Giuseppe Romano

Prediction of right ventricular failure after ventricular assist device implant: systematic review and meta-analysis of observational studies

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is associated with increased morbidity and mortality, but the identification of LVAD candidates at risk for RVF remains challenging. We undertook a systematic review and meta‐analysis of observational studies of risk factors associated with RVF after LVAD implant. Thirty‐six studies published between 1 January 1995 and 30 April 2015, comprising 995 RVF patients out of a pooled final population of 4428 patients, were identified. Meta‐analysed prevalence of post‐LVAD RVF was 35%. A need for mechanical ventilation [odds ratio (OR) 2.99], or continuous renal replacement therapy (CRRT; OR 4.61, area under the curve 0.78, specificity 0.91) were the clinical variables with the highest effect size (ES) in predicting RVF. International normalized ratio [INR; standardized mean difference (SMD) 0.49] and N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) (SMD 0.52) were the biochemical markers that best discriminated between RVF and No‐RVF populations, though NT‐proBNP was highly heterogeneous. Right ventricular stroke work index (RVSWI) and central venous pressure (CVP) (SMD −0.58 and 0.47, respectively) were the haemodynamic measures with the highest ES in identifying patients at risk of post‐LVAD RVF; CVP was particularly useful in risk stratifying patients undergoing continuous‐flow LVAD implant (SMD 0.59, P < 0.001, I2 = 20.9%). Finally, pre‐implant moderate to severe right ventricular (RV) dysfunction, as assessed qualitatively (OR 2.82), or a greater RV/LV diameter ratio (SMD 0.51) were the standard echocardiographic measurements with the highest ES in comparing RVF with No‐RVF patients. Longitudinal systolic strain of the RV free wall had the highest ES (SMD 0.73) but also the greatest heterogeneity (I2 = 74%) and was thus only marginally significant (P = 0.05). Patients on ventilatory support or CRRT are at high risk for post‐LVAD RVF, similarly to patients with slightly increased INR, high NT‐proBNP or leukocytosis. High CVP, low RVSWI, an enlarged right ventricle with concomitant low RV strain also identify patients at higher risk.

Can multiple previous treatment-requiring rejections affect biventricular myocardial function in heart transplant recipients? A two-dimensional speckle-tracking study

a Cardiology Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS— ISMETT (IstitutoMediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy b Cardiac Surgery and Heart Transplantation Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS— ISMETT (IstitutoMediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy c Research Office, IRCCS — ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Via Tricomi 5, 90127 Palermo, Italy d University of Liege Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium

Systemic or Endoventricular Thrombolysis to Treat HeartWare Left Ventricle Assist Device Thrombosis: A Clinical Dilemma.

Endoventricular thrombolytic procedure (ETP) has been used to treat continuous-flow left ventricle assist device (CF-LVAD) thrombosis. The study aims to investigate the occurrence of complications after ETP. Data were retrospectively reviewed and analyzed in a series of patients who underwent CF-LVAD followed by ETP. Since November 2010, 20 patients underwent HeartWare CF-LVAD implantation at our institute. Four patients (20%) developed pump thrombosis and underwent a total of nine ETPs with tissue plasminogen activator infused into the left ventricle. The mean age was 60.2 ± 9 years. ETP was performed via either the femoral (n = 6) or radial artery (n = 3). Five ETPs (55.5%) were complicated by left and right radial artery occlusion, two by groin hematomas, and one by femoral artery false aneurysm. ETP carries a strong risk of vascular access complications that, in CF-LVAD patients, may add to the already complex clinical profile and economic burden; thus, a less invasive treatment is advisable whenever required.

Is diuretic withdrawal safe in patients with heart failure and reduced ejection fraction? A retrospective analysis of our outpatient cohort

Although diuretics are essential to optimize volume status in patients with heart failurewith reduced ejection fraction (HFrEF) [1], safety and benefits of prolonged diuretic treatment are uncertain, in particular on patients with chronic and compensated HFrEF. In facts, diuretics can increase the neuro-humoral activation in HFrEF [2], determine electrolyte disturbances [3] and acute renal insufficiency [4]. On the contrary, Hopper et al. identified seven studies of diuretic withdrawal (DW) in stable chronic HF, in which clinical decompensation wasmore frequent in theDWgroup [5]. Our hypothesiswas that diuretic therapy could be safely suspended in patients with HFrEF after adequate therapeutic neuro-hormonal antagonism [6]. Therefore, we retrospectively analyzed our cohort of HFrEF outpatients with a twofold aim: first, to asses if DW is safe in patients with HFrEF and second, to identify clinical, biochemical or echocardiographic parameters associated to DW among HFrEF patients regularly followed-up at our outpatients clinic. The studywas conducted in our tertiary level HF clinical center. All ambulatory patients referred from November 2011 through September 2014 at our centerwere considered for recruitment. Exclusion criteria were as follows: (I) hospitalization for HF within 30 days before ambulatory evaluation, (II) myocardial revascularization and/or resynchronization therapy within 180 days before ambulatory visit, (III) congenital heart disease, (IV) severe valve heart disease. Overall, 216 consecutive clinically stable HFrEF patients (ejection fraction HF ≤ 35%) were evaluated for retrospective enrollment. Among them, 26 patientswere excluded, since theywere not takingdiuretics. Eventually, 190 patients were recruited and stratified according to diuretics continuation: no withdrawal group (NWG), N = 169 (89%), and diuretics withdrawal group (WG) N= 21 (11%) (Fig. 1S in supplementary materials). Furosemide was the only diuretic used. Patients were assessed at baseline visit. Medical history, physical exam, 12-lead electrocardiogram and laboratory analysis comprehensive of N-terminal pro brain natriuretic peptides (NT-proBNP) and highly sensitive troponin essay were obtained. To assess the safety of DW, furosemide dose in WG was tapered down (steps of 25 mg) at each visit usually at the sixth month re-evaluation, according to the following criteria: 1) no symptomsor signs of congestionwere evident at the clinical assessment and 2) NT-proBNP trend was in downturn. A standard 2-Dimensional and Doppler transthoracic echocardiogram was performed at baseline visit and repeated in case of worsening clinical conditions. Baseline

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

BACKGROUND Cirrhotic 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. METHODS We 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. RESULTS The 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. CONCLUSIONS The 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.

Aortic surgery in Marfan patients with severe pectus excavatum

Aims The optimal surgical management of the aortic root phenotype Marfan patients with severe pectus excavatum is a subject of debate. All the available literature were reviewed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) principles in order to assess the early outcomes of both pectus excavatum and aortic repair techniques. Methods Searches were done in PubMed and MEDLINE electronic databases dating from July 1953 to December 2015. Results A total of 97 peer-reviewed publications were retrieved, and 27 relevant publications were identified with a total of 39 Marfan patients with pectus excavatum who underwent ascending aorta and aortic root surgery. Emergency acute Type-A aortic dissection repair was reported in five cases. Concomitant pectus excavatum and aortic root repair and composite graft implantation were the most commonly performed procedures. Complications after a staged or a combined approach were uncommon and no deaths occurred. Conclusion Aortic surgery in Marfan patients with pectus excavatum was carried out according to a variety of strategies, surgical techniques and accesses with low complications rate and no mortality. Many of these were well tolerated with minimal complications and no mortality.

Sex differences in the management of acute coronary syndromes in Italy: data from the MANTRA registry

Aims Several studies have shown sex differences in acute coronary syndromes (ACS), but their understanding is far from complete. Thus, the study aims to evaluate sex differences in management and outcomes of unselected patients with ACS. Methods and Results From 22 April 2009 to 29 December 2010, 6394 consecutive patients with ACS (44.7% ST-elevation myocardial infarction) were prospectively enrolled and followed for 6 months. Women (N = 1894, 29.6%) were older, had more comorbidities, and worse clinical presentation than men. Fewer women underwent reperfusion [68.0% women vs. 84.1% men, P < 0.0001, adjusted odds ratio (OR): 0.53, 95% confidence interval (CI): 0.43–0.66] in ST-elevation myocardial infarction, and coronary angiography during hospitalization (72.2% women vs. 81.1% men, P < 0.0001, adjusted OR: 0.70, 95% CI: 0.57–0.85) in no-ST-elevation ACS. Women had worse outcomes than men during hospitalization, and at 6-month follow-up. At multivariable analysis, female sex was significantly associated with a higher risk of in-hospital Thrombolysis in Myocardial Infarction major bleedings (OR: 1.80, 95% CI: 1.09–2.96, P = 0.02), but not of 6-month death. Conclusion Women with ACS in clinical practice present a clustering of high-risk features that may contribute to their worse outcomes as compared with men, although female sex is not an independent predictor of death at 6-month follow-up.

Right ventricular free wall strain: a predictor of successful left ventricular assist device implantation.

A 54-year-old man with end-stage heart failure due to hypertrophic cardiomyopathy was admitted because of acute hemodynamic deterioration accompanied by disabling dyspnea and asthenia at rest, in association with fluid overload, poor urinary output, and a contextual increase of neurohormonal activation (brain natriuretic peptide level, 4,168 pg/mL). He was already enrolled for heart transplantation at our center. Despite continuing inotropic support (with milrinone) and high-dose diuretics, the patient developed evidence of kidney and liver dysfunction and deteriorated to Class II Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). The heart team considered him a possible candidate for left ventricular assist device (LVAD) implantation as a bridge to transplantation. Preimplantation echocardiographic evaluation revealed severely impaired left ventricular (LV) systolic function with only mild LV dilation (Fig. 1). Right ventricular (RV) evaluation revealed a fractional area change (34%) below the range of normal value (Fig. 2), low tricuspid annular plane systolic excursion (12 mm) (Fig. 3), and a tissue-Doppler peak systolic velocity (8 cm/s) of the tricuspid annulus, again below the range of normal (Fig. 4). Fig. 1 Transthoracic echocardiogram (apical 4-chamber view) shows a mildly dilated left ventricle with markedly reduced systolic function and preserved left ventricular wall thickness. Note also the severe left atrial enlargement. Fig. 2 Transthoracic echocardiogram (apical off-axis view), focused on the right ventricle. Note the visually preserved free wall longitudinal function, with reduced fractional area change. Fig. 3 M-mode transthoracic echocardiogram, at the level of the lateral tricuspid annulus, revealed low (12 mm) tricuspid annular plane systolic excursion and low longitudinal right ventricular function. Fig. 4 Tissue-Doppler image at the level of the lateral tricuspid annulus reveals a peak systolic velocity of 8 cm/s, indicating relatively low right ventricular longitudinal function. In contrast, the value for RV free-wall longitudinal strain obtained with use of 2-dimensional speckle-tracking echocardiography and EchoPAC PC software (GE Medical Systems; Horten, Norway) was high (−16%), predicting good RV performance after implantation. The 2-dimensional speckle-tracking echocardiograms (Fig. 5) were obtained through offline analysis of grayscale conventional transthoracic images acquired during breath-hold and with a stable electrocardiogram recording. For each figure, 3 consecutive heart cycles were recorded and averaged. The frame rate was set between 60 and 80 frames. Fig. 5 Two-dimensional speckle-tracking echocardiography (transthoracic apical off-axis view) was used to measure A) right ventricular free wall longitudinal strain (RVFWLS) and B) right ventricular global longitudinal strain (RVGLS). In A), the manual tracing ... The patient successfully underwent LVAD implantation during a short hospital stay.

Challenge of Pregnancy in Patients With Pre-Capillary Pulmonary Hypertension: Veno-Arterial Extracorporeal Membrane Oxygenation as an Innovative Support for Delivery

article Challenge of Pregnancy in Patients With Pre-Capillary Pulmonary Hypertension: Veno-Arterial Extracorporeal Membrane Oxygenation as an Innovative Support for Delivery Patrizio Vitulo, MD, Marta Beretta, MD, Gennaro Martucci, MD, Cesar Mario Hernandez Baravoglia, MD, Giuseppe Romano, MD, Alessandro Bertani, MD, Lavinia Martino, MD, Adriana Callari, MD, Giovanna Panarello, MD, Michele Pilato, MD, Antonio Arcadipane, MD

Biomechanical Determinants of Right Ventricular Failure in Pulmonary Hypertension

Pulmonary hypertension (PH) is a disease characterized by progressive adverse remodeling of the distal pulmonary arteries, resulting in elevated pulmonary vascular resistance and load pressure on the right ventricle (RV), ultimately leading to RV failure. Invasive hemodynamic testing is the gold standard for diagnosing PH and guiding patient therapy. We hypothesized that lumped-parameter and biventricular finite-element (FE) modeling may lead to noninvasive predictions of both PH-related hemodynamic and biomechanical parameters that induce PH. We created patient-specific biventricular FE models that characterize the biomechanical response of the heart and coupled them with a lumped-parameter model that represents the systemic and pulmonic circulation. Simulations were calibrated by adjusting the pulmonary vascular resistance and myocardial contractility parameters through matching imaging data of ventricular chambers. Linear regression analysis demonstrated that the lumped-derived RV cardiac index (CI) was in good agreement with catheterization measurements collected from 10 patients with PH (R2 = 0.82; p < 0.001). Biventricular FE analysis revealed a paradoxical leftward shift of the interventricular septum, and this correlated with invasive measurements of pulmonary vascular resistances (R = 0.70; p = 0.048) as found by Pearson’s coefficient. A significant difference was noted for RV myocardial fiber stress in healthy control patients (4.5 ± 0.7 kPa) compared with that of patients with PH at either rest (30.1 ± 12.1 kPa; p = 0.005) or simulated exercise conditions (69.6 ± 24.8 kPa; p < 0.001), thus suggesting adverse RV remodeling. This approach may become a useful and versatile tool for noninvasively assessing RV impairment induced by PH and realistically predicting ventricular mechanics and interactions for an improved management of patients with PH.