Rodolfo Citro

Echocardiography in Pulmonary Arterial Hypertension: from Diagnosis to Prognosis

Pulmonary arterial hypertension is most often diagnosed in its advanced stages because of the nonspecific nature of early symptoms and signs. Although clinical assessment is essential when evaluating patients with suspected pulmonary arterial hypertension, echocardiography is a key screening tool in the diagnostic algorithm. It provides an estimate of pulmonary artery pressure, either at rest or during exercise, and is useful in ruling out secondary causes of pulmonary hypertension. In addition, echocardiography is valuable in assessing prognosis and treatment options, monitoring the efficacy of specific therapeutic interventions, and detecting the preclinical stages of disease.

Comorbidities Frequency in Takotsubo Syndrome: An International Collaborative Systematic Review Including 1109 Patients

BACKGROUND To identify predisposing factors that can result in the onset of takotsubo syndrome, we performed an international, collaborative systematic review focusing on clinical characteristics and comorbidities of patients with takotsubo syndrome. METHODS We searched and reviewed cited references up to August 2013 to identify relevant studies. Corresponding authors of selected studies were contacted and asked to provide additional quantitative details. Data from each study were extracted by 2 independent reviewers. The cumulative prevalence of presenting features and comorbidities was assessed. Nineteen studies whose authors sent the requested information were included in the systematic review, with a total of 1109 patients (951 women; mean age, 59-76 years). Evaluation of risk factors showed that obesity was present in 17% of patients (range, 2%-48%), hypertension in 54% (range, 27%-83%), dyslipidemia in 32% (range, 7%-59%), diabetes in 17% (range, 4%-34%), and smoking in 22% (range, 6%-49%). Emotional stressors preceded takotsubo syndrome in 39% of patients and physical stressors in 35%. The most common comorbidities were psychological disorders (24%; range, 0-49%), pulmonary diseases (15%; range, 0-22%), and malignancies (10%; range, 4%-29%). Other common associated disorders were neurologic diseases (7%; range, 0-22%), chronic kidney disease (7%; range, 2%-27%), and thyroid diseases (6%; range, 0-37%). CONCLUSIONS Patients with takotsubo syndrome have a relevant prevalence of cardiovascular risk factors and associated comorbidities. Such of associations needs to be evaluated in further studies.

Chronobiological Patterns of Onset of Tako-Tsubo Cardiomyopathy: A Multicenter Italian Study

To the Editor: Several cardiovascular events, including acute myocardial infarction (AMI), show well-defined temporal patterns in their occurrence throughout the year and the day ([1,2][1]). Tako-Tsubo cardiomyopathy (TTC), also called “stress cardiomyopathy” or “transient left ventricular

Aortic root dimensions in elite athletes.

Although cardiac adaptation to different sports has been extensively described, the potential effect of top-level training on the aortic root dimension remains not investigated fully. To explore the full range of aortic root diameters in athletes, 615 elite athletes (370 endurance-trained athletes and 245 strength-trained athletes; 410 men; mean age 28.4 +/- 10.2 years, range 18 to 40) underwent transthoracic echocardiography. The end-diastolic aortic diameters were measured at 4 locations: (1) the aortic annulus, (2) the sinuses of Valsalva, (3) the sinotubular junction, and (4) the maximum diameter of the proximal ascending aorta. Ascending aorta dilation at the sinuses of Valsalva was defined as a diameter greater than the upper limit of the 95% confidence interval of the overall distribution. The left ventricular (LV) mass index and ejection fraction did not significantly differ between the 2 groups. However, the strength-trained athletes had an increased body surface area, sum of wall thickness (septum plus LV posterior wall), LV circumferential end-systolic stress, and relative wall thickness. In contrast, the left atrial volume index, LV stroke volume, and LV end-diastolic diameter were greater in the endurance-trained athletes. The aortic root diameter at all levels was significantly greater in the strength-trained athletes (p <0.05 for all comparisons). However, ascending aorta dilation was observed in only 6 male power athletes (1%). Mild aortic regurgitation was observed in 21 athletes (3.4%). On multivariate analyses, in the overall population of athletes, the body surface area (p <0.0001), type (p <0.001) and duration (p <0.01) of training, and LV circumferential end-systolic stress (p <0.01) were the only independent predictors of the aortic root diameter at all levels. In conclusion, the aortic root diameter was significantly greater in elite strength-trained athletes than in age- and gender-matched endurance athletes. However, significant ascending aorta dilation and aortic regurgitation proved to be uncommon.

Differences in Clinical Features and In‐Hospital Outcomes of Older Adults with Tako‐Tsubo Cardiomyopathy

To describe the clinical characteristics and in‐hospital outcomes of older adults with tako‐tsubo cardiomyopathy (TTC).

Identification of responders to cardiac resynchronization therapy by contractile reserve during stress echocardiography

The identification of responders to cardiac resynchronization therapy (CRT) remains a challenge. We assessed the role of dyssynchrony (DYS) and contractile reserve (CR) in identifying CRT responders.

Left ventricular myocardial velocities and deformation indexes in top-level athletes.

BACKGROUND The aim of this study was to define the range of left ventricular (LV) velocities and deformation indexes in highly trained athletes, analyzing potential differences induced by different long-term training protocols. METHODS Standard echocardiography, pulsed-wave tissue Doppler echocardiography, and two-dimensional strain echocardiography of the interventricular septum and lateral wall were performed in 370 endurance athletes and 280 power athletes. Using pulsed-wave tissue Doppler, the following parameters of myocardial function were assessed: systolic peak velocities (S(m)), early (E(m)) and late (A(m)) diastolic velocities, and the E(m)/A(m) ratio. By two-dimensional strain echocardiography, peaks of regional systolic strain and LV global longitudinal strain were calculated. RESULTS LV mass index and ejection fraction did not significantly differ between the two groups. However, power athletes showed an increased sum of wall thicknesses (P < .01) and relative wall thickness, while LV stroke volume and LV end-diastolic diameter (P < .001) were greater in endurance athletes. By pulsed-wave tissue Doppler analysis, E(m) and E(m)/A(m) at both the septal and lateral wall levels were higher in endurance athletes. By two-dimensional strain echocardiography, myocardial deformation indexes were comparable between the two groups. E(m)/A(m) ratios ≥ 1 were found in the overall population, while 90 % of athletes had an E(m) ≥ 16 cm/sec, S(m) ≥ 10 cm/sec, and global longitudinal strain ≤ -16%. Multivariate analyses evidenced independent positive association between Em peak velocity and LV end-diastolic volume (P < .001) and an independent correlation of global longitudinal strain with the sum of LV wall thicknesses (P < .005). CONCLUSIONS This study describes the full spectrum of systolic and diastolic myocardial velocities and deformation indexes in a large population of competitive athletes.

Revised clinical diagnostic criteria for Tako-tsubo syndrome: The Tako-tsubo Italian Network proposal

Tako-tsubo syndrome (TTS) or stress cardiomyopathy is a relatively new entity that manifests with a clinical scenariomimicking an acute myocardial infarction [1–6]. TTS accounts for ∼2% of all patients presenting with apparent symptoms of acute myocardial infarction [2]. The clinical characteristics are heterogeneous and the clinical spectrum of presentation somehow wide, a fact that has long proven researchers and physicians in their diagnostic competence. Current TTS diagnostic criteria have been initially proposed by the Mayo Clinic Investigators in 2004 [1], and only slightly modified in 2008 [7], despite the great amount in TTS literature provided in the last 10 years. Of note, TTS patients not correctly identified, but considered common acute coronary syndrome patients, may receive unjustified aggressive therapies resulting in increased complications and costs. Thus, accuracy is needed to differentiate TTC from acute myocardial infarction, because of the different therapeutic and prognostic implications [1–7]. For this purpose, the Tako-tsubo Italian Network (TIN) Investigators, in their multicentre registry including several hundreds of TTS patients, adopted modified TTS diagnostic criteria in order to better detect and treat patients with TTS. The TIN diagnostic criteria that could be considered modified and updated Mayo Clinic diagnostic criteria are summarized in Table 1. The main advantages and novelty of the TIN diagnostic criteria are the following:

Diffuse, marked, reversible impairment in coronary microcirculation in stress cardiomyopathy: A Doppler transthoracic echo study

The aim of the study was to assess coronary flow reserve (CFR) in tako-tsubo cardiomyopathy (TC). Methods and results. Thirty consecutive patients (5 males; age 68±12 years) meeting diagnostic criteria for TC were evaluated with transthoracic dipyridamole (0.84 mg/kg over 6 min) stress echo and pulsed Doppler CFR assessment on mid-distal left anterior descending (LAD) and posterior descending of right coronary artery (PD). Wall motion score index (WMSI) was evaluated at base-line and during stress. All patients were followed up clinically and—on day 1, day 7 (±2 days), and at 6 months—by repeat stress echo. Thirty gender- matched controls were also studied. CFR was obtained in all patients on LAD and in 25 on PD. All showed a transient apical ballooning in the acute phase (day 1 of admission), with progressive recovery of function at follow-up (WMSI, day 1 = 1.7±0.2; day 7 = 1.4±0.14; 6 months = 1.0±0.1; P<0.001 versus day 1 and versus day 7). When compared to controls (3.1±0.5), CFR on LAD was reduced on day 1 (1.8±0.24, P<0.001) (upon admission), and it showed early recovery in the subacute (pre-discharge) assessment on day 7. CFR values remained stable at 6-month follow-up (2.6±0.3). Conclusion. TC is characterized by a profound, diffuse coronary microcirculatory disturbance in the acute phase, with early reversal to near-normal values within a few days, paralleling the functional recovery in regional wall motion.

Takotsubo Cardiomyopathy: Overview

Takotsubo cardiomyopathy (TTC) is a unique acute syndrome characterized by transient left ventricular systolic dysfunction in the absence of significant coronary artery disease, occurring mostly in postmenopausal women after emotional and/or physical stress. Given the nonspecific symptoms and signs, a high clinical index of suspicion is necessary to detect the disease in different clinical settings and scenarios. Noninvasive multimodality imaging may be useful to distinguish this cardiomyopathy from other acute cardiac and thoracic diseases. Coronary angiography remains, however, mandatory to differentiate TTC from acute coronary syndromes. This article reviews the clinical features and management of TTC and some new insights.