Laura Lanzoni

Relationship Between Early Diastolic Dysfunction and Abnormal Microvolt T-Wave Alternans in Patients With Type 2 Diabetes

Background—Abnormal microvolt T-wave alternans (MTWA), a marker of ventricular arrhythmic risk, is a highly prevalent condition in patients with type 2 diabetes mellitus (T2DM) and is correlated with glycemic control. However, there is uncertainty as to whether central or peripheral hemodynamic factors are associated with abnormal MTWA in T2DM individuals. Methods and Results—We studied 50 consecutive, well-controlled T2DM outpatients without a history of ischemic heart disease and with normal systolic function. All patients underwent a complete echocardiographic Doppler evaluation with spectral tissue Doppler analysis. MTWA analysis was performed noninvasively during submaximal exercise. Effective arterial elastance, arterial compliance, and heart rate variability were also measured. Compared with patients with MTWA negativity (n=38), those with MTWA abnormality (n=12, 24%) had significantly lower e′ (7.6±1.3 versus 9.1±1.7 cm/s; P<0.01), a′ (10.2±1.6 versus 12.7±1.9 cm/s; P<0.001) and s′ velocities (8.7±1.1 versus 10.2±1.5 cm/s; P=0.001) and higher indexed left ventricular mass (121.3±16.4 versus 107.5±16.5 g/m2; P=0.016), indexed left atrial volume (33.5±11.9 versus 23.6±5.6 mL/m2; P<0.001), and E/e′ ratio (8.8±1.4 versus 6.5±1.3; P<0.001). Multivariable logistic regression analysis revealed that higher E/e′ ratio was the only independent correlate of abnormal MTWA (adjusted odds ratio, 3.52; 95% confidence interval, 1.19 to 10.6; P=0.02) after controlling for glycemic control and other potential confounders. Conclusions—In this pilot study, we found that early diastolic dysfunction, as measured by tissue Doppler imaging, is independently associated with MTWA abnormality in T2DM individuals with normal systolic function. Further larger studies are needed to examine the reproducibility of these results.

Early impairment in left ventricular longitudinal systolic function is associated with an increased risk of incident atrial fibrillation in patients with type 2 diabetes

AIMS It is known that type 2 diabetic patients are at high risk of atrial fibrillation (AF). However, the early echocardiographic determinants of AF vulnerability in this patient population remain poorly known. METHODS We followed-up for 2years a sample of 180 consecutive outpatients with type 2 diabetes, who were free from AF and ischemic heart disease at baseline. All patients underwent a baseline echocardiographic-Doppler evaluation with tissue Doppler and 2-D strain analysis. Standard electrocardiograms were performed twice per year, and a diagnosis of incident AF was confirmed in affected patients by a single cardiologist. RESULTS Over the 2-year follow-up period, 14 (7.8%) patients developed incident AF. In univariate analyses, echocardiographic predictors of new-onset AF were greater indexed cardiac mass, larger indexed left atrial volume (LAVI), lower global longitudinal strain (LSSYS), lower global diastolic strain rate during early phase of diastole (SRE), lower global diastolic strain rate during late phase of diastole (SRL), and higher E/SRE ratio. Multivariate logistic regression analysis showed that lower LSSYS remained the only significant predictor of new-onset AF (adjusted-odds ratio 1.63, 95%CI 1.17-2.27; p<0.005) after adjustment for age, sex, diabetes duration, indexed cardiac mass and LAVI. Results were unchanged even after adjustment for body mass index, hypertension and glycemic control. CONCLUSIONS This is the first prospective study to show that early LSSYS impairment independently predicts the risk of new-onset AF in type 2 diabetic patients with preserved ejection fraction and without ischemic heart disease. Future larger prospective studies are needed to confirm these findings.

Left atrial appendage closure in a patient with cor triatriatum and ASD: the added value of 3D echocardiography

A 47-year-old woman with cor triatriatum ( Panel A , see Supplementary data online, Video S1 and S2 ) and small ostium secundum atrial septal defect (ASD) was evaluated for percutaneous closure of left atrial appendage (LAA) due to permanent AF and Cooleys disease (CHA2-DS2-VASC:2;HAS-BLED:4). 3D transoesophageal echocardiography shows the fibromuscular membrane (F-M) dividing the left atrium into two chambers: …

Left ventricular chamber dilation and filling pressure may help to categorise patients with type 2 diabetes

Background Type 2 diabetes may alter cardiac structure and function. Many patients with type 2 diabetes have diastolic dysfunction with preserved ejection fraction (EF). Recently, this latter measure was criticised. Thus, this research looked at the impact of left ventricular end-diastolic volume and E/e′ ratio variations in patients with type 2 diabetes and preserved EF with the aim to recognise different clinical phenotypes. Methods In this cross-sectional study, we evaluated 176 men affected by type 2 diabetes with transthoracic echocardiography. All subjects have preserved EF (>50%). Patients were stratified into four groups based on the median value of both left ventricular end-diastolic volume and E/e′ ratio, and the clinical variables were registered. The independent predictors associated with the groups were analysed by a multinomial logistic regression model. Results Diabetes duration, age, estimated glomerular filtration rate and antihypertensive treatments were significantly different among the groups as were EF, left atrial volume index (LAVI), E/A, septum thickness and s′ mean wave. Multinomial regression analysis showed that the groups significantly differed for age, diabetes duration, EF, LAVI, septum thickness and s′ mean wave. The main result of this study was that patients with higher left ventricular volume and higher E/e′ ratio (group 2) showed the worse clinical profile. Conclusions Our study might suggest that variations of left ventricular end-diastolic volume along with E/e′ ratio variations, even in the normal range, may allow to recognise phenotypes of patients with type 2 diabetes with worse clinical characteristics. This finding should be tested in prospective studies to assess the predictive roles of these phenotypes.

Inter-atrial shunt inversion by the sitting position in a patient with a patent foramen ovale and acute pulmonary embolism.

A 67-year-old woman was admitted to our hospital because of the recent onset of dyspnoea. On hospital admission, the patient had moderate-to-severe dyspnoea and was distressed. Her peripheral blood oxygen saturation was 76% on room air when the patient was in the supine position (increasing to 88% after 12 L/min of oxygen supplementation), …