Maternal Anti-Ro/SSA Autoantibodies and Prolonged PR Interval in a Competitive Athlete: Beyond Training-Induced Electrical Remodeling

: Prolongation of the PR interval is common among competitive athletes. However, further investigations should be performed when the PR interval is markedly prolonged. We report the case of a young male athlete with an autoimmune-mediated atrioventricular block due to circulating anti-Ro/SSA-antibodies in the mother (late progressive congenital form). (Level of Difficulty: Advanced.)

Left atrial strain in patients with arterial hypertension

Background: Arterial hypertension (HTN) causes left ventricular (LV) cavity dysfunction even if ejection function (EF) remains preserved. Recent studies have shown that diastolic dysfunction and left atrial (LA) dilatation are also associated with myocardial dysfunction. The aim of the present study was to explore the nature of LA longitudinal function disturbances in hypertensive patients with normal LV and LA structure and conventional function parameters.Methods: Peak atrial longitudinal strain (PALS) was evaluated in 78 patients with systemic HTN and preserved EF (≥ 55%) divided in 41 patients with diastolic dysfunction but no hypertrophy (group HTNdd), and 37 patients with no diastolic dysfunction or hypertrophy (group eHTN). Results were compared with those from 38 age and gender-matched healthy controls.Results: Indexed LA area and indexed LA volume were within the normal range and not different between the two patient groups and controls. eHTN group had reduced global PALS (p &lt; 0.001) and four-and two-chamber average PALS (p &lt; 0.001 for both). Similar abnormalities were seen in HTNdd group but to a worse degree (P &lt; 0.01 for both). LV EF was not different between the eHTN and HTNdd groups compared to controls. LV E/e' ratio was the strongest predictor of reduced global PALS in both eHTN and HTNdd groups.Conclusion: Asymptomatic untreated HTN patients with preserved LVEF and normal diastolic function have compromised LA strain despite normal cavity size, consistent with preclinical LA myocardial dysfunction.</p

Left atrial fibrosis: an essential hallmark in chronic mitral regurgitation

Abstract Chronic mitral regurgitation (MR) is the second valvular heart disease for incidence, which worsening severity gradually affects all cardiac chambers and leads to poor outcome if untreated. The recent development of minimally invasive surgical techniques and percutaneous intervention has reduced the operative risk, allowing a more confident referral of these patients for intervention. Therefore, there is a growing need of reliable markers to select the best therapeutic strategies and to identify the optimal timing for intervention. Myocardial fibrosis (MF) gradually occurs as a result of left atrial and ventricular (LA and LV) remodeling due to MR pressure and volume overload. It has been identified as an index of clinical outcome and arrhythmic risk in patients with MR. Particularly, the assessment of LA fibrosis not only allows to define different MR etiology, but also was associated with prognosis and atrial fibrillation (AF) burden. Nowadays, noninvasive estimation of MF is possible through the use of advanced imaging modalities, particularly cardiac magnetic resonance and speckle tracking echocardiography. This review discusses the role of LA fibrosis as a diagnostic and prognostic marker in patients with MR and its quantification by noninvasive multimodality cardiac imaging

RV longitudinal deformation correlates with myocardial fibrosis in patients with end-stage heart failure

Objectives This study was performed to determine the accuracy of right ventricular (RV) longitudinal strain (LS) in predicting myocardial fibrosis in patients with severe heart failure (HF) undergoing heart transplantation. Background RVLS plays a key role in the evaluation of its systolic performance and clinical outcome in patients with refractory HF. Methods We studied 27 patients with severe systolic HF (ejection fraction 25% and New York Heart Association functional class III to IV, despite full medical therapy and cardiac resynchronization therapy) using echocardiography before heart transplantation. RV free wall LS, right atrial LS, sphericity index (SI), and tricuspid annular plane systolic excursion (TAPSE) were all measured. Upon removal of the heart, from the myocardial histologic analysis, the ratio of the fibrotic to the total sample area determined the extent of fibrosis (%). Results RV myocardial fibrosis correlated with RV free wall LS (r = 0.80; p < 0.0001), SI (r = 0.42; p = 0.01) and VO max (r = -0.41; p = 0.03), with a poor correlation with TAPSE (r = -0.34; p = 0.05) and right atrial LS (r = -0.37; p = 0.03). Stepwise multivariate analysis showed that RV free wall LS (β = 0.701, p < 0.0001) was independently associated with RV fibrosis (overall model R= 0.64, p < 0.0001). RV free wall LS was the main determinant of myocardial fibrosis. In the subgroup of patients with severe RV fibrosis, RV free wall LS had the highest diagnostic accuracy for detecting severe myocardial fibrosis (area under the curve = 0.87; 95% confidence interval: 0.80 to 0.94). Conclusions In late-stage HF patients, the right ventricle is enlarged, with reduced systolic function due to significant myocardial fibrosis. RV free wall myocardial deformation is the most accurate functional measure that correlates with the extent of RV myocardial fibrosis and functional capacity

How to evaluate resting ECG and imaging in children practising sport: a critical review and proposal of an algorithm for ECG interpretation

The athlete's heart is a well-known phenomenon in adults practising competitive sports. Unfortunately, to date, most of the studies on training-induced cardiac remodelling have been conducted in adults and the current recommendations refer mainly to adult individuals. However, an appropriate interpretation of resting ECG and imaging in children practising sports is crucial, given the possibility of early detect life-threatening conditions and managing therapy and eligibility to sports competitions in the rapidly growing paediatric athlete population. While several articles have been published on this topic in adult athletes, a practical guide for the clinical evaluation of paediatric athletes is still missing. In this critical review, we provided a comprehensive description of the current evidence on training-induced remodelling in paediatric athletes with a practical approach for clinicians on how to interpret the resting 12-lead ECG and cardiac imaging in the paediatric athlete. Indeed, given that training may mimic potential cardiovascular disorders, clinicians evaluating children practising sports should pay attention to the risk of missing a diagnosis of a life-threatening condition. However, this risk should be balanced with the risk of overdiagnosis and unwarranted disqualification from sports practice, when interpreting an ECG as pathological while, on the contrary, it may represent a physiological expression of athlete's heart. Accordingly, we proposed an algorithm for the evaluation of normal, borderline, and abnormal ECG findings that can be useful for the readers for their daily clinical practice

Wpływ lewosimendanu podawanego bez dawki nasycającej na skurczową i rozkurczową funkcję serca u pacjentów ze schyłkową niewydolnością serca

Wstęp: Lewosimendan (L) jest lekiem stosowanym w terapii ciężkiej niewydolności serca (HF). Działa inotropowo dodatnio oraz wazodylatacyjnie, nie zwiększając zapotrzebowania serca na tlen. W ostrej HF lewosimendan poprawia parametry hemodynamiczne. W dostępnych publikacjach wykazano, że pozytywnie wpływa na funkcję rozkurczową lewej komory (LV). Celem niniejszego badania była ocena wpływu lewosimendanu na zmiany długiej osi LV, która jest wczesnym markerem dysfunkcji rozkurczowej. Metody: Do badania włączono 41 pacjentów w średnim wieku 62 &#177; 12 lat przyjętych do kliniki autorów niniejszej pracy z powodu ostrej HF w klasie IV według NYHA z istotną dysfunkcją LV. Dwudziestu sześciu pacjentom podano lewosimendan w dawce 0,1 &#956;g/kg/min w ciągu 24 godzin bez dawki nasycającej (grupa L), zaś 15 chorych poddano standardowej terapii (grupa C). Wyniki: Grupy nie różniły się między sobą pod względem podstawowych danych demograficznych, klinicznych i wyników badań biochemicznych. Po tygodniu od leczenia lewosimendanem obserwowano istotną poprawę wydolności w klasie NYHA oraz obniżenie stężenia N-końcowego propeptydu natriuretycznego typu B (pro-BNP). W badaniu echokardiograficznym obserwowano poprawę funkcji skurczowej (p < 0,05) i frakcji wyrzutowej LV (p < 0,05) przy redukcji wskaźnika E/E&#8217; (p < 0,05) w grupie L. Grupę L podzielono na podgrupę z aktywnym niedokrwieniem i bez niedokrwienia oraz wykazano istotną poprawę funkcji skurczowej w pierwszej podgrupie. Nie wykazano różnic między podgrupami w odniesieniu do funkcji rozkurczowej LV. Wnioski: Stosowanie lewosimendanu bez dawki nasycającej poprawia funkcję LV i klasę NYHA u pacjentów z ostrą HF. Wydaje się, że przedłużony wpływ na parametry hemodynamiczne jest związany z działaniem aktywnych metabolitów leku. (Folia Cardiologica Excerpta 2012; 7, 2: 71-77

A multidisciplinary approach for the emergency care of patients with left ventricular assist devices: A practical guide

The use of a left ventricular assist device (LVAD) as a bridge-to-transplantation or destination therapy to support cardiac function in patients with end-stage heart failure (HF) is increasing in all developed countries. However, the expertise needed to implant and manage patients referred for LVAD treatment is limited to a few reference centers, which are often located far from the patient's home. Although patients undergoing LVAD implantation should be permanently referred to the LVAD center for the management and follow-up of the device also after implantation, they would refer to the local healthcare service for routine assistance and urgent health issues related to the device or generic devices. Therefore, every clinician, from a bigger to a smaller center, should be prepared to manage LVAD carriers and the possible risks associated with LVAD management. Particularly, emergency treatment of patients with LVAD differs slightly from conventional emergency protocols and requires specific knowledge and a multidisciplinary approach to avoid ineffective treatment or dangerous consequences. This review aims to provide a standard protocol for managing emergency and urgency in patients with LVAD, elucidating the role of each healthcare professional and emphasizing the importance of collaboration between the emergency department, in-hospital ward, and LVAD reference center, as well as algorithms designed to ensure timely, adequate, and effective treatment to patients with LVAD. Copyright © 2022 Cameli, Pastore, Mandoli, Landra, Lisi, Cavigli, D'Ascenzi, Focardi, Carrucola, Dokollari, Bisleri, Tsioulpas, Bernazzali, Maccherini and Valente

Correlation of Left Ventricular Myocardial Work Indices with Invasive Measurement of Stroke Work in Patients with Advanced Heart Failure

ObjectivesThis study aimed to explore the correlation between left ventricular (LV) myocardial work (MW) indices and invasively-derived LV stroke work index (SWI) in a cohort of patients with advanced heart failure (AHF) considered for heart transplantation. BackgroundLeft ventricular MW has emerged as a promising tool for diagnostic and prognostic purposes in heart failure (HF) but its relationship with hemodynamic data derived from right heart catheterization (RHC) has not been assessed in patients with advanced heart failure yet. Materials and methodsConsecutive patients with AHF considered for heart transplantation from 2016 to 2021 performing RHC and echocardiography as part of the workup were included. Conventional LV functional parameters and LV MW indices, including LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), LV global work efficiency (GWE), and other were calculated and compared with invasively-measured LV SWI. ResultsThe population included 44 patients. Median time between RHC and echocardiography was 0 days (IQR: 0-24). Median age was 60 years (IQR: 54-63). For the most part, etiology of HF was non-ischemic (61.4%) and all patients were either on class NYHA II (61.4%) or III (27.3%). Median left ventricular ejection fraction was 25% (IQR: 22.3-32.3), median NT-proBNP 1,377 pg/ml (IQR: 646-2570). LV global longitudinal strain (GLS) significantly correlated with LV SWI (r = -0.337; p = 0.031), whereas, LV ejection fraction (EF) did not (r = 0.308; p = 0.050). With regard to LV MW indices, some of them demonstrated correlation with LV SWI, particularly LV GWI (r = 0.425; p = 0.006), LV GCW (r = 0.506; p = 0.001), LV global positive work (LV GPW; r = 0.464; p = 0.003) and LV global systolic constructive work (GSCW; r = 0.471; p = 0.002). ConclusionAmong LV MW indices, LV GCW correlated better with invasively-derived SWI, potentially representing a powerful tool for a more comprehensive evaluation of myocardial function

Eligibility for vericiguat in a real‐world, contemporary heart failure population

Aims: Vericiguat is a soluble guanylate cyclase stimulator and improves survival in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and an increased risk of decompensation. As real-world data on how many patients could be eligible for vericiguat therapy derive from outdated registries, we aimed to assess eligibility in a prospective cohort of patients with HF. Methods and results: Data from consecutive HF patients undergoing an elective ambulatory visit at five university hospitals from 3 July to 28 July 2023 were collected. Independent investigators assessed which patients (i) met the eligibility criteria of the VICTORIA trial, (ii) complied with HF guideline recommendations, (iii) met regulatory agency criteria, or (iv) met criteria for refundability according to the Italian regulatory agency. Patients (n&nbsp;=&nbsp;346, 72% men, median age 69&nbsp;years) had HFrEF in 57% of cases, left ventricular ejection fraction&nbsp;&lt;&nbsp;45% in 68%, and New York Heart Association class II-IV symptoms in 76%. Patients meeting the eligibility criteria of the VICTORIA trial or European and American HF Guideline recommendations were 9% and 13%, respectively. Patients meeting Food and Drug Administration (FDA) or European Medicines Agency (EMA) label criteria were 19% and 17%, respectively. Drug costs would be covered by the Italian National Health System in 10% of patients [if a sodium-glucose cotransporter-2 inhibitor (SGLT2i) is not mandatory] or in 8% (if an SGLT2i is requested). Conclusions: In a real-world study, 9% of patients met the eligibility criteria of the VICTORIA trial, but up to 13% complied with guideline recommendations and up to 19% met FDA or EMA criteria. In Italy, drug costs would be covered by up to 10% of patients