bluuebunny/crossref_metadata_2025 huggingface dataset:
557 His bundle pacing: how to troubleshoot the implantation of a ventricular back-up lead
Authors: Piemontese Giuseppe Pio , Bartoli Lorenzo , Statuto Giovanni , Angeletti Andrea , Massaro Giulia , Martignani Cristian , Ziacchi Matteo , Biffi Mauro
Published: December 2021

Aims

Interest in permanent His bundle pacing (HBP) as a means of both preventing pacing-induced cardiomyopathy and providing physiological resynchronization by normalization of His-Purkinje activation is constantly growing. Current devices are not specifically designed for HBP, which gives rise to programming challenges. To evaluate the critical troubleshooting HBP options in patients with permanent atrial fibrillation (AF) and variable degree of atrio-ventricular block (AVB) who receive HBP through a lead connected to the atrial port, and an additional ventricular ‘backup’.

Methods and results

Between December 2018 and July 2021, 156 consecutive patients with indication for pacing underwent HBP. Among these, 37 had permanent AF with documented symptomatic pauses. Fourteen of them received a dual-chamber device which was used to place a backup right ventricle (RV) lead; in this scenario, the His lead is implanted in the right atrial (RA) port, the RV lead in the RV port. Depending on the presence of an additional left ventricle (LV) lead, either a dual-chamber and a CRT device can be used. In this context, the events marked as atrial sensed (As) or paced (Ap) are indeed ventricular, so that sensing is more complex. A clinical scenario is atrial activity oversensed on the His channel (As) leading to RV dyssynchronous pacing in the ventricular safety pacing (VSP) window. A second one is intrinsic QRS undersensing causing inappropriate His pacing. The interplay of intrinsic ventricular activity (rate, signal amplitude, and slew rate on both the His and the ventricular channel) and of the HV interval may be of key importance to troubleshoot As–Vp (atrial sensed–ventricular paced) (Figure 1A) as well as Vs–Ab (ventricular sensed–atrial blanking period) sequences (Figure 1B). Changing sensitivity and sensing configuration may help to fix these issues. DVI(R) mode programming may indeed prove safer than DDD(R) in the setting of preserved intrinsic activity or in the event of intermittent His capture loss. Paced AV delay should be programmed slightly longer than H-V+QRS duration to avoid unnecessary RV pacing with pseudo-fusion (too short) (Figure 2A) and possibly R/T events (too long). Stability of H-V interval and of QRS duration must be verified at each device follow-up by decremental His pacing to ensure consistent sensitivity of the ventricular signal beyond stable His capture, that may be challenged by infra-Hisian block (Figure 2B).

Conclusions

Owing to the absence of HBP-specific devices, HBP shall be made safe and effective by careful troubleshooting, consisting of sensitivity setting, paced AV interval and mode programming.

557 Figure
543 Paroxysmal atrial fibrillation in a young athlete: the importance of knowing the electrophysiological mechanism
Authors: Robles Antonio Gianluca , Petrungaro Mattia , Penco Maria , Romano Silvio , Sciarra Luigi
Published: December 2021

Aims

Atrial fibrillation (AF) is the most commonly sustained cardiac arrhythmia encountered in clinical practice. The prevalence of arrhythmia increases with age. However, paroxysmal AF can also arise in young or middle-aged individuals or otherwise healthy athletes. Electrical isolation of the pulmonary veins is the approach recommended by the guidelines for the ablative treatment of patients with symptomatic AF, although the risks associated with the procedure are not yet negligible. However, in order to increase the risk/benefit ratio of any ablation, it may be important to better define the electrophysiological mechanism underlying the arrhythmia. This could help plan a safer and more effective therapeutic approach, especially in young patients and/or patients with a structurally healthy heart and a prolonged history of paroxysmal AF.

Methods and results

We report the case of a 19-year-old basketball player who is strongly symptomatic for palpitations due to AF episodes. The electrophysiological study revealed the true mechanism underlying AF episodes: degeneration into AF of an atrial tachycardia (AT) originating from the right atrium lateral wall. Once the ectopic focus of AT had been ablated, the patient remained totally asymptomatic at the 4-year follow-up.

Conclusions

This case underlines the importance of the concept that young subjects with ‘lone AF’, in the absence of structural heart disease, may have different mechanisms underlying the arrhythmic phenomenon. In our case, the electrophysiological study enabled us to reconstruct the electrogenic mechanism at the base of the arrhythmia, allowing us to carry out a safe and effective therapy.
471 Arrhythmia-free survival in early-persistent atrial fibrillation patients undergoing radiofrequency catheter ablation
Authors: Magnocavallo Michele , Rocca Domenico Giovanni Della , Lavalle Carlo , Chimenti Cristina , Carola Gianni , Mohanty Sanghamitra , Trivedi Chintan , Bassiouny Mohamed , Al-Ahmad Amin , Burkhardt David J , Gallinghouse Joseph G , Sanchez Javier E , Horton Rodney P. , Natale Andrea
Published: December 2021

Aims

Despite advances in success rate of paroxysmal atrial fibrillation (PAF) ablation, outcomes of radiofrequency catheter ablation (RFCA) in patients with persistent AF are highly variable. Early persistent AF (EPsAF) is defined as AF that is sustained beyond 7 days but is less than 3 months in duration. Arrhythmia-free survival data after RFCA in this specific population are still limited. We sought to report the outcomes of RFCA in the subgroup of patients with EPsAF, compared to those with PAF and with ‘late’ persistent AF (LPsAF) lasting between 3 and 12 months.

Methods and results

Data from 1143 consecutive AF patients receiving their first RFCA were prospectively collected. Patients with EPsAF (n = 190) were compared with PAF (n = 531) and LPsAF (n = 422) patients. All patients received pulmonary vein antrum isolation + posterior wall and sustained non-pulmonary vein (PV) trigger ablation. Non-sustained non-PV triggers were ablated based on operator discretion. Non-PV triggers were defined as sites of firing leading to sustained (>30 s) or non-sustained arrhythmias (<30 s, including premature atrial contractions ≥10 beats/min) with earliest activation outside the PVs. Mean age of the population was 64 ± 11 years. Female patients were more in PAF group (39%) compared to EPsAF (26%) and LPsAF (28%) (P < 0.001). There was no difference in other clinical characteristics among populations. Non-PV triggers were detected more in EPsAF [127 (66.8%)], and LPsAF [296 (70.1%)] patients compared to PAF [185 (34.8%)] (P < 0.001).One-year arrhythmia-free survival rate after a single procedure was 75.0% (398), 74.2% (141), and 64.5% (272) in PAF, EPsAF, and LPsAF, respectively. Success rate was significantly higher in PAF {[HR: 0.67 (0.53, 0.84), P = 0.001] and EPsAF [HR: 0.67 (0.49, 0.93)], P = 0.015} compared to LPsAF.

Conclusions

In patients with EPsAF, RFCA may result in significantly better freedom from atrial arrhythmias, compared to LPsAF. In this cohort, ablation might be reasonable as first line approach to improve outcomes and prevent AF progression.
684 Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry
Authors: Vitolo Marrco , Malavasi Vincenzo Livio , Proietti Marco , Diemberger Igor , Fauchier Laurent , Marin Francisco , Nabauer Michael , Potpara Tatjana , Dan Gheorghe-Andrei , Kalarus Zbigniew , Tavazzi Luigi , Maggioni Aldo Pietro , Lane Deirdre A. , Lip Gregory Y.H. , Boriani Giuseppe
Published: December 2021

Aims

Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear. To assess the factors associated with cTn testing in routine clinical practice and to evaluate the association of elevated levels of cTn with adverse outcomes in a large contemporary cohort of European AF patients.

Methods and results

Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into three groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), and (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism/any acute coronary syndrome (ACS)/cardiovascular (CV) death, defined as major adverse cardiovascular events (MACE) and all-cause death were the main endpoints. 10 445 (94.1%) AF patients were included in this analysis [median age 71 years, interquartile range (IQR): 63–77; males 59.7%]. cTn were tested in 2834 (27.1%). Overall, cTn was elevated in 904 (8.7%) and in-range in 1930 (18.5%) patients. Patients in whom cTn was tested tended to be younger (P < 0.001) and more frequently presenting with first detected AF and atypical AF-related symptoms (i.e. chest pain, dyspnoea, or syncope) (P < 0.001). On multivariable logistic regression analysis, female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease (CAD), and atypical AF symptoms were independently associated with cTn testing. After a median follow-up of 730 days (IQR: 692–749), 957 (9.7%) composite endpoints occurred while all-cause death was 9.5%. Kaplan–Meier analysis showed a higher cumulative risk for both outcomes in patients with elevated cTn levels (Figure) (Log Rank tests, P < 0.001). On adjusted Cox regression analysis, elevated levels of cTn were independently associated with a higher risk for MACE [hazard ratio (HR): 1.74, 95% confidence interval (CI): 1.40–2.16] and all-cause death (HR 1.45, 95% CI: 1.21–1.74). Elevated levels of cTn were independently associated with a higher occurrence of MACE, all-cause death, any ACS, CV death and hospital readmission even after the exclusion of patients with history of CAD, diagnosis of ACS at discharge, those who underwent coronary revascularization during the admission and/or who were treated with oral anticoagulants plus antiplatelet therapy.

Conclusions

Elevated cTn levels were independently associated with an increased risk of all-cause mortality and adverse CV events, even after exclusion of CAD patients. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.
300 PCSK9 induces a prothrombotic response by activation of NFKB signalling pathway in mononuclear cells
Authors: Scalise Valentina , Sanguinetti Chiara , Neri Tommaso , Celi Alessandro , Pedrinelli Roberto
Published: December 2021

Aims

Strong evidence both experimental and clinical studies point out to an involvement of proprotein convertase subtilisin/kexin 9 (PCSK9), as an important player in hypercholesterolemia and atherosclerosis pathophysiology, identifying it, as a key molecule in the development of new cholesterol-lowering drugs and therapeutic target for atherosclerosis and related diseases. Emerging evidence shown that PCSK9 is straight implicated in inflammatory process where it may directly influence the activity of various cell types through NFkB activation, a key transcription factor involved in the induction of both pro-inflammatory cytokines and Tissue Factor (TF) expression, a major regulator of haemostasis and thrombosis in monocytes. Deductive reasoning makes therefore plausible to investigate a mechanistic link between circulation PCSK9 levels and TF expression, both in monocytes as well as on the surface of microparticles (MPs) generated from the same cells, with NFkB acting as the chain in the link. To investigate the involvement of NFkB signalling pathway in PCSK9-induced TF expression.

Methods

THP-1 cell line were stimulated with human (h) PCSK9 (5 μg/mL) or pre-incubated with BAY-117082 (BAY, 10−5M) an NFκB inhibitor, CLI-095 (3 × 10−6M), a highly TLR-4 signalling specific inhibitor and LPS-RS(5 μg/mL) a TLR-4 antagonist. TF procoagulant activity (PCA) was assessed by one-stage clotting assay using a STart Max semi-automated coagulation analyser. Concentration of TF-bearing MPs was determined using the Zymuphen MP-activity kit.

Results

hPCSK9 stimulated TF activity in THP-1 (PCA: from 50 ± 20 to 120 ± 20 ρg/mL, n = 10, P < 0.01). BAY, an NFkB inhibitor (PCA: −71 ± 23%, n = 5, P < 0.01) and CLI-095, a TLR-4 signalling inhibitor, (PCA: −86 ± 26%, n = 3, P < 0.05) and LPS-RS (PCA: −71 ± 23%, n = 5, P < 0.01) down-regulated PCSK9-induced TF activity completely. Furthermore THP-1stimulation with hPCSK9 causes the release of prothrombotic MPs-TF+ (MPs release from: 0.13 ± 0.07 to 0.42 ± 0.1 nM PS, n = 7, P < 0.05; PCA-MP+ from: 14 ± 3 to 44 ± 28 ρg/mL, n = 5, P < 0.05).

Conclusions

These data confirm the pivotal role of monocytes in the response PCSK9-induced TF-expression as well as the involvement of PCSK9 in inflammatory-thrombotic diseases through a direct stimulation of TF procoagulant activity and by the release of TF-bearing MPs. The possible mechanism of action involves recognition of PCSK9 by TLRs 2 and/or 4, on monocytes membrane surface, leading to activation of the transcription factor NFκB via an intracellular signalling cascade. Further studies will be needed to better understand the regulatory mechanisms underlying this complex set of biological responses that bind PCSK9, and coagulation events.
506 Role of inflammation and comorbidities in the association between heart failure and incident cancer in the HUNT3 cohort
Authors: Bertero Edoardo , Carmisciano Luca , Jonasson Christian , Maack Christoph , Ameri Pietro
Published: December 2021

Aims

Conflicting data exist regarding the risk of cancer in patients with heart failure (HF). It was first reported that incident cancer is more common among patients with than without HF, whereas more recent studies indicate that this association is primarily driven by comorbidities. HF, cancer, and comorbidities, such as chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD), share numerous risk factors, including a state of chronic low-grade inflammation reflected by elevated circulating levels of pro-inflammatory cytokines. The objective of this analysis was to assess whether chronic low-grade inflammation, as measured by levels of high-sensitivity C-reactive protein (hsCRP), and comorbidities mediate the association of HF with incident cancer.

Methods

We used data from the 3rd wave of the Nord-Trøndelag Health Study (HUNT3), a population-based study that enrolled 50 803 individuals ≥18-year-old between October 2006 and June 2008 in the Nord-Trøndelag County (Norway), and from the administrative health care records of the same region. Associations between baseline characteristics and the development of cancer were assessed using Cox proportional hazards regression models, using time from HUNT3 enrolment as the time scale. Analyses were performed using R statistical software, version 4.0.2.

Results

In HUNT3, hsCRP was measured in 47 571 individuals at the time of enrolment. Of these, we excluded 2308 patients because of missing information, leaving a cohort of 45 263 subjects. The prevalence of cardiovascular disease, comorbidities, and obesity was progressively higher with increasing concentrations of hsCRP. During a median follow-up of 12 years, there were 66/408 cases of incident cancer in patients with HF at baseline and 5024/47 163 in subjects without HF, with a more than 2-fold (HR 2.30; 95% CI 1.80–2.93; P < 0.001) increase in risk of developing cancer. After adjusting for age and sex, the excess risk decreased to 43% (HR 1.43; 95% CI 1.12–1.82). When including hsCRP in the model, the HF-related risk of cancer was 33% (HR 1.33; 95% CI 1.04–1.70; P = 0.022). Furthermore, when body mass index, CKD, COPD, and smoking and drinking habits were included in the model, the risk of cancer in HF patients compared to individuals without HF was no longer significant (HR 1.23; 95% CI 0.94–1.60; P = 0.127). Age, male sex, hsCRP, COPD, obesity, and smoking habits were all associated with an increased risk of cancer.

Conclusions

The increased risk of cancer in HF patients compared with the general population is at least in part explained by concomitant inflammation and comorbidities.
152 Effects of nutraceuticals on the control of the lipid-glycaemic structure and on endothelial protection, in patients with low cardiovascular risk profile
Authors: Cersosimo Angelica , Amore Ludovica , Cimino Giuliana , Gavazzoni Mara , Vizzardi Enrico , Raddino Riccardo
Published: December 2021

Aims

Nutraceuticals are dietary supplements that contain a concentrated form of a presumed bioactive substance originally derived from a food. There is a relationship between the consumption of monacolin K from red yeast rice and maintenance of normal blood low density lipoprotein cholesterol (LDL-C) concentrations recognized by the European Agency on Food Safety. The present study evaluates the effects of a therapeutical association of nutraceuticals (a combination of containing fermented red rice, named Monacolin K and Coenzyme Q10) on lipo-glycaemic profile and on the vascular function evaluated as endothelial function and arterial stiffness (using the non-invasive methods of EndoPAT and SphygmoCOR).

Methods

The present is a single-centre prospective study enrolling 30 patients with low cardiovascular risk profile (SCORE risk, cardiovascular disease risk <10% at 10 years). Patients were consecutive enrolled from March 2019 to February 2020 (recruitment period). The average follow-up was 14 weeks, from intaking monacolin K 10 mg + Coenzyme Q10 10 mg. The scheduled evaluations of the enrolled population were: before the beginning of the therapy and after a period of 14 weeks.

Results

After 14 weeks of treatment we demonstrated a statistically significant reduction in total cholesterol (P 0.015) and LDL (P 0.003). An important effect on the inflammatory profile was highlighted, resulting in a decrease in Hs-CRP at 12-weeks (P 0.052), associated with a progressive reduction of arterial stiffness (P 0.063) and an improvement in endothelial function (P 0.048).

Conclusions

Data obtained suggest that formulations with natural nutraceuticals, especially fermented red rice, have a protective cardiovascular effect, not also through reduction of plasma lipids but in endothelial function and arterial stiffness improvement.
767 Correlations between myocardial work parameters and pulse wave velocity
Authors: Parlavecchio Antonio , Caminiti Rodolfo , Vetta Giampaolo , Colarusso Luigi , Lofrumento Francesca , Pelaggi Giuseppe , Cusma Maurizio , Zito Concetta , Micari Antonio , Di Bella Gianluca , Carerj Scipione
Published: December 2021

Aims

The myocardial work (MW) is a new echocardiographic method, based on the pressure–strain loop, which allows to quantify the cardiac performance. On the other hand, the pulse wave velocity (PWV) evaluates arterial stiffness, knowing that as the stiffness of an artery increases, the transmission velocity of the anterograde and the retrograde sphygmic wave increase. The aim of the study is to evaluate the correlation between MW and PWV parameters.

Methods and results

We enrolled 32 healthy patients (mean age: 39 ± 17 years), who underwent transthoracic Doppler echocardiography (TTE). The MW parameters was derived from the strain–pressure loop, including in its calculation the measurement non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. The PWV measurement was obtained by tonometry at the level of the common carotid artery and the common femoral artery. None of the parameters measured was pathological according to the normality studies considered. It was found a linear correlation between PWV and global wasted work (GWW) (linear R2: 0.603; P = 0.001) and an inverse linear correlation between PWC and global work efficiency (GWE) (linear R2: −0.307; P = 0.032).

Conclusions

The study highlights the possibility of PWV to predict pre-clinical myocardial changes, given the correlation with GWW and the linear inverse correlation with GWE.
384 Morpho-functional analysis of subvalvular apparatus in mitral valve prolapse and response to dipyridamole stress echocardiography. A pilot study
Authors: Diana Giovanni , Filice Monica , Manfredonia Laura , Ravenna Emanuele , Graziani Francesca , Lombardo Antonella , Palma Federica , Lanza Gaetano Antonio , Massetti Massimo , Crea Filippo , Locorotondo Gabriella
Published: December 2021

Aims

Myocardial fibrosis has been found in papillary muscles (PM) and basal segment of left ventricular (LV) inferior-lateral wall in patients with mitral valve prolapse (MVP), which may be due to stretch from valve. Moreover, ST-segment depression is common in patients with MVP, despite low prevalence of epicardial coronary artery disease, and it is attributed to microvascular dysfunction or myocardial stretch. Longitudinal strain (LS) correlates with myocardial fibrosis, while dipyridamole stress echocardiography (DSE) identifies microvascular dysfunction. We aimed at assessing morphology and function of PM and left ventricular walls at rest and during DSE by LS, and at determining prevalence of microvascular dysfunction in patients with MVP.

Methods and results

Seven consecutive patients with MVP (age 55.4 ± 15.7 years, 57% female) and LV ejection fraction 64 ± 5% underwent DSE. Length and LS of PM were measured at rest and retrospectively compared with those of patients with ischaemic heart disease (n = 8, age 67.1 ± 10.1 years, 37% female) and healthy controls (n = 8, age 39.6 ± 13.3 years, 50% female). LS of PM and LV was also determined at rest and during stress in MVP. Length of PM did not differ among groups, but in MVP, posterior PM was longer than the anterior PM (24 ± 3.8 vs. 20.6 ± 3.6 mm, P = 0.028). Significant difference in resting PM LS was found among groups (overall P = 0.04), with PM LS value in MVP (16.7 ± 7.1%) intermediate between ischaemic (14.2 ± 3.2%) and controls (20.5 ± 2.7%). No difference was found between rest and stress LS of PM in MVP. Global LS tended to increase in MVP during DSE compared to rest (23.1 ± 3.8% vs. 21.1 ± 2.6%, respectively, P = 0.07), while no significant difference between rest and stress LS was found in every LV myocardial segments. Nevertheless, in MVP, LS of LV inferior-lateral wall tended to improve under DSE in patients with mild regurgitation (19.7 ± 4.6 vs. 14.2 ± 5 at rest), but to decrease (16 ± 6.1 vs. 20.3 ± 2.3 at rest) in patients with severe mitral regurgitation (P = 0.006 for interaction). ST-segment depression was elicited by DSE in 29% of MVP. No significant difference in echocardiographic parameters was found between patients with and without ST-segment depression.

Conclusions

In MVP, sub-valvular apparatus may have peculiar morpho-functional features. DSE does not alter LS of PM, neither of LV walls, except for inferior-lateral wall, which impairs in severe mitral regurgitation. Prevalence of microvascular dysfunction is comparable to that of the general population.
396 Echocardiography and magnetic resonance for differential diagnosis of left ventricular hypertrofy: diagnostic and prognostic implications
Authors: Licordari Roberto , Grigoratos Chrysanthos , Todiere Giancarlo , Barison Andrea , Di Bella Gianluca , Aquaro Giovanni Donato
Published: December 2021

Aims

Left ventricular hypertrophy (LVH) may be due to different causes, ranging from benign secondary forms to severe cardiomyopathies. Transthoracic Echocardiography (TTE) and ECG are the first level examination for LVH diagnosis. Cardiac magnetic resonance (CMR) defines accurately LVH type, extent and severity. To evaluate the diagnostic and prognostic role of CMR in patients with TTE and/or ECG evidence of LVH.

Methods and results

We performed CMR in 300 consecutive patients with echocardiographic and/or ECG signs of LVH. Overall, 275 patients had TTE evidence of LVH with initial suspicion of hypertrophic cardiomyopathy (HCM) in 132 (44%), cardiac amyloidosis in 41 (14%), hypertensive LVH in 48 (16%), aortic stenosis in 4 (1%), undetermined LVH in 50(16%). The initial echocardiographic diagnostic suspicion of LVH was confirmed in 172 patients (57.3%) and changed in 128 patients (42.7%, P < 0.0001): the diagnosis of HCM increased from 44% to 71% of patients; hypertensive and undetermined LVH decreased significantly (respectively, to 4% and 5%). CMR allowed a diagnosis in 41 out of 50 (82%) with undetermined LVH at TTE. CMR also identified HCM in 17 out of 25 patients with apparently normal echo but with ECG criteria for LVH. Finally, the reclassification of the diagnosis by CMR was associated with a change of survival risk of patients: after CMR reclassification no events occurred in patients with undetermined or hypertensive LVH.

Conclusions

CMR changed echocardiographic suspicion in almost half of patients with LVH. In the subgroup of patient with abnormal ECG, CMR identified LVH (particularly HCM) in 80% of patients. This study highlights the indication of CMR to better characterize the type, extent, and severity of LVH detected at echocardiography and suspected with ECG.
366 The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and function measured by cardiovascular magnetic resonance
Authors: Menè Roberto , Tondi Lara , Badano Luigi , Torlasco Camilla , Florescu Diana Ruxandra , Volpato Valentina , Parati Gianfranco , Giannattasio Cristina , Lombardi Massimo , Muraru Denisa
Published: December 2021

Aims

The use of apical views focused on the left atrium (LA) has improved the accuracy of LA volume evaluation by two-dimensional echocardiography. However, routine cardiac magnetic resonance (CMR) evaluation of LA volumes still uses standard 2- and 4-chamber cine images focused on the left ventricle. To investigate the potential of LA-focused CMR cine images, we compared LA maximal (LAVmax) and minimal (LAVmin) volumes, and emptying fraction (LA-EF) calculated on both standard and LA-focused long-axis cine images with LA volumes obtained by short-axis cine stacks covering the LA.

Methods and results

LA volumes and LA-EF were obtained from 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. Compared to the reference method, the standard approach significantly underestimated LA volumes (LAVmax: bias −13 ml; LOA = +11 ml, −37 ml; LAVmin; bias −10 ml, LOA: +9 ml, −28ml), and overestimated LA-EF (bias= 5%, LOA: +23%, −14%). Conversely, LA volumes (LAVmax bias −0.03 ml; LOA: +10 ml, −10 ml. LAVmin bias = −1.5 ml; LOA: +7 ml, −10 ml), and LA-EF (bias 2%, LOA: +11%, −7%) by LA-focused cine images were similar to those measured using the reference method. Moreover, LA volumes by LA-focused images were obtained faster than using the reference method (1.2 vs. 4.5 min, P < 0.001).

Conclusions

LA volumes and LA-EF measured using dedicated LA-focused long-axis cine imaging are more accurate than using standard (LV-focused) cine images.
94 Combined use of voltage mapping and speckle tracking echocardiography for the early diagnosis of ARVC/D: a case report
Authors: Sisti Nicolò , Santoro Amato , Baiocchi Claudia , Biancofiore Antonio , Pistoresi Simone , D’Ascenzi Flavio , Mandoli Giulia Elena , Cameli Matteo
Published: December 2021

A 38 years-old man was admitted to our hospital after ventricular tachycardia with left-bundle-branch block and inferior axis morphology. After undergoing different examinations the criteria for the diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) were met. An electrophysiological study was then performed together with endocardial bipolar and unipolar voltage map. Unipolar and bipolar voltage mapping of the right ventricle showed low voltage areas and corresponding fragmented potentials from the tricuspid annulus to the inferior apex. On the right ventricular outer tract (RVOT), the bipolar voltage mapping was normal while the unipolar mapping showed low-voltage areas in the antero-septal outer tract. An off-line map was used to perform speckle tracking analysis on intracardiac echocardiography (ICE) clips of right ventricle and standard echocardiography. A reduction of the strain analysis was stored in correspondence of the fragmented electrograms area, in particular, speckle tracking analysis on ICE views showed a reduction of the RV LS in the segments below tricuspid valve, in the three different myocardial layers. The endocardial longitudinal strain was reduced from sub-tricuspidalic segments to the RV apex in accordance with the fragmentated potentials stored during voltage mapping. On the contrary, at anterior RVOT wall, the unipolar voltage mapping showed fragmented potentials and the STE analysis revealed a reduced epicardial LS. This case report lays emphasis on the importance of the integration of ICE-derived right ventricular strain and voltage mapping in the improvement of the sensibility of an early diagnosis of the ARVC.
725 Assessment of myocardial work for the evaluation of patients undergoing transcatheter aortic valve implantation (TAVI)
Authors: Leo Isabella , Sabatino Jolanda , Strangio Antonio , Bella Sabrina La , Sorrentino Sabato , Polimeni Alberto , Spaccarotella Carmen , Mongiardo Annalisa , Procopio Concetta , Di Salvo Giovanni , De Rosa Salvatore , Indolfi Ciro
Published: December 2021

Aims

A growing number of patients is undergoing transcatheter treatment of severe Aortic Stenosis. Changes in cardiac mechanics after removal of afterload in these patients are under-investigated. Myocardial Work (MW) is emerging as a useful non-invasive correlate of invasively measured myocardial performance and oxygen consumption. Aim of this study was to assess the usefulness of non-invasive MW indices in the clinical assessment of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

Consecutive patients with severe aortic stenosis referred for TAVI in a single tertiary centre were included. Echocardiography recordings (GE-Healthcare) with systolic and diastolic non-invasive pressures, were obtained immediately before TAVI and after TAVI to measure myocardial work index (MWI), myocardial constructive work (MCW), myocardial wasted work (MWW), and myocardial work efficiency (MWE). Consecutive patients with severe AS (n = 73) undergoing TAVI and matched controls (n = 50) were included. Mean transaortic gradient, AV area, and peak transvalvular velocity were significantly improved (all P < 0.05). No changes in left ventricular ejection fraction nor in global longitudinal strain (GLS) were observed. GWI (P < 0.001) and GCW (P < 0.001) were significantly reduced after TAVI. On the contrary, we observed no significant change in GWW (P = 0.241) nor GWE (P = 0.854). Women had higher GWI (P = 0.007) and GCW (P = 0.014) compared to men, with a larger delta change of GCW. Patients with a low flow low gradient (LF-LG) AS had lower LVEF (P < 0.001), worse GLS (P < 0.001) and lower baseline GWI (P < 0.001), GCW (P < 0.001), and GWE (P = 0.003). The improvement in GWI and GCW observed after TAVI in the general study population were abolished among LF-LG patients.

Conclusions

The use of non-invasive myocardial work might be useful to further classify patients with AS and could be useful to predict non responders.
751 Quantitative changes in intracardiac vortices between patients with different ventricular geometry
Authors: Strangio Antonio , Sabatino Jolanda , Leo Isabella , Maglione Marco , Troilo Fabio , Loliva Giuseppe , Romano Letizia Rosa , Critelli Claudia , Di Salvo Giovanni , De Rosa Salvatore , Indolfi Ciro
Published: December 2021

Aims

Over the past decades growing evidence have demonstrated the promising role of intracardiac fluid-dynamics in evaluating cardiac performance. To investigate quantitative changes in vortices parameters in patients with different ventricular geometry.

Methods and results

We enrolled 50 consecutive patients with one of the following: LV concentric hypertrophy (CH), eccentric hypertrophy (EH), concentric remodelling, and normal LV geometry (CTRL). They underwent a complete echocardiographic examination with intracardiac fluid-dynamic analysis by Color Vector Flow Mapping (Hyperdoppler). The following parameters were obtained: vortex area (VA); vortex length (VL); and vortex depth (VD). Bland Altman Plot has been used to assess intra and inter-observer variability. Mean VD was higher in CR, CH, and EH compared to CTRL (P = 0.013, P = 0.001, and P = 0.022, respectively). Moreover, CH showed higher VL (P = 0.006) and larger VA (P = 0.012) compared to CTRL. A similar trend was noticed in EH patients, despite did not reach statistical significance (P = 0.21 and P = 0.07 for VA and VL, respectively). No significative differences in vortices parameters have been observed between CH and EH.

Conclusions

This is the first study providing quantitative echocardiographic parameters of vortex location and morphology in different LV geometries. Quantitative fluid-dynamic assessment was feasible and reliable in the whole population.
309 Upgrading from a dual-chamber pacemaker to a cardiac resynchronization therapy defibrillator in situs inversus totalis with dextrocardia following mitral valve replacement and tricuspid annuloplasty using a left-sided approach
Authors: Bacci Elodi , Santoro Amato , Sisti Nicolò , Baiocchi Claudia , Cameli Matteo
Published: December 2021

A 71-year-old female patient was referred to our centre to upgrade a dual-chamber pacemaker to a cardiac resynchronization therapy defibrillator (CRT-D) following the detection of worsened systolic function (ejection fraction: 25–30%) via transthoracic echocardiography. The patient had situs inversus totalis with dextrocardia. She had undergone mitral valve replacement and tricuspid annuloplasty in July 2019, with a concomitant left upper pulmonary lobectomy for neoplasm, detected at cardiac tomography incidentally. In January 2020, we performed an upgrade of the preexisting device to a CRT-D system because the patient developed heart failure, reduction in systolic function, and numerous nonsustained ventricular tachycardias. The right ventricular lead that had been previously implanted was extracted. To facilitate the intervention, we decided to flip the fluoroscopic image, obtained with a right-anterior oblique view, by 180 °C (right–left), creating the optical impression of a levocardial position.
121 Imaging of improved right ventricular function and risk status in pulmonary arterial hypertension
Authors: Miotti Cristiano , Badagliacca Roberto , Vizza Carmine Dario
Published: December 2021

Aims

Right ventricular function adaptation to afterload as assessed by the ratio of tricuspid annular plane excursion (TAPSE) to systolic pulmonary artery pressure (PASP) has been shown to be of prognostic relevance in pulmonary arterial hypertension (PAH). To test the hypothesis that improvement in TAPSE/PASP under targeted therapies is associated with the likelihood to achieve a better prognostic low-risk status in PAH.

Methods and results

The study retrospectively enrolled 677 PAH patients (55% idiopathic) with follow-up clinical, right heart catheterization, and echocardiographic evaluations within 12 months [interquartile range (IQR): 180–344 days] after initiation of targeted therapies from 2005 to 2017 in 11 Italian centres. European guidelines-derived and United States Registry to Evaluate Early and Long-Term PAH Disease Management registry REVEAL 2.0 risk scores were assessed at baseline and follow-up. The patients improved their functional class and 6-min walk distance, but a minority of them achieved or maintained the low risk status as assessed either with the European or the REVEAL 2.0 score (30% and 27%, respectively). The TAPSE/PASP ratio increased curvilinearly in proportion to decreased pulmonary vascular resistance (PVR) by more than 50%. Patients at low risk were, respectively, 4.93 and 3.37 times more likely to have TAPSE/PASP ≥0.35 mm/mmHg than those at intermediate or high risk, according to the ESC/ERS [odds ratio: (OR) 4.93, confidence interval (CI): 3.40–7.14; P = 0.0001] and the REVEAL 2.0 score (OR: 3.37, CI: 2.32–4.90; P = 0.0001).

Conclusions

Improvement of TAPSE/PASP under targeted therapies in PAH is associated with a low risk status, marked reduction in PVR, and improved outcome.
150 Incremental value of cardiopulmonary exercise testing in intermediate-risk pulmonary arterial hypertension
Authors: Badagliacca Roberto , Rischard Franz , Giudice Francesco Lo , Howard Luke , Papa Silvia , Valli Gabriele , Manzi Giovanna , Sciomer Susanna , Palange Paolo , Garcia Joe G. N , Vanderpool Rebecca , Rinaldo Rocco , Vigo Beatrice , Insel Michael , Fedele Francesco , Vizza Carmine Dario
Published: December 2021

Aims

Risk assessment in pulmonary arterial hypertension (PAH) is essential for prognostication. However, the majority of patients end-up in an intermediate risk status despite targeted-therapy, offering insufficient guidance in clinical practice. The added value of cardiopulmonary exercise testing (CPET) in this setting remains undefined.

Methods and results

Two independent cohorts with idiopathic PAH at intermediate risk were used to develop (n = 124) and externally validate (n = 143) the prognostic model. Risk assessment was based on the simplified version of the ESC/ERS guidelines score. The same definition of clinical worsening (CW) was used for both cohorts. Discrimination and calibration were assessed. Seventy-four derivation cohort patients experienced CW (51.2%) during a median of 34 months. Stroke volume index (SVI) and 6-min walk-distance (6MWD) were independent predictors of CW. With addition of CPET variables, SVI and VO2 peak independently improved the power of the prognostic model, determined by the integrated discrimination integral (IDI) index. ROC-derived cut-off values for SVI and VO2 peak were 34 and 14 ml/kg/min, respectively. Forty-eight validation cohort patients experienced CW (33.5%) during a median of 27 months follow-up. Different combinations of cut-off values of SVI and VO2 peak defined three meaningful groups showing good discrimination and calibration. The event-free survival rates at 1, 2, and 3 years were, respectively, 96%, 89%, and 89% for high SVI/high VO2 peak combination; 85%, 73%, and 61% for high SVI/low VO2 peak; and 80%, 70%, and 56% for low SVI/low VO2 peak.

Conclusions

Combinations of VO2 peak and SVI during follow-up is important in the prognostication of intermediate-risk prevalent patients with idiopathic PAH.
372 Machine learning and pulmonary hypertension
Authors: Soriente Lucia , Cerulo Luigi , Mercurio Giovanna , Iuliano Giuseppe , Mancini Francesco Paolo
Published: December 2021

Aims

Pulmonary hypertension (IP) characterized by an average resting pulmonary pressure ≥20 mmHg can sustain various clinical conditions that differ in physiopathological, haemodynamic, and therefore therapeutic aspects. The goal of our work was to apply a machine learning algorithm that could accurately distinguish pre- and post-heart pulmonary hypertension through non-invasive methods (medical history, clinical, and echocardiographic data).

Methods and results

In order to achieve our goal we used the ‘decision tree’ machine learning algorithm implemented in the C5.0 package of the R development environment. The first step was the preparation of the data. The dataset of patients with IP was composed of 85 patients divided into XX precapillary IP (1) and YY postcapillary (2). Each patient is described by 11 features: some comorbidities (arterial hypertension and atrial fibrillation), BMI, right axial deviation on ECG, DLCO, and some echocardiographic measurements (e/e′, right atrial area, S wave at TDI, acceleration time on the pulmonary, inferior vena cava, diameters of the right ventricle). The dataset was divided into a data.train training subset (45 patients) and an evaluation subset (40 patients), maintaining the proportion between classes. Starting from the training dataset, the C5.0 algorithm generated the decision tree shown in Figure 1. The root node was made up of the mitral pattern e/e′, followed by the right axis deviation on the ECG and the acceleration rate on the lung that the algorithm considered the best discriminated features. The model was then validated in the validation dataset and through the Caret package and the Confusion matrix function we calculated the performance metrics of the algorithm obtaining an accuracy of 0.87, a kappa statistic of 0.742, a sensitivity of 0.913, and a specificity of 0.823. The true positive rate was 0.87 while the true negative rate was 0.87. The performance of the model was also measured using the ROC curve, obtaining an area under the curve of 0.916.

Conclusions

Our results show that the ‘decision tree’ algorithm starting from echocardiographic data and the ECG has a good ability to discriminate between the precapillary and postcapillary IP. In particular, the decision chain consisting of: mitral pattern and / and ratio ≤8, right axial deviation on the ECG and acceleration time on the lung ≤80 ms seems to predict the IP class with reasonable accuracy. Our results confirm that the probability of prediction and the prediction itself depend, however, on what degree of purity the partitions learned during the decision tree construction process are made up. To improve the estimation of the algorithm’s performance and thus generalize the results obtained, we believe to evaluate this approach on larger datasets also considering different machine learning algorithms.

372 Figure
426 Percutaneous or surgical access for transfemoral transcatheter aortic valve implantation: a propensity matched analysis of a multicentre registry
Authors: Bruno Francesco , Crimi Gabriele , Ascenzo Fabrizio D’ , Marzo Vincenzo De , Scudeler Luca , Marco Federico De , Oreglia Jacopo , Testa Luca , Gorla Riccardo , Esposito Giuseppe , Spaccarotella Carmen , Soriano Francesco , Vercellino Matteo , Balbi Manrico , Morici Nuccia , Indolfi Ciro , Conrotto Federico , Bedogni Francesco , Porto Italo , Ferrari Gaetano Maria De
Published: December 2021

Aims

The transfemoral (TF) approach appeared to be the safest and the broadest used approach in TAVI, characterized by a lower rate of periprocedural bleedings and vascular complications and is currently recommended by the guidelines as a first line approach when feasible. If in the early experience TF access was achieved using a surgical cutdown approach, through the last years, there has been increasing evidence of the safety and efficacy of a fully percutaneous approach over a surgical access, albeit available evidences are controverting and mostly including first generation prostheses and high risk patients. The aim of the study is to compare percutaneous and surgical access in a large, real-word, multicentre of TF TAVI.

Methods and results

Consecutive patients undergoing successful TF TAVI were prospectively enrolled in local clinical registries of five high volume centres in Italy: IRCCS Ospedale Policlinico San Martino (Genoa), IRCCS Policlinico San Donato (Milan), Città Della Salute e della Scienza, (Turin), Ospedale Niguarda Ca’ Granda (Milan), Magna Graecia University, (Catanzaro), between January 2014 to December 2019. Univariate and multivariate analysis using IPTW were performed. A total of 1946 TF TAVI patients (female 42.8%) were prospectively included. Patients underwent surgical access had a significantly higher surgical risk (STS score of 8.9 vs. 6.4, P < 0.001, and EuroSCORE of 15.1 vs. 8.7, P < 0.001, respectively). Overall survival was comparable between the two groups (HR: 1.14, 95% CI: 0.76–1.71). Patients who underwent surgical access experienced more VARC-2 major and VARC-2 minor vascular complications (13% vs. 7%, P = 0.003 and 11% vs. 6.1%, P = 0.007, respectively) and more VARC-2 major/life threatening and minor bleeding (27.4% vs. 17.8, P = 0.001, and 9.6% vs. 2.1%, P < 0.001, respectively). After IPTW adjustment, surgical access was associated with an increased risk of major vascular complications (HR: 3.32, 95% CI: 1.84–5.97), minor bleeding (HR: 4.24, 95% CI: 1.16–15.54) and stage 2–3 AKI (HR: 2.60, 95% CI: 1.07–6.33).

Conclusions

The performance of the percutaneous transfemoral TAVI approach was safe and feasible and resulted in fewer major vascular complications, bleedings and AKI than the surgical femoral isolation. Procedural time and hospital length were also lower in the percutaneous group. Routine application of the percutaneous approach might reduce acute complications in patients undergoing transfemoral TAVI and reduce procedural time and hospital length.
700 The role of Impella CP in the management of malignant arrhythmias: a case of asymptomatic ventricular fibrillation
Authors: Caminiti Rodolfo , Colarusso Luigi , Parlavecchio Antonio , Vetta Giampaolo , Mancini Nastasia , Luzza Francesco , Micari Antonio , Bella Gianluca Di , Vizzari Giampiero , Crea Pasquale
Published: December 2021

Introduction

The Impella Heart Pump device (Abiomed, Danvers, MA, USA) is commonly used to provide mechanical circulatory support during high-risk percutaneous coronary intervention (PCI) and has demonstrated both efficacy and safety in patients with cardiogenic shock. Left ventricular assist devices (LVADs) alter the pathophysiological impact of ventricular arrhythmias in advanced heart failure; for example, life-threatening arrhythmias such as ventricular fibrillation (VF). We present a case of sustained VF tolerance in a patient with IMPELLA CP® support.

Methods and results

A 64-year-old man was admitted with typical chest pain that began 3 days earlier and an anterior myocardial infarction with ST-segment elevation. Urgent coronary angiogram showed a left anterior descending artery treated with angioplasty and stent implantation (TIMI 3). An initial echocardiogram, performed after PCI, showed a reduced left ventricular ejection fraction (LVEF) of approximately 35% with good right ventricular function. Two days later, the ECG tracing showed persistence of the ST elevation, and the patient developed recurrent ventricular tachycardia and an episode of acute pulmonary oedema; the echocardiogram showed a significant worsening of LVEF (15%). A percutaneous mechanical circulatory support device (Impella CP; Abiomed) was inserted through the right common femoral artery in order to preserve adequate systemic perfusion (Figure 1A). Twelve hours later, the patient developed rapid VT degenerating into VF without loss of consciousness (Figure 1C). During the arrhythmia, the patient was alert and his mental status was normal, Impella flow was 2.4–3.0 l/min, and invasive blood pressure (IBP) was 80/65 mmHg (Figure 1D). Intravenous lidocaine was administered without effect. After approximately 10 min of incessant VF, the patient received sedation with propofol from the anesthesiologist. A single unsynchronized DC shock of 200 J converted the patient to sinus rhythm. A bedside transthoracic echocardiogram was performed to check the optimal position of the Impella device (Figure 1B). In the following days, the patient had two new episodes of asymptomatic VF treated with DC-shock after sedation and was transferred to the cardiac surgery department to undergo urgent LVAD implantation.

Conclusions

Impella CP was helpful in the management of this patient with severe heart failure and malignant ventricular tachyarrhythmias, reducing the hemodynamic and neurological impact of this latter catastrophic arrhythmic event.