Maria Chiara Todaro

New echocardiographic techniques for evaluation of left atrial mechanics

Until recently the left atrium had been subordinate to the left ventricle, but cardiologists now recognize that left atrial (LA) function is indispensable to normal circulatory performance. Transthoracic two-dimensional (2D) and Doppler echocardiography can elucidate parameters of LA function non-invasively. Yet, with the advent of 2D speckle-tracking echocardiography, we are able to detect early LA dysfunction even before structural changes occur. This is pivotal in some common disease states, such as atrial fibrillation, hypertension, and heart failure, in which LA deformation parameters can influence clinical management. However, a unique standardized technique to investigate LA deformation needs to be validated.

Cardioncology: State of the heart

Cardiotoxicity caused by chemotherapy is a concerning reality plaguing oncologists and cardiologists. The coexistence of cancer and cardiovascular diseases in the same patient is more common due to the aging population and improvement of chemotherapeutic drug effectiveness. We review the incidence and clinical features of cardiotoxicity caused by some of the most common chemotherapeutic drugs to provide the cardiologist with information regarding general cardiovascular toxicity, early left ventricular dysfunction detection, cardiac damage prevention and follow-up. In conclusion, awareness of this emerging problem has important clinical implications as only highly specialized care will prevent patients who successfully overcome cancer from being defeated by the side effects of anticancer therapy.

Role of imaging in assessment of atrial fibrosis in patients with atrial fibrillation: state-of-the-art review.

Atrial fibrillation (AF) is the most common arrhythmia in the world. Despite the large number of studies focused on the causes and mechanisms of AF, it remains a clinical challenge. Atrial electrical and structural remodelling caused by AF is responsible for the perpetuation of the arrhythmia. However, a validated noninvasive method for assessment of atrial fibrosis in clinical practice is lacking. In this review, we aim to present an update about the origins and mechanisms of atrial remodelling, particularly focusing on atrial fibrosis, and compare imaging techniques that can detect atrial changes and greatly contribute to the clinical management of patients with AF.

Use of echocardiography to evaluate the cardiac effects of therapies used in cancer treatment: what do we know?

Cardiologists and oncologists today face the daunting challenge of identifying patients at risk for late-onset left ventricular (LV) systolic dysfunction from the use of various chemotherapeutic agents. Currently, the most widely used method in clinical practice for monitoring the potential of chemotherapy-induced cardiotoxicity is calculation of LV ejection fraction. The use of LV ejection fraction to determine whether to continue or discontinue the use of chemotherapeutic agents is limited, because decreases in LV ejection fraction frequently occur late and can be irreversible. These limitations have led to the exploration of diastolic function and newer modalities that assess myocardial mechanics to identify sensitive and specific variables that can predict the occurrence of late systolic function. The cancer therapies associated with cardiotoxicity are reviewed in this report. Additionally, the authors evaluate the role of present-day echocardiographic parameters, complementary noninvasive imaging modalities, and biomarkers in the prediction of cardiotoxicity. The authors address the evolving role of cardioprotective agents and potential therapies to prevent or reverse the progression of LV systolic dysfunction. Finally, they provide some ideas regarding future directions to enhance the knowledge of predicting late-onset LV systolic dysfunction secondary to cancer therapy.

Apical hypertrophic cardiomyopathy: Present status

Since the first description of apical hypertrophic cardiomyopathy in Japan 40years ago, contrasting information from all over the world has emerged regarding the natural history of the disease. This review provides an overview of incidence, phenotypic expressions, clinical features, prognosis, and management of this heterogeneous clinical entity, which may play a more relevant role in the burden of sudden cardiac death than previously thought.

Interplay between arterial stiffness and diastolic function: a marker of ventricular-vascular coupling.

Aims We evaluated the interplay between left ventricular diastolic function and large-artery stiffness in asymptomatic patients at increased risk of heart failure and no structural heart disease (Stage A). Methods We divided 127 consecutive patients (mean age 49 ± 17 years) with risk factors for heart failure who were referred to our laboratory to rule out structural heart disease into two groups according to presence (Group 1, n = 35) or absence (Group 2, n = 92) of grade I left ventricular diastolic dysfunction. Doppler imaging with high-resolution echo-tracking software was used to measure intima-media thickness (IMT) and stiffness of carotid arteries. Results Group 1 had significantly higher mean age, blood pressure, left ventricular mass index, carotid IMT and arterial stiffness than Group 2 (P < 0.05). Overall, carotid stiffness indices (&bgr;-stiffness index, augmentation index and elastic modulus) and ‘one-point’ pulse wave velocity each showed inverse correlation with E-wave velocity, E′ velocity and E/A ratio, and direct correlation with A-wave velocity, E-wave deceleration time and E/E′ ratio (P < 0.05). Arterial compliance showed negative correlations with the echocardiographic indices of left ventricular diastolic function (P < 0.05). On logistic regression analysis, age, hypertension, SBP, pulse pressure, left ventricular mass index, carotid IMT and stiffness parameters were associated with grade I left ventricular diastolic dysfunction (P < 0.05 for each). However, on multivariate logistic analysis, only ‘one-point’ pulse wave velocity and age were independent predictors (P = 0.038 and P = 0.016, respectively). Conclusion An independent association between grade I left ventricular diastolic dysfunction and increased arterial stiffness is demonstrated at the earliest stage of heart failure. Hence, assessment of vascular function, beyond cardiac function, should be included in a comprehensive clinical evaluation of these patients.

Accessory mitral valve tissue: an updated review of the literature

Accessory mitral valve tissue (AMVT) is a rare congenital cardiac anomaly sometimes responsible for left ventricular outflow tract (LVOT) obstruction. It is diagnosed during both neonate-childhood and adult periods in patients usually symptomatic for dyspnoea, chest pain, palpitations, fatigue, or syncope. Nevertheless, AMVT is often an incidental finding. AMVT is most often associated with other cardiac and vascular congenital malformations, such as septal defects and transposition of the great arteries. Surgery is indicated only in cases of significant LVOT obstruction and in patients undergoing correction of other cardiac malformations or exploration of an intracardiac mass. Two-dimensional echocardiography, both transthoracic and transoesophageal, is considered the main imaging modality for AMVT diagnosis and patient follow-up. The recent introduction of three-dimensional echocardiography allows a more realistic characterization of this entity. We present three clinical cases in which AMVT was incidentally diagnosed during standard echocardiography and an updated review of the literature highlighting the usefulness of echocardiography for AMVT morphological and functional characterization as well as the most relevant clinical implications due to its discovery.

Longitudinal Strain by Automated Function Imaging Detects Single-Vessel Coronary Artery Disease in Patients Undergoing Dipyridamole Stress Echocardiography

BACKGROUND The aim of this study was to investigate the incremental value of global longitudinal strain (GLS) by automated function imaging in respect to wall motion (WM) for the detection of coronary artery disease (CAD) during dipyridamole stress echocardiography. METHODS Fifty-two patients (mean age, 65.3 ± 8.7 years; 22 men) underwent dipyridamole stress echocardiography followed by coronary angiography within 1 week. Diagnostic accuracy for the identification of single-vessel CAD was evaluated for WM and GLS. The study population was divided into two groups according to coronary angiographic findings: those with CAD (n = 38; mean age, 67.2 ± 5.9 years; 19 men) and those without CAD (n = 14; mean age, 63.3 ± 6.4 years; three men). RESULTS A trend toward lower resting GLS values was found in patients with CAD than in those without (-18.7 ± 2.2% vs -20 ± 2.8%, P = .061). In patients without CAD, GLS progressively increased up to peak dose (from -20 ± 2.8% at rest to -20.7 ± 1.9% at low dose, P = .045; from -20.7 ± 1.9% at low dose to -21.5 ± 3.1% at peak dose, P = .032), whereas in patients with CAD, an increase of GLS from rest to low dose (from -18.7 ± 2.2% to -19.2 ± 3.9%, P = .046) followed by a decrease from low to peak dose (from -19.2 ± 3.9% to -17.5 ± 2.4%, P = .007) was observed. In addition, with regard to diagnostic accuracy in detecting CAD, WM yielded sensitivity of 44%, specificity of 55%, positive predictive value of 73%, and negative predictive value of 26%, whereas GLS, alternatively evaluated as the difference between peak dose and resting values or between peak and low-dose values, provided sensitivity of 61%, specificity of 90%, positive predictive value of 94%, and negative predictive value of 47% (respectively, P = .020, P = .001, P = .023, and P = .031, all vs WM) and sensitivity of 84%, specificity of 92%, positive predictive value of 96%, and negative predictive value of 68% (respectively, P < .001, P < .001, P = .001, P < .001, all vs WM). CONCLUSIONS GLS analysis, particularly performed by comparing peak-dose with low-dose values, improves the accuracy of dipyridamole stress echocardiography in the detection of single-vessel CAD compared with the sole assessment of WM changes.

New diagnostic perspectives on heart failure with preserved ejection fraction: systolic function beyond ejection fraction

Although preserved ejection fraction is found in more than 50% of patients with heart failure, its acceptance as a specific clinical entity is limited. More understanding of the physiopathology, early diagnosis and medical management is needed. With no existing systematic information in the literature, the aim of this review is to provide a comprehensive overview of the new imaging techniques for diagnosing heart failure with preserved ejection fraction, particularly in the early stages of the disease, underlying the pivotal role of new technologies such as two-dimensional speckle tracking echocardiography and vascular stiffness.

PFO: Button me up, but wait … Comprehensive evaluation of the patient

Patent foramen ovale (PFO) is a slit or tunnel-like communication in the atrial septum occurring in approximately 25% of the population. A wide number of pathological conditions have been linked to its presence, most notably, cryptogenic stroke (CS) and migraine. However, in the setting of a neurological event, it is not often clear whether the PFO is pathogenically related to the index event or an incidental finding. Therefore, a detailed analysis of several clues is needed for understanding PFOs clinical significance, with a frequent case-by-case decision about destination therapy. Indeed, the controversy about PFOs pathogenicity prompted a paradigm shift of research interest from medical therapy with antiplatelets or anticoagulants to percutaneous transcatheter closure, in secondary prevention. Observational data and meta-analysis of observational studies had previously suggested that PFO closure with a device was a safe procedure with a low recurrence rate of stroke. To date, however, recent randomized controlled trials have not shown the superiority of PFO closure over medical therapy. Thus, the optimal strategy for secondary prevention of paradoxical embolism in patients with a PFO remains unclear. Moreover, the latest guidelines for the prevention on stroke restricted indications for PFO closure to patients with deep vein thrombosis and high-risk of its recurrence. Given these recent data, in the present review, we critically discuss current treatment options, pointing out the role of a comprehensive patient evaluation in overcoming PFO closure restrictions and planning the best management for each patient.