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Lazzeroni D, Marchini C, Centorbi CS, Moderato L, Brambilla L, Bini M, Guazzi E, Magnani G, Aschieri D, Piepoli M, Nicolini F, Coruzzi P. Clinical parameters and cardiovascular risk factors related to heart failure with preserved ejection fraction: a comparative analysis between HFA-PEFF and H2FPEF Scores. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Heart failure with preserved ejection fraction (HFpEF) diagnosis remains challenging, since several mechanisms (diastolic and systolic reserve abnormalities, chronotropic incompetence, ventricular or vascular stiffening, atrial dysfunction, pulmonary hypertension, impaired vasodilation, endothelial dysfunction, energetic abnormalities and autonomic dysfunction) play different roles in HFpEF development. European Society of Cardiology HF guidelines recently suggested a stepwise non-invasive diagnostic approach consisting of three steps: the first is clinical, the second includes echocardiographic and laboratory data (natriuretic peptides), named HFA-PEEF score, and finally, in case of inconclusive findings, diastolic stress echocardiography is recommended. On the other hand, in United States, another multiparametric score, named H2FPEF, has been proposed for HFpEF diagnosis, and including, in addition to echocardiographic parameters, also clinical data; thereby more applicable in the outpatient clinical arena.
Purpose
Whether there is a clinical overlap between the two scores (HFA-PEEF and H2FPEF) as well as whether the addition of clinical data to the HFA-PEEF could improve its ability to identify different HFpEF phenotypes is still an open issue and these were the aims of our study.
Methods
HFA-PEEF and H2FPEF scores were systematically applied on 1,156 consecutive subjects with preserved ejection fraction who undergone cardiovascular evaluation at the Cardiovascular Prevention Center of Fondazione Don Gnocchi & University of Parma. All subjects underwent cardiovascular risk assessment followed by echocardiography and cardiopulmonary exercise testing; due to the outpatient (non-acute) setting of the evaluation, natriuretic peptides assay was not performed. Clinical data and cardiovascular risk factors data were compared between different groups of HFpEF risk.
Results
According to H2FPEF score, low risk (<40%) of HFpEF was found in 659 (57%), moderate in 300 (26%) and high (>75%) in 197 (17%); according to HFA-PEEF score, 675 (58%) had 0 or 1 point, 253 (22%) had 2 points and 230 (20%) had 3 or 4 points (moderate-to-high risk). Patients with higher HFA-PEEF score were older (p<0.001), had higher prevalence of HTN (p<0.001), diabetes (p<0.001), obesity (p<0.001), sedentary lifestyle (p<0.001), AF (p<0.001) and CCS (p<0.001) (figure 1). More specifically, AF was associated to a 6.3-fold higher risk (p<0.001) of high (3–4) HFA-PEEF Score, age >75 years to a 4.6-fold higher risk, HTN to a 3.6-fold higher risk (p<0.001), CCS to a 3.3-fold higher risk (p<0.001), obesity to a 2.2-fold higher risk (p<0.001), diabetes to a 1.9-fold higher risk (p<0.001) and sedentary to a 1.7-fold higher risk (p=0.001).
Conclusions
Although HFA-PEEF score does not include clinical data, patients with older age, atrial fibrillation, hypertension, hypertensive heart, diabetes, sedentary lifestyle and chronic coronary syndrome show a higher ESC risk of HFpEF.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Lazzeroni
- IRCCS Don Carlo Gnocchi Foundation , Florence , Italy
| | - C Marchini
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - C S Centorbi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - L Moderato
- Guglielmo da Saliceto Hospital , Piacenza , Italy
| | - L Brambilla
- Don Gnocchi Foundation - IRCCS Centro S. Maria Nascente , Milan , Italy
| | - M Bini
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - E Guazzi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - G Magnani
- University of Parma, Cardiology Unit , Parma , Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital , Piacenza , Italy
| | - M Piepoli
- Sant'Anna School of Advanced Studies , Pisa , Italy
| | - F Nicolini
- University of Parma, Cardiac surgery Unit , Parma , Italy
| | - P Coruzzi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
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Lazzeroni D, Marchini C, Centorbi CS, Moderato L, Brambilla L, Bini M, Guazzi E, Magnani G, Aschieri D, Piepoli M, Nicolini F, Coruzzi P. Cardiopulmonary response to exercise and heart failure with preserved ejection fraction risk: a comparative analysis of HFA-PEFF and H2FPEF scores. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Exercise intolerance evaluation in Heart failure with preserved ejection fraction (HFpEF) remains challenging, since several mechanisms (diastolic and systolic reserve abnormalities, low chronotropic reserve (CR), ventricular or vascular stiffening, atrial dysfunction, pulmonary hypertension, endothelial dysfunction, energetic abnormalities and autonomic dysfunction) play different roles. European Society of Cardiology HF guidelines recently suggested a stepwise non-invasive HFpEF diagnostic approach consisting of three steps: clinical, echocardiographic and laboratory data (natriuretic peptides), named HFA-PEEF Score, and finally, in case of inconclusive findings, diastolic stress echocardiography data. Cardiopulmonary exercise testing (CPET) may represent a promising further non-invasive diagnostic tool in HFpEF evaluation since allow to assess the presence of reduced functional capacity as well as to differentiate between cardiovascular, ventilatory or peripheral causes.
Purpose
Whether increased risk of HFpEF is associated with different and specific cardiopulmonary responses to exercise is still an open issue and this was the aim of our study.
Methods
1.156 consecutive subjects with preserved ejection fraction undergoing cardiovascular evaluation at the Cardiovascular Prevention Center of Fondazione Don Gnocchi & University of Parma were enrolled. All subjects underwent cardiovascular evaluation and echocardiography, HFA-PEEF and H2FPEF Score assessment and cardiopulmonary exercise testing. Different cardiopulmonary response to exercise were compared between different groups of HFpEF risk.
Results
According to HFA-PEEF Score, 675 (58%) had 0 or 1 point, 253 (22%) had 2 points and 230 (20%) had 3 or 4 points (moderate-to-high risk). Patients with both higher HFA-PEEF and H2FPEF Score showed lower functional capacity, expressed as low peak V02 (p<0.001) associated with lower oxygen pulse (V02/HR) (p<0.001), cardiac output (CO) at peak (p<0.001), CR (p<0.001), ventilatory efficiency (expressed as VE/VC02 slope) (p<0.001) and oxygen uptake extraction (OUES) (p<0.001). Moreover, higher H2FPEF Score patients showed lower stroke volume (SV) at peak (p<0.001), while high HFA-PEEF score was not associated to SV at peak (Table 1 and Figure 1). More specifically, the presence of reduced cardiovascular efficiency (V02/Watt Slope <7) was associated to a 2.2-fold higher risk of HFpEF (p=0.003), impaired ventilator efficiency (VE/VCO2 Slope >35) to a 2.4-fold higher risk (p<0.001), reduced CR (<70%) 4.3-fold higher risk (p<0.001).
Conclusions
Different degrees HFpEF risk, estimated using both HFA-PEEF and H2FPEF score, are associated with different cardiopulmonary responses to exercise. High HFpEF risk patients show low functional capacity, cardiovascular and ventilator efficiency due to lower cardiac output at peak, despite preserved ejection fraction, associated to lower chronotropic response to exercise.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D Lazzeroni
- IRCCS Don Carlo Gnocchi Foundation , Florence , Italy
| | - C Marchini
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - C S Centorbi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - L Moderato
- Guglielmo da Saliceto Hospital , Piacenza , Italy
| | - L Brambilla
- Don Gnocchi Foundation - IRCCS Centro S. Maria Nascente , Milan , Italy
| | - M Bini
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - E Guazzi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
| | - G Magnani
- University of Parma, Cardiology Unit , Parma , Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital , Piacenza , Italy
| | - M Piepoli
- Sant'Anna School of Advanced Studies , Pisa , Italy
| | - F Nicolini
- University of Parma, Cardiac surgery Unit , Parma , Italy
| | - P Coruzzi
- Fondazione Don Gnocchi, Cardiovascolar Prevention and Rehabilitation Unit , parma , Italy
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Bolognesi M, Iconomu E, Armentano C, Turchio P, Petrini M, Moderato L, Michieletti E, Aschieri D. P303 A CASE OF MYOPERICARDITIS AFTER II DOSE COVID 19 MRNA VACCINE IN YOUNG MALE. Eur Heart J Suppl 2022. [PMCID: PMC9383961 DOI: 10.1093/eurheartj/suac012.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
COVID 19 disease caused devasting health consequences from March 2020. The development of effective vaccines against SARs COV 2 is an important weapon to defeat this virus. However rare cases of vaccines complications have been reported including myopericarditis above all in young males that we have to follow strictly and to begin right therapy as soon as possible. Data regarding specific therapy about mypericarditis after COVid 19 vaccine are scanty. We report a case of 16 years old male with no health problems, admitted in emergency department with chest pain relieved by sitting posistion and persistent fever rised 24 h after receiving his second dose of mRNA COVID 19 vaccineA 12 lead ECG showed normal sinusal rhythm without ST changes. On admission the complete blood cells count was normal, PCR was high: 5,92 mg/dl and troponin I at high sensivity was elevated: 9249 ml/L. The patient was hospitalized in our cardiology department with suspected myopericarditis. Ecocardiography TT showed normal left ventricular ejection fraction and no pericardial effusion. We began immediately non steroidal anti inflammatory therapy at high dose (ibuprofen 600 mg x 3/die and colchicine 1 mg/die) with conseguently reduction of chest painfuls symptoms. We also began ACEi therapy. On the advice of of the infectious disease specialist we added in the 5 th day methilprednisolone 25 mg/die in consideration of an excessive acute inflammatory response and we observed a clinical improvement with an indices of inflammation reduction. Cardiac magnetic resonance (CMR) performed after 3 day in T2 weighted images showed intramyocardial and subepicardial hyperintensity localized to the mid and apical lateral, basal infero lateral, distal anterior segment, as myocardial edema. Furthermore after Injection of contrast: subepicardial late gadolinium enhancement in the same segment. Minimum (4 mm) pericardial effusion. The clinical setting was attributable as symptoms, elevated troponin above upper limit of normal, in absence of other identifiable cause of symptoms and findings, to confirmed case of acute myocarditis after vaccine in according to the “CDC case definitions”. Myocarditis after mRNA COVID 19 vaccination affect above all young males with mild and multifocal forms with risks and benefits in favour of vaccines. However we need to identify them for an early therapy. In these setting of myocarditis an early use of corticosteroids can be provided.
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Affiliation(s)
| | - E Iconomu
- OSPEDALE GUGLIELMO DI SALICETO, PIACENZA
| | | | - P Turchio
- OSPEDALE GUGLIELMO DI SALICETO, PIACENZA
| | - M Petrini
- OSPEDALE GUGLIELMO DI SALICETO, PIACENZA
| | - L Moderato
- OSPEDALE GUGLIELMO DI SALICETO, PIACENZA
| | | | - D Aschieri
- OSPEDALE GUGLIELMO DI SALICETO, PIACENZA
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Araiza-Garaygordobil D, Montalto C, Martinez-Amezcua P, Cabello-Lopez A, Gopar-Nieto R, Alabrese R, Almaghraby A, Catoya-Villa S, Chacon-Diaz M, Kaufmann CC, Corbi-Pascual M, Deharo P, El-Tahlawi M, Elgohari-Abdelwahab A, Guerra F, Jarakovic M, Martinez-Gomez E, Moderato L, Montero S, Morejon-Barragan P, Omar AM, Jorge-Pérez P, Przybyło P, Selim E, Sinan UY, Stratinaki M, Tica O, Trêpa M, Uribarri A, Uzokov J, Wilk K, Czerwińska-Jelonkiewicz K, Sionis A, Gierlotka M, Leonardi S, Krychtiuk KA, Tavazzi G. Impact of the COVID-19 pandemic on hospitalizations for acute coronary syndromes: a multinational study. QJM 2021; 114:642-647. [PMID: 33486512 PMCID: PMC7928691 DOI: 10.1093/qjmed/hcab013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND COVID-19 has challenged the health system organization requiring a fast reorganization of diagnostic/therapeutic pathways for patients affected by time-dependent diseases such as acute coronary syndromes (ACS). AIM To describe ACS hospitalizations, management, and complication rate before and after the COVID-19 pandemic was declared. DESIGN Ecological retrospective study. Methods: We analyzed aggregated epidemiological data of all patients > 18 years old admitted for ACS in twenty-nine hub cardiac centers from 17 Countries across 4 continents, from December 1st, 2019 to April 15th, 2020. Data from December 2018 to April 2019 were used as historical period. RESULTS A significant overall trend for reduction in the weekly number of ACS hospitalizations was observed (20.2%; 95% confidence interval CI [1.6, 35.4] P = 0.04). The incidence rate reached a 54% reduction during the second week of April (incidence rate ratio: 0.46, 95% CI [0.36, 0.58]) and was also significant when compared to the same months in 2019 (March and April, respectively IRR: 0.56, 95%CI [0.48, 0.67]; IRR: 0.43, 95%CI [0.32, 0.58] p < 0.001). A significant increase in door-to-balloon, door-to-needle, and total ischemic time (p <0.04 for all) in STEMI patents were reported during pandemic period. Finally, the proportion of patients with mechanical complications was higher (1.98% vs. 0.98%; P = 0.006) whereas GRACE risk score was not different. CONCLUSIONS Our results confirm that COVID-19 pandemic was associated with a significant decrease in ACS hospitalizations rate, an increase in total ischemic time and a higher rate of mechanical complications on a international scale.
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Affiliation(s)
- D Araiza-Garaygordobil
- From the Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, México
| | - C Montalto
- Department of Cardiology, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - P Martinez-Amezcua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins, Baltimore, MD, USA
| | - A Cabello-Lopez
- Occupational Health Research Unit, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - R Gopar-Nieto
- From the Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, México
| | - R Alabrese
- Department of Cardiology, Parma University Hospital, Italy
| | - A Almaghraby
- Department of Cardiology and Angiology, University of Alexandria, Egypt
| | - S Catoya-Villa
- Department of Cardiology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M Chacon-Diaz
- Cardiology Clinic and Intensive Cardiac Care, Instituto Nacional Cardiovascular INCOR-Essalud, Lima, Perú
| | - C C Kaufmann
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
| | - M Corbi-Pascual
- Coronary Care Unit, Cardiology Service, Albacete General Hospital, Albacete
| | - P Deharo
- Aix Marseille University, Inserm, Inra, C2VN, Marseille, France
| | - M El-Tahlawi
- Department of Cardiology, Zagazig University Hospital, Zagazig, Egypt
| | | | - F Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ospedali Riuniti “Umberto I—Lancisi—Salesi”, Ancona, Italy
| | - M Jarakovic
- Cardiology Intensive Care Unit, Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
| | - E Martinez-Gomez
- Acute Cardiovascular Care Unit, Hospital Clínico San Carlos, Madrid, Spain
| | - L Moderato
- Cardiology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - S Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - P Morejon-Barragan
- Coronary Care Unit, Cardiology Service, UAI University Hospital, Buenos Aires, Argentina
| | - A M Omar
- Tripoli University Hospital, Tripoli, Libya
| | - P Jorge-Pérez
- Acute Cardiovascular Care Unit, Cardiology Department, Canary Islands University Hospital, Tenerife, Spain
| | - P Przybyło
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Poland
| | - E Selim
- Coronary Care Unit, Emergency Department and Cardiology Clinic, Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - U Y Sinan
- Department of Cardiology, PH and ACHD, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| | - M Stratinaki
- Cardiology Department, General Hospital Venizeleio, Heraklion, Crete, Greece
| | - O Tica
- Faculty of Medicine and Pharmacy, University of Oradea; Emergency County Clinical Hospital of Oradea, Romania
| | - M Trêpa
- Cardiology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - A Uribarri
- Cardiovascular Care Unit, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
| | - J Uzokov
- Republican Specialized Scientific Practical Medical Center of Therapy and Medical Rehabilitation, Tashkent, Uzbekistan
| | - K Wilk
- Department of Cardiology, Medical University of Białystok, Bialystok, Poland
| | - K Czerwińska-Jelonkiewicz
- Intensive Therapy Unit, Harefield Hospital, Royal Brompton & Harefield NHS Fundation Trust, London, UK
| | - A Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Poland
| | - S Leonardi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - K A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria
| | - G Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
- Address correspondence to Dr Guido Tavazzi, MD, PhD, University of Pavia, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences; Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Anestesia e Rianimazione I, DEA Piano-1, Viale Golgi 19, 27100 Pavia, Italy.
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Moderato L, Binno S, Rusticali G, Dallospedale C, Aschieri D, Pastorini G, Piepoli MF. Mitral anular plane excursion predicts coronary stenosis during stress echocardiography with dipyridamole. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Dipyridamole stress echocardiography (DSE) is an important tool for detecting reversible ischemia in patients with suspected coronary artery disease (CAD); nonetheless, the results of the test are related to wall motion abnormalities, moderately operator-dependent, and left anterior descending (LAD) artery reserve, resulting in a moderate sensibility and specificity.
Purpose
Aim Of our study was to evaluate whether an easy-to-use parameter like mitral annular plane systolic excursion (MAPSE) could be useful to identify CAD during DSE.
Methods
We prospectively enrolled 512 patients that underwent DSE for suspected CAD; rest and peak MAPSE was acquired; 148 patients were referred to perform coronary angiography, with evidence of severe coronary stenosis in 91 patients.
The mean age was 66.7 ±11 years, male gender was prevalent (64%).
MAPSE at the peak was significantly different between patients with CAD and patient without (13,4mm vs 16,81 mm , p < 0.001); in fact, patients with CAD showed a blunted or no increase of MAPSE after dipyridamole infusion, with a significative difference in Delta Mapse (Mapse peak-Mapse rest) between groups ( -0.5mm vs 2.8mm) By using a Receiver Operating Curve, the Area under the curve was 0,764 (0.682-0.846), with the best cut-off value of +0.5mm (Sensibility 77%, Specificity 62% - Figure 1), comparabale with traditional methods like LAD reserve, FE reduction or Wall Motion Score Index.
Discussion
to our knowledge, this is the first study that compared the behavior of MAPSE during dipyridamole infusion in patients with and without coronary artery disease. MAPSE is a well-known surrogate of longitudinal systolic function and has increased sensitivity over traditional methods of systolic performance such as LV-EF: in this context, dipyridamole induced reversible ischemia could affect prematurely MAPSE then EF or wall motion abnormalities.
In our study, in patients with evidence of reversible ischemia during DSE, a blunted or no increase of MAPSE was able to predict CAD. Incorporating this easy-to-use parameter could improve the specificity of DSE and strengthen the suspect of reversible ischemia when clear wall motion abnormalities are not found.
Abstract Figure. Mean value of Mapse and ROC curve
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Affiliation(s)
- L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - S Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Rusticali
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - D Aschieri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Pastorini
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - MF Piepoli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Binno S, Moderato L, Capelli P, Piepoli MF, Scabini M, Mosso F, Aschieri D. The usefulness of dipyridamole stress echocardiography in high-risk patients before abdominal aneurism surgery. Eur Heart J Cardiovasc Imaging 2021. [PMCID: PMC7929003 DOI: 10.1093/ehjci/jeaa356.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Funding Acknowledgements Type of funding sources: None. Background Coronary artery disease (CAD) and aortic aneurysm (AA) share commons risk factors, such as hypertension, diabetes mellitus, hypercholesterolemia, and smoking. Cardiac assessment before aortic abdominal aneurysm (AAA) surgery is indicated for patients with symptomatic coronary artery disease (CAD). The usefulness of assessment of moderate/high-risk patients is still debated. Purpose the purpose of our study is to evaluate the safety and effectiveness of dipyridamole stress echocardiography (DSE) for the detection of CAD in patients undergoing AAA surgery with high cardiovascular risk. Methods From 2017th to 2019th 120 patients underwent surgery for aortic aneurysm (71 endovascular technique and 49 with open laparotomy). Of these, 74 asymptomatic patients with high cardiovascular risk underwent a pre-surgical contrast-enhanced dipyridamole stress echo (0,84 mg/kg over 6 minutes – protocol with LVO with sulfur hexafluoride), to exclude the presence of inducible myocardial ischemia, Mean follow-up was 6-24 months. Results Mean age was 77 years +/- 6.6, with male gender prevalent (83%). No complication during DSE occurred; mean SCORE risk was 9.8% +/- 2.3%, with 63% patients with very high risk. Only 1 patient showed inducible ischemia during stress echocardiography, with evidence of significant LAD stenosis; no myocardial infarction was reported at follow-up, while 1 ischemic stroke and 1 unplanned revascularization occurred. 11% of patients died, of which 50% for Sars-Cov-2 disease and 12% due to post-surgery dissection while no cardiac deaths were found. Conclusions dipyridamole stress echo is safe in patients with surgical-class abdominal aortic aneurism; in patients with high cardiovascular risk but no symptoms reversible ischemia is rare. DSE should not be routinely performed before high-risk surgery but only in patients with cardiac symptoms. Abstract Figure. Patients Diagram ![]()
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Affiliation(s)
- S Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - P Capelli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - MF Piepoli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - M Scabini
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - F Mosso
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Moderato L, Lazzeroni D, Biagi A, Spezzano T, Matrone B, Piepoli M, Binno S, Villani G, Aschieri D. Air pollution and out-of-hospital cardiac arrest risk. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide; it accounts for up to 50% of all cardiovascular deaths.It is well established that ambient air pollution triggers fatal and non-fatal cardiovascular events. However, the impact of air pollution on OHCA is still controversial. The objective of this study was to investigate the impact of short-term exposure to outdoor air pollutants on the incidence of OHCA in the urban area of Piacenza, Italy, one of the most polluted area in Europe.
Methods
From 01/01/2010 to 31/12/2017 day-by-day PM10 and PM2.5 levels, as well as climatic data, were extracted from Environmental Protection Agency (ARPA) local monitoring stations. OHCA were extracted from the prospective registry of Community-based automated external defibrillator Cardiac arrest “Progetto Vita”. OHCA data were included: audio recordings, event information and ECG tracings. Logistic regression analysis was used to estimate the association between the risk of OHC, expressed as odds ratios (OR), associated with the PM10 and PM2.5 levels.
Results
Mean PM10 levels were 33±29 μg/m3 and the safety threshold (50 μg/m3) recommended by both WHO and Italian legislation has been exceeded for 535 days (17.5%). Mean PM 5 levels were 33±29 μg/m3. During the follow-up period, 880 OHCA were recorded on 750 days; the remaining 2174 days without OHCA were used as control days. Mean age of OHCA patients was 76±15 years; male gender was prevalent (55% male vs 45% female; <0.001). Concentration of PM10 and PM 2.5 were significantly higher on days with the occurrence of OHCA (PM10 levels: 37.7±22 μg/m3 vs 32.7±19 μg/m3; p<0.001; PM 2.5 levels: 26±16 vs 22±15 p<0.001). Risk of OHCA was significantly increased with the progressive increase of PM10 (OR: 1.009, 95% CI 1.004–1.015; p<0.001) and PM2.5 levels (OR 1.012, 95% CI 1.007–1.017; p<0.001). Interestingly, the above mentioned results remain independent even when correct for external temperature or season (PM 2.5 levels: p=0.01 – PM 10 levels: p=0.002), Moreover, dividing PM10 values in quintiles, a 1.9 fold higher risk of cardiac arrest has been showed in the highest quintile (Highest quintile cut-off: <48μg/m3)
Conclusions
In large cohort of patients from a high pollution area, both PM10 and PM2.5 levels are associated with the risk of Out-of-hospital cardiac arrest.
PM10 and PM2.5 levels and risk of OHCA
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - D Lazzeroni
- Foundation Don Carlo Gnocchi Onlus, Milan, Italy
| | - A Biagi
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - T Spezzano
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - B Matrone
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - M.F Piepoli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - S Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G.Q Villani
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Moderato L, Pastorini G, Lazzeroni D, Monello A, Rusticali G, Piepoli M, Villani G, Binno S. Speckle-tracking during dipyridamole stress echocardiography in the detection of myocardial ischemia in patients with suspected coronary artery disease. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The aim of this study was to investigate the incremental value of global longitudinal strain (GLS), postsystolic strain index (PSI) and prestretch (PSE) by automated function imaging with respect to wall motion (WM) and coronary flow reserve (CFR) for the diagnosis of significant coronary artery disease (CAD) during dipyridamole stress echocardiography.
Methods
We retrospectibely enrolled 227 patients with known or suspected CAD, approaching our echo lab to perform a DSE; all patient underwent coronary angiography within 1 month for clinical reasons. Obstructive CAD was defined as the evidence of >70% stenosis during coronary angiogram. Obstructive CAD was detected in 143 (63%) patients, while 84 (37%) had no significant CAD.
Global longitudinal strain, PSI and PSE were measured at rest and peak of the stress (after 6 minutes of 0,84mg/kg of dipyridamole infusion).
Results
Patient with CAD showed a significantly lower GLS at rest (−16.9±4.2 vs −18.6±3.4; p<0.01) and peak (14.9±3.8 vs −21.50±3.3; p<0.01) Figure A; the behavior of GLS was opposite, in patient with CAD showed an increase while in patient without CAD a significant decrease after dipyridamole infusion. There was also a significant difference between groups for Delta PSI (PSIpeak − PSIrest) and Delta PSE (PSEpeak − PSErest), respectively 126±145 vs −40±97, (p<0.01) and 108±163 vs −41±106 (p<0.01) Figure C. ROC analyses produced a statistically valid model: Average GLS at peak (p 0.001; AUC=0.906, cut-off value −18%, sensitivity 83% and specificity 82%); on the basis of these results, we compared WM and myocardial deformation analysis and GLS was superior to CFR LAD, Delta EF, Delta ESV and Delta WMI (Figure B).
Conclusions
GLS, PSE and PSI show an opposite response to dipyridamole, in patients with CAD in patient without CAD and show much higher sensitivity and specificity compared to the conventional parameters like WMI, EF and CFR in detecting CAD
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Pastorini
- University Hospital of Parma, Cardiology Department, Parma, Italy
| | - D Lazzeroni
- Foundation Don Carlo Gnocchi Onlus, Milan, Italy
| | - A Monello
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Rusticali
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - M.F Piepoli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G.Q Villani
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - S Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Moderato L, Binno SM, Pastorini G, Dallospedale C, Benatti G, Lazzeroni D, Piepoli M, Aschieri D, Villani GQ. P1555 Delta mapse: an easy-to-use tool to evaluate coronary artery stenosis during dypiridamole pharmacological stress echocardiography. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Dypiridamol stress echocardiography (DSE) is an important tool for detecting reversible ischemia in patients with suspected coronary artery disease (CAD); nonetheless the results of the test are related to visualization of wall motion abnormalities, moderately operator-dependent, and left anterior descending (LAD) artery reserve, resulting in a moderate sensibility and specificity. Aim of our study was to evaluate whether an an easy-to-use parameter like mitral annular plane systolic excursion (MAPSE) could be useful to identify CAD during DSE.
Methods
We prospectively enrolled 300 patients with suspected CAD and perform a DSE; at rest and peak MAPSE was acquired. 59 patients with reversibile ischemia during stress echocardiography (positive) were referred to perform coronary angiography. Patients were divided according to MAPSE behaviour during DSE: group 1 (MAPSE ≤ 0) and group 2 (delta MAPSE > 0 mm).
Results
The mean age of was 63 ± 11 years, male gender was prevalent (73%); no differences were found in risk factors and left vetnricular ejection fraction (LV-EF) between two groups.Coronary arteries were normal in 14 patients (23%), while significant stenosis (>70%) was found in 45 patients (77%); in 31 patients (53%) left main (LM) or proximal LAD artery were involved, while in 17 (29%) and 22 (37%) right coronary artery and circumflex artery were affected respectively. Patients with CAD showed a lower (blunted or no increase) MAPSE after dypiridamole infusion, with a significative difference in Delta Mapse (Mapse peak-Mapse rest) between groups (0,2 mm vs 2,8 mm p = 0,004) (Figure 1B). By using a Receiver Operating Curve, the Area under the curve was 0,757, with the best cut-off value for CAD prediction at Delta Mapse= +2.5 mm (sensibility 0,667 and specificity 0,809 – p = 0.012 - Figure 1b). In particular, Delta Mapse was able to predict LM/LAD stenosis (Figure 1B AUC = 0.679 ;p = 0.019), rather than right coronary artery and circumflex artery disease, with higher predictivity than delta LV-EF (AUC = 0.577; p = 0.077).
Discussion
To our knowledge, this is the first study that compared the behaviour of MAPSE during dypiridamole infusion in patient with and withouth coronary artery disease. MAPSE is a well-known surrogate of longitudinal systolic function and have increased sensitivity over traditional methods of systolic performance such as LV-EF; in this context, dypiridamole induced reversible ischemia could affect prematurely MAPSE then EF or wall motion abnormalities. In our study, in patients with evidence of reversible ischemia during DSE, a blunted or no increase of MAPSE was able to predict CAD, mostly driven by LM/LAD disease, on top of other well known markers of ischemia. Incorporating this easy-to-use parameter could improve specificity of DSE and strenghten the suspect of reversibile ischemia when clear wall motion abnormalities are not found.
Abstract P1555 Figure 1A and 1B
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Affiliation(s)
- L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - S M Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Pastorini
- University Hospital of Parma, Cardiology Department, Parma, Italy
| | | | - G Benatti
- University Hospital of Parma, Cardiology Department, Parma, Italy
| | - D Lazzeroni
- Foundation Don Carlo Gnocchi Onlus, Milan, Italy
| | - M Piepoli
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Q Villani
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Binno SM, Moderato L, Pastorini G, Matrone B, Aschieri D, Moccia L, Magri P, Franco C, Villani GQ. P1317 Very late onset of platypnoea orthodeoxia syndrome as first clinical scenario of patent foramen ovale. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
We report a case of a 83-year-old female, who had an admission for dyspnea. Laboratory showed D-dimer 1000 ng/ml, haemoglobin 12.4 mg/dL, CPR 0.08mg/dl whereas on Arterial Blood Gas test she had hypoxia with respiratory alkalosis.
In view of suspected pulmonary embolism, she underwent Thoracic Computed Tomography scan that excluded it.
During the stay the patient seemed more symptomatic while in standing position(with SpO2s 89% while supine plunging to 50% while standing): ABGs were performed both standing (reservoir 15 l/min pH 7.50, pO2 37.2 mmHg, pCO2 37.1 mmHg, HCO3 28.9 mmol/l) and recumbent position (reservoir 15 l/min pH 7.47, pO2 65.5 mmHg, pCO2 35.1 mmHg, HCO3 25.6 mmol), showing a difference of 28 mmHg.
Subsequently the patient underwent v/p pulmonary scintigraphy: no signs of pulmonary embolism though it revealed a multiple focus of capitation Tc-99m macro aggregated albumin in brain, thyroid and kidneys (IMG top), compatible for veno-arterial shunt.
Trans-esophageal echocardiography (TOE) revealed a massive stretched patent foramen ovale (PFO) with continuous right-to-left shunting through the atria. The bubble test (IMG bottom) confirmed the presence of patency along with sudden passage of microbubbles through the foramen. Qp/Qs = 0.8, due to volume overload in the left atrium from the right atrium. The imaging along with clinical scenario confirmed the suspected diagnosis of platypnea-orthodeoxia, finding the patent foramen ovale as the anatomical cause.
Platypnea-orthodeoxia syndrome is a clinical condition characterized by dyspnea. Typically blood oxygen saturation declines with standing position while it resolves with recumbent.
The classification entails 3 groups: intracardiac shunting (most common presentation), pulmonary shunting, ventilation-perfusion mismatch.
Presence of multiple focus of albumin macroaggregates outside the lungs in v/p scintigraphy examination is suggestive for veno-arteriuous shunt: without shunt, normally all the albumin aggregates are hampered in the lungs’ field.
Images in bottom are taken in sequence from a single acquisition during the TOE, in one single cardiac beat. Here is depicted the evidence of the PFO, the influx of bubbles in the right atrium and the instantaneous and massive shunt of the bubbles across the interatrial septum, in the left atrium.
Usually the diagnosis is performed within 55 years old: it is interesting how late the diagnosis occurred in this patient with such resounding clinical manifestation.
Top
Scintigraphy with ventilation and perfusion lung scan sequences. Next, scintigraphy with capitation of Tc-99m macro aggregated albumin in brain, thyroid and kidneys.
Bottom, Transesophageal echocardiogram: images taken within the same heart beat proving right-to-left passage of bubble across the septum.
Abstract P1317 Figure. Scintigraphy and Transesophageal echo
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Affiliation(s)
- S M Binno
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - L Moderato
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Pastorini
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - B Matrone
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - D Aschieri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - L Moccia
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - P Magri
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - C Franco
- Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - G Q Villani
- Guglielmo da Saliceto Hospital, Piacenza, Italy
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Pontecorboli G, Lazzeroni D, Fierro N, Dastidar AG, Biglino G, Milano EG, De Garate E, Sighal P, Moderato L, Camici PG, Bucciarelli-Ducci C. P620Mitral annular plane systolic excursion on cardiac magnetic resonance imaging as a predictor of atrial fibrillation in hypertrophic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez116.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- G Pontecorboli
- Careggi University Hospital (AOUC), Cardiovascular and Thoracic Department, Florence, Italy
| | - D Lazzeroni
- University Vita-Salute San Raffaele, Milan, Italy
| | - N Fierro
- University Vita-Salute San Raffaele, Milan, Italy
| | - A G Dastidar
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - G Biglino
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - E G Milano
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - E De Garate
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - P Sighal
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - L Moderato
- University Vita-Salute San Raffaele, Milan, Italy
| | - P G Camici
- University Vita-Salute San Raffaele, Milan, Italy
| | - C Bucciarelli-Ducci
- Bristol Heart Institute, Cardiac MRI Unit, Bristol, United Kingdom of Great Britain & Northern Ireland
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Moderato L, Palumbo A, Coli S, Orlandini D, Russo G, Gaibazzi N. P981Lvot area measurement using gated ct data reclassifies aortic stenosis severity as graded by echocardiography. Eur Heart J Cardiovasc Imaging 2018; 17:ii193-ii201. [PMID: 28415115 DOI: 10.1093/ehjci/jew260.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Measurement of left ventricular outflow tract (LVOT) diameter and area for estimation of aortic valve area (AVA) using transthoracic echocardiography (TTE) and the continuity equation assumes circular LVOT. The use of direct planimetric measurement of LVOT area by gated-CT can theoretically improve accuracy of AVA calculation. Purpose We aim to assess reproducibility of LVOT echo measurement and its correlation and agreement with Gated CT measurements. In the subgroup with aortic stenosis (AS) we secondarily assessed the potential change in AS severity using LVOT area by CT instead of TTE in the continuity equation. Methods We retrospectively studied 93 patients, 43 of whom with severe AS. LVOT Area was measured with 2D TTE by 2 expert echocardiographers and gated-CT by 2 expert radiologists; inter-reader agreement and inter-method (Echo vs gated CT) agreement and correlation were measured. Finally we used the measurement of CT scan in the continuity equation instead of TTE measurement to assess potential reclassification of AS severity. Results Mean age was 78±11. Table shows inter-reader and inter-method agreement and correlation. The correlation between 2 echocardiophers for LVOT measurements was good (rho = 0,77) although not perfect. Out of 43 severe AS, defined as AVA<1 cm2 using TTE in the continuity equation, 18 were reclassified by gated-CT LVOT measurements into moderate AS. This was due to gated-CT LVOT area resulting on average 1.4 cm2 larger than LVOT area by TTE. Conclusion LVOT is elliptical and TTE tends to underestimate LVOT area and AVA due to the measurement of the shorter diameter of this ellipse. CT scan can provide more geometrically accurate measurement and requires different cut-offs compared with traditional TTE AVA measurement. By the way, in the current study the LVOT area by CT was on average 38% larger of the LVOT area measured by TTE. Such correcting factor (increase TTE LVOT area by 38%) should apparently be used to assess anatomical true planimetric area to be compared with gated-CT LVOT. summary tableTTE Inter-reader correlation LVOT area (Spearman rho)0.77TTE reader A vs CT 3-chamber equivalent correlation (Spearman rho)0.49TTE reader B vs CT 3-chamber equivalent correlation (Spearman rho)0.38TTE reader A area vs CT planimetric area correlation (Spearman rho)0.41TTE reader B area vs CT planimetric area correlation (Spearman rho)0.31Mean LVOT Area by TTE reader A3,60SD 0,6038%Mean LVOT Area by CT scan4,99SD 0,98 Abstract P981 Figure. summary table. Abstract P981 Figure.
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Affiliation(s)
- L Moderato
- University Hospital of Parma, Cardiology Department, Parma, Italy
| | - A Palumbo
- University Hospital of Parma, Radiology Department, Parma, Italy
| | - S Coli
- University Hospital of Parma, Cardiology Department, Parma, Italy
| | - D Orlandini
- University of Modena & Reggio Emilia, Cardiology, Modena, Italy
| | - G Russo
- University Hospital of Parma, Radiology Department, Parma, Italy
| | - N Gaibazzi
- University Hospital of Parma, Cardiology Department, Parma, Italy
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