Which is the correct management of patients with asymptomatic severe calcific aortic stenosis after symptomatic spontaneous calcium cerebral embolism?

Elective surgery cannot be recommended in every patient with asymptomatic severe aortic stenosis, and predictors identifying high-risk patients need to be identified. In guidelines we read that elective surgery, at the asymptomatic stage, can only be recommended in selected patients, at low operative risk (see guidelines of European Society of Cardiology and American Heart Association), but we have not read any reference to patients with severe calcific aortic stenosis after symptomatic spontaneous calcium cerebral embolism. Because cardioembolic stroke is associated with poor prognosis compared to other stroke subtypes, in patients with asymptomatic severe aortic stenosis and spontaneous calcific embolic stroke valve replacement appears to offer the best hope of avoiding a recidivation of stroke and should be considered in most cases. On the contrary, is it still correct to consider as asymptomatic patients with severe aortic stenosis and cerebral thromboembolism from a calcified aortic valve?

Right atrial size and deformation in patients with dilated cardiomyopathy undergoing cardiac resynchronization therapy.

AIMS: To evaluate right atrial (RA) morphology and deformation in patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: A total of 130 patients with either idiopathic (n = 70) or ischaemic (n = 60) DCM, and 60 controls underwent clinical examination, standard echocardiography, and RA two-dimensional strain echocardiography (2DSE). Six months after implantation of a cardiac resynchronization therapy (CRT) device, the DCM patients were re-evaluated, if their left ventricular (LV) end-systolic volume had decreased by at least 15% they were defined as echocardiographic responders. All DCM patients were in NYHA class III before CRT, with a mean LV ejection fraction of 29.2 +/- 5.5%. After CRT, 94 patients were in NYHA functional class I-II. The patients were subdivided into echocardiographic responders (n = 85) and non-responders (n = 45). Both RA area index (19.7 +/- 5.5 cm(2)/m in non-responders vs. 13.2 +/- 4.4 cm(2)/m in responders; P < 0.001) and RA strain of lateral wall (24.3 +/- 10.2% in non-responders vs. 40.2 +/- 8.9% in responders; P < 0.001) were significantly different between the two groups. A RA area index >or=16 cm(2)/m showed a sensitivity and specificity of 87.1 and 95.4%, respectively (P < 0.0001) to predict a negative response to CRT. By multivariable analysis, increased RA area index (P < 0.001), ischaemic aetiology of DCM (P < 0.01), and less severe radial intraventricular dyssynchrony were independent determinants of an unfavourable response to CRT. CONCLUSION: Right atrial area index was increased and RA myocardial deformation was impaired in patients with DCM who were non-responders to CRT.

Biventricular myocardial adaptation to different training protocols in competitive master athletes.

BACKGROUND: Conflicting data have been reported about the nature (physiologic versus pathologic) of left ventricular (LV) hypertrophy in master athletes. AIM OF THE STUDY: To analyze LV and right ventricular (RV) myocardial function in master athletes with LV hypertrophy induced by either endurance or strength training. METHODS: Standard Doppler echo and colour Doppler Myocardial Imaging (DMI) of LV and of RV basal lateral walls were performed in 40 competitive master (>45 years) endurance athletes (ATE), in 20 master strength-trained athletes (ATS) and 25 age-matched healthy sedentary subjects, all males. By use of DMI, the following parameters of myocardial function were assessed: systolic peak velocities, precontraction time, contraction time, early (E(m)) and late (A(m)) diastolic peak velocities, E(m)/A(m) ratio, relaxation time. RESULTS: The two groups were comparable for age, but ATS at rest showed higher heart rate, systolic blood pressure, and body surface area. LV mass index did not significantly differ between the two groups of athletes. However, ATS showed increased wall thickness and relative wall thickness, while LV stroke volume and both LV and RV end-diastolic diameters were greater in ATE. All transmitral and transtricuspid Doppler indexes were higher in ATE. DMI analysis showed in ATE higher E(m) and E(m)/A(m) ratio at the level of both RV and LV lateral walls. In the overall population of athletes, linear regression models evidenced independent positive association of RV peak E(m) velocity with both LV stroke volume and maximal workload achieved by bicycle ergometer (both p<0.001). CONCLUSIONS: RV early diastolic myocardial function is positively influenced by preload increase in master athletes and represents an independent determinant of cardiac performance during physical effort. Therefore, colour DMI may be taken into account to distinguish different cardiac adaptation to either endurance or strength sport training in master athletes.