Search

Introduction Left atrial appendage (LAA) is a finger-like muscular extension of the left atrium (LA). It acts as blood reservoir, modulates LA pressure and elicits adaptive responses to stress. Several LAA shapes and variants have been described. We report a case of congenital absence of LAA diagnosed by transesophageal echocardiography (TEE) and confirmed by computed tomography (CT). Case report A 55-year-old male patient with history of hypertension was admitted to our hospital for an episode of atrial fibrillation (AF). TEE was performed and showed normal LA volume, absence of thrombi and spontaneous echo contrast in the LA, but, despite acquiring three-dimensional (3D) en-face views, we were unable to identify LAA. Congenital absence of LAA was suspected and multidetector cardiac CT confirmed the abnormality. Discussion Congenital absence of LAA is an extremely rare condition: only eighteen cases were described on a review of the literature published in 2020. Associations with other congenital abnormalities or with atrial fibrillation have been reported, but a causal relationship cannot be established. Multiple imaging modalities can be used to define the anatomy and function of LAA, to detect or rule out in situ thrombosis and to guide catheter-based therapies, but the most widely used technique is TEE. Among intracardiac thrombi in patients with non-valvular atrial fibrillation, more than 90% are identified in the LAA, meaning that the remaining 10% may develop in other sites of the LA. The congenital absence of LAA could be considered similar to LAA percutaneous occlusion or surgical exclusion; because of the few published randomized controlled trials, the current ESC guidelines on atrial fibrillation are unclear about the true thrombotic risk in these cases. Since LAA percutaneous occlusion is actually indicated only in cases of contraindications for long-term anticoagulant treatment, in our opinion in patients with non-valvular AF, LAA congenital absence, high stroke risk and low bleeding risk, anticoagulant therapy should be considered. Conclusion Congenital absence of LAA is an extremely rare condition and its pathophysiological role, especially with regard to antithrombotic therapy in patients with AF, is still not well defined.

Aims Sacubitril/valsartan have changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodelling (LVRR). The aim of this multicentre study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration. Methods and results Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centres were included. Echocardiographic indexes including speckle tracking echocardiography (STE) indexes were used to predict LVRR [defined as LV end-systolic volume reduction and ejection fraction (LVEF) improvement > 10% at follow-up] at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations [N-terminal-pro-brain natriuretic peptide (NTproBNP)] were also evaluated as secondary endpoints. The final population (excluding patients with poor acoustic windows and missing data) consists of 341 patients [mean age: 65 ± 10 years; 18% female, median LVEF 30% (interquartile range: 25–34)]. At 6 months follow-up, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF Conclusions STE parameters at baseline could be useful to predict LVRR and clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF.

Aims This sub-study deriving from a multicentre Italian register (DISCOVER-ARNI) investigated whether sacubitril/valsartan in adjunction of optimal medical therapy (OMT) could reduce the rate of implantable cardioverter-defibrillator(ICD) indications for primary prevention in heart failure with reduced ejection fraction (HFrEF) according to European guidelines indications, and its potential predictors. Methods and results In this observational study, consecutive patients with HFrEF eligible for sacubitril/valsartan from 13 Italian centres were included. Lack of follow-up or speckle tracking data represented exclusion criteria. Demographic, clinical, biochemical and echocardiographic data were collected at baseline and after 6 months of therapy. Of 351 patients, 225 (64%) were ICD carriers and 126 (36%) were not ICD carriers (of whom 13 had not indication) at baseline. After 6 months of sacubitril/valsartan, among 113 non-ICD carriers despite having baseline left ventricular (LV)EF ≤ 35% and New York Heart Association (NYHA) class = II–III, 69(60%) did not show ICD indications; 44(40%) still fulfilled ICD criteria (Figure 1). Age, atrial fibrillation, mitral regurgitation>moderate, left atrial volume index (LAVi), and LV global longitudinal strain (GLS) significantly varied between the groups. With ROC curves, age ≥ 75 years, LAVi ≥ 42 ml/m2 and LV GLS ≥ −8.3% were associated with ICD indications persistence (AUC = 0.65, 0.68, and 0.68, respectively). With univariate and multivariate analysis, age and LV GLS emerged as the only significant predictors of ICD indications at follow-up. Conclusions Sacubitril/valsartan provided early improvement of NYHA class and LVEF, reducing the possible number of implanted ICD for primary prevention in HFrEF. Baseline advanced age and reduced LV GLS were markers of ICD indication despite OMT. Early therapy with sacubitril/valsartan may save infective/haemorrhagic risks and unnecessary costs deriving from ICDs.