Giampiero Vizzari

Multimodality Imaging in Cardiooncology

Cardiotoxicity represents a rising problem influencing prognosis and quality of life of chemotherapy-treated patients. Anthracyclines and trastuzumab are the drugs most commonly associated with development of a cardiotoxic effect. Heart failure, myocardial ischemia, hypertension, myocarditis, and thrombosis are typical manifestation of cardiotoxicity by chemotherapeutic agents. Diagnosis and monitoring of cardiac side-effects of cancer treatment is of paramount importance. Echocardiography and nuclear medicine methods are widely used in clinical practice and left ventricular ejection fraction is the most important parameter to asses myocardial damage secondary to chemotherapy. However, left ventricular ejection decrease is a delayed phenomenon, occurring after a long stage of silent myocardial damage that classic imaging methods are not able to detect. New imaging techniques including three-dimensional echocardiography, speckle tracking echocardiography, and cardiac magnetic resonance have demonstrated high sensitivity in detecting the earliest alteration of left ventricular function associated with future development of chemotherapy-induced cardiomyopathy. Early diagnosis of cardiac involvement in cancer patients can allow for timely and adequate treatment management and the introduction of cardioprotective strategies.

PFO: Button me up, but wait … Comprehensive evaluation of the patient

Patent foramen ovale (PFO) is a slit or tunnel-like communication in the atrial septum occurring in approximately 25% of the population. A wide number of pathological conditions have been linked to its presence, most notably, cryptogenic stroke (CS) and migraine. However, in the setting of a neurological event, it is not often clear whether the PFO is pathogenically related to the index event or an incidental finding. Therefore, a detailed analysis of several clues is needed for understanding PFOs clinical significance, with a frequent case-by-case decision about destination therapy. Indeed, the controversy about PFOs pathogenicity prompted a paradigm shift of research interest from medical therapy with antiplatelets or anticoagulants to percutaneous transcatheter closure, in secondary prevention. Observational data and meta-analysis of observational studies had previously suggested that PFO closure with a device was a safe procedure with a low recurrence rate of stroke. To date, however, recent randomized controlled trials have not shown the superiority of PFO closure over medical therapy. Thus, the optimal strategy for secondary prevention of paradoxical embolism in patients with a PFO remains unclear. Moreover, the latest guidelines for the prevention on stroke restricted indications for PFO closure to patients with deep vein thrombosis and high-risk of its recurrence. Given these recent data, in the present review, we critically discuss current treatment options, pointing out the role of a comprehensive patient evaluation in overcoming PFO closure restrictions and planning the best management for each patient.

Diagnosis of Chemotherapy-Induced Cardiotoxicity

Cardiotoxicity is a rising issue connected to use of chemotherapy and radiotherapy in the treatment of neoplastic diseases. Early diagnosis during follow-up is of paramount importance, and careful surveillance is recommended. Evaluation of left ventricular ejection fraction by echocardiography and nuclear medicine techniques is widely used in clinical practice; however, their sensitivity in detecting early cardiac damage is low. New instruments like speckle-tracking imaging, cardiac magnetic resonance and cardiac circulating biomarkers are available to clinicians to best evaluate the onset and progression of cardiotoxic effects, improving the therapeutic management and final outcome for the patient. (J Patient-Centered Res Rev. 2014;1:121-127.)

Percutaneous coronary intervention driven by combined use of intracoronary anatomy and physiology: Towards a tailored therapy for coronary artery disease

Coronary angiography classically allows a bidimensional evaluation of the vascular lumen, however with many limitations in the case of eccentric lesions, irregular contour or tortuosity of the vessel.Moreover, it does not enable to assess neither the features of the vessel wall, nor the functional significance of a lesion [1]. Newer technologies are available to overcome these limitations.We present a case of percutaneous coronary revascularization optimized by combined use of two of the most widely used techniques.

Congenital Gerbode Defect in a Patient With an Acute Myocardial Infarction and Cardiogenic Shock Masquerading as an Acute Ventricular Septal Defect.

EFT VENTRICLE-TO-RIGHT ATRIUM (LV-RA) shuntsare rare congenital or acquired defects of the membranousseptum described by Gerbode in 1958; their natural history canlead to enlargement of the right atrium and right ventriclefailure. Often the defects go unnoticed at birth, and diagnosis ismade in adulthood. The authors report a case of a 75-year-oldwoman with an acute myocardial infarction and cardiogenicshock for whom preoperative echocardiograms were readincorrectly as an infarct-related ventricular septal defect(IRVSD). The recognition of the pre-existing congenital LV-RA Gerbode malformation (GM) was made at the time ofsurgery for coronary revascularization, mitral and tricuspidannuloplasty, patent foramen ovale (PFO) closure, and ven-tricular septal defect (VSD) repair. The authors will review theimportant echocardiographic differences between the rare, pre-existing, congenital GM and the more common IRVSD.

Left ventricular endocardial longitudinal dysfunction persists after acute myocarditis with preserved ejection fraction

The aim of present study was to assess left ventricular (LV) myocardial deformation and changes over time in patients with acute myocarditis (AM) with preserved ejection fraction detected by late gadolinium enhancement (LGE) magnetic resonance imaging.

Percutaneous Repair of Post-myocardial Infarction Ventricular Septal Rupture

Post-myocardial infarction ventricular septal rupture (VSR) is one of the most serious complications occurring in patients with ST elevation myocardial infarction. Although surgical repair with concurrent coronary artery bypass grafting (CABG) is considered the treatment of choice, it carries a very high morbidity and mortality rates. For this reason, surgical approach to all patients might not be reasonable, in particular when patients are critically ill or with multiple comorbidities. Percutaneous interventional approach appears to be safe and effective in patients with a chronic VSR or treated for a residual shunt after initial surgical closure. Immediate primary transcatheter closure in acute setting may also be considered an alternative and effective strategy in selected patients ensuring greater effectiveness and fewer complications compared to surgery. The timing of surgical or percutaneous intervention is critical: the presence of cardiogenic shock and closure in the acute phase after VSR diagnosis are important risk factors of mortality. Due to the high mortality rate, the use of percutaneous occluders has been investigated as an alternative approach. The treatment with dedicated device is in general successful with few procedure-related complications. This strategy is a less invasive alternative to surgical approach; however it needs to be applied on a case-by-case basis.

Difficult Cases and Complications from the Catheterization Laboratory: Left Atrial Appendage Closure Step-By-Step

A 68-year-old man with hypertension, dyslipidemia, chronic kidney disease, and history of hemorrhagic stroke was admitted to our hospital because of atrial fibrillation (AF). After transesophageal echocardiography (TEE) that excluded the presence of left atrial appendage (LAA) thrombus, he underwent electrical cardioversion with sinus rhythm restoration. Nevertheless, he presented at 1-month follow-up visit with atrial fibrillation. Due to the history of hemorrhagic stroke and the subsequent contraindication to anticoagulation therapy, he was identified as a candidate to percutaneous closure of LAA. TEE was performed before the procedure to rule out the presence of LAA thrombus and to assess the dimensions and the morphology of the LAA. The procedure was performed under general anesthesia and TEE guidance. After transseptal puncture of the fossa ovalis, a 22-mm Amplatzer Cardiac Plug (ACP) (AGA, St. Jude Medical) device was advanced in the LAA through a dedicated delivery system (12-Fr Amplatzer TorqVue 45 × 45 Delivery Sheath – AGA, St. Jude Medical). Once the correct implanting zone was localized, the device was released under fluoroscopic and echocardiographic guidance. A check for pericardial effusion at the end of the procedure was done by transthoracic echo (TTE). The patient was discharged the day after the procedure with long-term therapy with a daily 100-mg aspirin and 75-mg clopidogrel for 3 months. Endocarditis antibiotic prophylaxis was also recommended for at least 6 months (Figs. 19.1, 19.2, 19.3, 19.4, 19.5, 19.6, 19.7, 19.8, and 19.9).

How often is patent foramen ovale an innocent bystander

Patent foramen ovale (PFO) is a risk factor for cryptogenetic stroke; its closure should be considered in selected patients. It is not always clear whether symptoms (presyncope, paresthesia) apparently due to paradoxical embolism are related with other cardiovascular disorders such as arrhythmias. Flecainide administration for post‐PFO‐closure supraventricular arrhythmias can unmask a latent undiagnosed Brugada syndrome.

Cardiac resynchronization therapy before and after MitraClip implantation: An advantageous upgrading to reduce mitral regurgitation

MitraClip therapy has been proposed as therapeutic option in selected patients with degenerative or functional mitral regurgitation (FMR), leading to clinical and prognostic benefits. Previous studies demonstrated the safety and the efficacy of MitraClip therapy on symptoms and left ventricular remodeling in cardiac resynchronization therapy (CRT) non-responder patients. We report a case of a CRT non-responder patient treated with MitraClip implantation followed by a new upgrading of the CRT for persistent FMR at the follow-up. The optimization of the interventricular delay, guided by echocardiographic parameters, resulted in a significant clinical and functional benefit. Echo-guided CRT upgrading can provide additive efficacy for patients in whom MitraClip implantation does not significantly improve FMR and symptoms.