / Documento di consenso ANMCO/SICI-GISE/SIC/SIECVI/SIRM: Appropriatezza dell'imaging multimodale nelle patologie cardiovascolari.

The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.

[Role of multimodality imaging in the clinical evaluation of hypertrophic cardiomyopathy]. / Valutazione clinica della cardiomiopatia ipertrofica: ruolo dell'imaging multimodale.

Sarcomeric hypertrophic cardiomyopathy is the most common cardiovascular genetic disease. Clinical evaluation and comprehensive echocardiography are crucial for the diagnosis and early evaluation of the hypertrophic phenotype, but multimodality imaging approach is often required to better define diagnosis and differential diagnosis from phenocopies. This review aims to assess the role of multimodality imaging and, in particular, advanced echocardiography and cardiac magnetic resonance in relation to differential diagnosis and preclinical diagnosis, identification of different phenotypes, and assessment of disease progression and risk of sudden cardiac death. A multimodality imaging approach is also crucial for the selection of patients amenable to surgical or percutaneous septal myectomy and for guiding both procedures.

The TRIBECA study: (TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease in (A)ortic position.

OBJECTIVE: To determine whether the Trifecta bioprosthetic aortic valve produces postoperative haemodynamic results comparable with or better than those of the Magna Ease aortic valve bioprosthesis. METHODS: We retrospectively reviewed the medical records of patients who had undergone aortic valve replacement with Trifecta or Magna Ease prostheses at eight European institutions between January 2011 and May 2013, and analysed early postoperative haemodynamic performance by means of echocardiography. RESULTS: A total of 791 patients underwent aortic valve replacement (469 Magna Ease, 322 Trifecta). Haemodynamic variables were evaluated on discharge and during the follow-up (minimum 6 months, maximum 12 months). The mean gradient and the indexed effective orifice area (IEOA) were as follows: 10 mmHg [interquartile range (IQR): 8-13] and 1.10 cm(2)/m(2) (IQR: 0.95-1.27) for Trifecta; 16 mmHg (IQR: 11-22) and 0.96 cm(2)/m(2) (IQR: 0.77-1.13) for Magna Ease (P < 0.001). These significant differences were maintained across all valve sizes. Similar statistically significant differences were found when patients were matched and/or stratified for preoperative characteristics: body-surface area, ejection fraction, mean gradients and valve size. Severe prosthesis-patient mismatch (IEOA: <0.65 cm(2)/m(2)) was detected in 2 patients (0.6%) with Trifecta and 40 patients (8.5%) with Magna Ease (P < 0.001). CONCLUSIONS: The haemodynamic performance of the Trifecta bioprosthesis was superior to that of the Magna Ease valve across all conventional prosthesis sizes, with almost no incidence of severe patient-prosthesis mismatch. The long-term follow-up is needed to determine whether these significant haemodynamic differences will persist, and influence clinical outcomes.

Role of hypertension on new onset congestive heart failure in patients receiving trastuzumab therapy for breast cancer.

BACKGROUND: Adjuvant trastuzumab therapy improves survival of Human Epidermal growth factor receptor 2 (HER2)-positive women with early breast cancer (EBC). Trastuzumab-induced cardiotoxicity is not uncommon. In the setting of community patients, the incidence, timing and phenotype of new onset congestive heart failure (CHF) is unknown. METHODS: Forty hundred and ninety nine consecutive HER2-positive women (mean age 55 ±â€Š11) with EBC treated with trastuzumab between January 2008 and June 2009 at 10 Italian institutions were followed-up for 1 year. We evaluated incidence, time of occurrence, clinical features associated with CHF. Left ventricular ejection fraction (LVEF) was evaluated by echocardiography at baseline and 3, 6, 9and 12 months during trastuzumab therapy. RESULTS: CHF occurred in 16 patients (3.2%), who were older, more hypertensive and with a higher degree of hypertension in comparison with patients who did not have CHF. All CHF patients had a significant reduction in LVEF with a mean peak of -12 points % detected at 3-month follow-up. CHF occurred in seven patients (44%) within 3-month follow-up, in four patients (25%) between 3-6 months, in three patients (19%) between 6-9 months and in two patients (12%) between 9 and 12 months. Trastuzumab was discontinued in 10 of 16 patients and re-started in five after LVEF recovery and clinical improvement. New onset CHF was predicted by the presence of hypertension [OR 2.9 (CI 1.1-7.9]). CONCLUSION: New onset CHF occurs seldom in HER2-positive women with EBC, prevalently in the first 6 months of therapy. CHF is associated with a significant reduction in LVEF and is predicted by a history of hypertension.

A giant coronary artery aneurysm with coronary arteriovenous fistula in asymptomatic elderly patient.

Coronary Arteriovenous Fistula (CAF) is a rare defect that occurs in 0.1-0.2% of patients undergoing coronary angiography; Coronary Artery Aneurism (CAA) also occurs in approximately 15-19% of patients with CAF. It is usually congenital, but in rare occasions it occurs after chest trauma, cardiac surgery, or coronary interventions. The case described is that of a 72-year-old woman, without previous history of cardiovascular disease, who presented a huge cardiac mass. A multimodal approach was necessary to diagnose a giant CAA with CAF responsible for compression and displacement of cardiac structures. Due to likely congenitally origin of the lesion and the absence of symptoms correlated to the CAA and to the CAF we decided to avoid invasive interventions and to treat the patient with medical therapy.