Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe

AIM

To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)].

METHODS

Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation.

RESULTS

Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001).

CONCLUSIONS

Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

The added value of the HFA/ICOS score in the prediction of chemotherapy-related cardiac dysfunction in breast cancer

BACKGROUND

The 2022 ESC Guidelines on Cardio-Oncology recommend baseline cardiovascular risk stratification before starting anticancer drugs, using the new risk assessment tools proposed by the Heart Failure Association (HFA) and the International Cardio-Oncology Society (ICOS).Our study aimed to assess the clinical application of HFA/ICOS risk score in breast cancer patients undergoing chemotherapy and its usefulness in predicting the development of chemotherapy-related cardiac dysfunction (CTRCD).

METHODS

A prospective multicentric study enrolled 109 breast cancer patients treated with anthracyclines with or without trastuzumab. A cardiological evaluation, including ECG and echocardiogram at baseline (T0), 3 (T1), 6 (T2), and 12 months (T3) after starting treatment was performed. HFA/ICOS score was assessed in all patients. The population was divided into low, medium, high, and very-high risk.During follow-up, CTRCD and other cardiovascular events have been evaluated.

RESULTS

61 patients were low risk, 37 medium, 9 high, 2 very-high risk criteria. We found a significantly higher incidence of overall cardiotoxicity (CTRCD and other cardiovascular events) in the very-high risk group (100%) compared with the medium (29%) and low risk groups (13%). CTRCD incidence was also significantly higher in the high risk group (55%). CTRCD resulted as being associated with baseline arterial hypertension and baseline HFA/ICOS risk score of high ( p  = 0.006) or very-high ( p  < 0.0001).

CONCLUSION

Our study confirms the HFA/ICOS score's ability to predict cardiovascular toxicity in breast cancer women and the need for close monitoring especially in high and very-high risk patients.

Management of cancer patients at high and very-high risk of cardiotoxicity: Main questions and answers

In recent years, important advances have been made in the field of Cardio-Oncology. The 2022 ESC Guidelines on Cardio-Oncology proposed a baseline cardiovascular risk stratification for cancer patients and preventive strategies in patients at high and very-high risk of cardiotoxicity. Cardiovascular toxic effects of anti-cancer drugs are being extensively studied; surveillance programs have been proposed, based on the baseline cardiovascular risk. On the other hand, there is little data on Cardio-Oncological management of patients at high and very-high cardiovascular risk with previous cardiovascular diseases. For example, little is known about management of cancer patients with heart failure with reduced ejection fraction (HFrEF), patients with a recent myocardial infarction or other cardiovascular diseases; when to resume anti-cancer drugs after a cardiovascular toxic event. Collaboration between Cardiologists and Oncologists and multidisciplinary team evaluations are certainly essential to decide the best therapeutic strategy for cancer patients, to treat cancer while saving the heart. Therefore, in the present review, we attempt to provide a useful guide to clinicians in treating patients with high and very-high risk of cardiotoxicity by enucleating main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.

Interdisciplinary Multidimensional Assessment of Transthyretin Amyloidosis before and after Tafamidis

BACKGROUND

Clinically, there is considerable heterogeneity in the presentation of transthyretin amyloidosis (ATTR), which ranges from primarily cardiac and primarily neurologic to mixed disease, among other manifestations. Because of this complex presentation, the diagnosis and management of patients with ATTR are often challenging and should be performed in interdisciplinary centers specialized in amyloidosis. Here, we aimed to increase awareness of ATTR detection and pathophysiology through a multidimensional multiorgan approach.

CASE REPORT

We reported on a 60-year-old man with wild-type ATTR who underwent a number of both basic and advanced cardiological and neurological investigations at baseline and after a treatment period with the TTR tetramer stabilizer, tafamidis. Several findings are provided here, some of which might be considered instrumental correlates of the patient's clinical improvement after therapy.

CONCLUSIONS

Adequate awareness and prompt recognition of ATTR support early diagnosis and faster access to therapies, thereby slowing the progression and improving the prognosis. The need for a multidisciplinary alliance between specialists and the opportunity to perform, at least in selected cases, a set of specific examinations for a detailed assessment of ATTR patients can also provide valuable insights into the physiopathology and response to therapy of a disease as complex and intriguing as ATTR.

Myocardial Work Appraisal in Transthyretin Cardiac Amyloidosis and Nonobstructive Hypertrophic Cardiomyopathy

Global left ventricular (LV) myocardial work (MW) indexes can be recognized at ultrasound imaging from the LV pressure/global longitudinal strain (GLS) loop analysis. A total of 4 indexes, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), have been demonstrated to overcome the methodological limitations of GLS and provide useful information on myocardial dysfunction in some clinical settings. Although impaired MW indexes have been demonstrated in patients with transthyretin cardiac amyloidosis (ATTR) or with nonobstructive hypertrophic cardiomyopathy (HCM), there are no comparative studies at present. This study aimed to describe the characteristics of MW in both these clinical settings compared with patients with well-controlled hypertension (HTN). A total of 83 patients, 32 with ATTR (aged 70 ± 11 years, 32% mutated, 68% wild-type, 72% men), 29 with HCM (aged 57 ± 17 years), and 22 HTN controls (aged 56 ± 5.6 years, 59% men) were prospectively enrolled at 2 clinical centers. All participants had New York Heart Association class I or II. Overall, the LV mass index was greater in both study groups than in HTN, whereas the LV ejection fraction (EF) was significantly lower in ATTR compared with other groups. Based on this finding, patients with ATTR were further divided into 2 subgroups: ATTR1 (LVEF ≤0.50), n = 14 (44%) and ATTR2 (LVEF >0.50), n = 18 (56%). Overall, the GWI and GCW were lower in all ATTR patients (mostly in ATTR1) than in the other groups (p <0.001), whereas only small differences in GWE and none in GWW were found among the groups. Of interest, the pairwise comparison and receiver operating characteristic analysis in preserved LVEF patients showed that GWI was a better discriminator of ATTR2 from HCM patients than GLS, with the cut-off value ≤1,419 mm Hg% (89% sensitivity; 55% specificity; p = 0.013). In conclusion, MW analysis was confirmed to be a modern way to investigate myocardial function in patients with hypertrophic phenocopies. GWI and GCW were more impaired in patients with ATTR compared with HCM and HTN controls. Furthermore, this study likely revealed an additional discriminative value of GWI over GLS alone in preserved LVEF settings.

Heart Rate Variability Indices of Student Pilots Undergo Modifications During Flight Training

INTRODUCTION: Heart rate variability (HRV) indicates the temporal fluctuation of the intervals between adjacent beats. HRV expresses neuro-cardiac activity and is generated by heart-brain interactions and dynamics related to the function of the autonomous nervous system and other components. To investigate this issue, we started a series of experiments by coupling the flight tasks of student pilots and their HRV.METHODS: Before each experimental session, the participating student was fitted with a five-electrode, three-channel Holter electrocardiogram monitor. We defined three time-phases for each training mission: before flight operations on the ground, during flight operations, and after flight operations on the ground. The HRV analysis was performed by quantifying some indices of the time domain and the frequency domain.RESULTS: The analysis of RR-wave intervals revealed two types of trends: 1) students whose RR intervals decreased during flight operations compared to before flight ground operations; and 2) students whose RR intervals increased during flight operations compared to before flight ground operations. These differences found in the RR intervals produced changes in the indices of both the time and frequency domains of the two students' samples.DISCUSSION: Flight training involves regular and advanced tasks and/or emergency situations. When this happens, the total power of the heart decreases because the RR intervals are forced toward low values. Flight activity involves continuous demanding tasks that can be potentially read by an analysis of the HRV; a high HRV ensures better management of tasks that require a greater commitment of cardiovascular function.Li Volsi G, Monte IP, Aruta A, Gulizzi A, Libra A, Mirulla S, Panebianco G, Patti G, Quattrocchi F, Bellantone V, Castorina W, Arcifa S, Papale F. Heart rate variability indices of student pilots undergo modifications during flight training. Aerosp Med Hum Perform. 2023; 94(11):835-842.

Sex Differences in Anderson-Fabry Cardiomyopathy: Clinical, Genetic, and Imaging Analysis in Women

Anderson-Fabry Disease (AFD) is a rare, systemic lysosomal storage disease triggered by mutations in the GLA gene, leading to α-galactosidase A (α-Gal A) deficiency. The disease's X-linked inheritance leads to more severe, early-onset presentations in males, while females exhibit variable, often insidious, manifestations, notably impacting cardiac health. This study aims to examine gender-based AFD cardiac manifestations in correlation with the variant type: classical (CL), late-onset (LO), or variants of uncertain significance (VUS). We analyzed data from 72 AFD patients (53 females, 19 males) referred to the "G. Rodolico" University Hospital, employing enzyme activity measurements, genetic analysis, periodic lyso-Gb3 monitoring, comprehensive medical histories, and advanced cardiac imaging techniques. Statistical analysis was performed using SPSS version 26. Our AFD cohort, with an average age of 45 ± 16.1 years, comprised 12 individuals with hypertrophy (AFD-LVH) and 60 without (AFD-N). Women, representing about 75% of the subjects, were generally older than men (47.2 ± 16.2 vs. 38.8 ± 14.6, p = 0.046). In the female group, 17% had CL variants, 43.3% LO, and 39.6% had VUS, compared to 21.1%, 36.8%, and 31.6% in the male group, respectively. Females exhibited significantly higher α-Gal A values (median 7.9 vs. 1.8 nmol/mL/h, p < 0.001) and lower lyso-Gb3 levels (1.5 [IQR 1.1-1.7] vs. 1.9 [1.5-17.3] nmol/L, p = 0.02). Regarding the NYHA class distribution, 70% of women were in class I and 28% in class II, compared to 84% and 16% of men, respectively. Among women, 7.5% exhibited ventricular arrhythmias (10.5% in men), and 9.4% had atrial fibrillation (10.5% in men). Cardiac MRIs revealed fibrosis in 57% of examined women, compared to 87% of men. Even among patients without LVH, significant differences persisted in α-Gal A and lyso-Gb3 levels (p = 0.003 and 0.04), as well as LVMi (61.5 vs. 77.5 g/sqm, p = 0.008) and GLS values (-20% vs. -17%, p = 0.01). The analysis underscored older age, decreased lyso-Gb3 deposition, reduced hypertrophy, and lesser GLS compromise in females, suggesting later disease onset. Severe cardiac patterns were associated with classic variants, while more nuanced manifestations were noted in those with VUS. Early GLS impairment in males, irrespective of hypertrophy, emphasized the role of subclinical damage in AFD.

Left Atrial Strain Imaging by Speckle Tracking Echocardiography: The Supportive Diagnostic Value in Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

Background: Left atrial (LA) function is crucial for assessing left ventricular filling in various cardiovascular conditions. Cardiac Amyloidosis (CA) is characterized by atrial myopathy and LA function impairment, with diastolic dysfunction up to restrictive filling pattern, leading to progressive heart failure and arrhythmias. This study evaluates LA function and deformation using speckle tracking echocardiography (STE) in patients with CA compared to a cohort of patients with sarcomeric Hypertrophic Cardiomyopathy (HCM) and a control group. Methods: We conducted a retrospective, observational study (from January 2019 to December 2022) including a total of 100 patients: 33 with ATTR-CA, 34 with HCMs, and 33 controls. Clinical evaluation, electrocardiograms, and transthoracic echocardiography were performed. Echocardiogram images were analyzed in post-processing using EchoPac software for LA strain quantification, including LA-reservoir, LA-conduit, and LA-contraction strain. Results: The CA group exhibited significantly impaired LA function compared to HCMs and control groups, with LA-reservoir median values of -9%, LA-conduit -6.7%, and LA-contraction -3%; this impairment was consistent even in the CA subgroup with preserved ejection fraction. LA strain parameters correlated with LV mass index, LA volume index, E/e', and LV-global longitudinal strain and were found to be associated with atrial fibrillation and exertional dyspnea. Conclusions: LA function assessed by STE is significantly impaired in CA patients compared to HCMs patients and healthy controls. These findings highlight the potential supportive role of STE in the early detection and management of the disease.

Heart Rate Variability of a Student Pilot During Flight Training

BACKGROUND: Heart rate (HR) indicates the number of beats per minute (bpm) of the heart, while heart rate variability (HRV) indicates the temporal fluctuation of the intervals between adjacent beats (NN). HRV expresses neuro-cardiac activity and is generated by heart-brain interactions and dynamics related to the function of the autonomic nervous system (ANS) and other components (e.g., body and ambient temperature, respiration, hormones, blood pressure). We are carrying out a series of experimental investigations with the aim of studying HRV in student pilots during training.CASE REPORT: For this purpose, we used a Holter electrocardiograph equipped with three channels and five electrodes positioned on the chest of the subject who participated in our investigation. The case report refers to a student pilot who, during a flight mission with the instructor, had to face a forced landing and a flap failure. We report data based on analysis of the time domain and frequency domain related to operations on the ground before the flight, during the flight, and on the ground after the flight.DISCUSSION: Our initial conclusion is that the extent of HRV constitutes an "energy store" for better cardiac performance in eustress activities. During advanced tasks, the "Total Power" of the heart decreases because the RR intervals are forced toward low values, where the heart is less able to be modulated by its many controllers. Furthermore, this experimental protocol can be useful to flight instructors for the training process of student pilots.Li Volsi G, Monte IP, Aruta A, Gulizzi A, Libra A, Mirulla S, Panebianco G, Patti G, Quattrocchi F, Bellantone V, Castorina W, Arcifa S, Papale F. Heart rate variability of a student pilot during flight training. Aerosp Med Hum Perform. 2023; 94(6):475-479.

Speckle tracking echocardiography-derived parameters as new prognostic markers in hypertrophic cardiomyopathies

Aims

Hypertrophic cardiomyopathies (HCM) are caused in 30-60% of cases by mutations in cardiac sarcomere genes but can also be an expression of cardiac involvement in multi-systemic metabolic diseases, such as Anderson-Fabry disease (AFD). HCM entails a risk of sudden cardiac death (SCD) of 0.9%/year and is the most common cause of SCD in young adults. Recent studies suggested mechanical dispersion (MD) by speckle tracking echocardiography (STE) as an additional arrhythmic risk marker. The aim of the study was to evaluate left ventricle global longitudinal strain (LV-GLS) and MD, in patients with HCM or AFD cardiomyopathy, and the association with ventricular arrhythmias (V-AR).

Methods and results

We evaluated 40 patients with HCM, 57 with AFD (12 with LV hypertrophy and 45 without), and 40 healthy subjects, between January 2014 and June 2022. We performed a comprehensive echocardiographic study and analysed systolic and diastolic functions, LV-GLS, and MD. We also analysed V-AR, including ventricular fibrillation and sustained/non-sustained ventricular tachycardia, by Holter electrocardiogram (Holter-EKG), in a subset of hypertrophic patients. Data were analysed by unpaired Student t-test or chi-square/Fisher's exact test as appropriate and binary logistic regression (SPSS Statistics ver.26). LV-GLS was significantly lower in the V-AR group compared with patients without V-AR (median -10.2% vs. -14%, P = 0.038); MD was significantly higher in the V-AR group (85.5 ms vs. 61.1 ms, P = 0.004). V-AR were found significantly associated with MD (OR, 1.030; 95% CI, 1.003-1.058; P = 0.03).

Conclusions

MD is a useful additional index in the evaluation of patients with HCM and may be a promising prognostic predictor of increased arrhythmic risk.

358 A POSSIBLE RARE CASE OF VENTRICULAR LIPOMATOSIS: A STIMULUS FOR A PANORAMA OF FATTY CARDIAC LESIONS

We exhibit the case of a 75 years-old man who undertook cardio-oncological assessment for Non-Hodgkin Lymphoma: baseline echo revealed typical features of lipomatous hypertrophy of the interatrial septum (LHIS) and an apical hypoechoic left ventricle (LV) lesion. Five years before, the patient performed MRI (Magnetic Resonance Imaging), which confirmed LHIS, but superabundant epicardial fat extended to the right ventricle and the apical junction between the two ventricles, both characterized by normal ejection fraction, and surrounded the origin of the pulmonary trunk. LV lateral and inferior walls presented lipomatous metaplasia foci and no history or ECG sign of previous myocardial injury could be pointed out. A slight band of late gadolinium enhancement at the basal infero-lateral wall of LV was highlighted. The patient referred episodes of fainting: the Holter-ECG showed pronounced bradycardia which couldn't be explained by other secondary causes. So a bicameral pace-maker was implanted. During our ambulatory evaluation, we decided to repeat MRI, which showed no difference in comparison with the previous one, so excluding malignant degeneration of the fatty mass surrounding the heart. Despite older age and the lack of sudden cardiac death family history we searched for pathognomonic arrhythmogenic cardiomyopathy (ACM) mutations. In consideration of the new evidence of the metabolic risk associated with abundant epicardial fat (EF) we asked for updated laboratory dosage of plasma glucose, LDL cholesterol and triglycerides and we recommended stricter control of blood pressure.

From 4% to 52% of cardiac mass is made up of fat but only EF interacts with myocardium and coronary arteries. Anomalous growth of fat in the heart can present itself as LHIS, excessive lipomatous infiltration or cardiac lipomas (real capsulated tumors) but also ACM is histologically characterized by fibrofatty replacement of cardiomyocites. Overabundant and inflammed EF is now considered a surrogate of metabolic risk and is associated with multivessel coronary disease, the finding of chronic total occlusions (CTO) and microvascular angina.

Identifying fatty heart lesions and defining their clinical and prognostic role remains an intriguing challenge. We suggest a general binary way to follow: the “mechanic one” for lipomas or lipomatous infiltration, that is paying attention to compression phenomena or the generation of arrhythmias, and the “metabolic one”, in other words optimizing cardiovascular prevention when EF is too much. A careful research of imaging features of ACM can't be omitted.

503 SPECKLE-TRACKING ECHOCARDIOGRAPHY FOR ARRHYTHMIC RISK ASSESSMENT IN HYPERTROPHIC AND FABRY CARDIOMYOPATHY

Background

Hypertrophic Cardiomyopathy (HCM) is burdened by sudden cardiac death (SCD) risk of 0.9%/year, and is the most common cause of SCD in young adults. It is an autosomal dominant inherited disease caused by mutations in cardiac sarcomere genes, but the hypertrophic phenotype can also be an expression of cardiac involvement in multiorgan metabolic storage diseases, such as Anderson-Fabry disease (AFD). Mechanical Dispersion (MD) by Speckle-Tracking Echocardiography (STE) has recently emerged as an additional arrhythmic risk marker.

Purpose

Aim of the study was to evaluate LV systolic and diastolic function, global longitudinal strain (GLS) and MD by STE and analyze their association with ventricular arrhythmias in patients with HCM and AFD.

Methods

We included in our analysis 36 patients with HCM, 54 with AFD, of which 10 with left ventricular hypertrophy (AFD-LVH) and 44 without (AFD-N), and 27 healthy subjects. We performed a comprehensive basic echocardiographic study and analyzed GLS and MD (post-processing through EchoPAC 2.02). We also evaluated ventricular arrhythmias (V-AR), including ventricular fibrillation and sustained and non-sustained ventricular tachycardia, by Holter ECG, and the data obtained by cardiac magnetic resonance (CMR) in hypertrophic patients. Data were analyzed by unpaired Student t-test or chi-square/Fisher's exact test as appropriate, and binary logistic regression (SPSS Statistics ver.26).

Results

Diastolic function was impaired in HCM and AFD-LVH patients compared to control and AFD without LVH. GLS was significantly lower in the V-AR group compared to patients without V-AR (9.7±2.9 vs 14.1±4, P=0.007), MD was significantly higher in the V-AR group (111±47 vs 68.1±16, P=0.03). We found a significant association between ventricular arrhythmias and GLS (P=0.005) and between ventricular arrhythmias and MD (P&lt;0.001). We found also a significant association of late gadolinium enhancement at CMR with GLS (P=0.005) and MD (P=0.03).

Conclusions

GLS and MD are useful additional indices in the evaluation of patients with HCM or AFD, also in presence of preserved LV ejection fraction, and promising prognostic predictors to identify patients at high risk for ventricular arrhythmias

Figures: MD in an HCM patient (on the left) and in an AFD-LVH patient (on the right).

354 THE ADDED VALUE OF MYOCARDIAL WORK IN EARLY DETECTION OF SYSTOLIC DYSFUNCTION IN CARDIAC AMYLOIDOSIS

Aim

The involvement of the heart represents the main determinant of mortality and morbidity for patients with systemic amyloidosis (SA). In cardiac amyloidosis (CA), numbered among the clearest examples of restrictive cardiomyopathies, EF (ejection fraction) often keeps itself preserved (≥ 50%) but this doesn't mean LV (left ventricle) systolic function couldn't be impaired, even in the early stages of disease. In this survey we searched for echocardiographic signs of early systolic impairment in CA: among them we adopted the analysis of myocardial work (MW), an emerging less load-dependent tool for the evaluation of cardiac performance.

Methods

We chose a cohort of patients (n=20; mean age 69±13 years) with AL or ATTR CA and we compared them with a control group (n=18; mean age 62±17 years) without evident cardiac damage. We examined their systolic and diastolic function and we calculated multilayer strain and all the contributors of MW from speckle tracking echocardiography.

Results

We found a statistically relevant difference in cardiac mass (138±35 versus 83±23 g/m2) and in signs of both systolic and diastolic function (LAVi, TR Vmax, E/e’) worsening between patients with CA and the control group. In CA average EF was 52±11% while the reduction in Global Longitudinal Strain (GLS) was significant, regardless of the considered wall layer and the stage of diastolic impairment. For our patients ejection fraction to strain ratio (EFSR, 4,41±1,38 vs 3,04±0,55), a simple way to quantify apical sparing, better underlined the dissociation between EF and strain than apex to base ratio. In CA we identified a dramatic decrease in Global Work Index (954±278 vs 2089±354 mmHg%) and Global Constructive Work (1103±323 vs 2376±390 mmHg%), with no significant difference between AL and ATTR amyloidosis.

Conclusions

The infiltration by amyloid and the consequent increase in cardiac mass lead to an early and often severe weakening of the intrinsic contractility of the heart in both AL and ATTR amyloidosis, even when ejection fraction is normal or slightly reduced. Therefore, we suggest the analysis of MW starting from the first echocardiographic evaluation in patients with known SA or multiple myeloma.

Fabry's Disease: The Utility of a Multidisciplinary Screening Approach

(1) Background: As a lysosomal storage disorder, Fabry’s disease (FD) shows variable clinical manifestations. We applied our multidisciplinary approach to identify any organ damage in a sample of adult patients with different pathogenic variants. (2) Methods: 49 participants (mean age 44.3 ± 14.2 years; 37 females), underwent a multidimensional clinical and instrumental assessment. (3) Results: At diagnosis, mean enzymatic activity was 5.2 ± 4.6 nM/mL/h in females and 1.4 ± 0.5 nM/mL/h in males (normal values > 3.0), whereas globotriaosylsphingosine was 2.3 ± 2.1 nM/L in females and 28.7 ± 3.5 nM/L in males (normal values < 2.0). Overall, cardiovascular, neurological, and audiological systems were the most involved, regardless of the variant detected. Patients with classic variants (10) showed typical multiorgan involvement and, in some cases, prevalent organ damage (cardiovascular, neurological, renal, and ocular). Those with late-onset variants (39) exhibited lower occurrence of multiorgan impairment, although some of them affected the cardiovascular and neurological systems more. In patients with lower enzymatic activity, the most frequent involvement was neurological, followed by peripheral vascular disease. (4) Conclusions: FD patients exhibited wide phenotypic variability, even at single-organ level, likely due to the individual genetic mutation, although other factors may contribute. Compared to the conventional management, a multidisciplinary approach, as that prompted at our Center, allows one to achieve early clinical detection and management.

Lung Semiotics Ultrasound in COVID-19 Infection

This paper aims to highlight the usefulness of "bedside" lung ultrasound in the context of the COVID-19 pandemic. The evaluation of lung artifacts allows to detect at the subpleural level the presence of an altered "tissue/air" ratio both in case of consolidative or not consolidative lung lesions. Furthermore, lung ultrasound allows acquiring topographical images of the lesions, establishing their extension on the lung surface as well as their evolution or regression over time, without radiation exposure. Since ultrasound semiotics is already widely known and described in other similar diseases (acute respiratory distress syndrome, interstitial flu virus, and pneumonia), thoracic ultrasound is a useful diagnostic tool in different scenarios in the COVID-19 pandemic: in the first triage of symptomatic patients, both in the prehospital setting or in the emergency department, in the prognostic stratification and monitoring of patients with pneumonia, and in the management of patients in the intensive care unit. Moreover, "bedside" lung ultrasound can reduce the number of health-care workers exposed to the virus during patient assessment and treatment.

Echocardiography and Multimodality Cardiac Imaging in COVID-19 Patients

The pandemic caused by the new SARS-CoV-2, named coronavirus disease 2019 (COVID-19) disease, has challenged the health-care systems and raised new diagnostic pathways and safety issues for cardiac imagers. Myocardial injury may complicate COVID-19 infection in more than a quarter of patients and due to the wide a range of possible insults, cardiac imaging plays a crucial diagnostic and prognostic role. There is still little evidence regarding the best-imaging pathway and the echocardiographic findings. Most of the data derive from the single centers experiences and case-reports; therefore, our review reflects the recommendations mainly based on expert opinion. Moreover, knowledge is constantly evolving. The health-care system and physicians are called to reorganize the diagnostic pathways to minimize the possibility of spreading the infection. Thus a rapid, bedside, ultrasound assessment of the heart, chest, and leg veins by point-of-care ultrasound seems to be the first-line tool of the fight against the SARS-CoV-2. A second Level of cardiac imaging is appropriate when the result may guide decision-making or may be life-saving. Dedicated scanners should be used and special pathways should be reserved for these patients. The current knowledge on cardiac imaging COVID-19 patients is reviewed.

Discordant Echocardiographic Grading in Low Gradient Aortic Stenosis (DEGAS Study) From the Italian Society of Echocardiography and Cardiovascular Imaging Research Network: Rationale and Study Design

Background

Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume <35 mL/m²) in the presence of reduced (classical low-flow AS) or preserved (paradoxical low-flow AS) ejection fraction. Furthermore, the occurrence of a normal-flow LG-AS is still advocated by many authors. Within this diagnostic complexity, the diagnosis of severe AS remains challenging.

Objective

The general objective of the Discordant Echocardiographic Grading in Low-gradient AS (DEGAS Study) study will be to assess the prevalence of true severe AS in this population and validate new parameters to improve the assessment and the clinical decision-making in patients with LG-AS.

Methods and Analyses

The DEGAS Study of the Italian Society of Echocardiography and Cardiovascular Imaging is a prospective, multicenter, observational diagnostic study that will enroll consecutively adult patients with LG-AS over 2 years. AS severity will be ideally confirmed by a multimodality approach, but only the quantification of calcium score by multidetector computed tomography will be mandatory. The primary clinical outcome variable will be 12-month all-cause mortality. The secondary outcome variables will be (i) 30-day mortality (for patients treated by Surgical aortic valve replacement or TAVR); (ii) 12-month cardiovascular mortality; (iii) 12-month new major cardiovascular events such as myocardial infarction, stroke, vascular complications, and rehospitalization for heart failure; and (iv) composite endpoint of cardiovascular mortality and hospitalization for heart failure. Data collection will take place through a web platform (REDCap), absolutely secure based on current standards concerning the ethical requirements and data integrity.

Thrombotic Risk in Cancer Patients: Diagnosis and Management of Venous Thromboembolism

Venous thromboembolism (VTE) represents a major health problem, especially in cancer patients, who experience a significantly higher incidence of both deep vein thrombosis and pulmonary embolism compared to the general population. Indeed, patients with cancer have a prothrombotic state resulting in both increased expression of procoagulants and suppression of fibrinolytic activity. In addition, VTE increases the morbidity and mortality of these patients. For all these reasons, the prevention and treatment of VTE in cancer setting represent major challenges in daily practice. In general, low-molecular-weight heparin monotherapy is the standard of care for the management of cancer-associated VTE, as Vitamin K antagonists are less effective in this setting. Direct oral anticoagulants offer a potentially promising treatment option for cancer patients with VTE, since recent studies demonstrated their efficacy and safety also in this peculiar setting.

Document Addressed to Cardiovascular Echography Operators at the Time of COVID-19: A Document by the "Società Italiana di Ecocardiografia e CardioVascular Imaging" Board 2019-2021

The epidemic of COVID-19 has grown to pandemic proportions and the preventive and mitigation measures have been widely spread through the media. The cardiologists are called as consultants for the cardiovascular pathologies and echocardiography is a fundamental examination in many clinical situations, but not without risks for health staff. Società Italiana di Ecocardiografia e CardioVascular Imaging Council has decided to formulate a document aimed to highlight the importance of a correct indication and execution procedure of the echocardiogram during a COVID-19 pandemic.

Valvular Damage

Valvular heart diseases (VHD) may be observed in patients with cancer for several reasons, including preexisting valve lesions, radiotherapy, infective endocarditis, and secondary to the left ventricle dysfunction. The incidence of VHD is especially in younger survivors treated with thoracic radiation therapy for certain malignancies, such as Hodgkin's lymphoma and breast cancer. The mechanism of radiation-induced damage to heart valves is not clear and includes diffuse fibrocalcific thickening of the valve. VHD is commonly diagnosed after a long latent period, in the context of clinical symptoms, or suspected on the basis of a new murmur. The evaluation includes identification of anatomical valve abnormalities, valve dysfunction, and assessing the functional consequences of valve dysfunction on the ventricles. Echocardiography is the optimal imaging technique for diagnostic and therapeutic management. Cardiovascular magnetic resonance and computed tomography (CT) may be used to assess the severity of VHD, but cardiac CT is mainly useful for detecting extensive calcifications of the ascending aorta. Patients exposed to mediastinal radiotherapy and minimal valve dysfunction require follow-up of 2–3 years, with moderate valve disease yearly, with severe, should be assessed for valve surgery.

Cardiac Tumors

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

P321 Cardiotoxicity related to cancer therapy. is the study of mechanical dispersion an additional value?

Myocardial dysfunction are the most concerning cardiovascular complications of cancer therapies with a poor prognosis, so it’s critical to detect subclinical cardiac abnormalities in order to start cardioprotective therapy early or increased surveillance frequency. Global longitudinal strain (GLS) by echocardiography is an excellent tool for assessing regional and global left ventricular (LV) function. Mechanical dispersion (MD) reflects heterogeneous myocardial contraction, evaluated in many cardiopathies.

We evaluated subclinical myocardial dysfunction by GLS and MD using 2D Speckle-tracking Echo, in order to established if MD could be a predictor of ventricular dysfunction in the field of Cardiotoxicity (CTX).

Were enrolled 42 women with breast cancer chemotherapy-treated and underwent to Echo evaluation during 3- and 6-months follow-up, compared to evaluation performed before starting chemotherapy (T0). Depending on chemotherapy type were identified 2 groups: Anthracyclines ± Taxol treated (group 1) and Anti-HER2 treated (group 2). CTX diagnosis was made according ESC criteria: LVEF &lt; 50%, LVEF decrease &gt;10% or GLS decrease &gt;15% compared to previous check.

At three months, 28% patients (p &lt; 0,009) developed CTX and, in this group, MD was significantly increased compared to T0 (64,4ms ± 18,6 vs 43,48ms ± 7.88 p &lt; 0,001). This finding was consistent regardless treatment group: 65,2 ms ± 5,30 (p &lt; 0.0001) in group 1 and 63,14 ms ± 36,40 (p 0.02) in group 2. Also, GLS was significantly changed: in CTX patients decreased of 9% compared to T0 (p 0.02), but this finding was consistent in group 1 in which GLS decreased of 18% (p 0,01), while in group 2 decrease only of 5% and wasn’t statistically significant compared to T0 (p = 0,3). These patients were treated by beta-blockers or ACE-inhibitors. At six months there was a normalization of MD value (47.7 ± 15.97 ms in CTX group) that was not statistically significant compared to T0 (p = 0,2) and we have interpreted as consequence of positive effect induced by cardioprotective therapy.

We believe that MD is a predictor of ventricular dysfunction earlier than GLS during Anti-HER2 treatment, so in this field MD could integrates information obtained from GLS about subclinical dysfunction.

Update on the Organizational Aspects of Echocardiography in Italy (From Operator Training to the Report: 2007-2019): A Consensus Document by the "Società Italiana di Ecocardiografia e CardioVascular Imaging" Accreditation Area and Board 2017-2019

In 2007, Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI) already SIEC, published the document on the organization of echocardiography in Italy. In the years following the technological evolution, cultural and health factors have changed "the way, we do echo" as a tool for the different clinical pathways. The SIECVI Accreditation Area and Board 2017-2019 considered necessary to review and update the document in the light of innovation in the application of ultrasound for the heart disease assessment. In the document, we have considered the role of SIECVI in multimodal imaging, the need of training and certification of operators, the quality of echo machines, the accreditation of laboratories, the compilation of the report and its responsibility, and the presence of the sonographers in the EchoLab.

Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies

BACKGROUND

Nowadays, patients involved in antiplatelet therapy required special attention during oral surgery procedures, due to the antiplatelet drugs assumption. The motivations of the assumption may be different and related to the patient's different systemic condition. For this reason, accordingly to the current international guidelines, different protocols can be followed. The aim of this work is to analyze how the dentist's approach to these patients has changed from the past to the present, evaluating the risk exposure for the patients.

METHODS

This review paper considered different published papers in literature through quoted scientific channels, going in search of "ancient" works in such a way as to highlight the differences in the protocols undertaken. The analyzed manuscripts are in the English language, taking into consideration reviews, case reports, and case series in such a way as to extrapolate a sufficient amount of data and for evaluating the past therapeutic approaches compared to those of today.

RESULTS

Colleagues in the past preferred to subject patients to substitution therapy with low molecular weight anticoagulants, by suspending antiplatelet agents to treatment patients, often for an arbitrary number of days. The new guidelines clarify everything, without highlighting an increased risk of bleeding during simple oral surgery in patients undergoing antiplatelet therapy.

CONCLUSION

Either patients take these medications for different reasons, because of cardiovascular pathologies, recent cardiovascular events, or even for simple prevention, although the latest research shows that there is no decrease of cardiovascular accidents in patients who carry out preventive therapy. Surely, it will be at the expense of the doctor to assess the patient's situation and risk according to the guidelines. For simple oral surgery, it is not necessary to stop therapy with antiplatelet agents because the risk of bleeding has not increased, and is localized to a post-extraction alveolus or to an implant preparation, compared to patients who do not carry out this therapy. From an analysis of the results it emerges that the substitutive therapy should no longer be performed and that it is possible to perform oral surgery safely in patients who take antiplatelet drugs, after a thorough medical history. Furthermore, by suspending therapy, we expose our patients to more serious risks, concerning their main pathology, where present.

Incidence of Long-Term Structural Valve Dysfunction and Bioprosthetic Valve Failure After Transcatheter Aortic Valve Replacement

Background Long-term data on durability of currently available transcatheter heart valves are sparse. We sought to assess the incidence of long-term (8-year) structural valve dysfunction and bioprosthetic valve failure in a cohort of patients with transcatheter aortic valve replacement ( TAVR ) who reached at least 5-year follow-up. Methods and Results Consecutive patients with at least 5-year follow-up available undergoing TAVR from June 4, 2007 to March 30, 2012 were included. Structural valve dysfunction and bioprosthetic valve failure were defined according to newly standardized European Association of Percutaneous Cardiovascular Interventions/ European Society of Cardiology/European Association for Cardio-Thoracic Surgery criteria and reported as cumulative incidence function to account for the competing risk of death. A total of 288 consecutive patients with a mean age of 80.7±5.3 years and with a mean Society of Thoracic Surgery mortality score of 8.1±5.1% were analyzed. Survival rate at 8 years was 29.8%. Mean pressure gradients decreased from 53.3±15.9 mm Hg (pre- TAVR ) to 10.5±4.5 mm Hg (in-hospital post- TAVR ) ( P<0.001). There was a small, not significant, increase in the transaortic gradient throughout follow-up. Bioprosthetic valve failure was observed in a total of 11 patients (8-year cumulative incidence function: 4.51%; 95% confidence interval , 1.95%-8.76%). Severe and moderate structural valve dysfunctions were reported in 7 patients (8-year cumulative incidence function: 2.39%; 95% confidence interval, 0.77%-5.71%) and 13 patients (8-year cumulative incidence function: 5.87%; 95% confidence interval , 3.06%-9.96%), respectively. Aortic valve reintervention (redo TAVR ) was successfully performed in 2 patients (0.7%) presenting with symptomatic severe restenosis and intraprosthetic regurgitation subsequent to endocarditis. Conclusions In an aged population of patients with symptomatic severe aortic stenosis treated with first-generation bioprostheses, TAVR was associated with a survival rate of 30% but low rates of bioprosthetic valve failure and structural valve dysfunction at 8 years.

A Membranous Septal Aneurysm Causing Right Ventricular Outflow Tract Obstruction in an Adult

We describe a case of a 69-year-old female referred for the evaluation of exertional dyspnea, with a small membranous ventricular septal defect (VSD) and right ventricle (RV) outflow tract obstruction. Using transthoracic echo was diagnosed VSD with left to right shunting and transesophageal echo (TEE) was used to a better anatomical characterization. TEE showed a perimembranous subaortic VSD that developed a high-velocity flow in RV. Pulmonary valve appears normal and right ventricular infundibular hypertrophy or double-chambered RV was excluded from the study. Furthermore, TEE showed a malaligned VSD and the presence of perimembranous mobile tissue protruding in RV. We hypothesized that this tissue can be attributed to broken septum aneurysm and protruding during systole, it causes a dynamic RV output tract obstruction.

Recurrent Supraventricular Arrhythmias as the First Clinical Warning of a Right Atrium Infiltrating Pulmonary Carcinoma

We report the case of a 45-year-old Caucasian male with negative cardiovascular history, heavy-smoker, who was referred to our Cardiology Unit for recurrent inexplicable tachycardia. Chaotic atrial tachycardia with intermittent fibrillation was observed at ECG, whereas a smoothed mass (approximately sized 8 × 8 cm) was unexpectedly found at echocardiography likely infiltrating the right atrial wall. Multi-detector computed tomography confirmed the mediastinal mass and the digital post-processing clearly identified its anatomic characteristics and invasivity. This study demonstrates that recurrent and refractory atrial arrhythmias can be early signs of cardiac infiltrating mediastinal masses. The combined approach by echocardiography and computed tomography was confirmed to provide precise anatomical and functional characteristics of the arrhythmogenic disease in this patient.

Long-Term Results after Percutaneous Closure of Atrial Septal Defect: Cardiac Remodeling and Quality of Life

BACKGROUND

Atrial septal defect (ASD) represents a common congenital heart malformation, cause of right ventricle (RV) volume overload, pulmonary hypertension, atrial arrhythmias, and paradoxical emboli. Percutaneous closure represents the treatment of choice for ASD. However, it is still difficult to associate symptoms to the success of ASD treatment.

OBJECTIVE

To investigate any possible correlation between transthoracic echocardiography (TTE) findings and patients' symptoms after ASD treatment.

MATERIALS AND METHODS

Thirty patients (mean age 49 ± 17 years; 10 younger ≤40 years and 20 > 40 years) underwent percutaneous closure of ASD type ostium secundum. Every patient underwent clinical examination, electrocardiogram (ECG) and TTE before procedure and at 1, 6, and 12 months after procedure and a multichoice questionnaire to collect patients' symptoms and complain severity.

STATISTICAL ANALYSIS

Continuous variables were summarized by means and standard deviation. Estimates of occurrence of events were expressed as percentages. Comparison between mean follow-ups was achieved using paired t-test sample.

RESULTS

At end of follow-up, TTE showed a decrease of RV dimensions (34.4 vs 37.5 mm preclosure; P = 0.01), pulmonary artery systolic pressure (PAPs 28.4 vs 39.5 mmHg; P = 0.00003), atrial dimensions (51 vs 56 mm; P = 0.085), and of right myocardial performance index (MPI; 0.39 vs 0.42; P = 0.05). PAPs was significantly reduced in group more than 40-years-old (P = 0.00004), while the reduction was not significant in the less or equal than 40 years of age (P = 0.08) group because the baseline value was significantly lower. Many patients after procedure complained headache, insomnia, palpitations, fatigue, and dyspnea; but no cardiac morphological abnormalities related to symptoms were found.

CONCLUSIONS

Our data showed a great improvement in symptoms and positive cardiac remodeling after closure of ASD, more effective in elderly patients compared to younger patients. The symptoms are not correlated with the principal disease or procedure.

Asymptomatic Left Ventricular Dysfunction and Metabolic Syndrome: Results from an Italian Multicenter Study

Context:

Metabolic syndrome (MS) is a cluster of interrelated common clinical disorders, including obesity, insulin resistance, glucose intolerance, hypertension and dyslipidemia, associated with a greater risk of atherosclerotic cardiovascular disease than any of its individual components. Although MS is associated with increased cardiovascular risk (CVR), its relationship with heart failure (HF) and left ventricular (LV) dysfunction is not fully understood.

Aims:

We sought to determine whether MS is associated to LV systolic and diastolic dysfunction in a sample of patients with MS and no symptoms for HF.

Subjects and Methods:

We enrolled 6422 consecutive asymptomatic patients admitted to echo-lab for a routine echocardiogram. We calculated LV systolic and diastolic function, by Simpson biplane method and validated Doppler parameters, respectively. MS was diagnosed if three or more CVR factors were found.

Results:

LV systolic function was evaluated in 6175 patients (96.2%). In the group of patients without MS (n = 5630), the prevalence of systolic dysfunction was 10.8% (n = 607) while in the group of patients with MS (n = 545) it was 12.5% (n = 87), (RR1.57; CI 95% 1.2-2.0; P < 0.001). Diastolic function was evaluated in 3936 patients (61.3%). In the group of patients without MS (n = 3566) the prevalence of diastolic dysfunction was 33.3% (n = 1187), while in patients with MS (n = 370) it was 45.7% (n = 169), (RR1.68; CI95% 1.3-2.0; P < 0.001). After adjustment for age and gender, MS proved to be an independent predictor of LV systolic and diastolic dysfunction.

Conclusions:

Our data show that asymptomatic LV systolic and diastolic dysfunction, is correlated with MS and demonstrate that echocardiography is a useful tool to detect patients at high risk for HF. Echocardiography in asymptomatic patients with MS may lead to a therapy initiation at early stages to prevent future cardiovascular events and HF.