Stress Echocardiography and Strain in Aortic Regurgitation (SESAR protocol): Left ventricular contractile reserve and myocardial work in asymptomatic patients with severe aortic regurgitation.

OBJECTIVES: To analyze left ventricular (LV) myocardial deformation and contractile reserve (CR) in asymptomatic patients with severe aortic regurgitation (AR) at rest and during exercise, and their correlation with functional capacity. BACKGROUND: The natural history of chronic AR is characterized by a prolonged silent phase before onset of symptoms and overt LV dysfunction. Assessment of LV systolic function and contractile reserve has an important role in the decision-making of AR asymptomatic patients. METHODS: Standard echo, lung ultrasound, and LV 2D speckle tracking strain were performed at rest and during exercise in asymptomatic patients with severe AR and in age- and sex-comparable healthy controls. RESULTS: 115 AR patients (male sex 58.2%; 52.3 ± 18.3 years) and 55 controls were enrolled. Baseline LV ejection fraction was comparable between the groups. Resting LV global longitudinal strain (GLS) and myocardial work efficiency (MWE) were significantly reduced in AR (GLS-15.8 ± 2.8 vs -21.4 ± 4.4; P < .001). Patients with AR and CR- showed reduced resting LV GLS and MWE and increased B-lines. MWE was closely related to peak effort watts, VO2 , LV E/e', and B-lines, at a multivariable analysis. Both GLS and MWE were strong independent predictors of CR. A resting LV GLS cutoff of -12% differentiated CR+ and CR- (78% sensitivity and 84% specificity). CONCLUSIONS: The lower resting values of LV GLS and MWE in severe AR asymptomatic patients suggest an early subclinical myocardial damage that seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during stress.

Sudden cardiac death in the young: the bogeyman.

Sudden cardiac death in the young is a relatively uncommon but marked event usually related to congenital diseases or anomalies. Despite the prevalence of each condition being variable, most common causes include primary myocardial diseases and arrhythmic disorder, frequently with inheritance pattern. Sudden cardiac death is usually preceded by symptoms, thus making personal and family history fundamental for its prevention. Nevertheless, in more than 50% of cases, sudden cardiac death is the first manifestation of the disease. In this review, we describe the different causes of sudden cardiac death, their incidence, and currently used preventive strategies.

Extraction of stylet-driven pacing lead for left bundle branch area pacing.

We present a case where a stylet-driven pacing lead was successfully extracted from the left bundle branch area pacing, 10 months after implantation. The procedure was performed without any complications, using a standard stylet and employing gentle counterclockwise rotations of the lead body.

An unusual cause of ischemic stroke with successful thrombolysis.

A 63-year-old woman was admitted because of sudden ischemic hemyplegia promptly cleared up by intravenous (IV) recombinant tissue plasminogen activator. On subsequent 2-dimensional echocardiogram, we observed an extremely mobile homogeneous mass attached by a short stalk to ventricular insertion of anterolateral papillary muscle chordae tendineae. The mass was surgically removed. Gross anatomy showed a mass with a gelatinoids appearance formed on histology by a lining of hyperplastic endocardial cells covering a hypocellular stroma consistent with papillary fibroelastoma. Given the prompt clinical improvement with IV thrombolytic therapy, we postulate that cerebral artery occlusion was at least in part because of thrombotic material.

[Echocardiography in telemedicine: a possible solution for containing waiting lists in cardiology]. / L'ecocardiografia in telemedicina: una possibile soluzione per il contenimento delle liste d'attesa in cardiologia.

BACKGROUND: The length of waiting lists in Italy for outpatient cardiology investigations provided by the National Health System is a serious dysfunction. The shortage of physicians in hospitals makes it difficult to solve this problem by drawing on internal resources. The waiting list at Valduce Hospital in Como for outpatient echocardiographic examinations was 12 months at the beginning of 2018. Therefore, we experimented a new way to deal with this inefficiency. METHODS: Starting in February 2018, we have undertaken in Valduce Hospital a partnership between the Department of Cardiology and an external startup (Ecocardioservice LLC) which guarantees for outpatients on-site performance by sonographers of echocardiographic examinations that are subsequently reported remotely via telemedicine by experienced cardiologists. RESULTS: From February 12, 2018 to July 7, 2022, 20 782 examinations were carried out by this mode. The waiting list was reduced from 12 months to 15-20 days. A new diagnosis or a significant change in pre-existing pathology were detected in 3466 patients well in advance of previous timelines. In 5640 patients we found a known stable pathology. Of the 8926 patients with pathologic examination, 3706 patients were taken over by the Cardiology Department for subsequent investigations, possible hospitalization and, when necessary, interventional or cardiac surgical procedures on an elective basis in 2636 cases (71%) and on an urgent basis in 1070 cases (29%). CONCLUSIONS: In our experience, a system in which echocardiograms are performed on-site by sonographers and then reported in telecardiology by cardiologists outside the facility makes it possible to meet the demands of the local area and free up internal resources. This organization allowed to bring outpatients waiting lists for echocardiography back within acceptable limits and to intercept early a significant proportion of patients with need for further investigations or procedures.

Clinical Course and Risk Factors for In-Hospital Mortality of 205 Patients with SARS-CoV-2 Pneumonia in Como, Lombardy Region, Italy.

The aim of this study is to explore risk factors for in-hospital mortality and describe the effectiveness of different treatment strategies of 205 laboratory-confirmed cases infected with SARS-CoV-2 during the Lombardy outbreak. All patients received the best supportive care and specific interventions that included the main drugs being tested for repurposing to treat COVID-19, such as hydroxychloroquine, anticoagulation and antiviral drugs, steroids, and interleukin-6 pathway inhibitors. Clinical, laboratory, and treatment characteristics were analyzed with univariate and multivariate logistic regression methods to explore their impact on in-hospital mortality. Univariate analyses showed prognostic significance for age greater than 70 years, the presence of two or more relevant comorbidities, a P/F ratio less than 200 at presentation, elevated LDH (lactate dehydrogenase) and CRP (C-reactive protein) values, intermediate- or therapeutic-dose anticoagulation, hydroxychloroquine, early antiviral therapy with lopinavir/ritonavir, short courses of steroids, and tocilizumab therapy. Multivariable regression confirmed increasing odds of in-hospital death associated with age older than 70 years (OR 3.26) and a reduction in mortality for patients treated with anticoagulant (-0.37), antiviral lopinavir/ritonavir (-1.22), or steroid (-0.59) therapy. In contrast, hydroxychloroquine and tocilizumab have not been confirmed to have a significant effect in the treatment of SARS-CoV-2 pneumonia. Results from this real-life single-center experience are in agreement and confirm actual literature data on SARS-CoV-2 pneumonia in terms of both clinical risk factors for in-hospital mortality and the effectiveness of the different therapies proposed for the management of COVID19 disease.

Cardiac Tumors.

Cardiac tumors (CTs) are extremely rare, with an incidence of approximately 0.02% in autopsy series. Primary tumors of the heart are far less common than metastatic tumors. CTs usually present with any possible clinical combination of heart failure, arrhythmias, or embolism. Echocardiography remains the first diagnostic approach when suspecting a CT which, on the other side, frequently appears unexpectedly during an echocardiographic examination. Yet, cardiac tomography and especially magnetic resonance imaging may offer several adjunctive opportunities in the diagnosis of CTs. Early and exact diagnosis is crucial for the following therapy and outcome of CTs.

Multimodality Imaging of Left Ventricular Clefts in an Asymptomatic Teenager.

Left ventricular clefts (LVCs) are defined as deep, tight blood-filled invaginations within the ventricular myocardium localized predominantly in the basal posterior septum and LV-free wall. Usually, they are asymptomatic and incidentally discovered during diagnostic imaging procedures. LVC has been reported both in healthy volunteers and in patients affected with hypertrophic cardiomyopathy. Clinicians should be able to recognize LVC and to distinguish this entity from other myocardial wall defects with different pathological profile and clinical significance. We describe a case of multimodality imaging of multiple septal myocardial clefts in an asymptomatic teenager.

Molecular evidence of Listeria monocytogenes infection relapse in a severe case of endocarditis.

Introduction. Endocarditis is a rare complication of bacteraemia due to Listeria monocytogenes and is characterized by a high fatality rate (37-50 %). Recurrent infection by Listeria monocytogenes occurs even more rarely. Case presentation. We report a case of recurrent Listeria monocytogenes infection that resulted in severe endocarditis in a 66-year-old patient with an aortic valve prosthesis. Relapse was confirmed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST). Conclusion. Our case highlights that the molecular subtyping approach is an important tool for the detection of microbial reinfections and for the support of clinical diagnosis.

Short-term air pollution exposure and cardiovascular events: A 10-year study in the urban area of Como, Italy.

BACKGROUND: In the last years several studies have investigated the effects of some air pollutants on cardiovascular diseases (CVD), but the results are not conclusive. Aim of this study was to investigate the association between short-term exposure to ambient air pollution and CVD events in a long-term observational period. METHODS: All CVD events (myocardial infarction - MI and ischemic stroke - IS) which occurred in residents of Como between January 2005 and December 2014 were included. Demographics and main vascular risk factors were registered for each patient. Principal meteorological variables and four ambient particles (O3, SO2, NO2, PM10) were recorded. Statistical analysis was performed using linear regression (GLM) and a generalized additive model (GAM) estimating Poisson distribution and adjusted for the main risk factors and ambient meteorological variables. RESULTS: A total of 4110 events were registered with a mild prevalence of MI (51.6%). In GLM analysis we observed a continuative association between CVD events and SO2 (p<0.05), while PM10 was associated with CVD occurrences at two-day lag time (p<0.05). Using GAM we observed a positive association between CVD and PM10 at the same day and at three- and four-day lag time with HRs ranging between 1.025 and 1.039 (p<0.001). These results were observed for both MI and IS, with an earlier effect for MI than for IS. CONCLUSIONS: These data confirm a possible association between some ambient air pollutants and CVD events, precisely MI and IS, with different temporal and cumulative effect.

Prevalence of previously undiagnosed abdominal aortic aneurysms in the area of Como: the ComoCuore "looking for AAA" ultrasonography screening.

The prognosis for abdominal aortic aneurysm (AAA) rupture is poor. Long-term follow-up of population-based randomized trials has demonstrated that ultrasound (US) screening for abdominal aortic aneurysms (AAAs) measuring 3 cm or greater decreases AAA-related mortality rates and is cost-effective. We though to prospectively perform during a 26-month period a limited US examination of the infrarenal aorta in volunteers of both gender aged 60-85 years without history of AAA living in the area of Como, Italy. From September 2010 to November 2013 ComoCuore, a no-profit nongovernmental association, enrolled 1555 people (aged 68.8 ± 6.8 years; 48.6 % males). Clinical data and a US imaging of the aorta were collected for each participant. AAA was found in 22 volunteers (1.4 %) mainly males (2.5 % in males vs. 0.4 % in females p = 0.005). Overall, the prevalence of cardiovascular risk factors was higher in patients with vs. without AAA (mean 2.9 ± 3.0 vs. 1.4 ± 1.0 respectively, p < 0.0001). Independent predictors of AAA on multivariate analysis were age (OR 1.14, 1.06-1.22; p < 0.0001), male gender (OR 8.23, 1.79-37.91; p = 0.007), and both current (OR 4.98, 1.57-15.79; p = 0.007) and previous smoking (OR 2.76, 1.12-8.94; p = 0.03). Our study confirms the feasibility of one time US screening for AAA in a large cohort of asymptomatic people. Independent predictors of AAA were male sex, older age and a history of smoking. Accordingly to recent data the prevalence of AAA seems to be declining, maybe due to a reduction of smoking in Italy.

Long term follow-up of "full metal jacket" of de novo coronary lesions with new generation Zotarolimus-eluting stents.

BACKGROUND: Diffuse coronary artery disease treatment still remains a challenge for interventional cardiologists and cardiac surgeons. There are few data on full metal jacket (FMJ) stenting, especially with new-generation drug-eluting stents. We aimed to assess the efficacy and safety of FMJ with new-generation Zotarolimus-eluting stents (n-ZES). METHODS AND RESULTS: All patients who underwent FMJ with n-ZES (≥60mm stent length) in eleven Italian interventional centers participating in the Clinical Service® project were included in this analysis. The project population consisted of 120 patients and 122 lesions. Mean age was 67±10years and 95 (79.2%) patients were male. A chronic total occlusion was present in 34 lesions (27.9%). The number of stents implanted per lesion was 2.9±0.8, and the diameter of the stents was 3.0±0.5mm. Predilation and post-dilatation were performed in 107 (87.7%) and 92 (75.4%) patients, respectively. At 41±21month follow-up there were 2 patients with subacute definite stent thrombosis, 6 patients (5.0%) had cardiac death and 5 patients (4.2%) had non-fatal myocardial infarction. Seven patients (5.8%) underwent clinically-driven target lesion revascularization. Fourteen patients (11.7%) had at least one major adverse cardiac event. CONCLUSION: The treatment of diffuse coronary artery disease with FMJ stenting with n-ZES appears to be effective and safe. Late and very-late ST does not seem to be an issue and the rate of restenosis and of major cardiac adverse events after more than 3-year follow-up is rather low.

Prognostic value of electrocardiograms, ventricular late potentials, ventricular arrhythmias, and left ventricular systolic dysfunction in patients with Duchenne muscular dystrophy.

Myocardial involvement is a common finding in patients with Duchenne-type muscular dystrophy (DMD). Nevertheless, the prognostic values of standard electrocardiogram (ECG), ventricular arrhythmias, ventricular late potentials (LPs), and left ventricular (LV) systolic dysfunction have not been extensively investigated. Eighty-four patients with DMD (aged 18.6 +/- 4.8 years) underwent standard and signal-averaged electrocardiography, 24-hour Holter monitoring, and echocardiography. The prevalence of electrocardiographic abnormalities, frequent ventricular premature complexes, LPs, and LV systolic dysfunction was 71%, 32%, 28%, and 35%, respectively. Median follow-up was 76 months (range 5 to 106). The mortality rate in the follow-up period was 27%. The typical DMD electrocardiographic alterations, ventricular arrhythmic pattern, and LPs were not predictors of mortality. In contrast, the presence of LV systolic dysfunction detected on echocardiography was a powerful predictor of mortality in the follow-up period (p = 0.013, hazard ratio 3.14, 95% confidence interval 1.27 to 7.79). Thus, echocardiographic assessment of LV systolic dysfunction provides prognostic information in patients with DMD. Electrocardiographic alterations, ventricular arrhythmias, and LPs have no prognostic value in predicting mortality in these patients.

Cardiopulmonary resuscitation training in high-school adolescents by distributing personal manikins. The Como-Cuore experience in the area of Como, Italy.

BACKGROUND: Most witnessed out-of-hospital cardiac arrests (OHCA) do not receive bystander cardiopulmonary resuscitation (CPR). The incidence of laypersonsO' CPR could be increased by widespread training. We evaluated the effect of distribution of CPR educational material to high-school students in the area of Como, Italy. METHODS AND RESULTS: From January 2008 to October 2009, we distributed 3200 resuscitation manikins to pupils (62% boys, mean age 16.5 ± 0.8 years) at 20 high schools in the area of Como. All students received a kit including a personal manikin and a 27 min educational digital video disc. Furthermore, they received 40 min school training in the fundamental maneuvers of CPR utilizing the manikin. Afterwards, they were encouraged to train friends and relatives at home (second tier), utilizing the kit. Eight months later, a questionnaire was randomly submitted to a sample of 600 students (19% of the distributed manikins). The 600 kits had been used to train 1058 from the second tier (mean, 1.77 persons per pupil; 95% confidence interval 1.62-1.93). Boys had a significantly lower multiplier effect than girls: 1.45 ± 1.01 vs. 2.26 ± 1.89 (P < 0.0001). Ninety-five percent of pupils considered themselves sufficiently trained in CPR and 62.3% declared their availability to effectively practice CPR if necessary. One pupil performed an effective CPR during her mother's OHCA. CONCLUSIONS: CPR training can be disseminated using personal manikins distributed to pupils. Most students declared themselves trained and willing to start bystander CPR if necessary. One successful CPR was effectively performed.

Ventricular dysfunction and number of non compacted segments in non compaction: non-independent predictors.

BACKGROUND: Isolated ventricular noncompaction (IVNC) is characterized by multiple prominent trabeculations and deep intertrabecular recesses. Some reports prove that the chronic heart failure may occur in approximately half of the patients. In this report we investigate the correlation between the number of non compacted segments and entity of systolic dysfunction from the registry and subregistries of the SIEC. METHOD: To identify the correlation between ventricular dysfunction and number of segments involved in non compaction we evaluated a consecutive series of 238 patients affected by non compaction, from the SIEC (Società Italiana di Ecografia Cardiovascolare) registry. The average age of patients was 41.5 years (range: 1-92 years), 137 were males and 101 females. In 122 cases we found ventricular systolic dysfunctions with an EF average of 34.6%. The number of affected segments by non-compactation and diastolic dysfunction were found to be non-independent predictors of LV systolic dysfunction. CONCLUSION: From the analyses we carried out, it seems that ventricular dysfunction seems to be completely independent from the segment numbers of non compacted segments.