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Renal resistance index (RRI) is a parameter which is easily evaluable by the echo Doppler technique and which has been demonstrated to predict worsening of renal function (WRF) in patients affected by chronic heart failure as well as among those undergoing coronary angiography. The aim of this study was designed to evaluate the role of the RRI in predicting WRF after cardiac surgery. Methods Thirty–one patients were enrolled. Their clinical characteristics are shown in Table 1. All patients underwent cardiac surgery. Before surgery, RRI was evaluated according to Peurcelot’s formula by renal interlobular arteries pulsed Doppler. WRF was defined as an increase in serum creatinine of > 0.3 mg/dl associated with a change > 25% or the need of renal replacement therapy due to severe acute kidney injury. Results Among the patients in 12 WRF occurred, in 10 a worsening of creatinine serum levels and in 2 a severe AKI requiring RRT were observed. As shown in Table 1, RRI and the presence of peripheral artery disease were the only parameters which were significantly different among patients with and without WRF, whereas no difference in GFR values was observed. Baseline RRI showed a significant AUC of 0.74 (95% CI, 0.55–0.93) whereas baseline GFR of 0.52 (95% CI, 0.28–0.75) was not significant. Conclusions Among patients with WRF after cardiac surgery an increased RRI but not a different baseline GFR is observed. This parameter could allow a more accurate stratification of the risk of cardiorenal syndrome worsening among patients candidated to cardiac surgery.

Worsening of renal function (WRF) is frequently observed after cardiac surgery and it is associated with both short– and long–term worse outcome. Among the pathophysiological conditions favoring the occurrence of WRF, the abnormalities in renal blood flow could play a key role. The aim of this study was to evaluate the changes in renal resistance index (RRI), a parameter reflecting renal parenchymal and hemodynamic parameters, after cardiac surgery. Methods Thirty–one patients were enrolled (age 65±12 years, 29% males, mean left ventricular ejection fraction 55±5%, mean creatinine serum levels 0.89±0.18 mg/dl, mean eGFR 89±28 ml/min*1.73 m2). All patients underwent cardiac surgery. Before cardiac surgery, after 3 days and before discharge, RRI was evaluated according to Peurcelot’s formula by renal interlobular arteries pulsed Doppler. Worsening of renal function was defined as an increase in serum creatinine of > 0.3 mg/dl associated with a change > 25% or the need of renal replacement therapy due to severe acute kidney injury. Results As shown in the table 1, after cardiac surgery a significant increase in RRI was observed at 3 days after cardiac surgery but not before discharge. The significant increase in RRI was observed both in patients with and without WRF. However, in patients with WRF significant higher values of RRI were observed before as well as after cardiac surgery. Conclusions Among patients undergoing cardiac surgery a significant increase in RRI values is observed after surgery. Among patients with WRF a significant greater values of RRI are observed before as well as cardiac surgery thus suggesting that a critical increase in renal resistance could play a role in the cardiorenal syndrome worsening.

Background Myocardial deformation evaluated by two–dimensional speckle tracking echocardiography (STE) is a useful tool to evaluate both left and right ventricular function. However, there are no conclusive data about the relationship between strain measures and heart rate (HR). Aim of the Study To analyse changes in left (LV) and right ventricular (RV) longitudinal strain associated with variations of HR in patients with and without chronic heart failure (CHF). Methods. We enrolled 45 patients. Of the 38 patients diagnosed with CHF, 21 were carrying an ICD (Group 1), and 17 an ICD with CRT (Group 2). Group 3 included 7 participants without CHF with sinus node dysfunction that were carrying a pacemaker. The frequency of atrial stimulation was increased to 90 beats/min and an echocardiogram was performed at each increase of 10 beats/min. Global LV and RV longitudinal strain (LVGLS and RVGLS, respectively) and RV free wall longitudinal strain (RVfwLS) were calculated at each HR, together with other echocardiographic parameters. Worsening or improvement of strain measures was defined as a relative change from baseline of 10%. Results The reproducibility of strain measurements was assessed in all the images obtained at the different HRs for 19 of the study participants. A high degree of reproducibility was observed for LVGLS (ICC = 0.96; 95% CI, 0.93 – 0.97) as well as for RVGLS (ICC = 0.91; 95%CI, 0.86 – 0.94) and RVfwLS (ICC = 0.91; 95%CI, 0.85 – 0.94). When analysed as continuous variables, significant reductions in LVGLS were detected at higher HRs, whereas improvements in both RVGLS and RVfwLS were observed (left panels of the figure). Patients with worsening of LVGLS (76% overall) were more likely to present lower baseline LV function and maximum relative changes of LVGLS correlated significantly with the E/e’ ratios (r = –0.56; p Conclusions Our findings revealed heterogeneous RV and LV responses to increases in HR. These findings might ultimately be used to optimize cardiac functionality at rest in patients diagnosed with CHF.

The electrocardiographic patterns, observed during 24-h Holter monitoring, of 10 patients (mean age 35 +/- 22 years) with first and second degree A-V block due to dual A-V nodal pathways are reported. Recordings were selected according to the presence of: sudden and persistent prolongation of the PR interval: sudden normalization of the PR interval: 'atypical' Wenckebach sequences showing sudden and pronounced prolongation of any PR interval prior to the blocked P wave. Besides the already recognized pattern, new aspects were identified: (1) Wenckebach sequences in the slow and fast pathways characterized by a progressive increase in the PR interval until a blocked P wave occurred during long and short PR interval periods, respectively; (2) Wenckebach periods first in the slow and then in the fast pathway; (3) 2:1 A-V block with a normal PR interval in the conducted beat after a Wenckebach sequence in the slow pathway; (4) Wenckebach in the fast pathway and, subsequently, in the slow one characterized by a slight prolongation of the PR interval for some beats followed by a sudden and pronounced increase in the PR interval of one beat and a subsequent progressive slight PR prolongation until a blocked P wave occurred; (5) Wenckebach sequence in the fast pathway with subsequent conduction over the slow pathway without a blocked P wave; (6) blocked P waves during both long and short PR interval periods with slight prolongation of the preceding PR interval. The electrophysiological mechanisms involved in these electrocardiographic patterns together with the nature (anatomical or functional) of the intranodal pathways and the clinical significance of this type of block are discussed.

Background: Tissue Doppler Imaging (TDI) may be useful in identifying subjects at higher risk among patients with Chronic Heart Failure (CHF). The clinical role of new developed TDI parameters, however, still need to be documented. Methods: A total of 113 consecutive patients with CHF enrolled in the daunia Heart Failure Registry underwent echocardiography assessment and were followed prospectively for a mean 234±262. days. Conventional echocardiography and TDI parameters were calculated. We have also calculated peak myocardial acceleration during isovolumic relaxation time (pIVA(r)) derived from TDI (peak velocity during isovolumic relaxation (pIVV(r))/Acceleration Time (AT)). Results: Subjects readmitted for worsening HF were characterized by lower levels of pIVA(r) (0.8±0.3 vs 1.3±0.5 m/s2, p

Background: Heat waves have been reported as associated with increased rates of hospitalizations and deaths. Modern technologies currently available for at-home assessment of patients calling Emergency Medical Service (EMS) may however be helpful in managing increased work burden caused by heat waves. Methods: In July 2011 a heat wave hit Southern Italy. We enrolled 9,282 consecutive patients who called Apulia regional free public EMS "118" (4-million inhabitants, South-Eastern Italy) during the entire month of July 2011. All patients were evaluated with pre-hospital ECG thanks to tele-cardiology support provided by a unique tele-medicine hub. Local temperatures and relative humidity were recorded and combined in order to calculate Heat Index (HI), a more accurate parameter to assess perceived discomfort caused by hot temperatures. HI month-through values were compared with rates of EMS calls and ECG performed in case of suspected acute heart disease. Results: Increased "118" callings were observed just after peaks in HI index (407 on July 11 vs 219 on July 1, +87%, p 70 vs

Background: Tele-medicine support is presently applied in several fields of medicine. Clinical evidence showed as pre-hospital ECG may shorten time to reperfusion in subjects with acute myocardial infarction, thus significantly affecting clinical outcomes of these patients. Methods: A tele-medicine service presently supports the public free Emergency Medical Service (EMS) "118" throughout whole Apulia, a 4-million inhabitants region in South-Eastern Italy. "118" is the Italian public free service for general medical or surgical emergencies, whose aim is an immediate diagnosis of critical diseases in order to avoid emergency room delay-to-diagnosis. Patients are discharged from the ambulance and not transported at all in case of normal findings; direct admission to a critical care unit is arranged according to the level of care. Thanks to tele-cardiology support, "118" crews may record a complete 12-lead pre-hospital ECG with an apposite device, in any case of suspected heart disease. The ECG is sent by mobile phone support to a single regional tele-cardiology "hub" control room where a cardiologist promptly reads the ECG and provides a consultation. The ECG may then be sent back via the internet and also visualized by EMS personnel on smart-phones or cath-lab physicians. The "118" control room, according to ECG and EMS crew report, then arranges for hospitalization when needed. Data from 2004 until early 2013 were hereby reported. Results: 523,449 ECGs were recorded since 2004. Constantly growing trend of ECGs performed by "118" crews emphasizes the usefulness and liability of tele-cardiology support in every-day EMS practice (16,534 ECGs in 2005, 31,535 2006, 42,854 2007, 49,999 2008, 69,198 2009, 94,326 2010, 106,870 in 2011, 109,750 in 2012). Referring symptoms were dyspnea (9%), dizziness or faint (21%), chest pain (24%), palpitations (7%), or other non-specific symptoms. In 35,898 cases (7%) ECG showed a significant arrhythmia, in 26,819 (5%) signs suggestive for myocardial ischemia needing further examination (ECG monitoring, cardiac enzyme assay, coronary care or cath-lab admission). Conclusions: A single tele-cardiology"hub" may easily support EMS in a 4-million-inhabitant region.

Programmed electrical stimulation (PES) was performed in 17 patients, mean age 31 +/- 8 years, with minor forms of right ventricular dysplasia diagnosed because of (1) premature ventricular beats (PVBs) of left bundle branch block (LBBB) morphology; (2) no clinical or non-invasive evidence of cardiac abnormalities; (3) angiographic evidence of right ventricular wall motion abnormalities and bioptic findings of fibro-adipose infiltration. Fifteen patients had frequent and complex PVBs while two had sustained ventricular tachycardia (VT). During PES, sustained VT was induced in 2/2 patients with spontaneous sustained VT; ventricular repetitive responses were induced in 2/15 cases (13%) with complex and frequent PVBs. In conclusion, in minor forms of right ventricular dysplasia, PES induces VT only in patients with clinical VT; on the contrary, in patients with PVBs it is only possible to induce repetitive ventricular responses in a small proportion of cases; it is therefore not possible to select patients at high risk of developing severe ventricular arrhythmias.

Two patients developed ventricular fibrillation (VF) while undergoing continuous electrocardiographic monitoring. Analysis showed that VF appeared only when a particular combination of circumstances occurred: a postextrasystolic pause, QT prolongation of the subsequent beat and a premature ventricular beat that did not have a short coupling interval. The relevance of this sequence as a trigger mechanism of VF is discussed.