[Single-center retrospective observational study on predictors of residual mitral regurgitation 1 year after MitraClip® implantation]. / Studio osservazionale retrospettivo monocentrico sui predittori di insufficienza mitralica residua a 1 anno dall'impianto di MitraClip®.

BACKGROUND: The extent of residual mitral regurgitation (MR) (1+ vs ≥2+) has a notable impact on the outcome of MitraClip (MC) repair of significant functional MR. In this retrospective single-center study, we evaluated the predictors of MI ≥2+ at 1 year in one of our case series. METHODS: Overall, 58 patients with moderate severe functional MR underwent MC implantation; of these, 48 patients had instrumental clinical follow-up for 1 year. RESULTS: At 1 year, 10 patients died (mortality 17.2%). In the remaining 48 patients, the incidence of rehospitalization was 8.3%, and the incidence of MR grade 1+ and ≥2+ was 54.1% (n = 26) and 45.9% (n = 22), respectively. In patients with MR ≥2+, clinical and instrumental outcomes were worse than in patients with MR 1+. The height of the posterior leaflet and the extent of immediate postprocedural MR were independent predictors of MR ≥2+. CONCLUSIONS: Percutaneous repair with MC of moderate/severe functional MR has favorable 1-year outcomes in terms of mortality and rehospitalizations. The best results are achieved in patients with residual MR 1+. Echocardiographic parameters are independent predictors of residual MR ≥2+.

A narrative review of diagnosis of infective endocarditis-imaging methods and comparison.

The profile of infective endocarditis (IE) has changed over the past few decades. The modified Duke's criteria is currently employed for diagnosis of IE. Emphasis on imaging modalities however, have been increasing due to the variety of presenting symptoms leading to diagnostic conundrums. This wide range of diagnostic tools must be adapted to permit localization of the infectious field which may involve multiple valves on either side of the heart. The availability of such diagnostic tools is also variable in different centres. The use of echocardiography has long been the default position, however the lack of specificity and sensitivity especially in prosthetic valve endocarditis has been highlighted throughout the literature. We therefore aimed to look at the different imaging modalities available and the strengths and weaknesses of each of these modalities to enhance the diagnostic yield and allow timely intervention for this condition. We highlight the role of the different forms of echocardiography, multi-detector computed tomography (MDCT), Nuclear Medicine, Magnetic Resonance Imaging and identify the special indications such as right sided infective endocarditis (RSIE) and cardiac implantable electronic device (CIED) endocarditis. Input from a specialist heart team is essential to ensure timely diagnosis and care are afforded. The role of alternative imaging techniques such as nuclear medicine in determining timing of cardiac surgery should be evaluated further by randomised trials.

Excessive increase in left ventricular mass identifies hypertensive subjects with clustered geometric and functional abnormalities.

BACKGROUND: Left ventricular mass (LVM) exceeding needs to sustain haemodynamic load has been termed 'inappropriate left ventricular mass'. We hypothesized that inappropriate LVM identifies hypertensive patients with clustered cardiac geometric and functional abnormalities. METHODS: For this purpose, 359 hypertensive individuals without prevalent cardiovascular disease underwent Doppler echocardiography. Observed LVM exceeding more than 28% of the value predicted for individual cardiac work, body size and sex was defined as inappropriate LVM. Concentric left ventricular geometry was defined as age-adjusted relative wall thickness (RWT) greater than 0.40. Systolic dysfunction was defined as ejection fraction less than 50% or midwall shortening less than 14.7%. Diastolic dysfunction was defined as isovolumic relaxation time (IVRT) greater than 100 ms, E-velocity deceleration time greater than 220 ms or age and heart rate-normalized early/late (E/A) ratio less than 0.66. Left ventricular hypertrophy (LVH) was defined as an LVM index greater than 49.2 g/m2.7 in men and 46.7 g/m2.7 in women. RESULTS: As expected, inappropriate LVM was associated with higher RWT, lower left ventricular systolic function, longer IVRT and prolonged E-deceleration time (all P < 0.05). Patients with inappropriate LVM had a higher prevalence of concentric geometry (65.5 versus 40.4%), systolic dysfunction (67.9 versus 47.4%) and diastolic dysfunction (46.4 versus 39%; all P < 0.001) than those with LVH. Inappropriate LVM had greater sensitivity (0.89 versus 0.54) and specificity (0.82 versus 0.62; both P < 0.01) than LVH in identifying patients with clustered left ventricular concentric geometry, systolic and diastolic dysfunction. CONCLUSIONS: Inappropriate LVM is associated with a cluster of concentric left ventricular geometry, delayed left ventricular relaxation and reduced systolic performance. Compared with LVH, inappropriate LVM is more accurate at identifying patients with clustered left ventricular geometric and functional abnormalities.

Myocardial mechano-energetic efficiency in hypertensive adults.

BACKGROUND: Myocardial mechanical efficiency can be measured as the ratio between systolic work and energy consumption. We evaluated the relation between myocardial mechanical efficiency and left ventricular (LV) mass in untreated hypertensive patients. METHODS: Myocardial work was estimated in 256 normotensive (35 +/- 12 years) and 306 hypertensive patients (47 +/- 10 years) with normal ejection fraction, as stroke work in gram-meters (stroke work = BPs x SV x 0.0144, where BPs is systolic blood pressure, SV is echocardiographic stroke volume). Myocardial O2 consumption was estimated as the product of heart rate (HR) x BPs (eMVO2). Myocardial mechanical efficiency was estimated as the ratio of stroke work/eMVO2, which can be simplified and expressed as ml/s. RESULTS: LV mass was greater in hypertensive than in normotensive patients (46 +/- 13 vs. 38 +/- 11 g/m2.7, P < 0.0001), but myocardial mechanical efficiency was identical (85 +/- 23 vs. 86 +/- 26 ml/s). Relations between myocardial mechanical efficiency and LV mass were close (both P < 0.0001), but more scattered among hypertensive patients because of 56 patients exhibiting low myocardial mechanical efficiency relative to the magnitude of LV mass. At comparable age and body size, these patients had higher HR, BPs, and pulse pressure than those with normal myocardial mechanical efficiency (all P < 0.001). After adjusting for age and sex, hypertensive patients with low myocardial mechanical efficiency showed greater relative wall thickness and lower ejection fraction and midwall shortening than those with normal myocardial mechanical efficiency (all P < 0.001). Low myocardial mechanical efficiency was also associated with inappropriately high LV mass (P < 0.0001). CONCLUSION: In some hypertensive patients the left ventricle works inefficiently with a high energy wasting, at the same level of LV mass as hypertensive patients with normal myocardial mechanical efficiency. Those patients feature a high cardiovascular risk phenotype, with concentric LV geometry, systolic dysfunction, and indirect signs of more severe vascular impairment.

Increased left ventricular mass in pre-liver transplantation cirrhotic patients.

OBJECTIVE: Severe liver disease is associated with abnormalities in cardiac geometry and function. We aimed to assess the prevalence of these abnormalities and to determine if they represent an adaptation of the heart to the haemodynamic overload associated with liver dysfunction. METHODS: Seventy cirrhotic patients underwent standard Doppler echocardiography, as a screening evaluation for liver transplantation, and were compared with 70 normal subjects matched for age and sex. The values of echocardiographically measured left ventricular mass (LVM) were compared with those predicted from individual haemodynamic load, sex and height, which represent the compensatory values. LVM was considered inappropriately high when the observed/predicted LVM ratio was >128%. RESULTS: Cirrhotic patients had higher LVM index (40.6 +/- 11.2 vs. 36.3 +/- 7.7 g/m; P = 0.009)), similar values of ejection fraction, but lower intrinsic wall mechanics (P < 0.01) compared to controls. The observed/predicted LVM ratio was also significantly increased (117.7 +/- 30.2 vs. 106.5 +/- 16.8%; P < 0.01) and prevalence of inappropriate LVM was almost three-fold higher in cirrhotic patients (27.7 vs. 10.0%; P < 0.05) than in controls. Cirrhotic patients also presented mild impairment of left ventricular systolic function, documented by lower values of midwall shortening. CONCLUSIONS: Patients with severe liver disease have LVM values exceeding the compensatory needs to sustain haemodynamic overload, associated with subclinical systolic dysfunction.