Deep Dive into Atrial Functional Mitral Regurgitation

Atrial functional mitral regurgitation (AFMR) has been recently recognized as a subcategory of functional mitral regurgitation characterized by severe left atrial (LA) dilation and normal left vent..

The management of non-culprit coronary lesions in patients with acute coronary syndrome

About 50% of patients diagnosed with ST-segment elevation myocardial infarction have multivessel disease on coronary angiography. Recent evidence has shown that a staged percutaneous coronary intervention (PCI) strategy of non-culprit lesions, achieving complete revascularization, significantly reduces the rate of recurrent cardiovascular events compared with a PCI strategy limited to culprit lesion. Although functional evaluation of intermediate coronary stenoses by functional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is widely used to detect residual myocardial ischaemia, the reliability of the study of non-culprit lesions in the acute phase of heart attack is controversial. On the other hand, the excess of new events in patients with acute coronary syndrome in whom PCI was deferred on the basis of FFR/iFR compared to patients with stable CAD could be due to both an inadequate functional evaluation and an intrinsic higher risk, related to the presence of untreated vulnerable plaques. In this context, intra-coronary imaging has shown that the presence of vulnerability features in non-culprit plaques is associated with an increased rate of ischaemic recurrence

Application of unsupervised learning and process simulation for energy optimization of a WWTP under various weather conditions

This paper outlines a hybrid modeling approach to facilitate weather-based operation and energy optimization for the largest Italian wastewater treatment plant (WWTP). Two clustering methods, K-means algorithm and Gaussian mixture model (GMM) based on the expectation-maximization (EM) algorithm, were applied to an extensive data set of historical and meteorological records. This study addresses the problem of determining the intrinsic structure of clustered data when no information other than the observed values is available. Two quantitative indexes, namely the Bayesian Information Criterion (BIC) and the Silhouette coefficient using Euclidean distance, as well as two general criteria, were implemented to assess the clustering quality. Furthermore, seven weather-based influent scenarios were introduced to the process simulation model, and sets of aeration strategies are proposed. The results indicate that incorporating weather-based aeration strategies in the operation of WWTP improves plant energy efficiency

Disorder of sex development: a rare case of a boy with an XY karyotype and Magnetic Resonance Imaging findings of hermaphroditism

Disorders of sexual differentiation are rare congenital conditions in which the chromosomal, anatomic or gonadal sex development is atypical. In some of these patients, chromosomal sex is inconsistent with phenotypic sex; in other cases, the phenotype is not classifiable as either male or female, resulting in a condition known as ambiguous genitalia. These are very complex cases in which diagnostic certainty is not always possible. A multidisciplinary team including geneticists, pediatricians, radiologists is certainly needed to approach these patients. We present the case of an 18-year-old boy with an XY karyotype, ambiguous genitalia, uterus and blind-ending vaginal pouch. The patient had not been previously diagnosed with a disorder of sex development. The patient underwent a panel of genetic analyses and diagnostic imaging investigations. Magnetic resonance imaging was decisive for the identification of the internal genital organs, especially the uterus. At the end of investigations, the patient was diagnosed with 46,XY disorder of sex development. Our purpose is to underline the role of imaging in the diagnosis and management of congenital disorders of sex differentiation

Energy optimization of a wastewater treatment plant based on energy audit data : small investment with high return

Ambitious energy targets in the 2020 European climate and energy package have encouraged many stakeholders to explore and implement measures improving the energy efficiency of water and wastewater treatment facilities. Model-based process optimization can improve the energy efficiency of wastewater treatment plants (WWTP) with modest investment and a short payback period. However, such methods are not widely practiced due to the labor-intensive workload required for monitoring and data collection processes. This study offers a multi-step simulation-based methodology to evaluate and optimize the energy consumption of the largest Italian WWTP using limited, preliminary energy audit data. An integrated modeling platform linking wastewater treatment processes, energy demand, and production sub-models is developed. The model is calibrated using a stepwise procedure based on available data. Further, a scenario-based optimization approach is proposed to obtain the non-dominated and optimized performance of the WWTP. The results confirmed that up to 5000 MWh annual energy saving in addition to improved effluent quality could be achieved in the studied case through operational changes only

Left atrioventricular coupling index in hypertrophic cardiomyopathy and risk of new-onset atrial fibrillation

BackgroundsThis study aimed to investigate the association between left atrioventricular coupling index (LACI) and the occurrence of atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM).MethodsA total of 373 patients with HCM and no history of AF were evaluated by transthoracic echocardiography. LACI was defined by the ratio of left atrial (LA) end-diastolic volume divided by left ventricular (LV) end-diastolic volume. The cut-off value for LACI (≥40%) to identify LA-LV uncoupling was chosen based on the risk excess of new-onset AF described with a spline curve analysis.ResultsThe median LACI was 37.5% (IQR: 24.4–56.7) and LA-LV uncoupling (LACI ≥40%) was observed in 171 (45.8%) patients. During a median follow-up of 11 (IQR 7–15) years, 118 (31.6%) subjects developed new-onset AF. The cumulative event-free survival at 10 years was 53% for patients with LA-LV uncoupling versus 94% for patients without LA-LV uncoupling (p p ConclusionIn patients with HCM, LACI was more predictive of the occurrence of new-onset AF than conventional LA parameters.</p

Noninvasive Left Ventricular Myocardial Work in Patients with Chronic Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

BackgroundLeft ventricular (LV) global longitudinal strain (GLS) has been proposed as a sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and preserved LV ejection fraction (LVEF). However, LV GLS does not take into account the afterload. Noninvasive LV myocardial work is a novel parameter of LV myocardial performance, which integrates measurements of myocardial deformation and noninvasive blood pressure (afterload). The aims of this study were (1) to assess noninvasive LV myocardial work in patients with chronic AR and preserved LVEF and its correlation with other echocardiographic parameters, (2) to evaluate changes of LV myocardial work after aortic valve replacement or repair (AVR), and (3) to assess the relationship between LV myocardial work and postoperative LV reverse remodeling.MethodsFifty-seven patients (53 ± 16 years; 67% men) with moderate or severe chronic AR and preserved LVEF treated by AVR were included. Noninvasive LV myocardial work indices were measured at baseline and postoperatively (between 2 and 12 months after surgery) and compared with previously reported normal reference ranges.ResultsBased on normal reference values, patients with chronic AR and preserved LVEF had preserved or increased values of LV global work index (GWI; 82% and 18%, respectively) and LV global constructive work (GCW; 74% and 25%, respectively) and preserved LV global work efficiency (GWE). Left ventricular GWI and GCW showed a positive correlation with markers of AR severity and parameters of LV systolic function. Left ventricular GWI, GCW, and GWE decreased after AVR (P P = .28). The postoperative impairment of LV GWI, observed in 28% of patients, was closely associated with reduced LV reverse remodeling.ConclusionsNoninvasive myocardial work may allow better understanding of myocardial function and energetics than afterload-dependent echocardiographic parameters in chronic AR with preserved LVEF.</p

Cardiovascular Effects of Autologous Bone Marrow-Derived Mesenchymal Stromal Cell Therapy With Early Tacrolimus Withdrawal in Renal Transplant Recipients: An Analysis of the Randomized TRITON Study

BackgroundAfter renal transplantation, there is a need of immunosuppressive regimens that effectively prevent allograft rejection while minimizing cardiovascular complications. This substudy of the TRITON trial evaluated the cardiovascular effects of autologous bone marrow–derived mesenchymal stromal cells (MSCs) in renal transplant recipients.Methods and ResultsRenal transplant recipients were randomized to MSC therapy, infused at weeks 6 and 7 after transplantation, with withdrawal at week 8 of tacrolimus or standard tacrolimus dose. Fifty‐four patients (MSC group=27; control group=27) underwent transthoracic echocardiography at weeks 4 and 24 after transplantation and were included in this substudy. Changes in clinical and echocardiographic variables were compared. The MSC group showed a benefit in blood pressure control, assessed by a significant interaction between changes in diastolic blood pressure and the treatment group (P=0.005), and a higher proportion of patients achieving the predefined blood pressure target of ConclusionsMSC strategy is associated with improved blood pressure control, regression of left ventricular hypertrophy, and prevention of progressive diastolic dysfunction at 24 weeks after transplantation.</p

Right Ventricular Reverse Remodeling After Tricuspid Valve Surgery for Significant Tricuspid Regurgitation

BackgroundChanges in right ventricular (RV) dimensions and function after tricuspid valve (TV) surgery and their association with long-term outcomes remain largely unexplored. The current study evaluated RV reverse remodeling, based on changes in RV dimensions and function, after TV surgery for significant (moderate or severe) tricuspid regurgitation (TR) and their association with outcome.MethodsA total of 121 patients (mean age 63 ± 12 years, 47% males) with significant TR treated with TV surgery were included in this analysis. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodeling and independent associates of mortality were investigated.ResultsTertile 3 consisted of patients presenting with a reduction in RVESA ≥17.2% and an improvement in RVFAC ≥2.3% after TV surgery. Cumulative survival rates were significantly better in patients within tertile 3 of RVESA reduction: 90% vs. 49% for tertile 1 and 69% for tertile 2 (log-rank p = 0.002) and within tertile 3 of RVFAC improvement: 87% vs. 57% for tertile 1 and 65% for tertile 2 (log-rank p = 0.02). Tertiles 3 of RVESA reduction and RVFAC improvement were both independently associated with better survival after TV surgery compared to tertiles 1 (hazard ratio: 0.221 [95% CI: 0.074-0.658] and 0.327 [95% CI: 0.118-0.907], respectively).ConclusionsThe extent of RV reverse remodeling, based on reduction in RVESA and improvement in RVFAC, was associated with better survival at 5-year follow-up of TV surgery for significant TR.</p

Left atrial dysfunction is an independent predictor of mortality in patients with cirrhosis treated by transjugular intrahepatic portosystemic shunt

The present study aimed to investigate (1) the association between left ventricular diastolic dysfunction (LVDD), graded according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium, and long-term survival in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) and (2) the additive prognostic value of left atrial (LA) function, as assessed by LA reservoir strain, using two-dimensional speckle-tracking echocardiography (2D-STE). A total of 129 TIPS candidates (mean +/- SD, 61 +/- 12 years; 61% men) underwent a comprehensive preprocedural echocardiography. LA dysfunction was defined by LA reservoir strain <= 35%, based on a previously suggested cut-off value. The outcome was all-cause mortality after TIPS. In the current cohort, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD, and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (based on LA reservoir strain <= 35%) was noted in 67 (52%) patients. After a median follow-up of 36 months (range, 12-80), 65 (50%) patients died. All-cause mortality rates increased along worse grades of LVDD (log-rank p = 0.007) and with LA dysfunction (log-rank p = 0.001). On multivariable Cox regression analysis, Model for End-Stage Liver Disease score (hazard ratio [HR],1.06; p = 0.003), hemoglobin (HR, 0.74; p = 0.022), and LA strain, expressed as a continuous variable (HR, 0.96; p = 0.005) were independently associated with all-cause mortality. Notably, the addition of LA strain to the model provided incremental prognostic value over the established prognostic variables (delta chi(2) = 8.27, p = 0.004). Conclusion: LA dysfunction assessed with 2D-STE is independently associated with all-cause mortality in patients with cirrhosis treated by TIPS