Use and Implications of Echocardiography in the Hemodynamic Assessment of Cardiogenic Shock

Cardiogenic shock (CS) is a complex multisystem syndrome due to pump failure, associated with high mortality and morbidity. Its hemodynamic characterization is key to the diagnostic algorithm and management. Pulmonary artery catheterization is the gold standard for the left and right hemodynamic evaluation, but some concerns exist for invasivity and untoward mechanical and infective complications. Transthoracic echocardiography is a robust noninvasive diagnostic tool for hemodynamic multiparametric assessment that well applies to the management of CS. Its applications expand from etiology definition to the choice of therapeutic intervention and their monitoring. The present review aims at detailing the role of ultrasounds in CS emphasizing the clinical implications of combining cardiac and non-cardiac ultrasounds examinations that may correlate with prognosis.

Aortic Valve Stenosis and Cancer: Problems of Management

Aortic valve stenosis and malignancy frequently coexist and share the same risk factors as atherosclerotic disease. Data reporting the prognosis of patients with severe aortic stenosis and cancer are limited. Tailoring the correct and optimal care for cancer patients with severe aortic stenosis is complex. Cancer patients may be further disadvantaged by aortic stenosis if it interferes with their treatment by increasing the risk associated with oncologic surgery and compounding the risks associated with cardiotoxicity and heart failure (HF). Surgical valve replacement, transcatheter valve implantation, balloon valvuloplasty, and medical therapy are possible treatments for aortic valve stenosis, but when malignancy is present, the choice between these options must take into account the stage of cancer and associated treatment, expected outcome, and comorbidities. Physical examination and Doppler echocardiography are critical in the diagnosis and evaluation of aortic stenosis. The current review considers the available data on the association between aortic stenosis and cancer and the therapeutic options.

Case Report: A rare homozygous patient affected by TTR systemic amyloidosis with a prominent heart involvement

Hereditary transthyretin amyloidosis is a severe, adult-onset autosomal dominant inherited systemic disease predominantly affecting the peripheral and autonomic nervous system, heart, kidney, and the eyes. We present a case of a Caucasian 65-year-old man with cardiac amyloidosis and the homozygous mutation Val142Ile (classically, Val122Ile) in the transthyretin gene. We provide a genotype-phenotype correlation regarding the genetic status of both heterozygous and homozygous individuals and their clinical conditions at the time of genetic testing.

Role of cardiac and lung ultrasound in the COVID-19 era

INTRODUCTION

The primary diagnostic method of Coronavirus disease 2019 is reverse transcription polymerase chain reaction of the nucleic acid of severe acute respiratory syndrome coronavirus 2 in nasopharyngeal swabs. There is growing evidence regarding the 2019 coronavirus disease imaging results on chest X-rays and computed tomography but the accessibility to standard diagnostic methods may be limited during the pandemic.

EVIDENCE ACQUISITION

Databases used for the search were MEDLINE (PubMed), Scopus Search, and Cochrane Library. The research took into consideration studies published in English until March 2022 and was conducted using the following research query: ((((sars cov [MeSH Terms])) OR (COVID-19)) OR (Sars-Cov2)) OR (Coronavirus)) AND (((((2d echocardiography [MeSH Terms]) OR (doppler ultrasound imaging [MeSH Terms]))) OR (echography [MeSH Terms])) OR (LUS)) OR ("LUNG ULTRASOUND")).

EVIDENCE SYNTHESIS

Pulmonary and cardiac ultrasound are cost-effective, widely available, and provide information that can influence management.

CONCLUSIONS

Point-of-care ultrasonography is a method that can provide relevant clinical and therapeutic information in patients with COVID-19 where other diagnostic methods may not be easily accessible.

Long-Term Effects of Sacubitril-Valsartan on Cardiac Remodeling: A Parallel Echocardiographic Study of Left and Right Heart Adaptive Response

Sacubitril/Valsartan (S/V) carries potential anti-remodeling properties, however long-term effects and biventricular adaptive response are poorly described. 76 HFrEF patients who underwent progressive uptitration of S/V, completed the annual scheduled follow-up. After a median follow-up of 11 (8-13) months, left ventricular (LV) reverse remodeling (RR) is defined as (1) absolute increase in LV ejection fraction (EF) ≥ 10% or LVEF ≥ 50% at follow-up and (2) decrease in indexed LV end-diastolic diameter (LVEDDi) of at least 10% or indexed LVEDDi ≤ 33 mm/m2, occurred in 27.6%. Non-ischemic etiology, shorter duration of HF, and absence of a history of AF were independently associated with LVRR (p < 0.05). TAPSE and TAPSE/PASP, a non-invasive index of right ventricular (RV) coupling to the pulmonary circulation, significantly improved at follow-up (0.45 vs. 0.56, p = 0.02). 41% of patients with baseline RV dysfunction obtained favorable RV remodeling despite only a moderate correlation between RV and LV function was observed (r = 0.478, p = 0.002). Our data point to a potential long-term reverse global remodeling effect by S/V, especially in patients who start S/V at an early stage of the disease, and focus our attention on a possible direct effect of the drug in synergistic hemodynamics between RV and pulmonary circulation.

Arrhythmogenic Mitral Valve Prolapse and Sudden Cardiac Death: An Update and Current Perspectives

Mitral valve prolapse (MVP) affects about 2% to 3% of the general population, mostly women, and is the most common cause of primary chronic mitral regurgitation (MR) in western countries. The natural history is heterogeneous and widely determined by the severity of MR. Although most patients remain asymptomatic with a near-normal life expectancy, approximately 5% to 10 % progress to severe MR. As largely recognized, left ventricular (LV) dysfunction due to chronic volume overload per se identifies a subgroup at risk of cardiac death. However, there is rising evidence of a link between MVP and life threating ventricular arrhythmias (VAs)/sudden cardiac death (SCD) in a small subset of middle-aged patients without significant MR, heart failure and remodeled hearts. The present review focuses on the underlying mechanism of electric instability and unexpected cardiac death in this subset of young patients, from the myocardial scarring of the LV infero-lateral wall due to mechanical stretch exerted by the prolapsing leaflets and mitral annular disjunction, to the inflammation's impact on fibrosis pathways along with a constitutional hyperadrenergic state. The heterogeneity of clinical course reveals a necessity of risk stratification, preferably through noninvasive multimodality imaging, that will help to identify and prevent adverse scenarios in young MVP patients.

The Global Burden of Valvular Heart Disease: From Clinical Epidemiology to Management

Valvular heart disease is a leading cause of cardiovascular morbidity and mortality and a major contributor of symptoms and functional disability. Knowledge of valvular heart disease epidemiology and a deep comprehension of the geographical and temporal trends are crucial for clinical advances and the formulation of effective health policy for primary and secondary prevention. This review mainly focuses on the epidemiology of primary (organic, related to the valve itself) valvular disease and its management, especially emphasizing the importance of heart valve centers in ensuring the best care of patients through a multidisciplinary team.

903 NOVEL MALIGNANT MUTATION IN HYPERTROPHIC CARDIOMYOPATHY

Background

Hypertrophic cardiomyopathy (HCM) is a common inherited disease almost invariably caused by mutations in sarcomeric genes. The HCM phenotype is clinically heterogeneous with myocyte hypertrophy, disarray, and myocardial fibrosis as histological hallmarks. This condition is recognized as an important cause of sudden cardiac death (SCD) in the youth and of heart failure (HF) in the elderly. Current guidelines mandate genetic analysis as a class I indication in HCM. Indeed, the advent of the next generation sequencing in the medical practice has led to decipher the molecular etiology of HCM and to assess the disease risk in family members with relevant insights into the clinical course.

Clinical case

A 62-year-old man followed-up at another Hospital with a non-obstructive HCM diagnosis, was referred to our Hospital for therapy optimization and clinical follow-up. Past medical history included third degree atrioventricular block at age 40 treated with dual chamber pacemaker (PM) and, at age of 60, atrial flutter with high ventricular response complicated with cardiogenic shock and stroke. Due to worsening systolic function and ventricular sustained tachycardia he was upgraded to implantable cardioverter defibrillator which delivered appropriate shocks. Echocardiography performed during current hospitalization showed a moderate concentric hypertrophy (intraventricular septum 17 mm, cardiac mass index 258 g/m2), dilated ventricle with reduced ejection fraction (33%) and akinesis of the mid inferior and infero-septal walls of the left ventricle and of the apex, with a stratified thrombotic apposition. Magnetic resonance was contraindicated because of non-compatible PM. Due to alteration in serum proteins and free light chain, to rule out systemic disease, extensive imaging diagnosis was performed including bone scintigraphy and abdominal ultrasonography which resulted negative. While waiting for bone marrow aspiration and biopsy the patient rapidly deteriorated with worsening renal failure, ensuing proteinuria until exitus. After an appropriate pre-test counseling the family consented to genetic test in the proband. Clinical exome sequencing revealed the presence of a missense mutation in MYH7 gene. This new mutation is characterized by the substitution of cysteine residue by a serine in 905 codon of MYH7 gene. Cys905Ser results in a semi-conservative amino acid substitution which may impact disulfide bond formation in the MYH7 protein. To date no study has described this mutation as a cause of HCM. A mutation affecting this same codon, Cys905Phe was reported in only one patient with HCM. From a biological point of view, this variant lies in the head region of the protein where the majority of the missense variants are grouped and statistically associated to HCM phenotype. Several studies reported that the occurrence of atrial fibrillation (AF) tends to be more prevalent in patients carrying the MYH7 mutation. Furthermore, AF is associated with substantial risk for HF-related mortality, stroke, and severe functional disability.

Awareness regarding the spectrum of MYH7 mutations probably related to SCD or HF combined with a thorough patient characterization for molecular and clinical features, may help to improve the genotype and phenotype correlation. This important challenge could elucidate better the mechanism of HCM enabling cardiologists to a better clinical decision-making and patients’ care.

Effects of Sacubitril/Valsartan on biomarkers of fibrosis and inflammation in patients with heart failure with reduced ejection fraction

AIMS

To evaluate the circulating levels of remodeling biomarkers procollagen type 1 C-terminal propeptide (PICP), human cartilage glycoprotein-39 (YKL-40), plasma renin activity (PRA), aldosterone (Aldo) as well as clinical and echocardiographic parameters in patients with heart failure with reduced ejection fraction (HFrEF), before and after treatment with Sacubitril/Valsartan (S/V).

METHODS AND RESULTS

A total of 26 consecutive patients with HFrEF on stable clinical conditions were studied. Clinical, echocardiographic parameters and circulating biomarkers were measured at baseline, after 30 and 60 days of S/V treatment. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) decreased, from 126 ± 15 to 113 ± 4 mmHg (p < 0.001) and from 77 ± 11 to 72 ± 9 mmHg (p = 0.005), respectively, at the end of study. Concomitantly, left ventricular ejection fraction (LVEF) increased by 22.8% from 29.5 ± 5% to 36.2 ± 5%, (p < 0.001) and indexed left ventricular end-systolic volume (LVESVi) decreased by 12% from 38.6 ± 8.7 ml/m² to 34.0 ± 10.0 ml/m². (p = 0.007). Circulating levels of PICP, YKL-40, PRA and Aldo decreased by - 42.2%, - 46.8%, - 79.1% and - 76.7%, respectively (p < 0.001 for all), the decrements being already maximal within 30 days of S/V treatment. No significant changes of plasma electrolytes and creatinine were observed during the study (all p > 0.05).

CONCLUSIONS

A decrease of circulating markers of inflammation and fibrosis during chronic treatment with S/V is associated with an improvement of hemodynamic and echographic parameters in patients with HRrEF. These data are compatible with an anti-fibrotic and anti-inflammatory effect of S/V, that may contribute to the beneficial outcomes of the drug in this clinical setting.

Echocardiographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Anorexia Nervosa is one of the most common form of eating disorders. Cardiac involvement occurs in approximately 80% of patients. Few reports focused on the association between body weight fluctuations and echocardiographic abnormalities, considering linear measurements. We describe echocardiographic and clinical features among male and female patients with anorexia nervosa and the effect of weight gain on these parameters. We performed a single center, retrospective study of patients followed at a dedicated multidisciplinary Unit. The study population consisted of 81 patients, mean age 25 ± 11 years, 94% female. Median body mass index was 14.4 kg/m² (25th-75th percentile 12.7-15.6 kg/m²). Patients with body mass index below the median value had more often pericardial effusion, smaller left ventricular mass and left ventricular end-diastolic volume and thinner interventricular septum. However, when indexed to body surface area, left ventricular mass and volumes were within the normal range in 90% of population. Patients with pericardial effusion showed mitral valve abnormalities and lower values of white blood cells and platelets, although within normal limits. Presence of pericardial effusion was not related to inflammatory parameters or low plasma protein levels. In 39 patients who displayed weight gain during a median follow-up of 189 days (25th-75th percentile 47-471), increased left ventricular mass, interventricular septum thickness, white blood cells and platelet count and decreased pericardial effusion were observed. Patients with anorexia nervosa have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates.

Impact of Right Ventricular‐Pulmonary Circulation Coupling on Mortality in SARS‐CoV‐2 Infection

Background

The COVID‐19–related pulmonary effects may negatively impact pulmonary hemodynamics and right ventricular function. We examined the prognostic relevance of right ventricular function and right ventricular‐to‐pulmonary circulation coupling assessed by bedside echocardiography in patients hospitalized with COVID‐19 pneumonia and a large spectrum of disease independently of indices of pneumonia severity and left ventricular function.

Methods and Results

Consecutive COVID‐19 subjects who underwent full cardiac echocardiographic evaluation along with gas analyses and computed tomography scans were included in the study. Measurements were performed offline, and quantitative analyses were obtained by an operator blinded to the clinical data. We analyzed 133 patients (mean age 69±12 years, 57% men). During a mean hospital stay of 26±16 days, 35 patients (26%) died. The mean tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio was 0.48±0.18 mm/Hg in nonsurvivors and 0.72±0.32 mm/Hg in survivors (P=0.002). For each 0.1 mm/mm Hg increase in TAPSE/PASP, there was a 27% lower risk of in‐hospital death (hazard ratio [HR], 0.73 [95% CI, 0.59–0.89]; P=0.003). At multivariable analysis, TAPSE/PASP ratio remained a predictor of in‐hospital death after adjustments for age, oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen, left ventricular ejection fraction, and computed tomography lung score. Receiver operating characteristic analysis was used to identify the cutoff value of the TAPSE/PASP ratio, which best specified high‐risk from lower‐risk patients. The best cutoff for predicting in‐hospital mortality was TAPSE/PASP <0.57 mm/mm Hg (75% sensitivity and 70% specificity) and was associated with a >4‐fold increased risk of in‐hospital death (HR, 4.8 [95% CI, 1.7–13.1]; P=0.007).

Conclusions

In patients hospitalized with COVID‐19 pneumonia, the assessment of right ventricular to pulmonary circulation coupling appears central to disease evolution and prediction of events. TAPSE/PASP ratio plays a mainstay role as prognostic determinant beyond markers of lung injury.

Lipoprotein(a) and aortic valve stenosis: A casual or causal association?

AIMS

This review aims to provide an update of available methods for imaging calcification activity and potential therapeutic options.

DATA SYNTHESIS

Aortic valve calcification represents the most common heart valve condition requiring treatment among adults in Western societies. No medical therapies are proven to be effective in treating symptoms or reducing disease progression. Therefore, surgical or transcatheter aortic valve replacement remains the only available treatment option. Elevated circulating concentrations of lipoprotein(a) is strongly associated with degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies.

CONCLUSIONS

New therapeutic targets have been identified and new imaging techniques could be used to test the effectiveness of new agents and further clarify the pathophysiology of AVS. No therapy that specifically lowers Lp (a) levels has been approved for clinical use.

An Update on New Generation Transcatheter Aortic Valves and Delivery Systems

Over the last 15 years, the management of aortic valve disease has been changed by transcatheter aortic valve replacement, which has become the standard of care across the entire spectrum of surgical risk. As a result of continuous evolution of this technique, several next-generation transcatheter heart valves (THVs) have been developed to minimize procedural complications and improve patient outcomes. This review aims to provide an update on the new generation THVs and delivery systems.

Sacubitril/Valsartan in heart failure with reduced ejection fraction: clinical and echocardiographic insights from a real world population

Background

Following the PARADIGM trial, some studies have identified cardiac remodeling as major background for hard end point benefits of Sacubitril/Valsartan (S/V), but few adopted a well described definition in the literature.

Purpose

We aimed at a comprehensive evaluation of the effects of S/V on echo-derived measures of cardiac remodeling along with clinical and laboratory data over a medium-term follow-up pointing to a real-world HFrEF population.

Methods

This is a prospective observational study of HFrEF patients on optimal medical therapy (OMT) initiated with S/V at Heart Failure Clinic of our institute (January 2017-January 2020). In 62 HFrEF, echocardiographic, laboratory and clinical data were collected at baseline and over 10 (Q1-Q3 8–13) months after S/V initiation. Mean age was 68±12 years, 79% men. Left ventricular reverse remodeling (LVRR) was defined as: 1) an absolute increase in LVEF ≥10 points or a LVEF ≥50% at follow-up and 2) a relative decrease in indexed left ventricular end-diastolic diameter of at least 10% or an indexed left ventricular end-diastolic diameter ≤33 mm/m2.

Results

Compared to baseline, S/V promoted a significant improvement of LV ejection fraction (LVEF, from 30% to 37%; p&lt;0,0001) with an absolute median increase in LVEF of 8 points. Parallel significant reductions in left ventricular and atrial volumes, lower mitral regurgitation degree and a better diastolic dysfunction along with clinical improvement (NYHA class and NT-proBNP values) were observed at follow up. sPAP (systolic Pulmonary Arterial Pressure) was significantly decreased at follow-up evaluation (37 mmHg vs 31 mmHg p=0,005) (Table 1). Overall, LVRR as defined above was observed in 30% of patients. Younger age (64 vs 74 years, p=0,007), a shorter duration of the disease (7 vs 23 months, p=0,009), and non ischaemic etiology (79% vs 33% p=0,003), along with a smaller baseline LAESVi (Left Atrial End Systolic Volume, 41 vs 48 ml/m2 p=0,012) were more common in patients with LVRR. sPAP and Right Ventricular (RV) function estimated by tricuspid annular plane systolic excursion (TAPSE) were significantly better in LVRR patients along with TAPSE/sPAP ratio (Table 2).

Conclusions

Our data point to a remarkable medium-term reverse remodeling effect by S/V in HFrEF. Findings reinforce the concept that the main benefits of S/V on hard end-points are mediated by its cardiac-related effects. Both a left and right reverse remodeling occur in HFrEF patients who start S/V in the most adaptable phase of the disease supporting an early administration.

Funding Acknowledgement

Type of funding sources: None.

Phenotyping the right heart according to left ventricular geometry patterns in severe HFrEF

Background

Right ventricular (RV) failure significantly impact on heart failure with reduced ejection fraction (HFrEF) prognosis. How and whether specific functional and geometrical phenotypes of the RV function adapt and combined with left ventricular (LV) geometry is unknown.

Purpose

To test the RV function across LV geometrical patterns looking at respective prognostic roles.

Methods

We retrospectively examined a population of patients homogenously diagnosed with chronic HFrEF (defined as LV ejection fraction (EF) less than 35%) and treated with optimal therapy (OT) and all implanted with ICD for primary prevention of sudden cardiac death. Patients were categorized by echocardiography according to remodeling pattern based on left ventricular mass index and relative wall thickness into four groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). RV parameters were: tricuspid annulus plane systolic excursion (TAPSE), TAPSE/pulmonary artery pressures (PAPs), RV basal diameter and fractional area change (FAC). Outcome variable was all-cause mortality, assessed with multivariable Cox proportional hazard (PH) models.

Results

Among 193 patients (age 66±11 years, 81% men, 74% with ischemic etiology of HF and EF 28±5%) 21% had NG, 3% had CR, 8% had CH, and 68% had EH. Distribution of RV echo parameters across LV remodeling groups is shown in table 1. Over a median follow-up time of 4 (1.9 – 6.1) years, 65 deaths occurred. In multivariable Cox PH models adjusted for age, LVEF, ischemic etiology and LV geometry, TAPSE, TAPSE/PAPs, RV basal diameter and FAC strongly and independently predicted the outcome variable [HR 0.92 (95% C.I. 0.86–0.98), HR 0.08 (95% C.I. 0.01–0.57), HR 1.87 (95% C.I. 1.29–2.71), HR 0.97 (95% C.I. 0.95–1.00), respectively all p-value &lt;0.05].

Conclusion

In a homogeneously defined population of severe HFrEF outpatients receiving OT, the majority showed EH remodeling pattern, which did not predict the primary outcome. LV geometry did not further stratify patients in this high risk group. Conversely, RV dysfunction proved to be a strong predictor of mortality, independently of age, LV function and etiology of HF, regardless LV morphology.

Funding Acknowledgement

Type of funding sources: None.

Consequences on the right ventricular to pulmonary circulation coupling of COVID-19 infection

Background

Right Ventricular (RV) dysfunction and pulmonary hypertension (PH) are two very likely acute and long term targets of COVID-19 pneumonia, with a potential prognostic implications.

Purpose

To determine the COVID-19 pneumonia effects on the right ventricular to pulmonary circulation coupling through bedside echocardiography and extend its implications to prognostic assessment.

Methods

Single-centre study including consecutive subjects hospitalized for COVID-19 pneumonia who underwent a clinical indicated echocardiogram between March 2020 and December 2020. Extensive analysis of cardiac function was performed offline by an operator blinded to clinical data, laboratory findings and CT scans.

Results

133 patients were enrolled (mean age 69±12 years, 57% men), 38% of whom already had cardiac disease in their medical history. In-hospital mortality was 26% (35 pts), during a mean hospital stay of 26±16 days. Non survivors had higher pulmonary artery systolic pressure (PASP) and worse RV function, assessed with both standard parameters (i.e. TAPSE) and with the novel speckle tracking analysis by RV-Global Longitudinal Strain (RV-GLS) and RV-Free Wall Longitudinal Strain (RV-FWLS). The combination of these two variables in TAPSE/PASP ratio allows assessment of RV to pulmonary circulation (Pc) coupling and was strongly associated with in-hospital death (HR 0.73, 95% CI 0.59–0.89, p=0.003) and patients with TAPSE/PASP&lt;0.57 mm/mmHg had a more than 4-fold increased risk of in-hospital death (HR 4.8, 95% CI 1.7–13.1, p=0.003). In patients where speckle tracking analysis was feasible, we examined RV-GLS/PASP and RV-FWLS/PASP and found that it was associated with in-hospital mortality. The best cut-offs for predicting in-hospital mortality was 0.51 for RV-GLS/PASP (94% sensitivity and 59% specificity) and 0.49 for RV-free wall LS (87% sensitivity and 70% specificity). At the multivariable analysis RV to Pc remained associated with in-hospital death after adjustments for age, PaO2/FiO2, LVEF, and severity of lung involvement at the CT.

Conclusions

Either PH and RV dysfunction predict in-hospital mortality in patients with COVID-19 pneumonia. The assessment of RV to Pc coupling, however, better describes the adaptive RV response to increased PASP and gives additional prognostic information in a population with a relevant prevalence of comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging

Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.

Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation

The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.

Cardiovascular Calcification as a Marker of Increased Cardiovascular Risk and a Surrogate for Subclinical Atherosclerosis: Role of Echocardiography

The risk prediction of future cardiovascular events is mainly based on conventional risk factor assessment by validated algorithms, such as the Framingham Risk Score, the Pooled Cohort Equations and the European SCORE Risk Charts. The identification of subclinical atherosclerosis has emerged as a promising tool to refine the individual cardiovascular risk identified by these models, to prognostic stratify asymptomatic individuals and to implement preventive strategies. Several imaging modalities have been proposed for the identification of subclinical organ damage, the main ones being coronary artery calcification scanning by cardiac computed tomography and the two-dimensional ultrasound evaluation of carotid arteries. In this context, echocardiography offers an assessment of cardiac calcifications at different sites, such as the mitral apparatus (including annulus, leaflets and papillary muscles), aortic valve and ascending aorta, findings that are associated with the clinical manifestation of atherosclerotic disease and are predictive of future cardiovascular events. The aim of this paper is to summarize the available evidence on clinical implications of cardiac calcification, review studies that propose semiquantitative ultrasound assessments of cardiac calcifications and evaluate the potential of ultrasound calcium scores for risk stratification and prevention of clinical events.

Prevalence of left atrial thrombus by real time three-dimensional echocardiography in patients undergoing electrical cardioversion of atrial fibrillation: A contemporary cohort study

BACKGROUND

The prevalence of left atrial thrombi in patients scheduled for electrical cardioversion (ECV) of atrial fibrillation (AF) remains unknown in contemporary real-life practice.

METHODS AND RESULTS

Patients scheduled for ECV underwent transesophageal echocardiography (TEE) regardless of AF duration and type of anticoagulant. Of 277 consecutive patients (65% men, mean age 71 ± 10 years, CHA₂ DS₂ -VASc 3.1 ± 1.4), 92 were on direct oral anticoagulants (DOACs) and 99 on antivitamin K (AVK) oral agents for at least 3 weeks before and 4 after ECV. Eighty-five patients with paroxysmal AF on low-molecular-weight heparin were also considered. Real time three-dimensional TEE detected left atrial appendage (LAA) thrombus in 7% of patients, without significant difference among three groups (P = .334). Anticoagulation was ineffective in eight patients on AVK oral agents, two of them had thrombus. Eight patients assumed incorrectly DOACs, four of them had thrombus. Among the 175 patients on effective anticoagulation, five showed thrombus, three on AVK oral agents, and two on DOACs (P = .716). Effective anticoagulation was associated with reduced risk of thrombosis (OR: 0.16, 95%CI: 0.06-0.45, P = .001). In patients with correct anticoagulation, predictors of thrombus were CHA₂ DS₂ VASc (for each point of increment OR: 1.97, 95%CI: 1.08-3.61, P = .029), low left ventricular ejection fraction (OR: 0.92, 95%CI: 0.86-0.99, P = .026), and degree of spontaneous echo-contrast (for each point increase OR: 10, 95%CI: 2-39, P < .0001).

CONCLUSION

Patients with AF, on effective anticoagulation, had a prevalence of thrombus not negligible regardless of type of anticoagulant. TEE is prudent before ECV and mandatory if unsuccessful anticoagulation is proved or suspected.

Echocardographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Funding Acknowledgements

Type of funding sources: None.

Background

Anorexia nervosa (AN) is one of the most common form of eating disorders and it is a severe and potentially fatal disease with high rates of morbidity and mortality especially in the population aged 15-25 years. Cardiac involvement occurs in approximately 80% of patients with AN. Cardiovascular complications include changes in the autonomic regulation (increased vagal tone, bradycardia, orthostatic hypotension, syncope), arrhythmias, congestive heart failure and sudden death. Few reports have described, in small series, a variety of echocardiographic abnormalities including decreased cardiac mass, mitral valve prolapse, pericardial effusion and reduced left ventricular (LV) dimensions. No previous studies, however, examined if there is a change in these abnormalities with weight fluctuations. 

Purpose

To describe echocardiographic findings among male and female patients with AN and to examine the effect of weight gain on clinical and echocardiographic parameters.

Methods

We performed a single center, retrospective, study of  patients diagnosed with AN using the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Clinical, laboratory and ECG-graphic data were obtained by reviewing each patient’s medical records. Echocardiographic parameters were measured off-line.

Results

The study population consisted of 81 patients, mean age 24.5 ± 11.6 years, 92.6% females. 75% showed an extreme AN degree. Mean body mass index (BMI) was 15.2 ± 2.1 kg/m2. Mean heart rate was 57.2 ± 12.7 beats per minute. Some patients showed right bundle branch block (7.4%) or prolonged QT interval (14.8%). Patients with BMI below the mean value had more often pericardial effusion, smaller LV mass and LV end-diastolic volume and thinner interventricular septum (all p &lt; 0.05). However, when index to BSA, LV mass and volumes were within normal range in the 90% of the population. They also showed mitral valve abnormalities and low values of white blood cells and platelets. The presence of pericardial effusion was not related to inflammatory parameters or protein deficiency. For 39 patients echocardiographic exams at the highest and the lowest weight were available. With weight gain, there was an improvement in LV mass, interventricular septum thickness, pericardial effusion and an increase in white blood cells and platelet count.

Conclusions

Our study showed that patients with AN have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates, hypothesis confirmed by the regression with weight gain. It is possible that pericardic effusion fills the gap left by mass loss.

Arrhythmic event prediction in patients with heart failure and reduced ejection fraction

AIMS

Implantable cardioverter defibrillator (ICD) is an effective treatment to reduce mortality in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) 35% or less. LVEF presents a low sensitivity for predicting arrhythmic events. Aim of this study was to identify predictors of sustained ventricular arrhythmias (SVAs), overall and according to the cause of heart failure.

METHODS

Single-center, retrospective, cohort study of 193 patients (51 nonischemic and 142 ischemic) with chronic heart failure and LVEF less than 35% who had received ICD for primary prevention of sudden cardiac death. We collected clinical data, echocardiographic parameters and SVAs detected by the ICD.

RESULTS

During a median follow-up of 1440 days, 32 (16.2%) patients had SVAs. SVAs incidence was similar in patients with nonischemic (15.6%) and ischemic cause of heart failure (16.9%). Hypertension, diabetes, chronic renal failure, atrial fibrillation, chronic obstructive pulmonary disease, New York Heart Association class at least III were predictors at univariate analysis of SVAs. A clinical score, assigning one point to each of these variables, was associated with a significantly increased risk of SVAs [odds ratio for each point increase = 1.92, 95% confidence interval 1.40-2.65, P < 0.0001, area under the curve (AUC) 0.73], with 72% sensitivity and 60% specificity for a cutoff at least three and remained significant in nonischemic (AUC 0.84) and ischemic (AUC 0.68) patients.

CONCLUSION

Our study shows the benefit of ICD implantation in primary prevention and its independency of cause. A simple clinical score, based on comorbidities, identifies patients with more benefits from ICD implantation.

Prognostic utility of quantitative offline 2D-echocardiography in hospitalized patients with COVID-19 disease

Purpose

To assess the prognostic utility of quantitative 2D‐echocardiography, including strain, in patients with COVID‐19 disease.

Methods

COVID‐19‐infected patients admitted to the San Paolo University Hospital of Milan that underwent a clinically indicated echocardiographic examination were included in the study. To limit contamination, all measurements were performed offline. Quantitative measurements were obtained by an operator blinded to the clinical data.

Results

Among the 49 patients, nonsurvivors (33%) had worse respiratory parameters, index of multiorgan failure, and worse markers of lung involvement. Right ventricular (RV) dysfunction (as assessed by conventional and 2‐dimensional speckle tracking) was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, P = .008, and global RV LS (RV‐GLS) showed an AUC 0.79 ± 0.04, P = .004. This association remained significant after correction for age (OR = 1.16, 95%CI 1.01–1.34, P = .029 for RV free wall LS and OR = 1.20, 95%CI 1.01–1.42, P = .033 for RV‐GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR = 1.28, 95%CI 1.04–1.57, P = .021 for RV free wall‐LS and OR = 1.30, 95%CI 1.04–1.62, P = .020 for RV‐GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02–1.19, P = .034 for RV free wall LS and OR = 1.30, 95%CI 1.04–1.63, P = .022 for RV‐GLS).

Conclusions

In patients hospitalized with COVID‐19, offline quantitative 2D‐echocardiographic assessment of cardiac function is feasible. Parameters of RV function are frequently abnormal and have an independent prognostic value over markers of lung involvement.

How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism

BACKGROUND

Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism.

CASE REPORT

A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection.

CONCLUSION

Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

Multimodal Imaging of Post-Stenting Mycotic Coronary Pseudoaneurysm Complicated by Device Fracture and Myocardial Abscess

Mycotic coronary aneurysm and pseudoaneurysm are rare infective complications of percutaneous coronary interventions, associated with poor prognosis. Multimodality imaging is recommended to achieve a correct diagnosis. We present a case of post-stenting mycotic coronary pseudoaneurysm complicated by myocardial abscess in which we used different imaging tools, each carrying additional information. (Level of Difficulty: Advanced.)

Assessing apathy in multiple sclerosis: Validation of the dimensional apathy scale and comparison with apathy evaluation scale

BACKGROUND

Apathy is a predictor of cognitive decline in the course of multiple sclerosis (MS). Early identification of apathetic patients is relevant in clinical settings.

OBJECTIVE

To assess applicability and psychometric properties of the self-rated version of the Dimensional Apathy Scale (DAS) in a large cohort of patients with MS and to compare its diagnosing accuracy with that of the Apathy Evaluation Scale (AES).

METHODS

One hundred and twenty-four patients underwent clinical interview based on diagnostic criteria for apathy, DAS, AES, and assessment of depression, global cognitive functioning, and non-verbal intelligence.

RESULTS

According to diagnostic criteria, apathy occurred in 33.4% of the patients. The DAS showed high consistency, and good convergent, discriminant and criterion validity. Factor analysis indicated a three-factor structure: executive, behavioural and emotional apathy. Unlike AES, no significant association between DAS score and severity of neurological disability (expressed by EDSS total score) was found, suggesting that the DAS might be less related to levels of disability. Receiver operating characteristics analyses, with clinical diagnostic criteria for apathy as the gold standard, revealed that a DAS score of 28/29 and an AES score of 35/36 were optimal cut-off values for identifying clinically relevant apathy. The two scales had similar diagnostic accuracy in the present sample.

CONCLUSIONS

The DAS is a valid and reliable multidimensional tool to assess apathy in MS, with diagnostic accuracy similar to that of the AES. However, the DAS score appears to be less strongly related to neurological disability.

Pulmonary embolism with migrating thrombus through patent foramen ovale: A case for a mixed pharmacological and percutaneous management

A 61-year-old man, admitted to our hospital for bilateral pulmonary embolism, complicated by right renal ischemia and multiple splenic infarcts due to a mobile thrombus entrapped in a patent foramen ovale, has been successfully treated with apixaban 5 mg twice daily followed by transcatheter patent foramen ovale closure. <Learning objective: Apixaban could be a therapeutic alternative to thrombolysis and surgery in patients with warfarin-resistant thrombus straddling in the patent foramen ovale (PFO). Furthermore, apixaban could be a simple and useful option to manage patients undergoing transcatheter PFO closure. Finally, in the evaluation and treatment of PFO, it is necessary to remember that it is associated not only with cryptogenic stroke but also with non-cerebral, paradoxical systemic embolic events such as myocardial infarction renal, infarct, and limb ischemia.>.

Apixaban-Induced Resolution of A Massive Left Atrial and Appendage Thrombosis in a Very Elderly Patient

A 86-year-old woman with first diagnosed atrial fibrillation (AF) underwent mitral valve annuloplasty 10 years before was admitted to our Unit due to congestive heart failure. Trans-thoracic echocardiogram (TTE) revealed a large fluctuant echogenic mass in the posterior wall of the left atrium. Trans-esophageal echo (TEE) showed the origin of the mass within the left atrial appendage. An adjusted dose of the novel oral anticoagulant (NOAC) apixaban, was prescribed. A complete disappearance was appreciated by examination at 12 weeks after the first drug administration. Although apixaban, resulted superior to warfarin in preventing stroke and thrombo-embolic events in patients with non valvular AF, while causing less bleeding, few data are actually available regarding the efficacy and safety of this drug in left atrium and appendage thrombosis management. Our report shows that this NOAC could be a simple and useful option to manage huge atrial thrombosis in very elderly patients.

Anxiety in Multiple Sclerosis: psychometric properties of the State-Trait Anxiety Inventory

OBJECTIVE

The aims of the present study were to examine psychometric properties of the Spielberger State-Trait Anxiety Inventory (STAI-Y-1 and STAI-Y-2, respectively) in a Multiple Sclerosis (MS) population and to identify a cut-off score to detect those MS patients with high level of state and/or trait anxiety who could be more vulnerable to development of depression and/or cognitive defects.

MATERIAL AND METHODS

The STAI-Y-1 and STAI-Y-2 was completed by a group of patients (n = 175) affected by MS and a group of healthy subjects (n = 150) matched for age, educational level, and gender. In MS patients internal consistency, divergent and discriminant validities were evaluated. Construct validity was examined by exploratory factor analysis for each scale.

RESULTS

There was no missing data, no floor or ceiling effects for both scales. The two scales showed high internal consistency, good divergent, and Known-groups validities. To identify high levels of state and trait anxiety in a patient with MS, we proposed three gender specific screening cut-off values (1, 1.5, 2 SD) for the STAI-Y-1 and the STAI-Y-2.

CONCLUSIONS

The findings showed that the STAI-Y-1 and the STAI-Y-2 are a valid tool for clinical use in MS patients and can be useful to measure the severity of anxiety and to identify those patients with high anxiety to introduce them in specific non-pharmacological intervention.

A randomized clinical trial to evaluate the effects of rasagiline on depressive symptoms in non-demented Parkinson's disease patients

BACKGROUND AND PURPOSE

Depressed mood is a common psychiatric problem associated with Parkinson's disease (PD), and studies have suggested a benefit of rasagiline treatment.

METHODS

ACCORDO (see the ) was a 12-week, double-blind, placebo-controlled trial to evaluate the effects of rasagiline 1 mg/day on depressive symptoms and cognition in non-demented PD patients with depressive symptoms. The primary efficacy variable was the change from baseline to week 12 in depressive symptoms measured by the Beck Depression Inventory (BDI-IA) total score. Secondary outcomes included change from baseline to week 12 in cognitive function as assessed by a comprehensive neuropsychological battery; Parkinson's disease quality of life questionnaire (PDQ-39) scores; Apathy Scale scores; and Unified Parkinson's Disease Rating Scale (UPDRS) subscores.

RESULTS

One hundred and twenty-three patients were randomized. At week 12 there was no significant difference between groups for the reduction in total BDI-IA score (primary efficacy variable). However, analysis at week 4 did show a significant difference in favour of rasagiline (marginal means difference ± SE: rasagiline -5.46 ± 0.73 vs. placebo -3.22 ± 0.67; P = 0.026). There were no significant differences between groups on any cognitive test. Rasagiline significantly improved UPDRS Parts I (P = 0.03) and II (P = 0.003) scores versus placebo at week 12. Post hoc analyses showed the statistical superiority of rasagiline versus placebo in the UPDRS Part I depression item (P = 0.04) and PDQ-39 mobility (P = 0.007) and cognition domains (P = 0.026).

CONCLUSIONS

Treatment with rasagiline did not have significant effects versus placebo on depressive symptoms or cognition in PD patients with moderate depressive symptoms. Although limited by lack of correction for multiple comparisons, post hoc analyses signalled some improvement in patient-rated cognitive and depression outcomes.

Cognitive performances and DAT imaging in early Parkinson's disease with mild cognitive impairment: a preliminary study

OBJECTIVES

Mild cognitive impairment (MCI) is a common feature in Parkinson's disease (PD). We performed an exploratory study to investigate dopaminergic nigrostriatal innervation and its cognitive correlates in early untreated PD patients with MCI as compared to cognitively intact patients.

PATIENTS AND METHODS

A consecutive series of 34-de-novo, drug-naïve patients with PD were enrolled. They underwent [123-I] FP-CIT SPECT and comprehensive neuropsychological battery. MCI was identified in 15 of 34 patients with PD.

RESULTS

The two groups did not show any statistically significant difference in age, sex, disease duration, education, lateralization, and H&Y and Hospital Anxiety and Depression Scale scores. Logistic regression analysis showed that UPDRS-III was weakly associated with MCI (P = 0.034). Partial correlation analysis controlling for UPDRS-III and age suggested that in PD patients with MCI reduced V3″ values in the more affected caudate were correlated with reduced performances in frontal assessment battery, Trail Making Test: part B minus Part A and copy task of the Rey-Osterrieth complex figure test. Reduced V3″ values in the more and less affected putamen were significantly related with reduced performance in frontal assessment battery and in copy task of Rey-Osterrieth complex figure test, respectively. No correlation was found between neuropsychological scores and DAT availability in PD patients without MCI.

CONCLUSIONS

Although preliminary, our results suggest that striatal dopamine depletion may contribute to some cognitive deficit in early never treated PD patients with MCI.

Increased bilirubin levels in de novo Parkinson's disease

BACKGROUND AND PURPOSE

Oxidative stress is a central pathogenic mechanism of Parkinson's disease (PD), and the heme oxygenase (HO) bilirubin pathway is one of the main mammalian antioxidative defences. Indeed, there is growing evidence of HO-bilirubin upregulation from early phases of PD. Our aim was to investigate bilirubin as a possible biomarker of PD diagnosis and progression.

METHODS

A cross-sectional case-control study was performed to evaluate differences in bilirubin levels between newly diagnosed, drug-naïve PD subjects and controls. Afterwards, PD subjects were included in a 2-year longitudinal study to evaluate disease progression in relation to baseline bilirubin levels.

RESULTS

Seventy-five de novo PD subjects were selected and matched with 75 controls by propensity score. Analysis of variance showed higher bilirubin levels in PD patients compared with controls (P < 0.001). Linear regression analysis failed to show a relationship between bilirubin and Unified Parkinson's Disease Rating Scale (UPDRS) part III (P = 0.283) at baseline evaluation. At 2-year follow-up, indirect relationships between bilirubin levels and UPDRS part III (P = 0.028) and between bilirubin levels and levodopa-equivalent daily dosage (P = 0.012) were found.

CONCLUSIONS

Parkinson's disease subjects showed higher levels of bilirubin compared with controls. Bilirubin increase might be due to HO overexpression as a compensatory response to oxidative stress occurring from early stages of PD.

Migraine and cranial autonomic symptoms in children and adolescents: a clinical study

The frequency of cranial autonomic symptoms in children affected by primary headaches is uncertain. The aim of our study was to estimate the frequency of symptoms in pediatric headaches and correlate it with main migraine characteristics. A questionnaire investigating the presence of cranial autonomic symptoms was administered to all children with primary headache for 2 years. A total of 230 children with primary headache (105 males, 125 females) were included. Two hundred two children were affected by migraine and 28 (12.2%) by other primary headaches. Cranial autonomic symptoms were significantly complained by migraineurs (55% vs. 17.8%) (P < .001) and by children with higher frequency of migraine attacks (odds ratio = 2.6, confidence interval = 1.4-4.7, P = .001). Our findings show that cranial autonomic symptoms are rather common during pediatric migraine attacks. The association between cranial autonomic symptoms and higher frequency of attacks might suggest the role of the trigeminal-autonomic reflex in migraine pathophysiology.