Left ventricular assist device and transcatheter edge-to-edge mitral valve repair in advanced heart failure: allies or enemies?

The implantation of left ventricular assist devices (LVADs) has been increasing, with good long-term results, in parallel with a growing population with advanced heart failure (HF). However, in some European countries, LVADs are still underused, with one of the main issues being the patient's late referral. On the contrary, the use of transcatheter edge-to-edge mitral valve repair (TEER) has exponentially increased over the past decade, expanding its potential use even in patients on the heart transplantation waiting list. Even though the study populations of the main trials that investigated the prognostic impact of LVAD and TEER are different, in clinical practice a clear distinction might not be so clear. Therefore, patients with refractory HF symptoms and significant mitral regurgitation should be thoroughly evaluated through a multidisciplinary Heart Team meeting with both an advanced HF specialist and interventional cardiologist, to avoid futile procedures and to define the optimal timing for advanced HF therapies, when they are indicated. We analyzed the main available studies and registries on both TEERs and LVADs and we compared their populations and outcomes, to provide the current evidence on the use of LVAD and TEER in the HF population, especially in the light of the recently released 5-year follow-up results, giving some insights on the Italian situation, and finally to stress the importance of a solid HF network between hospitals, aiming for advanced HF patients' timely referral for LVAD or heart transplants.

Risk stratification in cardiogenic shock: a focus on the available evidence.

Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients.

First Evidence of Cardiac Stem Cells From the Left Ventricular Apical Tip in Patients With Left Ventricular Assist Device Implantation.

BACKGROUND: Recent studies have challenged the dogma that the adult heart is a postmitotic organ and raise the possibility of the existence of resident cardiac stem cells (CSCs). Our study aimed to explore if these CSCs are present in the "ventricular tip" obtained during left ventricular assist device (LVAD) implantation from patients with end-stage heart failure (HF) and the relationship with LV dysfunctional area extent. METHODS: Four consecutive patients with ischemic cardiomyopathy and end-stage HF submitted to LVAD implantation were studied. The explanted "ventricular tip" was used as a sample of apical myocardial tissue for the pathological examination. Patients underwent clinical and echocardiographic examination, both standard transthoracic echocardiography (TTE) and speckle tracking echocardiography (STE), before LVAD implantation. RESULTS: All patients presented severe apical dysfunction, with apical akinesis/diskinesis and very low levels of apical longitudinal strain (-3.5 ± 2.9%). Despite this, the presence of CSCs was demonstrated in pathological myocardial samples of "ventricular tip" in all 4 of the patients. It was found to be a mean of 6 c-kit cells in 10 fields magnification 40×. CONCLUSIONS: Cardiac stem cells can be identified in the LV apical segment of patients who have undergone LVAD implantation despite LV apical fibrosis.

Evaluation of Right Ventricular Function in the Management of Patients Referred for Left Ventricular Assist Device Therapy.

BACKGROUND: Speckle tracking echocardiography analysis (STE) has recently allowed an in-depth analysis of right ventricular (RV) performance. The aim of the study was to observe RV function by STE in patients with advanced heart failure before and after left ventricular assist device (LVAD) implantation. METHODS: A transthoracic echocardiogram was performed in 19 patients referred for LVAD implant at baseline and with serial echocardiograms after LVAD implantation (Jarvik 2000). All echocardiographic images were analyzed off line by an independent operator to calculate with STE the RV free wall longitudinal strain (RVLS). RESULTS: All the patients, except 4, showed a progressive increase of RVLS after LVAD implant. However, 4 patients, who presented the lowest RVLS values at baseline, presented a further RV failure in the postoperative. The value of -11% represented the empirical preoperative cutoff able to identify patients at greater risk of postimplant RV failure. CONCLUSIONS: RV myocardial deformation may have important clinical implications for the selection and management of LVAD patients. It can be used to evaluate RV function before LVAD implantation, to drive decisional strategy regarding the management of this type of patients, and after LVAD implant for the follow-up.

Impact of alcohol consumption on winter sports-related injuries.

INTRODUCTION: This study was carried out to evaluate data about trauma-related winter sports, including risk factors such as high speed, gender, age, alcohol consumption, details about the accident and snow conditions. METHODS: A retrospective review was conducted to determine the injury patterns and crash circumstances in holiday skiers and snowboarders. The data recorded were obtained from the database of the Pre-Hospital Emergency Registry of six skiing areas in the Dolomite mountains during the winter seasons November 2004-May 2009, injury data for major traumas from Ski Patrol Injury reports (helicopter, ambulance or ski slopes' patrol reports), and intrahospital Emergency Department data. Alcohol concentration in blood was detected in 200 individuals suffering from major trauma. RESULTS: A total of 4550 injured patients, predominantly male (69%), mean age 22 years (range 16-72), were included in the observational analysis. Knee, wrist and shoulder injuries were frequently associated with major thoracic, abdominal or head traumas (64% of cases). Suboptimal technical level, high speed, low concentration, snow or weather conditions, faulty equipment and protective devices were among the various causes of accidents. The analysis revealed that high alcohol blood concentration was present in 43% of 200 patients. CONCLUSIONS: Even though the major causes of accidents were excessive speed, excessive fatigue, technical errors and bad weather conditions, alcohol abuse was often discovered. Random sampling and a non-systematic detection of alcohol blood levels likely led to an underestimation of alcohol consumption-related injuries. It is recommended that investigations into alcoholic intoxication in injured skiers should be carried out on a large scale.

Oncogenic risk in a chemical plant: a methological approach and preliminary results.

One of the major problems that occupational medicine has to deal with is cancer risk assessment. Recent Italian legislation requires the evaluation of occupational exposure to carcinogens in all workplaces, but a standardized method to be used in the environmental and biological criteria is generally lacking. The objective of this report is to identify a multidisciplinary approach to the research on this topic. The study is based on a chemical plant that produces pitch. The multidisciplinary approach is based on risk- and health-damage assessments. Ethical aspects are also taken into account, and the research design incorporates an informed consent for all employees. Some preliminary results are available. From the environmental point of view, all parameters provide an airborne concentration value below threshold limit values (TLVs), but biological monitoring demonstrates an increased urinary excretion of 1-OH-pyrene in all tested subjects. In conclusion, the first objective of our study is to demonstrate the carcinogenic risk of employees, searching for an agreement between environmental analysis, biological monitoring, and health effect data. A close collaboration between different professions is necessary.

Chemical characterization of the PM10 fraction of airborne particulate matter in the urban atmosphere.

This study examines the chemical composition of PM10, the thoracic fraction of atmospheric particulate matter. This fraction is characterized by a very complex composition and is able to penetrate the human organism corresponding to a "cut point" at the level of the larynx. We used a sampling device to separate the PM10 from other fractions with different aerodynamic behavior. The high volume sampler collected large amounts of material, making it easier to study the micropollutants. Furthermore, it met EPA performance specifications for the measurement of suspended PM10 fraction. We collected the samples during different metereological conditions in the urban area of the town of Leghorn in Tuscany, Italy. Two sites, characterized by different settings, were chosen in the city. Both sites were marked by intense motor vehicle traffic. A better chemical characterization of the collected material became possible using different analytical techniques. The use of large-size cellulose or glass fiber filters allowed us to subdivide the sample and to submit each portion to a different investigative technique. The PAH content of the PM10 fraction was examined, particularly for those compounds of toxicological interest. The concentrations of the compounds were evaluated by HPLC with diode array UV detection. We further determined the contents of various heavy metals from anthropic or telluric sources (Pb, Cu, Fe, Cr, Cd, Mn, V, and Ni) by means of an HGA Graphite Furnace AAS-Zeeman-Effect technique or AA-Flame spectrophotometry. The results of our experiment show that motor vehicle traffic is the prevailing pollution source. The metereological conditions also play a significant role. The samples taken closer to the industrial area of the town showed a slightly higher mean content of PM10 fraction. The concentrations of both heavy metals and PM10 were lower compared with equivalent data from other European cities.

Fast determination of the nonlinearity of photodetectors.

Superposition and calibrated attenuator methods are often used to determine the nonlinearity of photodetectors. A variation of these methods is described and applied to the calibration of optical pyrometers. This scheme allows a considerable reduction in the time needed for the measurement because only three independent sets of measurements are required, without any need to realize an accurate radiance scale on the sources.

Thermodynamic Studies of the α → ß Phase Transformation in Zirconium Using a Subsecond Pulse Heating Technique.

Measurements of the temperature and energy of the α → ß phase transformation, and the electrical resistivity near and at the transformation point of zirconium using a subsecond duration pulse heating technique are described. The results yield 1147 K for the transformation temperature and 3980 J · mol-1 for the transformation energy. Electrical resistivity is found to decrease by 17 percent during the transformation. Estimated inaccuracies of the measured properties are: 10 K for the transformation temperature, 5 percent for the transformation energy, and 2 percent for the electrical resistivity.

Simultaneous Measurements of Heat Capacity, Electrical Resistivity, and Hemispherical Total Emittance by a Pulse Heating Technique: Vanadium, 1500 to 2100 K.

Simultaneous measurements of heat capacity, electrical resistivity, and hemispherical total emittance of vanadium in the temperature range 1500 to 2100 K by a subsecond duration, pulse heating technique are described. The results are expressed by the relations: c p = 56.34 - 3.839 × 10-2 T + 1.563 × 10-5 T 2 ρ = 8.794 + 6.282 × 10-2 T - 6.804 × 10-6 T 2 where c p is in J · mol-1 · K-1, ρ is in 10-8 Ω · m, and T is in K. The values for the hemispherical total emittance are: 0.313 at 1900 K and 0.332 at 2000 K. Estimated inaccuracies of the measured properties are: 3 percent for heat capacity, 0.5 percent for electrical resistivity and 5 percent for hemispherical total emittance.

Simultaneous Measurements of Heat Capacity, Electrical Resistivity and Hemispherical Total Emittance by a Pulse Heating Technique: Zirconium, 1500 to 2100 K.

Simultaneous measurements of heat capacity, electrical resistivity and hemispherical total emittance of zirconium in the temperature range 1500 to 2100 K by a subsecond duration, pulse heating technique are described. The results are expressed by the relations: C p = 36.65 - 1.435 × 10 - 2 T + 6.624 × 10 - 6 T 2 ρ = 87.95 + 1.946 × 10 - 2 T ϵ = 0.2031 + 6.362 × 10 - 5 T where C p is in J · mol-1 · K-1, ρ is in 10-8 Ω · m, and T is in K. Estimated inaccuracies of the measured properties are: 3 percent for heat capacity, 2 percent for electrical resistivity and 5 percent for hemispherical total emittance.