Guido Tavazzi

Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view.

Introduction Assessment of the size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for severe hypovolaemia [1], predict fluid responsiveness (FR) [2, 3] and assess potential intolerance to fluid loading. IVC size, collapsibility (IVCc) [2] and distensibility (IVCd) [3] have gained acceptance by emergency and intensive care unit (ICU) clinicians as FR predictors in patients with shock [4]. The ease of acquisition, reproducibility of measurements and increasing availability of ultrasound devices have supported the expansion of its use. Conflicting results have also been published [5, 6]. Injudicious application in clinical contexts where these indices have not been specifically tested may, however, mislead. On the basis of physiological principles and available, although limited, scientific evidence, it can be hypothesized that in a number of clinical conditions IVC size and/or respiratory variability may not depend on volume status and may not predict FR accurately. Although not specifically investigated yet, these conditions can be described and grouped on the basis of their main physiological determinant, as follows (Table 1) (pictorial samples are also presented as electronic supplementary material, ESM):

Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure

Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.

Concept of the central clip: when to use one or two MitraClips®

AIMS Percutaneous edge-to-edge mitral valve repair with the MitraClip(®) was shown to be a safe and feasible alternative compared to conventional surgical mitral valve repair. We analyse the concept of the central clip and the predictors for the need of more than one MitraClip(®) in our high-risk surgical population with severe mitral regurgitation (MR). METHODS AND RESULTS Patients with severe MR (3 or 4+) and high operative risk (as defined by logistic EuroSCORE) refused for conventional mitral valve repair were considered for MitraClip(®). The procedure was performed under general anaesthesia with transoesophageal echocardiographic (TOE) guidance. Device success was defined as placement of one or more MitraClips(®) with a reduction of MR to ≤2+. Patients were followed up clinically and with TOE at one month and one year. From September 2009 to March 2012, 43 patients with severe MR with a mean age of 74.8±10.7 years (30 males, 13 females; mean logistic EuroSCORE 24.1±11, mean LVEF 47.5±18.5%; mean±SD) were treated. Median follow-up was 385 days (104-630; Q1-Q3). Device implantation success was 93%. All patients were treated following the central clip concept: 52.5% of MR was degenerative in aetiology and 47.5% was functional. The degree of MR was reduced from 3.6±0.4 to 1.4±0.6 (p<0.001); NYHA Class improved from 3.1±0.4 to 1.8±0.7 (p<0.001). Nineteen patients (47.5%) received two or more clips. Vena contracta (p<0.001) and the presence of two broad jets (p<0.001) were correlated with the need for a second clip. The presence of a restricted posterior mitral valve leaflet (PML) was inversely correlated with the need for more than one clip (p=0.02). A cut-off value of ≥7.5 mm for vena contracta predicted the need for a second clip (sensitivity 83%, specificity 90%, p=0.01). CONCLUSIONS The central MitraClip(®) concept achieved a significant reduction in the degree of mitral regurgitation in the majority of patients treated. The presence of a broad jet (quantified by a vena contracta greater than 7.5 mm) significantly predicted the need for more than one clip.

Modified Lung Ultrasound Score for Assessing and Monitoring Pulmonary Aeration

Purpose Lung Ultrasound Score (LUSS) is a useful tool for lung aeration assessment but presents two theoretical limitations. First, standard LUSS is based on longitudinal scan and detection of number/coalescence of B lines. In the longitudinal scan pleura visualization is limited by intercostal space width. Moreover, coalescence of B lines to define severe loss of aeration is not suitable for non-homogeneous lung pathologies where focal coalescence is possible. We therefore compared longitudinal vs. transversal scan and also cLUSS (standard coalescence-based LUSS) vs. qLUSS (quantitative LUSS based on % of involved pleura). Materials and methods 38 ICU patients were examined in 12 thoracic areas in longitudinal and transversal scan. B lines (number, coalescence), subpleural consolidations (SP), pleural length and pleural involvement (> or ≤ 50 %) were assessed. cLUSS and qLUSS were computed in longitudinal and transversal scan. Results Transversal scan visualized wider (3.9 [IQR 3.8 - 3.9] vs 2.0 [1.6 - 2.5] cm, p < 0.0001) and more constant (variance 0.02 vs 0.34 cm, p < 0.0001) pleural length, more B lines (70 vs 59 % of scans, p < 0.0001), coalescence (39 vs 28 %, p < 0.0001) and SP (22 vs 14 %, p < 0.0001) compared to longitudinal scan. Pleural involvement > 50 % was observed in 17 % and coalescence in 33 % of cases. Focal coalescence accounted for 52 % of cases of coalescence. qLUSS-transv generated a different distribution of aeration scores compared to cLUSS-long (p < 0.0001). Conclusion In unselected ICU patients, variability of pleural length in longitudinal scans is high and focal coalescence is frequent. Transversal scan and quantification of pleural involvement are simple measures to overcome these limitations of LUSS.

Are Neurogenic Stress Cardiomyopathy and Takotsubo Different Syndromes With Common Pathways?: Etiopathological Insights on Dysfunctional Hearts

The imbalance between the number of organ donors and the demand is currently a major health care problem, although improved technology and experience with long-term mechanical support are increasingly providing alternative solutions to end-stage heart disease. There are strict criteria to assess

Amino terminal pro brain natriuretic peptide predicts all-cause mortality in patients with chronic obstructive pulmonary disease: Systematic review and meta-analysis

Natriuretic peptides (NPs) are a family of prognostic biomarkers in patients with heart failure (HF). HF is one of the most frequent comorbidities in patients with chronic obstructive pulmonary disease (COPD). However, the prognostic role of NP in COPD patients remains unclear. The aim of this meta-analysis was to evaluate the relation between NP and all-cause mortality in COPD patients. We performed a systematic review and meta-analysis of observational studies assessing prognostic implications of elevated NP levels on all-cause mortality in COPD patients. Nine studies were considered for qualitative analysis for a total of 2788 patients. Only two studies focused on Mid Regional-pro Atrial Natriuretic Peptide (MR-proANP) and brain natriuretic peptide (BNP), respectively, but seven studies focused on pro-BNP (NT-proBNP) and were included in the quantitative analysis. Elevated NT-proBNP values were related to increased risk of all-cause mortality in COPD patients both with and without exacerbation (hazard ratio (HR): 2.87, p < 0.0001 and HR: 3.34, p = 0.04, respectively). The results were confirmed also after meta-regression analysis for confounding factors (previous cardiovascular history, hypertension, HF, forced expiratory volume at 1 second and mean age). NT-proBNP may be considered a reliable predictive biomarker of poor prognosis in patients with COPD.

A plea for an early ultrasound-clinical integrated approach in patients with acute heart failure. A proactive comment on the ESC Guidelines on Heart Failure 2016

BACKGROUND The European Association of Cardiology (ESC) Guidelines on the diagnosis and treatment of acute heart failure (AHF) indicate prompt therapy initiation and performance of relevant investigations as paramount. Specifically, echocardiography prior to treatment is advocated only with hemodynamic instability, and the evaluation of clinical signs of peripheral perfusion and congestion is suggested as guidance for early interventions. Given the growing body of evidence on the diagnostic/monitoring capabilities of bedside ultrasound (including focused cardiac ultrasound, comprehensive echocardiography, lung ultrasound), we discuss the potential benefit of an integrated clinical/ultrasound approach at the very early stages of acute heart failure. METHODS AND RESULTS We proposed a narrative review of the current evidence on the clinical-ultrasound integrated approach to AHF, with special emphasis on the components of the early diagnostic-therapeutic workup where cardiac, inferior vena cava and lung ultrasound showed high diagnostic accuracy and the capability of substantially changing an exclusively clinically-oriented patient management. A proactive comment to the ESC guidelines is made, suggesting an integration of clinical and biochemical assessment, as defined by guidelines, with combined bedside ultrasound on may help in the definition of AHF pathophysiology and treatment. CONCLUSION A multi-organ integrated clinical-ultrasound approach should be advocated as part of the clinical-diagnostic workup at AHF very early phase. Whenever competence and technology available, bedside ultrasound, along with clinical and biochemical assessment, should target AHF profiling, identify the cause of AHF, and subsequently aid disease course and response to treatment monitoring.

Heart Rate Modification of Cardiac Output Following Cardiac Surgery: The Importance of Cardiac Time Intervals

Objectives: Inadequate cardiac output is associated with a poor outcome following cardiac surgery and is generally modified by the use of positive inotropic agents, volume resuscitation, and pacing. Echocardiography-guided pacemaker optimization is used in the outpatient setting, using different variables including total isovolumic time and the Tei index. We sought to determine the acute impact of heart rate on cardiac electromechanics, cardiac output, and stroke volume in the perioperative setting. Design: Observational study. Setting: Cardiothoracic adult intensive care department. Patients: Twenty-four sequential patients admitted after cardiac surgery. Interventions: Patients with pacemaker set by the treating anesthesiologist using hemodynamic parameters in theatre, within 4 hours of returning to intensive care, they were reassessed using transthoracic echocardiography. A comprehensive baseline echocardiographic study was performed at the clinician set RR interval and at heart rates from 70 to 110 beats/min, in increments of 10 beats/min. Pearson correlation coefficients were used to assess relationships between the measurements. Measurements and Main Results: Cardiac output and cardiac index were increased significantly in 79% patients using echocardiography-guided pacemaker optimization (2.21 L/min [± 0.97] and 1.2 L/min/m2 [± 0.52]). The echocardiography-driven cardiac output optimization protocol led to a significant reduction of total isovolumic time with concurrent increase of cardiac output and cardiac index in the overall population (p < 0.001). There was no consistent correlation between changes in RR interval and stroke volume, cardiac output, or cardiac index in the overall population. A strong negative correlation was found between the left ventricular total isovolumic time and stroke volume, cardiac output, and cardiac index in all groups. Conclusion: Echocardiography-guided heart rate optimization results in a significant increase in cardiac output when compared with clinically derived pacing settings in the postoperative period. The optimal heart rate should be individualized for each patient, and total isovolumic time is the echocardiographic index with the highest sensitivity to determine the optimal hemodynamic profile.

An unexpected finding in an asymptomatic patient with atrial fibrillation: cardiac angiosarcoma

A 70-year-old asymptomatic man was found to have atrial fi brillation during a routine check-up by his family doctor. He was referred to hospital for further investigation, where transthoracic echocardiography showed a large echogenic intra-atrial mass that almost obliterated the left atrium (fi gure, videos). Transoesophageal echocardio graphy showed a spaceoccupying lesion 9·5 × 7·2 cm arising from the interatrial septum, fi lling the left atrium, bulging into the right atrium and close to the mitral-aortic continuity. Cardiac MRI showed that the mass was encapsulated, with mixed fi brous and cystic components (video). Coronary angiography was normal, and fl uorine-33-labelled fl uorodeoxyglucose (33FDG) PET-CT showed no FDG accumulation. Histology of the mass after complete surgical excision confi rmed an angiosarcoma. 1 year later he remained in atrial fi brillation but had no cardiac or systemic tumour recurrence and was otherwise well. Primary cardiac tumours are rare (0·0017–0·02% of all cardiac tumours), of which sarcomas account for about a third. 30–45% of malignant sarcomas are angiosarcomas, which usually arise in the right atrium near the atrioventricular groove (unlike myxomas, they rarely arise from the interatrial septum). Patients usually present with symptoms related to the tumour size, such as rightsided heart failure, compression syndrome, chest pain, or haemopericardium. Intracardiac angiosarcomas have an especially poor prognosis because they tend to present with metastatic disease, most frequently pulmonary and hepatic metastases. Incidental fi nding of angiosarcoma is rare. Evaluation of intracardiac tumours can be complex and should include a variety of diagnostic techniques. Diagnosis relies on non-invasive imaging techniques and tissue histology. Echocardiography is best for assessment of the tumour’s eff ect on fl ow dynamics, and cardiac MRI is useful for detection of tumour infi ltration and tissue characterisation.

Resolution of Cardiogenic Shock Using Echocardiography-Guided Pacing Optimization in Intensive Care: A Case Series

Objective:Inotropic and vasopressor drugs are routinely used in critically ill patients to maintain adequate blood pressure and cardiac output in patients with cardiogenic shock although potentially at the expense of increasing myocardial oxygen demand. Pacing optimization has been demonstrated as effective in reducing catecholamine requirements in patients with chronic heart failure by improving cardiac efficiency; however, there are no reports relating to the effectiveness of pacemaker optimization on cardiac output in critically ill patients with cardiogenic shock in the intensive care. Data Sources:Retrospective data analysis. Study Selection:Twenty-bed adult tertiary cardiothoracic ICU, university hospital. Data Extraction:Eight sequential patients receiving dual chamber pacemaker with DDD modality with cardiogenic shock and hemodynamic instability refractory to catecholamines underwent echocardiography-guided pacemaker optimization of cardiac output. An iterative method with Doppler echocardiography was used to assess changes in cardiac output, left ventricular filling time, ejection time, total isovolumic time, mitral regurgitation, ejection fraction, and blood pressure at different increments of heart rate, and atrioventricular and interventricular delay. All results are shown as median (minimum/maximum level) or mean ± SD. Data Synthesis:Using echocardiography-guided pacemaker optimization on cardiac output, the cardiac output increased from 3.2 (2.3/3.8) to 5.7 L/min (4.85/7.1) and cardiac index from 1.64 (1.1/1.9) to 2.68 L/min/m2 (2.1/3.2) and the total isovolumic time reduced from 22.8 to normal values (<14). In association, the glomerular filtration rate increased significantly except in one patient with stage IV chronic kidney disease. All inotropes and vasopressors were discontinued within 12 hours of pacemaker optimization on cardiac output, and all patients were discharged from the ICU within 1 week. Conclusions:Echocardiography-guided pacemaker optimization of cardiac output is a feasible bedside therapeutic option, which should be considered when standard medical treatments are insufficient for the treatment of cardiogenic shock refractory to inotropic support, thereby minimizing the detrimental effect of catecholamines.