Real-Time High-Frame-Rate Cardiac B-Mode and Tissue Doppler Imaging Based on Multiline Transmission and Multiline Acquisition.

Cardiovascular diseases, the leading cause of death in the world, are often associated with the dysfunction of the left ventricle. Even if, in clinical practice, the myocardial function is often assessed through visual wall motion scoring on B-mode images, quantitative techniques have been introduced, e.g., ultrasound tissue Doppler imaging (TDI). However, this technique suffers from the limited frame rate of currently available imaging techniques that needs to be balanced with the field of view. High-frame-rate (HFR) cardiac imaging has been recently tested off-line by simultaneously transmitting multiple focused beams into different directions and acquiring raw channel data into a PC. Several image lines were then reconstructed from the echoes of each transmission (TX) event. The same approach has been used to increase the TDI frame rate without restricting the field of view. This paper demonstrates the real-time feasibility of multiline TX and acquisition methods for both HFR cardiac B-mode and TDI. These approaches have been implemented on the ULA-OP 256 research scanner, by taking care that the related resources were optimally exploited for these new applications. The obtainable performance in terms of image quality and frame rate has also been investigated. Experiments performed with a 128-element phased array probe show, for the first time, that real-time B-mode imaging is feasible at up to 1150 Hz without significant reduction in image quality or field of view. The implementation of a real-time TDI algorithm allowed obtaining TDI images with a frame rate of 288 Hz for a 90°-wide field of view. Finally, in vivo examples demonstrate the feasibility and the suitability of the method in clinical studies.

The Difficult Evolution of Intensive Cardiac Care Units: An Overview of the BLITZ-3 Registry and Other Italian Surveys.

Coronary care units, initially developed to treat acute myocardial infarction, have moved to the care of a broader population of acute cardiac patients and are currently defined as Intensive Cardiac Care Units (ICCUs). However, very limited data are available on such evolution. Since 2008, in Italy, several surveys have been designed to assess ICCUs' activities. The largest and most comprehensive of these, the BLITZ-3 Registry, observed that patients admitted are mainly elderly males and suffer from several comorbidities. Direct admission to ICCUs through the Emergency Medical System was rather rare. Acute coronary syndromes (ACS) account for more than half of the discharge diagnoses. However, numbers of acute heart failure (AHF) admissions are substantial. Interestingly, age, resources availability, and networking have a strong influence on ICCUs' epidemiology and activities. In fact, while patients with ACS concentrate in ICCUs with interventional capabilities, older patients with AHF or non-ACS, non-AHF cardiac diseases prevail in peripheral ICCUs. In conclusion, although ACS is still the core business of ICCUs, aging, comorbidities, increasing numbers of non-ACS, technological improvements, and resources availability have had substantial effects on epidemiology and activities of ICCUs. The Italian surveys confirm these changes and call for a substantial update of ICCUs' organization and competences.

Impact of renal function impairment assessed by CKDEPI estimated glomerular filtration rate on early and late outcomes after coronary artery bypass grafting.

BACKGROUND: We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFRCKD-EPI). We also try to identify cut-off values of eGFRCKD-EPI able to predict post-CABG unfavorable events and assess whether a reclassification with new thresholds is necessary. METHODS: One-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFRCKD-EPI: Group 1 (≥60ml/min/1.73m2; n=1199), Group 2 (45-59ml/min/1.73m2; n=358), Group 3 (30-44ml/min/1.73m2; n=171) and Group 4 (≤29ml/min/1.73m2; n=126). Median follow-up was 66months [IQR 46-84]. RESULTS: eGFRCKD-EPI ≤30ml/min/1.73m2, ≤41ml/min/1.73m2, ≤27ml/min/1.73m2 and ≤29ml/min/1.73m2 were strong predictors of early mortality (OR 5.88 [95% CI 2.59-11.25]), stroke (2.59 [1.43-3.71]), prolonged length of stay (3.49 [1.24-5.92]) and postoperative dialysis (3.68 [1.34-4.91]), respectively. In addition, eGFRCKD-EPI ≤26ml/min/1.73m2, ≤25ml/min/1.73m2, ≤35ml/min/1.73m2 and ≤29ml/min/1.73m2 predicted all-cause death (hazard ratio 2.74 [95% CI 2.10-3.92] cardiovascular death (sub-hazard ratio 2.11 [95% CI 1.42-3.90]), myocardial infarction (2.01 [1.32-3.70]) and heart failure (2.24 [1.41-3.93]), respectively. Analyses corrected by age and left ventricular ejection fraction confirmed these findings. CONCLUSIONS: In our experience, the use of the eGFRCKD-EPI equation led to categorization with a significantly lower number of patients at risk for post-CABG complications. This might have important clinical repercussions on allocation of healthcare resources and more targeted prevention and management of CABG complications.

[Heart failure in Italian intensive cardiac care units: data from the BLITZ-3 survey]. / I pazienti con scompenso cardiaco nelle unità di terapia intensiva cardiologica italiane: i dati dello studio BLITZ-3.

BACKGROUND: Only limited information about clinical characteristics, diagnostic procedures and therapeutic options is available in patients admitted to an intensive cardiac care unit (ICCU) for heart failure. The aim of this study was to evaluate causes of admission, clinical characteristics, diagnostic and therapeutic options, and outcome of patients admitted for heart failure in the ICCU network. METHODS: The BLITZ-3 Registry prospectively included patients admitted by 332 Italian ICCUs. Data of the patients admitted with a principal diagnosis of heart failure are analyzed. RESULTS: From April 7 to 20, 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs; 966 (14%) out of 6986 patients were admitted for acute heart failure. Heart failure was the second cause of admission after acute coronary syndromes (52%). Mean age of patients admitted for heart failure was 73 years, 42% were female, and diabetes accounted for 32% of heart failure patients. Most patients were admitted to the emergency department (62%), and were discharged by the cardiology ward (65%). Median length of stay in the ICCU was 4 days, and during the stay in ICCU 5% of the patients with heart failure died. Advanced age and elevated creatinine values were associated with a higher risk of death. Echocardiography was performed in 79% of heart failure patients, coronary angiography in 10%, assisted ventilation in 15%, ultrafiltration in 3%, and right catheterization in 1%. Diuretics were administered in 93% of patients admitted for acute heart failure, intravenous nitrates in 41%, inotropes in 22%, beta-blockers in 42%, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 66%. CONCLUSIONS: In a nationwide survey, acute heart failure accounted for 14% of hospital admissions in ICCUs. Patients admitted for heart failure are usually old, with frequent comorbidities. Diagnostic and therapeutic procedures are rarely used, with the exception of echocardiography.

Elderly patients with acute coronary syndromes admitted to Italian intensive cardiac care units: a Blitz-3 Registry sub-analysis.

BACKGROUND: Guideline-recommended therapies for acute coronary syndromes (ACS) derive from randomized trials in which elderly patients are underrepresented. Although numbers of this population are increasing, they are largely undertreated in the real world. OBJECTIVE: The study evaluates the impact of older age on care for patients with ACS admitted to the Italian Intensive Cardiac Care Units (ICCUs) network. METHODS: We analyzed data from the BLITZ-3 Registry in order to assess in-hospital care among unselected elderly patients (≥75 years). RESULTS: From 7-20 April 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs and prospectively enrolled; 3636 (52%) had ACS and 38% of them were elderly. Elderly patients had a higher risk profile, their median length of stay in ICCU was longer [4 days, interquartile range (IQR): 3-6 vs. 3 days, IQR: 2-5; P < 0.0001] and guideline-recommended care was applied less often. At multivariable analysis, elderly patients were less likely to receive reperfusion [odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.42-0.67] for ST-elevation, or early coronary angiography (OR = 0.45, 95% CI = 0.37-0.56) for non-ST elevation ACS. Besides, unadjusted in-ICCU total mortality was higher for elderly patients with ST-elevation (11.8% elderly vs. 1.8% younger patients; P < 0.0001) or non-ST-elevation (3.9% elderly vs. 0.6% younger patients; P < 0.0001) ACS. CONCLUSION: In a nationwide survey, age impacts on care. The elderly with ACS have a higher risk profile but receive less guideline-recommended care than younger patients. Thus, further improvements in care of this population should be pursued.

[Distribution and appropriateness of hospital admissions, resource utilization in the Italian intensive cardiac care units. The BLITZ-3 study]. / Distribuzione e appropriatezza dei ricoveri ed utilizzo di risorse nelle unità di terapia intensiva cardiologica italiane. Lo studio BLITZ-3.

BACKGROUND: The BLITZ-3 study prospectively evaluated the epidemiology of hospital admissions, the patterns of care and the most important comorbidities in intensive cardiac care unit (ICCU) patients. METHODS: Distribution and level of appropriateness of hospital admissions in relation to type of ICCU were analyzed (type A, 32%, without cardiac cath lab or cardiac surgery; type B, 49%, with cath lab; type C, 19%, with both cath lab and cardiac surgery). The caseload was estimated on the basis of different levels of mortality risk during the ICCU stay: high (>5.1%), intermediate (0.7-5.1%), low (< or = 0.7%). RESULTS: A total of 6986 consecutive patients admitted to 332 ICCUs were enrolled. A median number of 19 patients (interquartile range 15-26) was admitted to each center during the 14 days of enrollment; 28% of the ICCUs admitted more than 25 patients, 48% between 15 and 25, and 24% less than 15. A higher number of type A ICCUs admitted less than 15 patients (p<0.0001), whereas a higher number of type C ICCUs admitted more than 25 patients (p<0.0001). Hospital admissions for ST-elevation myocardial infarction occurred more frequently in type B or C ICCUs (p<0.0001), whereas hospital admission for heart failure mostly occurred in type A ICCUs (p<0.0001). The number of patients not undergoing reperfusion (p<0.0001) or treated with thrombolytic therapy (p<0.0001) was higher in the type A ICCUs. Coronary revascularization with primary percutaneous coronary intervention was performed more frequently in type B and C ICCUs (p<0.0001). Similarly, patients hospitalized for acute coronary syndrome underwent coronary angiography (p<0.0001) and percutaneous coronary intervention more frequently in type B and C ICCUs (p<0.0001). Prevalence of low-risk rather than intermediate- or high-risk patients was higher in type A ICCUs (p<0.05), and prevalence of high- or intermediate-risk patients was higher in type C ICCUs (p<0.05). CONCLUSIONS: The results of the BLITZ-3 study should lead the Italian cardiological community to reflect upon the needed number of ICCUs, the role of Spoke centers for their integration in the interhospital network, and inappropriate hospital admissions for low-risk conditions.

[Clinical competence in intensive cardiac care units: from practical needs to training programs]. / Le competenze cliniche del cardiologo di unità di terapia intensiva cardiologica: dalle esigenze pratiche ai progetti formativi.

Since the early 1970s, intensive cardiac care is applied in coronary care units (CCUs), initially developed to treat lethal arrhythmias in patients with acute myocardial infarction. In the last decades, treatments offered within the CCUs have greatly expanded. Thus, these units have been called intensive cardiac care units (ICCUs) to reflect such evolution of care and the different epidemiology of patients admitted (subjects with acute coronary syndromes, acute and advanced heart failure, rhythm disturbances or severe valve dysfunction). At the same time, new drugs have become available but also different diagnostic, interventional and therapeutic procedures have been developed, resulting in better patient treatment and improved outcomes. These new devices require a high degree of specialization and specific skills that not every cardiologist is always used to. Consequently, specific training programs on intensive cardiac care for cardiologists working in ICCUs are clearly warranted. The present paper describes the advanced training programs on intensive cardiac care endorsed by the European Society of Cardiology and the Italian Association of Hospital Cardiologists (ANMCO). Both projects aim at improving current knowledge and skills of intensive cardiologists on specific pharmacologic and technical procedures, extending the competence of trained cardiologists to the management of critically ill cardiac patients, and uniforming the quality of care in any ICCU.

Epidemiology and patterns of care of patients admitted to Italian Intensive Cardiac Care units: the BLITZ-3 registry.

BACKGROUND: Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available. METHODS AND RESULTS: From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%. CONCLUSION: The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

Clinical implications and management of bleeding events in patients with acute coronary syndromes.

In the past decades, there has been a significant development in the management of patients with acute coronary syndromes (ACS), largely driven by advances in antithrombotic and antiplatelet agents. Despite significant improvements in efficacy end points such as death, myocardial infarction and repeated revascularization, these therapies are still associated with a significant risk of bleeding. Such bleedings are independent predictors of long-term adverse clinical events. Data that are currently available on the magnitude and the predictors of bleeding complications in patients with ACS have been obtained from randomized clinical trials. However, patients perceived to be at higher risk of complications, including the elderly or those with renal insufficiency, are often excluded from these trials, but constitute a significant percentage of patients treated for ACS. For these reasons, new bleeding risk scores are under evaluation to facilitate management and subsequent treatment decisions in the real world. Better identification of higher risk patients, careful dosing and appropriate monitoring of antithrombotic therapies, and incorporation of various peri-procedural strategies in routine clinical practice may potentially reduce the risk of bleeding of patients with ACS and further improve their clinical outcomes.

Severe hypoplasia of the posterior mitral leaflet.

A rare case of a 14-year-old child with congenital mitral insufficiency secondary to hypoplasia of the posterior leaflet is reported. Echocardiography revealed the almost complete absence of the posterior mitral leaflet, which determined massive regurgitation. At surgical inspection the posterior leaflet was almost completely absent, represented only by tags of fibrous tissue that strictly adhered to the posterior annulus with a total absence of chordae inserting into the hypoplastic leaflet. The mitral valve was successfully repaired by restrictive annuloplasty, which gained a satisfactory surface of coaptation between the anterior leaflet and the primordial posterior structure, resulting in stable valve continence.

Coronary embolism following valve surgery.

A 55-year-old man experienced chest pain on the seventh day after valve surgery. Coronary angiography showed embolic occlusion of the left anterior descending coronary artery. The lesion was treated successfully with thrombectomy using the angiojet rheolytic thrombectomy system, resulting in rapid mechanical thrombolysis and removal via the effluent lumen of the catheter. Thrombolysis in Myocardial Infarction 3 flow was restored.