The Evolving Phenotypes of Cardiovascular Disease during COVID-19 Pandemic.

COVID-19 pandemic has negatively impacted the management of patients with acute and chronic cardiovascular disease: acute coronary syndrome patients were often not timely reperfused, heart failure patients not adequately followed up and titrated, atrial arrhythmias not efficaciously treated and became chronic. New phenotypes of cardiovascular patients were more and more frequent during COVID-19 pandemic and are expected to be even more frequent in the next future in the new world shaped by the pandemic. We therefore aimed to briefly summarize the main changes in the phenotype of cardiovascular patients in the COVID-19 era, focusing on new clinical challenges and possible therapeutic options.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series.

AIM: Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS). METHODS: All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence. RESULTS: Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9). CONCLUSIONS: Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

Pharmacological Anti-Remodelling Effects of Disease-Modifying Drugs in Heart Failure with Reduced Ejection Fraction.

Cardiac remodelling is an adverse phenomenon linked to heart failure progression and an important contributor to heart failure severity. Cardiac remodelling could represent the real therapeutic goal in the treatment of patients with heart failure with reduced ejection fraction, being potentially reversed through different pharmacotherapies. Currently, there are well-established drugs such as angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and ß-blockers with anti-remodelling effects; recently, angiotensin receptor neprilysin inhibitor effects on inhibiting cardiac remodelling (improving N-terminal pro-B-type natriuretic peptide levels, echocardiographic parameters of reverse cardiac remodelling and right ventricular function in patients with heart failure with reduced ejection fraction) were demonstrated. More recently, hemodynamic consequences of gliflozins, reduced cardiac hydrostatic pressure as a possible cause of ventricular remodelling and hypertrophy were proposed to explain potential anti-remodelling effects of gliflozins. Gliflozins exert their cardioprotective effects by attenuating myofibroblast activity and collagen-mediated remodelling. Another postulated mechanism is represented by the reduction in sympathetic activity, through the reduction in renal afferent nervous activity and the suppression of central reflex mechanisms. Benefits of gliflozins on left ventricular hypertrophy, dilation, and systolic and diastolic function were also described. In this review, we aimed to provide a wide overview on cardiac remodelling with a particular focus on possible anti-remodelling effects of angiotensin receptor neprilysin inhibitors and gliflozins.

Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous.

BACKGROUND: Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficult-to-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis. OBJECTIVE: To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD. DESIGN: Single-center retrospective study. SETTING: Tertiary-care center for biliary surgery. PATIENTS: This study involved 22 patients with complete transection of the CBD after cholecystectomy. INTERVENTION: A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months. MAIN OUTCOME MEASUREMENTS: Success of the rendezvous maneuver, patient recovery, and patient mortality. RESULTS: After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeon's choice. LIMITATIONS: Single-center, retrospective study with a small population. CONCLUSION: Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.

Multiparametric risk stratification in patients with mild to moderate chronic heart failure.

BACKGROUND: Whether brain natriuretic peptide (BNP) combined with cardiopulmonary exercise test (CPx) and echocardiographic findings improves prognostic stratification in mild-to-moderate systolic heart failure (HF) is unclear. METHODS AND RESULTS: A total of 244 consecutive stable outpatients, median age of 71 (62-76) years, with New York Heart Association (NYHA) Class I-III HF and left ventricular ejection fraction (LVEF) < 45% underwent BNP measurement, Doppler echocardiography, and a maximal CPx. Median BNP was 166 (70-403) pg/mL, median LVEF 35% (28%-40%). A restrictive filling pattern (RFP) was present in 44 patients (18%). At CPx, peak oxygen uptake was 12 (9.7, 14.4) mL/kg/min and an enhanced ventilatory response to exercise (EVR, slope of the ventilation to CO2 production ratio, > or = 35) was found in 90 patients (37%) During 18 (9-37) follow-up months, 80 patients died or were admitted for worsening HF (33%). In addition to simple bedside clinical variables (NYHA Class III, creatinine clearance, hemoglobin), BNP levels were predictive of outcome (HR 1.35 [1.12-1.63]). However, both RFP (HR 3.36 [2.09-5.41]) and a steeper minute ventilation-carbon dioxide output slope (HR 1.50 [1.19-1.88]) outperformed BNP as prognostic markers. Patients with both RFP and EVR had a 7.30 (95% CI 4.02-13.25) HR for death or HF-admission versus subjects with neither predictor. CONCLUSIONS: This study highlights the importance of a multiparametric approach for optimal risk stratification in the elderly with mild-to-moderate HF. Patients at high risk should undergo closer follow-up and be carefully evaluated for different therapeutic options, including nonpharmacologic treatment.

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients.

BACKGROUND: Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases. METHODS: From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula. RESULTS: Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6-65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus. CONCLUSION: FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.

Prognostic value of plasma brain natriuretic peptide, urea nitrogen, and creatinine in outpatients >70 years of age with heart failure.

This study analyzed the relevance of plasma brain natriuretic peptide (BNP) and echocardiography in predicting cardiovascular events in a large population >70 years old with heart failure (HF). Three hundred four outpatients with HF (51.6% men, mean age 78.6) underwent transthoracic echocardiography and plasma BNP testing shortly before hospital discharge. Echocardiography was intended to reveal systolic dysfunction (left ventricular [LV] ejection fraction [EF] <50%) or diastolic dysfunction (EF > or =50% and abnormalities of ventricular relaxation). During 6-month follow-up, all-cause death and readmission were assessed. One hundred seventeen patients had diastolic dysfunction with preserved systolic LV function, and 187 had systolic dysfunction. At 6-month clinical follow-up, 33 subjects (10.9%) had died, and 62 (20.4%) needed readmission for cardiac decompensation. In all patients, univariate logistic regression demonstrated significant correlations between age (r = 0.14, p = 0.01), plasma BNP (r = 0.36, p = 0.0001), the EF (r = 0.16, p = 0.003), urea nitrogen (r = 0.35, p = 0.0001), serum creatinine (r = 0.27, p = 0.0001), and New York Heart Association (NYHA) class (r = 0.35, p = 0.0001) and the occurrence of cardiovascular events. In patients with HF in NYHA class III or IV, a BNP cut-off level of 200 pg/ml identified different outcomes (BNP <200 pg/ml in 1 of 20 events vs BNP >200 pg/ml in 55 of 85 events, p = 0.0001). In patients with HF who were >70 years old, BNP, NYHA class, and renal function predicted adverse outcome. In patients with severe HF, BNP was better than NYHA class in predicting future events.

The NT-proBNP assay identifies very elderly nursing home residents suffering from pre-clinical heart failure.

BACKGROUND: Little is known about the prevalence of heart failure among very old people, although hospitalisation rates for chronic heart failure are very high. Recently, brain natriuretic peptides have emerged as important diagnostic and prognostic serum markers for congestive heart failure. AIMS: The main purpose of our study was to determine whether there is a cut-off for NT-proBNP for detecting the echocardiographic features of left ventricular systolic and/or diastolic dysfunction and clinical heart failure among old people living in nursing homes. Secondarily, we investigated the medium-term prognostic power of the neurohormone levels. METHODS: We screened 101 old people (80% females, aged 84+/-9 years) from two nursing homes. We prospectively evaluated whether we could effectively stratify patients using a combination of (1) restrictive clinical criteria, (2) NT-proBNP measurements (Elecsys System, Roche Diagnostics) and (3) echocardiography for all patients. RESULTS: Forty-two percent of the subjects had left ventricular dysfunction: 11% systolic, 23% diastolic and 8% both systolic and diastolic. The mean NT-proBNP concentration was 2806+/-7028 pg/ml in the 42 patients with left ventricular systolic and/or diastolic dysfunction, compared with 365+/-456 pg/ml in the 59 patients with normal left ventricular function (p<0.01, Z=-4.8 Mann-Whitney U test). The neurohormone proved to be a good predictor of events within 6 months [area under the receiver-operated curve (ROC)=0.79]. CONCLUSIONS: Blood NT-proBNP concentrations can play an important role in stratifying old people into left ventricular dysfunction risk groups. The neurohormone is an independent marker for death or admission for heart failure in the medium term.

[Non-ST-elevation myocardial infarction with normal coronary arteries, clinical features and coronary artery flow]. / Valutazione del flusso coronarico nei pazienti con infarto miocardico acuto senza sopraslivellamento del tratto ST e rilievo angiografico di coronarie normali.

BACKGROUND: No assessment has been made up today concerning clinical features, coronary artery flow and mid-term prognosis between acute non-ST-elevation myocardial infarction (NSTEMI) patients without epicardial coronary disease and those with epicardial coronary artery stenosis > 50% of at least one vessel. METHODS: We evaluated consecutive NSTEMI patients who had undergone coronary angiography within the first 48 hours of infarction. We examined their age, sex, smoking habits, the incidence of diabetes, dyslipidemia, hypertension, and left ventricular ejection fraction. The coronary blood flow was assessed according to the conventional TIMI flow grade and with the TIMI frame count (TFC). RESULTS: From October 1, 2001 to December 31, 2003, 50 patients out of 996 with NSTEMI (20 males, 30 females, mean age 60 +/- 13 years), showed normal coronary arteries (5%). This subset of patients was compared with 50 NSTEMI patients with coronary stenosis. Patients of the first group were younger and more frequently female with respect to NSTEMI patients with coronary stenosis. The differences between the two groups with respect to diabetes, hypertension, dyslipidemia incidence and ejection fraction (52 vs 47%) were not statistically significant. With the corrected TFC (cTFC) method we found a slow flow in at least one coronary vessel in a high percentage of NSTEMI patients with normal coronary arteries. When we compared normal vessels between the two groups, we found a higher cTFC in NSTEMI patients with normal coronary arteries than in NSTEMI patients with coronary stenosis. After a 16 +/- 8 months of follow-up we observed 8 events in the normal vessel group and 10 in the coronary stenosis group (p = NS). CONCLUSIONS: The possible hypothesis of microvessel dysfunction as a pathogenesis of a slow flow in NSTEMI patients with normal coronary arteries is strong. Further studies are warranted to investigate microvessel disease and characteristics and possible causes of abnormalities. A larger perspective study with a longer follow-up is needed as well to evaluate the prognosis in this subset of patients.

Early 'shallow' needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla.

INTRODUCTION: Needle-knife sphincterotomy (NKS), known as 'precut', is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. METHODS: From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. RESULTS: Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. CONCLUSION: In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications.

[Electrical cardioversion for atrial fibrillation: advantages of the transthoracic biphasic method]. / Cardioversione elettrica della fibrillazione atriale: vantaggio della cardioversione transtoracica ad onda bifasica.

BACKGROUND: The purpose of this study was to evaluate efficacy and safety of biphasic shock for atrial fibrillation cardioversion to sinus rhythm. A second endpoint was to evaluate myocardial damage by means of cardiac troponin I dosage. METHODS: We studied 164 patients, with drug-resistant atrial fibrillation (208 episodes). Group A patients underwent biphasic shock normalized with respect to weight: 50 J (weight < 60 kg), 70 J (weight 61-84 kg) and 100 J (weight > 84 kg; the second and third shocks were 2 and 3 times higher than the first. Group B underwent sequential monophasic shock of 200, 300 and 360 J. Troponin I was evaluated at baseline, and 6, 12 and 24 hours after cardioversion. RESULTS: Total efficacy was 92% for biphasic shock and 89% for monophasic shock. First-shock efficacy with biphasic waveform (57.3%) was significantly greater than with first monophasic waveform (21.5%) (p = 0.000). Cardiac troponin I increased from 0.4 +/- 1.1 to 0.8 +/- 2.2 compared to a normal value of 2 ng/ml. CONCLUSIONS: For transthoracic cardioversion of atrial fibrillation, biphasic shock has a greater efficacy requiring less energy compared to monophasic shock. Normal mean values of cardiac troponin I proved the absence of myocardial damage.

[Treatment of biliary lithiasis with the advent of new technologies in Italy in the Lazio and Abruzzo regions over the past 15 years. Comparison between the patient series in a Roman university hospital and in a number of hospitals in the Abruzzo region]. / Il trattamento della litiasi biliare dopo l'avvento delle nuove tecnologie in Italia, nel Lazio ed Abruzzo negli ultimi 15 anni. Confronto tra la casistica di un ospedale universitario romano e alcuni ospedali abruzzesi.

Biliary lithiasis is a disease with a high incidence in the western world and a high social cost. To evaluate the impact of new technologies--mainly laparoscopic cholecystectomy and radiological and endoscopic techniques--in the treatment of biliary lithiasis, a statistical study was conducted on the surgical interventions performed over the past 15 years in Italy in the Lazio and Abruzzo regions. From 1985 to 1999, 150,000 cases of hepatobiliary lithiasis were hospitalized every year in Italy with a mean hospital stay of 7.8 days (13,000 in Lazio and 6,000 in Abruzzo). 100,000 cholecystectomies were performed every year in Italy in public hospitals, 30% of which by conventional laparotomy and 70% laparoscopically. Ten percent of these operations on average were performed in the Lazio region and 3% in the Abruzzo region. 10,615 cases of main bile duct stones were treated in 1999, 6,502 of which by ERCP and the others with open procedures and radiologically. The mortality was 0-0.1% for laparoscopic cholecystectomy as against 0-0.5% in open procedures.

Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network.

BACKGROUND: Secondary prevention is not adequately implemented after myocardial infarction (MI). We assessed the effect on quality of care and prognosis of a long-term, relatively intensive rehabilitation strategy after MI. METHODS: We conducted a multicenter, randomized controlled trial in patients following standard post-MI cardiac rehabilitation, comparing a long-term, reinforced, multifactorial educational and behavioral intervention with usual care. A total of 3241 patients with recent MI were randomized to a 3-year multifactorial continued educational and behavioral program (intervention group; n = 1620) or usual care (control group; n = 1621). The combination of cardiovascular (CV) mortality, nonfatal MI, nonfatal stroke, and hospitalization for angina pectoris, heart failure, or urgent revascularization procedure was the primary end point. Other end points were major CV events, major cardiac and cerebrovascular events, lifestyle habits, and drug prescriptions. RESULTS: End point events occurred in 556 patients (17.2%). Compared with usual care, the intensive intervention did not decrease the primary end point significantly (16.1% vs 18.2%; hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.74-1.04). However, the intensive intervention decreased several secondary end points: CV mortality plus nonfatal MI and stroke (3.2% vs 4.8%; HR, 0.67; 95% CI, 0.47-0.95), cardiac death plus nonfatal myocardial infarction (2.5% vs 4.0%; HR, 0.64; 95% CI, 0.43-0.94), and nonfatal MI (1.4% vs 2.7%; HR, 0.52; 95% CI, 0.31-0.86). A marked improvement in lifestyle habits (ie, exercise, diet, psychosocial stress, less deterioration of body weight control) and in prescription of drugs for secondary prevention was seen in the intervention group. CONCLUSION: The GOSPEL Study is the first trial to our knowledge to demonstrate that a multifactorial, continued reinforced intervention up to 3 years after rehabilitation following MI is effective in decreasing the risk of several important CV outcomes, particularly nonfatal MI, although the overall effect is small. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00421876.

Restrictive mitral inflow pattern is a strong independent predictor of lack of viable myocardium after a first acute myocardial infarction.

In patients with acute myocardial infarction (AMI) a restrictive mitral inflow pattern successfully predicts clinical outcome. The impact of myocardial viability on the mitral inflow velocities, however, is unknown. One hundred and forty-one patients with a first AMI underwent two-dimensional, Doppler and dobutamine stress echocardiography (DSE). Patients were classified into two groups based on Doppler measurement of left ventricular filling: a restrictive group (18 patients), and a non-restrictive group (123 patients). In the non-restrictive group, myocardial viability at DSE was found in 56 patients, while in the restrictive group only three patients showed contractile reserve (46% vs. 16%, p<0.03). The multivariate logistic regression analysis demonstrated that restrictive mitral inflow pattern was a strong independent predictor of lack of viable myocardium (OR=12.45, p<0.001).

Brain natriuretic peptide plasma level is a reliable indicator of advanced diastolic dysfunction in patients with chronic heart failure.

The aim of the study was to determine the value of brain natriuretic peptide for the identification of diastolic dysfunction status in congestive heart failure. We studied 204 patients with stable heart failure. Brain natriuretic peptide plasma levels were correlated with echocardiographic parameters of diastolic dysfunction. Diastolic dysfunction was classified as mild (abnormal echocardiographic relaxation pattern) and severe (pseudo-normal or restrictive pattern). A significant correlation between brain natriuretic peptide levels and the other parameters was detected. Brain natriuretic peptide dosage, then, seems to be a reliable tool for the assessment of diastolic dysfunction status in patients with congestive heart failure.

The cardiopulmonary exercise test is safe and reliable in elderly patients with chronic heart failure.

AIM: To assess safety and feasibility of cardiopulmonary exercise test (CPX) in elderly patients with chronic heart failure (CHF) and left ventricular dysfunction. METHODS AND RESULTS: We analysed 395 cardiopulmonary exercise tests (CPXs) performed in 227 clinically stable patients with CHF [mean age 76 years, males 70%, mean New York Heart Association (NYHA) class 2.2 +/- 0.5] and impaired left ventricular function (mean ejection fraction 43 +/- 12%). Ninety-eight out of 395 CPXs (25%) were performed in patients older than 80 years. A standard bicycle exercise ramp protocol was used, with increments of 10 W/min. An expiratory exchange ratio (RER) >or= 1.05 at the peak of CPX was considered as the index of maximal exercise. Average workload was 65 +/- 23 W. No adverse reactions were observed, although one test was stopped for non-sustained ventricular tachycardia. The main reasons for stopping were exhaustion (50%), dyspnoea (30%), maximal predicted heart rate (17%), orthopaedic problems (2.5%) and significant ST segment depression (0.5%). In the overall cohort, 80% of patients achieved an RER >or= 1.05 and, in 56% of them, the RER was >or= 1.15. The anaerobic threshold (AT) was detectable in 80% of CPXs, and mean oxygen consumption (VO2) at AT was 9 +/- 6 ml/kg per min, whereas mean peak VO2 was 11 +/- 3 ml/kg per min. In the cohort of patients aged > 80 years, 71% reached an RER >or= 1.05 and 47% reached an RER >or= 1.15. In these older patients, AT was detectable in 68% of CPXs performed, and the mean peak VO2 was 10 +/- 3 ml/kg per min. CONCLUSIONS: In elderly patients with CHF, the CPX is safe, feasible and able to provide basic information for individual risk assessment. These findings potentially extend the indications of CPX, which is currently applied to selected middle-aged patients with CHF, to the elderly population.

Comparison between four-slice computed tomography and coronary angiography for the assessment of coronary stents.

BACKGROUND: The present study aimed to evaluate the diagnostic accuracy of four-slice computed tomography for the detection, localization and patency assessment of metal coronary stents in a general population referred for coronary angiography late after coronary angioplasty. METHODS: Twenty-four consecutive patients with 34 coronary stents underwent multislice computed tomography within 24 h before a clinically driven coronary angiography performed 245 +/- 92 days after coronary stent implantation. For each patient, two independent operators were asked to evaluate the overall number of stents, the treated coronary vessels and segments, the presence of side-branches in the stented segment, the vessel patency, and the presence of binary in-stent restenosis. RESULTS: Four-slice computed tomography was feasible in 23 out of 24 patients (96%). Diagnostic accuracy was 94% for stent detection, 96% for the recognition of the stented coronary vessel and 97% for the identification of the stented segment. Accuracy in detection of side-branches in the stented segment, vessel patency and in-stent restenosis was 86%, 88% and 50%, respectively. CONCLUSIONS: Four-slice computed tomography is accurate in the identification of the stented coronary vessel and segment. By contrast, accuracy is low in the detection of vessel patency and in-stent restenosis. Such a technique does not appear to be useful as a screening tool before invasive diagnostic procedures.

Reliability of cardiac dimensions and valvular regurgitation assessment by sonographers using hand-carried ultrasound devices.

AIM: We sought to assess the reliability of some basic echocardiographic data obtained by trained sonographers using a hand-held ultrasound device. METHODS: One hundred and twelve consecutive patients (mean age 61, 64 males) referred for in-hospital or ambulatory routine echocardiography were considered. All patients underwent two-dimensional and colour Doppler examination performed by a trained sonographer equipped with a hand-held ultrasound device and by a certified cardiologist equipped with a standard platform, in random order. Indexed left ventricular end-diastolic and end-systolic transverse diameters, aortic root, end-systolic left atrium transverse diameter, end-diastolic interventricular septum and posterior wall thickness were calculated by two-dimensional left parasternal long-axis view in blind conditions. Mitral and aortic valve regurgitation were investigated by colour-Doppler imaging on parasternal and apical views and compared using a 0 to 4 semi-quantitative score. RESULTS: Overall feasibility was high for both settings (sonographers: 93%; cardiologists: 95%; P not significant). Excellent concordance of end-diastolic diameter (kappa 0.75), left atrium (kappa 0.76) and interventricular septum thickness (kappa 0.77) results was found. Good concordance was observed for end-systolic diameter (kappa 0.66), aortic root (kappa 0.64) and posterior wall thickness (kappa 0.67) results. A high linear correlation between the couples of results was present for all parameters. A good agreement of the mitral (kappa 0.66) and aortic (kappa 0.84) regurgitation scores was also found, with a low prevalence of discordant results (mitral regurgitation: 22%, aortic regurgitation: 9%) and no > or =2-point discrepancies. CONCLUSION: In a general population referred for Doppler echocardiography, basic cardiac linear dimensions and valvular regurgitation severity assessment by trained sonographers using hand-held ultrasound devices appear accurate and reliable for routine clinical use.