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

TAPSE: An old but useful tool in different diseases

5noreservedRV function is an important component of overall heart function with prognostic value in predicting symptomatic limitation and outcome in different cardiovascular pathologies. RV longitudinal contraction accounts for the majority of total RV function, up to 80%, as compared to transverse shortening. Calculation of RV volume and RV ejection fraction (RVEF) remains hampered by the complex RV geometry and we lack a good geometric model allowing the calculation of right ventricular ejection fraction; secondly, the large apical trabeculations of the right ventricle make the endocardial delineation more difficult to obtain than for the left ventricle. To notice, the gold standard method for the assessment of the chamber (MRI) is resource intensive and cannot be employed in many settings. Considering these problems, multiple parameters have been developed for the evaluation of RV systolic function: tricuspid annular plane systolic excursion (TAPSE), systolic excursion velocity (S′), and longitudinal strain by speckle tracking.mixedAloia, Elio; Cameli, Matteo; D'Ascenzi, Flavio; Sciaccaluga, Carlotta; Mondillo, SergioAloia, Elio; Cameli, Matteo; D'Ascenzi, Flavio; Sciaccaluga, Carlotta; Mondillo, Sergi

Syncope in the Young Adult and in the Athlete: Causes and Clinical Work-up to Exclude a Life-Threatening Cardiac Disease

Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. It is usually a benign event, but sometimes it may represent the initial presentation of several cardiac disorders associated with sudden cardiac death during physical activity. A careful evaluation is essential particularly in young adults and in competitive athletes in order to exclude the presence of an underlying life-threatening cardiovascular disease. The present review analyzes the main non-cardiac and cardiac causes of syncope and the contribution of the available tools for differential diagnosis. Clinical work-up of the athlete with syncope occurring in extreme environments and management in terms of sports eligibility and disqualification are also discussed

Reference values of left atrial size and function according to age: should we redefine the normal upper limits?

Different cut-offs have been proposed for left atrial (LA) size. Furthermore, conflicting results have been reported about the influence of age on LA size and data on the impact of age on LA myocardial function are scanty. The aim of this study was to derive references values for LA size and function in healthy subjects and to evaluate the impact of age. We conducted a systematic literature search of MEDLINE database. We included only studies evaluating healthy subjects, with age ranged between 18 and 80 years. Parameters were compared among four age groups, 45–60, > 60 years. Three hundred twenty-six studies met the inclusion criteria and the final population consisted of 62,821 subjects. LA volume index (LAVi) did not differ among different age groups (p = 0.21). The normal upper limit of LAVi was 24 mL/m 2 . LA reservoir function, measured by strain, did not differ among age groups (38 ± 3%, 32–43%; p = 0.74). Left ventricular (LV) size and function were not different among groups, except LV mass index. A decrease in E/A ratio and an increase in E/e′ ratio were found with advancing age (p < 0.0001 and p = 0.001, respectively). In healthy subjects the normal upper limit of LAVi was lower than that recommended and is not influenced by advancing age. Furthermore, also LA function measured by strain was not affected by age. The current reference values of LAVi should be used with caution when applied to healthy subjects

COVID-19 in patients with heart failure: the new and the old epidemic

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread in nearly 200 countries in less than 4&nbsp;months since its first identification; accordingly, the coronavirus disease 2019 (COVID 2019) has affirmed itself as a clinical challenge. The prevalence of pre-existing cardiovascular diseases in patients with COVID19 is high and this dreadful combination dictates poor prognosis along with the higher risk of intensive care mortality. In the setting of chronic heart failure, SARS-CoV-2 can be responsible for myocardial injury and acute decompensation through various mechanisms. Given the clinical and epidemiological complexity of COVID-19, patiens with heart failure may require particular care since the viral infection has been identified, considering an adequate re-evaluation of medical therapy and a careful monitoring during ventilation. ©Published by BMJ

Left ventricular assist device in cardiac amyloidosis: friend or foe?

The prevalence of cardiac amyloidosis has progressively increased over the last years, being recognized as a significant cause of heart failure. In fact, the management of advanced heart failure is a cornerstone treatment of amyloid cardiomyopathy due to the frequent delay in its diagnosis. Left ventricular assist devices (LVADs) have been gaining importance in the scenario of end-stage heart failure, representing an alternative to heart transplant. However, only few studies have investigated the role of LVAD in restrictive cardiomyopathies such as cardiac amyloidosis, since there are several problems to consider. In fact, both anatomical factors and the restrictive physiology of this condition make LVAD implant a relevant challenge in this subset of patients. Furthermore, due to the systemic involvement of amyloidosis, several factors have to be considered after LVAD implant, such as an increased risk of bleeding and right ventricular failure. This review attempts to summarize the current evidence of LVAD in cardiac amyloidosis, especially focusing on the challenges that this cardiomyopathy imposes both to the implant and to its management thereafter. © 2022, The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature

Heart transplantation and anti‐HLA antibodY: myocardial dysfunction and prognosis ‐ HeartLAy study

Abstract Aims The presence of anti‐human leucocyte antigen (HLA) antibodies has been implicated in a higher incidence of complications as well as mortality rate in heart transplantation. The aim of the study was to identify through non‐invasive parameters early signs of myocardial dysfunction in the presence of anti‐HLA antibodies but without evidence of antibody‐mediated rejection (AMR) and its possible prognostic impact. Methods and results A total of 113 heart‐transplanted patients without acute cellular rejection (ACR) and AMR or cardiac allograft vasculopathy (CAV) were prospectively enrolled and divided into two groups [‘HLA+’ (50 patients) and ‘HLA−’ (63 patients)], based on the presence of anti‐HLA antibodies. Each patient was followed for 2 years after the enrolment, recording episodes of AMR, ACR, CAV, and mortality. Clinical characteristics were similar between the two groups. Among laboratory data, N‐terminal pro‐B‐type natriuretic peptide and high‐sensitivity cardiac troponin values were significantly higher in the presence of anti‐HLA antibodies (P < 0.001 and P = 0.003, respectively). The echocardiographic parameters that showed a statistically significant difference between the two groups were deceleration time of E wave (DecT E, P < 0.001), left ventricular global longitudinal strain (P < 0.001), tricuspid annular plane systolic excursion (P = 0.011), tricuspid S′ wave (P = 0.002), and free wall right ventricular longitudinal strain (fwRVLS, P = 0.027), whereas left atrial strain did not differ significantly (P = 0.408). Univariate analysis showed that anti‐HLA antibodies were associated with the development of CAV at both 1 and 2 year follow‐up [odds ratio (OR) 11.90, 95% confidence interval (CI) 1.43–90.79, P = 0.022 and OR 3.37, 95% CI 1.78–9.67, P = 0.024, respectively]. Bivariate analysis demonstrated that both fwRVLS and DecT E were predictors of CAV development independently from HLA status. Conclusions The presence of circulating anti‐HLA antibodies is correlated with a mild cardiac dysfunction, even in the absence of AMR, and CAV development. Interestingly, reduced values of DecT E and fwRVLS were predictors of future development of CAV, independently from anti‐HLA antibody

Left Ventricular Mass with Delayed Enhancement as a Predictor of Major Events in Patients with Myocarditis with Preserved Ejection Fraction

Background: Cardiac Magnetic Resonance (CMR) has a key role in subjects presenting with acute myocarditis, independent from left ventricular ejection fraction; it is widely used as a non-invasive imaging test for both diagnostic and prognostic purposes. However, poor data is available about the CMR-derived prognostic parameters of acute myocarditis with preserved ejection fraction (AMpEF). The aim of this study was to investigate the role of CMR in predicting outcomes in patients followed up for AMpEF, using a composite endpoint of all-cause mortality and hospitalization for heart failure (HF). Methods: We retrospectively enrolled 61 patients with diagnosed AMpEF. All patients underwent biohumoral, echocardiographic and CMR evaluation in the acute phase. Myocarditis was confirmed by Lake&ndash;Louis criteria assessed on CMR images. Mean follow-up was 4.8 &plusmn; 0.6 years during which a composite endpoint of all-cause mortality and hospitalization for HF was investigated. Results: The population was fairly homogeneous regarding baseline clinical features. In particular, no significant differences in age and main cardiovascular risk factors were found between patients with and without events at follow-up. Seven patients met the endpoint. They had significantly higher levels of circulating neutrophils in the acute phase (76 &plusmn; 7% vs. 61 &plusmn; 11%, p = 0.014) and a higher amount of left ventricular mass with delayed enhancement (DE-LVM, 18 (14&ndash;29.5) vs. 12 (8&ndash;16) g, p = 0.028). At Cox univariate analysis, DE-LVM was the only significant predictor of endpoint, regardless of the site of inflammation. Conclusions: DE-LVM can predict the composite endpoint of all-cause mortality and hospitalization for HF in a population of patients with AMpEF, representing a new added tool for prognostic stratification

Tricuspid Regurgitation Velocity and Mean Pressure Gradient for the Prediction of Pulmonary Hypertension According to the New Hemodynamic Definition

Background: The hemodynamic definition of PH has recently been revised with unchanged threshold of peak tricuspid regurgitation velocity (TRV). The aim of this study was to evaluate the predictive accuracy of peak TRV for PH based on the new (>20 mmHg) and the old (>25 mmHg) cut-off value for mean pulmonary artery pressure (mPAP) and to compare it with the mean right ventricular–right atrial (RV–RA) pressure gradient. Methods: Patients with advanced heart failure were screened from 2016 to 2021. The exclusion criteria were absent right heart catheterization (RHC) results, chronic obstructive pulmonary disease, any septal defect, inadequate acoustic window or undetectable TR. The mean RV–RA gradient was calculated from the velocity–time integral of TR. Results: The study included 41 patients; 34 (82.9%) had mPAP > 20 mmHg and 24 (58.5%) had mPAP > 25 mmHg. The AUC for the prediction of PH with mPAP > 20 mmHg was 0.855 for peak TRV and mean RV–RA gradient was 0.811. AUC for the prediction of PH defined as mPAP > 25 mmHg for peak TRV was 0.860 and for mean RV–RA gradient was 0.830. A cutoff value of 2.4 m/s for peak TRV had 65% sensitivity and 100% positive predictive value for predicting PH according to the new definition. Conclusions: Peak TRV performed better than mean RV–RA pressure gradient in predicting PH irrespective of hemodynamic definitions. Peak TRV performed similarly with the two definitions of PH, but a lower cutoff value had higher sensitivity and equal positive predictive value for PH