Simone Frea

Meta-Analysis of the Usefulness of Mitraclip in Patients With Functional Mitral Regurgitation

Midterm outcomes for patients presenting with heart failure and functional mitral regurgitation (MR) treated with Mitraclip remain unclear. Pubmed, Medline, and Google Scholar were systematically searched for studies enrolling patients with severe-moderate MR who underwent Mitraclip implantation. All events after at least 6 months were the primary safety end point (including death, rehospitalization for heart failure, and reinterventions), whereas change in the ejection fraction, left ventricular volumes, arterial pulmonary pressure, and left atrial diameters were considered as secondary end points. Meta-regression analysis was performed to evaluate the effect of baseline clinical and echocardiographic parameters on efficacy outcomes: 875 patients were included in 9 studies; 1.48 clips (1.3 to 1.7) for patients were implanted, and after a median follow-up of 9 months (6 to 12), 409 patients (78% [75% to 83%]) were in class New York Heart Association I/II and 57 (11% [8% to 14%]) still had moderate-to-severe MR. Overall adverse events occurred in 137 (26% [20% to 31%]) of the patients and 78 (15% [1% to 17%]) of them died; 6-minute walk test improved by 100 m (83 to 111), whereas a significant reduction in left ventricular volumes and systolic pulmonary pressure was reported. At meta-regression analysis, an increase in left ventricle systolic volumes positively affected reduction of volumes after Mitraclip, whereas atrial fibrillation reduced the positive effect of the valve implantation on ejection fraction on end-diastolic and -systolic volumes. In conclusion, Mitraclip represents an efficacious strategy for patients with heart failure and severe MR. It offers a significant improvement in functional class and in cardiac remodeling, in patients with severely dilated hearts as well, although its efficacy remains limited in the presence of atrial fibrillation.

Role of TGF-β1 haplotypes in the occurrence of myocardial infarction in young Italian patients

BackgroundTransforming growth factor beta 1 (TGF-β1) gene play an important role in the acute myocardial infarction (AMI), however no investigation has been conducted so far in young AMI patients.In this study, we evaluated the influence of TGF-β1 polymorphisms/haplotypes on the onset and progression of AMI in young Italian population.Methods201 cases and 201 controls were genotyped for three TGF-β1 polymorphisms (G-800A, C-509T and Leu10Pro). The main follow-up end-points (mean follow-up, 107 ± 49 months) were death, myocardial infarction or revascularization procedures.ResultsSignificant risk factors were smoking (p < 10-4), family history for coronary artery disease (p < 10-4), hypercholesterolemia (p = 0.001) and hypertension (p = 0.002). The C-509T and Leu10Pro polymorphisms showed significant differences (p = 0.026 and p = 0.004) between cases and controls.The most common haplotypes revealed a possible protective effect (GCT, OR 0.75, 95% CI 0.57–0.99, p = 0.042) and an increased risk of AMI (GTC, OR 1.51, 95% CI 1.13–2.02, p = 0.005), respectively.No statistical differences were observed in genotype distribution in the follow-up study between the two groups: 61 patients with subsequent events (13 deaths) and 108 without events.ConclusionEven though our results need to be further confirmed in larger studies, this is the first study reporting on a possible role of TGFβ1 common haplotypes in the onset of AMI in young patients.

Prognostic incremental role of right ventricular function in acute decompensation of advanced chronic heart failure

The purpose of this study was to evaluate the additional prognostic value of echocardiography in acute decompensation of advanced chronic heart failure (CHF), focusing on right ventricular (RV) dysfunction and its interaction with loading conditions. Few data are available on the prognostic role of echocardiography in acute HF and on the significance of pulmonary hypertension in patients with severe RV failure.

Renin-angiotensin-aldosterone system polymorphisms: a role or a hole in occurrence and long-term prognosis of acute myocardial infarction at young age

BackgroundThe renin-angiotensin-aldosterone system (RAAS) is involved in the cardiovascular homeostasis as shown by previous studies reporting a positive association between specific RAAS genotypes and an increased risk of myocardial infarction. Anyhow the prognostic role in a long-term follow-up has not been yet investigated.Aim of the study was to evaluate the influence of the most studied RAAS genetic Single Nucleotide Polymorphisms (SNPs) on the occurrence and the long-term prognosis of acute myocardial infarction (AMI) at young age in an Italian population.MethodsThe study population consisted of 201 patients and 201 controls, matched for age and sex (mean age 40 ± 4 years; 90.5% males). The most frequent conventional risk factors were smoke (p < 0.001), family history for coronary artery diseases (p < 0.001), hypercholesterolemia (p = 0.001) and hypertension (p = 0.002). The tested genetic polymorphisms were angiotensin converting enzyme insertion/deletion (ACE I/D), angiotensin II type 1 receptor (AGTR1) A1166C and aldosterone synthase (CYP11B2) C-344T. Considering a long-term follow-up (9 ± 4 years) we compared genetic polymorphisms of patients with and without events (cardiac death, myocardial infarction, revascularization procedures).ResultsWe found a borderline significant association of occurrence of AMI with the ACE D/I polymorphism (DD genotype, 42% in cases vs 31% in controls; p = 0.056). DD genotype remained statistically involved in the incidence of AMI also after adjustment for clinical confounders.On the other hand, during the 9-year follow-up (65 events, including 13 deaths) we found a role concerning the AGTR1: the AC heterozygous resulted more represented in the event group (p = 0.016) even if not independent from clinical confounders. Anyhow the Kaplan-Meier event free curves seem to confirm the unfavourable role of this polymorphism.ConclusionPolymorphisms in RAAS genes can be important in the onset of a first AMI in young patients (ACE, CYP11B2 polymorphisms), but not in the disease progression after a long follow-up period. Larger collaborative studies are needed to confirm these results.

New echocardiographic insights in short QT syndrome: More than a channelopathy?

BACKGROUND Short QT syndrome (SQTS) is a congenital ion channel disease characterized by an increased risk of sudden cardiac death. Little is known about the possibility that accelerated repolarization alters mechanical function in SQTS. OBJECTIVES The study investigated the presence of left ventricular dysfunction and mechanical dispersion, assessed by tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE), and their correlation with QT interval duration and genetics. METHODS Fifteen SQTS patients (7 with HERG and 3 with KCNQ1 mutation) were studied. Electrocardiographic and echocardiographic parameters were compared with age- and sex-matched healthy controls. RESULTS When compared to the control group, SQTS patients showed reduced left ventricular contraction (global longitudinal strain: -16.0% ± 3.4% vs -22.6% ± 1.7%, P < .001; myocardial performance index 0.59 ± 0.17 vs 0.34 ± 0.08, P < .001) and a higher incidence of ejection fraction <55% (odds ratio 11, 95% confidence interval 1.045-374, P = .04). Mechanical dispersion assessed by TDI (P < .01) and STE (P < .001) was higher in the SQTS group than in controls; each parameter showed a significant inverse correlation with QT interval but not with QT dispersion. CONCLUSION This study showed that in SQTS systolic function may also be affected. SQTS patients presented a significant dispersion of myocardial contraction. TDI and STE could become part of the evaluation of this rare disease.

Berberine behind the thriller of marked symptomatic bradycardia

Patients with chronic aortic dissections are at high risk of catheter-induced complications. We report a Berberine is used in traditional Chinese medicine for the treatment of congestive heart failure, hypertension, diabetes, and dyslipidaemia and has a good safety profile. We report a case of a 53-year-old sportsman referred to our hospital for the onset of fatigue and dyspnoea upon exertion after he started berberine to treat hypercholesterolaemia. An electrocardiogram showed sinus bradycardia (45 bpm), first-degree atrioventricular block, and competitive junctional rhythm. An ergometric stress test showed slightly reduced chronotropic competence and the presence of runs of competitive junctional rhythm, atrial tachycardia, and sinus pauses in the recovery. After 10 d of wash-out from berberine, the patient experienced a complete resolution of symptoms, and an ergometric stress test showed good chronotropic competence. An electrocardiogram Holter showed a latent hypervagotonic state. This is the first case report that shows that berberine could present certain side effects in hypervagotonic people, even in the absence of a situation that could cause drug accumulation. Therefore, berberines use should be carefully weighed in hypervagotonic people due to the drugs bradycardic and antiarrhythmic properties, which could became proarrhythmic, exposing patients to potential health risks.

Fatal pulmonary embolism: when the cause is not a thrombus.

Study Design. We report a case of pulmonary embolism of polymethylmethacrylate material after percutaneous vertebroplasty. Objective. To describe a severe vertebroplasty complication, the pulmonary embolism, which proved to be fatal in a patient with many chronic disabilities. Summary of Background Data. Until 2007, the literature noted that the risk of embolism of polymethylmethacrylate after a percutaneous vertebroplasty counted a small number of pulmonary cement embolism and a smaller number of fatal consequences. The most recent research revealed that the risk of a pulmonary cement embolism ranges from 3.5% to 23% for osteoporotic compression fractures. Methods. This study is a case report of an 80-year-old patient with multiple medical comorbid factors, chronic obstructive pulmonary disease, mild renal failure, osteoporosis, and hepatic cirrhosis. Symptoms of pulmonary embolism developed 1 month after a percutaneous vertebroplasty. An echocardiography report suggested that the cement infiltrated the right atrium and the right pulmonary artery, and this was confirmed by a computed tomographic scan. As the therapy with oxygen and low-molecular-weight heparin failed to solve the thrombus, the patient required a surgical tricuspid annuloplasty and the extirpation of the right atrial and right pulmonary masses. Results. The course of the operation was complicated by pulmonary infection, and the patient ultimately succumbed to infection/respiratory failure. Conclusion. The presence of intravascular/intracardiac foreign bodies is underreported in literature, but it is quite common in clinical practice. We need to discuss the choice of some non–risk-free interventions such as vertebroplasty in older patients already affected by multiple main disabilities.

Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: an observational study.

Background The insertion of a temporary pacemaker can be a lifesaving procedure in the emergency setting. Objectives This is an observational monocentric study comparing echocardiography-guided temporary pacemaker via the right internal jugular vein to standard fluoroscopy-guided temporary pacemaker via the femoral vein; the procedure was tested for noninferiority. Methods Patients needing urgent pacing were consecutively enrolled. Primary efficacy endpoints were time to pacing and need for catheter replacement. Primary safety endpoint was a composite outcome of overall complications. Results One hundred and six patients (77 ± 10 years) were enrolled: 53 underwent echocardiographic-guided and 53 fluoroscopy-guided temporary pacemaker. Baseline characteristics of the two groups of treatment were similar. Time to pacing was shorter in the echocardiography-guided than in the fluoroscopy-guided group (439 ± 179 vs. 716 ± 235 s; P < 0.0001; power 100%). During the pacing (54 ± 35 h), there was a higher incidence of pacemaker malfunction in the fluoroscopy-guided group [15 vs. 3 patients; odds ratio (OR) 6.5, confidence interval (CI) 95% 1.9–29.7, P < 0.001; power 85.7%] and there was a significantly lower incidence of complications in the echocardiography-guided temporary pacemaker group (6 vs. 22 patients; OR 0.18, CI 95% 0.06–0.49, P < 0.001; echocardiography-guided temporary pacemaker events rate 0.1929 vs. fluoroscopy-guided temporary pacemaker events rate 1.398 per 100 person-hours paced, P < 0.0001). In the standard group there was one death attributable to a temporary pacemaker complication (sepsis). Conclusion Echocardiography-guided temporary pacemaker is a well-tolerated procedure that could allow reliable insertion of a temporary pacemaker; therefore, it is a well-tolerated option in an emergency setting and in hospitals where fluoroscopy is not available.

Left atrial appendage thrombi relate to easily accessible clinical parameters in patients undergoing atrial fibrillation transcatheter ablation: A multicenter study

BACKGROUND Transesophageal echocardiography (TEE) is routinely performed before atrial fibrillation (AF) transcatheter ablation to exclude the presence of left atrial (LA) or LA appendage (LAA) thrombi. The aim of the study is to evaluate if easily accessible clinical parameters may relate to the presence of LA or LAA thrombi to identify patients who could potentially avoid TEE. METHODS AND RESULTS Between January 2012 and September 2014, data from 1539 consecutive patients undergoing TEE, as a work-up before AF transcatheter ablation, in six large volume centers were collected. Baseline clinical features, CHA2DS2-VASc score, transthoracic echocardiography and presence of thrombi at TEE were recorded. Exclusion criteria were valvular, hypertrophic or dilated cardiomyopathy, previous heart surgery or an ejection fraction ≤35%. Mean age was 59.6±10.4years, 1215 (78.9%) were males; 951 (62.9%) presented in sinus rhythm (SR) on admission, 324 (21.1%) had undergone at least one previous ablation and 900 (58.5%) had CHA2DS2-VASc score 0-1. Thrombi were encountered in 12 patients (0.8%). SR at TEE independently related to the absence of thrombi (OR 5.15, 95% CI 1.38-19.02, p=0.015); in addition to this, no patient with a CHA2DS2-VASc score 0-1 and SR on admission presented thrombi at TEE (specificity 100%, p=0.011). CONCLUSION In a selected population of patients referred for AF ablation, LA/LAA thrombi prevalence is low. No patients in SR with CHA2DS2-VASc score 0-1 presented LAA thrombi at TEE, identifying a significant subset of patients who could potentially safely be spared from pre-procedural TEE.

Clinical and prognostic role of ammonia in advanced decompensated heart failure. The cardio-abdominal syndrome?

BACKGROUND Advanced heart failure is associated with end-organ damage. Recent literature suggested an intriguing crosstalk between failing heart, abdomen and kidneys. Venous ammonia, as a by-product of the gut, could be a marker of abdominal injury in heart failure patients. The aim of the study was to investigate the clinical and prognostic role of ammonia in patients with advanced decompensated heart failure (ADHF). METHODS & RESULTS 90 patients admitted with ADHF were prospectively studied. The prognostic role of ammonia at admission was evaluated. Primary end-points were: a composite of cardiac death, urgent heart transplantation and mechanical circulatory support at 3 months and need for renal replacement therapies (RRT). In the study cohort (age 59.0 ± 12.0 years, FE 21.6 ± 9.0%, INTERMACS profile 3.7 ± 0.9, creatinine 1.71 ± 0.95 mg/dl) 27 patients (30%) underwent the cardiac composite endpoint, while 9 patients (10%) needed RRT. At ROC curve analysis ammonia ≥ 130 μg/dl (abdominal damage) showed the best diagnostic accuracy. At multivariate analysis abdominal damage predicted the cardiac composite endpoint. Abdominal damage further increased risk among patient with cold profile at admission (HR 2.7, 95% CI 1.1-7.0, p = 0.046). At multivariate analysis abdominal damage also predicted need for RRT (OR 10.8, 95% CI 1.5-75.8, p = 0.017). The combined use of estimated right atrial pressure and ammonia showed the highest diagnostic accuracy and a very high specificity in prediction of need for RRT. CONCLUSION In a selected population admitted for ADHF ammonia, as a marker of abdominal derangement, predicted adverse cardiac events and need for RRT.