Cavitation in left ventricular assist device patients: a potential early sign of pump thrombosis.

Mechanical ventricular support with left ventricular assist device (LVAD) has emerged as a durable and safe therapy, both as bridge-to-transplant (BTT) or destination therapy (DT), in patients with advanced heart failure (HF). However, the occurrence of pump thrombosis (PT) still represents a serious complication, especially when LVADs of first or second generation are implanted. During the latest years, some investigations have recognized the occurrence of cavitation, evidenced through transthoracic echocardiography (TTE), as a potential early and indirect sign of PT. In the present manuscript, we reviewed the available data on the occurrence of cavitation in LVAD patients as an early potential marker of PT, also presenting the hemodynamic mechanisms involved.

Patent foramen ovale-related complications in left ventricular assist device patients: a reappraisal for cardiovascular professionals.

Left ventricular assist device (LVAD) implantation is an important treatment option for patients with advanced heart failure. The presence of a patent foramen ovale (PFO) may elicit undesired consequences in LVAD patients: hypoxemia and paradoxical embolization. The variable physiological status of the patient with heart failure can make pre-LVAD implant identification of a PFO elusive. When identified pre- or intraoperatively, PFO is closed at time of LVAD implantation. In the case of delayed diagnosis, percutaneous PFO closure has proven to be a feasible and safe solution. As mechanical circulatory support gains prevalence, it is important to raise awareness of physiological implications of right-to-left shunt during mechanical circulatory support. We reviewed the diagnostic and therapeutic management of PFO in LVAD patients.

Hypoplasia of the posterior mitral leaflet: A rare cause of mitral regurgitation in adulthood.

Hypoplasia of the posterior mitral valve leaflet (PMVL) is a rare congenital heart disease, usually presenting in infancy and childhood with severe mitral regurgitation, either in isolation or associated with other cardiac lesions. We report a case of a 69-year-old woman with recent-onset exertional dyspnea and severe mitral regurgitation. Two- and three-dimensional transesophageal echocardiography showed severe hypoplasia of the PMVL, confirmed by surgical inspection.

Usefulness of intracardiac echocardiography with a mechanical probe for catheter-based interventions: a 10-year prospective registry.

BACKGROUND: The clinical outcome benefit of intracardiac echocardiography (ICE) with a mechanical probe during congenital heart disease interventions has not been fully investigated. We reported the long-term results of a prospective registry of interatrial shunt closure guided by mechanical ICE. METHODS: We enrolled 537 patients (mean age 48 ± 19.0 years, 378 females) submitted to ICE-aided procedures in a prospective registry over a 10-year period (September 2003-September 2013). All patients underwent transesophageal echocardiography (TEE) before the planned procedure. We evaluated (1) structure identification capability, (2) fossa ovale and interatrial septum component measurement, (3) procedure monitoring capability, (4) procedural and fluoroscopy times, and radiograph dose, (5) probe-related complications. RESULTS: ICE was successfully performed and was able to correctly identify the structures previously assessed by TEE in all patients. In 24 patients (4.5%), ICE allowed better anatomy definition than TEE. In 35 other patients (6.5%), ICE identified structures not observed by TEE, which led to change indications to interventions or the operative technique to be used. In 131 patients (24.4%), ICE evaluation led to change the planned device to be implanted. There was only one probe-related complication (0.2%). CONCLUSIONS: Mechanical ICE may offer a valid alternative to conventional TEE in guiding congenital heart disease interventional procedures.

Organization and Activity of Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging.

Background: The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy. Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website. Results: Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS). Conclusions: This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Stress Echocardiography in Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging.

Background: The Italian Society of Echography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand the volumes of activity, modalities and stressors used during stress echocardiography (SE) in Italy. Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved through an electronic survey based on a structured questionnaire, uploaded on the SIECVI website. Results: Data were obtained from 228 echocardiographic laboratories, and SE examinations were performed in 179 centers (80.6%): 87 centers (47.5%) were in the northern regions of Italy, 33 centers (18.4%) were in the central regions, and 61 (34.1%) in the southern regions. We annotated a total of 4057 SE. We divided the SE centers into three groups, according to the numbers of SE performed: <10 SE (low-volume activity, 40 centers), between 10 and 39 SE (moderate volume activity, 102 centers) and ≥40 SE (high volume activity, 37 centers). Dipyridamole was used in 139 centers (77.6%); exercise in 120 centers (67.0%); dobutamine in 153 centers (85.4%); pacing in 37 centers (21.1%); and adenosine in 7 centers (4.0%). We found a significant difference between the stressors used and volume of activity of the centers, with a progressive increase in the prevalence of number of stressors from low to high volume activity (P = 0.033). The traditional evaluation of regional wall motion of the left ventricle was performed in all centers, with combined assessment of coronary flow velocity reserve (CFVR) in 90 centers (50.3%): there was a significant difference in the centers with different volume of SE activity: the incidence of analysis of CFVR was significantly higher in high volume centers compared to low - moderate - volume (32.5%, 41.0% and 73.0%, respectively, P < 0.001). The lung ultrasound (LUS) was assessed in 67 centers (37.4%). Furthermore for LUS, we found a significant difference in the centers with different volume of SE activity: significantly higher in high volume centers compared to low - moderate - volume (25.0%, 35.3% and 56.8%, respectively, P < 0.001). Conclusions: This nationwide survey demonstrated that SE was significantly widespread and practiced throughout Italy. In addition to the traditional indication to coronary artery disease based on regional wall motion analysis, other indications are emerging with an increase in the use of LUS and CFVR, especially in high-volume centers.

Changing of Left Atrial Function Index in Symptomatic Patients with Patent Foramen Ovale After Device Closure.

BACKGROUND: Left atrial function is impaired in patients with patent foramen ovale. This study aimed to evaluate the role of left atrial function index in monitoring the course of left atrial function in a patient with patent foramen ovale before and after percutaneous closure. METHODS: We retrospectively reviewed the findings of consecutive patients evaluated in our tertiary center for patent foramen ovale closure to identify those subjects with acute ischemic stroke, transient ischemic attack, or radiological evidence of cerebral ischemic events (index event) who performed a complete echocardiography evaluation reporting evidence of patent foramen ovale between September 2004 and September 2018. The left atrial function was evaluated at baseline and then yearly using the left atrial function index. RESULTS: The cohort of 448 consecutive patients (mean age 43.4 ± 10.4 years, 257 males) was divided into 2 groups according to the temporal window between the index event and patent foramen ovale closure, defined as <1-year (216 patients) and ≥1-year (232 patients). Patients treated within 1 year from the index event maintained similar parameters of left atrial function and left atrial function index over the time, also after the interventional procedure. Conversely, patients treated after 1 year demonstrated a significant reduction of left atrial emptying function and maximal left atrial volume (P < .001 for all) compared to the basal values. The same parameters slightly increased after the percutaneous closure during the second year without reaching the basal values. CONCLUSIONS: Left atrial function index can be used as a non-invasive marker of atrial dysfunction severity in patients with patent foramen ovale before and after the interventional procedure.

Incomplete aneurysm coverage after patent foramen ovale closure in patients with huge atrial septal aneurysm: effects on left atrial functional remodeling.

BACKGROUND: Large devices are often implanted to treat patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with increase risk of erosion and thrombosis. Our study is aimed to assess the impact on left atrium functional remodeling and clinical outcomes of partial coverage of the approach using moderately small Amplatzer ASD Cribriform Occluder in patients with large PFO and ASA. METHODS: We prospectively enrolled 30 consecutive patients with previous stroke (mean age 36 +/- 9.5 years, 19 females), significant PFO, and large ASA referred to our center for catheter-based PFO closure. Left atrium (LA) passive and active emptying, LA conduit function, and LA ejection fraction were computed before and after 6 months from the procedure by echocardiography. The preclosure values were compared to values of a normal healthy population of sex and heart rate matched 30 patients. RESULTS: Preclosure values demonstrated significantly greater reservoir function as well as passive and active emptying, with significantly reduced conduit function and LA ejection fraction, when compared normal healthy subjects. All patients underwent successful transcatheter closure (25 mm device in 15 patients, 30 mm device in 6 patients, mean ratio device/diameter of the interatrial septum = 0.74). Incomplete ASA coverage in both orthogonal views was observed in 21 patients. Compared to patients with complete coverage, there were no differences in LA functional parameters and occlusion rates. CONCLUSIONS: This study confirmed that large ASAs are associated with LA dysfunction. The use of relatively small Amplatzer ASD Cribriform Occluder devices is probably effective enough to promote functional remodeling of the left atrium.

Left atrial dysfunction in patients with patent foramen ovale and atrial septal aneurysm scheduled for transcatheter closure may play a role in aura genesis.

BACKGROUND: It has been suggested that a left atrial (LA) dysfunction induced by large shunt and large atrial septal aneurysm (ASA) may act as a concurrent mechanism of arterial embolism in patients with patent foramen ovale (PFO) and prior stroke. We aimed to evaluate the potential contribution of this mechanism as trigger of migraine in patients with PFO. METHODS: From January 2007 to September 2009, we prospectively enrolled subjects with migraine who underwent percutaneous PFO closure. Echocardiographic parameter of LA dysfunction was evaluated: pre- and postoperative values were compared to values of different sex and heart rate matched populations: 30 healthy patients, 21 migraine patients without PFO (MwoPFO), and a group of 25 PFO patients without migraine (PFOwoM). The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine. RESULTS: Forty-five patients (38 females, mean age 38 +/- 6.7 years, mean MIDAS 35.8 +/- 4.7, and 28 patients with migraine with aura) fulfilled the inclusion criteria. After successful percutaneous closure (mean follow-up of 18.2 +/- 4.8 months), PFO closure remained complete in 95%; 35 of 45 patients reported resolution or amelioration of migraine (mean MIDAS score 12.3 +/- 8.8, P < 0.03). All patients with aura reported aura resolution. Preclosure values demonstrated significantly greater LA dysfunction, when compared with healthy and MwoPFO groups. Among patients in the study group, only patients with migraine with aura showed LA dysfunction comparable to PFOwoM patients. CONCLUSION: This study suggests that LA dysfunction probably does not contribute to migraine itself but may play a role in the genesis of aura symptoms.

Embolic implications of combined risk factors in patients with patent foramen ovale (the CARPE criteria): consideration for primary prevention closure?

BACKGROUND: Large patent foramen ovale (PFO), spontaneous right-to-left shunt, large atrial septal aneurysm (ASA), coagulation abnormalities, and prominent eustachian valve (EV) have all been independently suggested as risk factors for recurrent stroke. We sought to retrospectively evaluate risk of stroke and impact of transcatheter PFO closure in patients with concurrent large PFO, spontaneous right-to-left shunt, large ASA, coagulation abnormalities, and prominent EV. METHODS: Between March 2006 and October 2008, 36 (mean age 44 +/- 10.9 years, 28 females) out of 120 consecutive patients referred to our center for transcatheter PFO closure had concomitant diagnosis of (a) large PFO on transcranial Doppler (TCD) and transesophageal echocardiography (TEE), (b) spontaneous right-to-left shunt on TCD, (c) large ASA, (d) prominent EV, and (e) coagulation abnormalities. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative TEE and brain magnetic resonance imaging (MRI), with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. RESULTS: Compared to the remaining PFO population in the same period, patients with all five concomitant features had more ischemic brain lesions on MRI, previous history of recurrent stroke, more frequently a history of venous thromboembolism, and more severe migraine with aura. The concomitance of all the features confers the highest risk of recurrent stroke (OR 9.9, 3.0-18 [95% CI], P < 0.001). CONCLUSIONS: Despite its small sample size and nonrandomized retrospective nature, this is the first study to suggest that patients with concurrence of all the investigated characteristics have potentially a higher risk of stroke compared to controls. We thus propose the CARP criteria as a basis for further larger, longitudinal studies to assess the potential benefits of transcatheter closure in this patient subset in the absence of clinical recurrent stroke.

Ventricular-arterial coupling in patients with heart failure treated with cardiac resynchronization therapy: may we predict the long-term clinical response?

OBJECTIVE: To evaluate the effects of cardiac resynchronization therapy (CRT) on ventricular-arterial coupling (VAC) in patients with refractory congestive heart failure (HF), left bundle brunch block, and sinus rhythm. BACKGROUND: The ratio between arterial elastance (Ea) and left ventricular end-systolic elastance (Ees), the so-called VAC, defines the efficiency of the myocardium in pumping blood. METHODS: Seventy-eight patients were studied with echocardiography before CRT, and 1 year later. End-systolic elastance was calculated according to the method of Chen. Arterial elastance (ratio of the systolic pressure to the stroke volume), end-systolic volume (ESV), and quality of life (QoL) (Minnesota Living with Heart Failure Questionnaire) were assessed at the baseline and after 1 year. Patients with a reduction>15% of ESV or a decrease>33% in QoL score were considered responders to CRT. RESULTS: QRS duration and interventricular delay were significantly reduced with CRT compared with baseline (156+/-2 vs. 195+/-3 ms, P<0.001; and 25+/-2 vs. 55+/-3 ms, P<0.001, respectively). Arterial elastance/Ees decreased significantly on CRT (2.47+/-1.48 vs. 1.41+/-0.87, P<0.0001). The lowering of Ea/Ees was congruent to a decrease in intraventricular delay (83.1+/-55.7 vs. 28.4+/-49.5 ms, P<0.0001) and an increase in ejection fraction (26+/-6.3 vs. 36.9+/-8.0%, P<0.0001). Responders to CRT were 74 and 71% of the overall patient population, considering as endpoint QoL or ESV, respectively. The analysis of VAC showed a baseline cut-off value of 2, above which 88% and 69% of patients responded to CRT, considering as endpoint QoL or ESV, respectively. CONCLUSIONS: The non-invasive assessment of VAC may be proposed as an immediate, easy, and optimal tool for quantifying the effect of CRT in patients with HF.

Transcatheter interatrial shunt closure as a cure for migraine: can it be justified by paradoxical embolism-risk-driven criteria?

BACKGROUND: Some ongoing trials have suggested that closure of the patent foramen ovale (PFO) may reduce migraine symptoms. We sought to assess the safety and effectiveness of migraine treatment by means of PFO transcatheter closure using paradoxical embolism risk-driven criteria. METHODS: We enrolled 75 patients (48 women and 27 men, mean age 40 +/- 3.7 years) who were referred to our center over a 12-month period for a prospective study to evaluate severe disabling migraine, despite antiheadache therapy and the PFO. Migraine Disability Assessment Score (MIDAS) was used to assess the incidence of migraine headache and severity. Criteria for intervention included all of the following: basal shunt, curtain shunt pattern on transcranial Doppler, presence of interatrial septal aneurysm, 3 to 4 class MIDAS score, symptomatic significant aura, coagulation abnormalities, migraine refractory to conventional drugs. RESULTS: On the basis of the inclusion criteria, we shortlisted 20 patients (12 women, mean age 35 +/- 6.7 years, mean MIDAS score 38.9 +/- 5.8) for transcatheter closure of PFO and excluded the rest who were referred to the neurologist for medical therapy. The procedure was successful in all of the patients with no perioperative or in-hospital complications. After a mean follow-up of 10 +/- 3.1 months (range 6-14), all patients' migraine symptoms improved (mean MIDAS score 3.0 +/- 2.1, P < 0.03) with PFO complete closure in all patients on transesophageal and transcranial Doppler ultrasound. CONCLUSION: In this small pilot series, we adopted the criteria which in our opinion best reflected the risk of paradoxical embolism in these patients. By adopting the proposed criteria, primary transcatheter closure of the PFO resulted in a significant reduction in migraine.

Transcatheter intracardiac echocardiography-assisted closure of interatrial shunts: complications and midterm follow-up.

OBJECTIVE: It has been suggested that intracardiac echocardiography (ICE) improves the safety and effectiveness of transcatheter device-based closure of interatrial shunts, but the impact of this technique on midterm follow-up is unknown. We sought to prospectively evaluate midterm follow-up results of ICE-aided transcatheter closure of interatrial shunts in adults. METHODS: Over a 48-month period, we prospectively enrolled 140 consecutive patients (mean age 43 +/- 15. 5 years, 98 females) who had been referred to our center for catheter-based closure of interatrial shunts. All patients were screened with transesophageal echocardiography (TEE) before the operation. Patients who met the inclusion criteria underwent ICE study and attempted closure. Immediate success rates, predischarge occlusion rates, complication rates, as well as fluoroscopy and procedural times, patients' radiological exposure, midterm complication rates, and midterm occlusion rates were evaluated. RESULTS: One hundred patients out of 140 (71.4%) underwent an attempt at transcatheter closure. After ICE study and measurements, the TEE-planned device type and size was changed in 31 patients with patent foramen ovale whereas the TEE-planned device size was changed in 41 patients with atrial septal defect (globally 72%). Procedural success rate, predischarge occlusion rate, and complication rate were 99, 90.7, and 12%, respectively. On mean follow-up of 36.6 +/- 14.8 months the follow-up occlusion rate was 96.5%. No aortic erosion or device thrombosis was observed. CONCLUSIONS: ICE-guided interatrial shunt transcatheter closure is safe and effective and appears to have excellent midterm results thus avoiding the complications caused by device oversizing, such as aortic erosion and device thrombosis.

Impact of different final optimization techniques on long-term clinical outcomes of left main cross-over stenting.

BACKGROUND: The optimal final optimization technique to be used in patients after Cross Over Left main stenting remainsdebatable. AIM: We evaluate the impact of the post-optimization technique (POT), kissing balloon (KB) and the POT-side-POT techniques on both cardiovascular mortality and event-free survival in patients receiving left main (LM) cross-over stenting for an isolated/distal bifurcation LM disease. METHODS: Clinical and instrumental records of 128 consecutive patients (102 males, mean age 73.39 ±â€¯9.54 years old) with isolated distal/bifurcation LM disease and bypass surgery contraindications or refusal enrolled to receive LM cross-over stenting between the 1st January 2012 and the 1st January 2017 at two institutions: the Rovigo General Hospital (Rovigo, Italy) and the Alexandrovka Hospital University School of Medicine (Sofia, Bulgaria). Patients has been divided into three groups (POT, KB and POT-side-POT) according the optimal final optimization technique used while the 5-year cardiovascular mortality has been evaluated using the log-rank (Mantel-Cox) analysis. RESULTS: Baseline angiographic characteristics of the LM disease were mostly equivalent among the three groups. Over a global follow-up of 61.03 ±â€¯0.92 months, the rates of target vessel revascularization, acute myocardial infarction, and stent thrombosis, were not different among groups. Patients treated with POT had a slightly better long-term survival. CONCLUSIONS: None of these optimization techniques appeared to have clearly better long-term outcomes after LM Cross-over stenting in our retrospective study. POT resulted in a slightly better survival compared to Pot-sid-POT and KB.

Left atrial enlargement as a maker of significant high-risk patent foramen ovale.

Left atrial (LA) enlargement is a marker of LA cardiopathy and, in patients with patent foramen ovale (PFO), is associated with an increased risk of ischemic stroke. The primary study outcome was the comparison of LA diameter between patients undergoing percutaneous PFO closure versus those treated conservatively. The secondary endpoints were the association of LA diameter with the Risk of Paradoxical Emboli (ROPE) score and the presence of Atrial septal aneurysm (ASA) and Right-To-Left Shunt (RLS). Retrospective analysis of clinical and instrumental data of 1040 subjects referred to a single tertiary center for PFO evaluation and treatment. Seven hundred and nineteen patients were enrolled: 495 patients (closure group, mean RoPE score 7.6 ± 0.8) underwent PFO closure while 224 patients (control group, mean RoPE score 4.1 ± 0.9. p < 0.001) were left to medical therapy. Preoperative LA diameter was significantly larger in closure group and reduced from 44.3 ± 9.1 to 37.3 ± 4.1 mm (p = 0.01) 1 year after the procedure to the size of controls. A larger LA diameter was associated with permanent RLS, RLS curtain pattern, ASA presence and multiple ischemic brain lesions pattern at neuroimaging. A LA diameter ≥ 43 mm was a predictor a RoPEscore > 7. In our patients' cohort, LA diameter was associated with the clinic severity of PFO and RLS. The reversal of LA enlargement after PFO closure suggests a role for RLS to induce LA cardiopathy. LA enlargement has the potential to be considered per se as an indication to transcatheter PFO repair.

Persistent venous valves correlate with increased shunt and multiple preceding cryptogenic embolic events in patients with patent foramen ovale: an intracardiac echocardiographic study.

BACKGROUND: It has been suggested that prominent Eustachian valve (EV) and Chiari's network (CN) predispose to paradoxical embolism but their presence in patients with presumed paradoxical stroke is not always easily detectable by transesophageal echocardiography (TEE). We sought to prospectively assess the frequency of EV/CN as assessed by intracardiac echocardiography (ICE) in patients submitted to patent foramen ovale (PFO) transcatheter closure in order to investigate their role in determining shunt severity and risk of multiple paradoxical embolisms. METHODS: Over a 36-month period, we prospectively enrolled 98 consecutive patients (mean age 37 +/- 12.5 years, 68 females) with previous stroke referred to our center for PFO catheter-based closure. All patients underwent transcranial Doppler ultrasound (TC-D), TEE and ICE-guided transcatheter closure. RESULTS: After ICE study and measurements, a prominent EV or CN were diagnosed on ICE in 72 patients (73.4%), whereas in 45 (45.9%, P < 0.01) on TEE. Patients with EV/CN had more frequently a curtain pattern on TC-D, a larger right-to-left shunt, and recurrent cerebral paradoxical embolisms before closure. EV/CN and medium-large shunt on TEE were the strongest predictors of recurrent paradoxical embolisms. CONCLUSIONS: This study suggests that EV and CN have a deep impact on the pathophysiology of paradoxical embolism: EV and CN should be considered as adjunctive risk factors for paradoxical embolism in the decision-making process involving PFO patients.

The association of different right atrium anatomical-functional characteristics correlates with the risk of paradoxical stroke: an intracardiac echocardiographic study.

BACKGROUND: The contribution of different right atrium anatomical-functional characteristics to the risk of paradoxical stroke has not been extensively investigated, probably in part because of the limits of standard echocardiography. OBJECTIVE: We sought to assess, using intracardiac echocardiography (ICE), the right atrium anatomical-functional characteristics and their role in the pathophysiology of paradoxical embolism in a sample of patent foramen ovale (PFO) patients undergoing transcatheter PFO closure. METHODS: Over a 36-month period, we prospectively enrolled 114 consecutive patients (mean age 38+/- 10.5 years, 67 female) referred to our center for PFO catheter-based closure. On ICE study, all sensible characteristics other than PFO and mild ASA were recorded, including prominent EV or large CN, basal shunt without Valsalva maneuver, moderate to severe ASA, and multiperforated fossa ovalis. RESULTS: After TEE and ICE study and measurements, a prominent EV or CN was diagnosed on ICE in 73%, a basal shunt was present in 48%, a moderate to severe ASA in 47%, and a multiperforated FO in 24% of patients. A tight correlation between number of concurrent factors and proportion of patients with curtain pattern on TC Doppler, larger right-to-left shunt, recurrent cerebral paradoxical embolism before closure, and migraine with aura was clearly evident (r > or = 0.97). Basal shunt and concurrent > or = 3 anatomical functional right atrium characteristics resulted as independent predictors of recurrent paradoxical embolisms. CONCLUSIONS: Our data suggest that right atrium anatomical-functional characteristics other than PFO and mild ASA as assessed by ICE deeply affect the pathophysiology of paradoxical stroke.

Migraine-patent foramen ovale connection: role of prominent eustachian valve and large Chiari network in migrainous patients.

BACKGROUND: We postulated that eustachian valve (EV) and Chiari network (CN) play a role in the pathophysiology of both migraine and paradoxical embolism. We sought to prospectively investigate the potential role of EV/CN in migraine-patent foramen ovale (PFO) connection assessing their prevalence by intracardiac echocardiography (ICE) in patients with migraine submitted to PFO transcatheter closure. METHODS: Over a 24-month period, we prospectively enrolled 50 consecutive patients (mean age 37+/-12.5 years, 38 females) with previous stroke and migraine referred to our centre for PFO catheter-based closure. Migraine with aura (MwA) and migraine without aura (MwoA) were diagnosed according to the International Headache Society criteria and Migraine Disability Assessment Score (MIDAS). Patients who met the inclusion criteria for closure underwent ICE study and closure attempt. RESULTS: After ICE study, a prominent EV or CN were diagnosed on ICE in 41 patients (82%): 100% in MwA patients, 60% in MwoA patients (p<0.001) and in 55.5% of patients with no migraine. Patients with EV and CN had more frequently a curtain pattern on TC Doppler, a larger right-to-left shunt, more recurrent cerebral paradoxical embolism before closure, and a higher preoperative MIDAS score. Patients with EV/CN had a larger decrease in MIDAS score after closure. CONCLUSIONS: This study suggests that EV and CN have a deep impact on MwA and paradoxical embolism pathophysiology: EV, CN, and MwA should be considered as adjunctive risk factors for paradoxical embolism in the work-up of both symptomatic and asymptomatic PFO patients.

Usefulness of the Finet law to guide stent size selection in ostial left main stenting: Comparison with standard angiographic estimation.

BACKGROUNDS: Intravascular ultrasound has been suggested to optimize stent diameter and length in Left Main (LM) procedures, but in the real-world ostial LM stenting is often accomplished with angiography only guidance. The Finet law which regulates the fractal geometry of human bifurcation has the potential to increase the accuracy of stent-sizing. To retrospectively evaluating the impact on outcomes of the addition of Finet Law to standard quantitative coronary angiography (QCA) in guiding stent selection of ostial LM stenting compared to standard angiography estimation. METHODS: We retrospectively evaluated the clinical and instrumental records of patients with isolated ostial LM disease and bypass surgery contraindications or refusal as determined by the local Heart Team who received stenting from 1 January 2012 to 1 January 2017 at Rovigo General Hospital. Patients were discrimined on the basis of the addition to QCA angiographic evaluation of the Finet-law. RESULTS: Seventy-three patients (45 males, mean age 69.9 ±â€¯10.9 years old) ostial LM stenting, 36 patients using QCA and Finet law (QCA-Finet) and 37 using standard QCA angiographic (QCA-angio) evaluation of the vessel diameter. By QCA, vessel size, mean stent diameter at implantation and after post-dilatation were clearly bigger in the QCA+ Finet than QCA-angio (4.4 ±â€¯0.8 and 3.8 ±â€¯0.7, p < 0.001). At a mean follow-up of 5.0 ±â€¯0.4 years, cardiovascular mortality and cardiovascular events incidence were higher in QCA-angio compared to QCA+Finet group of patients. CONCLUSIONS: Our study suggested that adding the Finet law to standard angiography estimation of the LM stent size may improve long-term outcomes.

Incidence of extracerebral paradoxical embolisms in patients with intracardiac shunts.

BACKGROUND: Although extracerebral embolism accounts for 5-10% of all paradoxical embolisms, it still remains a ghostlike entity in cardiovascular pathophysiology. The aim of this brief report was to analyze the profile of patients with paradoxical extracerebral embolism and intracardiac shunts, and the role of shunt closure on the recurrence of extracerebral paradoxical embolism (EPE) in a population of patients evaluated for patent foramen ovale (PFO)/atrial septal defect (ASD) transcatheter closure. METHODS: From July 2003 to December 2006, 150 patients (mean age 51.4+/-15.1 years, range13-78 years, M/F=49/101) were planned for transcatheter closure of PFO/ASD at our institutional program of Adult Congenital Heart Disease Management. Clinical history and medical records of all patients were reviewed searching for association of PFO/ASD, stroke, and presumptive EPE. RESULTS: Association of PFO with presumptive EPE was found in nine patients (6%, mean age 40.1+/-14 years, M/F=3/6). Five patients had ST-elevation myocardial infarction (mean value of troponin was 15.3+/-2.1 ng/ml), while four patients had inferior limb acute ischemia. In patients with coronary embolism, coronary angiography was performed immediately after chest pain onset revealing normal coronary artery and only a mild hypokinesia. In patients with peripheral acute ischemia, early (>4 h from symptoms onset) angiography demonstrated normal main peripheral vessel and an embolic closure of popliteal artery (one patient), distal tibial artery (two patients), or peroneal artery (one patient) that normalized with heparin therapy in a few hours except in one patient. Migraine with aura was present in seven of nine patients. Cerebral MRI revealed previous ischemic areas in four of nine patients. Coagulation disorders were detected in six of nine patients. Echocardiography demonstrated a large to medium PFO in seven patients and a cribrosus ASD in two patients. CONCLUSION: Although a large study is required to assess optimal diagnosis and clinical implications of EPE, the clinical profile emerging from our study may help to identify some easy criteria of diagnosis in order to improve diagnosis and decrease the recurrence of such probably underestimated manifestations of PFO/ASD.