Cardiac mass many years after heart transplantation-a case report.

The bi-atrial surgical technique of heart transplantation is associated with postoperative atrial dysfunction, sinus node dysfunction, valvular dysfunction, and bi-atrial enlargement predisposing to atrial arrhythmia with thrombus formation. This report deals with a very late thrombus formation in the neo-atrium of a heart transplanted using the bi-atrial technique. The absence of arrhythmia and absence of any history of intake of prothrombotic medications make it noteworthy. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01362-x.

Kounis syndrome, a disease to know: Case report and review of the literature.

The case deals with an anaphylactoid reaction to intravenous ampicillin/sulbactam resulting in cardiogenic syncope and myocardial damage. Symptoms and ECG modifications promptly disappeared after corticosteroids administration. The Kounis syndrome is an acute coronary syndrome, including coronary spasm, acute myocardial infarction and stent thrombosis, resulting from an anaphylactic or anaphylactoid or allergic or hypersensitivity insult. First described in 1991, it can be caused by a lot of substances, particularly antibiotics. The management should be directed to both the allergic reaction and the myocardial damage. The Kounis syndrome is a not rare disease that every physician should know because of the wideness of triggers and the possible fatal evolution if not promptly recognized.

Obstructive sleep apnoea-hypopnoea and arrhythmias: new updates.

AIMS: Obstructive sleep apnoea-hypopnoea (OSAH) is a prevalent condition characterized by repetitive pharyngeal collapse during sleep, leading to hypoxemia, hypercapnia, and persistent inspiratory efforts against an occluded airway until arousal. Several studies demonstrated that OSAH exerts acute and chronic effects on the cardiovascular system. Thus, although being a respiratory problem, the most important consequences of OSAH are cardiovascular, among which there are arrhythmias. The purpose of this review is to systematically analyse what has been recently published about the relationship between OSAH and every cardiac arrhythmia separately. METHODS: We searched Pubmed, Scopus, Web of Science and Cochrane Collaboration databases for 'OSAHS arrhythmias', 'OSAH arrhythmias' and 'OSA arrhythmias'. We analyse 1298 articles and meta-analyses, excluding already edited reviews. RESULTS: Arrhythmias, especially of ventricular origin, are frequent in OSAH. Ventricular premature beats, couplets and ventricular tachycardia runs are even more frequent in patients suffering from heart failure. They may be due to left heart remodelling, overwork and ischaemia and can explain at least some sudden deaths occurring between midnight and 6 a.m. Sinus pauses and atrioventricular blocks are increased according to the severity of the disturbance and may be reduced by continuous positive airway pressure therapy, preventing pace-maker implantation. Finally, atrial fibrillation, resistance against antiarrhythmic drugs and recurrences after surgical procedures are strongly related to OSAH. CONCLUSION: Arrhythmias are frequent in OSAH. Treatment of OSAH may reduce some of them. An implantable cardioverter-defibrillator and continuous positive airway pressure should be considered in some patients.

Different types of tricuspid flail: Case reports and review of the literature.

Tricuspid regurgitation (TR) is a common Doppler echocardiographic finding resulting from either intrinsic valve abnormalities or functional malcoaptation of structurally normal valves. TR caused by flail leaflets is most often post-traumatic, is caused by endocarditis or is a consequence of a myxomatously degenerated valve. The clinical presentation is severe and is characterized by excess mortality and high morbidity. Flail leaflets are reliably diagnosed using 2-dimensional and 3-dimensional echocardiography.

Prognostic value of RV isovolumic acceleration and tissue strain in moderate HFrEF.

BACKGROUND: Right ventricular (RV) dysfunction in heart failure (HF) with reduced left ventricular ejection fraction (LVEF) is associated with a poorer prognosis. No studies to date have investigated the prognostic utility of RV isovolumic acceleration (IVA) measured at tissue Doppler imaging (TDI) in HF. RV strain instead has been already correlated to a poorer prognosis in these patients. We aimed to assess the predictive value of both parameters in this context. MATERIALS AND METHODS: Sixty patients enrolled, NYHA II-III. Everyone underwent echocardiographic examination including TDI and strain analysis. Adverse event was defined as cardiovascular death or rehospitalization. RESULTS: Follow-up was 32 ± 13 months. Sixteen patients (26·7%) had an adverse event. IVA and RV strain were significantly lower in these patients. At logistic regression, they were both related to adverse event and their receiver operating characteristic (ROC) curve predictive (area under ROC 0·916 and 0·952, respectively). Kaplan-Meier survival curves were significantly worse for both parameters inferior to their respective means (P < 0·001 for both). Univariate and multivariate analyses confirmed their better utility than tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) or S' at TDI. CONCLUSIONS: our study demonstrated a useful prognostic role of RV strain and IVA, which are parameters of subclinical RV impairment. Patients with low values may benefit from a more aggressive therapy and a closer follow-up.

Effects of spironolactone on ventricular-arterial coupling in patients with chronic systolic heart failure and mild symptoms.

BACKGROUND: Several studies demonstrated that mineralocorticoid receptor antagonists (MRAs) are able to prevent myocardial and vascular fibrosis, and left ventricular (LV) remodeling in patients with systolic chronic heart failure (HF) and mild symptoms. Ventricular-arterial coupling (VAC) should be influenced by anti-fibrotic interventions. We have assessed the effects of spironolactone on VAC and its components, aortic elastance (Ea) and end-systolic LV elastance (Ees), in patients with HF. METHODS AND RESULTS: Changes from baseline in VAC were compared between 65 patients treated with spironolactone and 32 controls not receiving MRAs. All patients had HF, reduced LVEF with reduced LV ejection fraction (LVEF) and New York Heart Association (NYHA) functional class I-II symptoms, and underwent transthoracic echocardiography at baseline and after 6 months. VAC was estimated by the modified single-beat method as Ea/Ees. Parameters of LV function improved after 6 month treatment with spironolactone with an increase in the LVEF from 34 ± 8 to 39 ± 8 % (p < 0.001). Spironolactone increased Ees from 1.32 ± 0.38 to 1.57 ± 0.42 mmHg/mL (p < 0.001) and reduced VAC from 2.03 ± 0.59 to 1.66 ± 0.31 (p < 0.001), but did not affect Ea and V0 (LV volume at end-systolic pressure of 0 mmHg). No change in any of these parameters occurred in the control group. CONCLUSIONS: 6-month therapy with spironolactone improved VAC mainly through its effect on Ees in patients with mild HF.

Characteristics and mid-term follow-up of a single-center population affected by Tako-Tsubo cardiomyopathy.

INTRODUCTION: Tako-Tsubo cardiomyopathy (TTC) is an acute cardiomyopathy mimicking acute myocardial infarction. The aim of our study was to define clinical and instrumental features of an Italian population of patients with TTC and to report their short and mid-term outcome. METHODS: We retrospectively evaluated 42 patients admitted to our Department with diagnosis of TTC (100% women, age 67 ± 11 years) using Mayo Clinic-modified criteria. In this population, we analyzed the stressful event (if present), the clinical presentation, the ECG and echocardiogram at admission and the markers of myocardial cytonecrosis, such as troponin I, at admission and during the hospitalization. All the patients have been clinically evaluated after 6 months and 1 year of follow-up. RESULTS: In this population, a stressful event before TTC has been detected in 59% of patients. The most common clinical presentation was chest pain (81%) and the major sign was dyspnea (17%). ECG showed negative T waves and ST elevation, respectively, in 45 and 38%. Only 10% had a ST depression and 7% developed a newly acquired complete left bundle branch block. All of these abnormalities disappeared within 1.8 ± 0.9 days. The mean ejection fraction at admission was 35 ± 7% associated with apical (40%), mid-apical (56%) and mid-ventricular (4%) wall motion abnormalities. The recovery of these abnormalities occurred within 10 ± 3 days. At 6-month and 1-year follow-up, no patients had TTC recurrence, and 10 patients at 6 months and 20 patients at 1 year were re-hospitalized for a non-cardiac cause. CONCLUSION: Our data describe the characteristics of TTC in a small Italian population, which are similarly described in Japanese and North American people. TTC was related to a very low mortality, both in the short and mid term, but the risk of acute heart failure in the acute phase could not be neglected.

Quantitative analysis of right ventricular (RV) function with echocardiography in chronic heart failure with no or mild RV dysfunction: comparison with cardiac magnetic resonance imaging.

OBJECTIVES: Right ventricular (RV) performance parameters (tricuspid annular plane systolic excursion, systolic longitudinal velocity on tissue Doppler imaging, fractional area change, and tissue and 2-dimensional [2D] strain on the right free wall) have been validated. In comparative studies, they have been correlated with the prognosis of patients with heart failure on radionuclide ventriculography and thermodilution in right heart catheterization. This study aimed to evaluate RV systolic function in patients with heart failure with no or mild RV dysfunction and correlate the above-mentioned echocardiographic parameters with the magnetic resonance imaging (MRI)-calculated RV ejection fraction (RVEF), stroke volume, end-diastolic volume, and end-systolic volume. METHODS: Standard and pulsed Doppler tissue echocardiography and MRI were performed in 31 patients with New York Heart Association functional class II and III chronic heart failure. RESULTS: A high correlation between tricuspid annular plane systolic excursion, systolic longitudinal velocity, tissue strain, and 2D strain was noted, whereas the fractional area change did not correlate with any other parameter. The RVEF correlated with tricuspid annular plane systolic excursion, systolic longitudinal velocity, and tissue and 2D strain (all P< .01); under linear regression analysis, the 4 parameters independently correlated with RVEF. CONCLUSIONS: Echocardiographic RV performance parameters (tricuspid annular plane systolic excursion, systolic longitudinal velocity, tissue strain, and 2D strain) correlated with the MRI-calculated RVEF and overall predicted it. In particular, RV 2D strain and tissue strain were good markers for RV longitudinal motions. These echocardiographic parameters are easily obtained and may give important information about RV function for evaluation and prognostic stratification of patients with heart failure.

Ivabradine during cardiogenic shock: a clinical case and review of the literature.

Although the introduction of novel medical and invasive therapies in recent years has led to a significant reduction in mortality from heart failure, the same cannot be said for mortality due to cardiogenic shock. Drug therapy with inotropic agents and catecholamines has the disadvantage of causing increased myocardial oxygen consumption resulting in increased heart rate which may lead to the widening of the ischemic area. A reduction in heart rate with the administration of ß-blockers is contraindicated due to negative inotropic and blood pressure lowering effects, typical of this group of drugs. Thus the theoretical possibility of ivabradine administration for an isolated reduction in heart rate, associated with the absence of a negative inotropic effect, could favorably influence hemodynamics in patients with cardiogenic shock. We report a case of cardiogenic shock treated by adding ivabradine to the currently used therapy.

Echocardiographic evaluation of aortic atheromas in patients with aortic stenosis.

OBJECTIVES: The association of aortic atheromas in patients with isolated aortic stenosis has recently been acknowledged, probably because the pathogenic mechanisms are similar. Therefore, this study evaluated the extent and severity of thoracic aortic atheromas in patients with different grades of aortic stenosis using transesophageal echocardiography. METHODS: We retrospectively evaluated transesophageal echocardiographic examinations of 686 consecutive patients with a diagnosis of aortic stenosis. The prevalence and morphologic characteristics of atheromas in 3 segments of the thoracic aorta were assessed. Plaque thickness was measured at each segment, and the thickest plaque was used to establish severity. Atheromas were graded as mild, moderate, or severe according to plaque thickness (<2, 2-4, or >4 mm, respectively). Aortic stenosis was graded as mild, moderate, or severe on the basis of the gradient and anatomic aortic valve area (>1.5, 1.0-1.5, or <1.0 cm(2)). RESULTS: A total of 382 patients were men, and 304 were women (mean age ± SD, 74 ± 15 years); 86% of the patients had aortic atheromas. The severe stenosis group had a significantly higher rate of atheromas (95% versus 40%; P < .001) than the mild stenosis group, with more complex atheromas (52% versus 22%; P< .001). There was no significant difference in the atheroma grades between the severe and moderate stenosis groups, but moderate cases had more moderate and severe atheromas than mild cases (45% and 15% versus 19% and 3%; P < .01). CONCLUSIONS: This study showed a correlation in the extent of aortic atheromas across several degrees of aortic stenosis. Patients with moderate and severe stenosis had more extensive atherosclerotic atheromas than those with mild stenosis.

Mitral valve rheumatic multiple fenestrations: usefulness of 3D real-time echocardiography.

We describe a case that demonstrates and confirms the usefulness of 3D transesophageal echocardiography in the morphological analysis of the mitral valve in a rare occurrence of postrheumatic mitral leaflet perforation.

The effect of aldosterone-antagonist therapy on aortic elastic properties in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Many studies proved the prognostic importance of aortic stiffness as an independent predictor of cardiovascular morbidity and all-cause mortality. The decrease of arterial compliance has a high prevalence in patients with heart failure and affects both hemodynamics and prognosis. Aortic stiffness is partially caused by excessive activation of the renin-angiotensin-aldosterone system. Spironolactone, a mineralcorticoid receptor antagonist (MRA), has been shown to decrease aortic stiffness and fibrosis in experimental models. However, there are few studies that describe the effects of MRA on aortic stiffness in patients with nonischemic dilated cardiomyopathy. AIMS: To evaluate the effect of spironolactone on aortic stiffness in patients with nonischemic dilated cardiomyopathy. MATERIALS AND METHODS: We randomized (1 : 1) 102 patients with nonischemic dilated cardiomyopathy with New York Heart Association class I-II to receive spironolactone 25 mg/day (up to 100 mg/day) or placebo, in addition to recommended therapy. Aortic stiffness index, aortic strain, aortic distensibility and aortic dimensions were assessed at baseline and after 6 months. All measures were obtained with echocardiography M-mode at 3 cm above the aortic valve on parasternal long axis view and simultaneous brachial arterial pressure with sphygmomanometer. RESULTS: Ascending aorta diameters, aortic stiffness index, aortic distensibility and aortic strain were similar at randomization in the two groups. After 6 months of therapy in the treated group, we found a reduction of aortic stiffness index (7.2 ±â€Š3.5 versus 9.6 ±â€Š4.8 mmHg; P = 0.03) and an increase of aortic distensibility (3.77 ±â€Š1.0 versus 2.92 ±â€Š0.55 mmHg; P = 0.01) and systolic aortic strain (10.0 ±â€Š5.0 versus 8.0% ±â€Š2.1%; P = 0.01). There were no difference in systolic arterial pressure, diastolic arterial pressure and differential pressure in the two groups. CONCLUSION: Therapy with spironolactone is effective in reducing aortic stiffness in patients with nonischemic dilated cardiomyopathy. This effect could improve hemodynamics supporting the use of MRAs in patients with low New York Heart Association class (I-II).

Evaluation of ascending aorta wall in rheumatoid arthritis by tissue and strain Doppler imaging during anti-tumor necrosis factor-α therapy.

BACKGROUND: Patients with rheumatoid arthritis (RA) are at increased risk of vascular events. Data on the effects of tumor necrosis factor-α (TNF-α) blocking agents on aortic vascular function are still debated. HYPOTHESIS: To evaluate the effects of anti-TNF-α treatment on elastic properties of the ascending aorta (distensibility, stiffness, and tissue Doppler imaging [TDI] strain) in RA patients. METHODS: We prospectively followed 13 patients affected by RA without cardiovascular risk factors for 1 year during anti-TNF-α treatment. Every subject received an echocardiographic examination before starting anti-TNF-α drugs and after 1 year. Aortic elastic properties were calculated from the echocardiographically derived thoracic aortic diameters, and TDI strain was measured on the wall of the ascending aorta 3 cm above the aortic valve. RESULTS: We found lower distensibility (12.9 ± 3.5 vs 21.5 ± 7.5 mm Hg(-1); P <0.001) and a higher stiffness index (21.3 ± 3.6 vs 11.7 ± 1.4; P <0.001) in RA cases at baseline compared with values after 1 year of treatment. Peak systolic (S') and diastolic (E' and A') waves of the aortic wall TDI were similar at baseline and at 1 year follow-up (S' wave: 5.6 ± 2.2 cm/s vs 6.5 ± 2.6 cm/s, E' wave: -4.6 ± 2.9 vs -5.0 ± 1.2 cm/s, A' wave: -5.6 ± 0.19 vs -5.9 ± 2.05 cm/s), whereas TDI strain of the aortic wall was improved after anti-TNF-α treatment (-23.7 ± 1.4% vs -31.6 ± 2.8%, P < 0.001). CONCLUSIONS: Anti-TNF-α treatment after 12 months significantly modifies the elastic properties of the aorta. This may reflect the favorable changes in its elastic tissue after anti-TNF-α treatment in RA patients without cardiovascular risk factors. This suggests a potential cardiovascular risk benefit.

New frontiers in the management of acute coronary syndromes: cangrelor and elinogrel.

The activation and aggregation of platelets at sites of vascular injury or near to implanted stent are pivotal in the development of thrombotic events during and after an acute coronary syndrome (ACS) or a percutaneous coronary intervention (PCI). For that reason, an exclusively oral dual antiplatelet treatment regimen with platelet P2Y12 receptor antagonists in addition to the cyclooxygenase inhibitor aspirin has become the cornerstone of treatment in that contest. However, every trial underlines the same problem: if maximizing antiplatelet therapy significantly attenuates ischemic events in patients with coronary artery disease, on the other side it may also increase bleeding phenomena. These limitations have prompted a search for novel antiplatelet agents with a more favorable risk-benefit ratio. Moreover, an early onset of action is desirable during PCI and an early offset after bleeding events. Two novel antiplatelet agents, Cangrelor and Elinogrel, are available in intravenous form (Elinogrel also in oral form) and expand this context. Recent trials have tested them against Clopidogrel regarding efficacy and safety outcomes.This review aimed at providing an overview on intravenous emerging compounds and recent patents in the setting of ACS and PCI.

Predicting the difficulty of a lead extraction procedure: the LED index.

BACKGROUND: According to recent surveys, many sites performing permanent lead extractions do not meet the minimum prerequisites concerning personnel training, procedures' volume, or facility requirements. The current Heart Rhythm Society consensus on lead extractions suggests that patients should be referred to more experienced sites when a better outcome could be achieved. The purpose of this study was to develop a score aimed at predicting the difficulty of a lead extraction procedure through the analysis of a high-volume center database. This score could help to discriminate patients who should be sent to a referral site. METHODS: A total of 889 permanent leads were extracted from 469 patients. All procedures were performed from January 2009 to May 2012 by two expert electrophysiologists, at the University Hospital of Brescia. Factors influencing the difficulty of a procedure were assessed using a univariate and a multivariate logistic regression model. The fluoroscopy time of the procedure was taken as an index of difficulty. A Lead Extraction Difficulty (LED) score was defined, considering the strongest predictors. RESULTS: Overall, 873 of 889 (98.2%) leads were completely removed. Major complications were reported in one patient (0.2%) who manifested cardiac tamponade. Minor complications occurred in six (1.3%) patients. No deaths occurred. Median fluoroscopic time was 8.7 min (3.3-17.3). A procedure was classified as difficult when fluoroscopy time was more than 31.2 min [90th percentile (PCTL)].At a univariate analysis, the number of extracted leads and years from implant were significantly associated with an increased risk of fluoroscopy time above 90th PCTL [odds ratio (OR) 1.51, 95% confidence interval (CI) 1.08-2.11, P = 0.01; and OR 1.19, 95% CI 1.12-1.25, P < 0.001, respectively). After adjusting for patient age and sex, and combining with other covariates potentially influencing the extraction procedure, a multivariate analysis confirmed a 71% increased risk of fluoroscopy time above 90th PCTL for each additional lead extracted (OR 1.71, 95% CI 1.06-2.77, P = 0.028) and a 23% increased risk for each year of lead age (OR 1.23, 95% CI 1.15-1.31, P < 0.001). Further nonindependent factors increasing the risk were the presence of active fixation leads and dual-coil implantable cardiac defibrillator leads. Conversely, vegetations significantly favored lead extraction.The LED score was defined as: number of extracted leads within a procedure + lead age (years from implant) + 1 if dual-coil - 1 if vegetation. The LED score independently predicted complex procedure (with fluoroscopic time >90th PCTL) both at univariate and multivariate analysis. A receiver-operating characteristic analysis showed an area under the curve of 0.81. A LED score greater than 10 could predict fluoroscopy time above 90th PCTL with a sensitivity of 78.3% and a specificity of 76.7%. CONCLUSION: The LED score is easy to compute and potentially predicts fluoroscopy time above 90th PCTL with a relatively high accuracy.

Is there a role for ivabradine beyond its conventional use?

Results of recent clinical trials in patients with stable angina and chronic heart failure have successfully demonstrated a beneficial role of use of ivabradine in addition to the conventional therapy. Based on the results of these trials, the aim of our review was to give an overview of the literature about the use of ivabradine in clinical settings outside its usual purpose.