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Heart failure (HF) with reduced ejection fraction (HFrEF) has a well-known epidemic relevance in western countries. It affects up to 1–2% of patients > 60 years and reaches a prevalence of 12% in octogenarian patients. The role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitive troponin I (hsTnI) in risk stratifying HFrEF patients has been established; at present, evidence is exclusively based on one-time assessments, and the prognostic usefulness of serial biochemical assessments in this population still remains to be determined. We prospectively recruited 226 patients with chronic HFrEF, who were all referred to the Outpatient Clinic of our institution from November 2011 through September 2014. Recruited patients underwent full clinical evaluation with complete history taking and physical examination as well as ECG, biochemical assessment, and standard 2D and Doppler flow echocardiography at the first visit, and then again at each visit during the follow-up, repeated every 6 months. During the follow-up period, cardiovascular (CV) death, which occurred in 16 patients, was not statistically correlated with gender (p = 0.088) or age (p = 0.1636); however, baseline serum levels of NT-proBNP, which were 3 times higher in deceased patients, were significantly related to this clinical event (p = 0.001). We found that NT-proBNP represents a strong and independent predictor of CV outcome; serum levels of hsTnI, which are significantly related to an increased risk of hospitalization, cannot properly predict the relative risk of CV mortality. Our study validates, eventually, the multimarker strategy, which reflects the complexity of the HF pathophysiology.

Iron deficiency (ID) is recognized as an important comorbidity in patients undergoing cardiac surgery; however, it still remains under-diagnosed and under-treated in clinical practice. This study aims at comparing efficacy and the effects on exercise capacity of intravenous ferric carboxymaltose (FCM) versus ferric gluconate (FG) in patients with ID anemia (IDA) resulting from cardiac surgery. We retrospectively analyzed data from our records of in-hospital patients with IDA after cardiac surgery undergoing cardiac rehabilitation. Group I was treated with FG, group II with FCM. Efficacy measures included changes (baseline vs discharge) in hemoglobin (Hb) and in distance traveled at six-minutes walking test (6MWT). Data from 74 in-patients (mean age 67.5±10.4 years, 43% women) were analyzed. At discharge, patients treated with FCM showed higher levels of Hb (11.1±1.2g/dl vs 10.2±1.1 g/dl; p=0.001), greater distance traveled at 6MWT (279.2±108.8 meters vs 236.3±72.7 meters; p=0.048), and lower in-hospital rehabilitation length of stay (20.3±7 vs 25.3±11.7 days; p=0.043) as compared to FG group. At multivariate analysis, the most powerful predictors of Hb increase >1 g/dl at discharge were transferrin levels (p=0.019) and treatment with FCM (p100 meters) at discharge (p=0.13 and p=0.003, respectively). In patients with IDA following cardiac surgery, intravenous FCM is effective in restoring Hb levels and in improving exercise capacity after cardiac surgery.

Background: Sacubitril/valsartan has been shown to be superior to enalapril in reducing the risks of death and hospitalization for heart failure (HF). However the effect on cardiac performance remains unknown. We sought to evaluate the effects of sacubitril/valsartan on clinical, bioumoral and echocardiographic parameters in patients with HFrEF. Methods: Sacubitril/valsartan was administered to 205 HFrEF patients. Results: Among 230 patients (mean age 59 ± 10 years, 46% with ischemic heart disease) 205 (89%) completed the study. After a follow–up of 10.49 (2.93±18.44) months, the percentage of patients in NYHA class III changed from 40% to 17% (p

Background Previous studies showed that troponin blood levels may increase after exercise. In this study we assessed whether, among patients admitted with suspected unstable angina, the increase in high-sensitive troponin T (hs-TnT) levels after exercise stress test (EST) might help identify those with obstructive coronary artery disease (CAD) and predict symptom recurrence during short term follow-up. Methods Maximal treadmill EST was performed in 69 consecutive patients admitted to the emergency room with a suspicion of unstable angina (acute chest pain but confirmed normal serum levels of cardiac troponins) was measured before and 4 hours after EST. Coronary angiography was performed in 22 patients (32.8%). Results hs-TnT increased after EST compared to baseline in the whole population (from 0.84±0.65 to 1.17±0.87 ng/dL, p

Background. Sacubitril/valsartan in heart failure (HF) with reduced ejection fraction (HFrEF) was shown to be superior to enalapril in reducing the risk of death and hospitalization for HF. Our aim was to evaluate the cardiopulmonary effects of sacubitril/valsartan in patients with HFrEF. Methods. We conducted an observational study. Ninety-nine ambulatory patients with HFrEF underwent serial cardiopulmonary exercise tests (CPET) after initiation of sacubitril/valsartan in addition to recommended therapy. Results. At baseline, 37% of patients had New York Heart Association (NYHA) class III. After a median follow-up of 6.2 months (range 3&ndash, 14.9 months) systolic blood pressure decreased from 117 &plusmn, 14 to 101 &plusmn, 12 mmHg (p &lt, 0.0001), left ventricular ejection fraction (LVEF) increased from 27 &plusmn, 6 to 29.7 &plusmn, 7% (p &lt, 0.0001), peak oxygen consumption (VO2) improved from 14.6 &plusmn, 3.3 (% of predicted = 53.8 &plusmn, 14.1) to 17.2 &plusmn, 4.7 mL/kg/min (% of predicted = 64.7 &plusmn, 17.8) (p &lt, 0.0001), minute ventilation/carbon dioxide production relationship (VE/VCO2 Slope) decreased from 34.1 &plusmn, 6.3 to 31.7 &plusmn, 6.1 (p = 0.006), VO2 at anaerobic threshold increased from 11.3 &plusmn, 2.6 to 12.6 &plusmn, 3.5 mL/kg/min (p = 0.007), oxygen pulse increased from 11.5 &plusmn, 3.0 to 13.4 &plusmn, 4.3 mL/kg/min (p &lt, 0.0001), and ∆VO2/∆Work increased from 9.2 &plusmn, 1.5 to 10.1 &plusmn, 1.8 mL/min/watt (p = 0.0002). Conclusion. Sacubitril/valsartan improved exercise tolerance, LVEF, peak VO2, and ventilatory efficiency at 6.2 months follow-up. Further studies are necessary to better clarify underlying mechanisms of this functional improvement.

Background: Sacubitril/valsartan has been shown to be superior to enalapril in reducing the risks of death and hospitalization for heart failure (HF). However, knowledge of the impact on cardiac performance remains limited. We sought to evaluate the effects of sacubitril/valsartan on clinical, biochemical and echocardiographic parameters in patients with heart failure and reduced ejection fraction (HFrEF). Methods: Sacubitril/valsartan was administered to 205 HFrEF patients. Results: Among 230 patients (mean age 59 &plusmn, 10 years, 46% with ischemic heart disease) 205 (89%) completed the study. After a follow-up of 10.49 (2.93 &plusmn, 18.44) months, the percentage of patients in New York Heart Association (NYHA) class III changed from 40% to 17% (p &lt, 0.001). Median N&ndash, Type natriuretic peptide (Nt-proBNP) decreased from 1865 &plusmn, 2318 to 1514 &plusmn, 2205 pg/mL, (p = 0.01). Furosemide dose reduced from 131.3 &plusmn, 154.5 to 120 &plusmn, 142.5 (p = 0.047). Ejection fraction (from 27&plusmn, 5.9% to 30 &plusmn, 7.7% (p &lt, 0.001) and E/A ratio (from 1.67 &plusmn, 1.21 to 1.42 &plusmn, 1.12 (p = 0.002)) improved. Moderate to severe mitral regurgitation (from 30.1% to 17.4%, p = 0.002) and tricuspid velocity decreased from 2.8 &plusmn, 0.55 m/sec to 2.64 &plusmn, 0.59 m/sec (p &lt, 0.014). Conclusions: Sacubitril/valsartan induce &ldquo, hemodynamic recovery&rdquo, and, consistently with reduction in Nt-proBNP concentrations, improve NYHA class despite diuretic dose reduction.

Background & Aims: Studies have produced conflicting results of the incidence of hepatocellular carcinoma (HCC) in patients with hepatitis C virus–associated cirrhosis treated with direct-acting antivirals (DAAs). Data from clinics are needed to accurately assess the occurrence rate of HCC in patients with cirrhosis in the real world. Methods: We collected data from a large prospective study of 2,249 consecutive patients (mean age = 65.4 years, 56.9% male) with hepatitis C virus–associated cirrhosis (90.5% with Child-Pugh class A and 9.5% with Child-Pugh class B) treated with DAAs from March 2015 through July 2016 at 22 academic and community liver centers in Sicily, Italy. HCC occurrence was evaluated by Kaplan-Meier curves. Cox regression analysis was used to identify variables associated with HCC development. Results: A sustained virologic response (SVR) was achieved by 2,140 patients (total = 95.2%; 95.9% with Child Pugh class A and 88.3% with Child Pugh class B; P

Background and aims: Use of direct acting antivirals (DAAs) has allowed to clear HCV in almost all patients even in the presence of advanced cirrhosis. Although it has been suggested that cirrhotic portal hypertension may regress after SVR, the ultimate effect of HCV clearance on the development and progression of oesophagogastric varices (OV) is still unexplored. We assessed in a prospective cohort of patients with cirrhosis the evolution of endoscopic features of portal hypertension induced by SVR obtained with DAAs. Method: 321 consecutive patients (mean age: 65.1 ± 10.5, males: 58%) with HCV Child-Pugh A cirrhosis treated with DAAs were enrolled between January 2015 and May 2016. All patients underwent esophagogastroscopy (EGS), liver ultrasound (US), liver stiffness measurement (LSM) by Transient Elastography and laboratory tests before the starting DAAs and after achieving SVR. LS * spleen diameter/platelet ratio (LSPS) was calculated as previously described [1]. Results: Forty-one patients were excluded from the analysis, 32(10%) since they had F2/F3 OV at baseline, and 9(2.8%) since they did not achieve SVR. Overall, 280 SVR patients were analysed. At baseline, 100 patients (35.7%) did not have OV and 180(64.3%) had small OV. None received beta-blockers. After a median time of 24.6 months EGS showed de novo development of OV in 24/100(24%) patients and progression from F1 to F2/F3 OV in 30/180 patients (16.7%), p = 0.68 by Kaplan–Meier. By Cox regression analysis, LSPS as continuum variable (HR: 1.06, CI95%: 1.01–1.11, p = 0.025) or at a cut off ≥ 3(HR: 3.16, CI95%: 1.64–6.09, p = 0.001) was associated with OV progression. Age (p = 0.15), gender (p = 0.93) and BMI (p = 0.07) did not correlate with progression of OV. Conclusion: Progression of clinically significant portal hypertension, as assessed by the evolution of oesophagogastric varices, is not uncommon among patients with HCV cirrhosis after HCV clearance. Non-invasive evaluation using combined data of LS, spleen diameter, and platelet count can assist in identifying patients in whom portal hypertension is likely to progress notwithstanding SVR.

Infective endocarditis is a disease associated with high mortality and severe complications. We report a case of a young shepherd affected by valvular endocarditis on a bicuspid aortic valve, complicated by a pseudoaneurysm with periaortic abscess. Thanks to the use of multimodality diagnostic imaging (particular echocardiogram, Magnetic Risonance Imaging, Computed tomography-scan and coronary angiography), it was possible to make a correct diagnosis, in order to plan a tailored surgical strategy and to reduce the perioperative risks. The operation consisted of myocardial revascularization, closure of the annular pseudoaneurysm and aortic valve replacement with mechanical prosthesis. The patient maintained normal inflammation indices and was discharged at home in the absence of relevant clinical events. Infective endocarditis is a deadly disease. Multimodality imaging is crucial to clarify anatomical distorsions that can occur in complicated cases.

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. (Echocardiography 2011;28:1125-1132)

Objective The study of the mitral valve apparatus and its modifications during functional mitral regurgitation (FMR) is better revealed by 3-dimensional (3D) transesophageal echocardiography (TOE). To plan mitral valve repair by annuloplasty and papillary muscle (PPM) relocation, we proposed a valve repair procedure oriented by the new main features obtained by real-time 3D TOE reconstruction of the mitral valve apparatus. Methods Since January 2008, 25 patients with severe FMR before mitral valve repair were examined. Mean coaptation depth and mean tenting area were 1.3 ± 0.2 cm and 3.2 ± 0.5 cm 2 , respectively. Intraoperative 2D and 3D TOE were performed, followed by a 3D offline reconstruction of the mitral valve apparatus. A schematic mitral valve apparatus model was obtained. A geometric model like a truncated cone was traced in according to the preoperative measurements. The size of the prosthetic ring was selected preoperatively according to the anterior leaflet surface. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth about 0.6 cm was used to detect the new position of the PPM tips. Results Offline reconstruction of the mitral valve apparatus and respective truncated cone were feasible in all patients. The expected position of the PPM tips desirable to reach a normal tenting area with a coaptation depth 0.6 cm or less was obtained in all patients. After surgery, all parameters were calculated and no statistically significant difference was found compared with the expected data. Conclusions PPM relocation plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results for patients with severe FMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.