Recurrent arrhythmic storms and unsuccessful catheter ablation in chronic ischemic heart disease.

The prototypical substrate for reentrant ventricular tachycardia (VT) is post-myocardial infarction (MI) scar. Catheter ablation is an important therapeutic option for recurrent VT but sometimes it is not effective despite the technical advances. Here we describe the case of a 60-year-old man who suffered a MI in 1998 and presented with recurrent arrhythmic storms during his long-term follow-up. Twenty years later, he underwent two catheter ablations with bipolar electroanatomic voltage mapping (EVM) demonstrating only an area of low voltages in the lateral left ventricular free wall. Both procedures were unsuccessful and the patient eventually underwent cardiac transplantation in 2019. Pathology examination revealed circumferential subendocardial scar with hypertrabeculation, so that the reentry substrate was unreachable by ablation with the use of standard techniques. The comparison of EVM findings with the morphologic ones in patients with chronic ischemic heart disease can help to better understand the feasibility and effectiveness of VT substrate ablation.

Management of Pacemaker Implantation during COVID-19 Infection.

The management of device implantation during the COVID-19 infection has not well defined yet. This is the first case of complete atrioventricular block in a symptomatic patient affected by the COVID-19 infection treated with early pacemaker implantation to minimize the risk of virus contagion.

Role of Cardiovascular Ultrasound in the Evaluation of Obese Subjects.

Obesity represents a worldwide increasing health problem. Obesity, through complex and not fully understood pathogenetic mechanisms, induces different structural and functional changes of left heart chambers, right heart chambers, and arteries. Ultrasound techniques are the first choice for a comprehensive assessment of the cardiovascular adaptation to obesity. This review summarizes the up-to-date literature on the topic, with particular focus on the main clinical studies, which range over different cardiovascular adaptations to obesity, namely left ventricular mass, diastolic function, right ventricle structure and function, arterial stiffness, and intima-media thickness. Also, the importance of epicardial fat and of the degree of obesity is described. Finally, the role of weight loss and bariatric surgery and the study of cardiovascular obesity-induced abnormalities in children and adolescent are discussed.

Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk.

The prevalence of atrial fibrillation (AF) in end-stage renal failure is high, with an increased risk of stroke among these patients with AF compared with the AF population without severe renal impairment. Many trials have shown the net clinical benefit of oral anticoagulation therapy for primary and secondary prevention of stroke in patient populations with AF. However, current stroke risk stratification schemes are based on studies that have deliberately excluded patients with severe renal impairment. Indeed, there are no large randomized controlled trials that assess the real risk/benefit of full intensity anticoagulation in patients with severe renal impairment. Also, rates of major bleeding episodes in anticoagulated hemodialysis patients with AF are high. These data are influenced by the lack of appropriate monitoring, the difficulties in maintaining the international normalized ratio target (variable between the studies), and an inaccurate bleeding classification. Thus, the limited available data may be difficult to apply to such a heterogeneous patient population, characterized by both an increased risk of bleeding and a hypercoagulability state, as seen in the patient population with severe renal impairment.

Age as a risk factor for stroke in atrial fibrillation patients: implications for thromboprophylaxis.

The prevalence of atrial fibrillation (AF) is related to age and is projected to rise exponentially as the population ages and the prevalence of cardiovascular risk factors increases. The risk of ischemic stroke is significantly increased in AF patients, and there is evidence of a graded increased risk of stroke associated with advancing age. Oral anticoagulation (OAC) is far more effective than antiplatelet agents at reducing stroke risk in patients with AF. Therefore, increasing numbers of elderly patients are candidates for, and could benefit from, the use of anticoagulants. However, elderly people with AF are less likely to receive OAC therapy. This is mainly due to concerns about a higher risk of OAC-associated hemorrhage in the elderly population. Until recently, older patients were under-represented in randomized controlled trials of OAC versus placebo or antiplatelet therapy, and therefore the evidence base for the value of OAC in the elderly population was not known. However, analyses of the available trial data indicate that the expected net clinical benefit of warfarin therapy is highest among patients with the highest untreated risk for stroke, which includes the oldest age category. An important caveat with warfarin treatment is maintenance of a therapeutic international normalized ratio, regardless of the age of the patient, where time in therapeutic range should be > or =65%. Therefore, age alone should not prevent prescription of OAC in elderly patients, given an appropriate stroke and bleeding risk stratification.

Stroke prevention in atrial fibrillation patients.

IMPORTANCE OF THE FIELD: Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice and is associated with an increased risk of stroke, mortality and significant morbidity. Given the rapidly increasing incidence and prevalence of AF, and the resulting public health burden of the consequences associated with this arrhythmia, stroke prevention is an extremely important topic. AREAS COVERED IN THIS REVIEW: This review covers the epidemiology of AF, the pathophysiology of ischemic stroke in AF and current antithrombotic therapy choices for stroke prevention in this condition. In addition, this article discusses important topics such as the assessment of stroke risk stratification and bleeding risk assessment, which are key issues in deciding upon thromboprophylaxis for AF patients. Finally, the review highlights the advent of new anticoagulant therapies and discusses the future challenges for researchers in this area. WHAT THE READER WILL GAIN: This review summarizes all of the major antithrombotic trials conducted in AF patients over the last twenty years and highlights the importance of anticoagulation therapy for the prevention of stroke, after appropriate individual stroke and bleeding risk assessment. TAKE HOME MESSAGE: Assessment of individual stroke risk and bleeding risk is key in determining appropriate thromboprophylaxis for AF patients, given the associated thromboembolic and hemorrhagic complications. The availability of newer, safer and more convenient drugs will mean that oral anticoagulation is available for a larger proportion of AF patients who may benefit from it.

CME: long-term outcome in asymptomatic patients with severe aortic regurgitation, normal left ventricular ejection fraction, and severe left ventricular dilatation.

BACKGROUND: Although the guidelines consider severe left ventricular (LV) dilatation a class IIaC indication for surgery in asymptomatic patients with severe aortic regurgitation (AR) and normal LV function, the optimal management remains controversial. We aimed to assess the LV enlargement, hypertrophy and function, and the outcomes in these patients by the presence of severe LV dilatation at baseline. METHODS: From our 20-year database, we identified all asymptomatic patients with severe AR and LV ejection fraction (EF) >50% and ≥2 echocardiograms ≥1 year apart. LV end-diastolic diameter >70 mm or LV end-systolic diameter >50 mm or LV end-systolic diameter index >25 mm/m(2) defined severe LV dilatation. A composite end point included onset of symptoms or LV dysfunction. RESULTS: Eighty-four patients (52 ± 18 years, 61 men) were enrolled and followed-up for 7.1 ± 5.1 years. Two groups were defined: 22 patients with and 62 patients without severe LV dilatation at baseline. The progression of LV dilatation and hypertrophy, and the LVEF at last exam were similar in both groups. Twelve of 22 and 34 of 62 patients (P = 0.59) reached the end point. Vasodilators did not modify the progression of LV enlargement/hypertrophy. Ten of 22 and 25 of 62 patients (P = 0.45) underwent surgery and had similar postoperative LV diameters, mass, EF. CONCLUSIONS: The progression of LV enlargement/hypertrophy and outcomes in asymptomatic patients with severe AR, normal LV function, and severe LV dilatation or the postoperative LV parameters were not influenced by the severe LV dilatation, suggesting that a close follow-up could delay surgery in this population.

How many patients would be misclassified using M-mode and two-dimensional estimates of left atrial size instead of left atrial volume? A three-dimensional echocardiographic study.

OBJECTIVES: Left atrial size has shown prognostic importance in a variety of cardiac conditions. Diameters, area, and volume derived from M-mode and two-dimensional (2D) echocardiography are commonly used to estimate left atrial size. However, M-mode and 2D measures of left atrial size rely on various geometrical assumptions and their accuracy remains to be determined. To address this issue, we compared M-mode and 2D parameters routinely used to estimate left atrial size with three-dimensional (3D) echo measured left atrial volume (LAV) as a reference standard. METHODS: We studied 104 patients (55% males, 62 +/- 15 years, range 10-87 years), presenting for a routine echocardiographic evaluation. RESULTS: The mean 3D LAV for the study population was 90 +/- 68 ml (range 24-458 ml). We found highly significant (P < 0.0001) correlations between 3D LAV and left atrial anterior-posterior (r = 0.78, 95% CI = 0.69-0.85), superior-inferior (r = 0.74, 95% CI = 0.63-0.81) and medial-lateral (r = 0.91, 95% CI = 0.86-0.93) diameters. A highly significant correlation was also found between 3D LAV and left atrial area (r = 0.94, 95% CI = 0.91-0.96). However, using M-mode anterior-posterior diameter or left atrial area would have misclassified 57% and 70% of our study patients, respectively, regarding the degree of left atrial dilatation. Closer correlations and narrower confidence intervals were found between 3D LAV and single-plane (r = 0.98; 95% CI = 0.94-0.97) and biplane (r = 0.97; 95% CI = 0.96-0.98) 2D LAVs. CONCLUSION: Left atrial diameters and area measurements were poor predictors of 3D LAV, especially in the enlarged left atria. Therefore, these parameters can be misleading in assessing the severity of left atrial dilatation. Two-dimensional LAVs are accurate in estimating 3D LAV. The small additional accuracy obtained by using the biplane instead of the single-plane area-length method, and the fact that the biplane method is more technically demanding and time consuming, may allow the use of the area-length for routine clinical use.

Congenital quadricuspid aortic valve associated with obstructive hypertrophic cardiomyopathy.

Quadricuspid aortic valve is a rare congenital abnormality; it is usually an isolated lesion, but several concomitant congenital abnormalities have been described. We report a case of congenital quadricuspid aortic valve associated with obstructive hypertrophic cardiomyopathy. Two-dimensional (2D) transthoracic and transesophageal echocardiography and real-time three-dimensional (3D) echocardiography clarified the morphological and functional status of the aortic valve. To our knowledge, the association between quadricuspid aortic valve and obstructive hypertrophic cardiomyopathy has never been described before.

Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain.

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Are hospitalizations for percutaneous coronary procedures missed opportunities for teaching rules of secondary prevention?

BACKGROUND AND AIMS: Percutaneous coronary intervention (PCI) is the most frequently used revascularization approach, often repeatedly applied. The quest for the ultimate revascularization procedure however may capture cardiologist's attention and lead them to minimize the issue of secondary prevention in their patients. Aims of this study were to assess: 1. The individual risk factor profile, 2. The relation between the risk factors correction and the number of hospital admissions for elective procedures, 3. The appropriateness of medical treatment in patients admitted for elective coronary invasive procedures (diagnostic and interventional). 4. The patients knowledge of threshold values for cardiovascular risk factors. PATIENTS AND METHODS: 100 patients (71% males, mean age 68 years) consecutively admitted for elective coronary angiography or PCI. They underwent a classical risk factors assessment and were divided in three groups according to the number of admissions for coronary angiography and in two groups according to the number of PCIs. RESULTS: Fifty-seven% of patients had been previously admitted for invasive examination at least three times and 58% had already been treated with at least one PCI. Seventy-one% were treated with beta-blockers but only 25% of them received a dosage found effective in RCTs (randomized clinical trials). Sixty% were treated with ACE-inhibitors and 83% received the dosage found effective in RCTs. Fifty-two% were treated with statins and 95% received a dosage found effective in RCTs. Nine% were still active smokers. Fourty-nine% had a LDL cholesterol level above 100 mg/dL. The percentage of patients not on target was unrelated to the number of hospital admissions for invasive procedures. CONCLUSIONS: Modern cardiology is quickly embracing high tech procedures and trials results but often fails to spend enough time teaching how to control risk factors according to the recommendations of the evidence-based guidelines, even independently of the number of hospitalizations for invasive cardiovascular procedures.

[Bundle-branch block in the course of myocardial infarction. Recent advances]. / I blocchi di branca in corso di infarto miocardico. Recenti acquisizioni di fisiopatologia e clinica.

In case of acute myocardial infarction and a bundle-branch block (BBB) major diagnostic and prognostic issues should be addressed with different considerations, depending on the presence of a left BBB (LBBB) or a right BBB (RBBB), distinguishing new or presumably new BBB, considering the possibility that the BBB masks electrocardiographic features of MI with ST-segment elevation. In this paper we briefly discuss the results of published trials that assessed the prognostic difference between different types of BBB during the early phase of acute myocardial infarction. The Wong et al. analysis of HERO-2 trial demonstrates that in the setting of an anterior STEMI, the presence of an RBBB, whatever its onset, is associated with a higher risk of death. The same analysis shows as RBBB associated with an inferior infarction does not portend a worse prognosis independently of its onset. Patients with LBBB already present at randomization were found to have worse pre-infarction characteristics, responsible, by itself, for the worst prognosis. However, the occurrence of an LBBB after randomization indicates a 'true' ischaemic conduction damage, thus carrying an independent negative prognostic value due to the large percentage of myocardium involved. HERO-2 trial, showing prognostic differences between different clinical presentations, underlines the importance to be familiar with the mechanisms related to BBBs and with the prognostic implications of BBBs in the setting of an acute myocardial infarction.