Management of Pacemaker Implantation during COVID-19 Infection.

The management of device implantation during the COVID-19 infection has not well defined yet. This is the first case of complete atrioventricular block in a symptomatic patient affected by the COVID-19 infection treated with early pacemaker implantation to minimize the risk of virus contagion.

Multiparametric carotid and cardiac ultrasound compared with clinical risk scores for the prediction of angiographic coronary artery disease: a multicenter prospective study.

OBJECTIVE: Cardiovascular risk prediction is deemed fundamental and the assessment of organ damage is emerging as a potentially 'downstream' picture of individual risk. Our aim was to assess the feasibility and value of prediction of coronaropathy [coronary artery disease (CAD)] of integrated cardiovascular ultrasound examination. METHODS: This multicenter study involved eight cardiology centers that enrolled 457 consecutive patients. Blood pressures, carotid intima-media thickness (cIMT), carotid pulse wave velocity (cPWV), semiquantitative score of cardiac calcifications, global myocardial longitudinal strain (GLS), and rest Doppler flow velocity on the left anterior descending (LAD) coronary artery were measured. After coronary angiography, patients were divided in CAD, n = 273, at least one coronary stenosis higher than 50%, and no CAD, n = 184. RESULTS: CAD were older (65.9 ±â€Š10.7 versus 63.1 ±â€Š11.2 years, mean ±â€Šstandard deviation, P = 0.01), and had higher blood pressure (137.0 ±â€Š18.8/77.5 ±â€Š11.1 versus 130.2 ±â€Š17.4/75.1 ±â€Š9.7 mmHg, P < 0.02), cIMT (791.4 ±â€Š165.5 versus 712.0 ±â€Š141.5 mcm, P < 0.0001), cPWV (median: 9 versus 8.1 m/s, P < 0.01), score of calcium (median, 2 versus 1, P < 0.0001), LAD velocity (median, 38 versus 36, P < 0.07), and lower GLS (-17.6 ±â€Š4.3 versus -19.3 ±â€Š5.1, P < 0.05) than no CAD. Score of calcium was feasible in the totality of patients, cIMT in 97%, cPWV in 86%, GLS in 88%, and LAD in 84%. A combination of at least three variables was measurable in 80% of the patients. All ultrasound parameters significantly predicted CAD. However, in a stepwise logistic regression, the only combined predictors of obstructive CAD were score of calcium, cIMT, and LAD velocity. CONCLUSION: In Echo-Lab, Rome, Italy, the integrated cardiovascular ultrasound study is feasible in a high percentage of patients. The combination of three parameters, that is, score of calcium, cIMT, and LAD velocity, has incremental predictive value for obstructive CAD.

New diagnostic perspectives on heart failure with preserved ejection fraction: systolic function beyond ejection fraction.

Although preserved ejection fraction is found in more than 50% of patients with heart failure, its acceptance as a specific clinical entity is limited. More understanding of the physiopathology, early diagnosis and medical management is needed. With no existing systematic information in the literature, the aim of this review is to provide a comprehensive overview of the new imaging techniques for diagnosing heart failure with preserved ejection fraction, particularly in the early stages of the disease, underlying the pivotal role of new technologies such as two-dimensional speckle tracking echocardiography and vascular stiffness.

Interplay between arterial stiffness and diastolic function: a marker of ventricular-vascular coupling.

AIMS: We evaluated the interplay between left ventricular diastolic function and large-artery stiffness in asymptomatic patients at increased risk of heart failure and no structural heart disease (Stage A). METHODS: We divided 127 consecutive patients (mean age 49 ±â€Š17 years) with risk factors for heart failure who were referred to our laboratory to rule out structural heart disease into two groups according to presence (Group 1, n = 35) or absence (Group 2, n = 92) of grade I left ventricular diastolic dysfunction. Doppler imaging with high-resolution echo-tracking software was used to measure intima-media thickness (IMT) and stiffness of carotid arteries. RESULTS: Group 1 had significantly higher mean age, blood pressure, left ventricular mass index, carotid IMT and arterial stiffness than Group 2 (P < 0.05). Overall, carotid stiffness indices (ß-stiffness index, augmentation index and elastic modulus) and 'one-point' pulse wave velocity each showed inverse correlation with E-wave velocity, E' velocity and E/A ratio, and direct correlation with A-wave velocity, E-wave deceleration time and E/E' ratio (P < 0.05). Arterial compliance showed negative correlations with the echocardiographic indices of left ventricular diastolic function (P < 0.05). On logistic regression analysis, age, hypertension, SBP, pulse pressure, left ventricular mass index, carotid IMT and stiffness parameters were associated with grade I left ventricular diastolic dysfunction (P < 0.05 for each). However, on multivariate logistic analysis, only 'one-point' pulse wave velocity and age were independent predictors (P = 0.038 and P = 0.016, respectively). CONCLUSION: An independent association between grade I left ventricular diastolic dysfunction and increased arterial stiffness is demonstrated at the earliest stage of heart failure. Hence, assessment of vascular function, beyond cardiac function, should be included in a comprehensive clinical evaluation of these patients.

Accessory mitral valve tissue: an updated review of the literature.

Accessory mitral valve tissue (AMVT) is a rare congenital cardiac anomaly sometimes responsible for left ventricular outflow tract (LVOT) obstruction. It is diagnosed during both neonate-childhood and adult periods in patients usually symptomatic for dyspnoea, chest pain, palpitations, fatigue, or syncope. Nevertheless, AMVT is often an incidental finding. AMVT is most often associated with other cardiac and vascular congenital malformations, such as septal defects and transposition of the great arteries. Surgery is indicated only in cases of significant LVOT obstruction and in patients undergoing correction of other cardiac malformations or exploration of an intracardiac mass. Two-dimensional echocardiography, both transthoracic and transoesophageal, is considered the main imaging modality for AMVT diagnosis and patient follow-up. The recent introduction of three-dimensional echocardiography allows a more realistic characterization of this entity. We present three clinical cases in which AMVT was incidentally diagnosed during standard echocardiography and an updated review of the literature highlighting the usefulness of echocardiography for AMVT morphological and functional characterization as well as the most relevant clinical implications due to its discovery.

Arterial stiffness changes in patients with cardiovascular risk factors but normal carotid intima-media thickness.

AIMS: We aimed to evaluate, through an Echotracking system, the functional changes of carotid arteries with relation to the amount of cardiovascular risk factors in patients without structural atherosclerotic damage. METHODS: From a series of 260 asymptomatic consecutive patients we selected 75 patients (mean age: 47 ±â€Š8 years) with normal intima-media thickness (IMT) and without atherosclerotic plaques. In these patients, local arterial stiffness parameters were evaluated using a simple Echotracking system. Patients were divided in three groups: group 1 (n = 25 patients without risk factors), group 2 (n = 23 patients with one risk factor) and group 3 (n = 27 patients with two or more risk factors). RESULTS: Carotid IMT was similar in all groups (P = ns). On the contrary, stiffness parameters progressively increased according to the number of risk factors [pulse wave velocity (PWV) = 5.8 ±â€Š1.1 m/s, 6.4 ±â€Š1.2 m/s and 6.7 ±â€Š1.4 m/s in Group 1, 2 and 3, respectively, P = 0.002; ß-index = 7.5 ±â€Š3.4, 8.5 ±â€Š3.2 and 9.5 ±â€Š4.7 in Group 1, 2 and 3, respectively, P = 0.047]. Furthermore, on multivariate linear regression analysis, PWV and ß-index significantly correlated (P = 0.002 and P = 0.048, respectively) with the number of risk factors even when adjusted for age, gender and current therapy. CONCLUSION: In a population with normal carotid IMT and without plaques, changes in arterial stiffness are significantly related to the number of risk factors. This information could be relevant for a more tailored primary prevention in patients with risk factors even in absence of structural atherosclerotic abnormalities.

In patients with post-infarction left ventricular dysfunction, how does impaired basal rotation affect chronic ischemic mitral regurgitation?

BACKGROUND: The aim of this study was to explore the contribution of left ventricular (LV) basal rotation to the mechanism of chronic ischemic mitral regurgitation (MR). METHODS: Fifty-seven patients (52 men; mean age, 68.3 ± 11.8 years) with postinfarction LV dysfunction (defined as an ejection fraction ≤ 45%) were prospectively enrolled. Each invariably had functional MR. To assess MR degree, the effective regurgitant orifice area (EROA) was quantified by echocardiography using the proximal isovelocity surface area method. Furthermore, mitral valve deformation (valve tenting and annular function) and LV global (systolic and diastolic volumes, function, and sphericity) and local remodeling (displacement of papillary muscles, regional strain, and rotation by speckle-tracking) were assessed. The patients were subsequently subdivided into two groups according to the absence (group A) or presence (group B) on transthoracic echocardiography of infarct area in the inferior and/or posterior basal segments. RESULTS: A larger EROA was found in group B than in group A (P = .034) and in subjects with asymmetric rather than symmetric tethering in either group (P = .036 and P = .040 for groups A and B, respectively). Basal radial (P = .009), circumferential (P = .042), and longitudinal (P = .005) strain and rotation (P = .021) were lower in group B than in group A. There was also a significant inverse correlation between EROA and basal rotation in group B (r = -0.75, P < .001). Furthermore, using multivariate linear regression analysis, we found that the independent determinants of EROA were end-diastolic volume (P < .001) and tenting area (P = .004) in group A and asymmetric tethering (P = .029) and basal rotation (P < .001) in group B. CONCLUSIONS: Impaired basal rotational mechanics occurring after an inferior-posterior myocardial infarction is associated with increased MR.