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2.
J Am Coll Cardiol ; 74(18): 2278-2291, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672185

RESUMO

BACKGROUND: The assessment of coronary flow velocity reserve (CFVR) in left anterior descending coronary artery (LAD) expands the risk stratification potential of stress echocardiography (SE) based on stress-induced regional wall motion abnormalities (RWMA). OBJECTIVES: The purpose of this study was to assess the feasibility and functional correlates of CFVR. METHODS: This prospective, observational, multicenter study initially screened 3,410 patients (2,061 [60%] male; age 63 ± 11 years; ejection fraction 61 ± 9%) with known or suspected coronary artery disease and/or heart failure. All patients underwent SE (exercise, n = 1,288; vasodilator, n = 1,860; dobutamine, n = 262) based on new or worsening RWMA in 20 accredited laboratories of 8 countries. CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed-Doppler assessment of LAD flow. A subset of 1,867 patients was followed up. RESULTS: The success rate for CFVR on LAD was 3,002 of 3,410 (feasibility = 88%). Reduced (≤2.0) CFVR was found in 896 of 3,002 (30%) patients. At multivariable logistic regression analysis, inducible RWMA (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 4.9 to 8.5; p < 0.01), abnormal left ventricular contractile reserve (OR: 3.4; 95% CI: 2.7 to 4.2; p < 0.01), and B-lines (OR: 1.5; 95% CI: 1.1 to 1.9; p = 0.01) were associated with reduced CFVR. During a median follow-up time of 16 months, 218 events occurred. RWMA (hazard ratio: 3.8; 95% CI: 2.3 to 6.3; p < 0.001) and reduced CFVR (hazard ratio: 1.5; 95% CI: 1.1 to 2.2; p = 0.009) were independently associated with adverse outcome. CONCLUSIONS: CFVR is feasible with all SE protocols. Reduced CFVR is often accompanied by RWMA, abnormal LVCR, and pulmonary congestion during stress, and shows independent value over RWMA in predicting an adverse outcome.

3.
Eur Heart J Cardiovasc Imaging ; 20(9): 1012-1019, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30863840

RESUMO

AIMS: Functional mitral regurgitation (FMR) is a well-known pathophysiological factor in heart failure (HF) patients, and left atrial function (LAF) is a novel determinant of clinical status and outcome in this setting. However, little is known about the pathophysiological role of FMR on LAF in HFrEF patients. Aim of this study is to explore the possible interplay between the severity of FMR and LAF in heart failure with reduce ejection fraction (HFrEF) patients and their possible consequences. METHODS AND RESULTS: We studied 97 consecutive patients with FMR classified in two groups: mild-to-moderate MR ore less (FMR group, n = 38) and moderate-to-severe or more (SFMR group, n = 59). Using the phasic method, left atrial contractile, conduit, reservoir, and total emptying function (TLAEF) were calculated to assess LAF. SFMR group showed significantly lower values of LAF compared to FMR group. LA dysfunction (LA-dys) was defined for TLAEF values below the median and groups divided in four subgroups based on its presence. Patient with LA-Dys in SFMR group showed a worse clinical status, higher incidence of right ventricular dysfunction (RV-Dys), and pulmonary hypertension (PH), and a significant worse clinical survival compared to all other groups. CONCLUSION: In our study, the survival was significantly lower in SFMR/LA-Dys+ group. Furthermore, LA-Dys was strongly related with worse clinical status and higher incidence of PH and RV-Dys. These results suggest that in patients with SFMR and HFrEF, LA-Dys may represent both a marker of more advanced disease and a novel prognostic factor.

4.
Cardiovasc Ultrasound ; 16(1): 20, 2018 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-30249305

RESUMO

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.


Assuntos
Ecocardiografia sob Estresse/normas , Pulmão/diagnóstico por imagem , Edema Pulmonar/diagnóstico , Controle de Qualidade , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade
5.
Int J Cardiol ; 249: 479-485, 2017 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-28986062

RESUMO

BACKGROUND: The trial "Stress Echo (SE) 2020" evaluates novel applications of SE beyond coronary artery disease. The aim of the study was control quality and harmonize reading criteria. METHODS: One reader from 78 centers of the SE 2020 network asked for credentials to read a set of 20 SE video-clips selected by the core lab. All aspiring centers met the pre-requisite of high-volume and the years of experience in SE ranged from 5 to 31years (mean value 18years). The diagnostic gold standard was a reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%). RESULTS: Of the initial 78 who started, 57 completed the first attempt: individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor correlation between years of experience and the reader's score on first attempt (r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it again after the web-based session and their accuracy improved (74% vs. 96%, p<0.001). The kappa inter-observer agreement before and after web-based training was 0.59 on first attempt and rose to 0.91 on the last attempt. CONCLUSIONS: In SE reading, the volume of activity or years of experience is not synonymous with diagnostic quality. Qualitative analysis and operator-dependence can become a limiting weakness in clinical practice, in the absence of strict pathways of learning, credentialing and audit.


Assuntos
Cardiologistas/normas , Competência Clínica/normas , Doença das Coronárias/diagnóstico por imagem , Ecocardiografia sob Estresse/normas , Controle de Qualidade , Doença das Coronárias/epidemiologia , Ecocardiografia sob Estresse/métodos , Humanos , Internacionalidade , Reprodutibilidade dos Testes
6.
J Interv Cardiol ; 30(4): 368-373, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28675000

RESUMO

INTRODUCTION: Percutaneous mitral valve repair (PMVR) using MitraClip system has emerged as a therapeutic option for patients with functional severe mitral regurgitation (FMR) at prohibitive risk for surgery. In this setting, the echocardiographic assessment of FMR severity is challenging because the traditional echocardiographic methods have important limitations. The aim of this study was to assess the accuracy and reliability of a simple Doppler index, the mitral/aortic flow velocity integral ratio (MAVIR), to evaluate residual FMR severity after PMVR. METHODS: Eighty-five heart failure patients with functional MR and LV dysfunction (LVEF ≤ 40%) were included. FMR was quantified on the basis of traditional quantitative parameters of MR severity. MAVIR was expressed as the ratio of mitral and aortic time velocity integral (TVI) values. According to MR severity, 25 patients underwent MC implantation and at 6 months a complete echocardiographic follow-up was performed. RESULTS: A significant linear relationship was found between MAVIR and both VC and EROA. A MAVIR ≥1.02 identified pts with severe MR with a sensitivity of 86.7% and a specificity of 90.9%. At the 6 months echocardiographic follow-up after the MitraClip implantation, we observed a significant reduction of LAVI, LVED and LVES volume, while LVEF improved. Furthermore, MAVIR significantly decreased its decrease showed a significant linear relationship with LAVI reduction. CONCLUSION: Our data show a close relationship between MAVIR and traditional indexes of MR severity in patients with FMR. This Doppler-derived index seems applicable after PMVR where traditional echocardiographic index of MR severity shows significant limitations.


Assuntos
Insuficiência da Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/cirurgia , Intervenção Coronária Percutânea , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta , Velocidade do Fluxo Sanguíneo/fisiologia , Ecocardiografia Doppler , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem
8.
Cardiovasc Ultrasound ; 15(1): 3, 2017 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-28100277

RESUMO

BACKGROUND: Stress echocardiography (SE) has an established role in evidence-based guidelines, but recently its breadth and variety of applications have extended well beyond coronary artery disease (CAD). We lack a prospective research study of SE applications, in and beyond CAD, also considering a variety of signs in addition to regional wall motion abnormalities. METHODS: In a prospective, multicenter, international, observational study design, > 100 certified high-volume SE labs (initially from Italy, Brazil, Hungary, and Serbia) will be networked with an organized system of clinical, laboratory and imaging data collection at the time of physical or pharmacological SE, with structured follow-up information. The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on: contractile reserve for prediction of cardiac resynchronization or medical therapy response; stress B-lines in heart failure; hypertrophic cardiomyopathy; heart failure with preserved ejection fraction; mitral regurgitation after either transcatheter or surgical aortic valve replacement; outdoor SE in extreme physiology; right ventricular contractile reserve in repaired Tetralogy of Fallot; suspected or initial pulmonary arterial hypertension; coronary flow velocity, left ventricular elastance reserve and B-lines in known or suspected CAD; identification of subclinical familial disease in genotype-positive, phenotype- negative healthy relatives of inherited disease (such as hypertrophic cardiomyopathy). RESULTS: We expect to recruit about 10,000 patients over a 5-year period (2016-2020), with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot. This data-base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios. CONCLUSIONS: The study will create the cultural, informatic and scientific infrastructure connecting high-volume, accredited SE labs, sharing common criteria of indication, execution, reporting and image storage of SE to obtain original safety, feasibility, and outcome data in evidence-poor diagnostic fields, also outside the established core application of SE in CAD based on regional wall motion abnormalities. The study will standardize procedures, validate emerging signs, and integrate the new information with established knowledge, helping to build a next-generation SE lab without inner walls.


Assuntos
Cardiomiopatias/diagnóstico , Ecocardiografia sob Estresse/métodos , Ventrículos do Coração/diagnóstico por imagem , Isquemia Miocárdica/diagnóstico , Idoso , Cardiomiopatias/fisiopatologia , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/fisiopatologia , Estudos Prospectivos , Reprodutibilidade dos Testes
9.
World J Radiol ; 8(5): 460-71, 2016 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-27247712

RESUMO

Emergency physicians are required to care for unstable patients with life-threatening conditions, and thus must make decisions that are both quick and precise about unclear clinical situations. There is increasing consensus in favor of using ultrasound as a real-time bedside clinical tool for clinicians in emergency settings alongside the irreplaceable use of historical and physical examinations. B-mode sonography is an old technology that was first proposed for medical applications more than 50 years ago. Its application in the diagnosis of thoracic diseases has always been considered limited, due to the presence of air in the lung and the presence of the bones of the thoracic cage, which prevent the progression of the ultrasound beam. However, the close relationship between air and water in the lungs causes a variety of artifacts on ultrasounds. At the bedside, thoracic ultrasound is based primarily on the analysis of these artifacts, with the aim of improving accuracy and safety in the diagnosis and therapy of the various varieties of pulmonary pathologic diseases which are predominantly "water-rich" or "air-rich". The indications, contraindications, advantages, disadvantages, and techniques of thoracic ultrasound and its related procedures are analyzed in the present review.

10.
Echocardiography ; 32(10): 1463-70, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25865022

RESUMO

BACKGROUND: We prospectively assessed the incremental value of a pocket-sized echocardiography (PSE) device during cardiology consultations, in addition to physical examination, ECG reading, and chest x-ray. METHODS: A total of 443 consecutive patients (53% men), referred for bedside consultations, underwent physical examination, ECG, and CXR, followed by PSE examination. The physician completed a detailed questionnaire (clinical and echocardiographic data, scanning time, abnormal results). Receiver operating characteristic (ROC) curve analysis was generated to test the predictive discrimination value of the different methods. The incremental value of PSE examination compared to clinical visit alone or combined with ECG results was expressed as a global chi-square value. RESULTS: The PSE examination did not influence the definitive diagnosis in only 23.5% of cases, while 25.3% of the diagnoses were confirmed and verified by PSE. The clinical diagnosis was enriched by PSE in 21.9% of cases, and the diagnosis was changed in 26.2%. The area under curve (AUC) of physical examination + ECG results (sensitivity: 80%; specificity: 67%) was significantly higher than physical examination alone (sensitivity: 75%; specificity: 62%) (P < 0.0002), and the AUC of PSE results (sensitivity: 88%; specificity: 86%) was significantly higher than physical examination + ECG results (P < 0.0001). The PSE results, combined with clinical and ECG results, had a significant incremental diagnostic value during cardiology consultation when compared to the clinical visit alone or with ECG results (P < 0.0001). CONCLUSIONS: PSE had an incremental diagnostic value during bedside cardiology consultation, increasing the number of appropriate diagnoses and reducing the routine use of echocardiography.


Assuntos
Doenças Cardiovasculares/diagnóstico por imagem , Ecocardiografia/instrumentação , Exame Físico , Sistemas Automatizados de Assistência Junto ao Leito , Idoso , Eletrocardiografia , Feminino , Humanos , Itália , Masculino , Estudos Prospectivos , Radiografia Torácica , Sensibilidade e Especificidade , Inquéritos e Questionários
11.
J Cardiovasc Med (Hagerstown) ; 16(11): 736-42, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25022925

RESUMO

BACKGROUND AND AIMS: Intraventricular dyssynchrony has traditionally been studied by means of contraction delays between different myocardial segments. Recently, the discoordination of opposing wall contraction throughout the cardiac cycle has been proposed as a more faithful predictor of response. Aim of the current study was to evaluate which parameters - mechanical dyssynchrony or discoordination - normalize with left ventricular response to cardiac resynchronization therapy (CRT). METHODS: Cardiac mechanics were analysed before and after 6 months of CRT in 53 patients with left bundle branch block and advanced heart failure. Discoordination was quantified by means of the transverse strain discoordination index (TSDI) at basal and mid-ventricular segments; this index takes into account the percentage of time in the cardiac cycle in which cardiac deformation (transverse strain) of the two opposing walls occurs in noncoordinated directions. Dyssynchrony indices included septal to lateral peak-to-peak transverse strain delay and the standard deviation of time to peak tissue velocity in 12 mid-basal segments (Yu index). RESULTS: Around 63% of patients met the response criteria. Several baseline indices were predictive of reverse remodelling; TSDI at the mid-ventricular level demonstrated the best accuracy. Time from Q to peak velocity and strain tended to increase in all explored myocardial segments; despite a trend towards a decrease in septal-to-lateral strain delay, the latter decreased equally in responders and in nonresponding patients. Yu index decreased in responders more than in nonresponders, with borderline significance. Basal and medium TSDI remained unchanged in nonresponders and consistently normalized in patients who responded to CRT. The changes in TSDI were significantly correlated with improvements in left ventricular end-systolic volume and ejection fraction; the strongest correlation was observed for changes in TSDI measured at the mid-ventricular level. CONCLUSION: Left ventricular reverse remodelling after CRT is accompanied by the recoordination of opposite-wall contraction, as testified by changes in mid-ventricular TSDI, which also reveals as a very good predictor of response. On the contrary, changes of segmental peak-to-peak delays (dyssynchrony indices) fail to capture the complex nature of left ventricular response to CRT.


Assuntos
Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/terapia , Idoso , Bloqueio de Ramo/diagnóstico por imagem , Bloqueio de Ramo/terapia , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/fisiologia , Prognóstico , Resultado do Tratamento , Ultrassonografia , Remodelação Ventricular/fisiologia
12.
Indian J Psychol Med ; 36(3): 304-7, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25035557

RESUMO

BACKGROUND: Internet addiction (IAD) is one of the most diffuse mental disorders among adolescents. AIMS: The aim of our study was to evaluate the relationships between shame, self-efficacy and Internet addiction. MATERIALS AND METHODS: We recruited a total of 670 college students (males = 164, 24.5%; females = 506, 75.5%). The subjects were aged between 18 and 36 years (M = 20.93, SD = 2.52; males: M = 21.43, SD = 2.95; females: M = 20.76, SD = 2.35). We administered the following instruments: Experience of Shame Scale; Perceived Social Self-Efficacy Scale - Adult Version; Perceived Self-Efficacy in Handling Negative Emotions Scales; Internet Addiction Test. STATISTICS ANALYSIS: We applied multivariate analyses of variance (MANOVA), Pearson's correlation indices and linear regression analysis. RESULTS AND CONCLUSION: We found a significant inter-relation between Internet addiction and shame. Shame could be a good predictor of Internet addiction.

13.
J Cardiovasc Med (Hagerstown) ; 15(8): 674-82, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24978660

RESUMO

In continuation of a previous publication, the present study will take into account for each application and profile the clinical use, the minimal data settings, the echo data findings, the indications, the quality process, the accreditation requirements, educational tailored pathway contents and modalities. The aim of the present document was to define the main applications of echocardiography and to tailor for each application-derived profile, according with the previous definitions, requirements that clearly identify the indication, objective, clinical situation in which echocardiography is used, educational pathway and training, quality process and accreditation.


Assuntos
Cardiologia/educação , Competência Clínica , Ecocardiografia/normas , Educação Continuada/normas , Acreditação , Humanos , Itália , Qualidade da Assistência à Saúde
14.
J Cardiovasc Echogr ; 24(4): 103-113, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-28465917

RESUMO

Patients submitted to valve replacement with mechanical or biological prosthesis, may present symptoms related either to valvular malfunction or ventricular dysfunction from other causes. Because a clinical examination is not sufficient to evaluate a prosthetic valve, several diagnostic methods have been proposed to assess the functional status of a prosthetic valve. This review provides an overview of echocardiographic and Doppler techniques useful in evaluation of prosthetic heart valves. Compared to native valves, echocardiographic evaluation of prosthetic valves is certainly more complex, both for the examination and the interpretation. Echocardiography also allows discriminating between intra- and/or peri-prosthetic regurgitation, present in the majority of mechanical valves. Transthoracic echocardiography (TTE) requires different angles of the probe with unconventional views. Transesophageal echocardiography (TEE) is the method of choice in presence of technical difficulties. Three-dimensional (3D)-TEE seems to be superior to 2D-TEE, especially in the assessment of paravalvular leak regurgitation (PVL) that it provides improved localization and analysis of the PVL size and shape.

15.
J Med Internet Res ; 15(10): e225, 2013 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-24184961

RESUMO

BACKGROUND: The Internet Addiction Test (IAT) by Kimberly Young is one of the most utilized diagnostic instruments for Internet addiction. Although many studies have documented psychometric properties of the IAT, consensus on the optimal overall structure of the instrument has yet to emerge since previous analyses yielded markedly different factor analytic results. OBJECTIVE: The objective of this study was to evaluate the psychometric properties of the Italian version of the IAT, specifically testing the factor structure stability across cultures. METHODS: In order to determine the dimensional structure underlying the questionnaire, both exploratory and confirmatory factor analyses were performed. The reliability of the questionnaire was computed by the Cronbach alpha coefficient. RESULTS: Data analyses were conducted on a sample of 485 college students (32.3%, 157/485 males and 67.7%, 328/485 females) with a mean age of 24.05 years (SD 7.3, range 17-47). Results showed 176/485 (36.3%) participants with IAT score from 40 to 69, revealing excessive Internet use, and 11/485 (1.9%) participants with IAT score from 70 to 100, suggesting significant problems because of Internet use. The IAT Italian version showed good psychometric properties, in terms of internal consistency and factorial validity. Alpha values were satisfactory for both the one-factor solution (Cronbach alpha=.91), and the two-factor solution (Cronbach alpha=.88 and Cronbach alpha=.79). The one-factor solution comprised 20 items, explaining 36.18% of the variance. The two-factor solution, accounting for 42.15% of the variance, showed 11 items loading on Factor 1 (Emotional and Cognitive Preoccupation with the Internet) and 7 items on Factor 2 (Loss of Control and Interference with Daily Life). Goodness-of-fit indexes (NNFI: Non-Normed Fit Index; CFI: Comparative Fit Index; RMSEA: Root Mean Square Error of Approximation; SRMR: Standardized Root Mean Square Residual) from confirmatory factor analyses conducted on a random half subsample of participants (n=243) were satisfactory in both factorial solutions: two-factor model (χ²132= 354.17, P<.001, χ²/df=2.68, NNFI=.99, CFI=.99, RMSEA=.02 [90% CI 0.000-0.038], and SRMR=.07), and one-factor model (χ²169=483.79, P<.001, χ²/df=2.86, NNFI=.98, CFI=.99, RMSEA=.02 [90% CI 0.000-0.039], and SRMR=.07). CONCLUSIONS: Our study was aimed at determining the most parsimonious and veridical representation of the structure of Internet addiction as measured by the IAT. Based on our findings, support was provided for both single and two-factor models, with slightly strong support for the bidimensionality of the instrument. Given the inconsistency of the factor analytic literature of the IAT, researchers should exercise caution when using the instrument, dividing the scale into factors or subscales. Additional research examining the cross-cultural stability of factor solutions is still needed.


Assuntos
Comportamento Aditivo , Internet , Adolescente , Adulto , Análise Fatorial , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Psicometria , Reprodutibilidade dos Testes , Adulto Jovem
16.
Eur Heart J Cardiovasc Imaging ; 14(9): 858-64, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23288892

RESUMO

AIMS: Coronary flow reserve (CFR) assessment by transthoracic ultrasound of the left anterior descending (LAD) artery during dipyridamole stress echocardiography has been shown to predict prognosis in large unselected populations. Low values of CFR are strongly correlated with significant stenosis of the LAD; aim of the present study was to assess the prognostic impact of CFR in patients recovering from an acute coronary syndrome (ACS) with proven absence of LAD disease. METHODS: From an overall cohort of 325 patients with ACS who underwent a high-dose dipyridamole stress with combined assessment of CFR in the LAD and wall motion, 152 patients without LAD disease (stenosis <50%) were included in the present analysis; all subjects underwent coronary angiography and were subsequently monitored for the incidence of major cardiac events (MACE). RESULTS: After a median follow-up of 29 months, 22 patients developed MACE. Patients who experienced MACE differed from stable patients in terms of age, prevalence of diabetes, and CFR. Receiver-operating characteristic curve analysis defined a CFR <2.25 as the optimal cut point for prediction of MACE. Cox multivariable analysis for the prediction of MACE demonstrated independent predictive value only for CFR <2.25, smoking status, and number of stenotic vessels at angiogram. CONCLUSION: In high-risk patients with ACS, even in the absence of LAD disease, CFR significantly improves prediction of adverse events when added to standard evaluation. This finding supports a role of CFR in the risk stratification early after ACS and is in context with the concept that CFR reflects global atherosclerotic burden, endothelial dysfunction, and microvascular damage, more than just mirroring focal LAD disease.


Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/fisiopatologia , Dipiridamol , Ecocardiografia sob Estresse , Vasodilatadores , Síndrome Coronariana Aguda/terapia , Angiografia Coronária , Progressão da Doença , Feminino , Reserva Fracionada de Fluxo Miocárdico , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Resultado do Tratamento
17.
J Am Soc Echocardiogr ; 26(3): 270-7, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23261148

RESUMO

BACKGROUND: The aim of this study was to assess systolic left atrial (LA) reservoir function in patients with mitral stenosis (MS) using two-dimensional (2D) strain (ε) and strain rate imaging and its prognostic value in predicting atrial fibrillation (AF) at 4-year follow-up. METHODS: One hundred one asymptomatic patients with pure rheumatic MS and 70 healthy controls were evaluated using standard Doppler echocardiography (mitral valve area, mean gradient, systolic pulmonary pressure, LA width, LA volumes, and LA ejection fraction) and 2D speckle-tracking. RESULTS: LA width, volumes, and systolic pulmonary pressure were significantly increased (P < .0001), and LA 2D ε and strain rate were significantly impaired in patients with MS (P < .0001). At 4-year follow-up, 20 patients (20%) showed AF on standard electrocardiography or 24-hour Holter electrocardiography. Patients with MS who had AF were older than those who did not, without significant differences in LA dimensions, volumes, ejection fraction, and compliance index. Instead, atrial myocardial systolic 2D ε was significantly impaired in patients with events. On multivariate analysis (age, LA volume, planimetric mitral area, average annular Ea, and LA strain) the best predictor of AF was average LA peak systolic ε (coefficient, 0.43; SE, 0.098; P < .01), with an area under the receiver operating characteristic curve of 0.761 (SE, 0.085; 95% confidence interval, 0.587-0.888, P = .002) for a cutoff value of 17.4%. CONCLUSIONS: The results of 2D ε imaging are abnormal in patients with asymptomatic MS and predict AF at 4-year follow-up.


Assuntos
Fibrilação Atrial/diagnóstico por imagem , Ecocardiografia Doppler , Estenose da Valva Mitral/diagnóstico por imagem , Cardiopatia Reumática/diagnóstico por imagem , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Função do Átrio Esquerdo , Estudos de Casos e Controles , Eletrocardiografia Ambulatorial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Cardiopatia Reumática/complicações , Cardiopatia Reumática/fisiopatologia , Inquéritos e Questionários , Sístole
18.
Echocardiography ; 26(4): 431-40, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19054024

RESUMO

BACKGROUND: Several reports suggest that noninvasive measurements of coronary flow reserve (CFR) by use of echocardiography may support decision making in intermediate stenosis of the left anterior descending coronary artery (LAD). The aim of the present study was therefore to analyze the clinical outcome in patients with intermediate stenosis of LAD after deferral of coronary revascularization on the basis of noninvasive CFR measurement. METHODS: the study population included 280 patients with intermediate LAD stenosis (50-70% by angiography) (62.2 +/- 9.6 years). All the patients underwent transthoracic CFR assessment of LAD (after dipyridamole infusion) within 2 weeks from coronary angiography. If CFR of LAD was < or = 2, PTCA was recommended; if CFR was > 2, medical treatment was chosen. Primary end points were cardiac death, myocardial infarction, coronary revascularization procedure, and unstable angina. RESULTS: mean follow-up was 43 +/- 11 months (range 12-52 months). In 150 patients (53.6%) (CFR < or = 2), coronary artery revascularization was performed (PTCA group); the remaining 130 patients (46.4%) (CFR > 2) were medically treated (medical group). Survival from cardiac death was 94% in the PTCA group and 92.4% in the medical group (P = 0.56). As for all cardiac events, the Kaplan-Meier percentage survival from cardiac events was 88.3% in the PTCA group and 86.4% in the medical group (P = 0.36). CONCLUSIONS: even if CFR as a "stand-alone" diagnostic criterion suffers from several structural limitations, a combined strategy including also other clinical and instrumental measurements before undergoing interventional procedures could improve the cost-benefit practice, in particular, for the management of patients with intermediate LAD stenosis.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Reserva Fracionada de Fluxo Miocárdico , Revascularização Miocárdica/estatística & dados numéricos , Feminino , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento , Ultrassonografia
19.
Eur Heart J ; 28(22): 2738-48, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17959621

RESUMO

AIMS: In dilated cardiomyopathy (DCM), attenuation of left atrial (LA) booster pump function has been observed, and attributed both to altered LA loading conditions owing to left ventricular (LV) diastolic dysfunction and to LA involvement in the myopathic process. The aim of the present study was to detect LA systolic dysfunction in DCM using speckle-tracking two-dimensional strain echocardiography (2DSE), and to assess the effects of cardiac resynchronization therapy (CRT) on LA myocardial strain during 6 month follow-up. METHODS AND RESULTS: A total of 90 patients (aged, 52.4 +/- 10.2 years) with either idiopathic (n = 47) or ischaemic (n = 43) DCM underwent standard Doppler echo and 2DSE analysis of atrial longitudinal strain in the basal segments of LA septum and LA lateral wall, and in LA roof. The two groups were comparable for clinical variables (NYHA class: III in 72.2%; IV in 27.8%). LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. No significant differences were evidenced in Doppler transmitral inflow measurements. LA diameter and maximal volume were also similar between the two groups. Conversely, LA active emptying volume and fraction were both lower in patients with idiopathic DCM. Peak systolic myocardial atrial strain was significantly compromised in patients with idiopathic DCM compared with ischaemic DCM in all the analysed atrial segments (P < 0.001). At follow-up, 64 patients (71.1%) (37 idiopathic and 27 ischaemic) were responders, and 26 (28.9%) (10 idiopathic; 16 ischaemic) were non-responders to CRT (responder: decrease of LV end-systolic volume >15%). A significant improvement in LA systolic function was obtained only in patients with ischaemic DCM responders to CRT (P < 0.001). By multivariable analysis, in the overall population, it was found that ischaemic aetiology of DCM (beta-coefficient = 0.62; P < 0.0001) and positive response to CRT (beta-coefficient = 0.42; P < 0.01) were the only independent determinants of LA lateral wall systolic strain. CONCLUSIONS: Two-dimensional strain represents a promising non-invasive technique to assess LA atrial myocardial function in patients with DCM. LA pump and reservoir function at baseline and after CRT are more depressed in idiopathic compared with ischaemic DCM patients. Future longitudinal studies are warranted to understand further the natural history of LA myocardial function, the extent of reversibility of LA dysfunction with CRT, and the possible prognostic impact of such indexes in patients with congestive heart failure.


Assuntos
Fibrilação Atrial/terapia , Estimulação Cardíaca Artificial/métodos , Cardiomiopatia Dilatada/complicações , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Débito Cardíaco/fisiologia , Cardiomiopatia Dilatada/fisiopatologia , Estudos de Casos e Controles , Ecocardiografia Doppler/métodos , Ecocardiografia sob Estresse/métodos , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Sístole/fisiologia
20.
Eur Heart J ; 28(8): 1004-11, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17400608

RESUMO

AIMS: Cardiac resynchronization therapy (CRT) has become an attractive therapeutic option for patients with end-stage heart failure (HF). Currently, patients are selected for CRT on ECG and on echocardiographic criteria analysed at rest. Whether the physical effort may further increase myocardial dyssynchrony is not fully established. The aim of the study was to test by the use of Doppler myocardial imaging (DMI) if dynamic left ventricular (LV) dyssynchrony during physical effort may be a determinant of dynamic mitral regurgitation in patients with dilated cardiomyopathy and 'narrow' QRS. METHODS AND RESULTS: Sixty patients (62.3 +/- 8.3 years) with idiopathic dilated cardiomyopathy and narrow QRS duration ( < 120 ms) were selected. All the patients underwent standard Doppler echo, colour DMI, supine bicycle exercise stress echocardiography, and cardiopulmonary exercise testing. Cardiac synchronicity was assessed, at rest and at peak exercise, from measurements of time intervals (Ts) between the onset of the QRS complex and the peak myocardial systolic velocity, in a six-basal-six-mid-segmental model. Standard deviation of Ts of the 12 LV segments (Ts-SD-12) was also calculated. In baseline conditions, HF patients showed an LV ejection fraction of 30.1 +/- 4%, and a significant electromechanical delay (Ts-SD-12 > or = 34.4 ms) in 20 patients (33.3%). At peak of physical exercise, a significant electromechanical delay was detected in 35 patients (58.3%), whereas in 47 patients (78.3%) exercise-induced increase in mitral valve effective regurgitant orifice (ERO) was observed. By multivariable analysis, an independent positive association between changes in Ts-SD-12 and in mitral valve ERO (P < 0.0001), as well as an independent inverse correlation of the same changes in Ts-SD-12 with LV stroke volume (P < 0.0001) were detected. In addition, changes in Ts-SD-12 were also independent determinants of peak VO(2) (P < 0.0001) during cardiopulmonary exercise testing. CONCLUSION: Colour DMI is an effective technique for assessing the severity of regional delay in activation of LV walls in HF patients with narrow QRS both at rest and during stress test. The increase in LV dyssynchrony during exercise strongly correlates with the increase in mitral regurgitation severity and with the impairment of LV stroke volume.


Assuntos
Cardiomiopatia Dilatada/complicações , Exercício/fisiologia , Insuficiência da Valva Mitral/complicações , Disfunção Ventricular Esquerda/etiologia , Ecocardiografia Doppler em Cores , Ecocardiografia sob Estresse/métodos , Eletrocardiografia , Teste de Esforço/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico , Variações Dependentes do Observador , Consumo de Oxigênio , Disfunção Ventricular Esquerda/diagnóstico
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