Luigi Di Martino

Dynamic changes of QTc interval and prognostic significance in takotsubo (stress) cardiomyopathy

Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high‐risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role.

Importance of the left ventricular outflow tract in the need for pacemaker implantation after transcatheter aortic valve replacement.

BACKGROUND The interaction of left ventricular outflow tract (LVOT) and transcatheter heart valve (THV) is complex and may be device design specific. We sought to study LVOT characteristics and its relation with permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR). METHODS We studied 302 patients with a median age of 81years [75-84]. Computed tomography was used to assess LVOT in terms of amount of calcium, perimeter and device size relative to LVOT. RESULTS We implanted a Medtronic CoreValve (MCS) in 203 patients, Edwards-Sapien XT (ESV-XT) in 38, Edwards-Sapien S3 (ESV-S3) in 26 and Lotus in 35 patients. Sixty-eight patients (22.5%) received a new PPI within 30days after the index procedure. The incidence of PPI was 22.7% with MCS, 10.5% with ESV-XT, 26.9% with ESV-S3 and 31.4% with Lotus. By multivariate analysis RBBB at baseline (OR 2.9 [1.2-6.9, p=0.014), second generation valves (OR 2.1 [1.0-4.5], p=0.048), DOI (OR 1.20 per 1mm increment, [1.09-1.31], p<0.001) and LVOT sizing (OR per 1% increment 1.03 [1.01-1.07], p=0.022) were associated with need for PPI. Sensitivity analyses suggest that a lesser degree of LVOT oversizing triggers PPI with second generation THVs vs. first generation THVs. CONCLUSIONS More LVOT oversizing is associated with a higher need for permanent pacemaker implantation after TAVR, even more so with deeper THV implants and next generation devices (ESV-S3 and Lotus). Sizing algorithms should focus more on LVOT dimensions to reduce PPI.

Impact of persistent ST elevation on outcome in patients with Takotsubo syndrome. Results from the GErman Italian STress Cardiomyopathy (GEIST) registry

BACKGROUND Potential predictors of clinical complications of Takotsubo syndrome (TTS) are poorly known. Persistent ST-segment elevation (PSTE) may have an impact on outcome similar as previously reported in acute coronary syndrome. The aim of this study was to assess the prevalence and prognostic relevance of PSTE in patients with TTS. METHODS Two-hundred-sixty-nine consecutive patients were enrolled in an international multicenter registry. PSTE was defined as the documentation of ST-elevation at least for the first 48h of hospitalization. Long-term mortality was evaluated in median 1.9years after the acute event. RESULTS PSTE was found in 52 TTS patients (19%). Patients with PSTE were characterized by higher admission levels of troponin-I (23±12 vs 8±49ng/L, p<0.001), experienced a longer hospitalization (10±5 vs 8±3days, p=0.02) and a higher rate of in-hospital complications (31% vs 17% p=0.03). At multivariate analysis including PSTE, age, male sex, admission ejection fraction, PSTE (odds ratio [OR] 4.2; 95% confidence interval [CI] 1.4-13; p=0.01), age (OR 1.05; 95%CI 1.00-1.10; p=0.03) and admission ejection fraction (OR 0.93; 95%CI 0.87-0.99; p=0.02) were independent predictors of in-hospital complications. At long-term follow-up no significant differences in terms of mortality were observed between patients with and without PSTE (19% vs 15%; p=0.5). However, PSTE was a predictor of major cardiac adverse events (MACE) at follow-up (HR 2.32, 95% CI 1.02-5.31, p 0.045). CONCLUSIONS In TTS patients, PSTE is a common finding, represents an independent predictor of in-hospital complications and could be associated with MACE at follow-up.

Prediction of paravalvular leakage after transcatheter aortic valve implantation

Significant paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) is related to patient mortality. Predicting the development of PVL has focused on computed tomography (CT) derived variables but literature targeting CoreValve devices is limited, controversial, and did not make use of standardized echocardiographic methods. The study included 164 consecutive patients with severe aortic stenosis that underwent TAVI with a Medtronic CoreValve system©, with available pre-TAVI CT and pre-discharge transthoracic echocardiography. The predictive value for significant PVL of the CT-derived Agatston score, aortic annulus size and eccentricity, and “cover index” was assessed, according to both echocardiographic Valve Academic Research Consortium (VARC) criteria and angiographic Sellers criteria. Univariate predictors for more than mild PVL were the maximal diameter of the aortic annulus size (for both angiographic and echocardiographic assessment of PVL), cover index (for echocardiographic assessment of PVL only), and Agatston score (for both angiographic and echocardiographic assessment of PVL). The aortic annulus eccentricity index was not predicting PVL. At multivariate analysis, Agatston score was the only independent predictor for both angiographic and echocardiographic assessment of PVL. Agatston score is the only independent predictor of PVL regardless of the used imaging technique for the definition of PVL.

Limitations and difficulties of echocardiographic short-axis assessment of paravalvular leakage after corevalve transcatheter aortic valve implantation

To make assessment of paravalvular aortic leakage (PVL) after transcatheter aortic valve implantation (TAVI) more uniform the second Valve Academic Research Consortium (VARC) recently updated the echocardiographic criteria for mild, moderate and severe PVL. In the VARC recommendation the assessment of the circumferential extent of PVL in the short-axis view is considered critical. In this paper we will discuss our observational data on the limitations and difficulties of this particular view, that may potentially result in overestimation or underestimation of PVL severity.

Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular Tako-Tsubo cardiomyopathy

Tako-Tsubo cardiomyopathy (TTC) is a well-known form of acuteand reversible heart failure due to either an emotional or a physicalstressor,whichinvolvesmainlytheleftventriclewithatypicalechocar-diographic pattern (apical ballooningand basal hyperkinesis) [1].Rightventricular(RV)involvementhasaprevalenceof25%[2].Aclinicalcase,a short literature review and possible explaining mechanism areprovided.An86-yearoldwoman,withoutcardiovascularriskfactorsandwithhistory of bipolardisorder [3] cameto the emergency department afteran episode of syncope. At admission blood pressure was 70/50 mm Hg,ECG showed atrial fibrillation and ST-elevation in anterior and lateralleads (V2–V4, DI, aVL) (Fig. 1). Troponin I levels were increased(4.54 ng/ml, n.v. b 0.10). Trans-thoracic echocardiogram showed leftventricular (LV) systolic dysfunction (ejection fraction of 25%),akinesisofLVmidventricularsegments,dyskinesisofRVapicalsegmentsandin-complete coaptation of tricuspid leaflets (Video 1). At color-Dopplermild mitral regurgitation and severe tricuspid regurgitation werefound (Figs. 2 and 3, Video 2). Coronary angiography showed diffuseatherosclerosis not needing coronary intervention. Echocardiographyanomalies gradually recovered and the patient was discharged after acouple of weeks (Figs. 4 and 5) (Video 3). Discharge electrocardiogramshowed negative T-waves in anterior leads previously interested byST-elevation and diffuse decrease in QRS amplitude [4].Despite TTC affects mainly left ventricle, RV involvement is presentinoneoutoffourpatientsaffectedbyTTC.Severalechocardiographicstudies described acute mitral regurgitation and its clinical impor-tance in TTC[5], but, to the best of our knowledge, possible mecha-nism of tricuspid regurgitationduring RV TTC was never describedbefore.We report a case of RV apical dyskinesis causing traction of thepostero-lateral papillary muscle and consequent compromised coapta-tion of thetricuspid valve leaflets (Fig. 2);that could have led to severetricuspid regurgitation completely reversible after RV recovery.The mechanism of RV regurgitation seems to be different from thatwe have previously described in the left ventricle. LV basal hyperkinesis, consequent mitral valve area reduction and mitral leafletsredundancy may lead to LV outflow tract obstruction, increased intraventricular pressure and mitral regurgitation [6,7]. Systolic anteriormotion and tethering have been shown as independent predictors ofacute mitral regurgitation in patients with TTC [8].In thecaseof mid-LVballooning, rightward movement of midseptalsegmentsmayhaveincreasedRVpressure,thusimpairingRVgeometryand kinesis, and precipitating RV ballooning.Tricuspid regurgitation has not yet been evaluated as a marker ofprognosisinTTC;however,inacutemyocardialinfarctionoftheinferiorwall, moderate tricuspid regurgitation, affecting about one third ofpatients, is a predictor of rehospitalization at one-year follow-up [9].Although no in-hospital complication was present in our case, RVsystolic dysfunction represents an independent predictor of worseprognosis and is associated with a higher rate of in-hospital complica-tion both in inferior myocardial infarction [10] and TTC [2].Haghiet al. found in 34 patients with TTC that RV involvement is associatedwith a severe impairment in LV systolic function and a higher rate ofbilateral pleural effusion [2]. Elesber et al. showed in a population of30patientswithTTCthatRVinvolvementcarriesahigherriskofseverecongestive heart failure and longer in-hospital stay [11].We therefore believe that a systematic evaluation of RV function byechocardiogram is recommended for an optimal management of pa-tients with TTC. When an impaired LVEF is associated with abnormalRV function, there is a higher risk of hemodynamic complications.Therefore a strict monitoring is required and an early therapeuticstrategy including diuretics, levosimendan infusion and intra-aorticballoon pump counterpulsation should be considered [12–14].In conclusion, RV involvement in TTC may lead to severe tricuspidregurgitationduetoincompletecoaptationofvalveleaflets.This finding

“Lambda-wave” ST-elevation is associated with severe prognosis in stress (takotsubo) cardiomyopathy

Persistent ST‐segment elevation in acute coronary syndrome is associated with both short and long‐term complications. By contrast, there is limited information about ST‐elevation and its evolution during takotsubo (stress) cardiomyopathy (TTC).

Predictive value of very low frequency at spectral analysis among patients with unexplained syncope assessed by head-up tilt testing

BACKGROUND The role of heart rate variability (HRV) in the prediction of vasovagal syncope during head-up tilt testing (HUTt) is unclear. AIM To evaluate the ability of the spectral components of HRV at rest to predict vasovagal syncope among patients with unexplained syncope referred for HUTt. METHODS Twenty-six consecutive patients with unexplained syncope were enrolled in the study. All patients underwent HRV evaluation at rest (very low frequency [VLF], low frequency [LF], high frequency [HF] and LF/HF ratio) and during HUTt. HUTt was performed using the Westminster protocol. Continuous electrocardiogram and blood pressure monitoring were performed throughout the test. RESULTS Eight (31%) patients developed syncope during HUTt. There were no baseline differences in terms of clinical features and HRV variables among patients who developed syncope and those who did not, except for VLF (2421 vs 896ms2; P<0.001). In the multivariable logistic regression analysis, including age and sex, VLF was the only independent variable associated with syncope during HUTt (odds ratio 1.002, 95% confidence interval 1.0003-1.0032; P=0.02). The area under the curve at rest was 0.889 for VLF, 0.674 for HF and 0.611 for LF. A value of VLF>2048ms2 was the optimal cut-off to predict syncope during HUTt (sensitivity 87.5%, specificity 72.2%). CONCLUSIONS VLF at rest predicted the incidence of syncope during HUTt. Further studies are warranted to confirm these preliminary data.

Bicuspid aortic valve and lusory artery: an unusual association

A patient with bicuspid aortic valve was evaluated in our echocardiography laboratory over serial follow-up controls. Echocardiography showed trivial mitral valve regurgitation and the already known bicuspid aortic valve (Fig. 1a) with a mild regurgitation. An abnormal origin of the subclavian right artery, deriving from the distal aortic arch (Fig. 1b), was unexpectedly found. The patient underwent CT imaging of the thoracic aorta and supraaortic vessels, which confirmed the right subclavian originating from a lusory artery after a retroesophageal course (Fig. 1c–f). No further vascular abnormalities were found. The caliber of the thoracic aorta was normal as well. Lusory artery is an uncommon congenital vascular abnormality, whose incidence varies between 0.2–2.5 % [1], resulting from interruption of the fourth right aortic arch between the common carotid artery and subclavian artery and the persistence of the retroesophageal aortic arch [2]. The right subclavian artery thus originates as the last branch of the aortic arch. The condition is usually asymptomatic, even if it may cause dysphagia due to esophageal compression [1]. Complications are described, ranging from atherosclerotic disease and thrombosis [3], potentially eased by the abnormal retroesophageal course, to aneurysma [4] and arterioesophageal fistulae, and other possible serious events usually precipitated by the placement of nasogastric tubes in patients where the erosion of the esophagus was already present [5]. Despite the potentially dangerous implications, this anatomical variant does not usually require surgery, although restoring a normal course of the right subclavian artery by aortic arch repair is feasible and often recommended [1]. The lusory artery is known to be associated with other congenital abnormalities, especially Down syndrome [2]. The association with bicuspid aortic valve appears new. One of the most consistent findings in bicuspid aortic valve is dilatation of the ascending aorta, even in the absence of clinically significant valvular dysfunction. Dilatation of the ascending aorta represents a key risk factor for dissection and rupture. So, all patients with a bicuspid valve and dilatation of the ascending aorta should have evaluation of the aorta with an MRI or CT angiography. Cardiac MRI is preferred because it also provides the added benefit of information regarding LV function, LV dimensions, and assessment of valve stenosis/regurgitation severity. For those with no aortic dilatation, we tend to use only echocardiography for follow-up. To our knowledge, there is no any association between lusory artery and persistent branchial cleft cysts. Further attention should be placed in screening of paucisymptomatic vascular abnormalities in patients found to bear bicuspid aortic valve, so that the need for repair can be determined, according to the risk of potential complications and clinical conditions. L. D. Martino M. Correale (&) D. Cocco M. D. Biase N. D. Brunetti Department of Cardiology, ‘‘Ospedali Riuniti’’ OO.RR, University of Foggia, viale L Pinto, 1, 71100 Foggia, Italy e-mail: opsfco@tin.it

Long-term safety and efficacy of supraventricular tachycardia ablation with a simplified approach

Introduction Catheter-ablation (CA) is routinely used for the treatment of atrio-ventricular nodal re-entrant tachycardia (AVNRT) and accessory AV-pathways and is usually performed with 4 or 5 catheters. This study reports the short- and long-term results of an alternative simplified approach with a 2-catheter configuration for both electrophysiological study (EPS) and CA in patients with re-entrant supraventricular tachycardias. Methods In total, 274 consecutive patients who underwent EPS with a view to curative CA for AVNRT or AVRT were enrolled. A 2-catheter configuration was routinely used. Ablation success, acute in-hospital complications, symptoms recurrence, arrhythmia recurrence were recorded. Results 195 patients underwent ablation of AVNRT and 79 of a single AP. Immediate success after CA ablation was achieved in 99.6% of patients. Major complications occurred in 2 patients (0.73%, 2 cases of complete AV block, one of which requiring pacemaker implantation after 1 year, one during typical AVNRT ablation and one during epicardial AP-ablation). Vascular complications occurred in 4 patients (1.4%, 3 partial femoral vein thrombosis without embolic events, one femoral arteriovenous fistula). Minimal pericardial effusion occurred in 6 patients (2.2%). All vascular complications were medically successfully treated not requiring surgery. The mean follow-up was 86 months. Arrhythmia recurrence was observed in 5.6% of patients (2.6% with AP, 2.9% with AVNRT); a second successful catheter ablation was performed in 2.9%. Conclusions CA with simplified approach is effective in the treatment of supraventricular tachycardia due to APs and AVNRT and is associated with a low incidence of major and minor complications and late recurrence of arrhythmias.