Accurate Prediction Equations for Ventilatory Thresholds in Cardiometabolic Disease When Gas Exchange Analysis is Unavailable: Development and Validation.

AIMS: To develop and validate equations predicting heart rate (HR) at the first and second ventilatory thresholds (VTs) and an optimized range-adjusted prescription for patients with cardiometabolic disease (CMD). To compare their performance against guideline-based exercise intensity domains. METHODS: Cross-sectional study involving 2,868 CMD patients from nine countries. HR predictive equations for first and second VTs (VT1, VT2) were developed using multivariate linear regression with 975 cycle-ergometer cardiopulmonary exercise tests (CPET). 'Adjusted' percentages of peak HR (%HRpeak) and HR reserve (%HRR) were derived from this group. External validation with 1,893 CPET (cycle-ergometer or treadmill) assessed accuracy, agreement, and reliability against guideline-based %HRpeak and %HRR prescriptions using mean absolute percentage error (MAPE), Bland-Altman analyses, intraclass correlation coefficients (ICC). RESULTS: HR predictive equations (R²: 0.77 VT1, 0.88 VT2) and adjusted %HRR (VT1: 42%, VT2: 77%) were developed. External validation demonstrated superiority over widely used guideline-directed intensity domains for %HRpeak and %HRR. The new methods showed consistent performance across both VTs with lower MAPE (VT1: 7.1%, VT2: 5.0%), 'good' ICC for VT1 (0.81, 0.82) and 'excellent' for VT2 (0.93). Guideline-based exercise intensity domains had higher MAPE (VT1: 6.8%-21.3%, VT2: 5.1%-16.7%), 'poor' to 'good' ICC for VT1, and 'poor' to 'excellent' for VT2, indicating inconsistencies related to specific VTs across guidelines. CONCLUSION: Developed and validated HR predictive equations and the optimized %HRR for CMD patients for determining VT1 and VT2 outperformed the guideline-based exercise intensity domains and showed ergometer interchangeability. They offer a superior alternative for prescribing moderate intensity exercise when CPET is unavailable.

Equations to predict heart rate at ventilatory thresholds were developed and externally validated, offering a new perspective when a cardiopulmonary exercise test is unavailable to accurately determine the aerobic exercise intensity domains. Additionally, an adjusted range for exercise intensity prescription based on the percentage of heart rate reserve (%HRR) was provided, utilizing a large sample from eight countries. The proposed equations and the range-adjusted %HRR significantly outperformed the guideline-directed methods for determining exercise intensity, exhibiting higher accuracy, agreement, and reliability. Exercise intensity prescription based on the percentage of heart rate peak showed higher errors, raising concerns about its clinical applicability. Our study may enhance the efficacy of exercise training and physical activity advice when gas exchange analysis is unavailable, potentially leading to improved clinical outcomes, even in low-resource settings. Employing these approaches in research could facilitate more tailored and consistent interventions, introducing a contemporary perspective for studies comparing exercise intensity prescriptions.

Reverse Septal Movement: A Step Forward in the Comprehension of the Underlying Causes.

(1) Background: Reverse septal movement (RSM) often occurs after cardiac surgery, consisting of a paradoxical systolic movement of the interventricular septum. In this retrospective study, we aimed to investigate possible determinants of RSM after coronary artery bypass surgery (CABG). (2) Methods: Patients who underwent CABG with on- or off-pump techniques at our center from March 2019 to October 2021 were retrospectively included. Exclusion criteria were: exposure to combined procedures (e.g., valve implantation), prior cardiac surgery, intraventricular conduction delays, and previous pacemaker implantation. Laboratory tests and echocardiographic and cardiopulmonary bypass (CPB) duration data were collected. (3) Results: We enrolled 138 patients, of whom 32 (23.2%) underwent off-pump CABG. Approximately 89.1% of the population was male; the mean age was 70 ± 11 years. There was no difference in RSM incidence in patients undergoing the off-pump and on-pump techniques (71.9% vs. 62.3%; p = 0.319). In patients undergoing on-pump surgery, the incidence of RSM was slightly higher in longer CPB procedures (OR 1.02 (1.00-1.03) p = 0.012), and clamping aortic time was also greater (OR 1.02 (1.00-1.03) p = 0.042). (4) Conclusions: CPB length seems to be correlated with a higher RSM appearance. This better knowledge of RSM reinforces the safety of CABG and its neutral effect on global biventricular function.

Myocardial work and left heart deformation parameters across primary mitral regurgitation severity.

AIMS: Myocardial work (MW) estimation by pressure-strain loops using speckle tracking echocardiography (STE) has shown to evaluate left ventricular (LV) contraction overcoming the load-dependency limit of LV global longitudinal strain (GLS). This has proved useful in hemodynamic variation settings e.g. heart failure and valvular heart disease. However, the variation of MW and strain parameters across different stages of primary mitral regurgitation (MR) and its impact on symptoms, which was the aim of our study, has never been investigated. METHODS AND RESULTS: Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery. Clinical evaluation, blood sample tests, ECG and echocardiography with STE and MW measurement were performed. Patients were then divided into groups according to MR severity. Differences among the groups and predictors of symptoms (as NYHA class≥2) were explored as study endpoints. Overall, 180 patients were enrolled (60 mild,60 moderate,60 severe MR). LV GLS and global peak atrial longitudinal strain (PALS) reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved, while global work efficiency (GWE) reduced, in patients with moderate and severe MR. Among echocardiographic parameters, global PALS emerged as the best predictor of NYHA class (p < 0.001;area under curve,AUC = 0.7). CONCLUSIONS: MW parameters accurately describe the pathophysiology of MR, with initial attempt of LV increased contractility to compensate volume overload parallel to the disease progress, although with low efficacy, while global PALS is the most associated with the burden of MR symptoms.

Electrical and structural remodelling in female athlete's heart: A comparative study in women vs men athletes and controls.

BACKGROUND: Athlete's heart is associated with physiological electrical and structural remodelling. Despite the plethora of data published on male athletes, solid data derived from female athletes, compared to male counterparts or sedentary women, are still scarce. OBJECTIVES: We aimed to analyze the electrical, structural, and functional characteristics of athlete's heart in female and male athletes vs sedentary controls. METHODS: Olympic athletes and sedentary controls were evaluated by resting ECG and echocardiography. Athletes were divided into 4 different sports groups. RESULTS: The study population included 1096 individuals (360 female athletes, 410 male athletes, 130 sedentary women and 196 sedentary men). Female athletes had lower resting heart rate, longer PR interval, higher voltage of R, and T waves and more frequently incomplete RBBB, left ventricular (LV) hypertrophy, early repolarization, and anterior T-wave inversion as compared to controls. Biventricular cavity dimensions and LV wall thickness were greater in female athletes than in female controls. However, women showed a lower degree of training-induced structural remodelling than men. In female athletes, both cavity dimensions and LV wall thickness increased from those engaged in skill and power to mixed and endurance disciplines. However, in female athletes, contrary to males, the ECG changes were not significantly different according to the different types of sport discipline. CONCLUSIONS: Highly-trained women demonstrate relevant training-induced electrical and structural remodelling. However, the type of sport did not influence ECG parameters in women, contrary to men, while it impacted biventricular morphologic remodelling, with endurance athletes showing the greatest degree of adaptation.

Left ventricular fibrosis as a main determinant of filling pressures and left atrial function in advanced heart failure.

AIMS: Advanced heart failure (AdHF) is characterized by variable degrees of left ventricular (LV) dysfunction, myocardial fibrosis, and raised filling pressures which lead to left atrial (LA) dilatation and cavity dysfunction. This study investigated the relationship between LA peak atrial longitudinal strain (PALS), assessed by speckle-tracking echocardiography (STE), and invasive measures of LV filling pressures and fibrosis in a group of AdHF patients undergoing heart transplantation (HTX). METHODS AND RESULTS: We consecutively enrolled patients with AdHF who underwent HTX at our Department. Demographic and basic echocardiographic data were registered, then invasive intracardiac pressures were obtained from right heart catheterization, and STE was also performed. After HTX, biopsy specimens from explanted hearts were collected to quantify the degree of LV myocardial fibrosis. Sixty-four patients were included in the study (mean age 62.5 ± 11 years, 42% female). The mean LV ejection fraction (LVEF) was 26.7 ± 6.1%, global PALS was 9.65 ± 4.5%, and mean pulmonary capillary wedge pressure (PCWP) was 18.8 ± 4.8 mmHg. Seventy-three % of patients proved to have severe LV fibrosis. Global PALS was inversely correlated with PCWP (R = -0.83; P < 0.0001) and with LV fibrosis severity (R = -0.78; P < 0.0001) but did not correlate with LVEF (R = 0.15; P = 0.2). Among echocardiographic indices of LV filling pressures, global PALS proved the strongest [area under the curve 0.955 (95% confidence interval 0.87-0.99)] predictor of raised (>18 mmHg) PCWP. CONCLUSION: In patients with AdHF, reduced global PALS strongly correlated with the invasively assessed LV filling pressure and degree of LV fibrosis. Such relationship could be used as non-invasive indicator for optimum patient stratification for therapeutic strategies.

Tricuspid Regurgitation Velocity and Mean Pressure Gradient for the Prediction of Pulmonary Hypertension According to the New Hemodynamic Definition.

BACKGROUND: The hemodynamic definition of PH has recently been revised with unchanged threshold of peak tricuspid regurgitation velocity (TRV). The aim of this study was to evaluate the predictive accuracy of peak TRV for PH based on the new (>20 mmHg) and the old (>25 mmHg) cut-off value for mean pulmonary artery pressure (mPAP) and to compare it with the mean right ventricular-right atrial (RV-RA) pressure gradient. METHODS: Patients with advanced heart failure were screened from 2016 to 2021. The exclusion criteria were absent right heart catheterization (RHC) results, chronic obstructive pulmonary disease, any septal defect, inadequate acoustic window or undetectable TR. The mean RV-RA gradient was calculated from the velocity-time integral of TR. RESULTS: The study included 41 patients; 34 (82.9%) had mPAP > 20 mmHg and 24 (58.5%) had mPAP > 25 mmHg. The AUC for the prediction of PH with mPAP > 20 mmHg was 0.855 for peak TRV and mean RV-RA gradient was 0.811. AUC for the prediction of PH defined as mPAP > 25 mmHg for peak TRV was 0.860 and for mean RV-RA gradient was 0.830. A cutoff value of 2.4 m/s for peak TRV had 65% sensitivity and 100% positive predictive value for predicting PH according to the new definition. CONCLUSIONS: Peak TRV performed better than mean RV-RA pressure gradient in predicting PH irrespective of hemodynamic definitions. Peak TRV performed similarly with the two definitions of PH, but a lower cutoff value had higher sensitivity and equal positive predictive value for PH.

Right ventricular myocardial work for the prediction of early right heart failure and long-term mortality after left ventricular assist device implant.

AIMS: Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant. METHODS AND RESULTS: Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033). CONCLUSION: RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.

Sports cardiology: A glorious past, a well-defined present, a bright future.

The attention towards sports cardiology has dramatically grown after the introduction of preparticipation screening and the need for specific education on electrocardiogram interpretation in athletes, given the differences between athletes and the general population. The present article stresses the need for specific skills, knowledge, and clinical expertise in sports cardiology, which are essential for appropriately screening competitive athletes to prevent sudden cardiac death and avoid overdiagnosis. However, disqualification from sports competitions may lead to sports inactivity, and athletes may enter a gray zone where little or no information is provided about what they can or cannot do to stay active. However, modern sports cardiology cannot neglect the patient's needs and the importance of the safe practice of regular exercise. In this context, the personalized exercise prescription plays a crucial role in the core curriculum and the clinical activity of professionals involved in sports cardiology programs. Given its specificities, sports cardiology requires a formal education plan for medical school students and all residents. Additional education and practice are required for young colleagues who want to focus their professional lives on sports cardiology. The future directions of emerging modern sports cardiology should not neglect the importance of a scientific community that works together, designing multicenter international outcomes-based research to address the many remaining areas of uncertainty.

Aortic root/left ventricular diameters golden ratio in competitive athletes.

BACKGROUND: The athlete's heart is a well-known phenomenon characterized by a harmonic remodelling that affects the cardiac chambers. However, whether mild-to-moderate aortic dilatation can be considered normal in athletes is debated. This study aimed to evaluate the ratio between left ventricular (LV) size and aortic dimensions, reporting the normal values of the ratio between the aortic root diameters at the level of the sinuses of Valsalva and LV diameters (AoD/LVEDD ratio) in a wide cohort of competitive athletes. MATERIALS AND METHODS: Competitive athletes were compared with sedentary subjects and patients with aortic dilatation. 1901 subjects who underwent echocardiography from 2019 to 2022 were retrospectively enrolled: 993 athletes (74% males, mean age 26 ± 7 years), 410 sedentary (74.1% males, mean age 29 ± 11 years) and 498 patients with aortic dilatation (74.3% males, mean age 56 ± 7 years). RESULTS: Patients with aortic dilatation had both an absolute (39.2 ± 2.4 mm) and indexed (19.4 ± 2.2 mm/m2) aortic diameter larger than athletes (30.6 ± 3.2 mm; 16.1 ± 1.5 mm/m2, p < 0.05) and sedentary subjects (30.5 ± 3.1 mm; 16.5 ± 1.6 mm/m2, p < 0.05), with no differences between athletes and sedentary subjects. The AoD/LVEDD ratio was lower in athletes (0.59 ± 0.06) compared to controls (0.65 ± 0.05, p < 0.05) and patients with aortic dilatation (0.81 ± 0.06, p < 0.05). The patients with aortopathy had the lowest LVEDD/AoD ratio, while competitive athletes had the highest, with values of 1.71 ± 0.16 in the latter (overall p value<0.001). CONCLUSIONS: In this study, we reported the AoD/LVEDD and LVEDD/AoD ratio values in a cohort of healthy athletes, additional parameters that could help confirm the harmonic remodelling in the athlete's heart.

Pressure-strain loops unveil haemodynamics behind mechanical circulatory support systems.

AIMS: Mechanical circulatory support (MCS) systems are increasingly employed in cardiogenic shock and advanced heart failure. A thorough understanding of the complex interactions occurring among heart, vasculature, and device is essential to optimize patient's management. The aim of this study is to explore non-invasive haemodynamic profiling of patients undergoing MCS based on pressure-strain (PS) analysis. METHODS: Clinical and echocardiographic data from consecutive patients undergoing different MCS systems positioning/implantation admitted to the third level cardiological intensive care unit of Siena Hospital from August 2021 to November 2021 were retrospectively reviewed. Patients without a useful echocardiographic exam or without arterial blood pressure recording at the time of echocardiography were excluded. Myocardial work analysis was performed in the included patients. RESULTS: We reviewed 18 patients, of which nine were excluded. Included patients were three patients with intra-aortic balloon pump (IABP), two patients with durable left ventricular assist device (dLVAD), two patients with Impella®, one patient with extracorporeal membrane oxygenation (ECMO), and one patient with ECMO and IABP. Myocardial work analysis was feasible in each included patient. The use of IABP shifted the PS curve rightward and downward. Global work index (GWI) and global wasted work (GWW) decreased after IABP positioning, whereas global work efficiency (GWE) increased. The use of continuous-flow pumps, whether temporaneous (Impella®) or long term (dLVAD), induced a change in the PS loop morphology, with a shift towards a triangular shape. ECMO positioning alone resulted in a narrowing of the PS loop, with a decrease in GWI and GWE and an increase in GWW and mean arterial pressure. The combined used of IABP with ECMO widened the PS loop and improved GWI and GWE. CONCLUSIONS: PS loops analysis in patients undergoing MCS seems to be feasible and may unveil MCS-induced haemodynamic variations. Myocardial work could be used to monitor ventricular-arterial-device coupling and guide tailored MCS management.

ADONHERS (Aged DONor HEart Rescue by Stress Echo) National Protocol: Recipient's Survival after 10-Year Follow-Up.

Background: The gold-standard treatment for end-stage heart failure is heart transplantation, but the lack of organ donors remains an important limitation in this field. An accurate selection of marginal hearts is fundamental to increase organ availability. Purpose: In our study we analyzed if recipients receiving marginal donor (MD) hearts, selected by dipyridamole stress echocardiography according to the ADOHERS national protocol, had different outcomes compared to recipients with acceptable donor (AD) hearts. Methods: Data were collected and retrospectively analyzed from patients who received an orthotopic heart transplant at our institution between 2006 and 2014. Dipyridamole stress echo was performed on identified marginal donors and selected hearts were eventually transplanted. Clinical, laboratory and instrumental features of the recipients were evaluated and patients with homogenous baseline characteristics were selected. Results: Eleven recipients transplanted with a selected marginal heart and eleven recipients transplanted with an acceptable heart were included. Mean donor age was 41 ± 23. The median follow-up was 113 months (IQR 86-146 months). Age, cardiovascular risk and morpho-functional characteristics of the left ventricle were comparable between the two populations (p > 0.05). Left atrial size was significantly higher in patients with marginal hearts (acceptable atrial volume: 23 ± 5 mL; marginal atrial volume: 38 ± 5 mL; p = 0.003). Acceptable donor recipients showed a higher impact of Cardiac Allograph Vasculopathy (p = 0.019). No rejection differences were found between the two groups. Four patients deceased, three were standard donor recipients and one was from the marginal donor group. Conclusions: Our study shows how cardiac transplant (Htx) from selected marginal donor hearts through a non-invasive bedside technique can alleviate the shortage of organs without a difference in survival compared to acceptable donor hearts.

Prediction of congestive state in acute and chronic heart failure: The association between NT-proBNP and left atrial strain and its prognostic value.

BACKGROUND: The relief of congestion is crucial to improve heart failure (HF) patient's quality of life and prognosis. N-terminal-pro-brain natriuretic peptide (NT-proBNP) is a well-known marker of congestion, although with limited specificity. Peak atrial longitudinal strain (PALS) by speckle tracking echocardiography (STE) is an index of intracardiac pressure and HF prognosis. We aimed to determine the association between NT-proBNP and PALS and its prognostic implications in patients with HF. METHODS: Patients hospitalized for de-novo or recurrent HF and outpatients with chronic HF were included in this retrospective study. Patients with missing data, previous cardiac surgery, non-feasible STE were excluded. Clinical, laboratory and echocardiographic data were collected. STE was performed on echocardiographic records. Primary endpoint was a combination of all-cause death and HF hospitalization. RESULTS: Overall, 388 patients were included (172 acute HF, 216 chronic HF, mean age = 65 ± 12 years, 37% female). Mean LV ejection fraction = 31 ± 9%. Global PALS showed a significant inverse correlation with NT-proBNP in acute and chronic HF (all p < 0.001). During a median follow-up of 4 years, 180 patients reached the combined endpoint. NT-proBNP (AUC = 0.87) and global PALS (AUC = 0.82) were good predictors of the combined endpoint. Global PALS was the only independent predictor of the combined endpoint. Optimal risk stratification for the composite endpoint was provided combining PALS ≤15% and NTproBNP ≥874.5 ng/l. CONCLUSIONS: Global PALS is associated with NT-proBNP in acute and chronic HF and may be used as additional index of congestion to optimize therapeutic management. The combination of global PALS and NT-proBNP could enhance the prognostic stratification of HF.

How to evaluate resting ECG and imaging in children practising sport: a critical review and proposal of an algorithm for ECG interpretation.

The athlete's heart is a well-known phenomenon in adults practising competitive sports. Unfortunately, to date, most of the studies on training-induced cardiac remodelling have been conducted in adults and the current recommendations refer mainly to adult individuals. However, an appropriate interpretation of resting ECG and imaging in children practising sports is crucial, given the possibility of early detect life-threatening conditions and managing therapy and eligibility to sports competitions in the rapidly growing paediatric athlete population. While several articles have been published on this topic in adult athletes, a practical guide for the clinical evaluation of paediatric athletes is still missing. In this critical review, we provided a comprehensive description of the current evidence on training-induced remodelling in paediatric athletes with a practical approach for clinicians on how to interpret the resting 12-lead ECG and cardiac imaging in the paediatric athlete. Indeed, given that training may mimic potential cardiovascular disorders, clinicians evaluating children practising sports should pay attention to the risk of missing a diagnosis of a life-threatening condition. However, this risk should be balanced with the risk of overdiagnosis and unwarranted disqualification from sports practice, when interpreting an ECG as pathological while, on the contrary, it may represent a physiological expression of athlete's heart. Accordingly, we proposed an algorithm for the evaluation of normal, borderline, and abnormal ECG findings that can be useful for the readers for their daily clinical practice.

Reproducibility of ventricular arrhythmias at exercise testing for prediction of non-ischaemic left ventricular scar in athletes.

AIMS: The non-ischaemic left ventricular scar (NILVS) is an emerging substrate of ventricular arrhythmias (VA) in the athlete. We tested the diagnostic value of VA reproducibility at repeated exercise testing (ET). METHODS AND RESULTS: We included consecutive athletes who underwent cardiac magnetic resonance (CMR) for evaluation of VA and two consecutive ET off-therapy within 12 months. Those with a positive family history of premature sudden death/cardiomyopathy, syncope/pre-syncope, ECG or echocardiography abnormalities, or low-risk VA (exercise-suppressed infundibular or fascicular VA) were excluded. The NILVS was defined as subepicardial/midmyocardial stria of late gadolinium enhancement involving >5% of the LV mass. Reproducibility was defined as the occurrence of VA with the same pattern and behaviour during repeated ET. Of 325 athletes who underwent CMR for evaluation of VA, 75 were included, and 30 showed NILVS involving three [2-4] LV segments. At first ET, athletes with NILVS showed a higher prevalence of exercise-induced VA (93% vs. 53%, P < 0.001), while other VA characteristics did not differ between groups. At repeated ET, reproducibility was observed in 97% of athletes with vs. 13% without NILVS (P < 0.001). The remaining 87% of athletes with normal CMR either did not show any VA at repeated ET (59%) or showed arrhythmias with different patterns, mostly infundibular. Reproducibility yielded a positive predictive value for NILVS of 83% and a negative predictive value of 98%. CONCLUSION: VA reproducibility at repeated ET predicted an underlying NILVS in athletes with VA and otherwise normal clinical work-up. This finding may improve risk stratification and appropriate CMR referral of athletes with apparently idiopathic VA.

Left Atrial Remodeling in Response to Aortic Valve Replacement: Pathophysiology and Myocardial Strain Analysis.

Severe aortic stenosis (AS) is the most common valve disease in the elderly and is associated with poor prognosis if treated only medically. AS causes chronic pressure overload, concentric left ventricular (LV) hypertrophy, myocardial stiffness, and diastolic dysfunction. This adverse remodeling also affects the left atrium (LA), which dilates and develops myocardial fibrosis, with a reduction in intrinsic function and a consequent high risk of the development of atrial fibrillation. Speckle-tracking echocardiography is able to detect myocardial dysfunction before other conventional parameters, such as LV ejection fraction, and also predict clinical outcomes. This review aims at describing LV and LA remodeling in AS and before and after aortic valve replacement and the usefulness of myocardial strain analysis in this clinical setting.

Left Ventricular Mass with Delayed Enhancement as a Predictor of Major Events in Patients with Myocarditis with Preserved Ejection Fraction.

Background: Cardiac Magnetic Resonance (CMR) has a key role in subjects presenting with acute myocarditis, independent from left ventricular ejection fraction; it is widely used as a non-invasive imaging test for both diagnostic and prognostic purposes. However, poor data is available about the CMR-derived prognostic parameters of acute myocarditis with preserved ejection fraction (AMpEF). The aim of this study was to investigate the role of CMR in predicting outcomes in patients followed up for AMpEF, using a composite endpoint of all-cause mortality and hospitalization for heart failure (HF). Methods: We retrospectively enrolled 61 patients with diagnosed AMpEF. All patients underwent biohumoral, echocardiographic and CMR evaluation in the acute phase. Myocarditis was confirmed by Lake-Louis criteria assessed on CMR images. Mean follow-up was 4.8 ± 0.6 years during which a composite endpoint of all-cause mortality and hospitalization for HF was investigated. Results: The population was fairly homogeneous regarding baseline clinical features. In particular, no significant differences in age and main cardiovascular risk factors were found between patients with and without events at follow-up. Seven patients met the endpoint. They had significantly higher levels of circulating neutrophils in the acute phase (76 ± 7% vs. 61 ± 11%, p = 0.014) and a higher amount of left ventricular mass with delayed enhancement (DE-LVM, 18 (14-29.5) vs. 12 (8-16) g, p = 0.028). At Cox univariate analysis, DE-LVM was the only significant predictor of endpoint, regardless of the site of inflammation. Conclusions: DE-LVM can predict the composite endpoint of all-cause mortality and hospitalization for HF in a population of patients with AMpEF, representing a new added tool for prognostic stratification.

Left atrial myocardial intrinsic function remodeling response to repair of primary mitral regurgitation.

Severe mitral regurgitation (MR) is a common valve disease which is associated with high mortality, if only managed medically. MR produces chronic and progressive volume overload with left atrial (LA) and left ventricular (LV) dilatation and dysfunction, atrial fibrillation (AF) and eventually myocardial fibrosis, irrespective of ejection fraction (EF). Surgical correction (mitral valve repair) of MR removes the volume overload, hence unmasks pre-operative LV structure and function disturbances, including reduced EF and global longitudinal and circumferential strain, as well as LA volume and strain. This review aims at describing LA remodeling before and after surgical repair.

Maternal Anti-Ro/SSA Autoantibodies and Prolonged PR Interval in a Competitive Athlete: Beyond Training-Induced Electrical Remodeling.

Prolongation of the PR interval is common among competitive athletes. However, further investigations should be performed when the PR interval is markedly prolonged. We report the case of a young male athlete with an autoimmune-mediated atrioventricular block due to circulating anti-Ro/SSA-antibodies in the mother (late progressive congenital form). (Level of Difficulty: Advanced.).

A multidisciplinary approach for the emergency care of patients with left ventricular assist devices: A practical guide.

The use of a left ventricular assist device (LVAD) as a bridge-to-transplantation or destination therapy to support cardiac function in patients with end-stage heart failure (HF) is increasing in all developed countries. However, the expertise needed to implant and manage patients referred for LVAD treatment is limited to a few reference centers, which are often located far from the patient's home. Although patients undergoing LVAD implantation should be permanently referred to the LVAD center for the management and follow-up of the device also after implantation, they would refer to the local healthcare service for routine assistance and urgent health issues related to the device or generic devices. Therefore, every clinician, from a bigger to a smaller center, should be prepared to manage LVAD carriers and the possible risks associated with LVAD management. Particularly, emergency treatment of patients with LVAD differs slightly from conventional emergency protocols and requires specific knowledge and a multidisciplinary approach to avoid ineffective treatment or dangerous consequences. This review aims to provide a standard protocol for managing emergency and urgency in patients with LVAD, elucidating the role of each healthcare professional and emphasizing the importance of collaboration between the emergency department, in-hospital ward, and LVAD reference center, as well as algorithms designed to ensure timely, adequate, and effective treatment to patients with LVAD.