Risk stratification in cardiogenic shock: a focus on the available evidence.

Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients.

The role of non-invasive imaging modalities in cardiac allograft vasculopathy: an updated focus on current evidences.

Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse form of vasculopathy affecting almost 50% of patients after 10 years from heart transplant and represents the most common cause of long-term cardiovascular mortality among heart transplant recipients. The gold standard diagnostic technique is still invasive coronary angiography, which however holds potential for complications, especially contrast-related kidney injury and procedure-related vascular lesions. Non-invasive and contrast-sparing imaging techniques have been advocated and investigated over the past decades, in order to identify those that could replace coronary angiography or at least reach comparable accuracy in CAV detection. In addition, they could help the clinician in defining optimal timing for invasive testing. This review attempts to examine the currently available non-invasive imaging techniques that may be used in the follow-up of heart transplant patients, spanning from echocardiography to nuclear imaging, cardiac magnetic resonance and cardiac computed tomography angiography, weighting their advantages and disadvantages.

Cardiogenic shock and acute kidney injury: the rule rather than the exception.

Cardiogenic shock (CS) is a life-threatening condition of poor end-organ perfusion, caused by any cardiovascular disease resulting in a severe depression of cardiac output. Despite recent advances in replacement therapies, the outcome of CS is still poor, and its management depends more on empirical decisions rather than on evidence-based strategies. By its side, acute kidney injury (AKI) is a frequent complication of CS, resulting in the onset of a cardiorenal syndrome. The combination of CS with AKI depicts a worse clinical scenario and holds a worse prognosis. Many factors can lead to acute renal impairment in the setting of CS, either for natural disease progression or for iatrogenic causes. This review aims at collecting the current evidence-based acknowledgments in epidemiology, pathophysiology, clinical features, diagnosis, and management of CS with AKI. We also attempted to highlight the major gaps in evidence as well as to point out possible strategies to improve the outcome.

Traditional and Novel Imaging of Right Ventricular Function in Patients with Heart Failure and Reduced Ejection Fraction.

PURPOSE OF REVIEW: This review attempts to summarize the role of standard and advanced echocardiographic techniques together with CMR in the evaluation of the RV in HF, providing an outlook on the recent evidence. RECENT FINDINGS: In the last decade, there has been growing interest in the study of the RV, and it is now widely established that RV function is a strong predictor of mortality, in several cardiovascular diseases, in particular in the setting of heart failure (HF). The evaluation of RV function might be particularly challenging, which justifies the necessity of multi-modality imaging. The echocardiographic assessment remains the mainstay technique even though it might be complex, due to RV crescent shape and its position in the chest, requiring both qualitative and quantitative parameters. Cardiac magnetic resonance (CMR) represents a complementary exam which is particularly useful when precise structural and functional assessment are needed, considering the most recently developed sequences. Despite the technological improvement attested over the last years, there is still no universally accepted parameter that univocally defines RV function, hence the necessity to evaluate several parameters, combining different imaging techniques.

The prevalence and clinical significance of premature ventricular beats in the athlete.

Adolescents and adults with cardiovascular disease who are engaged in sports activity have an increased risk of sudden cardiac death (SCD) that is three times greater than that of their non-athletic counterparts. Sport acts as a trigger for cardiac arrest in the presence of underlying cardiovascular diseases predisposing to life-threatening ventricular arrhythmias. Frequent and complex premature ventricular beats (PVBs) detected during the cardiovascular screening of the athletic population may be a sign of an underlying cardiovascular disease at risk of SCD, but are also often recorded in trained athletes without cardiovascular abnormalities. Thus, the interpretation of PVBs could represent a clinical dilemma, particularly in the athlete. However, while some characteristics of PVBs can be considered common and benign, others occur uncommonly in the athletic population and raise the suspicion of an underlying cardiovascular disease. This review discusses the prevalence and clinical significance of PVBs in the athlete, with a focus on exercise-induced PVBs, on the analysis of PVB's morphology at 12-lead ECG, and on the morphological substrates identified by imaging techniques. The implications on eligibility for competitive sports participation are also discussed, according to the relevance of PVB detection for disqualifying athletes from competitions.

A quantitative assessment of circulating progenitor cells in competitive athletes and in sedentary subjects.

AIM: Hematopoietic stem cells (HSCs) and endothelial progenitor cells (EPCs) are known to play a role in the vascular responses and adaptations to exercise. We performed a quantitative assessment of HSCs and EPCs in adolescents in order to investigate whether resting levels of circulating HSCs and EPCs are comparable between elite athletes and sedentary healthy subjects. METHODS: HSCs and EPCs levels were measured in adolescent competitive football players and in age- and sex-matched sedentary controls. A laboratory testing was also performed to determine the white blood cells count and the lipid profile. All athletes were evaluated at the same stage of their training program, after 6 months of training. Controls were not engaged in any kind of routine training program. RESULTS: Twenty male competitive athletes (18.4 ± 0.5 years) and 9 sedentary controls (18.7 ± 0.4 years) participated in the study. As expected, HDL cholesterol was higher in athletes as compared with controls (P<0.05). No significant differences in the other laboratory parameters were observed among groups. Circulating levels of HSCs were significantly lower in athletes in comparison with sedentary controls (P<0.05). Conversely, EPCs and KDR+ cell subpopulations did not substantially differ between athletes and controls. CONCLUSION: Adolescent athletes exhibit lower levels of circulating HSCs but not of EPCs compared to sedentary controls. The process of tissue repair associated with intensive training can contribute to this difference, acting as a stimulus for mobilization and homing of HSCs in the site of injuries.

Speckle tracking echocardiography in plasma cell disorders: The role of advanced imaging in the early diagnosis of AL systemic cardiac amyloidosis.

INTRODUCTION: Amyloid light-chain amyloidosis is a rare condition characterized by the abnormal production of immunoglobulin light chain that misshape and form amyloid fibrils. Over time, these amyloid deposits can accumulate slowly, causing dysfunction in organs and tissues. Early identification is crucial to ensure optimal treatment. We aim to identify a better marker of cardiac amyloidosis, using advanced echocardiography, to improve diagnosis and the timing of available treatments. MATERIALS AND METHODS: 108 consecutive hematological patients (32, 30% female and 76, 70% male) with a plasma cell disorder referred to our Cardiological center underwent ECG, first and second-level echocardiography (Speckle Tracking) and complete biochemical profile. The best predictors of ALCA (AUC ≥ 0.8) were included in a further analysis stratified by AL score. RESULTS: At ROC analysis, the best bio-humoral predictors for the diagnosis of ALCA were Nt-pro-BNP (AUC: 0.97; p < 0.01) and Hs-Tn (AUC: 0.87; p < 0.01). Regarding echocardiography, the best diagnostic predictors were left atrial stiffness (LAS) (AUC: 0.83; p < 0.01) for the left atrium; free wall thickness for the right ventricle (AUC: 0.82; <0.01); left ventricular global longitudinal strain (LVGLS) (AUC: 0.92; p < 0.01) and LVMi (AUC 0.80; p < 0.001) for the left ventricle; and AL-score (AUC 0.83 p < 0.01). In patients with AL-SCORE < 1, LAS (AUC 0.86 vs AUC 0.79), LVGLS (AUC 0.92 vs AUC 0.86) and LV mass (AUC 0.91 vs AUC 0.72) had better diagnostic accuracy than patients with higher AL-score (AL SCORE ≥ 1). CONCLUSION: Multi-parametric imaging approach with LVGLS and LAS may be helpful for detecting early cardiac involvement in AL amyloidosis.

Left atrial remodelling in competitive adolescent soccer players.

Left atrial (LA) enlargement and improved myocardial diastolic properties are a component of athlete's heart. We performed a longitudinal study involving adolescent athletes to investigate the impact of training on LA remodelling and diastolic function. 21 competitive adolescent soccer players were enrolled and engaged in an 8-month training program. Echocardiographic analysis was performed at baseline, after 4 and 8 months. We assessed diastolic function by Doppler tissue imaging and we analyzed LA adaptations by 2D speckle-tracking echocardiography. After 4 months, LA mean volume index significantly increased (Δ=5.47 ± 4.38 mL/m2, p ≤ 0.0001). After 8 months, a further increase occurred (Δ=8.95 ± 4.47 mL/m2, p ≤ 0.0001). A higher E velocity (p=0.001; p=0.001), a greater E/A ratio (p=0.002; p=0.0009), a higher e' peak (p= 0.005; p=0.001), and a greater e'/a' ratio (p=0.01; p=0.0006) were observed at 4 and at 8 months, respectively. E/e' ratio significantly decreased after 8 months (p ≤ 0.005). Global peak atrial longitudinal strain and global peak atrial contraction strain values significantly decreased after 8 months (p=0.0004, p=0.01, respectively). An 8-month training program is associated with LA dimensional and functional training-specific adaptations in competitive adolescent soccer players. Myocardial diastolic properties can improve after training also in subjects already presenting with features of athlete's heart.

Clinical, echocardiographic and hemodynamic predictors of right heart failure after LVAD placement.

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implant is associated with increasing morbidity and mortality. The aim of this study was to identify the best predictors of RVF post LVAD-implant among biochemical, haemodynamic and echocardiographic parameters. From 2009 to 2019, 38 patients who underwent LVAD implantation at our centre were prospectively enrolled. Preoperative clinical, laboratory, echocardiographic and haemodynamic parameters were reported. Overall, eight patients (21%) developed RVF over time, which revealed to be strongly related to overall mortality. Pulmonary artery pulsatility index (PAPi) resulted to be the most significant right heart catheterization index in discriminating RVF vs no RVF patients [(1.32 ± 0.26 vs. 3.95 ± 3.39 respectively) p = 0.0036]. Regarding transthoracic echocardiography, RVF was associated with reduced free wall right ventricular longitudinal strain (fw-RVLS) (- 7.9 ± 1.29 vs. - 16.14 ± 5.83) (p < 0.009), which was superior to other echocardiographic determinants of RVF. Among laboratory values, N-terminal pro-brain natriuretic peptide (NT-proBNP) was strongly increased in RVF patients [(10,496.13 pg/ml ± 5272.96 pg/ml vs. 2865, 5 pg/ml ± 2595.61 pg/ml) p = 0.006]. PAPi, NT-proBNP and fwRVLS were the best pre-operative predictors of RVF, a post-LVAD implant complication which was confirmed to have a great impact on survival. In particular, fwRVLS has been proven to be the strongest independent predictor.

Multimodality imaging of the ischemic right ventricle: an overview and proposal of a diagnostic algorithm.

Right ventricular (RV) involvement is frequently detected in patients presenting with acute left ventricular myocardial infarction. The ischemic right ventricle carries a dismal outcome by predisposing the heart to arrhythmic events and mechanical or hemodynamic complications. A comprehensive RV evaluation by multimodality imaging could guide clinical practice but has always been a conundrum for the imagers. Two-dimensional echocardiography is the best first-line tool due to its availability of bedside capabilities. More advanced imaging techniques provide a more comprehensive evaluation of the complex RV geometry but are mostly reserved for the post-acute setting. Three-dimensional echocardiography has improved the evaluation of RV volumes and function. The recent application of speckle-tracking echocardiography to the right ventricle appears promising, allowing the earlier detection of subtle RV dysfunction. Cardiac magnetic resonance imaging is considered the gold standard for the RV assessment. Cardiac multidetector computed tomography could be a reliable alternative. The aim of this review is to focus on the growing importance of multimodality imaging of the ischemic right ventricle and to propose a diagnostic algorithm, in order to reach a comprehensive assessment of this too frequently neglected chamber.

Evaluation of Right Ventricular Function in the Management of Patients Referred for Left Ventricular Assist Device Therapy.

BACKGROUND: Speckle tracking echocardiography analysis (STE) has recently allowed an in-depth analysis of right ventricular (RV) performance. The aim of the study was to observe RV function by STE in patients with advanced heart failure before and after left ventricular assist device (LVAD) implantation. METHODS: A transthoracic echocardiogram was performed in 19 patients referred for LVAD implant at baseline and with serial echocardiograms after LVAD implantation (Jarvik 2000). All echocardiographic images were analyzed off line by an independent operator to calculate with STE the RV free wall longitudinal strain (RVLS). RESULTS: All the patients, except 4, showed a progressive increase of RVLS after LVAD implant. However, 4 patients, who presented the lowest RVLS values at baseline, presented a further RV failure in the postoperative. The value of -11% represented the empirical preoperative cutoff able to identify patients at greater risk of postimplant RV failure. CONCLUSIONS: RV myocardial deformation may have important clinical implications for the selection and management of LVAD patients. It can be used to evaluate RV function before LVAD implantation, to drive decisional strategy regarding the management of this type of patients, and after LVAD implant for the follow-up.