Ilaria D'Angeli

Assessment of right ventricular function by strain rate imaging in chronic obstructive pulmonary disease

The purpose of the current study was to compare right ventricular (RV) myocardial wall velocities (tissue Doppler imaging) and strain rate imaging (SRI) parameters with conventional echocardiographic indices evaluating RV function in chronic obstructive pulmonary disease (COPD) patients. In total, 39 patients with COPD and 22 healthy subjects were included in the current study. Seventeen patients had pulmonary artery pressure <35 mmHg (group I) and 22 patients had pulmonary artery pressure >35 mmHg (group II). Tissue Doppler imaging, strain and strain rate (SR) values were obtained from RV free wall (FW) and interventricular septum. Respiratory function tests were performed (forced expiratory volume in one second/vital capacity (FEV1/VC) and carbon monoxide diffusion lung capacity per unit of alveolar volume (DL,CO/VA)). Strain/SR values were reduced in all segments of group II patients compared with group I patients and controls with lowest values at basal FW site. A significant relationship was shown between peak systolic SR at basal FW site and radionuclide RV ejection fraction. A significant relationship was shown between peak systolic SR at basal FW site and DL,CO/VA and FEV1/VC. In conclusion, in chronic obstructive pulmonary disease patients, strain rate imaging parameters can determine right ventricular dysfunction that is complementary to conventional echocardiographic indices and is correlated with pulmonary hypertension and respiratory function tests.

Right ventricular function in acute pulmonary embolism: a combined assessment by three-dimensional and speckle-tracking echocardiography.

BACKGROUND The aim of this study was to assess changes in right ventricular (RV) parameters determined by three-dimensional (3D) echocardiography and speckle-tracking echocardiography in patients with acute pulmonary embolism and RV dysfunction without systemic hypotension (submassive pulmonary embolism). METHODS Sixty-six patients were prospectively studied at the onset of the acute episode and after median follow-up periods of 30 days and 6 months. Sixty-six controls were selected. RV fractional area change, tricuspid annular plane systolic excursion, and myocardial performance index were determined. RV systolic pressure was assessed using continuous-wave Doppler echocardiography. Three-dimensional RV ejection fraction (RVEF) was calculated. Two-dimensional peak systolic RV longitudinal strain (RVLS) was measured in the basal free wall, mid free wall (MFW), and apical free wall and the septum. RESULTS Tricuspid annular plane systolic excursion and fractional area change were smaller and myocardial performance index was larger compared with controls (P < .05). Global RVLS (P < .05), MFW RVLS (P < .001), and 3D RVEF (P < .001) were lower in patients with pulmonary embolism than in controls. There was earlier reversal of MFW RVLS values on 30-day follow-up and longer reversal of 3D RVEF and RV systolic pressure values at 6-month follow-up. Receiver operating characteristic curve analysis showed that changes in 3D RVEF and MFW RVLS were the most sensitive predictors of adverse events. By multivariate analysis, RV systolic pressure (P = .007), MFW RVLS (P = .002), and 3D RVEF (P = .001) were independently associated with adverse outcomes. CONCLUSIONS Acute submassive pulmonary embolism has a significant impact on RV function as assessed by 3D echocardiography and speckle-tracking echocardiography. Decreases in MFW RVLS and 3D RVEF may persist during short-term and long-term follow-up and correlate with unfavorable outcomes.

Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure

AIMS Percutaneous closure of patent foramen ovale (PFO) in cryptogenic cerebrovascular events is an alternative to medical therapy. The interpretation of residual shunts after implantation of different devices for PFO with different morphologies is controversial. METHODS AND RESULTS Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n = 46), Figulla Occlutech (n = 41), and Atriasept Cardia (n = 36). Fifty-six patients presented with simple PFO and 67 patients had complex morphologies. All patients were studied with contrast enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6-12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive TEE studies. Various PFO morphologies were identified by TEE before device implantation. The device size to PFO diameter ratio was significantly increased in patients with complex PFO compared with those patients with a simple PFO morphology (P < 0.05). The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer P = 0.0027, Figulla P = 0.0043, and Atriasept P < 0.01). The mean follow-up period was 3.4 years (median 2.7 years) with a cerebrovascular re-event rate of 2.4% per year. In three patients, thrombi were detected in the 6-month TEE controls and resolved after medical therapy. In three other patients, the implantation of an adjunctive device was necessary for residual shunt. CONCLUSION In our series of patients, the closure rate was dependent on PFO morphology more than occluder size and type. An adjunctive device was implanted in selected cases.

Carotid Stenting and Transcranial Doppler Monitoring: Indications for Carotid Stenosis Treatment

Background: Recently, angioplasty and stenting of carotid arteries (CAS) have taken the place of surgery. The aim of our study is to assess the role of transcranial Doppler (TCD) monitoring during CAS to address the embolic complications during the stages of the procedure, with or without embolic cerebral protection devices. Methods: A total of 152 patients were submitted to carotid stenting. All patients were submitted to carotid arteries Duplex scanning. Results: Neurological complications are related to TCD detection of corpuscolate signals in rapid succession. Even if no reduction of the overall incidence rate of microembolic signals (MES) was observed, a decrease in the number of corpuscolate emboli were recorded when a cerebral protection was working. Conclusions: According to our study, even in selected patients on the basis of preoperative diagnostic criteria, CAS is burdened by a nonnegligible risk of subclinical embolic ischemic events detected at TCD and confirmed by diffusion-weighted magnetic resonance imaging (DW-MRI).

Type B aortic dissection in a patient with unknown left ventricular non-compaction cardiomyopathy: Cardiovascular magnetic resonance diagnosis

A 61-year-old man was referred at our hospital for a cardiac evaluation after an episode of oppressive chest pain at rest. He was discharged with a MRI diagnosis of non-compaction cardiomyopathy presented with typical angina, left ventricle dysfunction and ischemic EKG findings without atherosclerotic narrowing and also with a type B aortic dissection, documented also by computed tomography.

Giant cardiac myxoma: real-time characterization by 64-slice computed tomography.

CLINICAL SUMMARY A 70-year-old woman was admitted at our institution because of recent onset of palpitations, dyspnea, and fatigue. On physical examination, she appeared well and she did not present particular signs except for a pulse rate of 114 beats per minute; her blood pressure was 155/85 mm Hg, axillary temperature was 36.7 C, respirations were 16 breaths per minute, and arterial blood gas measurements were normal. The chemistry and hematologic laboratory values were within the normal reference ranges. Electrocardiography revealed sinus tachycardia at a rate of 115 beats per minute and diphasic P waves in leads II, aVF, and V3 through V5. A chest radiography showed no abnormalities of the heart and mediastinum, and the lungs were clear. However, in the lateral view, an egg-shaped image corresponding to the atria was present and appeared highly suspicious for an intracardiac mass. A transthoracic echocardiographic examination disclosed a dilated left atrium (60 3 40 mm) filled almost entirely by a mobile, pedunculated mass of echoes, 2.7 by 7 cm, that partially prolapsed into the left ventricle during diastole with an incomplete closure of the mitral valve leaflets and an associated jet of mild regurgitation (Figure 1). The mass was highly mobile and appeared to be attached to the interatrial septum by a large stalk (2 cm). Transesophageal echocardiogram was impracticable because of the presence of Zenker’s diverticulum. A 64-slice contrast-enhanced computed tomography (LightSpeed VCT, GE Healthcare, Milwaukee, Wis) was Video clip is available online.

Spheric balloon technique for ostial bifurcation lesion treatment

thrombushadbeen incompletelycontainedwithin theaspirationcatheter, and non-contained thrombus dislodged at the level of the left main coronary artery (LMCA) or attached to the guiding catheter tip, thus causing embolisation to both the LCx and the LAD branches during export catheterwithdrawal or during subsequent injection. It is likely that during the following injection, smaller thrombi embolised into the LCx, and a larger discrete thrombus embolised to the LAD resulting in impaction and occlusion at the site of the previously demonstrated mid LAD lesion. Although it is theoretically possible that the LAD lesionwasdue toanacute plaque rupture, the sequence of events, and the observation that the angiographic appearance of the 70% LAD lesion after balloon angioplasty was identical to that before occlusionwithout evidence of plaque rupture argues against plaque rupture. As the patient was optimally treated with anti-thrombotic medications including aspirin, clopidogrel, and intravenous heparin during the procedure, de-novo thrombus formation in the LAD during the angiogram is highly unlikely. Previous studies evaluating the efficacy of thrombus aspiration have not reported any complications directly attributable to the aspiration catheter. However, 2 cases of systemic embolisation complicating thrombus aspiration have been recently described [7]. This suggests that both coronary and systemic embolisation can occur due to thrombus dislodgement during aspiration. We propose several simple measures to reduce the risk of this potential complication: (1) maintaining constant negativepressureuntil the export catheter is outside theguiding catheter, to ensure that thrombotic material cannot be dislodged with loss of suction; (2)maintaining co-axial alignmentof the aspiration catheterand the guide to minimize the possibility of dislodgement at the tip of the guide; and (3) following removal of the aspiration catheter, aspirating the guide prior to injection of contrast. Prompt recognition of this complication will minimise myocardial injury and is compatible with excellent functional recovery. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8].