The relationship between mitral valve prolapse and thoracic skeletal abnormalities in clinical practice: a systematic review

BACKGROUND

Literature data suggest high inter-study variability in mitral valve prolapse (MVP) prevalence among individuals with thoracic skeletal abnormalities (TSA). This systematic review aimed at estimating the overall prevalence of MVP in individuals with the most common TSA, including not only the oldest studies (before the year 2000) but also the most recent ones (after the year 2000).

METHODS

PubMed and EMBASE databases were systematically reviewed in November 2023. Studies assessing the relationship between MVP and TSA and estimating the MVP prevalence in pectus excavatum (PE), pectus carinatum (PC), scoliosis, straight back syndrome (SBS) and Marfan syndrome (MS) were included. There was no limitation on time periods.

RESULTS

Twenty-five studies with a total of 2800 patients (27.9 ± 13.9 years, 48.2% females) were analyzed. The highest prevalence of MVP was observed among MS patients (47.3%), while the lowest was detected in PC individuals (23%). Prevalence of MVP was similar among PE (30.8%), scoliosis (26.3%) and SBS (25.5%) patients. When dividing the studies on the basis of temporal period, the average MVP prevalence was approximately two-fold higher in all studies conducted before the year 2000 in comparison with the most recent ones, regardless of TSA type. This discrepancy might be primarily ascribed to relevant differences in the echocardiographic criteria employed for MVP diagnosis before (less specific) and after (more specific) the year 2000, respectively.

CONCLUSIONS

The estimated MVP prevalence in TSA individuals is significantly higher than that observed in the general population. Individuals with TSA should be screened for MVP presence on transthoracic echocardiography.

Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes

Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.

TAPSE/SPAP ratio stratifies mortality risk in mild-to-moderate idiopathic pulmonary fibrosis

BACKGROUND: Due to paucity of literature data, we aimed at evaluating the prognostic role of the ratio of tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (SPAP) in idiopathic pulmonary fibrosis (IPF) patients without severe pulmonary hypertension and at assessing its correlation with effective arterial elastance index (EaI). METHODS: Multi-instrumental data obtained in 60 IPF patients (73.2 ± 6.8 years) and 60 matched controls were retrospectively analysed. Primary endpoint was all-cause mortality, while secondary endpoint was the composite of all-cause mortality and re-hospitalisations for all-causes over medium-term follow-up. RESULTS: ;At baseline, TAPSE/SPAP was significantly lower in patients with IPF than in controls (0.36 ± 0.25 vs. 0.77 ± 0.18 mm/mmHg; P < 0.001). TAPSE/SPAP was inversely correlated with EaI (r = -0.96) in IPF patients. During follow-up (3.5 ± 1.5 years), 21 patients died and 25 were re-hospitalised due to cardiopulmonary causes. TAPSE/SPAP was independently associated with both primary (HR 0.79, 95%CI 0.65-0.97) and secondary (HR 0.94, 95%CI 0.92-0.97) endpoints. A TAPSE/SPAP ratio of <0.20 and <0.44 mm/mmHg showed the greatest sensitivity and specificity for predicting primary (AUC 0.98) and secondary (AUC 0.99) endpoints, respectively. CONCLUSIONS: TAPSE/SPAP is a strong predictor of adverse outcomes in mild-to-moderate IPF. The strong correlation between TAPSE/SPAP and EaI might be an expression of a systemic fibrotic process which involves the heart, lungs and circulation.

The effect of gestational diabetes mellitus on carotid artery intima-media thickness in and after pregnancy: a systematic review and meta-analysis

AIMS

The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA) intima-media thickness (IMT) is still controversial. This systematic review and meta-analysis was performed to assess the correlation between GDM and CCA-IMT in and after pregnancy.

METHODS

PubMed and EMBASE databases were systematically reviewed on April 2023. Studies measuring CCA-IMT in both pregnant women with GDM and women with previous history of GDM (pGDM) vs. healthy controls were included. The subtotal and overall standardized mean differences (SMDs) of CCA-IMT were calculated using the random-effect model.

RESULTS

Nineteen studies with a total of 302 GDM and 861 pGDM women were analyzed. The average value of CCA-IMT measured in GDM/pGDM (0.59 ± 0.12 mm) was slightly increased in comparison to the accepted reference limits of IMT according to age classes. Substantial heterogeneity was detected for the studies involving both GDM and pGDM women, with an overall statistic I2 of 86.0% (p < 0.001). Large SMDs were obtained for the studies conducted on both GDM and pGDM women, with an overall SMD of 0.89 (95%CI 0.63-1.15, p < 0.001). Egger's test for a regression intercept gave a p-value of 0.37, indicating no publication bias. On meta-regression analysis, all potential confounders (number of patients, age at pregnancy, body mass index, measuring time, follow-up duration and GDM criteria) were not significantly associated with effect modification.

CONCLUSIONS

GDM in and after pregnancy is independently associated with subclinical atherosclerosis. The association between GDM and carotid remodeling is potentially mediated by the longstanding underlying risk.

The Influence of Anthropometrics on Cardiac Mechanics in Healthy Women With Opposite Obesity Phenotypes (Android vs Gynoid)

BACKGROUND

The possible influence exerted by mechanical factors and/or compressive phenomena on myocardial strain parameters in healthy individuals with opposite obesity phenotypes (android vs gynoid) has never been previously investigated. Accordingly, we aimed at evaluating the relationship between anthropometrics, such as the waist-to-hip ratio (WHR), modified Haller index (MHI, the ratio of chest transverse diameter over the distance between sternum and spine), and epicardial adipose tissue (EAT), and left ventricular (LV)-global longitudinal strain (GLS), in healthy women with opposite obesity phenotypes (android vs gynoid).

METHODS

Forty healthy women with obesity (body mass index (BMI) ≥30 Kg/m2) and WHR ≥0.85 ("android group") (52.5±13.2 yrs), 40 age- and BMI-matched healthy women with obesityand WHR <0.78 ("gynoid group") (49.8±13.4 yrs) and 40 age-matched healthy women without obesity (BMI <30 Kg/m2) (controls) (50.3±12.5 yrs) were retrospectively analyzed. All women underwent transthoracic echocardiography implemented with echocardiographic strain analysis of all cardiac chambers. Correlation between LV-GLS and anthropometrics (WHR, MHI, and EAT) was assessed in both groups of obese women. Age, WHR, homeostasis model assessment for insulin resistance (HOMA-IR), and left ventricular mass index (LVMi) were included in the logistic regression analysis performed for evaluating the independent predictors of reduced LV-GLS magnitude (less negative than -20%) in women with android obesity.

RESULTS

Compared to the other groups of women, those with android obesity were found with significantly greater LVMi, higher LV filling pressures, and lower biventricular and biatrial deformation indices. A strong inverse correlation between LV-GLS and all anthropometrics (WHR, MHI, and EAT) was demonstrated in both groups of women with obesity. Univariate logistic regression analysis revealed that WHR (OR 1.58, 95%CI 1.22-2.03, p<0.001) and LVMi (OR 1.09, 95%CI 1.02-1.16, p=0.006) were independently correlated with LV-GLS impairment in women with android obesity. On multivariate logistic regression analysis, the WHR maintained a statistically significant association with the above-mentioned outcome (OR 1.68, 95%CI 1.14-2.48, p=0.009). Receiver operating characteristic (ROC) curve analysis showed that a WHR value ≥1.01 had 93% sensitivity and 100% specificity for detecting LV-GLS impairment in women with android obesity (AUC=0.98; 95%CI 0.96-1.00).

CONCLUSIONS

Anthropometrics may strongly influence cardiac mechanics in healthy women with obesity. The WHR is associated with reduced LV-GLS magnitude in healthy women with android obesity, independent of age, glycometabolic status, and LV size.

Influence of gestational diabetes mellitus on subclinical myocardial dysfunction during pregnancy: A systematic review and meta-analysis

OBJECTIVE

The correlation between gestational diabetes mellitus (GDM) and subclinical myocardial dysfunction has been poorly investigated. Accordingly, we performed a meta-analysis to examine the influence of GDM on left ventricular (LV) global longitudinal strain (GLS), assessed by speckle tracking echocardiography (STE), during pregnancy.

STUDY DESIGN

All echocardiographic studies assessing conventional echoDoppler parameters and LV-GLS in GDM women vs. healthy controls, selected from PubMed and EMBASE databases, were included. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment of Case-Control Studies. The subtotal and overall standardized mean differences (SMDs) of LV-GLS were calculated using the random-effect model.

RESULTS

The full-texts of 10 studies with 1147 women with GDM and 7706 pregnant women without diabetes were analyzed. GDM women enrolled in the included studies were diagnosed with a small reduction in LV-GLS in comparison to controls (average value -19.4 ± 2.5 vs -21.8 ± 2.5 %, P < 0.001) and to the accepted reference values (more negative than -20 %). Substantial heterogeneity was detected for the included studies, with an overall statistic value I2 of 94.4 % (P < 0.001). Large SMDs were obtained for the included studies, with an overall SMD of -0.97 (95 %CI -1.32, -0.63, P < 0.001). Egger's test for a regression intercept gave a P-value of 0.99, indicating no publication bias. On meta-regression analysis, all moderators and/or potential confounders (age at pregnancy, BMI, systolic blood pressure and ethnicity) were not significantly associated with effect modification (all P < 0.05).

CONCLUSIONS

GDM is independently associated with subclinical myocardial dysfunction in pregnancy. STE analysis allows to identify, among GDM women, those who might benefit of targeted non-pharmacological and/or pharmacological interventions, aimed at reducing the risk of developing type 2 diabetes and cardiovascular complications later in life.

From ejection fraction, to myocardial strain, and myocardial work in echocardiography: Clinical impact and controversies

Enhancing an echocardiographic tool, aimed to detect even subtle left ventricular (LV) systolic function abnormalities, capable of obtaining both early diagnosis and risk prediction of heart disease, represents an ambitious, attractive, and arduous purpose in the modern era of cardiovascular imaging. Ideally, that tool should be simple, reliable, and reproducible, in order to be concretely applied in routine clinical practice. Importantly, that technique should be physiologically plausible and useful both at the population-level, as well as in the individual subject. For a long time, LV ejection fraction (EF) has been considered the first-line parameter for assessing LV global systolic function, strictly related to the prognosis, at least in some settings. However, LV EF limitations are well-known, even though frequently overemphasized, including its load-dependency. Therefore, myocardial strain techniques have been proposed, deemed able to disclose even subtle early LV function anomalies. Nevertheless, many disadvantages of myocardial strain have been reported as well. More recently, myocardial work (MW) analysis has been introduced as a new echocardiographic tool for the evaluation of LV global systolic function, attempting to overcome EF and strain disadvantages. However, MW has shown many limits as well. Notwithstanding, LV EF still remains a landmark functional classification marker for heart failure and cardiac oncology, allowing reliable fast reassessment of LV function changes during patient management, in order to guide treatment in individual cases as well. Notably, global longitudinal strain and MW parameters seem to show better meaningful results at the population-level, but controversial clinical impact, major limitations, wide cut-offs spread and overlap, when the single value needs to be applied to the single case. Taking into account the recent literature-based evidence, the scope of the present narrative critical review is trying to delineate the different types of information given by the described LV global systolic function parameters, both at the population-level and in the individual case, in order to trace a comparative analysis of advantages and limitations in clinical practice.

Incidental Finding of Lipomatous Hypertrophy of the Right Atrial Free Wall in an Elderly Female With Severe Pulmonary Hypertension: Early Detection by Multimodality Imaging

Lipomatous atrial hypertrophy (LAH) is a benign cardiac lesion characterized by fat accumulation in the interatrial septum that spares the fossa ovalis. It is associated with obesity and is more frequently observed in elderly and female patients. It is most often detected as an incidental finding on transthoracic echocardiography (TTE). The deposition of adipose tissue may rarely involve both the interatrial septum and the right atrial (RA) free wall. Herein, we describe an extremely rare case of LAH limited to a portion of the RA free wall only, mimicking a myxoma or a thrombotic formation. A multi-instrumental evaluation comprehensive of TTE implemented with pulsed-wave tissue Doppler imaging (PW-TDI), transesophageal echocardiography (TEE), and computed tomography (CT) angiography, performed during the patient's stay in the emergency department, allowed to quickly diagnose the benign RA pseudomass.

Presumed Takotsubo syndrome is associated with high in-hospital mortality in very elderly frail females: a case series

Given the aging of general population, very elderly females with Takotsubo syndrome (TTS) are not rarely encountered in clinical practice. Although coronary angiography with left ventriculography is the gold standard diagnostic tool to exclude or confirm TTS, currently, this invasive procedure is less frequently performed in older patients with several comorbidities, such as renal failure, anemia, infections, neurological disorders, malignancy, and severe frailty. In these patients, a "presumed" TTS is diagnosed on the basis of clinical presentation, electrocardiogram, cardiac biomarkers, and echocardiographic findings without coronary angiography. While, in younger patients, TTS is generally a benign condition, in very elderly females, it is associated with higher in-hospital mortality and poor prognosis. Herein, we present four cases of ultra-octogenarian females diagnosed with "presumed TTS", who did not undergo coronary angiography due to severe frailty and multiple comorbidities and who exhibited poor outcome. This could arise the question if an early more aggressive approach could have changed final results. Probably, the solution could only be a personalized decision deriving from a profound and detailed discussion of each case through a multidisciplinary team approach.

Ejection fraction at hospital admission stratifies mortality risk in HFmrEF patients aged ≥ 70 years: a retrospective analysis from a tertiary university institution

BACKGROUND

During the last few years, increasing focus has been placed on heart failure with mildly reduced ejection fraction (HFmrEF), an intermediate phenotype from preserved to reduced ejection fraction (EF). However, clinical features and outcome of HFmrEF in elderly patients aged ≥ 70 yrs have been poorly investigated.

METHODS

The present study retrospectively included all consecutive patients aged ≥ 70 yrs discharged from our Institution with a first diagnosis of HFmrEF, between January 2020 and November 2020. All patients underwent transthoracic echocardiography. The primary outcome was all-cause mortality, while the secondary one was the composite of all-cause mortality + rehospitalization for all causes over a mid-term follow-up.

RESULTS

The study included 107 HFmrEF patients (84.3 ± 7.4 yrs, 61.7% females). Patients were classified as "old" (70-84 yrs, n = 55) and "oldest-old" (≥ 85 yrs, n = 52) and separately analyzed. As compared to the "oldest-old" patients, the "old" ones were more commonly males (58.2% vs 17.3%, p < 0.001), with history of coronary artery disease (CAD) (54.5% vs 15.4%, p < 0.001) and significantly lower EF (43.5 ± 2.7% vs 47.3 ± 3.6%, p < 0.001) at hospital admission. Mean follow-up was 1.8 ± 1.1 yrs. During follow-up, 29 patients died and 45 were re-hospitalized. Male sex (HR 6.71, 95% CI 1.59-28.4), history of CAD (HR 5.37, 95% CI 2.04-14.1) and EF (HR 0.48, 95% CI 0.34-0.68) were independently associated with all-cause mortality in the whole study population. EF also predicted the composite of all-cause mortality + rehospitalization for all causes. EF < 45% was the best cut-off value to predict both outcomes.

CONCLUSIONS

EF at hospital admission is independently associated with all-cause mortality and rehospitalization for all causes in elderly HFmrEF patients over a mid-term follow-up.

Patent foramen ovale closure after cryptogenic stroke: sometimes uncertain benefit maybe, or even potential harm in the long run?

The main published studies on patent foramen ovale (PFO) closure after cryptogenic stroke tend to consider it positively, in light of the reported both procedural risk profile and outcomes. On the other hand, many blind spots and controversial issues of the topic are still present, mainly including both early procedural complications, and mid- and long-term associated comorbidities as well. Oftentimes, several biases appear to be present, with the evident risk of modifying indications for both intervention, and decision-making process. Biases should be considered and discussed during the diagnostic approach as well, including the supposed evidence of correlation, or cause-effect relationship, between the clinical event and patent foramen ovale. Furthermore, such studies have mostly shown results based on short-term follow-up and very low event rates. Conversely, those patients will keep the device lifelong, generally with long life expectancy, and the increased possibility of recurrent stroke from any other cause over time, along with many potential device-related comorbidities (e.g. atrial fibrillation, nearby anatomical structures impairment, and thrombosis). Consequently, it is hard to demonstrate the mid-term and long-term device-related advantages, due to the possible higher incidence of stroke associated with iatrogenic or concurrent factors. Thus, larger, well designed, long-term, multicentric, and more inclusive studies are needed, aimed to demonstrate a net clinical benefit, ideally including a number-needed-to-treat calculation at short-term, mid-term, and long-term, as well as taking into account and comparing the long-term complications, related outcomes, and recurrent events in patients with and without devices.

Artificial Intelligence in Cardiology: Why So Many Great Promises and Expectations, but Still a Limited Clinical Impact?

Looking at the extremely large amount of literature, as summarized in two recent reviews on applications of Artificial Intelligence in Cardiology, both in the adult and pediatric age groups, published in the Journal of Clinical Medicine [...].

An Unusual Case of Ascending Aorta Dissection 4 Years after Perceval Sutureless Bioprosthesis Implantation: Easier Access to Diagnosis through the Right Parasternal Longitudinal Echocardiographic Window

Sutureless bioprostheses are more frequently used for the surgical treatment of elderly patients with high burden of comorbidity, who are candidates to aortic valve replacement (AVR). Among the sutureless bioprostheses, the Perceval valve has shown a good midterm durability, with very few reports of valve deterioration and low risk of complications. Herein, we present an unusual case of ascending aorta dissection which occurred 4 years after AVR with a Perceval sutureless pericardial bioprosthesis, likely related to the peculiar prosthetic design. A high right parasternal longitudinal view of the aorta in the right lateral decubitus allowed to suspect the acute aortic syndrome, thus accelerating the subsequent diagnostic and therapeutic iter.

The influence of pectus excavatum on cardiac kinetics and function in otherwise healthy individuals: A systematic review

BACKGROUND

A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics.

METHODS

A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included.

RESULTS

The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals.

CONCLUSIONS

Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants.

[Why artificial intelligence applied to the electrocardiogram is not yet clinical routine?]

Artificial intelligence opens up multiple application scenarios to the electrocardiogram (Ai-Ecg) in various clinical settings, with potentially extremely interesting expected results. However, the introduction of prediction models of clinical diagnosis, of the results of different therapies and of the different clinical risks based on artificial intelligence requires that the limits of this approach be adequately considered, limits ranging from conflicts of interest to the transparency of procedures, from product certification to cyber security, to the need for coordination between the most diverse professional figures involved. In order for the Ai-Ecg to become a routine clinical resource, it is necessary to institutionally invest in projects that have as their objectives an ever greater and more extensive attention to its developments and its applications in vast and heterogeneous extended clinical contexts.

Modified Haller index validation and correlation with left ventricular strain in a cohort of subjects with obesity and without overt heart disease

The present study was primarily designed to validate the modified Haller index (MHI), the ratio of chest transverse diameter over the distance between sternum and spine, measured by a ruler and transthoracic echocardiography (TTE), respectively, in a cohort of subjects with obesity, but otherwise healthy, by comparing the results to the conventional Haller index (HI) measured on chest X-ray (CXR). 100 consecutive subjects with body mass index (BMI) ≥ 30 kg/m² and 60 matched controls with BMI < 30 kg/m², who underwent a two-plane CXR for any clinical indication, were prospectively examined over a 6-month period. All participants underwent MHI assessment, TTE and speckle-tracking analysis of left ventricular (LV) global longitudinal strain (GLS). Bland-Altman analysis was used to compare the radiological and nonradiological techniques. Second, independent predictors of subclinical myocardial dysfunction, defined as LV-GLS less negative than - 20%, were evaluated. Bland-Altman analysis revealed a bias of - 4.91 cm for latero-lateral thoracic diameter, of - 0.74 cm for antero-posterior (A-P) thoracic diameter and of - 0.22 for HI assessment, suggesting a systematic overestimation of the nonradiological methodology in comparison to that radiological. Despite normal LV systolic function on TTE, LV-GLS resulted impaired in 76% of subjects with obesity. Waist circumference (OR 1.13, 95%CI 1.04-1.22) and nonradiological A-P thoracic diameter (OR 0.51, 95%CI 0.28-0.93) were the main independent predictors of subclinical myocardial dysfunction in subjects with obesity. The impairment in LV myocardial strain detected in subjects with obesity appears to be primarily related to extrinsic abdominal and thoracic compressive phenomena, rather than intrinsic myocardial dysfunction.

[Artificial intelligence in cardiology]

Artificial intelligence (AI) in cardiology represents a great opportunity, if further developed in a trustworthy way, to support human intelligence in daily practice. AI could help cardiologists to operate with greater efficacy and efficiency, supporting precision, timeliness, ethics, while meeting all patients' needs. AI, however, is not yet so widely diffused in cardiology and important challenges and obstacles have to be overcome, concerning ethics, conflict of interests, algorithm improvements and transparency, product certification, input processing, cyber security, privacy, and need for collaboration and cooperation of different involved professions, within and between different institutions of heterogeneous complexity.

Obesity in pregnancy is a predictor of persistent subclinical myocardial dysfunction over postpartum period

PURPOSE

No previous study provided a complete functional evaluation of all cardiac chambers in pregnant women with obesity. Moreover, the impact of cardiovascular changes associated with obesity in pregnancy on maternal outcome is unclear.

METHODS

46 consecutive pregnant women with obesity, defined by body mass index (BMI) ≥ 30 Kg/m2, and 83 age- (35.5 ± 4.1 vs. 34.1 ± 5.1 yrs, p = 0.11), ethnicity- (caucasian 65.2 vs. 66.3%, p = 0.90) and gestational week-matched (36.3 ± 1.7 vs. 36.5 ± 1.5 wks, p = 0.49) pregnant women without obesity (BMI < 30 Kg/m2) were examined in the first trimester (12-14 weeks), third trimester (36-38 weeks) and 6-10 weeks postpartum. All women underwent obstetric visit, blood tests and transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography analysis of biventricular and biatrial myocardial deformation indices at the three time points. Outcome was persistent subclinical myocardial dysfunction, defined as an absolute value of left ventricular global longitudinal strain (LV-GLS) less negative than - 20%, in postpartum.

RESULTS

Despite normal biventricular systolic function, all myocardial strain indices were significantly lower in pregnant women with obesity than controls. At 8.2 ± 2.2 weeks postpartum, LV-GLS remained less negative than - 20% in 86.9% of women with obesity in pregnancy. Maternal age (OR 1.68, 95%CI 1.14-2.48), third trimester BMI (OR 7.17, 95%CI 1.77-28.9) and third trimester neutrophil-to-lymphocyte ratio (NLR) (OR 1.75, 95%CI 1.22-2.51) were independently associated with outcome. Maternal age ≥ 35 years, BMI ≥ 30 Kg/m2 and NLR ≥ 5.5 were the optimal cut-off values for predicting persistent subclinical myocardial dysfunction in postpartum.

CONCLUSIONS

Pregnant women with obesity, age ≥ 35 yrs and low chronic inflammation have significantly increased risk of persistent subclinical myocardial dysfunction over postpartum.

Comprehensive assessment of biventricular myocardial function by two-dimensional speckle tracking echocardiography in infants of gestational diabetic mothers

AIMS

No previous research provided a complete biventricular and multidirectional left ventricular (LV) functional assessment by two-dimensional (2D) speckle tracking echocardiography (STE) in infants of gestational diabetic mothers (IGDM) METHODS: A total of 30 consecutive IGDM and 30 infants of healthy mothers were examined between March 2021 and July 2021. Both groups of infants underwent evaluation by neonatologist and 2D transthoracic echocardiography (TTE) implemented with 2D-STE quantification of LV-global longitudinal strain (GLS), LV-global circumferential strain (GCS), LV-global radial strain (GRS) and right ventricular (RV)-GLS, within 3 days of life and at 40 days after birth. Predictors of persistent subclinical myocardial dysfunction, defined as a LVGLS less negative than -20% at 40-day follow-up, in IGDM population, were determined.

RESULTS

At 2.2 ± 1.3 days after birth, LV-GLS (- 17.2 ± 1.9 vs. - 23.9 ± 3.8%), LV-GCS (- 17.9 ± 2.7 vs. - 27.3 ± 3.4%), LV-GRS (25.6 ± 3.4 vs. 35.8 ± 3.6%) and RV-GLS (- 17.6 ± 3.6 vs. - 22.6 ± 3.8%) were significantly impaired in IGDM than controls (all p < 0.001). At 36.8 ± 5.2 days of life, LV-GLS was still impaired (less negative than -20%) in 26.6% of IGDM. Maternal third trimester body mass index (BMI) (OR 1.89, 95%CI 1.05-3.39) and third trimester glycosylated hemoglobin (HbA1C) (OR 1.59, 95%CI 1.08-2.19) were independently associated with persistent LV-GLS impairment in IGDM. Maternal BMI ≥ 30 Kg/m2 and HbA1C ≥ 38 mmol/mol showed the maximum of sensitivity and specificity for predicting persistent subclinical myocardial dysfunction in IGDM at 40 days of life.

CONCLUSIONS

IGDM have diffuse pattern of myocardial dysfunction during perinatal period. This dysfunction may be persistent up to 40 days of life in infants of GDM women with obesity and uncontrolled diabetes.

Charlson comorbidity index, neutrophil-to-lymphocyte ratio and undertreatment with renin-angiotensin-aldosterone system inhibitors predict in-hospital mortality of hospitalized COVID-19 patients during the omicron dominant period

Purpose

To investigate the clinical predictors of in-hospital mortality in hospitalized patients with Coronavirus disease 2019 (COVID-19) infection during the Omicron period.

Methods

All consecutive hospitalized laboratory‐confirmed COVID-19 patients between January and May 2022 were retrospectively analyzed. All patients underwent accurate physical, laboratory, radiographic and echocardiographic examination. Primary endpoint was in-hospital mortality.

Results

74 consecutive COVID-19 patients (80.0 ± 12.6 yrs, 45.9% males) were included. Patients who died during hospitalization (27%) and those who were discharged alive (73%) were separately analyzed. Compared to patients discharged alive, those who died were significantly older, with higher comorbidity burden and greater prevalence of laboratory, radiographic and echographic signs of pulmonary and systemic congestion. Charlson comorbidity index (CCI) (OR 1.76, 95%CI 1.07-2.92), neutrophil-to-lymphocyte ratio (NLR) (OR 1.24, 95%CI 1.10-1.39) and absence of angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) therapy (OR 0.01, 95%CI 0.00-0.22) independently predicted the primary endpoint. CCI ≥7 and NLR ≥9 were the best cut-off values for predicting mortality. The mortality risk for patients with CCI ≥7, NLR ≥9 and not in ACEI/ARBs therapy was high (86%); for patients with CCI <7, NLR ≥9, with (16.6%) or without (25%) ACEI/ARBs therapy was intermediate; for patients with CCI <7, NLR <9 and in ACEI/ARBs therapy was of 0%.

Conclusions

High comorbidity burden, high levels of NLR and the undertreatment with ACEI/ARBs were the main prognostic indicators of in-hospital mortality. The risk stratification of COVID-19 patients at hospital admission would help the clinicians to take care of the high-risk patients and reduce the mortality.

Liver stiffness measurement identifies subclinical myocardial dysfunction in non-advanced non-alcoholic fatty liver disease patients without overt heart disease

Patients with non-advanced non-alcoholic fatty liver disease (NAFLD) have an increased cardiovascular risk. The present study was designed to evaluate the relationship between liver stiffness measurement (LSM) by transient elastography (TE) and myocardial deformation indices of all cardiac chambers in NAFLD patients without overt heart disease. All consecutive NAFLD patients diagnosed with LSM < 12.5 kPa on TE between September 2021 and December 2021 entered the study. All participants underwent blood tests, TE and two-dimensional (2D) transthoracic echocardiography (TTE) implemented with speckle-tracking echocardiography (STE) analysis of left ventricular (LV) global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS), right ventricular (RV) GLS, left atrial (LA) total global strain (TGSA) and right atrial (RA) TGSA. Main independent predictors of impaired LV-GLS (defined as absolute value less negative than - 20%) were evaluated. A total of 92 NAFLD patients (54.0 ± 11.1 years, 50% males) were prospectively analyzed. Mean LSM was 6.2 ± 2.4 kPa. Fibroscan results revealed that 76.1% of patients had F0-F1, 5.4% F2 and 18.5% F3 liver fibrosis. Despite normal biventricular systolic function on 2D-TTE, LV-GLS, LV-GCS and LV-GRS, RV-GLS, LA-TGSA and RA-TGSA were reduced in 64.1%, 38.0%, 38.0%, 31.5%, 39.1% and 41.3% of patients, respectively. Body mass index (BMI) (OR 1.76, 95% CI 1.18-2.64), neutrophil-to-lymphocyte ratio (NLR) (OR 4.93, 95% CI 1.15-31.8) and LSM (OR 9.26, 95% CI 2.24-38.3) were independently associated to impaired LV-GLS. BMI ≥ 29.3 kg/m², NLR ≥ 1.8 and LSM ≥ 5.5 kPa were the best cut-off values for detecting outcome. LSM ≥ 5.5 kPa identifies NAFLD patients with subclinical myocardial dysfunction.

Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results

AIMS

The influence of chest wall shape on exercise stress echocardiography (ESE) results has been poorly investigated. We aimed at evaluating the main predictors of true positive (TP)-ESE in a population of subjects with suspected coronary artery disease (CAD), categorized according to chest wall conformation, assessed by modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine).

METHODS

All consecutive patients with suspected CAD referred to our EchoLab for performing ESE between September 2011 and October 2021 were retrospectively enrolled. Preliminary assessment of both pretest probability (PTP) and MHI was performed. All patients with positive ESE underwent coronary angiography. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. Outcome was TP ESE result.

RESULTS

One thousand two hundred and seventy-five consecutive patients (64.9 ± 13.0 years) entered the study. Subjects with concave-shaped chest wall (MHI > 2.5) (10.7%) and those with normal chest shape (MHI ≤ 2.5) (89.3%) were separately analyzed. PTP was similar in both groups (21.8 ± 13.2 vs. 23.5 ± 13.3%, P  = 0.15). One hundred and seventy patients were diagnosed with positive ESE: 129 (75.9%) had obstructive CAD (TP), whereas the remaining 41 (24.1%) had no CAD. Only 2.3% of TP ESE was detected in subjects with MHI >2.5. PTP [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04], dyslipidemia (OR 4.37, 95% CI 2.81-6.80), dyssynergy in the left anterior descending territory (OR 8.21, 95% CI 5.07-13.3) were linearly correlated with TP ESE, whereas MHI >2.5 (OR 0.25, 95% CI 0.14-0.67) was inversely associated with outcome.

CONCLUSIONS

Subjects with MHI >2.5 have low prevalence of TP ESE, regardless of PTP. Preliminary MHI assessment may reduce overestimation of PTP of CAD.

Chest Shape Influences Ventricular-Arterial Coupling Parameters in Infants with Pectus Excavatum

Background

The present study was designed to investigate the possible influence of chest shape, noninvasively assessed by modified Haller index (MHI), on ventricular-arterial coupling (VAC) parameters in a population of term infants with pectus excavatum (PE).

Methods

Sixteen consecutive PE infants (MHI >2.5) and 44 infants with normal chest shape (MHI ≤2.5) were prospectively analyzed. All infants underwent evaluation by a neonatologist, transthoracic echocardiography, and MHI assessment (ratio of chest transverse diameter over the distance between sternum and spine) within 3 days of life. Arterial elastance index (EaI) was determined as end-systolic pressure (ESP)/stroke volume index, whereas end-systolic elastance index (EesI) was measured as ESP/left ventricular end-systolic volume index. Finally, VAC was derived by the Ea/Ees ratio.

Results

At 2.1 ± 1 days after birth, compared to controls (MHI = 2.01 ± 0.2), PE infants (MHI = 2.76 ± 0.2) were diagnosed with significantly smaller size of all cardiac chambers. Biventricular systolic function, left ventricular filling pressures, and pulmonary hemodynamics were similar in both the groups of infants. Both EaI (4.4 ± 1.0 mmHg/ml/m2 vs. 3.4 ± 0.6 mmHg/ml/m2, P < 0.001) and EesI (15.1 ± 3.0 mmHg/ml/m2 vs. 12.7 ± 2.5 mmHg/ml/m2, P = 0.003) were significantly increased in PE infants than controls. The resultant VAC (0.30 ± 0.10 vs. 0.30 ± 0.08, P > 0.99) was similar in both the groups of infants. Both EaI (r = 0.93) and EesI (r = 0.87) were linearly correlated with MHI in PE infants, but not in controls. On the other hand, no correlation was found between MHI and VAC in both the groups of infants.

Conclusions

Chest deformity strongly influences both Ea and Ees in PE infants, due to extrinsic cardiac compression, in the absence of any intrinsic cardiovascular dysfunction.

Artificial intelligence applied to cardiovascular imaging, a critical focus on echocardiography: The point-of-view from "the other side of the coin"

Cardiovascular imaging has achieved a crucial role in the management of cardiovascular diseases. In this field, echocardiography advantages include wide availability, portability, and affordability, at a relatively low cost. However, echocardiographic assessment requires highly trained operators, and implies high observer variability, as compared with the other cardiac imaging modalities. Hence, artificial intelligence might be extremely helpful. From the point-of-view of the peripheral "Spoke" Hospital potential user ("the other side of the coin"), artificial intelligence development appears very slow in the clinical arena. Many limitations are still present, and require full involvement, cooperation, and coordination of professional operators into Hub-and-Spoke network.

Left ventricular strain predicts subclinical atherosclerosis in nonadvanced nonalcoholic fatty liver disease patients

OBJECTIVES

The association between nonalcoholic fatty liver disease (NAFLD) and carotid atherosclerosis is still controversial. The present study was designed to assess the relationship between left ventricular systolic mechanics, noninvasively assessed by two-dimensional (2D) speckle-tracking echocardiography (STE) and common carotid artery (CCA) intima-media thickness (IMT), in patients with nonadvanced NAFLD.

METHODS

All consecutive NAFLD patients diagnosed with liver stiffness measurement (LSM) <12.5 kPa on transient elastography between September 2021 and December 2021 were prospectively enrolled. All participants underwent blood tests, transient elastography, 2D transthoracic echocardiography (TTE) implemented with 2D-STE analysis of left ventricular (LV) global longitudinal strain (GLS) and finally carotid ultrasonography. Main independent predictors of subclinical atherosclerosis, defined as CCA-IMT >0. 9 mm, were evaluated.

RESULTS

A total of 92 NAFLD patients (54.0 ± 11.1 years, 50% males) were prospectively analyzed. Mean LSM was 6.2 ± 2.4 kPa. FibroScan results revealed that 76.1% of patients had F0-F1, 5.4% F2 and 18.5% F3 liver fibrosis. Despite normal biventricular systolic function on 2D-TTE, LV-GLS was reduced (less negative than -20%) in 64.1% of patients. However, 62.0% of NAFLD patients were found with CCA-IMT >0. 9 mm. Age [odds ratio (OR),1.19; 95% confidence interval (CI), 1.05-1.36], hypertension (OR, 3.73; 95% CI, 1.53-9.11), LSM (OR, 4.83; 95% CI, 2.43-9.59), LV-GLS (OR, 0.49; 95% CI, 0.36-0.68) and statin therapy (OR, 0.10; 95% CI, 0.02-0.60) were independently associated with subclinical atherosclerosis. Age ≥51 years, LSM ≥5.5 kPa and LV-GLS less negative than -20% were the best cutoff values for predicting subclinical atherosclerosis.

CONCLUSIONS

Subclinical myocardial dysfunction and subclinical atherosclerosis are simultaneously present in patients with nonadvanced NAFLD.

Influence of chest wall conformation on spirometry parameters and outcome in mild-to-moderate idiopathic pulmonary fibrosis

Extrinsic causes of restrictive lung syndrome in idiopathic pulmonary fibrosis (IPF) patients have been poorly investigated. We aimed to investigate the influence of the anterior chest wall deformity, noninvasively assessed by modified Haller index (MHI), on spirometry parameters and outcome in a consecutive population of patients with mild-to-moderate IPF. Sixty consecutive IPF patients (73.8 ± 6.6 years, 45 males) were included in this retrospective study. All patients underwent physical examination, spirometry, blood tests, conventional transthoracic echocardiography and MHI assessment (chest transverse diameter over the distance between sternum and spine) at basal evaluation. During follow-up, we evaluated the composite endpoint of (1) pulmonary or cardiovascular hospitalizations and (2) all-cause mortality. IPF patients with concave-shaped chest wall (MHI > 2.5) (36.7% of total) and those with normal chest shape (MHI ≤ 2.5) (63.3%) were separately analyzed. In comparison to IPF patients with MHI ≤ 2.5, those with MHI > 2.5: were less likely to be men and smokers; had a more severe restrictive pattern; had significantly smaller cardiac chamber dimensions and significantly higher systolic pulmonary artery pressure (51.9 ± 15.1 vs 42.4 ± 14.3 mmHg, p = 0.02). Mean follow-up time was 2.5 ± 1.4 years. During follow-up, 13 deaths and 16 pulmonary or cardiovascular hospitalizations were detected. At multivariate Cox regression analysis, concave-shaped chest wall (MHI > 2.5) (HR 4.55, 95% CI 1.02-20.4), increased C-reactive protein (HR 1.68, 95% CI 1.08-2.61) and absence of beta-blocker therapy (HR 0.13, 95% CI 0.01-0.26) were independently associated to the investigated outcome. MHI assessment and implementation may help the clinician to identify, among IPF patients, those with poorer prognosis over a medium-term follow-up.

Prevalence and clinical outcome of main echocardiographic and hemodynamic heart failure phenotypes in a population of hospitalized patients 70 years old and older

BACKGROUND

Heart failure (HF) echocardiographic and hemodynamic categories are poorly characterized in the elderly. We aimed to evaluate the prevalence and clinical outcomes of echocardiographic and hemodynamic HF phenotypes in a consecutive series of hospitalized patients aged ≥ 70 years.

METHODS

All consecutive patients ≥ 70 years old discharged from the Internal Medicine Unit of our Hospital with a diagnosis of HF, between January and November 2020, entered this retrospective study. All patients underwent physical examination, complete blood tests, chest X-ray and transthoracic echocardiography. At 1-year follow-up, we evaluated the occurrence of the composite outcome of all-cause mortality and re-hospitalization.

RESULTS

Two hundred and sixty-one patients (86.3 ± 6.4 years, 60.9% women) were retrospectively analyzed. From the study group, 106 "old" (70-84 years) and 155 "oldest-old" (≥ 85 years) patients were separately analyzed. A total of 169 (64.7%) patients reported the composite outcome during follow-up: 41 (15.7%) died and 128 (49.0%) were re-hospitalized. At 1-year follow-up, survival analysis did not show any statistically significant difference between age groups (p = 0.31) and between HF echocardiographic categories (p = 0.34), whereas HF patients with "cold-dry" phenotype had significantly poorer survival compared to the other hemodynamic subtypes (p < 0.001). Male sex (HR 1.44, 95% CI 1.04-1.98), "cold-dry" phenotype (HR 3.90, 95% CI 1.73-8.77), high sodium level (HR 1.03, 95% CI 1.01-1.04) and low estimated glomerular filtration rate (eGFR) (HR 0.98, 95% CI 0.97-0.99) were independently associated with the outcome occurrence.

CONCLUSIONS

Male sex, "cold-dry" phenotype, high sodium level and low eGFR are the main adverse prognostic indicators over a mid-term follow-up in hospitalized patients aged ≥ 70 years.

Incremental prognostic value of arterial elastance in mild-to-moderate idiopathic pulmonary fibrosis

Previous reports suggested that poor pulmonary function was associated with increased arterial elastance (Ea) in patients with chronic obstructive pulmonary disease and systemic sclerosis. The mechanisms connecting pulmonary function and Ea have not yet been accurately studied in patients with idiopathic pulmonary fibrosis (IPF). The present study was designed to assess Ea in IPF patients without chronic severe pulmonary hypertension and to determine its prognostic role over a medium-term follow-up. This retrospective study included 60 consecutive patients with mild-to-moderate IPF (73.8 ± 6.6 years, 75% males) and 60 controls matched by age, sex and cardiovascular risk factors. All patients underwent physical examination, spirometry, blood tests, modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine) assessment, conventional transthoracic echocardiography implemented with speckle tracking analysis of left atrial positive global strain (LA-GSA+ ) and finally carotid Doppler ultrasonography, at basal evaluation. The effective arterial elastance index (EaI) was calculated as the ratio of end-systolic pressure to stroke volume index. During follow-up period, we evaluated the composite endpoint of (1) pulmonary or cardiovascular hospitalizations; (2) all-cause mortality. At baseline, EaI was significantly higher in IPF patients than controls (4.1 ± 1.3 vs 3.5 ± 1.0 mmHg/ml/m2, p = 0.01). EaI was strongly correlated to the following variables: C-reactive protein (CRP) (r = 0.86), forced vital capacity (FVC) (r =  - 0.91), E/e' ratio (r = 0.91), LA-GSA+  (r =  - 0.92), common carotid artery-cross sectional area (CCA-CSA) (r = 0.89) and MHI (r = 0.86), in IPF patients. Mean follow-up time was 2.4 ± 1.3 years. During follow-up, 12 patients died and 17 were hospitalized due to major adverse clinical events. At univariate Cox analysis, CRP (HR 1.51, 95% CI 1.25-1.82), FVC (HR 0.88, 95% CI 0.85-0.91), LA-GSA+  (HR 0.85, 95% CI 0.77-0.94), CCA-CSA (HR 1.12, 95% CI 1.03-1.22) and EaI (HR 2.43, 95% CI 1.75-3.37) were significantly associated with outcome. At multivariate Cox analysis, only EaI (HR 1.60, 95% CI 1.03-2.50) retained statistical significance. An EaI ≥ 4 mmHg/ml/m2 showed 100% sensitivity and 99.4% specificity for predicting outcome (AUC = 0.98). In patients with mild-to-moderate IPF, an EaI ≥ 4 mmHg/ml/m2 is a negative prognostic factor over a medium-term follow-up.

The impact of short-term hyperglycemia and obesity on biventricular and biatrial myocardial function assessed by speckle tracking echocardiography in a population of women with gestational diabetes mellitus

BACKGROUND AND AIMS

To compare biventricular and biatrial myocardial strain indices assessed by two-dimensional speckle tracking echocardiography (2D-STE) in women with gestational diabetes mellitus (GDM) and those with uncomplicated pregnancy at the third trimester of pregnancy and in post-partum.

METHODS AND RESULTS

30 consecutive GDM women and 30 age-, ethnicity- and gestational week-matched controls without any comorbidity were examined in this prospective case-control study. All women underwent obstetric visit, blood tests and transthoracic echocardiography (TTE) implemented with 2D-STE analysis of all cardiac chambers at 36-38 weeks' gestation. TTE and 2D-STE were repeated at 6-10 weeks after delivery. At 36-38 weeks' gestation, GDM women, compared to controls, had significantly higher body mass index (BMI), blood pressure values and inflammatory markers. TTE showed increased left ventricular (LV) mass and impaired LV diastolic function in GDM women, whereas there was no significant difference between the groups in ejection fraction. 2D-STE revealed that biventricular global longitudinal strain (GLS) and biatrial reservoir strain indices were significantly lower in GDM women than controls. Third trimester BMI was inversely correlated with LV-GLS (r = -0.86) and was independently associated with reduced LV-GLS (less negative than -20%) in GDM women in post-partum (OR 1.81, 95%CI 1.14-2.89). A BMI value ≥ 30 kg/m² had 100% sensitivity and 99.5% specificity for identifying GDM women with impaired LV-GLS in post-partum (AUC = 0.97).

CONCLUSION

Women with GDM, compared to women with uncomplicated pregnancy, have significantly lower biventricular and biatrial myocardial deformation indices. These abnormalities may be persistent in post-partum in GDM women with obesity.

Does chest shape influence exercise stress echocardiographic results in patients with suspected coronary artery disease?

Despite the good specificity of exercise stress echocardiography (ESE) for the detection of coronary artery disease (CAD), false positive (FP) results may occur. We have previously reported that chest abnormalities may affect parameters of cardiac contractility. The influence of chest shape on ESE results has never been previously investigated. We retrospectively analyzed 160 consecutive patients (64.4 ± 13.0-year old, 91 women) who had undergone coronary angiography at our Institution because of positive ESE, between June 2014 and May 2020. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥ 70% stenosis in any epicardial coronary artery. Outcome was false-positivity at ESE. 80.6% of patients were diagnosed with obstructive CAD, while 19.4% had no CAD (FP). We separately analyzed patients with normal chest shape (MHI ≤ 2.5) and those with concave-shaped chest wall (MHI > 2.5). These latter were mostly women with small cardiac chambers, mitral valve prolapse (MVP) and exercise-induced ST-segment changes. Likelihood of false-positivity was significantly higher in subjects with MHI > 2.5 than those with MHI ≤ 2.5 (30.7% vs 9.4%, p = 0.001). By multivariate logistic regression analysis, MHI > 2.5 (OR 4.04, 95%CI 1.45-11.2, p = 0.007), MVP (OR 3.47, 95%CI 1.32-9-12, p = 0.01) and dyssynergy in the left circumflex territory (OR = 3.35, 95%CI 1.26-8.93, p = 0.01) were independently associated with false-positivity. Concave-shaped chest wall (MHI > 2.5) may be associated with false-positive stress echocardiographic result. Mechanisms underpinning this finding need to be further explored.

Impact of Chest Wall Conformation on the Outcome of Primary Mitral Regurgitation due to Mitral Valve Prolapse

Background

The possible influence of chest wall conformation on cardiovascular (CV) outcome of patients with mitral regurgitation (MR) due to mitral valve prolapse (MVP) has never been previously investigated.

Methods

This retrospective study included all consecutive symptomatic patients with MVP and moderate MR who underwent exercise stress echocardiography at our institution between February 2014 and February 2021. Modified Haller Index (MHI; chest transverse diameter over the distance between sternum and spine) was noninvasively assessed. During the follow-up, we evaluated the occurrence of any of the following: (1) CV hospitalization, (2) mitral valve (MV) surgery, and (3) cardiac death or sudden death.

Results

Four hundred and twenty-four consecutive patients (66.8 ± 11.5 years, 48.3% men) were retrospectively analyzed. Overall, MVP patients had concave-shaped chest wall (MHI = 2.55 ± 0.34) and were found with small cardiac chamber dimensions. During a mean follow-up time of 3.2 ± 1.7 years, no patients died, 55 patients were hospitalized due to CV events, and 20 patients underwent MV surgery. On multivariate Cox analysis, age (heart rate [HR] 1.05, 95% confidence interval [CI] 1.03-1.06), diabetes mellitus (HR 3.26, 95% CI 2.04-5.20), peak exercise-E/e' ratio (HR 1.07, 95%CI 1.05-1.09), and peak exercise-effective regurgitant orifice area (HR 2.53, 95% CI 1.83-3.51) were directly associated to outcome, whereas MHI (HR 0.15, 95%CI 0.07-0.33) and beta-blocker therapy (HR 0.26, 95% CI 0.19-0.36) showed strong inverse correlation. An MHI ≥2.7 showed 80% sensitivity and 100% specificity for predicting event-free survival (area under the curve = 0.98).

Conclusions

Symptomatic patients with moderate MR due to MVP and MHI ≥2.7 have an excellent prognosis over a medium-term follow-up. Noninvasive chest wall shape assessment should be encouraged in clinical practice.

Prognostic indicators of persistent carotid intima-media thickness increase in postpartum period in a population of normotensive women with gestational diabetes mellitus

OBJECTIVE

The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA)-intima media thickness (IMT) is still controversial. In the present study, we aimed to compare the CCA-IMT measured in GDM women to that obtained in healthy pregnant women in the third trimester of pregnancy. Secondly, we investigated the main independent predictors of persistent CCA-IMT increase (defined as CCA-IMT ≥ 0.6 mm) in postpartum period in GDM women.

STUDY DESIGN

30 consecutive GDM women and 30 healthy pregnant women matched for anagraphic age (34.1 ± 4.5 vs 32.8 ± 4.2 yrs, p = 0.25), ethnicity (caucasian 56.7 vs 63.3%, p = 0.59), gestational age (36.2 ± 1.7 vs 36.5 ± 1.6 weeks, p = 0.48) and cardiovascular risk factors were examined in this prospective case-control study. All women underwent obstetric visit, blood tests, conventional transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography analysis of left ventricular and left atrial myocardial strain parameters and carotid ultrasound examination at two time points: 36-38 weeks' gestation and 6-10 weeks after delivery.

RESULTS

At 36.2 ± 1.7 weeks of gestation, CCA-IMT was significantly increased in GDM women than controls (0.81 ± 0.11 vs 0.55 ± 0.12, p < 0.001). Twelve GDM women (40% of the total) were found with persistent CCA-IMT increase (0.76 ± 0.14 mm) in postpartum period (8.2 ± 2.2 weeks), whereas the remaining 18 (60% of the total) showed a normalization in CCA-IMT (0.56 ± 0.1 mm). At multivariate logistic regression analysis, third trimester body mass index (BMI) (OR 1.78, 95%CI 1.24-2.54, p = 0.01), glycosylated hemoglobin (HbA1C) (OR 1.51, 95%CI 1.13-1.89, p = 0.03) and neutrophil-to-lymphocyte ratio (NLR) (OR 1.68, 95%CI 1.25-4.65, p = 0.02) resulted to be independently associated with persistent CCA-IMT increase in postpartum period in GDM women. A BMI ≥ 29.2 Kg/m², an HbA1C ≥ 37.5 mmol/mol and a NLR ≥ 5.5 were the best cut-off values for identifying GDM women with persistent CCA-IMT increase in postpartum period.

CONCLUSIONS

GDM is associated with increased CCA-IMT during pregnancy. This increase may be persistent in postpartum period in GDM women with obesity, uncontrolled diabetes and increased inflammatory markers.

Usefulness of second trimester left ventricular global longitudinal strain for predicting adverse maternal outcome in pregnant women aged 35 years or older

The present study was primarily designed to accurately determine biventricular and biatrial myocardial function, assessed by two-dimensional speckle tracking echocardiography (2D-STE), in a prospective cohort of pregnant women aged ≥ 35 years, at the second trimester of pregnancy. Secondly, we aimed at investigating the main independent predictors of adverse maternal outcome (AMO) in the same study population. 80 consecutive pregnant women aged ≥ 35 years, 80 gestational week-matched (18.4 ± 1.6 vs 18.5 ± 1.8 weeks, p = 0.71) pregnant women aged < 35 years and 80 non-pregnant women aged ≥ 35 years without any comorbidity were included in this prospective study. All pregnant women underwent obstetric evaluation, modified Haller index (MHI) assessment and a conventional two-dimensional transthoracic echocardiography implemented with complete 2D-STE analysis of both ventricles and atria at the second trimester of pregnancy. AMO was defined as the occurrence of any of the following: gestational hypertension (GH) including preeclampsia; gestational diabetes mellitus (GDM); preterm delivery (PD); emergency caesarean section (ECS); postpartum haemorrhage (PPH); premature rupture of membranes (PROM); maternal death. Compared to younger pregnant women, pregnant women aged ≥ 35 years were more likely to be found with: (1) body mass index (BMI) ≥ 30 kg/m2 (37.5% of total); (2) significantly increased inflammatory markers; (3) significantly greater left ventricular mass index; (4) significantly impaired hemodynamics; (5) significantly reduced bi-atrial and bi-ventricular myocardial strain parameters, despite normal ejection fraction. A strong inverse correlation between second trimester BMI and left ventricular (LV)-global longitudinal strain (GLS) (r =  - 0.84) and between second trimester MHI and LV-GLS (r =  - 0.81) was demonstrated in pregnant women aged ≥ 35 years. GH, GDM, PD, ECS, PPH and PROM were detected in 15%, 12.5%, 10%, 8.7%, 8.7% and 7.5% of women, respectively. Age (OR 2.04, 95% CI 1.46-2.84), second trimester BMI (OR 2.40, 95% CI 1.64-3.51) and second trimester LV-GLS (OR 0.07, 95%C I 0.01-0.34) were independently associated with outcome. Age ≥ 37 years, BMI ≥ 30 kg/m2 and LV-GLS less negative than - 18% were the best cut-off values for predicting AMO. A LV-GLS less negative than - 18% allows to identify, among older pregnant women, those with an increased risk of AMO. Both intrinsic myocardial dysfunction and extrinsic compressive mechanical phenomena might affect global myocardial deformation during gestation.

Does chest wall conformation influence myocardial strain parameters in infants with pectus excavatum?

PURPOSE

To investigate the possible influence of chest wall conformation on myocardial strain parameters in a consecutive population of infants with pectus excavatum (PE), noninvasively assessed by modified Haller index (MHI).

METHODS

Sixteen consecutive PE infants (MHI >2.5) and 44 infants with normal chest shape (MHI ≤2.5) entered in this prospective case-control study. All infants underwent evaluation by neonatologist, transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography (2D-STE) analysis of both ventricles and MHI assessment (ratio of chest transverse diameter over the distance between sternum and spine), at two time points: within 3 days and at about 40 days of life.

RESULTS

At 2.1 ± 1 days of life, compared to controls (MHI = 2.01 ± 0.2), PE infants (MHI = 2.76 ± 0.2) were diagnosed with significantly smaller cardiac chambers dimensions. Biventricular contractile function and hemodynamics were similar in both groups of infants. Left ventricular (LV) global longitudinal strain (GLS) (-16.0 ± 2.8 vs. -21.7 ± 2.2%), LV-global circumferential strain (GCS) (-16.3 ± 2.7 vs. -24.0 ± 5.2%), LV-global radial strain (GRS) (24.2 ± 3.0 vs. 31.5 ± 6.3%), and right ventricular free wall longitudinal strain (RVFWLS) (-16.0 ± 3.2 vs. -22.3 ± 4.4%) were significantly reduced in PE infants versus controls (all p < 0.001). A strong inverse correlation between MHI and the following parameters: LV-GLS (r = -0.92), LV-GCS (r = -0.88), LV-GRS (r = -0.87), and RVFWLS (r = -0.88), was demonstrated in PE infants, but not in controls, in perinatal period (all p < 0.001). Analogous results were obtained at 36.8 ± 5.2 days after birth.

CONCLUSIONS

Abnormal chest anatomy progressively impairs myocardial strain parameters in PE infants. This impairment might reflect intraventricular dyssynchrony due to compressive phenomena rather than intrinsic myocardial dysfunction.

Chest conformation spuriously influences strain parameters of myocardial contractile function in healthy pregnant women

AIMS

Left ventricular (LV) contractility during noncomplicated pregnancy has been previously investigated by two-dimensional speckle-tracking echocardiography (2D-STE), with conflicting results. Chest abnormalities might affect myocardial strain parameters, yet this issue has not been previously investigated during pregnancy. We evaluated the influence of chest conformation on myocardial strain parameters in healthy pregnant women.

METHODS

Between October 2019 and February 2020, 50 healthy pregnant women (32.3 ± 4.0 years old) were consecutively studied. They underwent obstetric visit, assessment of chest shape by modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) and transthoracic echocardiography implemented with 2D-STE analysis of all myocardial strain parameters in the first trimester (12-14 weeks), third trimester (36-38 weeks) and 6-9 weeks after delivery.

RESULTS

LV ejection fraction remained substantially unchanged (P = 0.13), while on the average all myocardial strain parameters showed a small but significant decrease during pregnancy, and recovered postpartum (all P < 0.001). Women with concave-shaped chest wall (MHI > 2.5, n = 29), and those with normal chest conformation (MHI ≤ 2.5, n = 21) were then separately analyzed. Pregnant women with MHI above 2.5, but not those with MHI 2.5 or less, showed a progressive but reversible decrease in all myocardial strain parameters (all P < 0.001). MHI was strongly correlated with LV global longitudinal strain (r = -0.87) and LV global circumferential strain (r = -0.83) in the third trimester of pregnancy.

CONCLUSION

Myocardial strain impairment during healthy pregnancy may not reflect intrinsic myocardial dysfunction but rather intraventricular dyssynchrony related to a narrow antero-posterior chest diameter and rise in the diaphragm, with consequent extrinsic myocardial compression.

Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Transesophageal echocardiography (TEE) is the gold standard for assessing left atrial appendage (LAA) mechanic and thrombosis (LAAT); however, TEE is a high-risk procedure for viral transmission during coronavirus disease 2019 (COVID-19) pandemic. We investigated whether deformation indices of left atrium (LA) at transthoracic echocardiography (TTE) correlate with those of LAA assessed by TEE in nonvalvular atrial fibrillation (NVAF) patients undergoing electrical cardioversion (ECV). Consecutive patients with NVAF of ≥ 48 h or unknown duration, who underwent TEE and TTE at our Institution before ECV were retrospectively investigated. Standard echo-Doppler and LA and LAA myocardial strain and strain rate parameters were analyzed. A total of 115 NVAF patients (71.3 ± 8.1 yr/o, 59.1% men) were included: LAAT was diagnosed in 25 (21.7%) patients. Compared to patients without LAAT, those with LAAT had significantly higher CHA₂DS₂-VASc Risk score (4.5 ± 1.4 vs. 3.5 ± 1.1, p < 0.001), and lower ejection fraction (46.0 ± 14.8 vs. 57.6 ± 8.6%, p < 0.001). In LAAT patients, global strain of LA (8.7 ± 2.6 vs. 16.3 ± 4.5%, p < 0.001) and LAA (7.0 ± 1.7 vs. 11.7 ± 2.0%, p < 0.001) was significantly reduced compared to non-LAAT patients. A close relationship between left atrial strain reservoir (LASr) and LAA-global strain was demonstrated (r = 0.81). By univariable analysis, CHA₂DS₂-VASc Risk Score (OR 2.01, 95%CI 1.34–3.00), NT-proBNP (OR 1.36, 95%CI 1.19–1.54), ejection fraction (OR 0.92, 95%CI 0.88–0.96), E/e’ ratio (OR 2.07, 95%CI 1.51–2.85), and LASr (OR 0.39, 95%CI 0.25–0.62) were strongly associated with LAAT presence at TEE. By multivariable analysis, only LASr (OR 0.40, 95%CI 0.24–0.70) retained statistical significance. ROC curve analysis revealed that an LASr cut-off value ≤ 9.3% had 98.9% sensibility and 100% specificity to identify LAAT by TEE (AUC = 0.98). In patients with NVAF of ≥ 48 h or unknown duration, scheduled to undergo ECV, LA deformation assessment by TTE might substitute invasive measurement of LAA function by TEE, simplifying diagnostic approach and possibly contributing to reduce COVID-19 infection diffusion.

Rapid Risk Stratification of Acute Ischemic Stroke Patients in the Emergency Department: The Incremental Prognostic Role of Left Atrial Reservoir Strain

OBJECTIVES

To determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED).

METHODS

All consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6-12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations.

RESULTS

A total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19-0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15-1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28-0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15-2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86).

CONCLUSIONS

A LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.

Prognostic Value of Modified Haller Index in Patients with Suspected Coronary Artery Disease Referred for Exercise Stress Echocardiography

Background:

The influence of chest conformation on outcome of patients with suspected coronary artery disease (CAD) is actually unknown.

Materials and Methods:

This retrospective study included all consecutive patients who underwent exercise stress echocardiography (ESE) for suspected CAD at our institution between February 2011 and September 2019. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. During the follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations and (2) cardiac death or sudden death.

Results:

A total of 1091 consecutive patients (62.4 ± 12.6 years, 57.2% of men) were included in the study. Patients with normal chest shape (MHI ≤2.5) and those with concave-shaped chest wall (MHI >2.5) were separately analyzed. A positive ESE was diagnosed in 171 patients of which 80.7% had an obstructive CAD (true positive), while 19.3 not (false positive [FP]). Majority of FP ESE (70.9%) derived from concave-shaped chest wall group. During follow-up time (2.5 ± 1.9 years), 9 patients died and 281 were hospitalized because of heart failure (163), acute coronary syndromes (39), and arrhythmias (79). At the multivariate Cox regression analysis, age (heart rate [HR]: 1.02, 95% confidence interval [CI]: 1.01–1.03), MHI >2.5 (HR: 0.39, 95% CI: 0.26–0.56), diabetes mellitus (HR: 4.89, 95% CI: 3.78–6.32), horizontal ST depression ≥1 mm (HR: 2.86, 95% CI: 1.98–4.15), peak exercise average E/e' ratio (HR: 1.08, 95% CI: 1.06–1.10), and peak exercise wall motion score index (HR: 1.79, 95% CI: 1.36–2.35) were independently correlated with outcome.

Conclusions:

Patients with concave-shaped chest wall (MHI >2.5) have a significantly lower probability of CV events than those with normal chest shape (MHI ≤2.5) over a medium-term follow-up. A noninvasive chest shape assessment could identify subjects at lower risk of CV events.

An unusual case of painless type A aortic dissection

The pathogenesis of acute aortic dissection (AAD) is not fully elucidated yet, but it was recently shown that inflammation contributes to the occurrence and development of both Stanford type A and type B AAD. We describe a rare case of a painless type A aortic dissection that occurred in an 85-year-old male, with moderate calcified aortic stenosis and a moderately dilated ascending aorta in 6-month clinical and echocardiographic follow-up. A chronic calculous cholecystitis with neutrophilic leukocytosis and severely increased C reactive protein was diagnosed in the last 3 months. In this patient, a chronic systemic inflammatory state might have contributed to generate the intimal entry tear in the aortic root. In particular, a neutrophil mobilization might have played a causative role in aortic rupture.

Case Report: An Unusual Case of Biventricular Thrombosis in a COVID-19 Patient With Ischemic Dilated Cardiomyopathy: Assessment of Mass Mobility and Embolic Risk by Tissue Doppler Imaging

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein binds to angiotensin-converting enzyme 2 (ACE2) receptor on vascular cells. As a consequence, patients with COVID-19 have an increased incidence of thromboembolic complications of the SARS-CoV-2 infection and subsequent endothelial cell damage with consequence of development of systemic vasculitis and diffuse intravascular coagulation. The present case describes a COVID-19 female patient with ischemic dilated cardiomyopathy, who presented with congestive heart failure and echocardiographic evidence of biventricular apical thrombi. The peak antegrade longitudinal velocity (Va) of each thrombotic mass was measured by pulsed wave tissue Doppler imaging (PW-TDI). Both left ventricular and right ventricular apical thrombi were found with a TDI-derived mass peak Va < 10 cm/s. There was no clinical evidence of neither systemic nor pulmonary embolization, probably due to the hypomobility of both left and right ventricular masses.

Influence of chest conformation on ventricular-arterial coupling during normal pregnancy

PURPOSE

There is still controversy regarding the changes of ventricular-arterial coupling (VAC) during normal pregnancy. The possible influence of chest shape on VAC during normal pregnancy has never been investigated.

METHODS

Between October 2019 and June 2020, 59 healthy pregnant women (33.7 ± 4.4 years/old) were consecutively included. They underwent obstetric visit, modified Haller index (MHI) assessment, and complete echocardiographic evaluation with blood pressure measurement to assess arterial elastance (Ea), end-systolic elastance (Ees), and Ea/Ees as an index of VAC, at 12-14 weeks and 36-38 weeks gestation, then 6-9 weeks after delivery.

RESULTS

VAC progressively increased from the first to the third trimester of pregnancy, then decreased in the postpartum (P < 0.0001) in the whole study population. Women with concave-shaped chest wall (MHI >2.5, n = 31) but not women with normal chest shape (MHI ≤2.5, n = 28) showed a progressive increase in VAC during normal pregnancy. Women with MHI >2.5 showed a significantly less pronounced increase in stroke volume index (SVi) from the first to the third trimester of pregnancy. There was a strong linear correlation between third trimester MHI and VAC (r = 0.93).

CONCLUSIONS

Anatomical and/or extrinsic mechanical factors rather than impaired arterial elastance or reduced left ventricular contractility may contribute to changes in VAC during normal pregnancy in women with concave-shaped chest wall.

Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease

The hypothesis that modified Haller index (MHI) integration with the existing appropriate use criteria (AUC) categories may predict exercise stress echocardiography (ESE) results and outcome of patients with suspected coronary artery disease (CAD) has never been previously investigated. We retrospectively analyzed 1230 consecutive patients (64.8 ± 13.1 years, 58.9% men) who underwent ESE for suspected CAD between February 2011 and September 2019 at our institution. MHI (chest transverse diameter over the distance between sternum and spine) was assessed in all patients. A true positive (TP) ESE was a positive ESE with obstructive CAD according to subsequent coronary angiography. During follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations; (2) Cardiac death or sudden death. Overall, 734 (59.7%), 357 (29.0%) and 139 (11.3%) indications for ESE were classified as appropriate (Group 1), rarely appropriate (Group 2) and which may be appropriate (Group 3), respectively. A funnel chest (defined by an MHI > 2.5) was detected in 30.3%, 82.1% and 49.6% of Groups 1, 2 and 3 subjects, respectively (p < 0.0001). On multivariate logistic regression analysis, male sex (OR 1.41, 95%CI 1.02-2.03, p = 0.01) and type-2 diabetes (OR 3.63, 95%CI 2.49-5.55, p = 0.001) were directly correlated to a TP ESE, while "rarely appropriate" indication for ESE with MHI > 2.5 (OR 0.16, 95%CI 0.11-0.22, p < 0.0001) showed a significant inverse correlation with the outcome. During a mean follow-up of 2.5 ± 1.9 years, 299 CV events occurred: 76.4%, 3.5% and 20.1% in Groups 1, 2 and 3, respectively. On multivariate Cox regression analysis, smoking (HR 1.33, 95%CI 1.19-1.48), type 2 diabetes (HR 2.28, 95%CI 1.74-2.97), dyslipidemia (HR 3.51, 95%CI 2.33-5.15), beta-blockers (HR 0.55, 95%CI 0.41-0.75), statins (HR 0.60, 95%CI 0.45-0.80), peak exercise average E/e' ratio (HR 1.08, 95%CI 1.06-1.09), positive ESE (HR 3.12, 95%CI 2.43-4.01) and finally "rarely appropriate" indication for ESE with MHI > 2.5 (HR 0.15, 95%CI 0.08-0.23) were independently associated with CV events. The implementation of AUC categories with MHI assessment may select a group of patients with extremely low probability of both TP ESE and adverse CV events over a medium-term follow-up. A simple noninvasive chest shape assessment could reduce unnecessary exams.