Mapping the occurrence of Eustrongylides spp. in fish species caught from six lakes in Central Italy (Tuscany and Latium regions): Implications for local fishery supply chains

In the present study, in order to expand the knowledge on the distribution of parasites of the genus Eustrongylides in never investigated Italian lacustrine areas of Tuscany and Latium, fish specimens from four Tuscan lakes (Bilancino, Chiusi, Montedoglio and San Cipriano) and two Latium lakes (Bolsena and Bracciano) were collected and analyzed. The parasitological analysis, consisting of a visual inspection followed by a chloro-peptic digestion, was performed on 1650 specimens belonging to 17 species: European perch (Perca fluviatilis), Pumpkinseed (Lepomis gibbosus), Pike-perch (Sander lucioperca), Largemouth black bass (Micropterus salmoides), Pike (Esox lucius), Big-scale sand smelt (Atherina boyeri), Tench (Tinca), European Whitefish (Coregonus lavaretus), Channel catfish (Ictalurus punctatus), Chub (Squalius cephalus), Rudd (Scardinius erythrophthalmus), Common bleak (Alburnus alborella), South European roach (Sarmarutilus rubilio), South European nase (Protochondrostoma genei), Italian riffle dace (Telestes muticellus), Goldfish (Carassius auratus), and Freshwater bream (Abramis brama). Eustrongylides spp. larvae were only found in one specimen of European perch caught in Bracciano Lake and purchased from a local fishmonger (P = 3.3%; MI = 1; MA = 0.03). The only isolated Eustrongylides spp. larva was submitted to molecular analysis of the ITS gene region and identified as E. excisus. This finding adds Bracciano Lake to the list of the several Italian lakes in which nematodes belonging to this genus have been reported. Even if the observed prevalence is currently low, the presence of the parasite in this local freshwater fish supply chain requires FBOs to adopt risk management measures to prevent contaminated products from reaching final consumer. Moreover, future investigations will show if the parasite expands in these areas.

The Occurrence of Microplastics in Donax trunculus (Mollusca: Bivalvia) Collected along the Tuscany Coast (Mediterranean Sea)

Microplastics (MPs) (0.1 µm-5 mm particles) have been documented in oceans and seas. Bivalve molluscs (BMs) can accumulate MPs and transfer to humans through the food chain. BMs (especially mussels) are used to assess MPs' contamination, but the genus Donax has not been thoroughly investigated. The aim of this study was to detect and characterize MPs in D. trunculus specimens collected along the Tuscan coast (Italy), and to assess the potential risk for consumers. The samples (~10 g of tissue and intervalval liquid from 35 specimens) were digested using a solution of 10% KOH, subjected to NaCl density separation, and filtered through 5 μm pore-size filters. All items were morphologically classified and measured, and their mean abundance (MA) was calculated. Furthermore, 20% of them were analyzed by Raman spectroscopy and, based on the obtained results, the MA was recalculated (corrected MA) and the annual human exposure was estimated. In the 39 samples analyzed, 85 items fibers (n = 45; 52.94%) and fragments (n = 40; 47.06%) were found. The MA was 0.23 ± 0.17 items/grww. Additionally, 83.33% of the items were confirmed as MPs (polyethylene and polyethylene terephthalate). Based on the correct MA (0.18 MPs/grww), D. trunculus consumers could be exposed to 19.2 MPs/per capita/year. The health risk level of MPs was classified as level III (moderate).

The Characterisation of Lactococcus garvieae Isolated in an Outbreak of Septicaemic Disease in Farmed Sea Bass (Dicentrarchus labrax, Linnaues 1758) in Italy

In aquaculture, Lactococcus garvieae is a common fish pathogen that can cause significant economic losses in several fresh and saltwater species. Despite the extensive range of hosts, L. garvieae infection in sea bass (Dicentrarchus labrax) has rarely been reported. During the summer of 2023, an outbreak occurred in an inland farm in the Gulf of Follonica (Tuscany, Italy). Fish of various sizes were affected, showing apathy, inappetence, erratic swimming and eye lesions, while the mortality was low (2-3% per month). Anatomopathological examinations suggested a septicaemic infection characterised by melanosis, diffuse redness (skin and fins), paleness (gills and internal organs), haemorrhages and splenomegaly. Seventy swabs from the viscera of 14 subjects were collected and colonies similar to Streptococcus spp. grew from all the samples. Lactococcus garvieae was identified via the biochemical tests, API20STREP, MALDI-TOF, 16S rDNA and whole genome sequencing. Genetical characterisation revealed remarkable differences between this isolate and the strains previously isolated in Italian fish farms. Feed treatments with flumequine and erythromycin were ineffective. Considering the limited effects of antimicrobials, preventive measures, such as vaccination and biosecurity, should be implemented.

Marine phycotoxin levels in shellfish-14 years of data gathered along the Italian coast

Along the Italian coasts, toxins of algal origin in wild and cultivated shellfish have been reported since the 1970s. In this study, we used data gathered by the Veterinary Public Health Institutes (IZS) and the Italian Environmental Health Protection Agencies (ARPA) from 2006 to 2019 to investigate toxicity events along the Italian coasts and relate them to the distribution of potentially toxic species. Among the detected toxins (OA and analogs, YTXs, PTXs, STXs, DAs, AZAs), OA and YTX were those most frequently reported. Levels exceeding regulatory limits in the case of OA (≤2,448 μg equivalent kg-1) were associated with high abundances of Dinophysis spp., and in the case of YTXs (≤22 mg equivalent kg-1) with blooms of Gonyaulax spinifera, Lingulodinium polyedra, and Protoceratium reticulatum. Seasonal blooms of Pseudo-nitzschia spp. occur all along the Italian coast, but DA has only occasionally been detected in shellfish at concentrations always below the regulatory limit (≤18 mg kg-1). Alexandrium spp. were recorded in several areas, although STXs (≤13,782 µg equivalent kg-1) rarely and only in few sites exceeded the regulatory limit in shellfish. Azadinium spp. have been sporadically recorded, and AZAs have been sometimes detected but always in low concentrations (≤7 µg equivalent kg-1). Among the emerging toxins, PLTX-like toxins (≤971 μg kg-1 OVTX-a) have often been detected mainly in wild mussels and sea urchins from rocky shores due to the presence of Ostreopsis cf. ovata. Overall, Italian coastal waters harbour a high number of potentially toxic species, with a few HAB hotspots mainly related to DSP toxins. Nevertheless, rare cases of intoxications have occurred so far, reflecting the whole Mediterranean Sea conditions.

Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center

AIMS

We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery.

METHODS

A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation.

RESULTS

In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation.

CONCLUSION

Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted.

LEVEL OF EVIDENCE

IV Clinical Case Series.

Analysis and management of the COVID-19 pandemic impact on a multispecialty diagnostic imaging department

Introduction

The propose of this study was to evaluate the impact of the first two waves of the COVID-19 pandemic on a multispecialty radiology department in a large tertiary university hospital in Northern Italy.

Methods

The numbers of all radiological exams performed in the radiology department of Scientific Institute for Research, Hospitalization and Healthcare (namely, IRCCS) Policlinico San Donato (San Donato Milanese, Italy) from March 2019 to March 2021 were collected and compared, subdividing them both temporally, modality, sub-specialty, and setting.

Results

Comparing the first 12 months of the COVID-19 pandemic (from March 2020 to February 2021) with the previous 12 months (from March 2019 to February 2020), there was an overall decrease in total radiological examinations equal to 26% (from 127,998 to 94,550). The most affected modality was DXA (from 4,706 to 2,989, -36%), followed by ultrasonography (from 17,212 to 11,644, -32%), digital radiography (from 66,050 to 47,374, -28%), MRI (from 13,332 to 10,140, -24%), CT (from 19,208 to 15,746, -18%), and mammograms (from 7,490 to 6,657, -11%). Chest CTs of inpatients saw a +15% surge (from 1,087 to 1,144), with far larger sizable increments being observed for chest X-ray examinations of outpatients (from 3,032 to 7,536, +131%). Further sub-analysis according to pandemic waves highlighted an overall -65% decrease of radiological services during the first wave (from March to May 2020), curtailed to -3% during the June–October period and then again rising to -23% during the second wave (from November 2020 to February 2021).

Conclusion

The COVID-19 pandemic led to a marked decrease of total radiological examinations during the two pandemic waves, limited to -26% by the implementation of safety protocols during the second wave and by increased activity during the inter-wave period.

Postoperative outcomes in total hip arthroplasty following femoral head avascular necrosis in HIV-positive patients

Background:

Few clinical studies have been published reporting the clinical outcomes of total hip replacement (THA) in HIV-positive patients affected by femoral head avascular necrosis (AVN) often with controversial results and often without any correlation with the immunological patient status. Our study aim is to retrospectively review the outcome of a HIV-positive patient series.

Material and Methods:

24 THAs perfomed between 2007 and 2017 were assessed in the study. All patients have been classified with Charlson Comorbidity Index (CCI) and the CDC (Center for Disease Control and Prevention) HIV classification. At the latest follow-up each patient have been evaluated using Harris Hip Score (HHS), WOMAC score, a numerical pain rating scale (NRS) and procedure-related complications were collected.

Results:

At a mean mean follow up of 96,41 months the mean WOMAC score was 91,66 and the mean Harris Hip Score was 86,77 with excellent results in 18 hips, good in 1 and poor in the 5. Post-operative complications were reported in 7 hips, 3 patients developed a periprosthetic joint infection (PJI) in patients with low CD4+ count and history of intravenous drug consumption.

Conclusion:

We registered a good outcome in HIV patient with femoral head AVN treated with Total Hip replacement. However, we reported a significant increase in complications and revision rate especially referred to PJI, in patient with history of intravenous drug consumption and low CD4+ count. The authors advocate further prospective multicentric studies with larger population in the future. (www.actabiomedica.it9

Multimodality Approach for Endovascular Left Atrial Appendage Closure: Head-To-Head Comparison among 2D and 3D Echocardiography, Angiography, and Computer Tomography

Background: Percutaneous left atrial appendage closure (LAAC) requires accurate pre- and intraprocedural measurements, and multimodality imaging is an essential tool for guiding the procedure. Two-dimensional (2D TOE) and three-dimensional (3D TOE) transoesophageal echocardiography, cardiac computed tomography (CCT), and conventional cardiac angiography (CCA) are commonly used to evaluate left atrial appendage (LAA) size. However, standardized approaches in measurement methods by different imaging modalities are lacking. The aims of the study were to evaluate the LAA dimension and morphology in patients undergoing LAAC and to compare data obtained by different imaging modalities: 2D and 3D TOE, CCT, and CCA. Methods: A total of 200 patients (mean age 70 ± 8 years, 128 males) were examined by different imaging techniques (161 2D TOE, 103 3D TOE, 98 CCT, and 200 CCA). Patients underwent preoperative CCT and intraoperative 2D and 3D TOE and CCA. Results: A significant correlation was found among all measurements obtained by different modalities. In particular, 3D TOE and CCT measurements were highly correlated with an excellent agreement for the landing zone (LZ) dimensions (LZ diameter: r = 0.87; LAA depth: r = 0.91, p < 0.001). Conclusions: Head-to-head comparison among imaging techniques (2D and 3D TOE, CCT, and CCA) showed a good correlation among LZ diameter measurements obtained by different imaging modalities, which is a parameter of paramount importance for the choice of the LAAC device size. LZ diameters and area by 3D TOE had the best correlation with CCT.

Cardiac patient care during a pandemic: how to reorganise a heart failure unit at the time of COVID-19

To date, the pandemic spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has involved over 100 countries in a matter of weeks, and Italy suffers from almost 1/3 of the dead cases worldwide.

In this report, we show the strategies adopted to face the emergency at Centro Cardiologico Monzino, a mono-specialist cardiology hospital sited in the region of Italy most affected by the pandemic, and specifically we describe how we have progressively modified in a few weeks the organization of our Heart Failure Unit in order to cope with the new COVID-19 outbreak. In fact, on the background of the pandemic, cardiovascular diseases still occur frequently in the general population, but we observed consistent reduction in hospital admissions for acute cardiovascular events and a dramatic increase of late presentation acute myocardial infarction. Despite a reduction of healthcare workers number, our ward has been rearranged in order to take care of both COVID-19 and cardiovascular patients. In particular according to a triple step procedure we divided admitted patients in confirmed, suspected and excluded cases (respectively allocated in “red”, “pink” and “green” separated areas).

Due to the absence of definite guidelines, our aim was to describe our strategy in facing the current emergency, in order to reorganize our hospital in a dynamic and proactive manner. To quote the famous Italian writer Alessandro Manzoni ‘It is less bad to be agitated in doubt than to rest in error.’

P1799 The importance of 3D imaging techniques in left atrial appendage closure: landing zone eccentricity influence on peri-device leak incidence and its implication in long-term clinical outcomes

Background

A complex left atrial appendage (LAA) morphology and a non-circular landing zone (LZ) are frequently encountered in patients undergoing percutaneous LAA occlusion (LAAO). Three-dimensional (3D) imaging modalities as 3D transoesophageal echocardiography (3D TOE) and cardiac computed tomography (CCT) should be preferred over two dimensional techniques for better evaluation of LAA diameters, especially for the LZ. In fact, non-circular shape could impair the choice of occluder device size and may be implicated in the occurrence of residual leaks. Incomplete LAA occlusion is recognized to be associated with thromboembolic events.

Purpose

The aim of the study was to evaluate the utility of 3D imaging techniques to predict LAA device size and the landing zone eccentricity index as a potential predictor of residual peri-device leaks and to assess their clinical implications on long-term follow-up.

Methods

It was a retrospective, single-center study including 137 consecutive patients undergoing successful LAAO from January 2010 to July 2018. Pre-procedural 3D TOE and CCT were used to predict device size based upon LZ diameters and quantify LAA orifice eccentricity. Leaks were defined as the presence of peri-device flow at 2D TOE immediately after the device implantation and at 3 months follow-up. Leaks were classified as significant (color jet width ≥4 mm) or minor (&lt;3 mm). A clinical evaluation of thromboembolic events was performed at 48 ± 27 months from the procedure.

Results

LAAO closure was performed implanting either Amulet or Watchman devices (n = 98 and n = 40, respectively). The assessment of LZ measurements with 3D TOE and CCT showed a significant correlation with the device size selected on the basis of 2D techniques (r = 0.82 and r = 0.74, respectively). As concerns the peri-device leaks, the presence of an eccentric LZ (eccentricity index &gt;0.20) was not associated to the development of post-procedural leaks in the overall population; a significant correlation was detected only in the subgroup of patients treated with the Amulet device (p = 0.045). Residual leaks included only 1 significant leak (0.7%) after Amulet device implantation, which was related to a major neurological event (stroke) and 47 (34%) minor leaks (n = 28 in the Amulet group, n = 19 in the Watchman group). In this last population, 2 patients (1.5%) developed minor neurological events (transient ischemic attack).

Conclusions

3D TOE and CCT better predict device size overcoming the limit of 2D imaging techniques undersizing. In eccentric LAA, Watchman device may reduce the incidence of peri-device leaks. The presence of significant residual leaks is uncommon but associated with major clinical events, whilst minor leaks are relatively frequent but do not seem to be related to life-threatining thromboembolic accidents.

Natriuretic peptide B plasma concentration increases in the first 12 h of pulmonary edema recovery

BACKGROUND

According to guidelines, single determination of B-type Natriuretic peptide (BNP) should be used for distinguishing between cardiac and non-cardiac acute dyspnea at the emergency room. BNP measurement is also recommended before hospital discharge in patients hospitalized for heart failure to assess prognosis and to evaluate treatment efficacy. In acute cardiogenic pulmonary edema, BNP is measured using a single BNP determination, but the temporal behavior of BNP during pulmonary edema recovery is unknown.

METHODS

Fifty chronic low ejection fraction (<40%) heart failure patients (age 77 ± 9 years, 17 M-33F) admitted for acute pulmonary edema were studied. Patients were grouped according to 50% dyspnea recovery time into 3 groups: ≤30 min (n = 14), 30 to 60 min (n = 19), and > 60 min (n = 17). BNP was measured at arrival and 4, 8, 12 and 24 h afterwards.

RESULTS

At arrival, BNP was elevated in all patients without significant difference among groups. In the entire population, BNP median and interquartile range value were 791 (528-1327) pg/ml, 785(559-1299) pg/ml, 1014(761-1573) pg/ml, 1049(784-1412) pg/ml, 805(497-1271) pg/ml at arrival and 4, 8, 12 and 24 h afterwards, respectively, showing higher values at 8 and 12 h. This peculiar temporal behavior of BNP was shared by all study groups. Patients with the longest edema resolution showed the highest BNP level 8 and 12 h after admission.

CONCLUSIONS

In acute pulmonary edema, BNP increased up to 12 h after emergency admission regardless of dyspnea recovery time, making BNP quantitative meaning in the acute phase of pulmonary edema uncertain.

Minimally invasive procedure for the stabilization of the painful "prearthritic" carpometacarpal joint of the thumb

The painful thumb carpometacarpal joint without arthritic changes with joint laxity is a common condition mainly affecting the female population in their early decades. Despite this, there is a lack of literature on the available treatment options. In the existing literature ligament reconstruction and extension osteotomy have both been described. In these methods the surgical trauma is quite extensive. In this paper, the authors document and present a new minimally invasive procedure for the treatment of this condition. Patients with painful and lax thumb carpometacarpal joint who did not benefit from conservative treatment underwent surgical treatment. The integrity of the cartilage was checked arthroscopically and it was considered an absolute indication to perform the technique consisting of stabilizing the space between the first and second metacarpal base with a suture button device. A standard postoperative protocol followed. No major complications occurred. According to preliminary experience and short-term follow-up results this technique is a comparatively safer, less invasive, and less aggressive procedure.

Single portal endoscopic treatment for chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome of the forearm is an unusual disease not commonly found in the daily practice of a hand surgeon. This condition is quite rare in the general population but occurs more frequently among musicians and athletes, with the highest incidence found in professional motorcycle drivers. It is mainly because of a critical augmentation of the extracellular pressure of the forearm compartments. The diagnosis is mainly clinical, based on stress dynamic tests and intracompartmental pressure measurements. Traditionally, the treatment of this disease has revolved around trigger activity suspension. In the case of professional athletes, this solution cannot be considered and thus the standard surgical treatment consists of an open forearm fasciotomy. This procedure usually requires a lengthy operation period and has a long recovery time before patients can resume their regular activity. Different surgical endoscopic solutions with mini-open techniques have been proposed to shorten this time and reduce the incision size. The aim of this study was to present a new technique for endoscopic-assisted fasciotomy of the forearm in chronic exertional compartment syndrome using a single mini-incision. Four surgical procedures were performed in 3 patients. They were all treated at our center for this condition, and in one case the disease was found on both sides.

Detection of Cyprinid herpesvirus 2 in association with an Aeromonas sobria infection of Carassius carassius (L.), in Italy

Sixteen specimens of female crucian carp, Carassius carassius (L.), during the breeding season, were investigated for post-mortem and full diagnostic examination during a mortality outbreak in a tributary stream of the Arno River in Tuscany in 2011. Necropsy highlighted the presence of a swollen anus and widespread haemorrhages in the body, fins, gills and eyes. Haemorrhages in internal organs and spleen granulomas were also observed. Bacteria isolated from the brain, kidney and spleen of affected fish were identified as A. sobria. Microscopic lesions observed in gills were characterized by necrosis of the secondary lamellae, congestion and multifocal lamellar fusion. The kidney showed necrosis, oedema, fibrin exudation and areas of haemorrhages, while in the spleen the main lesions were by multifocal necrosis of the lymphoid tissue. In the gills, transmission electron microscopy revealed herpesvirus-like particles, subsequently identified as Cyprinid herpesvirus-2 (CyHV-2) with a nested PCR protocol. Although it was not possible to attribute a pathogenic role to CyHV-2 in this mortality event, the identification of this herpesvirus in crucian carp increases the concern about its potential role in this species.

Feasibility of a new generation three-dimensional echocardiography for right ventricular volumetric and functional measurements

Right ventricular (RV) dimensions and function are of diagnostic and prognostic importance in cardiac disease. Because of the peculiar morphology of the right ventricle, 2-dimensional echocardiography has several limitations in RV evaluation. Recently, new 3-dimensional transthoracic echocardiographic software adapted for RV morphology was introduced. The aims of this study were to evaluate the feasibility of 3-dimensional RV analysis in a large population and to compare and correlate 3-dimensional RV data with classic 2-dimensional and Doppler parameters, including tricuspid annular plane systolic excursion and peak systolic velocity on Doppler tissue imaging, RV fractional shortening area, RV stroke volume (by the Doppler method), and pulmonary arterial systolic pressure. Two hundred subjects were studied: 48 normal controls and 152 patients with valvular heart disease (104 patients), idiopathic dilated cardiomyopathy (20 patients), or pulmonary hypertension (28 patients). The mean times for 3-dimensional acquisition and 3-dimensional reconstruction were 3 +/- 1 and 4 +/- 2 minutes, respectively. Imaging quality was good in most cases (85%). The mean RV diastolic and systolic volumes were 103 +/- 38 and 46 +/- 28 ml, respectively. The RV ejection fraction (RVEF) was correlated negatively with pulmonary arterial systolic pressure and positively with tricuspid annular plane systolic excursion, peak systolic velocity, and fractional shortening area. The pathologic group was characterized by larger RV volumes and lower RVEFs. Three-dimensional echocardiography clearly showed that in the pathologic group, patients with pulmonary hypertension had the largest RV volumes and the lowest RVEFs and that those with idiopathic dilated cardiomyopathy were characterized by RVEFs lower than those of patients with valvular disease. In conclusion, this new quantitative 3-dimensional method to assess RV volumes and function is feasible, relatively simple, and not time consuming. Data obtained with 3-dimensional analysis are well correlated with those obtained by 2-dimensional and Doppler methods and can differentiate normal and pathologic subjects.

Incidence and characteristics of left ventricular false tendons and trabeculations in the normal and pathologic heart by second harmonic echocardiography

We sought to review echocardiographic incidence of anomalous images (AI) as false tendons and trabeculations of the left ventricle (LV) in light of recent advancements in echocardiographic evaluation of heart anatomy. In 1580 patients the presence of false tendons, trabeculations, or thrombi was evaluated with transthoracic echocardiography and correlated to clinical characteristics and echocardiographic parameters. Incidence of AI was 46.7% (75% false tendons, 23% trabeculations, 2% thrombi), slightly higher in pathologic (48.9%) than in normal hearts (40.8%). AI were more frequent in male patients (52%) than in female patients (39.7%) and associated with LV dilatation, hypertrophy, and systolic dysfunction. False tendons and trabeculations were not related to age. Male sex was the most significant independent predictor of AI. In 2 patients, isolated LV noncompaction of myocardium was diagnosed and confirmed by magnetic resonance imaging. This study shows a high prevalence of AI for patients with and without pathologic hearts suggesting the need of updating LV echocardiographic anatomy. It also emphasizes the necessity for an awareness of these anatomic variants when evaluating patients for mural thrombi and cardiomyopathies.

Effects of acute angiotensin-converting enzyme inhibition on diastolic ventricular interaction in the dilated heart

BACKGROUND

The normal and dilated heart behaves as a single functional unit during preload reduction: volume unloading in the setting of diastolic ventricular interaction allows for increased left ventricular (LV) filling.

HYPOTHESIS

We hypothesized that reduction of venous return induced by a physiologic stimulus (tilting) or by acute angiotensin-converting enzyme (ACE) inhibitors in dilated heart is likely to have a marked and similar effect on ventricular chamber geometry and filling. This study was designed to assess how the normal and dilated heart adapts to preload reduction.

METHODS

Twenty normal subjects and 20 patients with moderate heart failure due to dilated cardiomyopathy were studied with two-dimensional and Doppler echocardiography in supine position (B) and after 40 degrees of head-up tilting (T). The following day, patients repeated supine (C) and tilting test (TC) after administration of captopril (25 mg s.l.). Right ventricular (RV) and LV dimensions, LV geometry, and tricuspid, mitral, and pulmonary venous flow patterns were recorded at each step of the study.

RESULTS

In the two groups, T was associated with reduction of RV area and LV volumes; C and TC produced a similar effect on RV and LV. Changes in LV septal-lateral diameter and anterior-posterior diameter were different at each step of the study: during T (both groups) and after C and TC, the septallateral diameter increased slightly while the anterior-posterior diameter decreased. During T, mitral and tricuspid peak flow velocities decreased, peak late velocities were unchanged, and the deceleration time of mitral flow increased; the systolic forward flow of pulmonary venous flow decreased, the diastolic forward flow did not change, and the difference in duration between reverse pulmonary flow and mitral peak late flow decreased: C and CT induced similar changes.

CONCLUSION

Preload reduction induced by tilting or by ACE inhibitors induces profound and similar effects on LV and RV dimensions, LV geometry, and biventricular filling. Reduction of RV dimension is associated with adaptation of LV geometry and decrease of LV diastolic pressure, which facilitates LV filling and pulmonary venous drainage: ACE inhibition associated with tilting exerts an additional effect on these changes. These data confirm the role of ventricular interaction in modulating LV filling in heart failure.

Synergistic efficacy of enalapril and losartan on exercise performance and oxygen consumption at peak exercise in congestive heart failure

Oxygen consumption at peak exercise (peak VO2) is a strong independent predictor of the outcome in congestive heart failure (CHF). Renin-angiotensin system inhibition with either ACE or AT1 receptor blockers is effective on peak VO2. We evaluated whether mechanisms are similar for the 2 categories of drugs and whether their combination is able to produce a synergistic effect. Twenty CHF patients were randomized to receive, in a double-blind fashion, placebo + placebo (P+P), enalapril (20 mg/day) + placebo (E+P), losartan (50 mg/day) + placebo (L+P), and enalapril + losartan (E+L) or the same preparations in a reverse order, each for 8 weeks. Two patients did not complete the trial. Pulmonary function, cardiopulmonary exercise test, plasma neurohormones, and quality of life were assessed at the end of each treatment. Compared with P+P, E+P, and L+P similarly (16% and 15%, respectively) and significantly (p <0.01) augmented peak VO2. Enalapril improved lung function (reduced slope of ventilation vs carbon dioxide production and dead space to tidal volume ratio, and increased alveolar membrane conductance and tidal volume). Losartan likely activated the exercising muscle perfusion (raised delta VO2/delta work rate, which is a measure of aerobic work efficiency). In combination, they further increased peak VO2, 10% from E+P (p <0.05) and 11% from L+P (p <0.05). Compared with run-in, E+P and L+P significantly reduced plasma norepinephrine by 70 +/- 14 pg/ml and 100 +/- 16 pg/ml and aldosterone by 1.6 +/- 0.7 ng/dl and 1.6 +/- 0.8 ng/dl. These changes were significantly greater when the drugs were combined (140 +/- 20 pg/ml for norepinephrine, and 5.6 +/- 0.9 ng/dl for aldosterone). Quality-of-life score did not improve significantly at each treatment step. Thus, lorsartan and enalapril similarly increased peak VO2 in CHF patients, but mediators of this effect were, at least in part, different therapeutic targets that may be synergistic when the 2 drugs are combined.