Myocardial Work Assessment in Patients after Coronary Artery Bypass Grafting during Cardiac Rehabilitation.

BACKGROUND: Myocardial work is an innovative echocardiographic tool to assess left ventricular performance. Emerging data have shown the added value of this method for evaluating cardiac function compared to traditional echocardiographic parameters and global longitudinal strain. However, few studies are present in the literature about the role of myocardial work during cardiac rehabilitation. Our aim was to assess the impact of a rehabilitation program on myocardial work indices in patients with preserved left ventricular ejection fraction and after coronary artery bypass grafting. In addition, we assessed the correlation between baseline myocardial work indices and their change after cardiac rehabilitation, establishing an optimal cut-off value to predict the improvement. METHODS: An observational, single-center, and prospective study was conducted. We enrolled patients referred to cardiac rehabilitation after coronary artery bypass grafting and with preserved left ventricular ejection fraction. Before and after the cardiac rehabilitation program, a comprehensive patient assessment was performed, including traditional transthoracic echocardiography, myocardial work analysis, and a six-minute walk test. RESULTS: Eighty-four patients were enrolled; the mean age was 67.96 (±7.42) years and 78.6% were male. The left ventricular ejection fraction was preserved in all patients, and the global longitudinal strain was -16.18 ± 2.55%, the global work index was 1588.56 ± 345 mmHg%, the global constructive work was 1771.27 ± 366.36 mmHg%, the global wasted work was 105.8 ± 72.02 mmHg%, and the global work efficiency was 92.63 ± 3.9% at baseline. After the cardiac rehabilitation program, the global work index, the global constructive work, and the six-minute walk test improved significantly (1588.56 ± 345 vs. 1960.2 ± 377.03 mmHg%, p-value < 0.001; 1771.27 ± 366.36 vs. 2172.01 ± 418.73 mmHg%, p-value < 0.001; 70.71 ± 40.2 vs. 437.5 ± 108.70 m, p-value < 0.001, respectively). CONCLUSIONS: Myocardial work indices, specifically global work index and global constructive work, improve after cardiac rehabilitation program in patients undergoing coronary artery bypass grafting with preserved left ventricular ejection fraction.

[Heart involvement in multisystem inflammatory syndrome in children correlated with SARS-CoV-2 infection: a review by ANMCO/SICP]. / Le manifestazioni cardiache nella sindrome multisistemica infiammatoria del bambino correlate all'infezione da SARS-CoV-2: una rassegna a cura di ANMCO/SICP.

Acute clinical manifestations of COVID-19 are generally less severe in childhood, however a proportion of them can develop a severe systemic hyperinflammatory syndrome after SARS-CoV-2 infection, known as the multisystem inflammatory syndrome (multisystem inflammatory syndrome in children, MIS-C). Cardiovascular manifestations in MIS-C are frequent (34-82%), including myocardial dysfunction, coronary artery dilation or aneurysms, arrhythmias, conduction abnormalities, pericarditis and valvulitis. The most affected cases can develop cardiogenic shock needing intensive care unit admission, inotropic support and sometimes even mechanical circulatory support. The elevation of myocardial necrosis markers, the frequently transient left ventricular systolic dysfunction and the presence of changes on magnetic resonance imaging, support the hypothesis of an immune-mediated post-viral pathogenesis similar to myocarditis. Although MIS-C shows excellent short-term survival, further studies are needed to demonstrate complete reversibility of residual subclinical heart damage.

Left atrial strain determinants and clinical features according to the heart failure stages. New insight from EACVI MASCOT registry.

Few studies analyzed left atrial (LA) peak atrial longitudinal strain (PALS) determinants, particularly across heart failure (HF) stages. We aimed to analyze the pathophysiological and clinical PALS correlates in a large multicentric prospective study. This is a multicenter prospective observational study enrolling 745 patients with HF stages. Data included PALS and left ventricular global longitudinal strain (LV-GLS). Exclusion criteria were: valvular prosthesis; atrial fibrillation; cardiac transplantation; poor acoustic window. Median global PALS was 17% [24-32]. 29% of patients were in HF-stage 0/A, 35% in stage-B, and 36% in stage-C. Together with age, the echocardiographic determinants of PALS were LA volume and LV-GLS (overall model R2 = 0.50, p < 0.0001). LV-GLS had the strongest association with PALS at multivariable analysis (beta: -3.60 ± 0.20, p < 0.0001). Among HF stages, LV-GLS remained the most important PALS predictor (p < 0.0001) whereas age was only associated with PALS in lower HF-stage 0/A or B (R = - 0.26 p < 0.0001, R = - 0.23 p = 0.0001). LA volume increased its association to PALS moving from stage 0/A (R = - 0.11; P = 0.1) to C (R = - 0.42; P < 0.0001). PALS was the single most potent echocardiographic parameter in predicting the HF stage (AUC for B vs. 0/A 0.81, and AUC vs. 0/A for C 0.76). PALS remained independently associated with HF stages after adjusting for ejection fraction, E/e' ratio, and mitral regurgitation grade (p < 0.0001). Although influenced by LV-GLS and LA size across HF stages, PALS is incrementally and independently associated with clinical status. LA function may reflect a substantial part of the hemodynamic consequences of ventricular dysfunction.

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study.

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume-pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.

Update on the Organizational Aspects of Echocardiography in Italy (From Operator Training to the Report: 2007-2019): A Consensus Document by the "Società Italiana di Ecocardiografia e CardioVascular Imaging" Accreditation Area and Board 2017-2019.

In 2007, Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI) already SIEC, published the document on the organization of echocardiography in Italy. In the years following the technological evolution, cultural and health factors have changed "the way, we do echo" as a tool for the different clinical pathways. The SIECVI Accreditation Area and Board 2017-2019 considered necessary to review and update the document in the light of innovation in the application of ultrasound for the heart disease assessment. In the document, we have considered the role of SIECVI in multimodal imaging, the need of training and certification of operators, the quality of echo machines, the accreditation of laboratories, the compilation of the report and its responsibility, and the presence of the sonographers in the EchoLab.

Left atrium by echocardiography in clinical practice: from conventional methods to new echocardiographic techniques.

Although often referred to as "the forgotten chamber", compared with left ventricle (LV), especially in the past years, the left atrium (LA) plays a critical role in the clinical expression and prognosis of patients with heart and cerebrovascular disease, as demonstrated by several studies. Echocardiographers initially focused on early detection of atrial geometrical abnormalities through monodimensional atrial diameter quantification and then bidimensional (2D) areas and volume estimation. Now, together with conventional echocardiographic parameters, new echocardiographic techniques, such as strain Doppler, 2D speckle tracking and three-dimensional (3D) echocardiography, allow assessing early LA dysfunction and they all play a fundamental role to detect early functional remodelling before anatomical alterations occur. LA dysfunction and its important prognostic implications may be detected sooner by LA strain than by volumetric measurements.

Two-dimensional atrial systolic strain imaging predicts atrial fibrillation at 4-year follow-up in asymptomatic rheumatic mitral stenosis.

BACKGROUND: The aim of this study was to assess systolic left atrial (LA) reservoir function in patients with mitral stenosis (MS) using two-dimensional (2D) strain (ε) and strain rate imaging and its prognostic value in predicting atrial fibrillation (AF) at 4-year follow-up. METHODS: One hundred one asymptomatic patients with pure rheumatic MS and 70 healthy controls were evaluated using standard Doppler echocardiography (mitral valve area, mean gradient, systolic pulmonary pressure, LA width, LA volumes, and LA ejection fraction) and 2D speckle-tracking. RESULTS: LA width, volumes, and systolic pulmonary pressure were significantly increased (P < .0001), and LA 2D ε and strain rate were significantly impaired in patients with MS (P < .0001). At 4-year follow-up, 20 patients (20%) showed AF on standard electrocardiography or 24-hour Holter electrocardiography. Patients with MS who had AF were older than those who did not, without significant differences in LA dimensions, volumes, ejection fraction, and compliance index. Instead, atrial myocardial systolic 2D ε was significantly impaired in patients with events. On multivariate analysis (age, LA volume, planimetric mitral area, average annular Ea, and LA strain) the best predictor of AF was average LA peak systolic ε (coefficient, 0.43; SE, 0.098; P < .01), with an area under the receiver operating characteristic curve of 0.761 (SE, 0.085; 95% confidence interval, 0.587-0.888, P = .002) for a cutoff value of 17.4%. CONCLUSIONS: The results of 2D ε imaging are abnormal in patients with asymptomatic MS and predict AF at 4-year follow-up.

Clinical course and risk profile in adolescents with idiopathic dilated cardiomyopathy.

We sought to analyze the prevalence, clinical course, and risk profile of left ventricular systolic dysfunction in adolescents with idiopathic dilated cardiomyopathy. Patients with clinical onset at <13 years (n = 18) or >19 years (n = 14) of age and/or patients followed up for <12 months were excluded. Clinical and biochemical markers were evaluated during 4 +/- 3 years of follow-up to determinate predictors of adverse outcome. A composite end point (hospitalization for worsening heart failure, cardiac transplantation, and death) was investigated. The final cohort consisted of 48 patients (median age 17 years) with idiopathic dilated cardiomyopathy. During follow-up, 11 patients required hospitalization for heart failure (21%) and 6 patients entered the transplantation list (4 underwent orthotopic cardiac transplantation, 8%). A Cox multivariate model evidenced N-terminus pro-brain natriuretic peptide (NT-pro-BNP; odds ratio 1, confidence interval 1 to 1.1, p = 0.001), New York Heart Association (NYHA) classes III to IV (odds ratio 2.5, confidence interval 1 to 5.9, p = 0.04), and electrocardiographic atrial enlargement (odd ratios 6.7, confidence interval 1.8 to 25, p = 0.005) as predictors of adverse events (composite end point) at 60 months. The association of NYHA classes III to IV, electrocardiographic atrial enlargement, and NT-pro-BNP value > or =250 pg/ml (are under the curve 0.88) showed 100% sensitivity, 77% specificity, 62% positive predictive value, and 100% negative predictive value. In conclusion, compared to other clinical, echocardiographic, and biochemical parameters, the combination of advanced NYHA class, electrocardiographic atrial enlargement, and NT-pro-BNP > or =250 pg/ml seem to better predict the risk of adverse events in adolescent with long-term systolic dysfunction.

Right atrial mass following transcatheter radiofrequency ablation for recurrent atrial fibrillation: thrombus, endocarditis or mixoma?

We report a case of an asymptomatic patient in whom a right atrial mass was fortuitously documented by echocardiography few months after a transcatheter radiofrequency catheter ablation for recurrent AF. No masses were seen in the cardiac chambers before the ablative procedure, raising important diagnostic and decision-making issues. The patient was referred to the surgeon and a diagnosis of right atrial myxoma was made.

Potential clinical perspectives of Doppler myocardial imaging and strain rate imaging during stress echocardiography.

Stress echocardiography has become a common non-invasive test in patients with chest pain and known or suspected coronary artery disease, but, as with exercise electrocardiography, it shows several major limitations. Analysis of gray-scale images based on subjective visual interpretation of wall motion and thickening has considerable variability even among experts. Doppler myocardial imaging and strain rate imaging echocardiography provides additional information in comparison with conventional echocardiography. These techniques provide quantification of regional wall motion at rest and during stress. Quantification of both systolic and diastolic myocardial function by either Doppler myocardial imaging or strain rate imaging mapping during dobutamine stress test has been shown to be a feasible, accurate, non-invasive tool that should be considered to be a sensitive alternative to the present echocardiographic and scintigraphic imaging techniques for stress tests. Time consuming off-line analysis of color images is required in the present state of technology. However, these non-invasive techniques are rapidly evolving and expanding. Further refinements in signal processing and quantitative analysis are likely in the near future.

Impact of pulmonary regurgitation and age at surgical repair on textural and functional right ventricular myocardial properties in patients with tetralogy of Fallot.

BACKGROUND: The aim of this study was to identify non-invasively the potential impact of pulmonary regurgitation and age at surgical repair on the right ventricular (RV) textural and functional myocardial properties in patients operated on for tetralogy of Fallot (TOF). METHODS: We assessed the average intensity (Int.(1B)) and the cyclic variation (CV(IB)) of the echocardiographic backscatter curve in 30 TOF patients (mean age 16.2 +/- 8.3 years), who had undergone corrective surgery (mean age at repair 3.2 +/- 2.6 years, range 0.2-11 years). They were divided into three age- and body surface area (BSA)-matched subgroups according to the results of the surgical repair: 12 patients had no significant postsurgical sequelae (group I), 12 patients had isolated moderate-severe pulmonary regurgitation (group II), and 6 patients had pulmonary regurgitation associated with significant (> 30 mmHg) RV outflow tract obstruction (group III). In addition, 30 age-, sex- and BSA-matched normal subjects were identified as the control group. RESULTS: In our study population, CV(IB) was lower (7.86 +/- 2.5 vs 10.6 +/- 1.4 dB, p < 0.001) and Int.IB higher (-18.6 +/- 4.1 vs -21 +/- 2.8 dB, p = 0.01) compared to the control group. Comparison between the control group and each subgroup of TOF patients showed: a) comparable values of CV(IB) and Int.(IB) in group I (10.6 +/- 1.4 vs 9.4 +/- 2.3 dB, p = 0.07; and -21 +/- 2.8 vs -21.4 +/- 2.3 dB, p = 0.7, respectively); b) Int.(IB) was significantly different only in group III (-21 +/- 2.8 vs -13.3 +/- 4.6 dB, p < 0.0001), c) CV(IB) was different either in group II or III (10.6 +/- 1.4 vs 7.42 +/- 2, p < 0.001; and 10.6 +/- 1.4 vs 5.56 +/- 1.8, p < 0.001, respectively). In addition, comparison of integrated backscatter indexes among the TOF subgroups revealed significant differences of CV(IB) between group I and II (9.4 +/- 2.4 vs 7.4 +/- 2, p = 0.03) and between group I and III (9.4 +/- 2.4 vs 5.56 +/- 1.8, p = 0.004), and of Int.(IB) between group I and III (-21.4 +/- 2.3 vs -13.3 +/- 4.66, p < 0.001) and between group II and III (-21.4 +/- 2.3 vs -18.6 +/- 2.8, p = 0.006). Group III patients, who had the most significant RV dilation, expressed as the ratio between RV and left ventricular end-diastolic diameter (0.55 +/- 0.8) compared to group II (0.67 +/- 0.11, p = 0.038) and group I (0.55 +/- 0.87, p < 0.001), showed the lowest values of CV(IB) (5.56 +/- 1.8 dB) and the highest values of Int.(IB) (-13.3 +/- 4.6 dB) Finally, in our study population, both the degree of RV dilation and the age at surgical repair significantly correlated with Int.(IB) (r = 0.49 and r = 0.4, p = 0.06 and p = 0.033, respectively) and inversely correlated with CV(IB) (r = -0.55 and r = -0.53, p = 0.002 and p = 0.003, respectively). CONCLUSIONS: In patients operated on for TOF: a) integrated backscatter analysis may identify patients with significant RV myocardial abnormalities related to postsurgical sequelae; b) residual pulmonary regurgitation, particularly if associated with pulmonary stenosis, appears to affect RV myocardial properties; c) an earlier repair of TOF may result in better preservation of myocardial characteristics.