Cardiology of the future: xenotransplantation with porcine heart

The reduced availability of human donor hearts compared with the needs of patients with advanced heart failure refractory to medical therapy has promoted the search for therapeutic alternatives to cardiac allografts. Porcine heart xenotransplantation represents one of the most promising frontiers in this field today. From the first researches in the 1960s to today, the numerous advances achieved in the field of surgical techniques, genetic engineering and immunosuppression have made it possible at the beginning of 2022 to carry out the first swine-to-human heart transplant, attaining a survival of 2 months after surgery. The main intellectual and experimental stages that have marked the history of xenotransplantation, the latest acquisitions in terms of genetic editing, as well as the improvement of immunosuppressive therapy are discussed analytically in this article in order to illustrate the underlying complexity of this therapeutic model

Evidence of a double anaerobic threshold in healthy subjects

The anaerobic threshold (AT) is an important cardiopulmonary exercise test (CPET) parameter both in healthy and in patients. It is normally determined with three approaches: V-slope method, ventilatory equivalent method, and end-tidal method. The finding of different AT values with these methods is only anecdotic. We defined the presence of a double threshold (DT) when a \u394VO2 > 15\u2009mL/min was observed between the V-slope method (met AT) and the other two methods (vent AT). The aim was to identify whether there is a DT in healthy subjects

Grey zones in the supportive treatments of cardiac amyloidosis

Recent advances in the diagnosis and treatment of cardiac amyloidosis (CA) have translated into a longer life expectancy of patients and more challenging clinical scenarios. Compared to the past, patients with CA and heart failure (HF) currently encountered in clinical practice are a more heterogeneous population and require tailored strategies. The perception of CA as a treatable disease has opened new possibilities for the management of these patients, but many grey areas remain to be explored. The aim of this review is to provide practical suggestions for daily clinical activity in the management of challenging scenarios in CA, including the effectiveness and tolerability of evidence-based HF medication; rate vs. rhythm control in atrial fibrillation, thromboembolic risk, and anticoagulation therapies; replacement of severe aortic valve stenosis; the impact of implantable cardioverter defibrillator on survival; and the usefulness of cardiac resynchronization therapy

The double anaerobic threshold in heart failure: MECKI score database overview

Abstract Aims In heart failure (HF), anaerobic threshold (AT) may be indeterminable but its value held a relevant prognostic role. AT is evaluated joining three methods: V‐slope, ventilatory equivalent, and end‐tidal methods. The possible non‐concordance between the V‐slope (met AT) and the other two methods (vent AT) has been highlighted in healthy individuals and named double threshold (DT). Methods and results We reanalysed 1075 cardiopulmonary exercise tests of HF patients recruited in the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score database. We identified DT in 43% of cases. Met AT precedes vent AT being met–ventΔVO2 221 (interquartile range: 129–319) mL/min. Peak VO2, 1307 ± 485 vs. 1343 ± 446 mL/min (63 ± 17 vs. 63 ± 17 percentage of predicted), was similar between DT+ and DT− patients. Differently, DT+ showed a lower ventilatory vs. carbon dioxide production (VE/VCO2) slope (29.6 ± 6.1 vs. 31.0 ± 6.3), a lower peak exercise end‐tidal oxygen tension (PetO2) 115.3 (111.5–118.9) vs. 116.4 (112.4–120.2) mmHg, and a higher carbon dioxide tension (PetCO2) 34.2 (30.9–37.1) vs. 32.4 (28.7–35.5) mmHg. Vent AT showed a significant higher VO2, 957 ± 318 vs. 719 ± 252 mL/min, VCO2, 939 ± 319 vs. 627 ± 226 mL/min, ventilation, 31.0 ± 8.3 vs. 22.5 ± 6.3 L/min, respiratory exchange ratio, 0.98 ± 0.08 vs. 0.87 ± 0.07, PetO2, 108 (104–112) vs. 105 (101–109) mmHg, PetCO2, 37 (34–40) vs. 36 (33–39) mmHg, and VE/VO2 ratio, 33.5 ± 6.7 vs. 32.6 ± 6.9, but lower VE/VCO2 ratio, 33 (30–37) vs. 36 (32–41), compared with met AT. At 2 year survival by Kaplan–Meier analysis, even adjusted for confounders, DT resulted not associated with survival. Conclusions Double threshold is frequently observed in HF patients. DT+ is associated to a decreased ventilatory response during exercise

Prognostic Significance of Feature-Tracking Right Ventricular Global Longitudinal Strain in Non-ischemic Dilated Cardiomyopathy

Aims: Left ventricular global longitudinal strain (GLS) by cardiac magnetic resonance feature tracking (CMR-FT) analysis has shown an incremental prognostic value compared to classical parameters in non-ischemic dilated cardiomyopathy (NICM). However, less is known about the role of right ventricular (RV) GLS. Our objective was to evaluate the prognostic impact of RV-GLS by CMR-FT analysis in a population of NICM patients.Methods: In this multicenter study, we examined NICM patients evaluated with a comprehensive CMR-FT study. Major cardiac events (MACEs) were considered as the study primary outcome measure and were defined as a composite of (a) cardiovascular death, (b) cardiac transplant or destination therapy ventricular assist device, (c) hospitalization for life-threatening ventricular arrhythmias or implantable cardiac defibrillator appropriate intervention. Heart failure (HF) related events, including hospitalizations and life-threatening arrhythmia-related events were considered as secondary end-points. Receiver operating time-dependent analysis were used to calculate the possible additional effect of RV-GLS to standard evaluation.Results: We consecutively enrolled 273 patients. During a median follow-up of 39 months, 41 patients (15%) experienced MACEs. RV-GLS and LV late gadolinium emerged as the strongest prognostic CMR-FT variables: their association provided an estimated 3-year MACEs rate of 29%. The addition of RV-GLS significantly improved the prognostic accuracy in predicting MACEs with respect to the standard evaluation including LGE (areas under the curve from 0.71 [0.66-0.82] to 0.76 [0.66-0.86], p = 0.03). On competing risk analysis, RV-GLS showed a significant ability to reclassify overall both HF-related and life-threatening arrhythmia-related events, regardless of LV and RV ejection fraction.Conclusions: In NICM patients, RV-GLS showed a significant prognostic role in reclassifying the risk of MACEs, incremental with respect to standard evaluation with standard prognostic parameters

Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy

19Objectives Reduced cardiac output (CO) has been considered crucial in symptoms' genesis in hypertrophic cardiomyopathy (HCM). Absolute value and temporal behaviour of O-2-pulse (oxygen uptake/heart rate (VO2/HR)), and the VO2/work relationship during exercise reflect closely stroke volume (SV) and CO changes, respectively. We hypothesise that adding O-2-pulse absolute value and kinetics, and VO2/work relationship to standard cardiopulmonary exercise testing (CPET) could help identify more exercise-limited patients with HCM. Methods CPETs were performed in 3 HCM dedicated clinical units. We retrospectively enrolled non-end-stage consecutive patients with HCM, grouped according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuvre (72% of patients with LVOTO = 50 mm Hg). We evaluated the CPET response in HCM focusing on parameters strongly associated with SV and CO, such as O-2-pulse and VO2, respectively, considering their absolute values and temporal behaviour during exercise. Results We included 312 patients (70% males, age 49 +/- 18 years). Peak VO2 (percentage of predicted), O-2-pulse and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety-six (31%) patients with HCM presented an abnormal O-2-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106 +/- 45 vs 130 +/- 49 W), VO2 (21.3 +/- 6.6 vs 24.1 +/- 7.7 mL/min/kg; 74%+/- 17% vs 80%+/- 20%) and O-2-pulse (12 (9-14) vs 14 (11-17) mL/beat), with higher VE/VCO2 slope (28 (25-31) vs 27 (24-31)) (p<0.005 for all). Only 2 patients had an abnormal VO2/work slope. Conclusion None of the frequently used CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal temporal behaviour of O-2-pulse during exercise, which is strongly related to inadequate SV increase, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, identifying more advanced disease irrespectively of LVOTO.nonenoneMapelli, Massimo; Romani, Simona; Magrì, Damiano; Merlo, Marco; Cittar, Marco; Masè, Marco; Muratori, Manuela; Gallo, Giovanna; Sclafani, Matteo; Carriere, Cosimo; Zaffalon, Denise; Salvioni, Elisabetta; Mattavelli, Irene; Vignati, Carlo; De Martino, Fabiana; Rovai, Sara; Autore, Camillo; Sinagra, Gianfranco; Agostoni, PiergiuseppeMapelli, Massimo; Romani, Simona; Magrì, Damiano; Merlo, Marco; Cittar, Marco; Masè, Marco; Muratori, Manuela; Gallo, Giovanna; Sclafani, Matteo; Carriere, Cosimo; Zaffalon, Denise; Salvioni, Elisabetta; Mattavelli, Irene; Vignati, Carlo; De Martino, Fabiana; Rovai, Sara; Autore, Camillo; Sinagra, Gianfranco; Agostoni, Piergiusepp

Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

none25siPrognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization. Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF.Porcari, Aldostefano; Merlo, Marco; Baggio, Chiara; Gagno, Giulia; Cittar, Marco; Barbati, Giulia; Paldino, Alessia; Castrichini, Matteo; Vitrella, Giancarlo; Pagnan, Lorenzo; Cannatà, Antonio; Andreis, Alessandro; Cecere, Annagrazia; Cipriani, Alberto; Raafs, Anne; Bromage, Daniel I; Rosmini, Stefania; Scott, Paul; Sado, Daniel; Di Bella, Gianluca; Nucifora, Gaetano; Marra, Martina Perazzolo; Heymans, Stephane; Imazio, Massimo; Sinagra, GianfrancoPorcari, Aldostefano; Merlo, Marco; Baggio, Chiara; Gagno, Giulia; Cittar, Marco; Barbati, Giulia; Paldino, Alessia; Castrichini, Matteo; Vitrella, Giancarlo; Pagnan, Lorenzo; Cannatà, Antonio; Andreis, Alessandro; Cecere, Annagrazia; Cipriani, Alberto; Raafs, Anne; Bromage, Daniel I; Rosmini, Stefania; Scott, Paul; Sado, Daniel; Di Bella, Gianluca; Nucifora, Gaetano; Marra, Martina Perazzolo; Heymans, Stephane; Imazio, Massimo; Sinagra, Gianfranc