Inappropriate Asystole Detection in Early Postoperative Phase after Loop Recorder Implantation

The implantable loop recorder is a useful diagnostic tool for patients with unexplained syncope. The capability to automatically detect and store arrhythmic events, implemented in the last generations of these devices, can further improve the diagnostic yield, but this feature can be compromised by inappropriate detection of false arrhythmias. We herein report the case of a patient in which several inappropriate activations of long-lasting asystole occurred in the two days following the implant, probably because of an intermittently loose contact between the device and subcutaneous tissue for a small pocket haematoma

Left atrial conduit flow rate at baseline and during exercise: an index of impaired relaxation in HFpEF patients

Aims In healthy subjects, adrenergic stimulation augments left ventricular (LV) long-axis shortening and lengthening, and increases left atrial (LA) to LV intracavitary pressure gradients in early diastole. Lower increments are observed in patients with heart failure with preserved ejection fraction (HFpEF). We hypothesized that exercise in HFpEF would further impair passive LV filling in early-mid diastole, during conduit flow from pulmonary veins. Methods and results Twenty HFpEF patients (67.8 ± 9.8 years; 11 women), diagnosed using 2007 ESC recommendations, underwent ramped semi-supine bicycle exercise to submaximal target heart rate (∼100 bpm) or symptoms. Seventeen asymptomatic subjects (64.3 ± 8.9 years; 7 women) were controls. Simultaneous LA and LV volumes were measured from pyramidal 3D-echocardiographic full-volume datasets acquired from an apical window at baseline and during stress, together with brachial arterial pressure. LA conduit flow was computed from the increase in LV volume from its minimum at end-systole to the last frame before atrial contraction (onset of the P wave), minus the reduction in LA volume during the same time interval; the difference was integrated and expressed as average flow rate, according to a published formula. The slope of single-beat preload recruitable stroke work (PRSW) quantified LV inotropic state. 3D LV torsion (rotation of the apex minus rotation of the base divided by LV length) was also measurable, both at rest and during stress, in 10 HFpEF patients and 4 controls. There were divergent responses in conduit flow rate, which increased by 40% during exercise in controls (+17.8 ± 37.3 mL/s) but decreased by 18% in patients with HFpEF (−9.6 ± 42.3 mL/s) (P = 0.046), along with congruent changes (+1.77 ± 1.13°/cm vs. −1.94 ± 2.73°/cm) in apical torsion (P = 0.032). Increments of conduit flow rate and apical torsion during stress correlated with changes in PRSW slope (P = 0.003 and P = 0.006, respectively). Conclusions In HFpEF, conduit flow rate decreases when diastolic dysfunction develops during exercise, in parallel with changes in LV inotropic state and torsion, contributing to impaired stroke volume reserve. Conduit flow is measurable using 3D-echocardiographic full-volume atrio-ventricular datasets, and as a marker of LV relaxation can contribute to the diagnosis of HFpEF

Atrioventricular and ventricular properties in patients implanted with CRT as descriptors of acute changes during device optimization

Background. There is strong evidence that CRT reduces mortality and hospitalization. Unfortunately, there are still no available parameters to identify non-responders. Purpose. We test if parameters, describing dyssynchrony and efficiency, can better identified acute recovery of ventricles treated with a CRT and if lead position can modify this relationship. Methods. We enrolled 65 patients referred for CRT implantation. We performed a CRT-off and /\u2013on 2d- and 3d echocardiogram during devices optimization. We assessed left ventricular (LV) volumes 3D; then, by the peckletracking analysis we evaluated ventricular dyssynchrony, based on temporary uniformity of strain (TUS) 3D long and circ. We obtained also non-invasivally myocardial efficiency (Effic) based on interaction between pressure work index (PWI), representing an estimation of myocardial oxygen consumption, and mechanical external work. At the end, we indicate as concordant, patients presenting LV lead position (defined from a chest X-ray) in the same segment as the latest systolic 3Dcircunferantial strain curves. Results. No statistically significant differences were found both in the diastolic parameters and in atrial function. There was some trend for improvement for both longitudinal and circumferential 3D TUS during CRT-on. Only Effic demonstrated an important gain between CRT-off/-on phase. The analysis of the matrix CRT off/on and LV lead, demonstrated only a statistically significant improvement for Effic between CRT-off/on phase (p=0,01), although without any significant interaction. At the end, the MANOVA test suggested a statistically significant interaction (p=0,04) between the behavior of our ventricular parameters (Effic, PWI and TUS 3Dlong) in relation to CRT on/off and LV lead concordance/discordance. Conclusions. Evaluation of lead position relative to the LV segment with latest 3D circ strain could ameliorate concordance, improving Effic and minimizing the number of non-responders

Coronary sinus for cardiac resynchronization therapy: leave it alone and go for the branch! a case report

Coronary sinus is the target of an increasing number of percutaneous interventional procedures. Thus, in some patients, conventional cardiac resynchronization therapy (CRT) may not be feasible or preferable, and 'alternative' CRT approaches should be applied

Infective endocarditis complicating COVID-19 pneumonia: a case report

During the COVID-19 outbreak, cardiovascular imaging, especially transoesophageal echocardiography (TOE), may expose healthcare personnel to virus contamination and should be performed only if strictly necessary. On the other hand, transthoracic echocardiography (TTE) and TOE represent the first-line imaging exams for the diagnosis of infective endocarditis (IE). To date, this is the first case of COVID-19 complicated by IE

Potential role of cardiopulmonary exercise testing in evaluating functional improvement after transcatheter edge-to-edge tricuspid valve repair: a case report

Background Tricuspid regurgitation (TR) is common and severe or greater TR is linked to poor prognosis. Treatment of TR with transcatheter edge-to-edge repair has emerged as a safe and potentially effective therapy in these patients. However, the impact of transcatheter tricuspid repair on functional capacity remains to be elucidated.Case summary We describe the case of a 77-year-old woman complaining of heart failure symptoms, undergoing transcatheter edge-to-edge valve repair for severe TR with the PASCAL Ace (R) device. One month later, cardiopulmonary exercise testing (CPET) showed significant improvement in peak O2 uptake and O2 pulse compared with the test performed before the procedure.Discussion A positive impact of novel transcatheter edge-to-edge valve repair on symptoms and quality of life in patients with severe or greater TR at prohibitive surgical risk has recently emerged. The presence of severe TR has prognostic relevance, and novel percutaneous tricuspid valve repair systems have emerged in the last few years. Cardiopulmonary exercise testing is an established tool to assess functional capacity and prognosis in heart failure patient. Detecting functional capacity improvement after transcatheter edge-to-edge repair for severe TR can be challenging, and CPET may arise as a promising tool to help these purposes

Usefulness of a multiparametric evaluation including global longitudinal strain for an early diagnosis of acute myocarditis

Cardiac magnetic resonance imaging (CMRI) represents the main imaging modality for diagnosing acute myocarditis. However, its limited availability could entail missing or delayed diagnosis. A reduction of left ventricular global longitudinal strain (LV GLS) by speckle tracking echocardiography (STE) correlates with amount of oedema in acute myocarditis and here may be early detected. Aim was to evaluate the diagnostic and prognostic role of 3-layers LV GLS in patients with acute myocarditis. Out of 122 patients with suspected acute myocarditis, a total of 86 consecutive patients with CMRI-confirmed acute myocarditis admitted in two Italian institutions were retrospectively screened. Exclusion criteria were met in 29 patients because of poor acoustic window or missing data. A total of 57 patients were then included. Clinical characteristics, laboratory examinations, transthoracic echocardiography data and STE parameters were collected early after hospitalization. In the study population, mean age was 38.8 +/- 15.6 years, the prevalence of male gender was 90%. On admission, 22 patients (39%) had fever (body temperature > 37.5 degrees), mean white blood cell (WBC) count was 10.9 +/- 1.7/103 and overall LV ejection fraction was 50.1% +/- 11.2. An epicardial LV GLS 10.0/103 was able to identify all patients with CMRI-diagnosed acute myocarditis. An epicardial LV GLS < 15.3% (absolute value) at baseline significantly predicted the lack of myocarditis resolution during follow-up (AUC 0.76, 95% CI 0.58-0.93, p = 0.02). A multiparametric model including epicardial LV GLS, fever and elevated WBC count on admission could be useful for early diagnosing an acute myocarditis, especially when CMRI is not promptly available. Baseline epicardial LV GLS may also identify patients with less-likely myocarditis resolution

Non-invasively estimated left atrial stiffness is associated with short-term recurrence of atrial fibrillation after electrical cardioversion

Background As atrial stiffness (Kla) is an important determinant of cardiac pump function, better mechanical characterization of left atrial (LA) cavity would be clinically relevant. Pulmonary venous ablation is an option for atrial fibrillation (AF) treatment that offers a powerful context for improving our understanding of LA mechanical function. We hypothesized that a relation could be detected between invasive estimation of Kla and new non-invasive deformation parameters and traditional LA and left ventricular (LV) function descriptors, so that Kla can be estimated non-invasively. We also hypothesized that a non-invasive surrogate of Kla would be useful in predicting AF recurrence after cardioversion. Methods In 20 patients undergoing AF ablation, LA pressure–volume curves were derived from invasive pressure and echocardiographic images; Kla was calculated during ascending limb of V-loop as ΔLA pressure/ΔLA volume. 2D-speckle-tracking echocardiographic LA and LV longitudinal strains and volumes, ejection fraction (EF) and ventricular stiffness (Klv), as obtained from mitral deceleration time, were tested as non-invasive Kla predictors. In 128 sinus rhythm patients 1 month after electrical cardioversion for persistent AF, non-invasively estimated Kla (computed-Kla) was tested as predictor of recurrence at 6 months. Results Tertiles of mean LA pressure correlated with increasing Kla (trend, p = 0.06) and decreasing LA peak strain, LVEF, and LV longitudinal strain (p = 0.029, p = 0.019, and p = 0.024). There were no differences in LA and LV volumes and Klv across groups. Multiple regression analysis identified LV longitudinal strain as the only independent predictor of Kla (p = 0.014). Patients in highest quartile of computed-Kla (estimated as [log] = 0.735 + 0.051 × LV strain) tended to have highest AF recurrence rate (25%) as compared with remaining 3 quartiles (9%, 9%, 3%, p = 0.09). Conclusion Kla can be assessed invasively in patients undergoing AF ablation and it can be estimated non-invasively using LV strain. AF recurrence after cardioversion tends to be highest in highest quartile of computed-Kla

Acute contractile recovery extent during biventricular pacing is not associated with follow-up in patients undergoing resynchronization

It has been reported that contractility, as assessed using dobutamine infusion, is independently associated with reverse remodeling after CRT. Controversy, however, exists about the capacity of this approach to predict a long-term clinical response. This studys purpose was to assess whether long-term CRT clinical effects can be predicted according to acute inotropic response induced by biventricular stimulation (CRT on), as compared with AAI–VVI right stimulation pacing mode (CRT off), quantified at the time of implantation. In 98 patients (ejection fraction 29 ± 10%), acute changes in left ventricular (LV) elastance (Ees), arterial elastance (Ea), and Ees/Ea, as assessed from slope changes of the force–frequency relation obtained when the heart rate increased, and also assessed while measuring triplane LV volumes and continuous noninvasive blood pressure, were related to death or rehospitalization during a 3-year follow-up. Other covariances tested were age, gender, disease etiology, QRS duration, amount of mitral regurgitation, LV diastolic volume, ejection fraction, and the degree of asynchrony and longitudinal strain at baseline. There was a marked increment in the Ees slope with CRT (interaction P = 0.004), no Ea change, and modest Ees/Ea increase (interaction P < 0.05). In Cox analysis, however, neither slope changes nor baseline values of Ees, Ea, and Ees/Ea were associated with long-term follow-up. Only ventricular diastolic volume (direct relation P = 0.002) and QRS duration (inverse relation P = 0.009) predicted death/rehospitalization. Acute contractile recovery in CRT patients is not associated with 3 years prognosis. Instead, death or rehospitalization can be predicted from QRS duration and LV diastolic volume at baseline