Alice Calabrese

Long‐term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction

To assess long‐term prognosis in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction, receiving current standard pharmacological therapy.

Echocardiographic myocardial scar burden predicts response to cardiac resynchronization therapy in ischemic heart failure.

BACKGROUND Because echocardiography is routinely applied for left ventricle (LV) evaluation before cardiac resynchronization therapy (CRT), it is important to know whether echocardiographic assessment of myocardial scar burden may also help to predict CRT response in patients with drug-refractory systolic heart failure of ischemic origin. METHODS Seventy-one patients with ischemic heart failure who underwent CRT were retrospectively analyzed. The number of LV scar segments was evaluated in each patient, defining transmural scar as an end-diastolic wall thickness < or = 5 mm associated with increased acoustic reflectance. CRT response was defined by LV end-systolic volume decrease by at least 10% after 6 months of treatment. The role of pacing site with respect to scar location was also assessed. RESULTS Thirty-nine patients (55%) were responders and 32 patients (45%) were nonresponders to CRT. At baseline, responders had a lower number of scar segments (1.7 +/- 1.6 vs 3.5 +/- 2.5, P = .001). The number of scar segments was significantly associated with CRT response and correlated significantly with end-systolic volume variation (r = 0.57, P = .0001). The presence of 3 or more scar segments allowed the identification of nonresponders with a sensitivity of 62% and specificity of 71%. In responders, the pacing stimulus was more frequently delivered remote from scar segments, whereas in nonresponders it was more often delivered over the scar segments. CONCLUSION Echocardiographic evaluation of transmural scar burden predicts CRT response after 6 months of treatment and should be performed in all candidates for CRT with ischemic heart failure before biventricular pacemaker implantation.

Pacing transmural scar tissue reduces left ventricle reverse remodeling after cardiac resynchronization therapy

BACKGROUND In patients with ischemic heart failure undergoing cardiac resynchronization therapy (CRT) the underlying myocardial substrate at the left ventricle (LV) pacing site may affect CRT response. However, the effect of delivering the pacing stimulus remote, adjacent to or over LV transmural scar tissue (TST) identified by echocardiography is still unknown. METHODS First, 35 patients with healed myocardial infarction (57 ± 11 years) were prospectically studied to demonstrate the capability of echocardiographic end-diastolic wall thickness (EDWT) to identify LV-TST as defined by delayed enhancement magnetic resonance imaging (DE-MRI). Subsequently, in 136 patients (65 ± 10 years) who underwent CRT, EDWT was retrospectively evaluated at baseline. The LV catheter placement was defined over, adjacent to and remote from TST if pacing was delivered at a scarred segment, at a site 1 segment adjacent to or remote from scarred segments. CRT response was defined as LV end-systolic volume (ESV) decrease by at least 10% after 6 months. RESULTS A EDWT ≤ 5mm identified TST at DE-MRI with 92% sensitivity and 96% specificity. In the 76 CRT responders, less overall and posterolateral TST segments and more segments paced remote from TST areas were found. At the multivariate regression analysis, the number of TST segments and scar/pacing relationship showed a significant association with CRT response. CONCLUSIONS In addition to LV global scar burden, CRT response relates also to the myocardial substrate underlying pacing site as evaluated by standard echocardiography. This information may expand the role of echocardiography to guide pacing site avoiding pacing at TST areas.

Anti-inflammatory action of apoptotic cells in patients with acute coronary syndromes

OBJECTIVES Atherosclerotic plaques contain both apoptotic cells and phagocytes. Apoptotic cells are known to exert an anti-inflammatory effect. Little is known on their action in patients with acute coronary syndromes. METHODS AND RESULTS We challenged mononuclear phagocytes from the peripheral blood of patients with acute coronary syndromes (n=20) and healthy controls (n=30) with lipopolysaccharide (LPS, 100ng/ml) or peptidoglycan (PGN, 20microg/ml) in the presence or in the absence of apoptotic cells. After 24h, mononuclear phagocytes from patients with acute coronary syndromes produced more TNFalpha and IL-10 than controls; moreover, they were significantly more susceptible to the anti-inflammatory action of apoptotic cells. Apoptotic cells were more effective in ACS patients with C-reactive protein levels <3mg/l than in patients with CRP levels >3mg/l. CONCLUSIONS Patients with acute coronary syndromes and low circulating C-reactive protein levels are more sensitive to the anti-inflammatory action of apoptotic cells: this suggests the existence of an enhanced anti-inflammatory feedback circuit, which could contribute to protect from plaque instability.

Strategy to identify subjects with diabetes mellitus more suitable for selective echocardiographic screening: The DAVID-Berg study

BACKGROUND Despite the burden of pre-clinical heart failure (HF) among diabetes mellitus (DM) patients, routine screening echocardiography is not currently recommended. We prospectively assessed risk prediction for HF/death of a screening strategy combining clinical data, electrocardiogram, NTproBNP, and echocardiogram, aiming to identify DM patients more suitable for selective echocardiography. METHODS Among 4047 screened subjects aged≥55/≤80years, the DAVID-Berg Study prospectively enrolled 623 outpatients with DM, or hypertension, or known cardiovascular disease but with no HF history/symptoms. The present analysis focuses on data obtained during a longitudinal follow-up of the 219 patients with DM. RESULTS Mean age was 68years, 61% were men, and median DM duration was 4.9years. During a median follow-up of 5.2years, 50 subjects developed HF or died. A predictive model using clinical data demonstrated moderate predictive power, which significantly improved by adding electrocardiogram (C-statistic 0.75 versus 0.70; p<0.05), but not NTproBNP (C-statistic 0.72, p=0.20). Subjects with normal clinical variables or abnormal clinical variables but normal electrocardiogram had low events rate (1.3 versus 2.4events/100-person-years, p=NS). Conversely, subjects with both clinical and electrocardiogram abnormalities (47%) carried higher risk (9.0events/100-person-years, p<0.001). The predictive power for mortality/HF development increased when echocardiography was added (13.6events/100-person-years, C-statistic 0.80, p<0.05). CONCLUSIONS Our prospective study found that a selective echocardiographic screening strategy guided by abnormal clinical/electrocardiogram data can reliably identify DM subjects at higher risk for incident HF and death. This screening approach may hold promise in guiding HF prevention efforts among DM patients.

Is mild asymptomatic left ventricular systolic dysfunction always predictive of adverse events in high-risk populations? Insights from the DAVID-Berg study: Mild asymptomatic systolic dysfunction and prognosis

Mild asymptomatic left ventricular systolic dysfunction (ALVSD) may be associated with incident heart failure (HF). However, this gray zone group needs incremental risk refinement. We hypothesized that diastolic dysfunction (DD) may refine HF and death risk prediction in mild ALVSD.

Crater-Like Ulceration of Aortic Arch.

We report the case of a 78-year-old female who presented to our hospital with signs of hemorrhagic shock and breathlessness. A transthoracic echocardiography demonstrated pericardial effusion. Computed tomography of the chest showed a penetrating atherosclerotic ulcer of the aortic arch with an intramural hematoma of the ascending and descending aorta. Endovascular repair with stent-grafting was urgently performed and a pericardial window placement was done to reduce mediastinal bleeding.