Acute changes in mitral valve geometry after percutaneous valve repair with MitraClip XTR by three-dimensional echocardiography.

BACKGROUND: Mitral valve (MV) repair with MitraClip system is a safe treatment option for high-risk patients with significant mitral regurgitation (MR). We aimed to characterize, by three-dimensional echocardiography (3D-E), changes occurring in MV after implantation of third generation MitraClip XTR device, with specific reference to the underlying MR mechanism (functional vs degenerative, FMR vs DMR). METHODS: We prospectively enrolled 59 patients, who underwent intra-procedural 3D-E before and after device deployment. Three-D datasets were analyzed off-line, using a dedicated semiautomatic software, to obtain parametric quantification of mitral anatomy. RESULTS: Post-procedural MR of mild or lesser degree was achieved in 40 patients (68%), with no differences between FMR and DMR (p 0.9). After MitraClip XTR implantation, the FMR group experienced an immediate annular resizing, with reduction of antero-posterior diameter (p 0.024) and sphericity index (p 0.017), next to a recovery of physiological saddle-shape, defined by lower non-planar angle (p ≤0.001) and higher annulus height to commissural width ratio (p ≤0.001). On the opposite, the DMR group revealed a significant decrease of maximum annular velocity (p 0.027), addressing a mechanic effect of the device deployment. Finally, baseline anterior mitral leaflet angle was found as an independent predictor of acute procedural result (OR 6.7, [CI 1.01-44.33], p 0.049). CONCLUSIONS: MitraClip XTR implantation acts in restoring the original mitral geometry, with distinctive effects according to MR mechanism. Three-D parametric quantification of MV sheds new light on changes occurring in the valvular apparatus, and helps identifying possible new predictors of acute procedural success.

Right heart failure due to a fistula between a giant aortic pseudoaneurysm and the left atrium: a late complication after cardiovascular surgery.

: A 69-year-old woman, treated 5 years before with mechanical aortic valve and vascular prosthesis of ascending aorta implantation for severe aortic regurgitation and dilation of ascending aorta, was referred to our center for dyspnea and peripheral edema. The transthoracic echocardiography showed a giant pseudoaneurysm incorporating the vascular prosthesis and a fistula of it with the left atrium. These findings were confirmed using the transesophageal echocardiogram, cardiac computed tomography, and during cardiac surgery, which was performed 5 days later. The reparative intervention consisted of suturing of both the connections; the patient survived the surgery, but she died 6 weeks later due to infectious complications.

Maternal and sex dependency of insulin resistance: longitudinal PET and echocardiography study from the healthy fetus to the adult minipig.

UNLABELLED: Cardiovascular and metabolic vulnerability have an early developmental origin. We evaluated the potential influence of innate life factors, including the metabolism of the mother and the sex of the offspring, on cardiometabolic risk, including organ-specific insulin resistance, subclinical cardiac dysfunction, and DNA oxidative damage throughout the lifespan. METHODS: Two female minipigs were studied during late pregnancy, and their offspring were restudied at the ages of 1 mo (n = 11), 6 mo (n = 9), and 9 mo (n = 10, 6 offspring and 4 age-matched animals). We measured insulin-mediated glucose disposal in skeletal muscle, adipose tissue, liver, and myocardium using (18)F-FDG PET; cardiac function using 2-dimensional strain echocardiography; and DNA damage using the comet assay. RESULTS: Glucose metabolism showed the 2 sows to have differences similar to those in their respective 1-mo-old offspring. Over time, compared with female animals, male animals developed myocardial insulin resistance (male animals vs. female animals: 34 ± 5 vs. 58 ± 8 µmol/min/kg at 6 mo, P = 0.03; 29 ± 8 vs. 60 ± 7 µmol/min/kg at 9 mo, P = 0.02). Cardiac function progressively deteriorated in male animals from 1 mo (radial strain, -60% ± 7%; strain rate, -5.4 ± 0.9 s(-1)) to 6 mo (radial strain, -41% ± 5%; strain rate, -2.5 ± 0.2 s(-1), P < 0.05 vs. 1 mo) and 9 mo (radial strain, -32% ± 5%; strain rate, -1.6 ± 0.2 s(-1), P < 0.01 vs. 1 mo) and was significantly different from that in female animals (radial strain, -48% ± 4%; strain rate, -3.1 ± 0.2 s(-1), P < 0.05 and P < 0.01, respectively). Oxidative damage was reduced in female animals and increased in male animals across age categories (P < 0.05). CONCLUSION: The metabolism of minipig offspring is influenced by maternal insulin sensitivity during early life stages. Sex-related effects prevail thereafter in healthy minipigs, documenting a precocious onset of cardiometabolic vulnerability in male offspring.

Intramural myocardial hemorrhagic rupture in a patient with metastatic cancer and myocardial infarction.

A 77-year-old man with anterior ST-elevated myocardial infarction and lateral myocardial rupture underwent successful percutaneous revascularization. Cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET) unveiled a disseminated metastatic cancer, likely responsible not only for a prothrombotic paraneoplastic syndrome but also for ventricular metastasis and myocardial rupture. The patient unfortunately died because of noncardiovascular complications of cancer.

Feasibility of real-time three-dimensional stress echocardiography: pharmacological and semi-supine exercise.

BACKGROUND: Real time three dimensional (RT3D) echocardiography is an accurate and reproducible method for assessing left ventricular shape and function. AIM: assess the feasibility and reproducibility of RT3D stress echocardiography (SE) (exercise and pharmacological) in the evaluation of left ventricular function compared to 2D. METHODS AND RESULTS: One hundred eleven patients with known or suspected coronary artery disease underwent 2D and RT3DSE. The agreement in WMSI, EDV, ESV measurements was made off-line.The feasibility of RT-3DSE was 67%. The inter-observer variability for WMSI by RT3D echo was higher during exercise and with suboptimal quality images (good: k = 0.88; bad: k = 0.69); and with high heart rate both for pharmacological (HR < 100 bpm, k = 0.83; HR > or = 100 bpm, k = 0.49) and exercise SE (HR < 120 bpm, k = 0.88; HR > or = 120 bpm, k = 0.78). The RT3D reproducibility was high for ESV volumes (0.3 +/- 14 ml; CI 95%: -27 to 27 ml; p = n.s.). CONCLUSIONS: RT3DSE is more vulnerable than 2D due to tachycardia, signal quality, patient decubitus and suboptimal resting image quality, making exercise RT3DSE less attractive than pharmacological stress.

Circulating soluble receptor for advanced glycation end-product levels are decreased in patients with calcific aortic valve stenosis.

OBJECTIVE: It has been suggested that atherosclerotic mechanisms are involved in the pathogenesis of aortic valve stenosis (AVS). We hypothesised that low levels of the soluble receptor for advanced glycation end-products (sRAGE) might be associated with AVS due to its clinical and pathological associations with atherosclerosis. METHODS: We enrolled 75 consecutive patients with severe AVS scheduled for surgical aortic valve replacement and 39 controls without AVS matched for age and gender. Besides the traditional risk factors, we evaluated plasma levels of sRAGE, C-reactive protein (CRP) and IL-6. All patients underwent transthoracic echocardiography, carotid arteries ultrasound scan and coronary angiography. The aortic and coronary calcium by multislice computed tomography was assessed in AVS patients. RESULTS: The values of sRAGE were significantly lower (p<0.01) in AVS patients than in controls, while the CRP levels were significantly higher (p<0.05) in AVS patients than in controls. In AVS patients the sRAGE levels correlated inversely with age, cholesterol levels and coronary calcification. In all study subjects, we found an inverse correlation between circulating sRAGE and the number of echographically assessed sites of calcification (ANOVA, p<0.0001). In multivariable logistic regression analysis after adjustment for potential confounders, the sRAGE levels were significantly and independently associated with the risk of AVS (OR=0.997, 95% CI=0.994-1.000, p=0.048). CONCLUSION: Since sRAGE could exert antiatherogenic effects by preventing inflammatory responses mediated by cell surface RAGE activation, low levels in AVS patients indicate that ligand-RAGE axis could contribute to pathogenesis of AVS.

Cardiac calcification by transthoracic echocardiography in patients with known or suspected coronary artery disease.

OBJECTIVES: To estimate the correlation between the total heart calcification score index (CSI), assessed by echocardiography, left ventricle mass index (LVMI), Framingham risk score (FRS), and angiographically assessed coronary artery disease (CAD). BACKGROUND: Aortic valve and root sclerosis (AVS, ARS) and mitral annular calcium (MAC) detected by echocardiography have been associated with atherosclerosis. FRS is recommended for estimation of total coronary heart disease risk over the course of 10 years. The anatomic extent of CAD can be assessed with coronary angiography. Total and cardiovascular mortality risk increases with increasing LVMI. METHODS: 167 consecutive in-hospital patients (mean age 66.6+/-9.7 yrs, 119 men) underwent: 1) complete transthoracic echocardiography (TTE), with CSI assessment (from 0=normal to 10=diffuse calcification of aortic valve, mitral annulus and aortic root), 2) the FRS evaluation (FRSor=11 and or=21=high risk), and 3) coronary angiography (with Duke score evaluation, from 0=normal to 100=severe left main disease). RESULTS: The mean CSI of the entire population was 3.94+/-2.1, with a mean of 2.75+/-2 in patients at low risk, with a progressive increase in patients at average risk (4.11+/-2.2), at high risk (4.7+/-1.7), respectively. CSI was associated with the presence of CAD (p=0.003) and the presence of abnormal LVMI (p=0.002). CONCLUSIONS: Echocardiographically assessed CSI is correlated to FRS, Duke score and LVMI and can provide a simple, radiation-free index of cardiovascular risk.