Nicola Gaibazzi

Aortic valve sclerosis as a marker of coronary artery atherosclerosis; a multicenter study of a large population with a low prevalence of coronary artery disease

UNLABELLEDnThere are no studies analyzing the association between aortic valve sclerosis (AVS) and coronary artery disease (CAD) in a large and multicenter patient population with an overall low prevalence of CAD. We hypothesized that AVS could predict the presence and degree of CAD in patients with severe organic mitral regurgitation.nnnMETHODSnWe retrospectively analyzed consecutive patients with flail mitral leaflet who had coronary angiography for pre-surgical screening and not because suspect of CAD. End-points were considered: 1) any degree of CAD (stenosis>20%) and 2) obstructive CAD (stenosis>75% of at least one coronary artery). AVS was defined as focal areas of increased echogenicity and thickening of the leaflets. Traditional clinical risk factors were considered: age, male gender, hypertension (>140/90 mmHg or medical therapy), hypercholesterolemia (total cholesterol>200 mg/dl or statin), diabetes, family history of CAD and smoking habit.nnnRESULTSn675 patients (mean age: 64±12; 27% female) formed the study population. Among patients with AVS, 60% and 39% had any-CAD and ob-CAD respectively, on the opposite among patients without AVS 12% and 7% had any-CAD and ob-cad. After adjustment for clinical risk factors, AVS was associated with a 22.7 fold increased risk of any degree of CAD (95% CI 8.1 63.6 p<0.0001) and with a 21.8 fold increased risk of obstructive-CAD (95% CI 6.6 71.9; p<0.0001).nnnCONCLUSIONnIn a large and multicenter sample of patient with flail mitral leaflet, AVS was strongly associated with the presence and degree of CAD independently of clinical risk factors.

Anatomy of a wrong diagnosis: false Sinus Venosus Atrial Septal Defect

In contrast with transthoracic echocardiography, transesophageal echocardiography provides a sure way to make the diagnosis of sinus venosus atrial septal defect; on the other hand this abnormality is more complex than that seen with the secundum atrial septal defect, and inexperienced operators may fail to recognize properly the defect. In front of a high reported sensitivity using transesophageal echocardiography, specificity is difficult to assess, due to possible underreporting of diagnostic errors. We describe a false positive diagnosis of sinus venosus atrial septal defect, in the setting of enlarged right chambers of the heart because of pressure overload. Modified anatomy of the heart, together with the presence of a prominent linear structure(probably Eustachian Valve) and an incomplete examination in this case made image interpretation very prone to misinterpretation. In this anatomical setting transesophageal longitudinal bicaval view may be sub-optimal for examining the atrial septum, potentially showing false images that need to be known for correct image interpretation. Nonetheless, a scan plane taken more accurately at the superior level would have demonstrated/excluded the pathognomonic feature of sinus venosus atrial septal defect in the high atrial septum, between the fatty limbus and the inferior aspect of the right pulmonary artery; moreover TEE allows morphological information about the posterior structures of the heart that need to be investigated in detail for a complete diagnosis.

Obesity paradox in patients with aortic valve stenosis. Protective effect of body mass index independently of age, disease severity, treatment modality and non-cardiac comorbidities

An increased body mass index (BMI) is considered a risk factor forcardiovascular (CV) disease and mortality in the general population[1]. However, after the onset of established disease the associationbetween BMI and outcome is paradoxically inverted [2].Inpatientswith aortic stenosis (AS) contrasting results have been reported [3,4].A recent study denied the BMI paradox in AS, but the enrolledpopulation was asymptomatic and relatively young [4]. Notably, inother conditions this phenomenon has been described only in elderlypatients with more advanced disease stage [5]. We aimed to assessthe prognostic value of BMI in a large population of severe AS patientsand to verify its independency from cardiac and non-CV confoundingvariables.The study population consisted of in-hospital patients with severeAS (defined as aortic valve area [AVA] b 0.6 cm

Less than “straight” anginal symptoms

False positive results during provocative tests may be related to microvascular disease or mildly/diffusely atherosclerotic coronaries; other underappreciated conditions, such as coronary tortuosity, can reduce subendocardial perfusion pressure during stress. Panels A and B show two patientswith effort angina inwhich invasive coronary angiography (A) and multidetector-CT coronary angiography (B) respectively detected “normal” coronaries. Flash-replenishment perfusion imaging during contrast dipyridamole stress-echocardiography demonstrated perfusion defects in themyocardial segments related to the tortuous coronary arteries (Videos A, B). In panel C (Fig. 1) fluid dynamics offers an explanation for the presence of perfusion defects distal to a tortuous coronary artery: repetitive bends cause energy loss, resulting in perfusion pressure decay at the capillary level under stress conditions. In panel D colour-doppler still frames during stress (parasternal view), illustrates how coronary tortuosity can be directly imaged using contrast-echocardiography (Video D). We propose coronary tortuosity as a novel mechanism for myocardial perfusion defects in the absence of obstructive coronary artery disease. Panel C is reproducedwith the authors permission from Zegers ES, Meursing BT, Zegers EB, Oude Ophuis AJ. Coronary tortuosity: a long and winding road. Neth Heart J. 2007 May;15(5):191–5. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [1]. The following are the supplementary materials related to this article. Video A. Flash-replenishment sequence at peak stress during contrast-echocardiography showing apical and apical-lateral perfusion defect. Video B. Flash-replenishment sequence at peak stress during contrast-echocardiography showing apical perfusion defect. Video D. Colour-Doppler during stress (parasternal view), illustrating how coronary tortuosity can be directly imaged using contrastechocardiography. Supplementary materials related to this article can be found online at doi:10.1016/j.ijcard.2010.12.001.

Autonomic function in Takotsubo syndrome long after the acute phase

OBJECTIVESnAlthough it is well documented that an exaggerated sympathetic stimulation plays a role in the development of Takotsubo Syndrome (TS) during the acute phase, only few studies have focused on autonomic adaptations in stress-induced cardiomyopathy long after the acute phase. Aim of the study was to investigate whether an impairment of the autonomic function is still present long after a TS event. This was done by comparing the response to a maximal exercise test in TS patients after apparent recovery (>1-year after the acute event) with that obtained in healthy subjects and in post-myocardial infarction (post-MI) patients.nnnMETHODSnTo assess heart rate recovery (HRR) and chronotropic response (CR), 24 TS patients, 25 healthy subjects and 22 post-MI patients underwent maximal exercise test, after at least 3 days of β-blockers wash-out.nnnRESULTSnHRR in TS patients (19.2±9.7bpm) was lower than in healthy subjects (27.7±8.3, p=0.003), and similar to post-MI patients (19.3±8.4; p=0.99). A decreasing CR trend (p=0.06), higher in healthy subjects (72±13%) than in TS (65±22%) and post-MI (57±21%) patients, was also found.nnnCONCLUSIONnCompared to healthy subjects, TS patients showed a blunted parasympathetic reactivation after exercise, similar to that observed in post-MI patients, thereby suggesting that vagal control of heart rate after exercise is abnormal long after the acute presentation of TS.

Beta-blockers can improve survival in medically-treated patients with severe symptomatic aortic stenosis

a Department of Medicine, Section of Cardiology, University of Verona, Italy b Cardiology Division, Fondazione Salvatore Maugeri, IRCCS, Veruno, Italy c Division of Cardiology, University of Parma, Italy d Cardiology Department, Villa Bianca Hospital, Trento, Italy e Cardiology Service, CMSR Veneto Medica, Altavilla Vicentina, Italy f Department of Cardiology, Spedali Civili Hospital and University of Brescia, Italy g Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy

Prevalence and characterization of bystander coronary artery disease in Tako-tsubo cardiomyopathy using a multi-imaging approach.

Article history: Received 24 January 2016 Accepted 2 February 2016 Available online 4 February 2016 methods were previously published [6]. A high risk plaque was defined at least one of the following criteria: (i) a necrotic core with high attenuation value (attenuation value b30 HU), (ii) positive remodelling. CMR Data Acquisition and Image Analysis: All CMR studies were acquired using a 1.5 T MRI system (Philips Achieva, Philips Medical System, Best, The Netherlands), the LGE images were analyzed by

Prognostic value of new left atrial volume index severity partition cutoffs after cardiac rehabilitation program in patients undergoing cardiac surgery.

BackgroundPrevious studies showed that left atrial enlargement is an independent marker of adverse outcomes in both primary and secondary cardiovascular prevention. However, no data are available on long-term outcomes in patients undergoing valve surgery and/or coronary artery by-pass graft (CABG) surgery. Aim of the study was to evaluate long-term prognostic role of left atrial volume index (LAVi) after cardiac surgery, using the cutoff values recently proposed by the European Association of Cardiovascular Imaging and American Society of Echocardiography.MethodsWe created a retrospective registry of 1703 consecutive patients who underwent cardiovascular rehabilitation program after cardiac surgery, including CABG, valve surgery and valveu2009+u2009CABG surgery. LAVi was calculated as ratio of left atrium volume to body surface area, in ml/m2 at discharge; 563 patients with available LAVi data were included in the study.ResultsIn the whole population LAVi was 36u2009±u200914xa0ml/m2 (meanu2009±u2009SD) and the follow-up time was 5u2009±u20091.5xa0years. Increased LAVi (>34xa0ml/m2) predicted major adverse cardiovascular and cerebrovascular events (MACCEs) (HRu2009=u20092.1; CI95 %: 1.4–3.1; pu2009<u20090.001) and cardiovascular mortality (HRu2009=u20092.2; CI95 %: 1.0–4.5; pu2009=u20090.032). An increased LAVi remained MACCEs predictor after adjustement for age, gender, diabetes, atrial fibrillation at discharge, echocardiographic E/A ratio and left ventricular ejection fraction (HRu2009=u20091.8; CI95 %: 1.0–3.0; pu2009=u20090.036). When the study population was split according to increasing LAVi values, left atrium enlargement resulted a predictor of progressively worse adverse outcome.ConclusionsLAVi is a predictor of long-term adverse cardiovascular outcome after cardiac surgery, even after correction for main clinical and echocardiographic variables. The recently recommended LAVi severity cutoffs appear adequate to effectively stratify outcome in patients undergoing rehabilitation after cardiac surgery.

Anxiety disorders and stressful events in Takotsubo syndrome

BACKGROUNDnAnxiety disorders are more common in Takotsubo syndrome (TS) than in acute coronary syndrome patients. The aim of this study was to investigate whether pre-existing anxiety disorders predispose to TS triggered by exclusively emotional stressful events.nnnMETHODSnTriggering events were compared in 58 TS patients with and without pre-existing anxiety disorders; clinical, electrocardiographic and echocardiographic data were also collected.nnnRESULTSnThirty-one (53%) patients had a previous history of anxiety disorders. The exclusively emotional stressful event-rate was higher in TS patients with pre-existing anxiety disorder (74% vs. 30%, p = 0.001), while TS caused by an undetermined trigger were significantly higher in patients without anxiety disorders (33% vs. 10%, p = 0.027). Moreover, in TS patients without a previous history of anxiety disorders, a trend of higher prevalence of physical events was found (16% vs. 37%, p = 0.07).nnnCONCLUSIONSnIn patients with pre-existing anxiety disorders, TS was predominantly triggered by exclusively emotional stressful events, thereby suggesting a possible relationship between anxiety and emotional cardiac frailty in TS patients.

Contrast-echocardiography for the differential diagnosis of atrial masses.

A 64-year-old man with chronic liver disease presented with dyspnoea, and a chest contrast computed tomography (CT) was performed to evaluate the suspect of pulmonary embolism ( Panel A ).nnA mass occupying the right atrium, of the same density of the myocardium at …