The Additional Value of Three-Dimensional Transesophageal Echocardiography in the Diagnosis of Unusual Complication of Bioprosthetic Mitral Valve.

Primary tissue failure of bioprosthetic mitral valves due to cusp perforations or ruptures is an unusual complication on short-term follow-up. An 88-year-old male with a known history of mitral regurgitation (MR) treated with bioprosthetic valve replacement in 2016 was referred to our center for recurrent heart failure. The two-dimensional (2D) transthoracic echocardiography documented an intraprosthetic jet of regurgitation without identifying a clear morphological mechanism, nor quantifying precisely the mitral insufficiency. 3D transesophageal echocardiography (TOE) with the tool FlexiSlice added relevant information by providing insights into the pathophysiological mechanisms of MR. The present case emphasizes the importance of 3D TOE as a fundamental tool for the diagnostic algorithm of bioprosthetic valves failure, even in the more demanding cases.

Acute Cardiovascular Adaptation to Strenuous Exercise: An Integrative Ultrasound Study.

OBJECTIVES: The aim of this study was to evaluate the acute effects of participation in an Ironman distance triathlon competition on arterial function by ultrasound, in relation to cardiac function and body water content. METHODS: Twenty-eight male triathletes participating in an Ironman distance competition underwent carotid, femoral, and cardiac ultrasound examinations. Moreover, the presence of extravascular lung water was identified by lung echo B-lines (echogenic coherent wedge-shaped signal with a narrow origin from the hyperechoic pleural line) at rest and within 20 minutes of arrival. RESULTS: At the end of the competition, athletes showed an increased heart rate (mean ± SD, from 60.2 ± 13.1 to 82.8 ± 15.6 beats/min; P < .0001) and unchanged mean blood pressure (from 93 ± 14 to 91 ± 10 mm Hg; P > .05) in the presence of negligible dehydration (total body water from 48.0 ± 4.0 to 46.5 ± 3.9 kg; P > .05). Cardiac output increased (from 5.5 ± 1.2 to 6.7 ± 2.4 L/min; P < .05) in the presence of an unchanged stroke volume (from 64 ± 14 to 59 ± 16 mL; P > .05) and unchanged left ventricular elastance (from 1.52 ± 0.48 to 1.39 ± 0.48 mm Hg/mL/m2 ; P > .05). The mean carotid diameter increased (from 7.19 ± 0.65 to 7.61 ± 0.76 mm; P < .05), whereas the mean femoral diameter was unchanged at the end of the competition (from 10.41 ± 0.83 to 10.49 ± 0.82 mm; P > .05). Carotid intima-media thickness was significantly reduced (from 537 ± 70 to 495 ± 70 µm; P < .05), whereas B-lines increased significantly after the competition (from 1 [0-4] to 12 [5-23]; P < .0001). CONCLUSIONS: These data suggest different acute functional adaptation in central arteries with respect to peripheral leg vessels.

Quality control of B-lines analysis in stress Echo 2020.

BACKGROUND: The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE: To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS: 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS: All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS: Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.

[Pro-arrhythmic effect of cardiac memory in a patient with long QT syndrome]. / Effetto pro-aritmico della memoria elettrica cardiaca in un paziente con sindrome del QT lungo.

We describe the case of a patient with a congenital long QT syndrome (LQTS) who showed signs of cardiac memory associated with early afterdepolarizations and ventricular arrhythmias, after a change in the pacing mode from VVI to AAI. Cardiac memory, further altering the potassium ion channel function, may have pro-arrhythmic potential in patients with LQTS.

Assessment of carotid elasticity during exercise: a reproducibility study.

The study aimed to evaluate the reproducibility of carotid elasticity during exercise. Eighteen healthy volunteers (nine males, age 34 ± 3 years, BMI 22 ± 6 kg/m(2)) underwent maximal exercise testing on a graded semi-supine cycle ergometer in two different sessions 3 days apart. Ultrasound B-mode image sequences of the right common carotid were acquired at different steps and analyzed by an automatic system; pressures were estimated by tonometry. Compliance (CC) and distensibility (DC) were significantly decreased at exercise peak and in the first recovery minute (CC from 1.6 ± 0.8 to 1 ± 0.6 mm^(2)/KPa, DC from 56.2 ± 25.3 to 34.5 ± 20 10^(-3)/KPa, p < 0.05). For the whole examination, intraclass coefficient was 0.780 for CC and 0.694 for DC. Mean coefficient of variation was maximum at peak exercise (CC = 19 ± 6%, DC = 24 ± 15%), but at first minute of recovery it was comparable to resting values (CC = 12 ± 9%, DC = 12 ± 11%). When designing future studies, acquisitions during first recovery minute might be preferred to peak measures.

Patterns of left ventricular remodeling in chronic heart failure: prevalence and prognostic implications.

BACKGROUND AND AIM: Many descriptors of left ventricular (LV) remodeling have important prognostic implications in patients with chronic systolic heart failure (HF). We sought to assess the prognostic value of the combination of increased LV mass with a disproportion between wall thickness and internal diameter. METHODS AND PATIENTS: Patients (n = 536) with chronic HF, ejection fraction <50% and LV end-diastolic volume index >91 mL/m(2), classified according to LV mass index and relative wall thickness (RWT), were followed up for 33 ± 21 months. Ventricular mass was determined using a standard M-mode echocardiographic method. Relative wall thickness was defined as the ratio of (sum of interventricular septum thickness in diastole + posterior wall thickness in diastole)/LV end-diastolic diameter. RESULTS: Prevalence of the pattern of increased LV mass index, defined as LV mass index >148 g/m(2) in men and >122 g/m(2) in women, and decreased RWT (<0.34) was 29%. Multivariable predictors of all-cause mortality were age >70 years (P < .0001), New York Heart Association class >2 (P < .0001), increased LV mass index, and decreased RWT (P = .003), E wave deceleration time ≤140 ms (P = .005), and male gender (P = .025). Patients with increased LV mass index and decreased RWT had a worse survival (33%) than patients with less LV mass index and normal to reduced RWT (log-rank 23.92; P < .0001). Comparisons of Cox models showed that the combination of increased mass index and decreased RWT added prognostic value to a model that included ejection fraction and end-systolic volume index. CONCLUSION: In patients with systolic HF, an independent and incremental risk of adverse outcome was associated with increased mass index and decreased RWT.

[Common pathogenetic features between calcific aortic stenosis and atherosclerosis: role of receptor for advanced glycation end-products]. / Aspetti patogenetici comuni tra stenosi aortica calcifica e aterosclerosi: ruolo del recettore dei prodotti di glicosilazione avanzata.

Clinical and experimental studies identified several similarities between calcific aortic stenosis and atherosclerosis, suggesting the involvement of similar pathogenic pathways in both conditions.There are several molecules involved in regulating the development, progression and calcification of the valve sclerosis and in growth and complications of atherosclerotic plaque. Among these molecules, the receptor of advanced glycation end-products, a multi-ligand receptor involved in the pathogenesis of several degenerative, inflammatory and immune diseases, could have an important regulatory role in both diseases and therefore worthy of study as a potential target therapeutic for both conditions.