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In recent years, the cancer survival of patients has improved thanks to advances in the pharmacological field. In many guidelines, cardiotoxicity induced by anticancer drugs was defined as a reduction from baseline in the left ventricular ejection fraction (LVEF) assessed by echocardiography. It is known that LVEF is not a sensible parameter in the detection of cardiotoxicity. Therefore, a decrease from baseline in the global longitudinal strain (GLS) or troponins elevation is used to detect subclinical cardiotoxicity. LVEF and GLS as well as the increase in some biomarkers are influenced by loading conditions that are frequent during chemotherapy. Other parameters not influenced by loading conditions should be used in the early diagnosis of cardiotoxicity. The aim of this review is to delineate the role of current strategies used in the early diagnosis of cardiotoxicity and to identify new strategies that could have greater application in the future in cardioncology., Competing Interests: Declaration of competing interest None declared., (Published by Elsevier Inc.)

Background: Identifying candidates for left ventricular assist device surgery at risk of right ventricular failure remains difficult. The aim was to identify the most accurate predictors of right ventricular failure among clinical, biological, and imaging markers, assessed by agreement of different supervised machine learning algorithms., Methods: Seventy-four patients, referred to HeartWare left ventricular assist device since 2010 in two Italian centers, were recruited. Biomarkers, right ventricular standard, and strain echocardiography, as well as cath-lab measures, were compared among patients who did not develop right ventricular failure (N = 56), those with acute-right ventricular failure (N = 8, 11%) or chronic-right ventricular failure (N = 10, 14%). Logistic regression, penalized logistic regression, linear support vector machines, and naïve Bayes algorithms with leave-one-out validation were used to evaluate the efficiency of any combination of three collected variables in an "all-subsets" approach., Results: Michigan risk score combined with central venous pressure assessed invasively and apical longitudinal systolic strain of the right ventricular-free wall were the most significant predictors of acute-right ventricular failure (maximum receiver operating characteristic-area under the curve = 0.95, 95% confidence interval = 0.91-1.00, by the naïve Bayes), while the right ventricular-free wall systolic strain of the middle segment, right atrial strain (QRS-synced), and tricuspid annular plane systolic excursion were the most significant predictors of Chronic-RVF (receiver operating characteristic-area under the curve = 0.97, 95% confidence interval = 0.91-1.00, according to naïve Bayes)., Conclusion: Apical right ventricular strain as well as right atrial strain provides complementary information, both critical to predict acute-right ventricular failure and chronic-right ventricular failure, respectively.

Objective: The aim of this study was to evaluate in patients with microvascular angina and heart failure with preserved ejection fraction, the speckle-tracking echocardiography, and longitudinal myocardial strain to evaluate the possible presence of alterations in heart failure with preserved ejection fraction patients compared with a control population. We also investigated the correlation between the longitudinal strain analysis and the TIMI frame count after coronary angiography., Methods: Our study was performed on a population 41 patients with microvascular angina that underwent coronary angiography and speckle-tracking echocardiography. We divided the sample into two categories: patients with heart failure with preserved ejection fraction (n-21) and patients without heart failure with preserved ejection fraction (n-20). We calculated TIMI frame count indices for each patient based on angiographic images., Results: Patients with heart failure with preserved ejection fraction had reduced global longitudinal strain values (-17.88) compared with the total control population, and this reduction was statistically significant (P = .028). This reduction was more marked in patients who had a significantly increased TIMI frame count. Therefore, a statistically significant correlation was observed between TIMI frame count and global longitudinal strain., Conclusion: Our results show that cardiac contractile mechanics are altered in patients with heart failure with preserved ejection fraction at a subclinical level hard to identifiable with conventional echocardiography. The dysfunction of the microcirculation and the consequent alteration of the TIMI frame count probably results in a reduction of myocardial performance., (© 2019 John Wiley & Sons Ltd.)

Cardiac surgical techniques and circulatory supports have strongly evolved in the last years. Right ventricular (RV) function during the post-operatory period is still subject of study, although its relevant prognostic impact has been variably described in different papers. RV post-surgical dysfunction's underlying mechanisms are still not clear and include a different hypothesis. Echocardiography, with both first and second level parameters, offers the possibility to accurately analyze the right ventricle and optimize these patients' management. This paper describes the pathophysiology of the right ventricle, the most used echo indexes of RV function, whether they alter after surgery, the different supposed mechanisms of RV dysfunction and its role in the prognosis of patients undergoing cardiac surgery.

Aims: Recent advancements in echocardiographic technology allow to analyse myocardial strain in multiple layers. Little is known about the impact of age on layer-specific longitudinal strain in healthy subjects. The aim of this study was to analyse the influence of age on multilayer longitudinal strain and establish normal reference values of layer-specific strain according to age decades in a healthy population referring to our echo laboratory using 2D speckle-tracking echocardiography with layer-specific software., Methods and Results: Two-hundred sixty-six healthy, consecutive subjects (mean age = 39.2 ± 17.5 years, women/men = 137/129), free of cardiovascular risk factors, were enrolled. Subjects were divided according to six age decades: 10-19, 20-29, 30-39, 40-49, 50-59, >60 years. All subjects underwent a complete echo Doppler examination including quantitation of 2D global longitudinal strain (GLS). Subendocardial longitudinal strain (LSsubendo), subepicardial longitudinal strain (LSsubepi), and strain gradient (LSsubendo - LSsubepi) were also determined. GLS (P < 0.001), LSsubendo, and LSsubepi (both P < 0.0001) were all progressively reduced with increasing age decades, but post hoc intra-group analyses demonstrated that the decline of GLS, LSsubendo, and LSsubepi was significant in the decades 50-60 and ≥60 years. In separate multiple linear regression analyses, the effect of age on GLS, LSsubendo, and LSsubepi remained significant even after adjusting for clinical and echocardiographic confounders. Strain gradient remained unchanged in age decades., Conclusion: Ageing shows an independent effect on GLS, LSsubendo, and, particularly on, LSsubepi. Our data also provide normal reference values of layer-specific longitudinal strain for age decades.

The use of conventional echocardiography in the intensive care unit (ICU) is today established to assess left and right ventricular systolic function, for preload determination and procedural guidance. Next step in ICU echocardiography could be the use of novel ultrasound techniques such as strain echocardiography to assist in the management of patients with acute coronary syndrome, heart failure, or pulmonary embolism. This review has gathered the available evidence supporting the incremental value of strain in the diagnostic workup of cardiac diseases treated in ICU., (© 2018 Wiley Periodicals, Inc.)

Left ventricular hypertrophy (LVH) develops in response to a variety of physical, genetic, and biochemical stimuli and represents the early stage of ventricular remodeling. In patients with LVH, subclinical left ventricular (LV) dysfunction despite normal ejection fraction (EF) may be present before the onset of symptoms, which portends a dismal prognosis. Strain measurement with two-dimensional speckle tracking echocardiography (STE) represents a highly reproducible and accurate alternative to LVEF determination. The present review focuses on current available evidence that supports the incremental value of STE in the diagnostic and prognostic workup of LVH. When assessing the components of LV contraction, STE has an incremental value in differentiating between primary and secondary LVH and in the differential diagnosis with storage diseases. In addition, STE provides unique information for the stratification of patients with LVH, enabling to detect intrinsic myocardial dysfunction before LVEF reduction., (© 2017, Wiley Periodicals, Inc.)

Speckle tracking echocardiography (STE) has recently emerged as a quantitative technique to accurately estimate myocardial function. By the analysis of the motion of speckles in the two-dimensional ultrasonic image, this technique allows a non-Doppler angle-independent objective analysis of myocardial deformation, with the possibility to quantify thickening, shortening and rotation dynamics of cardiac function. Since this technique does not require Doppler imaging, the analysis is relatively angle-independent and is marginally affected by cardiac in-plane motion artifacts. Data regarding feasibility, reproducibility and diagnostic accuracy appear to be optimal in several clinical contexts. This review describes the fundamental concepts of deformation imaging, explains how to obtain myocardial deformation measurements in clinical practice and highlights current clinical applications of STE. In addition, in relation with the recent extension of STE to three-dimensional echocardiography with the potential for a more comprehensive analysis of global and segmental myocardial function, a window is also opened on the perspectives of three-dimensional STE.

Objective: The aim of our study was to evaluate the diagnostic performance of cardiac computed tomography (CCT) in the evaluation of coronary artery stenosis in patients with ascending aorta aneurysm detected at transthoracic echocardiography., Methods: We conducted a retrospective analysis of patients with an aneurysm 45 mm or greater at transthoracic echocardiography who underwent CCT from 2012 to 2014 in our hospital. We calculated the sensitivity, specificity, and positive and negative predictive values of CCT for the assessment of coronary artery stenosis (<50% or ≥50% stenosis) in patients who underwent conventional coronary angiography., Results: We included 104 patients (73 men, aged 64 [SD, 10.8] years) in our study. Obstructive coronary artery disease was found in 22.1% of patients. Sensitivity, specificity, and positive and negative predictive values of CCT for detecting significant stenoses were 100%, 98%, and 82% and 100% on a segment-by-segment analysis and 100%, 83%, and 65% and 100% on a per-patient analysis, respectively., Conclusions: Cardiac computed tomography provides a comprehensive evaluation of ascending aorta aneurysms and coronary artery tree.

Objectives: Intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has been suggested to be a valuable technique for the evaluation of the mechanisms of ischemic mitral regurgitation (IMR). Studies comparing multiplane two-dimensional (2D) with 3D TEE reconstruction of the mitral valve using the new mitral valve quantification (MVQ) software are lacking. We undertook a prospective comparison between multiplane 2D and 3D TEE for the assessment of IMR., Methods: We evaluated echocardiographically 45 patients with IMR who underwent mitral valve surgery in our institution. 2D and 3D TEE examinations followed by a 3D offline assessment of the mitral valve apparatus were performed in all patients. Offline analysis of mitral valve apparatus was conducted with QLAB-MVQ., Results: 3D TEE image acquisitions were performed in a short period of time and were feasible in all patients. Real time 3D TEE imaging was superior to 2D in identifying specific mitral scallops (A1, A3, P1, P3) and commissures. When compared with 2D TEE, 3D offline reconstruction of the mitral valve allows an accurate quantification of the shape and diameters of the mitral annulus. Both approaches provide almost similar values for the tenting area and the coaptation depth. The 3D approach gave the advantage of direct calculation of the leaflets angles, tenting volume, and surface of the leaflets. The interpapillary muscles distance at the level of the papillary muscle head was greater in 2D than in 3D., Conclusions: 3D TEE imaging provides valuable and complementary information to multiplane 2D TEE for the assessment of patients with IMR., (© 2011, Wiley Periodicals, Inc.)

Aims: Sacubitril/valsartan has changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects on morbidity and mortality, partly mediated by left ventricular (LV) reverse remodelling (LVRR). The aim of this multicenter 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 parameters including LV global longitudinal strain (GLS) and global peak atrial longitudinal strain by speckle tracking echocardiography were measured to find the predictors of LVRR [= LV end‐systolic volume reduction ≥10% and ejection fraction (LVEF) improvement ≥10% at follow‐up] at 6 month follow‐up as the primary endpoint. Changes in symptoms [New York Heart Association (NYHA) class] and neurohormonal activations [N‐terminal pro‐brain natriuretic peptide (NT‐proBNP)] were also evaluated as secondary endpoints; 341 patients (excluding patients with poor acoustic windows and missing data) were analysed (mean age: 65 ± 10 years; 18% female, median LVEF 30% [inter‐quartile range: 25−34]). At 6 month follow‐up, 82 (24%) patients showed early complete response (LVRR and LVEF ≥ 35%), 55 (16%) early incomplete response (LVRR and LVEF < 35%), and 204 (60%) no response (no LVRR and LVEF < 35%). Non‐ischaemic aetiology, a lower left atrial volume index, and a higher GLS were all independent predictors of LVRR at multivariable logistic analysis (all P < 0.01). A baseline GLS < −9.3% was significantly associated with early response (area under the curve 0.75, P < 0.0001). Left atrial strain was the best predictor of positive changes in NYHA class and NT‐proBNP (all P < 0.05). Conclusions: Speckle tracking echocardiography parameters at baseline could be useful to predict LVRR and clinical response to sacubitril–valsartan and could be used as a guide for treatment in patients with HFrEF. [ABSTRACT FROM AUTHOR]

Background: The aim of the study is to evaluate the subclinical alterations of cardiac mechanics detected using speckle-tracking echocardiography and compare these data with the coronary angiography indices used during coronary angiography in a population of patients diagnosed with ischemia with no obstructive coronary artery (INOCA) and microvascular angina (MVA). Methods: The study included 85 patients admitted to our center between November 2019 and January 2022 who were diagnosed with INOCA compared with a control group of 70 healthy patients. A collection of anamnestic data and a complete cardiovascular physical examination, and echocardiogram at rest with longitudinal strain were performed for all patients. Furthermore, the TIMI frame count (TFC) for the three coronary vessels was calculated according to Gibson's indications. All parameters were compared with a control population with similar characteristics. Results: Patients with INOCA compared to the control population showed statistically significant changes in the parameters assessed on the longitudinal strain analysis. In particular, patients with INOCA showed statistically significant changes in GLS (−16.71) compared to the control population (−19.64) (p = 0.003). In patients with INOCA, the total TIMI frame count (tTFC) correlated with the GLS value with a correlation coefficient of 0.418 (p = 0.021). Conclusions: In patients with angina, documented myocardial ischemia, the absence of angiographically significant stenosis (INOCA) and LVEF > 50%, the prevalence of microvascular dysfunction documented by TFC was extremely represented. A statistically significant reduction in GLS was observed in these patients. TFC and longitudinal strain, therefore, appear to be two reliable, sensitive and easily accessible methods for the study of alterations in coronary microcirculation and the characterization of patients with INOCA and microvascular angina. [ABSTRACT FROM AUTHOR]

Background: Myocarditis have variable clinical presentation, evolution and prognosis. Aim of our study was to evaluate the value of speckle tracking echocardiography and cardiac magnetic resonance (CMR) in the short‐term prediction of supraventricular arrhythmias (SVA) in patients with acute myocarditis. Methods: Seventy patients (mean age 31±14 years old) with acute myocarditis and preserved left ventricular ejection fraction (LVEF) were enrolled. Longitudinal systolic strain (LS) of the left ventricle (LV), mechanical dispersion (MD) and CMR with quantitative measurement of delayed enhancement (DE) were performed in a subset of 43 patients. Logistic regression and ROC analysis were used to identify predictors of SVA Results: Only LS measured at sup‐epicardial, mid‐wall and sub‐endocardial level of the apical 4‐chamber view was significantly lower in patients with SVA, while MD was marginally prolonged in this setting. A value of LS > ‐ 16.1% measured at LV mid‐wall in the apical 4‐chamber view (ROC‐AUC.75, Sensitivity 63%, Specificity 85%) was the most accurate measure to identify patients with SVA. DE mass was also helpful with a ROC‐AUC.76; a DE‐Mass > 18.9 gr. had a Sensitivity 63% and a Specificity 77%, to identify patients at risk of SVA. Conclusions: Both DE mass and LS were associated with higher risk of SVA in patients with acute myocarditis and preserved LVEF. However, LS measured at the mid‐wall level and limited to LV segments included in the apical 4‐chamber view was the most accurate measure and did not show interaction with DE mass. [ABSTRACT FROM AUTHOR]

Purpose: Only a few studies are available on dose-related effects of sacubitril/valsartan (angiotensin receptor neprilysin inhibition (ARNI)) in real-life patients with heart failure and reduced ejection fraction (HFrEF). We sought to investigate clinical and functional effects in real-life HFrEF patients receiving ARNI at a different cumulative dose. Methods: This was an observational study in consecutive outpatients admitted for HFrEF from October 2017 to June 2019. The PARADIGM criteria were needed for enrolment. ARNI was uptitrated according to blood pressure, drug tolerability, renal function and kaliemia. At least 10-month follow-up was required in each patient. Clinical assessment, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, 6-min walk test and strain echocardiography were performed in each patient on a regular basis during the observational period. At the end of the study, patients were divided into two groups based on the median yearly dose of the ARNI medication. Results: A total of 90 patients, 64 ± 11 years, 82% males, were enrolled. The cut-off dose was established in 75 mg BID, and the study population was divided into group A (≤ 75 mg), 52 patients (58%), and group B (> 75 mg), 38 patients (42%). The follow-up duration was 12 months (range 11–13). NYHA class, KCCQ score and 6MWT performance ameliorated in both groups, with a quicker time to benefit in group B. The proportion of patients walking > 350 m increased from 21 to 58% in group A (p < 0.001), and from 29 to 82% in group B (p < 0.001). A positive effect was also disclosed in the left ventricular remodelling, strain deformation and diastolic function. Conclusion: One-year ARNI treatment was effective in our real-life HFrEF patient population, leading to clinical and functional improvement in both study groups, slightly greater and with a shorter time to benefit in group B. [ABSTRACT FROM AUTHOR]

Background Transcatheter approach for large and complex atrial septal defects may represent a therapeutic challenge, particularly when the postero-inferior rim is deficient and floppy. Case summary Here, we describe a successful catheter-based closure of a large (>30 mm) secundum atrial septal defect associated with postero-inferior rim deficiency in a 35-year-old female with congestive heart failure using pulmonary vein slide-out assisted implantation technique. Discussion Inferior–posterior rim deficiency is a well-known risk factor for device instability or embolization. Transcatheter closure may represent a safe and effective alternative to the traditional surgical approach provided that modified implantation techniques are employed. [ABSTRACT FROM AUTHOR]

Aims: Echocardiographic assessment of left ventricular filling pressures is performed using a multi‐parametric algorithm. Unselected sample of patients with heart failure with reduced ejection fraction (HFrEF) patients may demonstrate an indeterminate status of diastolic indices making interpretation challenging. We sought to test improvement in the diagnostic accuracy of standard and strain echocardiography of the left ventricle and left atrium (LA) to estimate a pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with HFrEF. Methods and results: Out of 82 consecutive patients, 78 patients were included in the final analysis and right heat catheterization, and echocardiogram was performed simultaneously. According to the univariable analysis, E wave velocity, the ratio between E‐wave/A‐wave (E/A, area under the curve [AUC] = 0.81, respectively), isovolumic relaxation time (AUC = 0.83), pulmonary vein D wave (AUC = 0.84), pulmonary vein S/D Ratio (AUC = 0.85), early pulmonary regurgitation velocity (AUC = 0.80), and accelerationa time at right ventricular out‐flow tract (RVOT AT, AUC = 0.84) identified with the highest accuracy PCWP > 15 mmHg. They were all tested in multivariate analysis, and they were not independently correlated with PCWP. Tricuspid regurgitation (TR) velocity was measurement with the highest predictive value in identifying PCWP > 15 mmHg (AUC = 0.89), compared with other established parameters such as the ratio between e‐wave velocity divided by mitral annular e' velocity (E/e'), deceleration time, or LA indexed volume (LAVi), which all reached a lower accuracy level (AUC = 0.75; 0.78; 0.76). Among strain measures, global longitudinal strain in four chamber view (GLS 4ch), the ratio between e‐wave velocity divided by mitral annular e' strain rate (E/e'sr), and LA longitudinal strain at the reservoir phase were helpful in estimating elevated PCWP (AUC = 0.77; 0.76; 0.75). According to multivariable analysis, the following two models had the greatest accuracy in detecting PCWP > 15 mmHg: (i) TR velocity, LAVi, and E wave velocity (receiver operating characteristic [ROC]‐AUC = 0.98), (ii) AT RVOT, LAVi and GLS 4ch (ROC‐AUC = 0.96). Neither E/A (ROC‐AUC = 0.81) nor E/e' (ROC‐AUC = 0.75) was an independent predictor when included in the model. The two MODELS were applicable to the entire population and demonstrated better agreement with the invasive reference (91% and 88%) than the guidelines algorithm (77%) regardless of the type of rhythm. Conclusions: Our suggested echocardiographic approach could be used to potentially reduce the frequency of "doubtful" classification and increase the accuracy in predicting elevated left ventricular filling pressure leading to a decrease in the number of invasive assessment made by right heart catheterization. [ABSTRACT FROM AUTHOR]

Objectives: To analyze left ventricular (LV) myocardial deformation and contractile reserve (CR) in asymptomatic patients with severe aortic regurgitation (AR) at rest and during exercise, and their correlation with functional capacity. Background: The natural history of chronic AR is characterized by a prolonged silent phase before onset of symptoms and overt LV dysfunction. Assessment of LV systolic function and contractile reserve has an important role in the decision‐making of AR asymptomatic patients. Methods: Standard echo, lung ultrasound, and LV 2D speckle tracking strain were performed at rest and during exercise in asymptomatic patients with severe AR and in age‐ and sex‐comparable healthy controls. Results: 115 AR patients (male sex 58.2%; 52.3 ± 18.3 years) and 55 controls were enrolled. Baseline LV ejection fraction was comparable between the groups. Resting LV global longitudinal strain (GLS) and myocardial work efficiency (MWE) were significantly reduced in AR (GLS‐15.8 ± 2.8 vs −21.4 ± 4.4; P <.001). Patients with AR and CR− showed reduced resting LV GLS and MWE and increased B‐lines. MWE was closely related to peak effort watts, VO2, LV E/e′, and B‐lines, at a multivariable analysis. Both GLS and MWE were strong independent predictors of CR. A resting LV GLS cutoff of −12% differentiated CR+ and CR− (78% sensitivity and 84% specificity). Conclusions: The lower resting values of LV GLS and MWE in severe AR asymptomatic patients suggest an early subclinical myocardial damage that seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during stress. [ABSTRACT FROM AUTHOR]

Background: Target therapy can cause various cardiovascular complications. The aim of this study was to evaluate the burden of cardiovascular complications related to treatment with anti-BCR-ABL tyrosine kinase inhibitors (TKIs) and to determine if there are differences between the latest- and first-generation TKIs. Methods: A retrospective observational study was carried out on 55 patients (39 men, 16 women; mean age ± SD: 58 ± 11 years) treated with TKIs targeting Bcr-Abl for a median period of 3.5 years. Patients were divided in two groups according to the type of treatment. Group A included patients treated with latest-generation TKI (nilotinib, dasatinib, and ponatinib), while group B included patients treated with first-generation TKI (imatinib). Cardiological evaluation included electrocardiogram, echocardiogram with global longitudinal strain of left ventricle (GLS), and carotid ultrasound scan with arterial stiffness measurement (pulse wave velocity, PWV). Adverse cardiovascular events were recorded in both groups. Results: Statistical analysis showed that cardiovascular adverse events (myocardial ischemia, peripheral artery disease, deep vein thrombosis, and pleural effusion) were significantly more frequent in group A than group B (p value = 0.044). Moreover, there was a significant reduction in GLS and PWV in group A when compared to group B (respectively, p = 0.03 and p = 0.004). Conclusions: Our study confirms that imatinib is a relatively safe drug, while it reveals that the latest-generation TKIs may cause a burden of cardiovascular complications. GLS and PWV allow detection of early signs of cardiac and vascular toxicity in oncohematologic patients treated with TKI, and their use is advisable. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases are possible complications of antineoplastic treatment and may lead to premature morbidity and mortality among cancer survivors. A symptom-based follow-up is ineffective, and there are growing evidences that early detection of myocardial damage in patients treated with antineoplastic drugs is the key point to prevent the occurrence of damage and improve the prognosis of these patients. Different techniques have been proposed to monitor cardiac function in oncologic patients such as cardiac imaging (echocardiography, nuclear imaging, and cardiac magnetic resonance) and biomarkers (troponin and natriuretic peptides). The European Association of Cardiovascular Imaging/American Society of Echocardiography consensus document encourages an integrated approach to early detect cardiotoxicity. [ABSTRACT FROM AUTHOR]

Aims Recent advancements in echocardiographic technology allow to analyse myocardial strain in multiple layers. Little is known about the impact of age on layer-specific longitudinal strain in healthy subjects. The aim of this study was to analyse the influence of age on multilayer longitudinal strain and establish normal reference values of layer-specific strain according to age decades in a healthy population referring to our echo laboratory using 2D speckle-tracking echocardiography with layer-specific software. Methods and results Two-hundred sixty-six healthy, consecutive subjects (mean age = 39.2 ± 17.5 years, women/men = 137/129), free of cardiovascular risk factors, were enrolled. Subjects were divided according to six age decades: 10–19, 20–29, 30–39, 40–49, 50–59, >60 years. All subjects underwent a complete echo Doppler examination including quantitation of 2D global longitudinal strain (GLS). Subendocardial longitudinal strain (LSsubendo), subepicardial longitudinal strain (LSsubepi), and strain gradient (LSsubendo − LSsubepi) were also determined. GLS (P < 0.001), LSsubendo, and LSsubepi (both P < 0.0001) were all progressively reduced with increasing age decades, but post hoc intra-group analyses demonstrated that the decline of GLS, LSsubendo, and LSsubepi was significant in the decades 50–60 and ≥60 years. In separate multiple linear regression analyses, the effect of age on GLS, LSsubendo, and LSsubepi remained significant even after adjusting for clinical and echocardiographic confounders. Strain gradient remained unchanged in age decades. Conclusion Ageing shows an independent effect on GLS, LSsubendo, and, particularly on, LSsubepi. Our data also provide normal reference values of layer-specific longitudinal strain for age decades. [ABSTRACT FROM AUTHOR]

Summary: Background: Cirrhosis is associated with morpho‐functional cardiovascular alterations. Aims: To detect early features of cardiovascular damage in HCV‐compensated cirrhotic patients using myocardial deformation indices and carotid arterial stiffness, and, further, to evaluate their short‐term behaviour after HCV eradication with direct antiviral agents (DAAs). Methods: Thirty‐nine consecutive patients with HCV cirrhosis, without previous cardiovascular events, were studied and matched for age, gender and cardiovascular risk factors to 39 controls without liver or cardiovascular disease. Patients and controls underwent a baseline echocardiographic evaluation including global longitudinal strain and ultrasound scan of carotid arteries. HCV‐cirrhotics were reassessed by echocardiography and carotid ultrasound after obtaining sustained virological response (SVR) on DAAs. Results: HCV‐cirrhotics showed at baseline a significantly reduced global longitudinal strain compared to controls −18.1 (16.3‐20.5) vs −21.2 (20.4‐22.3), P < 0.001. They also had a significantly higher pulse wave velocity 8.6 (7.7‐9.1) m/s vs 6.6 (6.0‐7.1) m/s, P = 0.0001, and β‐stiffness index 12.4 (11.1‐13.5) vs 8.6 (8.0‐9.2) P = 0.0001. At multiple regression analysis, diabetes and HCV cirrhosis were independent predictors of global longitudinal strain. All HCV‐cirrhotic patients had SVR on DAAs. Follow‐up available in 32 of 39 (82%) at 9 (8‐10) months showed a significant improvement of tricuspid annular plane systolic excursion (P = 0.01) and lateral E’ velocity compared to baseline (P = 0.001). Conclusions: HCV‐cirrhotics show a significant rate of subclinical cardiac and vascular abnormalities. At a time when their survival is less linked to progression of liver disease, due to viral eradication on DAAs, cardiovascular morbidity and mortality may take a significant role. [ABSTRACT FROM AUTHOR]

Objective: Stress cardiomyopathy is characterized by symptoms with ECG modification and increased MI-STE typical myocytolysis markers in post-menopausal women who have suffered from an episode or a period of intense emotional stress. A normal coronary artery and a peculiar and reversible morphology of the left ventricle in systole that has taken the Japanese name of Tako-Tsubo. Method: What truly causes the adverse outcome in tako-tsubo cardiomyopathy? The TS basics of pathophysiology have not come to a definitive conclusion. Numerous mechanisms have been proposed. Active triggers are common, but little is known about psychological background characteristics. Results: Anxiety and depression contribute to increasing the risk of myocardial infarction or simulating a coronary syndrome.From a medical point of view, therefore, psychiatric disorders must be placed at the same level with type 2 diabetes, smoking, hypercholesterolemia and hypertension. Although the prognosis is good and spontaneous resolution is common, clinical manifestations may last for weeks. Conclusions: The reported clinical case has characteristics that are compatible with stress cardiomyopathy and could be an example of how such a clinical syndrome if not properly treated can be reproduced. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to evaluate myocardial perfusion and coronary blood flow through validated angiography indices to assess whether there is greater MVD in patients with microvascular angina and HFPEF compared to those who do not have. Methods Our study was performed on a population of 286 patients with stable angina that underwent coronary angiography and echocardiography. They showed epicardial coronary arteries free from stenosis. We divided the sample into two categories: patients with HFPEF and those without. We calculated indices for each patient based on angiographic images, including TFC, MBG, and TMBS. Results Our sample compared two groups: HFPEF ( n = 155) and non-HFPEF ( n = 135) patients. We showed that patients with HFPEF had a longest TFC of three major coronary arteries (TFC LAD 44.7 ± 12.5; TFC RCA 26.2 ± 6.9; TFC CX 27 ± 5.9) than non-HFPEF patients (TFC LAD 40.7 ± 11.6; TFC RCA 25 ± 6.3; TFC CX 21 ± 4.7). On the other hand, we found lower MBG on three coronary arteries (MBG LAD 2.1 ± 0.3; MBG RCA 2.1 ± 0.3; MBG CX 2.0 ± 0.32) in HFPEF than non-HFPEF patients (MBG LAD 2.6 ± 0.5; MBG RCA 2.2 ± 0.47; MBG CX 2.3 ± 0.4). Conclusion Analysis of microcirculation through angiography indices in patients with and without HFPEF has led to assess that the HFPEF population has a greater involvement of microcirculation than patients without HFPEF. [ABSTRACT FROM AUTHOR]

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Abstract: Objective: Degenerative aortic stenosis shows similarities with atherosclerosis. To confirm the hypothesis that aortic stenosis is an “atherosclerosis-like” disease, we investigated the association between degenerative aortic stenosis and atherosclerosis of carotid arteries. Methods: We studied 270 consecutive patients, 135 with degenerative aortic stenosis (trans-aortic peak velocity ≥ 2 m/sec) and other 135 subjects without aortic valve disease. All patients underwent echocardiography and ultrasound scan of the supra-aortic trunks to assess the presence of plaque and/or intima-media thickening (IMT). Results: Atherosclerosis of carotid arteries (IMT and plaque) was significantly more frequent in patients with aortic stenosis than in controls (95.5% vs. 66.6%, p < 0.0001). The same result was confirmed as concerns carotid plaques (69.6% vs. 42.2%, p < 0.0001). In addition, there was a significant association between aortic stenosis and degenerative carotid plaque (OR = 3.13; 95% C.I. = 1.90–5.17). Thus the presence of a linear correlation between the trans-aortic peak velocity of the cases and the thickness of the plaques and IMT was evaluated by calculating the coefficient of correlation (R = 0.15 for plaque and R = 0.53 for IMT). Conclusions: The presence of carotid atherosclerosis is associated with degenerative aortic stenosis and the severity of aortic stenosis corresponds to an increase of the thickness of plaque and IMT. This relationship is quite new. Our result strengthens the pathogenetic hypothesis “atherosclerosis-like” of degenerative aortic stenosis and suggest the ultrasound scan as a non invasive method for risk stratification in patient with aortic stenosis, with therapeutic implications especially for higher risk subgroups. [Copyright &y& Elsevier]

Background: The aim of the study was to evaluate the clinical and echocardiographic outcomes, at rest and under exercise testing, of patients with moderate ischemic mitral regurgitation (IMR) undergoing isolated coronary artery bypass graft surgery (CABG). Methods: Between February 2003 and March 2008, 180 patients with moderate IMR who had isolated CABG were enrolled. Patients were matched 1:2 (n = 360) with patients who underwent isolated CABG without IMR (by propensity score). The study endpoints were freedom from all death, cardiac related-death, late events, and cardiac-related events. Late outcomes and left ventricular remodeling were evaluated according to preoperative percent of ejection fraction. Symptoms and MR grade under exercise test were investigated. Mean follow-up was 30 ± 16 months. Results: The 5-year freedom from all deaths and from cardiac-related deaths among patients without IMR versus with IMR was, respectively, 90.5% ± 1.8% versus 73.7% ± 2.1% (p < 0.001) and 94.2% ± 1.6% versus 79.5% ± 1.5% (p < 0.001). Ischemic mitral regurgitation affects significantly late survival only in patients with ejection fraction 40% or less. The 5-year freedom from cardiac-related events among patients without and with IMR was, respectively, 88.2% ± 2.1% and 62.1% ± 1.2% (p < 0.0001). Patients with IMR experienced more cardiac-related events in comparison with patients without IMR. Ischemic mitral regurgitation promotes left ventricular remodeling in all patients. During exercise testing, the grade of MR moved from mild to moderate in 10 patients (28.5%) and to severe in 5 (14.3%). Among the 42 patients with moderate MR at rest, 32 patients (76%) moved from moderate to severe MR during exercise. Conclusions: Ischemic mitral regurgitation significantly increases the incidence of cardiac-related deaths among patients with ejection fraction 40% or less and the incidence of cardiac-related events, and promotes left ventricular remodeling. Most patients who had at-rest residual mild to moderate MR presented with a worse MR grade under exercise with the appearance of dyspnea. [Copyright &y& Elsevier]

Abstract: Non-compaction of the ventricular myocardium (LCVM) is a rare disorder of myocardial morphogenesis usually diagnosed in paediatric age. The diagnosis was echocardiographically made on the basis of a reported spongeous/compacted ratio >2 in one or more segments of the left ventricle during the diastolic period. We aimed to test the diagnostic accuracy of cardiovascular magnetic resonance (CMR) imaging in distinguishing pathological left ventricular non-compaction. Methods: We collected a consecutive series of 8 patients, 5 males and 3 females, with a mean age of 14.9 years with non-compaction of left ventricular myocardium. All patients were admitted in our divisions of cardiology. In all cases the diagnosis was performed by echocardiography. The diagnosis was obtained when the spongeous/compacted ratio was >2 in one or more segments of left ventricle, evaluated in systolic and diastolic period. In the end we completed the diagnosis by scanning with a Signa HD 1.5 T (GE, Milwaukee, USA) the same 8 patients affected by non compaction of ventricular myocardium. In all patients cardiac-gated T1 and T2 black-blood FSE images in short axis and in four-chamber horizontal long axis were obtained. Breath hold cine MR sequences (FIESTA) were performed, covering the whole left ventricle in short-axis plane and in four-chamber view. A segmented inversion-recovery fast gradient echo sequence (IR-FGE) was performed in the short-axis plane of the LV and in four-chamber-view after Gadolinium injection in 8 patients affected by non compaction of left ventricle. At the end of examination the spongeous/compacted ratio >2 was calculated in all involved segments of the left ventricle in diastole. Results: In all cases we demonstrated by echocardiography an involvement of the ventricular apex. In 3 cases the structural alterations involved also lateral wall of left ventricle. Magnetic resonance evaluation showed that involvement demonstrated by the echocardiogram was the same: ventricular apex involved in every patient, lateral wall in 3 and all segments in 2. However the spongeous/compacted ratio was >>2 in all patients, with a mean value of 3,1. Conclusions: Although our data refer to a small population of patients and need further confirmation, they suggest that it seems reasonable increase the cut-off for spongeous/compacted ratio from a value of 2 to 2.5 for non-compaction diagnosis when high-resolution magnetic resonance is used. [Copyright &y& Elsevier]

Abstract: In a recent report about noncompaction Nemes et al. reported that systolic left ventricular (LV) dysfunction assessed using the wall motion score during 2D echocardiography in noncompaction is not confined to noncompacted LV segments. These results confirmed some published reports of our group. Recently we analyzed a population of 238 patients affected by noncompaction, and demonstrated that the number of noncompacted segment is uncorrelated with the degree of systolic dysfunction. It is an attractive hypothesis that the systolic dysfunction could be depend on the fibrosis of the left ventricle, itself a consequence of microcirculatory dysfunction, which has been confirmed by reports that describe microvascular dysfunction using myocardial scintigraphy. [Copyright &y& Elsevier]

Abstract: Aim: To evaluate if the intima-media thickening (IMT) and asymptomatic carotid plaque (ACP), as expression of carotid preclinical atherosclerosis (pre-ATS), can provide further information on the global cardiovascular risk (GCVR). Methods: We studied 454 asymptomatic subjects, with a cluster of risk factors (RF), and evaluated the incidence of a first cardiovascular (CV) event in a five-year follow-up. The subjects at admission were subdivided in three groups of risk. Results: Events occurred in 38% of subjects at high risk, in 13% and 6% of subjects at intermediate and low risk (p <0.003). Among evaluated parameters, carotid pre-ATS was a predictive marker of CV events (OR 2.7, 95% IC 1.4–5.1, p <0.0024). In subjects with GCVR <20% the prevalence of events was 8% for normal carotid ultrasound findings, 13% for increased IMT and 15% for ACP. Conclusions: In primary prevention, the IMT measurement can give further information for a better stratification of GCVR. The pre-ATS of carotid arteries should be considered a strong predictor of future CV events and should suggest a more aggressive treatment of RF. [Copyright &y& Elsevier]

Abstract: Background: Non-compaction of ventricular myocardium is a rare congenital cardiomyopathy characterized by the presence of an extremely thickened endocardial layer with prominent trabeculations and deep recesses in communication with ventricular chamber and determining the typical spongeous aspect. The diagnosis of non-compaction of ventricular myocardium is possible through the identification of morphological alterations by echocardiographic evaluation. Ebstein''s anomaly is a rare congenital cardiac disease, defined as the significant apical displacement of the part of the tricuspid valve causing significant tricuspid regurgitation and reduction of the functional right ventricle, right atrial and right ventricular dilatation and atrial and ventricular arrhythmias. Case report: We present a case of biventricular non-compaction and Ebstein''s anomaly in a 29-year-old Italian man that was referred for chest pain. Diagnosis of Ebstein''s anomaly was made during a medical control for military service through an echocardiographic evaluation which left the suspicion of myocardium non-compaction. We present the cardiac image of the 2D and 3D eco, RMN, scintigraphy and ventriculaography. [Copyright &y& Elsevier]