Percutaneous mitral valve repair: The last chance for symptoms improvement in advanced refractory chronic heart failure?

BACKGROUND: The role of percutaneous mitral valve repair (PMVR) in patients with end-stage heart failure (HF) and functional mitral regurgitation (FMR) is unclear. METHODS: Seventy-five consecutive patients with FMR grade≥3+ and severe HF symptoms despite optimal medical therapy and resynchronization therapy underwent PMVR with the MitraClip system (Abbott, Abbott Park, IL, USA) at 3 centers. Clinical evaluation, echocardiography and pro-BNP measurement were performed at baseline and at 6-month. RESULTS: Mean age was 67±11years, logistic EuroSCORE=23±18%, left ventricle ejection fraction (LVEF) 30±9%. In 6 patients (8%) PMVR was performed as a bridge to heart transplant; many patients were dependent from iv diuretics and/or inotropes. Rate of serious adverse in-hospital events was 1.3% (1 patient who died after conversion to cardiac surgery). Sixty-three patients (84%) were discharged with MR≤2+. At 6-month, 4 patients died (5%), 80% had MR≤2+ and 75% were in New York Heart Association class ≤II. Median pro-BNP decreased from 4395pg/ml to 2594pg/ml (p=0.04). There were no significant changes in LV end-diastolic volume (222±75ml vs. 217±79, p=0.19), end-systolic volume (LVESV, 154±66ml vs. 156±69, p=0.54) and LVEF (30±9% vs. 30±12%, p=0.86). Significant reverse remodeling (reduction of LVESV≥10%) was observed in 25%, without apparent association with baseline characteristics. The number of hospitalizations for HF in comparison with the 6months before PMVR were reduced from 1.1±0.8 to 0.3±0.6 (p<0.001). CONCLUSIONS: In extreme risk HF patients with FMR, PMVR improved symptoms and reduced re-hospitalization and pro-BNP levels at 6months, despite the lack of LV reverse remodeling.

Differences in clinical features and in-hospital outcomes of older adults with tako-tsubo cardiomyopathy.

OBJECTIVES: To describe the clinical characteristics and in-hospital outcomes of older adults with tako-tsubo cardiomyopathy (TTC). DESIGN: Partially retrospective, partially prospective observational study. SETTING: Eleven Italian referral cardiac centers included in the Tako-tsubo Italian Network. PARTICIPANTS: One hundred ninety consecutive individuals with TTC (92.1% female, mean age 66) were divided into three groups according to age (<65, n = 78; 65-74, n = 61; ≥75, n = 51). MEASUREMENTS: Clinical findings and in-hospital outcomes were evaluated in each group. RESULTS: Participants aged 65 and older had a greater prevalence of hypertension (P = .001) and a lower glomerular filtration rate (P < .001), and those aged 65 to 74 had a greater prevalence of psychiatric disorders (P = .01), ST-segment elevation on admission (P = .01) and a cerebrovascular disease (P = .003) than those younger than 65. Despite similar left ventricular ejection fraction (LVEF) on admission (P = .26), the oldest group had a lower LVEF at discharge (P = .03). Inotropic agents were used more frequently in older adults (P = .03). In-hospital composite adverse events (all-cause death, acute heart failure, life-threatening arrhythmias, stroke, and cardiogenic shock; P = .03) and overall complications (P = .004) were more common in participants aged 75 and older. Overall in-hospital mortality was low (2.8%) but was more prevalent in participants aged 75 and older (6.3%). On multivariate analysis, age of 75 and older (hazard ratio (HR) = 2.45, 95% confidence interval (CI) = 1.28-5.82, P = .04) and LVEF on admission (HR = 0.874, 95% CI = 0.81-0.95, P < .001) were the only independent predictors of in-hospital adverse events. CONCLUSION: The clinical profile of participants aged 75 and older with TTC was different from that of those younger than 75 with TTC, and they had a higher in-hospital complication rate.

Is mitral E/E' ratio a reliable predictor of left ventricular diastolic pressures in patients without heart failure?

UNLABELLED: Aim Conflicting evidence exists as to whether the mitral E/E' ratio can be a reliable predictor of the left ventricular end-diastolic pressure (LVEDP). Our aim was to assess the value of the mitral E/E' ratio for the estimation of left ventricular diastolic pressures (LVDP) in patients without heart failure (HF). METHODS AND RESULTS: Echo-Doppler examination and left heart catheterization were carried out in 100 consecutive patients to assess the correlation between echo-Doppler parameters and the LVDP. The E/A ratio showed the best correlation with the pre-a LVDP and the LVEDP, whereas septal and mean E/E' ratios were significantly correlated with pre-a LVDP but not with the LVEDP. No difference in the echo-Doppler parameters was found between patients with normal and elevated LVEDP. Mitral E/E' ratio was significantly higher in patients with an ejection fraction (EF) <50% compared with those with the EF ≥ 50% and in patients with a dilated left ventricular (LV) compared with those with a normal LV. No significant difference in mean LVEDP was found among the three groups with E/E' ratios of <8, 8-15, and >15. The best cut-off values identified by receiver operating characteristic curve analysis for septal, lateral, and mean E/E' had sensitivities of 53, 68, and 54% and specificities of 66, 51, and 69% for identifying a >15 mmHg LVEDP. CONCLUSION: In patients without HF mitral E/E' ratio is influenced by EF and LV volumes and is better correlated with the pre-a LVDP than with the LVEDP. The suboptimal sensitivity and specificity of E/E' for predicting increased LVDP suggest that the mitral E/E' ratio is of limited clinical value in patients without HF.

Patients with acute coronary syndrome and nonobstructive coronary artery disease in the real world are markedly undertreated.

OBJECTIVES: We assessed the clinical profile of patients with acute coronary syndrome (ACS) and nonobstructive coronary artery disease (CAD) in a real world setting, focusing on pattern of care and on prognosis. METHODS: Each nonobstructive CAD (<50% stenosis in any epicardial coronary artery) patient was matched with an obstructive CAD patient; adjusted estimates of prescription of guideline-recommended drugs at discharge and of long-term prognosis were evaluated. RESULTS: Among 2995 consecutive ACS patients who underwent coronary angiography, 125 (4.2%) had nonobstructive CAD. Nonobstructive CAD patients had significantly lower odds of receiving aspirin [odds ratio (OR) 0.31, 95% confidence interval (CI): 0.14-0.68], thienopyridines (OR 0.01, 95% CI: 0.00-0.07), statins (OR 0.31, 95% CI: 0.17-0.58), beta-blockers (OR 0.32, 95% CI: 0.17-0.63) and angiotensin converting enzyme-inhibitors /angiotensin receptor blockers (OR 0.36, 95% CI: 0.17-0.91) compared with matched patients. During a 3-year follow-up, nonobstructive CAD patients had significantly fewer cardiovascular deaths and myocardial infarctions but numerically more episodes of unstable angina. CONCLUSIONS: The prevalence of nonobstructive CAD appears lower (4.2%) compared with published data. After extensive adjustment, patients with nonobstructive CAD were significantly less likely to be treated with guideline-recommended therapy, including aspirin and statins. Multicenter prospective studies targeting this specific population and the potential benefit of guideline-recommended therapies appear warranted.

Clinical characteristics and outcome of left ventricular ballooning syndrome in a European population.

We assessed the clinical characteristics and determinants of the prognosis of patients with left ventricular ballooning syndrome (LVBS) in an European population. A total of 128 patients with LVBS (98% women, age 67 ± 11 years) were prospectively followed up for a median of 13 months. A trigger event was identifiable in 58% of the patients. Anterior ST-segment elevation was documented in 38% and negative T waves in 41% of the patients. Apical ballooning was present in 82% and midventricular ballooning in 18%. The initial LV ejection fraction was 41 ± 9%. In-hospital events included the death of 1 patient (0.8%), LV failure in 13 (10%), LV thrombi in 4 (3.1%), sustained ventricular or supraventricular tachyarrhythmias in 6 (4.7%) and asystole in 2 patients (1.6%). The extent of wall motion abnormalities (odds ratio 4.16, p = 0.012), dyspnea at presentation (odds ratio 3.42, p = 0.01), and treatment with nitrates (odds ratio 0.30, p = 0.015) were significant univariate predictors of in-hospital events. The recovery of regional wall motion abnormalities occurred within 1 month of the event in 73% of patients. During follow-up, events occurred in 7 (6%) of 121 patients, including noncardiac death in 1 (0.8%), recurrent LVBS in 2 (1.6%), heart failure in 1 (0.8%), and recurrent chest pain in 3 (2.5%). In conclusion, in a European population, LVBS was characterized by a significant rate of in-hospital events, mainly related to pump failure, and low short-term mortality. The extent of wall motion abnormalities was the best predictor of acute events. Contractile recovery occurred within 1 month in most patients. The long-term prognosis was good, with a recurrence rate of <2%/year.

Monday preference in onset of takotsubo cardiomyopathy.

OBJECTIVE: Acute cardiovascular events show definite temporal patterns of occurrence. Takotsubo cardiomyopathy (TTC) has been recently shown to exhibit a seasonal (summer) and circadian (morning) temporal distribution. The aim of this study, based on the database of a multicenter Italian network, was to investigate the possible existence of a weekly pattern of onset of TTC. METHODS: The study included all cases of TTC admitted to the coronary care unit of 8 referral cardiac centers in Italy (five in Southern Italy and three in Northern Italy, respectively), belonging to the Takotsubo Italian Network (January 2002-December 2008). Day of admission was categorized into seven 1-day intervals according by week, and chronobiological analysis was performed by partial Fourier series. RESULTS: The database included 112 patients with TTC (92.9% females). The weekly distribution identified the highest number of cases on Monday and the lowest on Saturday. Chronobiologic analysis yielded a rhythmic pattern with a significant peak on Monday (P = .036). CONCLUSIONS: This study confirms a Monday preference for TTC occurrence on Monday, similar to that reported for acute myocardial infarction. Stress of starting weekly day life activities, could play a triggering role.

Dobutamine stress echocardiography for assessing the role of dynamic intraventricular obstruction in left ventricular ballooning syndrome.

BACKGROUND: Dynamic intraventricular obstruction has been observed in patients with left ventricular ballooning syndrome (LVBS) and has been hypothesized as a possible mechanism of the syndrome. The aim of this study was to assess the prevalence and significance of dynamic intraventricular obstruction in patients with LVBS. METHODS AND RESULTS: Dobutamine stress echocardiography was carried out in 22 patients with LVBS (82% apical), all women, aged 68 +/- 9 years. At baseline 1 patient had a > 30 mmHg LV gradient; during stress a LV gradient > 30 mm Hg developed in 6/21 patients (28%) and was caused by systolic anterior motion of the mitral valve in the 3 patients with severe gradient (mean 116 +/- 29 mmHg), who developed mitral regurgitation and impaired apical wall motion and by obstruction at mid-ventricular level in the other 3 with a moderate gradient (mean 46 +/- 16 mmHg). Compared with patients without obstruction those with obstruction had a greater mean septal thickness (11.6 +/- .6 vs 9.8. +/- 3, p < .01), a higher prevalence of septal hypertrophy (71% vs 7%, p < .005) and a higher peak wall motion score index (1.62 +/- .4 vs 1.08 +/- .4, p < .01). CONCLUSION: Spontaneous or dobutamine-induced dynamic LV obstruction is documented in 32% of patients with LVBS, is correlated with the presence of septal hypertrophy and may play a role in the development of LVBS in this subset of patients. In those without septal hypertrophy a dynamic obstruction is rarely induced with dobutamine and is unlikely to be a major pathogenetic factor of the syndrome.

Role of dynamic intraventricular obstruction and protective effect of beta-blocking therapy in left ventricular apical ballooning syndrome: a case report.

This paper reports on a 58-year old woman with left ventricular apical ballooning syndrome (LVABS), who after interruption of beta-blocking therapy had a recurrence of symptoms and developed a severe dynamic left ventricular obstruction (LV-DYN-O) during sympathetic stimulation with dobutamine.

Left ventricular apical ballooning syndrome: prevalence, clinical characteristics and pathogenetic mechanisms in a European population.

BACKGROUND: Left ventricular apical ballooning syndrome (LVABS) is a cardiac syndrome mimicking acute myocardial infarction, whose prevalence in western populations and pathogenesis are not yet well defined. The aim of the study was to assess its prevalence, clinical characteristics and pathophysiological mechanisms in a European population of myocardial infarction patients. METHODS: Of a series of 1457 patients with acute myocardial infarction 18 fulfilled the diagnostic criteria for LVABS. To evaluate the pathogenetic mechanisms we studied coronary blood flow with TIMI flow grade and corrected TIMI frame count (CTFC) in all patients and performed provocative testing with ergonovine and dobutamine echocardiography in 14. RESULTS: All patients were women aged 72+/-9 years. A triggering event was identifiable in 39% of cases. LV ejection fraction in the acute phase was 46+/-5%. No deaths or major complications occurred during hospitalization. Response to ergonovine was negative in all 14 patients and dobutamine induced a dynamic LV obstruction in 4/14 (28%). Mean CTFC was abnormally prolonged in all 3 major coronary arteries and 16/18 patients (89%) had an abnormal CTFC in >/=1 coronary vessel. No cardiac deaths occurred during follow-up and 1 patient only had a recurrence. CONCLUSIONS: The prevalence of LVABS is 1.2% among all patients with acute myocardial infarction, but rises to 4.9% in women. Short- and long-term prognosis is good. Abnormal CTFC suggests the presence of a coronary microvascular dysfunction, while dynamic LV obstruction can contribute to the development of LVABS in a minority of patients.

[Takotsubo cardiomyopathy: a consensus document]. / La cardiomiopatia takotsubo: documento di consenso.

Takotsubo cardiomyopathy is a syndrome characterized by acute regional systolic dysfunction of the left ventricle, frequently related to psycho-physical acute stress, and usually reversible. This rare syndrome involves more often the female sex with the highest frequency of occurrence between the seventh and eighth decade of life. Etiology has not been clarified yet and several hypotheses have been postulated: multiple epicardial coronary artery damage, abnormal coronary microcirculation, catecholamine-mediated cardiac toxicity, and neurogenic stunning. Clinical presentation is not easy to distinguish from an acute coronary syndrome: chest pain at rest or dyspnea, new-onset electrocardiographic changes, characterized by ST-segment elevation or T-wave inversion. Coronary angiography, which should be performed within 48 h of symptom onset in order to be diagnostic, excludes the presence of significant atherosclerotic stenosis or plaque rupture. Ventricular angiography shows the typical regional wall motion abnormalities (apical akinesia and hyperkinesia of the mid-basal segments) that give to the syndrome its name (takotsubo is a traditional Japanese octopus trap or pot). Echocardiography performed in the acute phase also evidences wall motion abnormalities that characteristically regress in the following days. There is no specific treatment for this syndrome, but supportive and symptomatic therapy is usually administered.

[Usefulness and limitations of contrast echocardiography during dobutamine stress test]. / Utilità e limiti dell'ecocontrastografia durante eco-stress con dobutamina.

BACKGROUND: The aim of this study was to evaluate whether the use of contrast agent in addition to second harmonic imaging during dobutamine stress echocardiography can improve endocardial visualization and interobserver agreement in the evaluation of regional wall motion in patients with suboptimal or poor acoustic window. METHODS: Twenty-one patients with a poor or suboptimal acoustic window underwent dobutamine stress echocardiography. Echocardiographic images in parasternal long-axis and short-axis, apical 4-chamber and 2-chamber views were cine-looped at baseline and peak stress before and after injection of contrast medium (Levovist at a concentration of 400 mg/ml). Endocardial visualization and regional wall motion were evaluated by two blinded observers. RESULTS: The contrast medium improved segment visualization both at baseline (complete visualization in 74% of segments with contrast vs 71% without, p = NS) and at peak stress (76 vs 64%, p < 0.001). Contrast medium improved significantly segment visualization in apical 4-chamber view both at baseline (complete visualization in 87% of segments with contrast vs 72% without, p < 0.01) and at peak (89 vs 66%, p < 0.001) and in apical 2-chamber view both at baseline (81 vs 61%, p < 0.001) and at peak (89 vs 55%, p < 0.001). When individual segments were analyzed, endocardial visualization improved significantly in all segments of the anterior wall and in the mid and distal segments of the lateral wall both at baseline and at peak stress. The use of contrast medium did not improve significantly interobserver agreement in the evaluation of regional wall motion at peak stress (k = 0.63 vs 0.67 without and with contrast, respectively). CONCLUSIONS: The use of Levovist during dobutamine stress echocardiography improves significantly segment visualization in the apical views both at baseline and at peak stress and increases interobserver agreement in the evaluation of regional wall motion at peak stress.

Dobutamine-induced ST-segment elevation associated with a biphasic response of wall motion in patients with a recent myocardial infarction is caused by myocardial ischaemia and is abolished by revascularization of the infarct-related artery.

OBJECTIVE: ST-segment elevation is frequently induced by dobutamine in patients with a recent myocardial infarction and may represent dyskinesia of the infarcted region or myocardial viability and ischaemia. Revascularization of the infarct-related artery may abolish myocardial ischaemia, and thus represents a useful tool to verify the significance of this finding. The aim of this study was to assess the relation between ST-segment elevation and wall motion response during dobutamine echo stress test and to evaluate the effect of coronary revascularization with percutaneous coronary angioplasty of the infarct-related artery on stress test results. METHODS AND RESULTS: Twenty-two patients (17 men; mean age 58+/-12 years) with a first acute myocardial infarction (5 anterior (23%) and 17 (77%) inferior) who showed ST-segment elevation during a dobutamine echo stress test performed early (7+/-5 days) after the acute event where included in the analysis. All patients underwent coronary arteriography followed by percutaneous revascularization with coronary angioplasty or atherectomy with or without stenting of the culprit lesion and a second dobutamine echo stress test at a mean of 40+/-20 days after revascularization. The minimal lumen diameter increased from 0.63+/-0.36 to 3+/-0.44 mm and % diameter stenosis decreased from 80+/-11 to 12+/-7 after revascularization. At baseline evaluation there were 62 normal moving segments (34%), 57 (32%) akinetic and 62 (34%) hypokinetic segments within the area at risk. Maximal ST-segment shift changed from a basal mean value of 0.41+/-0.6 to a peak value of 2.15+/-0.9 mm; angina developed in 6/22 patients (22%). A biphasic response to dobutamine indicative of myocardial ischaemia within the infarcted area was observed in 20/22 patients (91%) and in 54/74 (73%) segments showing wall motion abnormalities. After revascularization of the infarct-related artery 78 (43%) segments were considered to be normal, 46 (25%) akinetic and 57 (32%) hypokinetic. Dobutamine-induced ST-segment elevation in 6/22 cases (27%), but the amount of ST-segment shift at peak stress was significantly reduced (from 2.15+/-0.9 to 0.30+/-0.5 mm) and angina was present in 1 patient only (5%) despite a significant increase of double product compared to the pre-revascularization test (from 17,348+/-3536 to 21,005+/-4105, p < 0.003). At echocardiographic analysis, ischaemia involved only 4 segments (2%), 3 of them showing the persistence of a biphasic response to dobutamine. CONCLUSIONS: In patients with a recent myocardial infarction and no baseline dyskinesia dobutamine-induced ST-segment elevation in the infarct-related leads is usually associated with a biphasic response of wall motion within the infarcted region and may be considered an ancillary sign of myocardial ischaemia because it is abolished in the great majority of cases by successful revascularization of the infarct-related artery.