Gabriele Di Gesaro

Obesity: a new pathology to pay attention to in young people.

Obesity in young people is a form of malnutrition that is found more and more in industrialized countries known both for its association with obesity in adult age and the chronic-degenerate pathologies correlated to it. In 1998 in the United States the prevalence of obesity in 4-12 year olds was 22% for the Hispanics and Afro-Americans and 12.3% for the non Hispanic Caucasians Also in children as in adults, the consequence of obesity is hyperinsulinemia, in direct proportion to the body weight. In this review we discuss the effects of hyperinsulinemia and obesity in young people, and evaluated the difference of cardiovascular complication in young and in adults.

Sympathetic tone and ventricular tachycardia.

Background The pathogenesis of idiopathic monomorphic ventricular tachycardia is not clear. We suppose that a lack of balance of the sympathetic system could be involved. Frequency domain analyses of the heart rate can be useful to understand autonomic system balance. Therefore we performed this evaluation on a sample of seven children affected by idiopathic monomorphic ventricular tachycardia. Methods and results We performed a Holter recording for palpitations on all the children, with an average age of 12 (range: 7–18 years). In all the patients many episodes of repeated sustained or nonsustained ventricular tachycardia were demonstrated, with an average heart rate of 170 bpm. We excluded any structural heart defect through echocardiography and magnetic resonance imaging studies in all the children. A negative tridimensional electroanatomic mapping was performed on five of them. Holter analysis of ventricular rate variability was performed in the frequency domain. Two main components were distinguished in a spectrum calculated on the basis of 24 h-long recordings. We studied low frequency and high frequency components. We compared the values obtained with those of a control group of 10 healthy children, admitted to our cardiology division, day-care system. Affected patients showed a reduction of average high frequency as a sign of a reduction of vagal activity and an average increase of the low frequency/high frequency ratio. Conclusions The data may confirm our hypothesis of the involvement of the sympathetic nervous system in idiopathic monomorphic ventricular tachycardia in children.

Diastolic dysfunction diagnosed by tissue Doppler imaging in cirrhotic patients: Prevalence and its possible relationship with clinical outcome☆

BACKGROUNDnCirrhotic cardiomyopathy has been characterized by impaired contractile response to stress and/or altered diastolic relaxation, with electrophysiological abnormalities in the absence of known cardiac disease. However, the clinical significance of diastolic dysfunction (DDF) in cirrhotic patients has not been clarified.nnnMETHODSnWe studied 84 cirrhotic patients with normal systolic function to evaluate the prevalence of DDF using tissue Doppler imaging, and to investigate the possible correlation of DDF with outcomes (hospitalization, death) and with the specific causes of death.nnnRESULTSnThe mean follow-up was 10±8months. DDF was diagnosed in 22 patients (26.2%). Patients with DDF more frequently had ascites (90.9% vs. 64.5 %; p=0.026), lower levels of albumin (OR: 5.39; p=0.004), higher NT-proBNP levels, and longer QTc interval (464±23ms vs. 452±30ms; p=0.039). At follow-up, patients with DDF did not have a higher incidence of adverse events in terms of hospitalization and death.nnnCONCLUSIONSnThe presence of diastolic dysfunction has not been found to be clearly associated with outcome, and prognosis has been determined primarily by the severity of liver disease.

Thalassemia and Heart Surgery: Aortic Valve Repair After Endocarditis

Outcome after heart valve surgery in patients affected by thalassemia is an unreported issue and to the best of our knowledge only 7 cases have been described in the literature. Heart valve disease is commonly encountered in thalassemia patients and heart valve replacement carries high risk of prosthesis complications including thrombosis and embolization despite optimal anticoagulation management. We report a successful long-term outcome after a case of aortic valve repair after mycotic valve endocarditis.

Mechanical Circulatory Support Before And After Heart Transplantation: Impact On Survival

Objective To investigate the impact on survival of pre and post heart transplant (HT) use of mechanical circulatory support (MCS). Figure. No caption available. Methods Data were collected retrospectively. ECMO was the MCS used to treat severe early graft failure (EGF). Log-rank test was used to compare Kaplan-Meier survival curves. A p-value <0.05 was considered statistically significant. Results 147 HT were done from 2004 to October 2016. The average male and female recipient’s age was 50±13 years and 47±14 years, respectively. Percentage of use of MCS and IABP to bridge patients to HT were 16% and 7%, respectively. MCS included: 8 HeartWare LVAD (5.4%), 6 ECMO (4.1%), 6 Levitronix BiVAD (4.1%), 2 Thoratec LVAD (1.4%) and 2 Levitronix LVAD (1.4%). Hospital mortality was 14.3% (21pt). 1-year survival was 82% and 5-year survival was 75%. Overall pre-transplant MCS was not correlated to worse post-transplant prognosis, p=0.822. Left sided MCS showed a worse survival compared to the no-MCS group (p=0.045) and to the ECMO and BiVAD (p=0.02). Severe primary EGF strongly impact the early mortality after heart transplantation (p<0.001). Excluding the 90 day mortality, the survival between patients with EGF and those without is similar (p=0.874).The risk of mortality increased almost 2 fold according each hour of ischemic time [OR=1.7, 95% IC, 1.1-2.7, p=0.017]. Figure. No caption available. Conclusions ECMO because of severe EGF remains associated with worse post-transplant outcomes however, patients discharged after severe EGF, showed a long term survival comparable to those without EGF. A LVAD before HT seems to affect the hospital mortality.

Risk Factors Associated With Peripheral Neuropathy in Heart Failure Patients Candidates for Transplantation

Introduction: Peripheral neuropathy can affect patients with heart failure, though its prevalence is unknown. After heart transplantation, it can influence the postoperative course and quality of life, but screening for neuromuscular disease is not routinely performed. Objective: The aim of this study was to identify the factors associated with neuropathy in a population of patients with heart failure who are candidates for heart transplantation. Study Design: Data regarding patients’ clinical history, including recent hospitalizations, were collected. All patients underwent a complete neurological examination and a neurophysiological protocol including nerve conduction studies and concentric needle electromyography. Results: Thirty-two patients were included in the study, and neuropathy was diagnosed in 10 (31.3%). Neuropathy was associated with the number of admissions (P = .023; odds ratio [OR]: 1.96) and the total number of days of hospitalization in the year prior to inclusion in the study (P = .010; OR: 1.03). The majority of hospitalizations occurred in the step-down unit (85%), with acute heart failure the leading cause of admission (42%). Conclusions: This study shows that neuropathy is frequent in patients with advanced heart failure and that hospitalization for cardiac care, also in the absence of intensive care, is a marker of high risk of neurologic damage. These data can help physicians in selecting and managing candidates for transplantation and can guide decisions on the best immunosuppressive regimen or rehabilitation strategy.

Modeling Right Ventricle Failure After Continuous Flow Left Ventricular Assist Device: A Biventricular Finite-Element and Lumped-Parameter Analysis

The risk of right ventricle (RV) failure remains a major contraindication for continuous-flow left ventricular assist device (CF-LVAD) implantation in patients with heart failure. It is therefore critical to identify the patients who will benefit from early intervention to avoid adverse outcomes. We sought to advance the computational modeling description of the mechanisms underlying RV failure in LVAD-supported patients. RV failure was studied by computational modeling of hemodynamic and cardiac mechanics using lumped-parameter and biventricular finite element (FE) analysis. Findings were validated by comparison of bi-dimensional speckle-tracking echocardiographic strain assessment of the RV free wall vs. patient-specific computational strain estimations, and by non-invasive lumped-based hemodynamic predictions vs. invasive right heart catheterization data. Correlation analysis revealed that lumped-derived RV cardiac output (Ru2009=u20090.94) and RV stroke work index (Ru2009=u20090.85) were in good agreement with catheterization data collected from 7 patients with CF-LVAD. Biventricular FE analysis showed abnormal motion of the interventricular septum towards the left ventricular free wall, suggesting impaired right heart mechanics. Good agreement between computationally predicted and echocardiographic measured longitudinal strains was found at basal (−xa019.1u2009±u20093.0% for ECHO, and −xa016.4u2009±u20093.2% for FEM), apical (−xa020.0u2009±u20093.7% for ECHO, and −xa017.4u2009±u20092.7% for FEM), and mid-level of the RV free wall (−xa020.1u2009±u20095.9% for echo, and −xa018.0u2009±u20095.4% for FEM). Simulation approach here presented could serve as a tool for less invasive and early diagnosis of the severity of RV failure in patients with LVAD, although future studies are needed to validate our findings against clinical outcomes.

Heart transplant program at IRCCS-ISMETT: Impact of mechanical circulatory support on pre- and post -transplant survival

BACKGROUNDnHeart transplantation (HTx) improves the quality of life and survival in patients affected by end-stage heart failure. The purpose of the current study is to present the patients clinical data and results of HTx in a single Center of Sicily. Focus on survival after pre and post HTx mechanical circulatory support use will be performed.nnnMETHODSn133 HTx were done from 2004 to the end of 2015.The average donor age was 34±13.5years and the proportion of male donors was 67%. Percentage of use of mechanical circulatory support to bridge patients to HTx was 18%.nnnRESULTSnOverall pre-transplant mechanical circulatory support was not correlated to worse post-transplant prognosis, p=0.757. Severe primary early graft failure requiring extra corporeal membrane oxygenator support strongly impact the early mortality after heart transplantation (p<0.001).nnnCONCLUSIONSnThe results of HTx at ISMETT are comparable to those reported in high volume Italian transplant centers as well as in the ISHLT registry. The favorable outcome can be related to focus on multidisciplinary approach, strict recipients selection and young donor population. Post HTx mechanical circulatory support use in general remains associated with worse post-transplant outcomes. This does not apply to pre-op mechanical circulatory support population.