Roberto Favilli

Usefulness of Left Ventricular Diastolic Dysfunction Assessed by Pulsed Tissue Doppler Imaging as a Predictor of Atrial Fibrillation Recurrence After Successful Electrical Cardioversion

The impact of left ventricular (LV) diastolic dysfunction on risk of atrial fibrillation (AF) recurrence is still unknown. The aim of this study was to assess the role of LV diastolic dysfunction in predicting AF recurrence after successful electrical cardioversion in patients with nonvalvular AF. In 51 patients with a first episode of nonvalvular AF undergoing successful electrical cardioversion, tissue Doppler echocardiography was performed to measure peak early diastolic mitral annulus velocity (E(m)) and the ratio of mitral inflow to mitral annulus velocity at end-diastole (E/E(m)). Clinical end points were recurrent persistent AF at 2-week follow-up (early AF recurrence [ERAF]) and at 1-year follow-up (including ERAF and late AF recurrence). Seventeen patients showed evidence of ERAF, whereas late AF recurrence occurred in another 5 patients. In time-independent analysis E/E(m) (odds ratio [OR] 1.746, p = 0.0084) and indexed LV end-systolic volume (OR 1.083, p = 0.040) were independent predictors of ERAF. Based on a logistic model risk of ERAF was 25% for an E/E(m) of 5.6 but increased to 50% for an E/E(m) of 8.1 and to 75% for an E/E(m) of 10.5. In time-dependent analysis E/E(m) emerged as the only predictor of ERAF (OR 1.757, p = 0.0078). E/E(m) also independently predicted risk of recurrence at 1 year in time-independent (OR 1.757, p = 0.0078) and time-dependent (OR 1.319, p = 0.0003) analyses. In conclusion LV diastolic dysfunction independently predicts AF recurrence in patients with nonvalvular AF undergoing successful electrical cardioversion.

Profiling cardiac resynchronization therapy patients: responders, non-responders and those who cannot respond—The good, the bad and the ugly?

Cardiac resynchronization therapy (CRT) is an effective option for the management of heart failure (HF) patients with left ventricular systolic dysfunction and prolongation of the QRS interval. Unfortunately, a variable proportion of eligible patients fail to benefit from this treatment, the so-called “non-responders”. Despite intensive investigations aimed at identifying reliable diagnostic tools, additional to standard criteria, for the selection of responders, partly due to the complexity and multi-factorial nature of the mechanism underlying response, no conclusive evidence is currently available about which of the many variables assessed may predict individual response and should be included in selection criteria. Accordingly, even if labeled as a non-responder, a patient should receive a CRT device being the certain risk of withholding the treatment more consistent than the potential risk of being a non-responder. However, a possible third profile of patients along with responders and non-responders is emerging consisting of a limited subset of individuals, mainly among those with HF of ischemic aetiology, who simply do not possess the anatomical requisite for conventional biventricular pacing to be effective. Such patients may be referred to as those who cannot respond to CRT and their identification is potentially feasible by integrating non-invasive imaging findings and of clinical relevance in the definition of the therapeutic strategy. In conclusion, this review will provide an analysis of gathered data about the selection of candidates to CRT beyond responders and non-responders with the perspective of the potential characterization of patients who cannot respond to CRT.

Effects of ω-3 PUFAs Supplementation on Myocardial Function and Oxidative Stress Markers in Typical Rett Syndrome

Rett syndrome (RTT) is a devastating neurodevelopmental disorder with a 300-fold increased risk rate for sudden cardiac death. A subclinical myocardial biventricular dysfunction has been recently reported in RTT by our group and found to be associated with an enhanced oxidative stress (OS) status. Here, we tested the effects of the naturally occurring antioxidants ω-3 polyunsaturated fatty acids (ω-3 PUFAs) on echocardiographic parameters and systemic OS markers in a population of RTT patients with the typical clinical form. A total of 66 RTT girls were evaluated, half of whom being treated for 12 months with a dietary supplementation of ω-3 PUFAs at high dosage (docosahexaenoic acid ~71.9 ± 13.9 mg/kg b.w./day plus eicosapentaenoic acid ~115.5 ± 22.4 mg/kg b.w./day) versus the remaining half untreated population. Echocardiographic systolic longitudinal parameters of both ventricles, but not biventricular diastolic measures, improved following ω-3 PUFAs supplementation, with a parallel decrease in the OS markers levels. No significant changes in the examined echocardiographic parameters nor in the OS markers were detectable in the untreated RTT population. Our data indicate that ω-3 PUFAs are able to improve the biventricular myocardial systolic function in RTT and that this functional gain is partially mediated through a regulation of the redox balance.

Cardiogenic shock complicating myocardial infarction in a doped athlete

Abuse of doping agents may pose a higher risk for heart disease including acute myocardial infarction. We report the case of a 50-year-old body-builder Caucasian man with a long-standing abuse of nandrolone and erythropoietin that developed a ventricular septal defect following acute myocardial infarction. This mechanical complication led to cardiogenic shock ultimately treated with the implantation of a circulatory support by means of extracorporeal membrane oxygenation. The patient subsequently underwent orthotopic heart transplantation. The association of intense isometric exercise, abuse of erythropoietin and nandrolone is likely to have predisposed to coronary thrombus formation and acute myocardial infarction, as the patient presented no traditional cardiovascular risk factors.

Takotsubo cardiomyopathy in a Caucasian Italian woman: Case report

BackgroundTakotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levelsCase presentationA 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.ConclusionTakotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.

Recovery from cardiomyopathy after abstinence from cocaine

In August, 2005, a 31-year-old man presented to the emergency department of the Siena General Hospital with fatigue, dyspnoea, and chest pain. He had no previous medical history but admitted longstanding cocaine misuse. The patient’s blood pressure was 130/80 mm Hg, and his serum troponin I concentration was 3 μg/L; the urine toxicology screen was negative. Chest radiography indicated cardiomegaly and bilateral pulmonary congestion (fi gure, A). Transthoracic echocardio graphy showed left-ventricular dilatation, with an end-diastolic diameter of 80 mm; there was diff use hypokinesia and severe impairment of contractile function, the ejection fraction being as low as 20%. We found no evidence of alcohol misuse, thyrotoxicosis or a viral infection; in view of the patient’s history, we considered it likely that his dilated cardiomyopathy was caused by cocaine. There was no evidence of coronary artery disease: cardiac catheterisation indicated patent arteries; nor was there serological evidence of myocarditis. The patient was discharged on a regimen of carvedilol, ramipril, furosemide, potassium canrenoate, and warfarin. In the months following discharge, he received drug abuse counselling, and tested negative on a series of unscheduled urine toxicology screens. He was considered likely to be abstinent from cocaine. When last seen in September 2006, the patient was asymptomatic. His chest radiograph showed no cardiomegaly and no signs of pulmonary congestion (fi gure, B). On transthoracic echocardiography, the end-diastolic diameter of the left ventricle was found to be only 57 mm; the diff use hypokinesia was far less marked, and the ejection fraction had increased to 50%. In recent years, cocaine use has risen to epidemic proportions in the USA and Europe. The observation of cardiovascular complications associated with cocaine use has become progressively more frequent: a history of cocaine use should be considered when assessing previously healthy young patients with heart disease. Cocaine is well known to cause myocardial ischaemia and infarction. There is also evidence of an increased prevalence of left-ventricular systolic dysfunction in longterm users, which can be secondary to ischaemia or infarction. Another possible mechanism is the (inadvertent) administration of adulterants or infectious agents together with cocaine, leading to myocarditis; and cocaine may cause myocyte apoptosis, aff ect cytokine production, and change the structure of myocardial proteins by inducing gene transcription. Cocaine also causes microscopic changes similar to those observed in patients with phaeochromocytoma—which, like cocaine, causes sympathetic overstimulation and cardio myo pathy. Debate continues over whether, and how, cardiomyopathy caused by cocaine use can resolve on abstinence. We hypothesise that abstinence allows recovery from sympathetic overstimulation, rather like surgical removal of a phaeochromocytoma.

Dopaminergic stimulation of HGH in diabetes mellitus and in obesity.

SummaryThe behavior of HGH in basal conditions and after L-Dopa infusion was studied in a group of patients with diabetic retinopathy, in 9 obese and 8 control subjects. In both diabetics and obese subjects, increases found in HGH plasma levels after administration of the drug were slighter than in the controls. On the basis of these results it can be concluded that in diabetics the availability of energetic substrates may modify the HGH response to the L-Dopa stimulus. In obesity, the possibility is considered of a reversible defect in the sensitivity of the dopaminergic receptors, induced by metabolic and endocrine factors.

Neurohumoral improvement and torsional dynamics in patients with heart failure after treatment with levosimendan

Background Levosimendan improves clinical and hemodynamic parameters exerting an anti-inflammatory and antiapoptotic effect in decompensated heart failure. The aim of this study was to evaluate the effects of levosimendan on LV torsion, plasma levels of NT-proBNP and on the balance between pro-inflammatory (TNF-α, IL-6) and anti-inflammatory cytokines (IL-10). Methods We enrolled 24 patients (age 62 ± 7 years) with acute HF, NYHA class IV and severe LV dysfunction. All patients underwent transthoracic echocardiography using two-dimensional speckle tracking analysis to detect LV twist angle (LVTA), at baseline and 1 week after treatment with levosimendan infusion. Biochemical parameters (pro-BNP, IL-6, IL-10, TNF-α) were determined by enzyme-linked immunosorbent (ELISA). Results After one week, we observed an improvement in LV function especially in LVTA (4.15 ± 2.54 vs 2.9 ± 2.1 p < 0.01), in LV ejection fraction (27.3 ± 8.04 vs 21.6 ± 6.8 p = 0.03) and also a significant reduction in BNP levels (1844 ± 560 vs 4713 ± 1050, p = 0.03). The multiple linear regression analysis showed a significant relation between a reduction of TNF α/IL-10 ratio (Δ > 20%) and BNP (Δ > 40%), LVEF (Δ > 10%) and LVTA (Δ > 20%) (O.R. 1.77, 95% C.I. 1.11–2.83; O.R. 1.49, 95% C.I. 1.08–2.67; O.R. 1.66, 95% C.I. 1.10–2.74, respectively, confirmed p, all < 0.01 by Hosmer–Lemeshov confirmation and the formal test for interaction). Conclusions Levosimendan exerts a hemodynamic effect by improving EF and LV torsion in patients with acute HF in association with a positive effect on the balance between pro and anti-inflammatory cytokines.

Incessant ventricular tachycardia and concomitant recurrent left ventricular thrombus: to ablate or not to ablate?

We report the case of a 75-year-old man with ischaemic dilated cardiomyopathy complicated by a large apical aneurysm and previous left ventricular (LV) thrombosis presenting the first episode of sustained (>40 h at implantable cardioverter-defibrillator interrogation), haemodinamically tolerated, monomorphic ventricular tachycardia (VT) in September 2014 and a recurrence …

Acute and long-term efficacy and safety of sildenafil for the treatment of chronic thromboembolic pulmonary hypertension in a heart transplant recipient.

We report on the successful treatment with sildenafil of a unique case of severe chronic thromboembolic pulmonary hypertension which developed as a late complication in a 71-year-old heart transplant recipient, with focus on the potential therapeutic challenges encountered in the management of such a peculiar association of clinical conditions.