A 26-weeks pregnant woman presented with progressively worsening dyspnoea and poor general conditions. Using low-dose radiation multi-imaging techniques and thoracic biopsy a primary mediastinal large B cell was diagnosed. A multidisciplinary approach identified the correct hemodynamic management, the best therapeutic strategy and the timing for delivery.
Sarcomeric hypertrophic cardiomyopathy is the most common cardiovascular genetic disease. Clinical evaluation and comprehensive echocardiography are crucial for the diagnosis and early evaluation of the hypertrophic phenotype, but multimodality imaging approach is often required to better define diagnosis and differential diagnosis from phenocopies. This review aims to assess the role of multimodality imaging and, in particular, advanced echocardiography and cardiac magnetic resonance in relation to differential diagnosis and preclinical diagnosis, identification of different phenotypes, and assessment of disease progression and risk of sudden cardiac death. A multimodality imaging approach is also crucial for the selection of patients amenable to surgical or percutaneous septal myectomy and for guiding both procedures.
Abstract: Background : Cardiac dysfunction remains the major cause of death in beta‐thalassemia. Aim of this study was to assess early myocardial damage in thalassemic patients with no symptoms or echocardiographic evidence of dysfunction at routine monitoring. Methods : Twenty patients (seven females; median 25 yr [first quartile 22,third quartile 28]) with beta‐thalassemia underwent radionuclide angiography (RNA) at rest and during low‐dose dobutamine infusion (5–10 γ /kg/min). Right and left ventricular ejection fractions (EF) were determined by first‐pass method and gated equilibrium acquisition, respectively. Twenty‐four‐hour Holter monitoring with time‐domain heart rate variability (HRV) assessment and echocardiographic follow‐up (21 months [5,27]) were performed. Results : Eleven patients showed regional wall motion abnormalities at RNA; left ventricular EF, HR and diastolic measurements significantly increased after dobutamine infusion. Patients with abnormal RNA right ventricular EF ( n = 8, <0.45) showed lower echocardiographic left ventricular EF at the enrolment (0.54 [0.50,0.61] vs. 0.62 [0.56,0.67], P = 0.02) than those with a normal right ventricular EF. Patients with reduced standard deviation of the averages of RR intervals in all 5‐minute periods of entire recording (SDANN) ( n = 6, <100 ms), a measure of HRV, had lower echocardiographic left ventricular EF (0.53 [0.49,0.62] vs. 0.62 [0.56,0.66], P = 0.03) and lower fractional shortening (0.28 [0.25,0.32] vs. 0.36 [0.30,0.39], P = 0.003) at the enrolment than those with normal SDANN. No significant association was found between RNA and HRV measurements and follow‐up left ventricular function. Conclusions : Right ventricular dysfunction and abnormal HRV may represent the early features of cardiac disease in thalassemic patients with no evidence of ventricular dysfunction at routine evaluation.
Introduction: Despite the improvements in medical and surgical treatments, the incidence of end-stage heart failure (ESHF) continues to increase. Different mechanical systems have been adopted to support failing left ventricles. Among continuous-flow devices, the HeartWare-HVAD was the first to use a centrifugal pump rather than an axial one.Areas covered: In this review article, we provide an overview of the HeartWare-HVAD as a ventricular assist device for ESHF, discussing indications, echocardiographic assessment, surgical techniques, outcomes, concerns and controversies. Scientific literature was reviewed with a MEDLINE search strategy combining ‘HeartWare’ or ‘HVAD’ with ‘heart failure’. A total of 263 papers were found using the reported search. From these, 16 were identified to provide the best evidence on the subject reporting outcomes in ≥50 patients.Expert commentary: HeartWare-HVAD is a minute device that provides full circulatory support in patients with ESHF. Its main indication remains bridge to heart transplantation (HTx). Median sternotomy is the preferred technique of implantation although less invasive procedures have been described. Early outcomes are satisfactory. Nevertheless, some fearing complications still occur during the mid- and long-term follow-up. Further technical developments and optimal medical management will guarantee better outcomes.
Objective: Abnormal large artery function plays an important role in the pathogenesis of cardiovascular (CV) diseases. Prior studies have suggested that the principal determinants of arterial stiffening are age, Blood Pressure (BP) and others CV risk factors such as dyslipidemia and diabetes. However the role of psychological characteristics on the long-term progression of arterial stiffness has not yet been evaluated. The aim of the current longitudinal study was to evaluate the psychological determinants of the Pulse Wave Velocity (PWV) progression over a 3 years follow-up period in treated hypertensives subjects. Design and method: We enrolled 350 consecutive 18–80 aged outpatients, followed by the Hypertension Unit of S. Gerardo Hospital (Monza, Italy) affected by essential hypertension. At baseline (T0) anamnestic data, clinical BP, laboratory data and PWV were evaluated; also psychological tests were performed. In a subgroup of 50 subjects, after a median follow-up time of 2.96 ± 0.33 years, we performed again psychological tests and PWV examination (T1). Psychological tests were administered by trained researchers for measuring perceived stress, resiliency factors (self-esteem, sense of coherence), and perceived social support. Results: At T0 the mean age was 55.9 ± 10.1years, SBP and DBP were 135.6 ± 17.7 and 82.5 ± 9.1mmHg and PWV was 8.6 ± 2.1m/s. Despite a significant improvement in the blood pressure control (from 72 to 84%; PAS from 135.6 ± 17.7 to 130.1 ± 14.2, p = 0.08; PAD from 82.5 ± 9.1 to 77.5 ± 9.4, p < 0.05), at follow-up examination PWV didn’t showed significant changes (from 8.6 ± 2.1 to 8.6 ± 2.4, p = 0.87) with a mean deltaPWV of −0.05 ± 2.8m/s. Focusing on PWV changes over the follow-up period and on psychological test, subjects where then divided accordingly to their deltaPWV in those in which an increase was showed and those in which the values decrease. For similar baseline values, subjects with positive deltaPWV showed higher T1 values of stress (37.4 ± 1.1vs36.8 ± 0.8, p = 0.02) and lower values of self-esteem (2.9 ± 0.5 vs 3.3 ± 0.4, p = 0.02), sense of coherence (4.4 ± 0.7vs4.9 ± 0.8, p = 0.02), and a worse family climate (3.5 ± 0.9vs4.1 ± 0.8, p = 0.02). No significant differences were showed regarding BP values and CV risk factors. Conclusions: The current longitudinal study shows that arterial stiffness didn’t shown any significant changes despite BP improvement. PWV increase is related to higher stress and lower self-esteem and familiar support.
Background: In patients with nonvalvular atrial fibrillation and contraindications for oral anticoagulation interventional occlusion of the left atrial appendage (LAA) is an established approach for prevention of embolic stroke.Due to complex LAA anatomy appropriate device size selection is challenging.It is unclear which modality yields the most reliable LAA measurements.Purpose: The study compares preprocedural two-dimensional (2D-TEE), threedimensional transoesophageal echocardiography (3D-TEE), computed tomography (CT) and fluoroscopy (FC) measurements of LAA size with postprocedural plug size as a surrogate for true LAA size.Methods: 28 consecutive patients (14 male; median age 79 years; CHA2DS2VASC 3.661.7;HASBLED 3.861.1)were included into the study.We used a second generation nitinol occluder with polyester inlay (plug and disc design).For measurement of the landing zone (LZ) 2D-TEE, 3D-TEE and contrast enhanced ECG-triggered 320 slice volume CT was done before implantation.We measured the minimal and maximal diameter of LZ (DLZmin; DLZmax) with all modalities and the planimetric area of the landing zone (ALZ) on 3D-TEE and CT.During the procedure the LAA was measured with FC in 2 different angulations.After implantation we measured the minimal plug diameter (DPLmin) in 2 angulations on FC.DPLmin served as a surrogate for true size of the LZ and therefore as a reference for all measurements before implantation.All measurements were done blinded to results from the other modalities.Device selection for a given LZ size was based on the manufacturer s sizing chart.Results: Due to the elliptic shape of the LZ DLZmin and DLZmax differed significantly independent from modality: (1762.8mm vs. 2262.8mm,p<0,001 for TEE; 1863.4mm vs. 2563.4mm,p<0,001 for CT and 2163.7mm vs. 2463.9mm,p<0,001 for FL.DLZmin were smaller on 2D-TEE than compared to the other modalities (p< 0.01).ALZ on 3D-TEE was smaller than on CT (279699 mm2 vs. 322674mm2, p<0.05).Compared to the reference DPLmin, 2D-TEE underestimated LAA size.There was no significant difference between DLZmin on CT and FC compared to the postprocedural DPLmin.The best correlation was found between DLZmin on FC and DPLmin (r¼0,74).Based on echo alone a smaller device would have been selected than finally chosen in 26/28 cases.Conclusion: Fluoroscopy and CT are suited for correct LAA sizing.Both, 2D-and 3D-TEE underestimate LAA size and may result in selection of smaller than appropriate occluder devices. P1223
Vascular diseases -1 1079 as primary patency, freedom from stent occlusion and major adverse limb events (MALE) using Kaplan-Meier method.Stent patency was assessed by either duplex ultrasound or angiography.Results: Mean follow-up period was 1232±650 days.Primary patency of BMS and DES were 81% vs 85% at a year and 71% and 63% at 3 years.(p=0.52)Freedom from stent occlusion were 92% vs 91% at a year and 88% vs 79% at 3 years.(p=0.22)Freedom from MALE at 3 years was 95% vs 90%.(p=0.22)Kaplan-Meier estimation curve showed that incidence of stent occlusion over a year was significantly higher in DES group.(p<0.05)Conclusion: Though 3 year clinical outcomes after EVT with BMS and DES were not significantly different, DES causes higher incidence of stent occlusion in chronic phase.
In 2007, Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI) already SIEC, published the document on the organization of echocardiography in Italy. In the years following the technological evolution, cultural and health factors have changed "the way, we do echo" as a tool for the different clinical pathways. The SIECVI Accreditation Area and Board 2017-2019 considered necessary to review and update the document in the light of innovation in the application of ultrasound for the heart disease assessment. In the document, we have considered the role of SIECVI in multimodal imaging, the need of training and certification of operators, the quality of echo machines, the accreditation of laboratories, the compilation of the report and its responsibility, and the presence of the sonographers in the EchoLab.
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