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.

Acute Effects of Triathlon Race on Oxidative Stress Biomarkers.

The response to strenuous exercise was investigated by reactive oxygen species (ROS) production, oxidative damage, thiol redox status, and inflammation assessments in 32 enrolled triathlon athletes (41.9 ± 7.9 yrs) during Ironman® (IR), or half Ironman® (HIR) competition. In biological samples, inflammatory cytokines, aminothiols (glutathione (GSH), homocysteine (Hcy), cysteine (Cys), and cysteinylglycine (CysGly)), creatinine and neopterin, oxidative stress (OxS) biomarkers (protein carbonyl (PC), thiobarbituric acid-reactive substances (TBARS)), and ROS were assessed. Thirteen HIR and fourteen IR athletes finished the race. Postrace, ROS (HIR +20%; IR +28%; p < 0.0001), TBARS (HIR +57%; IR +101%), PC (HIR +101%; IR +130%) and urinary neopterin (HIR +19%, IR +27%) significantly (range p < 0.05-0.0001) increased. Moreover, HIR showed an increase in total Cys +28%, while IR showed total aminothiols, Cys, Hcy, CysGly, and GSH increase by +48, +30, +58, and +158%, respectively (range p < 0.05-0.0001). ROS production was significantly correlated with TBARS and PC (R 2 = 0.38 and R 2 = 0.40; p < 0.0001) and aminothiols levels (range R 2 = 0.17-0.47; range p < 0.01-0.0001). In particular, ROS was directly correlated with the athletes' age (R 2 = 0.19; p < 0.05), with ultraendurance years of training (R 2 = 0.18; p < 0.05) and the days/week training activity (R 2 = 0.16; p < 0.05). Finally, the days/week training activity (hours/in the last 2 weeks) was found inversely correlated with the IL-6 postrace (R 2 = -0.21; p < 0.01). A strenuous performance, the Ironman® distance triathlon competition, alters the oxidant/antioxidant balance through a great OxS response that is directly correlated to the inflammatory parameters; furthermore, the obtained data suggest that an appropriate training time has to be selected in order to achieve the lowest ROS production and IL-6 concentration at the same time.

The Additional Value of Three-Dimensional Transesophageal Echocardiography in the Diagnosis of Unusual Complication of Bioprosthetic Mitral Valve.

Primary tissue failure of bioprosthetic mitral valves due to cusp perforations or ruptures is an unusual complication on short-term follow-up. An 88-year-old male with a known history of mitral regurgitation (MR) treated with bioprosthetic valve replacement in 2016 was referred to our center for recurrent heart failure. The two-dimensional (2D) transthoracic echocardiography documented an intraprosthetic jet of regurgitation without identifying a clear morphological mechanism, nor quantifying precisely the mitral insufficiency. 3D transesophageal echocardiography (TOE) with the tool FlexiSlice added relevant information by providing insights into the pathophysiological mechanisms of MR. The present case emphasizes the importance of 3D TOE as a fundamental tool for the diagnostic algorithm of bioprosthetic valves failure, even in the more demanding cases.

Acute Cardiovascular Adaptation to Strenuous Exercise: An Integrative Ultrasound Study.

OBJECTIVES: The aim of this study was to evaluate the acute effects of participation in an Ironman distance triathlon competition on arterial function by ultrasound, in relation to cardiac function and body water content. METHODS: Twenty-eight male triathletes participating in an Ironman distance competition underwent carotid, femoral, and cardiac ultrasound examinations. Moreover, the presence of extravascular lung water was identified by lung echo B-lines (echogenic coherent wedge-shaped signal with a narrow origin from the hyperechoic pleural line) at rest and within 20 minutes of arrival. RESULTS: At the end of the competition, athletes showed an increased heart rate (mean ± SD, from 60.2 ± 13.1 to 82.8 ± 15.6 beats/min; P < .0001) and unchanged mean blood pressure (from 93 ± 14 to 91 ± 10 mm Hg; P > .05) in the presence of negligible dehydration (total body water from 48.0 ± 4.0 to 46.5 ± 3.9 kg; P > .05). Cardiac output increased (from 5.5 ± 1.2 to 6.7 ± 2.4 L/min; P < .05) in the presence of an unchanged stroke volume (from 64 ± 14 to 59 ± 16 mL; P > .05) and unchanged left ventricular elastance (from 1.52 ± 0.48 to 1.39 ± 0.48 mm Hg/mL/m2 ; P > .05). The mean carotid diameter increased (from 7.19 ± 0.65 to 7.61 ± 0.76 mm; P < .05), whereas the mean femoral diameter was unchanged at the end of the competition (from 10.41 ± 0.83 to 10.49 ± 0.82 mm; P > .05). Carotid intima-media thickness was significantly reduced (from 537 ± 70 to 495 ± 70 µm; P < .05), whereas B-lines increased significantly after the competition (from 1 [0-4] to 12 [5-23]; P < .0001). CONCLUSIONS: These data suggest different acute functional adaptation in central arteries with respect to peripheral leg vessels.

Quality control of B-lines analysis in stress Echo 2020.

BACKGROUND: The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE: To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS: 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS: All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS: Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.

Novel percutaneous suture-mediated patent foramen ovale closure technique: early results of the NobleStitch EL Italian Registry.

AIMS: The aim of this study was to assess the efficacy of a novel percutaneous "deviceless" suture-mediated patent foramen ovale (PFO) closure system. METHODS AND RESULTS: Between June 2016 and October 2017, a prospective registry aimed at assessing the safety and efficacy of the NobleStitch EL (HeartStitch, Fountain Valley, CA, USA) suture-based PFO closure system was carried out at 12 sites in Italy. Among 200 consecutive patients evaluated, 192 were considered suitable for suture-mediated PFO closure (44±13 years, 114 female). Suture of the septum with the NobleStitch EL system was carried out successfully in 186 (96%) patients. Median fluoroscopy time was 16.1 (13.0-22.5) minutes and contrast volume 200 (150-270) ml. At 206±130 days follow-up, contrast transthoracic echocardiography with the Valsalva manoeuvre revealed no RLS (grade 0) in 139 (75%) patients and RLS grade ≤1 in 166 (89%) patients. Significant RLS was present in 20 (11%) patients (grade 2 and 3 in 11 and nine patients, respectively). There were no device-related complications. CONCLUSIONS: The early results of this first Italian registry indicate that the suture-mediated "deviceless" closure of PFO is feasible in the majority of septal anatomies, and provides an effective closure of PFO comparable to traditional devices with a good safety profile at medium-term follow-up.

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.

Tailored use of transradial access for above-the-knee angioplasty.

PURPOSE: To report the results and complications of a single-center experience of above-the-knee angioplasty via transradial access (TRA). METHODS: In a prospective study, 110 consecutive patients (88 men; mean age 72 years, range 37-90) referred for critical limb ischemia (26, 24%) or claudication were eligible for lower limb angioplasty via TRA (patients with TASC D lesions of the superficial femoral artery and below-the-knee lesions were excluded). RESULTS: The majority of patients (84, 76%) were treated via a left TRA. A total of 170 lesions were addressed, of which 38 (22%) were occlusions; 113 stents were positioned in 82 patients. The overall technical success rate was 91%, with a 63% success rate in occlusions and a 98% success rate in stenoses; by location, the success rates were 91% in suprainguinal lesions and 90% in infrainguinal lesions. No hemorrhagic or local complications requiring surgery were observed. At 1-month follow-up, 101 patients had a downward shift of at least one category in the Rutherford classification of symptoms (clinical success rate 92%); 18 (16%) patients had occlusion of their access radial artery, but none had symptoms or discomfort. CONCLUSION: The present study demonstrates that TRA is a safe and effective approach for lower extremity arterial revascularization, at least for interventionists with longstanding experience in TRA and in selected anatomical subsets.

[Pro-arrhythmic effect of cardiac memory in a patient with long QT syndrome]. / Effetto pro-aritmico della memoria elettrica cardiaca in un paziente con sindrome del QT lungo.

We describe the case of a patient with a congenital long QT syndrome (LQTS) who showed signs of cardiac memory associated with early afterdepolarizations and ventricular arrhythmias, after a change in the pacing mode from VVI to AAI. Cardiac memory, further altering the potassium ion channel function, may have pro-arrhythmic potential in patients with LQTS.

Assessment of carotid elasticity during exercise: a reproducibility study.

The study aimed to evaluate the reproducibility of carotid elasticity during exercise. Eighteen healthy volunteers (nine males, age 34 ± 3 years, BMI 22 ± 6 kg/m(2)) underwent maximal exercise testing on a graded semi-supine cycle ergometer in two different sessions 3 days apart. Ultrasound B-mode image sequences of the right common carotid were acquired at different steps and analyzed by an automatic system; pressures were estimated by tonometry. Compliance (CC) and distensibility (DC) were significantly decreased at exercise peak and in the first recovery minute (CC from 1.6 ± 0.8 to 1 ± 0.6 mm^(2)/KPa, DC from 56.2 ± 25.3 to 34.5 ± 20 10^(-3)/KPa, p < 0.05). For the whole examination, intraclass coefficient was 0.780 for CC and 0.694 for DC. Mean coefficient of variation was maximum at peak exercise (CC = 19 ± 6%, DC = 24 ± 15%), but at first minute of recovery it was comparable to resting values (CC = 12 ± 9%, DC = 12 ± 11%). When designing future studies, acquisitions during first recovery minute might be preferred to peak measures.

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.

Patterns of left ventricular remodeling in chronic heart failure: prevalence and prognostic implications.

BACKGROUND AND AIM: Many descriptors of left ventricular (LV) remodeling have important prognostic implications in patients with chronic systolic heart failure (HF). We sought to assess the prognostic value of the combination of increased LV mass with a disproportion between wall thickness and internal diameter. METHODS AND PATIENTS: Patients (n = 536) with chronic HF, ejection fraction <50% and LV end-diastolic volume index >91 mL/m(2), classified according to LV mass index and relative wall thickness (RWT), were followed up for 33 ± 21 months. Ventricular mass was determined using a standard M-mode echocardiographic method. Relative wall thickness was defined as the ratio of (sum of interventricular septum thickness in diastole + posterior wall thickness in diastole)/LV end-diastolic diameter. RESULTS: Prevalence of the pattern of increased LV mass index, defined as LV mass index >148 g/m(2) in men and >122 g/m(2) in women, and decreased RWT (<0.34) was 29%. Multivariable predictors of all-cause mortality were age >70 years (P < .0001), New York Heart Association class >2 (P < .0001), increased LV mass index, and decreased RWT (P = .003), E wave deceleration time ≤140 ms (P = .005), and male gender (P = .025). Patients with increased LV mass index and decreased RWT had a worse survival (33%) than patients with less LV mass index and normal to reduced RWT (log-rank 23.92; P < .0001). Comparisons of Cox models showed that the combination of increased mass index and decreased RWT added prognostic value to a model that included ejection fraction and end-systolic volume index. CONCLUSION: In patients with systolic HF, an independent and incremental risk of adverse outcome was associated with increased mass index and decreased RWT.

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.

[Common pathogenetic features between calcific aortic stenosis and atherosclerosis: role of receptor for advanced glycation end-products]. / Aspetti patogenetici comuni tra stenosi aortica calcifica e aterosclerosi: ruolo del recettore dei prodotti di glicosilazione avanzata.

Clinical and experimental studies identified several similarities between calcific aortic stenosis and atherosclerosis, suggesting the involvement of similar pathogenic pathways in both conditions.There are several molecules involved in regulating the development, progression and calcification of the valve sclerosis and in growth and complications of atherosclerotic plaque. Among these molecules, the receptor of advanced glycation end-products, a multi-ligand receptor involved in the pathogenesis of several degenerative, inflammatory and immune diseases, could have an important regulatory role in both diseases and therefore worthy of study as a potential target therapeutic for both conditions.

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.