Motion Index: a new parameter to evaluate the diastole by M-Mode imaging

AIM

Heart failure with normal left ventricle (LV) ejection fraction is commonly understood as diastolic heart failure because this expression implies the presence of LV diastolic dysfunction diagnosed by specific echocardiographic findings, such as slow LV relaxation and increased LV stiffness. In this work the authors propose a new parameter named Motion Index, which is measurable by M-Mode technique and it is likely linked to diastolic dysfunction.

METHODS

A patient population composed by 134 subjects was enrolled. They all were in New York Heart Association (NYHA) functional class II. Echocardiogram carried out in all patients allowed the authors to distinguish 2 patient arms depending on the presence or absence of diastolic dysfunction, evaluated by flow Doppler and tissue Doppler.

RESULTS

After carrying out every echocardiographic examination, the authors also measured the new parameter that called Motion Index, and found that it had an average value of 46 in patients with normal diastolic function and 33.5 in patients with diastolic dysfunction. This parameter did not depend on systolic dysfunction.

CONCLUSIONS

Data obtained showed a statistically significant correlation between Motion Index and means of diastolic function assessed by both flow and tissue Doppler.

Anticoagulant drugs in noncompaction: a mandatory therapy?

BACKGROUND

Noncompaction of left ventricular myocardium is a rare congenital cardiomyopathy resulting from an incomplete myocardial morphogenesis that leads to the persistence of the embryonic myocardium. This condition is characterized by a thin compacted epicardial and an extremely thickened endocardial layer with prominent trabeculations and deep intertrabecular recesses. It is not clear, in noncompaction of myocardium, whether intertrabecular recesses could be responsible for thrombi formation and thromboembolic complications.

METHODS

The prevalence of stroke and echocardiographic finding of thrombus was evaluated in a continuous series of 229 patients (men and women) affected by noncompaction of the left ventricular myocardium, who were included in the SIEC registry. We excluded patients affected by atrial fibrillation.

RESULTS

The mean age of the patients was 49.5 years. Fifty percent of the patients were affected by a ventricular systolic dysfunction. The mean period of follow-up was 7.3 years. Only four patients had a history of ischemic stroke. A large thrombus into the left ventricular chamber was observed in a 1-year-old child affected by Behcet's disease (high risk of thrombi formation).

CONCLUSION

Noncompaction of the left ventricular myocardium, by itself, does not seem to be a risk factor for stroke or embolic results, so there is no indication for oral anticoagulant therapy.

Magnetic resonance in isolated noncompaction of the ventricular myocardium

Non-compaction of the ventricular myocardium (LCVM) is a rare disorder of myocardial morphogenesis usually diagnosed in paediatric age. The diagnosis was echocardiographically made on the basis of a reported spongeous/compacted ratio >2 in one or more segments of the left ventricle during the diastolic period. We aimed to test the diagnostic accuracy of cardiovascular magnetic resonance (CMR) imaging in distinguishing pathological left ventricular non-compaction.

METHODS

We collected a consecutive series of 8 patients, 5 males and 3 females, with a mean age of 14.9 years with non-compaction of left ventricular myocardium. All patients were admitted in our divisions of cardiology. In all cases the diagnosis was performed by echocardiography. The diagnosis was obtained when the spongeous/compacted ratio was >2 in one or more segments of left ventricle, evaluated in systolic and diastolic period. In the end we completed the diagnosis by scanning with a Signa HD 1.5 T (GE, Milwaukee, USA) the same 8 patients affected by non compaction of ventricular myocardium. In all patients cardiac-gated T1 and T2 black-blood FSE images in short axis and in four-chamber horizontal long axis were obtained. Breath hold cine MR sequences (FIESTA) were performed, covering the whole left ventricle in short-axis plane and in four-chamber view. A segmented inversion-recovery fast gradient echo sequence (IR-FGE) was performed in the short-axis plane of the LV and in four-chamber-view after Gadolinium injection in 8 patients affected by non compaction of left ventricle. At the end of examination the spongeous/compacted ratio >2 was calculated in all involved segments of the left ventricle in diastole.

RESULTS

In all cases we demonstrated by echocardiography an involvement of the ventricular apex. In 3 cases the structural alterations involved also lateral wall of left ventricle. Magnetic resonance evaluation showed that involvement demonstrated by the echocardiogram was the same: ventricular apex involved in every patient, lateral wall in 3 and all segments in 2. However the spongeous/compacted ratio was >>2 in all patients, with a mean value of 3,1.

CONCLUSIONS

Although our data refer to a small population of patients and need further confirmation, they suggest that it seems reasonable increase the cut-off for spongeous/compacted ratio from a value of 2 to 2.5 for non-compaction diagnosis when high-resolution magnetic resonance is used.

The long QT syndrome in pediatric age: prognosis and risk factor

AIM

Long QT syndrome is a rare arrhythmic disease with a low incidence in the general population. There are no sure clinical or electrocardiographic parameters that could lead to a correct prognostic stratification in patients affected by this syndrome. The correlation between the incidence of a sudden death or dangerous ventricular arrhythmias and the duration of QTc interval is still a controversial topic.

METHODS

Twenty nine children affected by QT long syndrome were admitted to the Division of Pediatric Cardiology of the Casa del Sole Hospital of Palermo (Italy). Their diagnosis was made by electrocardiogram (ECG). The average age of the patients was 7.6 years. The average follow-up was 4 years and three months. A therapy with beta-blocker was administered to all the children. During the follow-up of 4 year and three months, patients were genotyped. Twenty-three out of 29 children had at least one relative affected by the syndrome. Three of them had a familiar dead because of this syndrome and everyone had a duration of maximum QTc higher than the cut off (P=0.0002). All the people who died had not followed the therapy with beta-blocker. Patients with a maximum QTc recorded <500 had not familiar death by this syndrome.

RESULTS

Holter and echocardiogram recorded periodically during the observation did not show dangerous arrhythmic events. All children maintained a good health during the follow-up.

CONCLUSION

Although conducted on a small study population, the data analysis recorded during this study suggests that in patients affected by QT long syndrome younger than 16 years old undergoing a beta-blocker therapy the prognosis is excellent. The duration of QTc interval appears as a negative prognostic factor, although the beta-blocker therapy has been reduced considerably the incidence of sudden death.

Supraventricular arrhythmias in noncompaction of left ventricle: Is this a frequent complication?

BACKGROUND

Isolated left ventricular noncompaction is the result of incomplete myocardial morphogenesis, leading to persistence of the embryonic myocardium. The condition is recognised by an excessively prominent trabecular meshwork and deep intertrabecular recesses of the left ventricle. Whether these intertrabecular recesses are a favorable substrate for supraventricular arrhythmias is unclear, even if the incidence of chronic heart failure seems to be high.

RESULTS

We evaluated a continuous series of 238 patients affected by noncompaction. In 4 cases the patients reported palpitations and in 4 an episode of syncope. Periodic holter monitoring was performed every 6 months for 4 years. Only 9 patients had documented atrial fibrillation. In no cases we observed supraventricular tachycardia.

CONCLUSIONS

Noncompaction alone does not seem to be a risk factor for supraventricular arrhythmias.

Symptomatic acute myocardial infarction in a patient bearer of heart transplantation following ischemic heart disease

In 2005 Syeda et al. reported that the major factor limiting the long term of cardiac transplantation is the development of accelerated arteriosclerosis that occurs in the coronary arteries of the cardiac allograft. Transplant arteriosclerosis is characterized by diffuse, uniform, concentric narrowing of the artery by a fibrous proliferation of sub-intima cells. This atherosclerosis was estimate to occur in approximately 50% of patients by 5 years after transplantation. Unfortunately, as a consequence of cardiac denervation, symptoms are often atypical or completely absent. When these are present, the symptoms are those typical of effort angina. Very uncommon is the acute coronary syndrome. We present a case of a patient, underwent to a cardiac transplant for ischemic cardiomyopathy that after 10 years from the transplantation, was affected by an anterior myocardial infarct. In our case the presence of a single noncircumferential atherosclerotic plaque makes to think that it is a consequence of a patient's systemic atherosclerotic disease better then the result of the heart transplant's typical atherosclerosis.

Segmental dyskinesia in Wolff–Parkinson–White syndrome: A possible cause of dilatative cardiomyopathy

Wolff-Parkinson-White (WPW) is a syndrome characterized by the presence of an accessory pathway that skipping A-V node may lead the electrical stimulus from the atrium directly to the ventricle. Some studies reported the finding of myocardial dyskinesia in the segments precociously activated by the accessory pathway, at echocardiogram and at nuclear cardiac study. Soria et al. reported, in 1985, an increased incidence of dilative cardiomyopathy in patients with WPW. The pathophysiological pathway that leads to ventricular dilation may be due to the increase of end-diastolic pressure secondary to a tachycardia-induced cardiomyopathy. Tachycardia-induced cardiomyopathy is usually secondary to frequent and prolonged tachycardia episodes. In this paper we report the cases of three patients affected by WPW who developed dilative cardiomyopathy during the follow-up. Particularly dyskinetic segments, working such as a functional aneurysm, could induce deep modifications of intraventricular haemodynamics, leading to remodelling and progressive ventricular dilation. This hypothesis could have important empirical consequences because it could imply the necessity of a precocious ablative therapy in this kind of patients.

The noncompaction of the left ventricular myocardium: our paediatric experience

OBJECTIVES

The noncompaction of the left ventricular myocardium is a rare congenital heart disease, characterized by an excessive prominence of trabecular meshwork, spaced out by deep intertrabecular recesses, consequent to the arrest of the normal myocardium embryogenesis. Although there are numerous descriptions, the physiopathological effects of the structural alterations, just like the clinical spectrum and the evolution of the disease, are not totally clarified. In the present study, we have evaluated the natural history of the disease, the familial incidence and the alterations of the systolic and diastolic function.

METHODS

We collected a series of 21 young patients who were affected by noncompaction of left ventricular myocardium. In all cases, a diagnosis was echocardiographically made on the basis of a reported spongy/compacted ratio > 2 in one or more segments of the left ventricle. Thirteen patients were male and eight were female, with a mean age of 12.7 years (range 21 days to 27 years). The average follow-up time was 7.8 years (range 1-18 years); all patients were periodically tested by ECG Holter and two-dimensional and Doppler echocardiogram. In 14 patients, the last echocardiographic evaluation included the analysis of tissue Doppler imaging (TDI).

RESULTS

The noncompaction of left ventricular myocardium was isolated in nine cases and associated with a structural cardiopathy in 12 cases: with atrial septal defect in four cases, ventricular septal defect in four cases, aortopulmonary window in one case, aortic coarctation in one case and bicuspid aortic valve in one case. One case presented a type Kent ventricular pre-excitation. Twelve cases were symptomatic at the moment of the diagnosis (for heart failure in 11 cases and for syncope in one case). Nine cases were asymptomatic and the diagnosis was made during a family screening or occasionally. In ten of the 11 subjects affected by congestive heart failure, medical therapy re-established a good haemodynamic balance (in two cases, it was possible to suspend the therapy). In one case with congestive heart failure and pulmonary hypertension in New York Heart Association class III, we recommended heart transplantation. We did not find any dysrhythmia in any of the cases. Diastolic function impairment, tested by transmitral blood pressure monitoring and TDI, was found in seven of 14 patients, all with reduced left ventricular contractility.

CONCLUSIONS

We noticed a considerable variability of clinical presentation in our cases, according to the number of the ventricular segments affected by the anomaly. According to our data, middle-term prognosis appears to be better than that previously reported in the literature. We found a reduction of the systolic function only in 50% of cases, all with severe involvement of the apical and postero-lateral segments. Diastolic function was compromised only in those patients with severe impairment of systolic function.

A coronary right fistula canalized in a small accessory right atrial chamber

The coronary artery fistulas are rare congenital anomalies with a very low incidence. These can be symptomatic or asymptomatic because the hemodynamic consequences of the fistula vary and depend on the shunt dimensions. Discordant opinions instead are present in the literature for the defect closing in asymptomatic patients. Here, we describe a patient affected by a coronary right fistula canalized in a small accessory right atrial chamber. During follow-up, we observed a progressive dilatation of the right coronary artery (maximum diameter 10.3 mm) with hemodynamic overload of the right sections.

Chronic pharmacological treatment in takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy is a disorder that has been appreciated only recently. In most of reported cases, this syndrome mimes an acute myocardial infarction. Till this moment no data are available from literature about the treatment in the acute phase of this disease.

AIM OF THE STUDY

In our multicentric experience we have retrospectively looked at the benefits of a treatment with ACE-inhibitors, beta-blockers, Aspirin and calcium channels blockers, started until the early phases of the disease and continued for 30 days, in 36 patients affected by Takotsubo cardiomyopathy. We chose as endpoint of the study the efficacy of the used drug in improving left ventricular myocardial function and the rapidity of the effects of the same drug.bethods: from an international registry about the Takotsubo cardiomiopathy, co-ordinate by our research group, we evaluated the long term efficacy of some drugs, administrated like single treatment in some patients.

RESULTS

Obtained data did not show any statistically significant difference in the percentages of improvement in the left ventricle ejection fraction evaluated at the admission to the hospital, before the discharge and after 30 days of treatment between each treated group and the control group of non-treated patients. No significant differences were found in hospitalization times between treated patients and controls. None of our patients experienced during the observation period a relapse of the disease.

CONCLUSIONS

The results of our survey suggest that a chronic treatment with beta-blockers, ACE-inhibitors, calcium channels blockers and aspirin does not provide any benefit in patients with Takotsubo cardiomyopathy. Thus, it seem to be important an early correct differential diagnosis to avoid any chronic treatment in these patients.

Inefficiency of renin-angiotensin inhibitors in preventing atrial fibrillation in patients with a normal heart

AIM

Recent scientific evidence has emphasized the possible role of inhibitors of the renin-angiotensin system in preventing arrhythmic relapses in patients with paroxysmal or persistent atrial fibrillation and co-existing left ventricular hypertrophy or left ventricular dysfunction.

METHODS

In order to verify the effects of these drugs on patients with a normal heart, we collected a series of 187 patients admitted to our division of cardiology for paroxysmal or persistent atrial fibrillation. All patients underwent cardioversion (with antiarrhythmic drugs and/or by electrical cardioversion) and were discharged in sinus rhythm. Episodes of recurrent arrhythmia were recorded during a mean follow-up period was 2 years. Patients were subdivided into 2 groups according to therapy: group 1 comprised patients receiving renin-angiotensin system inhibitors, group 2 comprised those not receiving therapy with these agents. All 91 patients in group 1 and 76 of those in group 2 had hypertension. Among the 91 patients in the group 1, 55 were treated with angiotensin-converting enzyme (ACE) inhibitors and 36 with angiotensin receptor blockers. There were no statistically significant differences in cardiovascular risk factors or antiarrhythmic drug use between the 2 groups.

RESULTS

In group 1, 83% of patients experienced <2 recurrences of atrial fibrillation during the follow-up period, while 17% had >2 episodes. In group 2, 86% of patients experienced <2 relapses during the follow-up period, while the remaining 14% had >2 relapses. There was no statistically significant difference between the 2 groups (P=0.85). A subgroup analysis showed that treatment with angiotensin receptor blockers, beta-blockers, diuretics, and calcium-channel blockers brought no advantage in sinus rhythm maintenance.

CONCLUSION

In our sample of hypertensive patients with a healthy heart, treatment with ACE inhibitors showed no statistically significant advantage in the prevention of atrial fibrillation relapses.

[Current therapeutic approach in patients with Alzheimer disease]

Even if a complete recovery is not an available outcome for Alzheimer disease, it is possibile to improve the clinical symptoms (selfsufficiency, cognitive impairment and behavioral disturbances) with pharmacological and non-pharmacological therapies. The treatment of the patient with dementia is a complex one, that cannot rely only on the use of drugs but needs of a global approach that take into account all the different aspect of the disease. The most used drugs are the cholinesterase inhibitors that have been shown to stabilize or slow down cognitive and functional decline and retard institutionalization, but new treatments are on the way. Extremely important is a strong alliance with the family. Non pharmacological cognitive rehabilitation techniques are also useful in potentiating residual cognitive functions in the patient and in supporting the family and the caregivers.

Ventricular Tachycardia in Non-Compaction of Left Ventricle: Is This a Frequent Complication?

BACKGROUND

Isolated left ventricular non-compaction is the result of incomplete myocardial morphogenesis, leading to persistence of the embryonic myocardium. The condition is recognized by an excessively prominent trabecular meshwork and deep intertrabecular recesses of the left ventricle. Whether these intertrabecular recesses are a favorable substrate for ventricular arrhythmias is unclear. Some reports have found that the fatal ventricular arrhythmias may occur in approximately half of the patients. In this report we investigated about this association.

METHODS AND RESULTS

In total we evaluated a continuous series of 238 patients affected by non-compaction. Periodic Holter monitoring was performed every 6 months for 4 years. Only 11 patients had documented ventricular tachycardia, which was sustained in two cases and non-sustained in nine. In no cases we observed ventricular fibrillation.

CONCLUSIONS

Non-compaction alone does not seem to be a risk factor for malignant ventricular arrhythmias.

Evaluation of diastolic function by the Tissue doppler in children affected by non-compaction

The Tissue doppler analysis is a new echocardiographic approach to evaluate the diastolic function. In this report we performed a Tissue doppler analysis in a series of 15 children affected by non-compaction. The bidimensional echo-cardiogram showed a systolic function which was reduced only in 8 patients. Alterations of the diastolic function were founded in 7 patients: in 2 cases, a reduction of the E tissue wave was present in all segments. In 3 patients the diastolic dysfunction was limited to apical and lateral segments. In the last 2 children a reduction of the E wave interested only the apical segments. There was a strong correlation between systolic and diastolic dysfunction: in fact all patients with diastolic dysfunction also presented a severe reduction of the systolic function.

[Heart failure and cardiomyopathies: a case report]

Isolated noncompaction of left ventricular myocardium is a rare congenital heart disease, characterized by an excessive prominence of trabecular meshwork, spaced out by deep intertrabecular recesses, consequent to the arrest of the normal myocardial embryogenesis. Although there are numerous descriptions, the pathophysiological effects of the structural alterations, like the clinical spectrum and the evolution of the disease, are not fully clarified. In this paper we evaluated the natural history of the disease, the family incidence and the alterations of the systolic and diastolic function. An interesting case report is described concerning a patient affected by noncompaction and atrial fibrillation.

[Rupture of the atherosclerotic plaque: is Chlamydia pneumoniae a possible agent?]

BACKGROUND

The natural history of atherosclerosis has not clearly been elucidated yet. Some works reported that flogosis plays a role in plaque instability. Why does this inflammatory process start? We investigated the correlation between Chlamydia pneumoniae acute infection and plaque rupture.

METHODS

We compared blood concentrations of IgM anti-Chlamydia pneumoniae in patients affected by acute myocardial infarction (AMI) and in patients affected by stable angina.

RESULTS

Our results showed a minimal statistical difference, with a more positive value in patients with AMI. Subsequently, the group affected by AMI was divided into two subgroups with and without plaque rupture: the subgroup with plaque rupture showed a higher blood concentration of Chlamydia antibodies. This subgroup was also divided into two other subgroups according to blood white cell concentration: the subgroup with normal concentration of white blood cells showed the highest value of Chlamydia antibodies.

CONCLUSIONS

Chlamydia pneumoniae could play an important role in atherosclerotic plaque instability

Two cases of tako-tsubo cardiomyopathy in Caucasians

Tako-tsubo cardiomyopathy is a recently described disease characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes. The disease takes its name from the typical left apical ballooning observed at left ventriculogram. Tako-tsubo cardiomyopathy was first described by Sato in 1990. Since then sporadic cases were reported by Japanese authors, and only a few European publications are available. We describe 2 cases of patients affected by this syndrome.