704-3 Relation of Neurohormonal Activation to Functional Class in Patients with Primary or Precapillary Secondary Pulmonary Hypertension

Intense neurohormonal activation has been demonstrated in patients with primary or precapillary secondary pulmonary hypertension (PH) but the relation of neurohormons to functional impairment is not well known. Plasma levels of atrial natriuretic peptide (ANP), aldosterone (ALD), renin activity (PRA), epinephrine (PE), norepinephrine (PNE) and endothelin (ET) were assessed from the antecubital vein in 12 patients with primary PH, 7 patients with precapillary secondary PH (2 connective tissue disease, 2 chronic thromboembolic, 3 closed atrial septal defect) and 10 control subjects. Twelve patients were in NYHA functional class II (PH-II) and 7 in class III/IV (PH-III/IV). Mean PA pressure (PAP), cardiac index (CI), pulmonary vascular resistance (PVR) and right atrial pressure were assessed by heart catheterization:PAPCIPVRRAP(mmHg)(l/minlm2)(RU)(mmHg)PH-II53 ± 132.4 ± 0.412 ± 33 ± 2PH-III/IV61 ± 92.0 ± 0518 ± 611 ±5P0.170.070.0090.0001Neurohormons plasma levels in control subjects (C), PH-II and PH-III/IV patients were as follows:ANPALDPRAPEPNEET(pg/ml)(pg/ml)(ng/ml/h)(pg/ml)(pg/ml)(pg/ml)C58 ± 18110 ± 650.7 ± 0.433 ± 19220 ± 1011.7 ± 0.3PH-II167 ± 96*144 ± 10215 ± 2.0298 ± 263*420 ± 294*3.6 ± 1.4*PH-III/IV276 ± 153*†209 ± 2703.2 ± 3.9*462 ± 524*820 ± 693*†8.4 ± 3.9*°*p < 0.05 vs C° p < 0.001 vs PH-II †P < 0.09 vs PH-IIConclusionsNeurohormonal activation in primary or precapillary secondary PH is detectable also in patients without overt clinical and hemodynamic signs of right heart failure (PH-II). Neurohormonal activation seems to be progressive and is more severe in functional class III/IV patients. ET shows the best statistically significant relation with functional impairment

Educational pathway, competence, indication and quality process of the new classification of echocardiography according to the appropriateness of use and application

In continuation of a previous publication, the present study will take into account for each application and profile the clinical use, the minimal data settings, the echo data findings, the indications, the quality process, the accreditation requirements, educational tailored pathway contents and modalities. The aim of the present document was to define the main applications of echocardiography and to tailor for each application-derived profile, according with the previous definitions, requirements that clearly identify the indication, objective, clinical situation in which echocardiography is used, educational pathway and training, quality process and accreditation. © 2014 Italian Federation of Cardiology

Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: Expert opinion of the Italian Society of Cardiology and GISE

The introduction of percutaneous treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) remains one of the greatest achievements of interventional cardiology. In fact, TAVI emerged as a better option than either medical therapy or balloon aortic valvuloplasty for patients who cannot undergo surgical aortic valve replacement (SAVR) or are at high surgical risk. Recently, increased operator experience and improved device systems have led to a worldwide trend toward the extension of TAVI to low-risk or intermediate-risk patients. In this expert opinion paper, we first discuss the basic pathophysiology of aortic stenosis in different settings then the key results of recent clinical investigations on TAVI in intermediate-risk aortic stenosis patients are summarized. Particular emphasis is placed on the results of the nordic aortic valve intervention, placement of aortic transcatheter valves (PARTNER) 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation Randomized trials. The PARTNER 2 was the first large randomized trial that evaluated the outcome of TAVI in patients at intermediate risk. The PARTNER 2 data demonstrated that TAVI is a feasible and reasonable alternative to surgery in intermediate-risk patients (Society of Thoracic Surgeons 4-8%), especially if they are elderly or frail. There was a significant interaction between TAVI approach and mortality, with transfemoral TAVI showing superiority over SAVR. Moreover, we examine the complementary results of the recently concluded Surgical Replacement and Transcatheter Aortic Valve Implantation trial. This prospective randomized trial demonstrated that TAVI is comparable with surgery (primary end point 12.6% in the TAVI group vs. 14.0% in the SAVR group) in severe aortic stenosis patients deemed to be at intermediate risk. We review the most relevant clinical evidence deriving from nonrandomized studies and meta-analyses. Altogether, clinical outcome available data suggest that TAVI with a newer generation device might be the preferred treatment option in this patient subgroup. Finally, the differences between the latest European and American Guidelines on TAVI were reported and discussed. The conclusion of this expert opinion article is that TAVI, if feasible, is the treatment of choice in patients with prohibitive or high surgical risk and may lead to similar or lower early and midterm mortality rates compared with SAVR in intermediate-risk patients with severe aortic stenosis