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Pastore MC, Vannuccini F, Mandoli GE, Lisi M, Iuliano MA, Santoro A, Niglio FP, Diviggiano EE, Lorenz V, Montesi G, Cavigli L, Focardi M, D'Ascenzi F, Cameli M. Myocardial work and left heart deformation parameters across primary mitral regurgitation severity. Int J Cardiol 2024; 399:131772. [PMID: 38211675 DOI: 10.1016/j.ijcard.2024.131772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/22/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
AIMS Myocardial work (MW) estimation by pressure-strain loops using speckle tracking echocardiography (STE) has shown to evaluate left ventricular (LV) contraction overcoming the load-dependency limit of LV global longitudinal strain (GLS). This has proved useful in hemodynamic variation settings e.g. heart failure and valvular heart disease. However, the variation of MW and strain parameters across different stages of primary mitral regurgitation (MR) and its impact on symptoms, which was the aim of our study, has never been investigated. METHODS AND RESULTS Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery. Clinical evaluation, blood sample tests, ECG and echocardiography with STE and MW measurement were performed. Patients were then divided into groups according to MR severity. Differences among the groups and predictors of symptoms (as NYHA class≥2) were explored as study endpoints. Overall, 180 patients were enrolled (60 mild,60 moderate,60 severe MR). LV GLS and global peak atrial longitudinal strain (PALS) reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved, while global work efficiency (GWE) reduced, in patients with moderate and severe MR. Among echocardiographic parameters, global PALS emerged as the best predictor of NYHA class (p < 0.001;area under curve,AUC = 0.7). CONCLUSIONS MW parameters accurately describe the pathophysiology of MR, with initial attempt of LV increased contractility to compensate volume overload parallel to the disease progress, although with low efficacy, while global PALS is the most associated with the burden of MR symptoms.
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - Francesca Vannuccini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Lisi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Alma Iuliano
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Alfonso Santoro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Paolo Niglio
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Enrico Emilio Diviggiano
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Veronica Lorenz
- Division of Cardio-Thoracic Surgery, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Gianfranco Montesi
- Division of Cardio-Thoracic Surgery, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Palazzuoli A, Cartocci A, Pirrotta F, Tavera MC, Morrone F, Vannuccini F, Campora A, Ruocco G. Usefulness of Combined Ultrasound Assessment of E/e' Ratio, Pulmonary Pressure, and Cava Vein Status in Patients With Acute Heart Failure. Am J Cardiol 2024; 213:36-44. [PMID: 38104754 DOI: 10.1016/j.amjcard.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Congestion is poorly investigated by ultrasound scans during acute heart failure (AHF) and systematic studies evaluating ultrasound indexes of cardiac pulmonary and systemic congestion during early hospital admission are lacking. We aimed to investigate the prevalence of ultrasound cardiac pulmonary and systemic congestion in a consecutive cohort of hospitalized patients with AHF, analyzing the relevance of each ultrasound congestion component (cardiac, pulmonary, and systemic) in predicting the risk of death and rehospitalization. This is a prospective research study of a single center that evaluates patients with an AHF diagnosis who are divided according to the left ventricular ejection fraction in patients with heart failure with preserved ejection fraction or reduced ejection fraction. We performed a complete bedside echocardiography and lung ultrasound analyses within the first 24 hours of hospital admission. The ultrasound congestion score was preliminarily established by measuring the following parameters: cardiac congestion, which was defined as the contemporary presence of E/e' >15 and pulmonary systolic pressure >35 mm Hg and the pulmonary congestion, defined as the total B-line number >25 at the lung ultrasound performed in 8 chest sites; moreover, the systemic congestion was defined if the inferior vena cava (IVC) was >21 mm and if it was associated with a reduced inspiratory collapse >50%. We thoroughly assessed 230 patients and evaluated their results. Of these patients, 135 had heart failure with reduced ejection fraction and there were 95 patients with heart failure with preserved ejection fraction; 122 patients experienced adverse events during the 180-day follow-up. The receiver operating characteristic curve analysis showed that the tricuspid annular peak systolic excursion (TAPSE) (area under the curve [AUC] 0.34 [0.26 to 0.41], p <0.001), E/e' (AUC 0.62 [0.54 to 0.69], p = 0.003), and IVC (AUC 0.70 [0.63 to 0.77], p <0.001) were all significantly related to poor prognosis detection. The univariate Cox regression analysis revealed that cardiac congestion in terms of E/e' and pulmonary systolic pressure (hazard ratio [HR] 1.49 [1.02 to 2.17], p = 0.037), TAPSE (HR 0.90 [0.85 to 0.94], p <0.001), and systemic congestion (HR 2.64 [1.53 to 4.56], p <0.001) were all significantly related to the 180-day outcome. After adjustment for potential confounders, only TAPSE (HR 0.92 [0.88 to 0.98], p = 0.005) and IVC (HR 1.92 [1.07 to 3.46], p = 0.029) confirmed their prognostic role. The multivariable analysis of multiple congestion levels in terms of systemic plus cardiac (HR 1.54 [1.05 to 2.25], p = 0.03), systemic plus pulmonary (HR 2.26 [1.47 to 3.47], p <0.001), and all 3 congestion features (HR 1.53 [1.06 to 2.23], p = 0.02) revealed an incremental prognostic role for each additional determinant. In conclusion, among the ultrasound indexes of congestion, IVC and TAPSE are related to adverse prognosis, and the addition of pulmonary and cardiac congestion indexes increases the risk prediction accuracy. Our data confirmed that right ventricular dysfunction and systemic congestion are the most powerful predictive factors in AHF.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy.
| | - Alessandra Cartocci
- Department of Medical Biotechnology, and Postgraduate School of Cardiology, University of Siena, Siena, Italy
| | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy
| | - Maria Cristina Tavera
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy
| | - Francesco Morrone
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Francesca Vannuccini
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Alessandro Campora
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Gaetano Ruocco
- Cardiology Unit, "Buon Consiglio Hospital" Fatebenefratelli, Naples, Italy
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Palazzuoli A, Cartocci A, Pirrotta F, Vannuccini F, Campora A, Martini L, Dini FL, Carluccio E, Ruocco G. Different right ventricular dysfunction and pulmonary coupling in acute heart failure according to the left ventricular ejection fraction. Prog Cardiovasc Dis 2023; 81:89-97. [PMID: 37536484 DOI: 10.1016/j.pcad.2023.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Right ventricular (RV) dysfunction and pulmonary uncoupling are two acknowledged features associated with poor outcome, however few data defined RV adaptation across the different left ventricular ejection fraction (EF) cut-off. Additionally, less data are reported in patients with acute heart failure (AHF). AIMS The aim of present study was to analyse RV function in AHF patients presenting with either reduced or preserved EF. METHODS This is a multi-center observational study including 380 patients affected by AHF: 235 had AHF with reduced EF (AHFrEF) and 145 had AHF with preserved EF (AHFpEF). Pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), S' wave velocity, and the RV end-diastolic diameter (RVEDD) were measured by echocardiography. TAPSE/PASP and S'/PASP ratios were calculated as non-invasive surrogates of RV-pulmonary arterial coupling. RESULTS Factors associated with poor outcome were higher values of PASP (45 [40-55] mmHg vs 40 [35-46] mmHg; p < 0.001), RVEDD (44 [38-47] mm vs 37 [35-42] mm; p < 0.001), lower TAPSE values (17 [15-20] mm vs 20 [18-22] mm; p < 0.001) and S' wave (10 [8-12] cm/s vs 11 [10-13] cm/s; p < 0.001), reduced TAPSE/PASP (0.37 [0.29-0.47] vs 0.50 [0.40-0.60]; p < 0.001) and S'/PASP ratios (0.22 [0.18-0.28] vs 0.28 [0.22-0.34]; p < 0.001). However, the prognostic parameters differed according to the LVEF value: in AHFpEF S'/PASP between 0.22 and 0.29 and > 0.29 demonstrated a protective prognostic value (Respectively HR 0.29 (0.16-0.53), p < 0.001 and HR 0.22 [0.12-0.42], p < 0.001). Conversely, in AHFrEF, TAPSE <16 mm (HR 2.59 [1.67-4.03], p < 0.001), ICV > 21 mm (HR 1.17 [1.17-1.28], p = 0.001) and TAPSE/PASP <0.49 HR 1.92 [1.10-3.37], p = 0.023) were related to adverse outcome. CONCLUSIONS RV adaptation and RV pulmonary coupling differ in AHF according to the level of LVEF. S' wave, and S'/PASP are associated with adverse outcome in patients with preserved EF; reduced TAPSE and TAPSE/PASP are better prognostic predictors in patients with reduced EF.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy.
| | | | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy
| | - Francesca Vannuccini
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy
| | - Alessandro Campora
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy
| | - Luca Martini
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy
| | - Frank Loyd Dini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, S. Maria della Misericordia Hospital, University of Perugia, Italy
| | - Gaetano Ruocco
- Cardiology Unit, "Buon Consiglio Hospital" Fatebenefratelli, Naples, Italy
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Carluccio E, Dini FL, Correale M, Dattilo G, Ciccarelli M, Vannuccini F, Sforna S, Pacileo G, Masarone D, Scelsi L, Ghio S, Tocchetti CG, Mercurio V, Brunetti ND, Nodari S, Ambrosio G, Palazzuoli A. Effect of sacubitril/valsartan on cardiac remodeling compared with other renin-angiotensin system inhibitors: a difference-in-difference analysis of propensity-score matched samples. Clin Res Cardiol 2023:10.1007/s00392-023-02306-0. [PMID: 37733084 DOI: 10.1007/s00392-023-02306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In patients with heart failure with reduced ejection fraction (HFrEF), treatment with sacubitril-valsartan (S/V) may reverse left ventricular remodeling (rLVR). Whether this effect is superior to that induced by other renin-angiotensin system (RAS) inhibitors is not well known. METHODS HFrEF patients treated with S/V (n = 795) were compared, by propensity score matching, with a historical cohort of 831 HFrEF patients (non-S/V group) treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (RAS inhibitors). All patients were also treated with beta-blockers and shared the same protocol with repeat echocardiogram 8-12 months after starting therapy. The difference-in-difference (DiD) analysis was used to evaluate the impact of S/V on CR indices between the two groups. RESULTS After propensity score matching, compared to non-S/V group (n = 354), S/V group (n = 354) showed a relative greater reduction in end-diastolic and end-systolic volume index (ESVI), and greater increase in ejection fraction (DiD estimator = + 5.42 mL/m2, P = 0.0005; + 4.68 mL/m2, P = 0.0009, and + 1.76%, P = 0.002, respectively). Reverse LVR (reduction in ESVI ≥ 15% from baseline) was more prevalent in S/V than in non-S/V group (34% vs 26%, P = 0.017), while adverse LVR (aLVR, increase in ESVI at follow-up ≥ 15%) was more frequent in non-S/V than in S/V (16% vs 7%, P < 0.001). The beneficial effect of S/V on CR over other RAS inhibitors was appreciable across a wide range of patient's age and baseline end-diastolic volume index, but it tended to attenuate in more dilated left ventricles (P for interaction = NS for both). CONCLUSION In HFrEF patients treated with beta-blockers, sacubitril/valsartan is associated with a relative greater benefit in LV reverse remodeling indices than other RAS inhibitors.
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Affiliation(s)
- Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, S. Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy.
| | - Frank L Dini
- Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Michele Correale
- Department of Cardiology, University Hospital Foggia, Foggia, Italy
| | - Giuseppe Dattilo
- Department of Biomedical, Dental Sciences, and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Michele Ciccarelli
- Chair of Cardiology, Department of Medicine, Surgery and Dentistry, University of Salerno, Fisciano, Italy
| | - Francesca Vannuccini
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Stefano Sforna
- Cardiology and Cardiovascular Pathophysiology, S. Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Daniele Masarone
- Heart Failure Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Stefano Ghio
- Division of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Savina Nodari
- Department of Cardiology, University of Brescia and ASST Spedali Civili Di Brescia, Brescia, Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, S. Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
- CERICLET-Centro Ricerca Clinica E Traslazionale, University of Perugia, Perugia, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Siena, Italy
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Capponi G, Belli G, Giovannini M, Remaschi G, Brambilla A, Vannuccini F, Favilli S, Porcedda G, De Simone L. Supraventricular tachycardias in the first year of life: what is the best pharmacological treatment? 24 years of experience in a single centre. BMC Cardiovasc Disord 2021; 21:137. [PMID: 33722203 PMCID: PMC7958399 DOI: 10.1186/s12872-020-01843-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/27/2020] [Indexed: 11/22/2022] Open
Abstract
Background Supraventricular tachycardias (SVTs) are common in the first year of life and may be life-threatening. Acute cardioversion is usually effective, with both pharmacological and non-pharmacological procedures. However, as yet no international consensus exists concerning the best drug required for a stable conversion to sinus rhythm (maintenance treatment). Our study intends to describe the experience of a single centre with maintenance drug treatment of both re-entry and automatic SVTs in the first year of life. Methods From March 1995 to April 2019, 55 patients under one year of age with SVT were observed in our Centre. The SVTs were divided into two groups: 45 re-entry and 10 automatic tachycardias. As regards maintenance therapy, in re-entry tachycardias, we chose to start with oral flecainide and in case of relapses switched to combined treatment with beta-blockers or digoxin. In automatic tachycardias we first administered a beta-blocker, later combined with flecainide or amiodarone when ineffective. Results The patients’ median follow-up time was 35 months. In re-entry tachycardias, flecainide was effective as monotherapy in 23/45 patients (51.1%) and in 20/45 patients (44.4%) in combination with nadolol, sotalol or digoxin (overall 95.5%). In automatic tachycardias, a beta-blocker alone was effective in 3/10 patients (30.0%), however, the best results were obtained when combined with flecainide: overall 9/10 (90%). Conclusions In this retrospective study on pharmacological treatment of SVTs under 1 year of age the combination of flecainide and beta-blockers was highly effective in long-term maintenance of sinus rhythm in both re-entry and automatic tachycardias.
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Affiliation(s)
- Guglielmo Capponi
- Department of Health Sciences, Post-Graduate School of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Gilda Belli
- Department of Health Sciences, Post-Graduate School of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Department of Health Sciences, Post-Graduate School of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Giulia Remaschi
- Neonatology Department and Neonatal Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Alice Brambilla
- Cardiology Unit, Anna Meyer Children's University Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
| | - Francesca Vannuccini
- Cardiology Unit, Anna Meyer Children's University Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
| | - Silvia Favilli
- Cardiology Unit, Anna Meyer Children's University Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
| | - Giulio Porcedda
- Cardiology Unit, Anna Meyer Children's University Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy
| | - Luciano De Simone
- Cardiology Unit, Anna Meyer Children's University Hospital, Viale Gaetano Pieraccini 24, 50139, Florence, Italy.
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