Antonio Totaro

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.

Tissue Doppler Time Intervals Predict the Occurrence of Rehospitalization in Chronic Heart Failure: Data from the Daunia Heart Failure Registry

Background: Patients with chronic heart failure (HF) are often rehospitalized; rehospitalization identifies subjects with a poorer quality of life and a worse prognosis. Estimates of the time intervals by tissue Doppler imaging (TDI) in patients with chronic HF has not been fully investigated, despite recent studies having explored the prognostic role of TDI‐derived parameters in major cardiac diseases, such as HF. We, therefore, aimed to assess the prognostic value of time intervals evaluated by TDI in patients with chronic HF. Methods: A total of 249 patients with chronic HF enrolled in the Daunia Heart Failure Registry underwent echocardiography assessment and were followed prospectively for a mean 284 ± 210 days. Conventional echocardiography and TDI parameters were calculated; time intervals were calculated by TDI: ST (systolic time), ET (ejection time), FT (filling time), and ICT (isovolumic contraction time). We also have calculated ICT/ET and tissue myocardial performance index ([ICT+IRT]/ET). Results: At univariate analysis, ET (RR: 0.80, 95% confidence interval [CI] 0.71–0.90, P < 0.001), ST (RR: 0.88, 95% CI 0.78–0.99, P < 0.05), FT (RR: 0.88, 95% CI 0.78–0.99, P < 0.05), ICT/ET (RR: 1.21, 95% CI 1.07–1.37, P < 0.01) were related to the occurrence of rehospitalization during follow‐up. At multivariate Cox regression analysis, correlations remained significant for ET and ST (P < 0.05 and P < 0.01, respectively). Conclusions: Time intervals assessed by TDI may be helpful in predicting the risk of rehospitalization in subjects with chronic HF.

Acute phase proteins in acute coronary syndrome: an up-to-date.

Inflammation is essential for atherogenesis, and many inflammatory markers have been analyzed for their association with short- and long-term outcome in patients with manifestations of coronary artery disease. C-reactive protein (CRP) plasma levels increase in patients with acute coronary syndrome (ACS). CPR is an important prognostic marker in ACS. Although CRP will remain over time a useful marker, the role and implications of increased plasma concentrations of other acute phase proteins (APPs), such as alpha-1-antitrypsin (A1AT), alpha-1 glycoprotein (A1GP), haptoglobin (HG), ceruloplasmin (CP), and C3c and C4 complement fraction, in patients with ACS are still not completely defined. Controversy is the role of statins and other drugs on inflammatory markers. This review summarizes the experimental and clinical evidence regarding the role, and the biological and clinical significance of these APPs in ACS. Furthermore, biological and clinical significance of Pentraxin 3 (PTX3), a member of the pentraxin superfamily, are discussesed.

Peak myocardial acceleration during isovolumic relaxation time predicts the occurrence of rehospitalization in chronic heart failure: data from the Daunia heart failure registry.

Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of new developed TDI parameters, however, still needs to be documented.

Tissue Doppler imaging in coronary artery diseases and heart failure.

Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as coronary artery disease (CAD) and heart failure (HF). In these conditions, myocardial mitral annular systolic (S’) and early diastolic (E’) velocities have been shown to predict mortality or cardiovascular events. In heart failure non invasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/E’) is a strong prognosticator, especially when E/E’ is > or =15. Moreover, other parameters derived by TDI, as cardiac time intervals and Myocardial Performance Index, might play a role in the prognostic stratification in CAD and HF. Recently, a three-dimensional (3-D) TDI imaging modality, triplane TDI, has become available, and this allows calculation of 3-Dvolumes and LV ejection fraction. We present a brief update of TDI.

Tissue Doppler Imaging predicts central sleep apnea in patients with chronic heart failure: data from the Daunia Registry

Tissue Doppler imaging (TDI) is used to improve risk stratification in patients with chronic heart failure (CHF). So far, few studies have used this method to investigate the characteristics of subjects with CHF and Cheyne–Stokes breathing (CSB). The aim of this study was therefore to evaluate whether TDI assessment may predict the presence of CSB in patients with CHF.

Right ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy

We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancementmay be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m; indexed end-systolic volume, 25 mL/m). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m; indexed endsystolic volume, 19 mL/m). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3].

Left ventricular fibroma: What cardiac magnetic resonance imaging may add?

Cardiac fibromas are benign connective tissue tumors derived fromfibroblaststhat occur predominantlyin children andconstitutethesec-ond most common type (after the rhabdomyoma) of primary cardiactumoroccurringinthepediatricagegroup[1].Mostaredetectedinchil-dren younger than 10 years, and about one-third are diagnosed in in-fants younger than 1 year. Males and females appear to be equallyaffected. Cardiac fibromas are typically large tumors ranging from 3 to10cmin diameter.They usuallyoccurwithintheventricularmyocardi-um and much more frequently within the anterior free wall of the leftventricular wall or the inter-ventricular septum than in the posteriorleft ventricular wall or right ventricle [2]. Approximately 70% of fibro-mas are symptomatic, causing mechanical interference with intra-cardiac flow (usually with bulky intra-cavitary left ventricular or rightventricular tumors), ventricular systolic function (usually with largeintra-myocardial left ventricular tumors), or conduction disturbances(usually with tumors arising in the inter-ventricular septum). Themost common clinical manifestations are congestive heart failure(21%), ventricular tachy-arrhythmias (13%) and atypical chest pain(3.5%)[3].Suddencardiacdeathoccursin14%ofpatientswithfibromas,typically in infants. Cardiac fibromas do not show spontaneous regres-sion and surgical resection generally remains the treatment of choicefor these tumors in children.A 51-year old man (C.R.) was referred to the emergency room fortypical dizziness, sweating and vomit. Electrocardiogram showedsinus rhythm with Q wave in D1, D2, aVL and from V4 to V6 with Twave inversion from V4 to V6. Blood pressure at admission was150/100mmHg,troponin-Ivalueswerenormal.Thepatientwasthere-fore admitted to the acute cardiac care unit with a diagnosis ofsuspected acute coronary syndrome. Echocardiography showed, in offaxis views, a heterogeneous oval mass of the left ventricular lateralwall (5 × 3 cm) without involvement of mitral valve apparatus(Fig. 1a–b). Coronary angiography was normal.Cardiacmagneticresonanceimaging(cMRI),performedwitha1.5-Tmagnet(PhilipsAchieva)andacardiacphased-arraymulti-coil,showedin the mid-apical left ventricular lateral wall and inferior-lateral wallsegments a nodular intra-myocardial formation (5.3 × 3.6 cm) iso-intense in the sequences T1-TSE (turbo spin echo Fig. 2 left) and inCINE-TFE sequences (turbo field echo Fig. 2 right; Videos 1–3), hypo-intense in the sequences T2-SPIRR BB (black-blood — T2-short-tau-in-version recovery Fig. 3a–b; Video 4). In the sequences for the dynamicstudy of first pass a minimal and inhomogeneous enhancement aftergadolinium was evident (Fig. 4 left; Video 5). In late enhancementPSIR-TFE (phase sensitive inversion recovery turbo field echo) se-quences, the nodular formation was hyper-intense (Fig. 5; Video 6).A diagnosis of cardiac fibroma was therefore based on such cMRIfindings (iso-intense mass in cine“bright blood” balanced fast field-echo images and in T1, hypo-intense in T2-STIR, minimal enhance-ment with gadolinium at the dynamicfirst pass and hyper-intensein PSIR sequences). The patient did not undergo endo-myocardialbiopsy and surgical excision because of the large dimension of themass.Thecardiac fibromaisararebenigntumoroftheheart.Thefirsttoolto assess such lesion is echocardiography, which can provide informa-tion on the tumors extent and on ventricular and valvular function.cMRImayimproveandhelpthediagnosisbythetissuecharacterizationof the lesion. cMRI allows the identification of cardiac and para-cardiacsuspicious masses; a precise definition of the extension and the rela-tionships as well as possible involvement of vascular and mediastinalstructures, the infiltration of the pericardium and relationships withnormal intra-cardiac structures may be obtained. Finally, the signalcharacteristics and contrast are useful for tissue characterization of

Early recurrence of atrial fibrillation after catheter ablation with left atrial fibrosis identified at cardiac magnetic resonance by late gadolinium enhancement

In patients with atrial fibrillation (AF), extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging has been associated with early recurrence of AF after catheter ablation. We present a case of a patient with extensive atrial fibrosis and AF recurrence. The study of late gadolinium enhancement with cardiac magnetic resonance imaging in patients with AF could be a valuable noninvasive tool for the selection of patients suitable for successful catheter ablation.

Additional Prognostic Value of EAS index in predicting the occurrence of rehospitalizations in chronic heart failure: data from the Daunia Heart Failure Registry

Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of newly developed TDI parameters, however, still needs to be documented.