Roberta Manganaro

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.

Endothelial dysfunction in patients with coronary artery disease: insights from a flow-mediated dilation study.

Background: The use of flow-mediated dilation (FMD) as a surrogate indicator for the extent of coronary artery disease (CAD) remains largely unknown. We assessed FMD at the brachial artery in 89 consecutive patients undergoing coronary angiography. Methods and Results: Patients were classified in groups 0 to 3 according to the number of diseased vessels and the SYNTAX score was calculated. The FMD decreased significantly from groups 0 to 3 (P < .001). There was a significant linear relation between SYNTAX score and FMD (corrected r 2 = .64, P < .001). In multivariate analysis, a reduced FMD was the only significant independent predictor of the presence of CAD (odds ratio [OR] 1.78, P = .032) and of CAD severity (OR 1.85, P = .005). Conclusion: This study confirms that FMD is reduced in patients with CAD and that such reduction in FMD is related to the extent of the disease. Therefore, FMD at the brachial artery is likely to represent a reliable indicator of CAD burden.

Peripheral Artery Disease and Stroke

Peripheral artery disease (PAD) and stroke can occur as vascular complication of anticancer treatment. Interruption of vascular endothelial growth factor (VEGF) inhibitor signaling (i.e., bevacizumab) is associated with vascular toxicity and clinical sequelae such as hypertension, stroke, and thromboembolism beyond acute coronary syndromes. However, BCR-ABL tyrosinekinase inhibitors (TKIs), used for the treatment of chronic myeloid leukemia (CML), are the main antineoplastic drugs involved in the development of PAD. In particular, secondand thirdgeneration TKIs, such as nilotinib and ponatinib, while emerging as a potent arm in contrasting CML, are associated with a higher risk of PAD development rather than imatinib. Factors favoring vascular complication are the presence of traditional cardiovascular risk factors (CVRF) and predisposing genetic factors, high doses of BCR-ABL TKIs, longer time of drug exposure, and sequential use of potent TKIs. In addition, circulating concentrations of VEGF are reduced by cyclophosphamide administered at continuous low doses, which might underpin some of the observed vascular toxicity, as seen in patients treated with VEGFIs. This alkylating agent is therefore associated with vascular complications including stroke. The risk of stroke is also increased after treatment with anthracyclines that can induce endothelial dysfunction and increase arterial stiffness. Head and neck radiotherapy is associated with a doubled risk of cerebrovascular ischemic event, especially if exposure occurs in childhood. The mechanisms involved in radiation vasculopathy are represented by endothelial dysfunction, medial necrosis, fibrosis, and accelerated atherosclerosis. An accurate cardiovascular risk stratification is strongly recommended in patients candidate to anticancer treatment associated with higher risk of vascular complication, in order to correct CVRF and select appropriate patient tailored strategy of treatment. Then a clinical follow-up, eventually associated to instrumental evaluation through vascular ultrasound, should be performed.

Arterial stiffness and mitral regurgitation in arterial hypertension: An intriguing pathophysiological link

BACKGROUND We examined the relative impact of arterial stiffness on the presence and/or severity of chronic mitral regurgitation (MR) in hypertensive patients. METHODS We prospectively enrolled 141 untreated hypertensive patients (mean age 56.6 ± 11.5 years): 94 with MR, 47 without MR. As a measure of arterial stiffness, pulse wave velocity (PWV) was assessed by applanation tonometry. Assessment of MR severity was obtained through calculation of effective regurgitant orifice area (EROA) and vena contracta by standard two-dimensional transthoracic echocardiography. RESULTS PWV appears to progressively increase according to the presence and severity of MR (no MR = 7.3 ± 1.1 m/s, mild MR = 7.9 ± 1.3 m/s, moderate MR = 9.0 ± 1.7 m/s, severe MR = 13.3 ± 4.1 m/s; P < 0.001 for all comparisons). EROA was positively correlated with age (P = 0.011), left atrial volume index (P = 0.023), PWV (P < 0.001) and augmentation index (P < 0.001), and negatively correlated with left ventricular ejection fraction (P = 0.002) and heart rate (HR) (P = 0.018). On stepwise multivariate logistic regression analysis, only PWV (OR = 2.87, 95% CI 1.750-4.738, P < 0.001) and HR (OR = 0.94, 95% CI 0.895-0.994, P = 0.02) appeared to be independent predictors of severe MR. Receiver operating characteristic curves showed that a cutoff of 9 m/s for PWV provided the best sensitivity/specificity for predicting both the presence of any degree of MR (sensitivity 73%, specificity 87%, AUC = 0.863; P < 0.001) and MR severity (sensitivity 100%, specificity 81%, AUC = 0.954; P < 0.001). CONCLUSION Reduced arterial elasticity because of increased stiffness may be an important marker for the presence and severity of MR in hypertensive patients.

To promote endothelial function: The elusive link between physical therapy of venous thromboembolism and improved outcomes?

Article history: Received 12 February 2016 Accepted 19 March 2016 Available online 24 March 2016 ECS after deep vein thrombosis to prevent post-thrombotic syndrome (PTS) in a randomized placebo-controlled trial [12]. The main finding of this trial was that ECS did not prevent PTS after a first proximal deep venous thrombosis [12] and therefore routine wearing of ECS after deep vein thrombosis appeared not supported. The SOX Investigators should be congratulated for having conducted such a rigorous trial

Chronic ischemic mitral regurgitation and LV remodeling: new insights from a combined magnetic resonance and speckle tracking analysis

Published on behalf of the European Society of Cardiology. All rights reserved.