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Massimo Zoni-Berisso, Fabrizio Lercari, Tiziana Carazza, Stefano DomenicucciDepartment of Cardiology, ASL 3, Padre A Micone Hospital, Genoa, ItalyAbstract: In the last 20 years, atrial fibrillation (AF) has become one of the most important public health problems and a significant cause of increasing health care costs in western countries. The prevalence of AF is increasing due to our greater ability to treat chronic cardiac and noncardiac diseases, and the improved ability to suspect and diagnose AF. At the present time, the prevalence of AF (2%) is double that reported in the last decade. The prevalence of AF varies with age and sex. AF is present in 0.12%–0.16% of those younger than 49 years, in 3.7%–4.2% of those aged 60–70 years, and in 10%–17% of those aged 80 years or older. In addition, it occurs more frequently in males, with a male to female ratio of 1.2:1. The incidence of AF ranges between 0.21 and 0.41 per 1,000 person/years. Permanent AF occurs in approximately 50% of patients, and paroxysmal and persistent AF in 25% each. AF is frequently associated with cardiac disease and comorbidities. The most common concomitant diseases are coronary artery disease, valvular heart disease, and cardiomyopathy. The most common comorbidities are hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, renal failure, stroke, and cognitive disturbance. Paroxysmal AF occurs in younger patients and with a reduced burden of both cardiac disease and comorbidities. Generally, the history of AF is long, burdened by frequent recurrences, and associated with symptoms (in two thirds of patients). Patients with AF have a five-fold and two-fold higher risk of stroke and death, respectively. We estimate that the number of patients with AF in 2030 in Europe will be 14–17 million and the number of new cases of AF per year at 120,000–215,000. Given that AF is associated with significant morbidity and mortality, this increasing number of individuals with AF will have major public health implications.Keywords: atrial fibrillation, epidemiology, risk factors, mortality, stroke

Supravalvular aortic stenosis (McKusick 18550) is a rare hereditary condition with autosomal dominant transmission. However, the available data have been limited to small family groups which do not allow the definition of the degree of penetrance of the disease. The present study describes a large family with a high frequency of supravalvular aortic stenosis including five generations and 80 subjects, the largest family group with this disease studied so far. The study was carried out prospectively in 66 subjects (clinical examination, ECG, M mode and two dimensional echocardiography). In 14 subjects available data were examined retrospectively. In 10 patients cardiac catheterisation was performed (prospective study in eight). The disease was present in 36 (45%) of the 80 subjects investigated, on the basis of clinical, echocardiographic, and haemodynamic (when available) criteria. The disease was found to be severe in eight cases (22%), moderate in six cases (17%), mild in 13 (36%), and undefined in eight (22%) patients. In one case (3%), multiple pulmonary stenoses were noted in the absence of supravalvular aortic stenosis. Genetic analysis of these data shows, for the first time, the degree of penetrance of the supravalvular aortic stenosis trait (K = 0.86) and confirms that it is transmitted with incomplete penetrance and variable expressivity. [ABSTRACT FROM PUBLISHER]

The progression of hypertrophy was studied in 39 patients with hypertrophic cardiomyopathy by echocardiography at follow up from January 1979 to September 1983 (mean follow up 42 months). Thirty two patients were treated medically and 11 had had a septal myotomy-myectomy. Progression of the hypertrophy was noted in four patients treated with propranolol. An additional region in the left ventricular long axis plane was affected in two, extending to the apical region in one and to the basal region in the other, and an additional segment in the left ventricular short axis plane in two extending from the septum into the free wall. The electrocardiograms of these four patients showed a significant increase in QRS voltages (Sokolow-Lyon index increase greater than 10 mm) and of the Romhilt-Estes score (increase greater than or equal to 3 points) in two, development of a left bundle branch block in one, and no change in one. Progression of hypertrophy was seen in none of the 11 patients treated with myotomy-myectomy. Thus echocardiography accurately detects the progression of hypertrophy in patients with hypertrophic cardiomyopathy, which may be prevented by septal myotomy-myectomy. [ABSTRACT FROM PUBLISHER]

In recent years, increasing evidence has pointed to the potential of dipyridamole stress echocardiography as a fast, effective, inexpensive method of risk stratification after an acute myocardial infarction. A very early stratification by this test could improve the patient's management and reduce the duration of in-hospital stay, and, thus, the costs. Two-hundred and fifty-one consecutive patients (208 male, age 58 ± 11) with a two-dimensional echocardiogram of good technical quality underwent a dipyridamole echocardiographic test (DET) 70 ±6 h after an acute myocardial infarction. Criterion for positivity was the identification of a transient regional asynergy that was absent or of a lower degree in the baseline examination. Positivity was defined as ‘at low-dose’ or ‘at high- dose’ if the asynergy was detected before or after the 8th min of a drug infusion. All tests were performed without any major side effects. DET was positive in 149 (59%) and negative in 102 (41%) patients. During the hospital stay, cardiac events (death, reinfarction, angina) occurred in 521251 patients: in 491149 with a positive and in 31102 with a negative test (sensitivity 94%, negative predictive value 97%, P<000001). Severe events (death and reinfarction) occurred in 14/251: in 121149 with a positive DET and in 21102 with a negative DET (sensitivity 86%; negative predictive value: 98%; V<0.05). Moreover, cardiac events occurred in 28165 patients with a low-dose positive DET, in 21184 with a high-dose positive DET and in 31102 with a negative DET (low-dose positive vs negative DET: P<0 00001, and vs high-dose positive DET: P<002; high-dose positive vs negative DET: P<000001). Hence, DET performed 3 days after acute myocardial infarction is feasible, well tolerated and safe, and allows early stratification of patients with different degrees of risk of in-hospital cardiac events. [ABSTRACT FROM PUBLISHER]

Left ventricular thrombus may develop both early and late after acute anterior myocardial infarction. To assess the possible prognostic implication of the time of thrombus appearance, 125 patients (87 males; age ranging from 35 to 92 years, mean: 65±10 years) consecutively admitted to our coronary care unit within 24 h of a first acute anterior myocardial infarction, untreated with antithrombotic drugs, underwent serial two-dimensional echocardiographic studies during hospitalization, then monthly for a follow-up of 1–48 (mean: 23±16) months among survivors. Left ventricular thrombi, detected in 71 patients (57%), appeared from 1 to 362 (mean: 13±44) days after acute infarction. In 40patients (56%), early thrombus development, within 48 h of symptom onset, was noted. During the study period, 52 patients (42%) died. Global mortality rate was similar in patients with thrombi compared with those without thrombi (32/71: 45%, vs 20/54:37%;P=ns). However, in-hospital mortality of patients who developed left ventricular thrombi within 48 h (17/40:42–%) was significantly higher compared with both patients with later thrombus appearance (4/31:13%; P < 0008) and those without thrombi (10/54: 20%; P<0–01). Embolic events were more frequent in patients with thrombi (9/71, 13% vs 1/54, 2%; P<002), but there was no relationship with the time of thrombus appearance. The values of peak CPK levels and the degree of left ventricular wall motion abnormalities observed in patients with early left ventricular thrombus were significantly higher than the values detected in patients without thrombi, but similar to those obtained in patients with later thrombus occurrence. The frequency of Killip class III or IV, assessed at hospital admittance, was similar in the three groups. Multivariate regression analysis of the variables predictive of in-hospital death confirmed a high significance of early thrombus appearance (P< 00004), and showed a lower predictive value (P < 0–05) of the development of left ventricular aneurysm within 2 days after acute infarction. Therefore, early development of left ventricular thrombus after acute anterior myocardial infarction, within 48 h of symptom onset, is an independent predictor of higher in-hospital mortality. [ABSTRACT FROM PUBLISHER]

To evaluate the possible relation between the age of intracardiac thrombi and the presence and degree of their activity, 29 patients with left ventricular thrombi that developed after an anterior myocardial infarction were evaluated by means of In-oxine autologous platelet imaging. None of the patients was treated with anti-coagulants or platelet inhibitors during either the acute phase of infarction or the follow-up. The time of appearance and the shape of left ventricular thrombi were assessed by serial cross-sectional echocardiograms, obtained within 24 hours of onset of the chest pain, every 24 hours until the fifth day, every 48 hours until the 15th day, and then every month for a follow-up of 1 to 17 months (mean: 8 months). At the time of the scintigraphic examination, left ventricular thrombi were aged 1 month in 9 patients, and 2 to 14 months in the remaining 20 patients. In-oxine imaging with autologous platelets was obtained in all patients at 4, 24, 48 and 72 hours, in the sagittal, 30° and 45° left anterior oblique projections. In 25 patients the degree of haematological activity of the thrombi was evaluated by dividing the values of thrombus activity/background activity, obtained at 4, 24, 48 and 72 hours, respectively, by the value observed at 4 hours (uptake index). Scintigraphic imaging showed the presence of an active thrombus in every patient. In the 9 patients with recent thrombi, the uptake index was significantly greater than in subjects with older ones (P<0.01). Hence, in patients with anterior myocardial infarction, untreated with anticoagulants or platelet inhibitors, haematologically active thrombi can be observed even more than one year after their appearance. The uptake of platelets on the surface of thrombi is greater in recent left ventricular thrombi than in older ones. [ABSTRACT FROM PUBLISHER]

To assess the usefulness of a step by step evaluation of exercise left ventricular ejection fraction (LVEF), 219 consecutive patients with recent uncomplicated myocardial infarction and 30 normal subjects underwent a symptom-limited cycloergometer test followed by exercise radionuclide ventriculography (ExRNV). LVEF was monitored throughout the whole test. 49 patients underwent coronary arteriography for clinical reasons. 5 patterns of exercise LVEF could be observed: (a) progressive increase: 55 patients (25%) and 27 normal subjects (90%); (b) progressive decrease: 37 patients (17%); (c) initial increase followed by significant decrease: 54 patients (25%); (d) lack of initial modification and terminal decrease: 35 patients (16%); (e) no modification: 38 patients (17%) and 3 normal subjects (10%). Grouping the patients in this fashion allowed us to increase the specificity of ExRNV from 70% to 100%, without loss of sensitivity (95%). As for the patients in subgroup C, 32/54 showed unequivocal ECG ischaemic changes, occurring simultaneously with LVEF decrease; in 33/54 LVEF dropped during the last workload; in 25/54 the last stage LVEF was equal to or higher than the basal LVEF. The statistical analysis showed that ischaemic ECG changes (P<0.0001), exercise-induced wall-motion abnormalities (P<0.0001), and the presence of multivessel coronary artery disease (P<0.0001) were significantly more frequent in patients showing patterns (b)–(d), which should be considered as ischaemic. Our method allowed the unequivocal identification of ischaemic patterns in LVEF during exercise, which might be missed if only its basal and final values are considered. [ABSTRACT FROM PUBLISHER]

To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 +/- 13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis. [ABSTRACT FROM AUTHOR]

Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 +/- 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction < or = 40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class > I and early intravenous beta-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral beta-blocker therapy given or not given after early intravenous beta-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction < 40%. Killip class > I and the early intravenous beta-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic,new models, paradigms, interventional approaches, values and priorities should be suggested and implemented., (Published on behalf of the European Society of Cardiology. © The Author(s) 2021.)

Atherosclerosis often affects the coronary arterial tree. Frequently the disease does not translate in significant narrowing of the vessels, thus determining only a non-obstructive disease. This condition that is described as non-obstructive coronary artery disease (NobsCAD) should be distinguished from the absence of disease (i.e. smooth coronary arteries) as it carries a specific prognostic value. The detection and reporting of NobsCAD should prompt preventive measures that can be individualized upon the degree of the underlying burden of disease. The accompanying clinical condition, the other cardiovascular risk factors present, and the description of the severity and extent of NobsCAD should provide the framework for an individualized treatment that should also consider the best available scientific evidence and guidelines. The description of NobsCAD represents important information to be collected whenever a coronary angiogram (both invasive and non-invasive) is performed. Treating the patient according to the presence and extent of NobsCAD offers prognostic benefits well beyond those offered by considering only the traditional cardiovascular risk factors. In order to reach this goal, NobsCAD should not be confused with the absence of coronary atherosclerosis or even ignored when detected as if it was a trivial information to provide., (Published on behalf of the European Society of Cardiology. © The Author(s) 2021.)

The European Society of Cardiology guidelines on non-ST-elevation acute coronary syndromes suggest different temporal strategies for the angiographic study depending on the risk profile. The scientific evidence underlying the guideline recommendations and the critical issues currently existing in Italy, that often do not allow either an extended strategy of revascularization within 24 h or the application of the principle of the same day transfer from a spoke to a hub centre, are analysed. The position paper focuses, in particular, on the subgroup of patients with a defined diagnosis of non-ST-elevation myocardial infarction by proposing a timing of coronary angiography/revascularization that takes into account the available scientific evidence and the organizational possibilities of a considerable part of national cardiology services., (Published on behalf of the European Society of Cardiology. © The Author(s) 2021.)

Bloodstream cholesterol is a central contributor to atherosclerotic cardiovascular diseases. For several decades, low-density lipoprotein cholesterol (LDL-C) has been the main biomarker for the prediction of cardiovascular events and therapeutic target of lipid-lowering treatments. More recently, several findings have supported the greater reliability of non-high-density lipoprotein cholesterol (non-HDL-C) as a predictive factor and possible therapeutic target in refining antiatherogenic treatments, especially among patients with lower LDL-C and higher triglyceride values. This article discusses the limits of current standard methods for assessing LDL-C levels and emphasizes the persistent residual cardiovascular risk in patients treated with lipid-lowering agents on the basis of recommended LDL-C targets. It highlights that patients with controlled LDL-C and non-targeted non-HDL-C have a higher cardiovascular risk. The article focuses on the role of non-HDL-C as a better predictor of atherosclerotic disease as compared with LDL-C and as a therapeutic target. Finally, this article includes an executive summary aimed at refining preventive approaches in atherosclerotic cardiovascular disease., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

The central role of high low-density lipoprotein cholesterol levels in atherosclerotic cardiovascular disease has led to research focused on lipid-lowering agents for cardiovascular risk reduction. Bempedoic acid is an emerging treatment for hypercholesterolemia that has recently been approved for marketing in the United States and Europe. This review focuses on its mechanism of action and summarizes the main preclinical study findings. Furthermore, we report the clinical evidence supporting and guiding its use in hypercholesterolemia management., (Copyright © 2020 Italian Federation of Cardiology - I.F.C. All rights reserved.)

At the end of 2019 a new Coronavirus appeared in China and, from there, it spread to the rest of the world. On 24th May, 2020, the confirmed cases in the world were more than 5 million and the deaths almost 350.000. At the end of May, Italy reported more than 27.000 cases among healthcare professionals and 163 deaths among physicians. The National Health Systems from almost all over the world, including Italy's, were unprepared for this pandemic, and this generated important consequences of organizational nature. All elective and urgent specialized activities were completely reorganized, and many hospital units were partially or completely converted to the care of the COVID-19 patients. A significant reduction in hospital admissions for acute heart disease were recorded during the SARS-CoV-2 pandemic and, in order to gradually resume hospital activities, the Italian National Phase 2 Plan for the partial recovery of activities, must necessarily be associated with a Phase 2 Health Plan. In regards to the cardiac outpatient activities we need to identify short term goals, i.e. reschedule the suspended outpatient activities, revise the waiting lists, review the 'timings' of the bookings. This will reduce the number of available examinations compared to the pre-Covid-19 era. The GP's collaboration could represent an important resource, a structured telephone follow-up plan is advisable with the nursing staff's involvement. It is equally important to set medium-long term goals, the pandemic could be an appropriate moment for making a virtue of necessity. It is time to reason on prescriptive appropriateness, telemedicine implementation intended as integration to the traditional management. It is time to restructure the cardiological units related to the issue of structural adjustment to the needs for functional isolation. Moreover, the creation of 'grey zones' with multidisciplinary management according to the intensity of care levels seems to be necessary as well as the identification of Covid dedicated cardiologies. Finally, the pandemic could represent the opportunity for a permanent renovation of the cardiological and territorial medicine activities., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

The aim of this document is the management and organization of patients in need of urgent access to electrophysiology (EP) and pacing procedures during the COVID-19 emergency. Specifically, non-deferrable procedures or irreplaceable with a drug therapy prior to the resolution of the COVID-19 virus emergency [pacemaker (PM) implant/replacement/urgent defibrillator (implantable cardioverter-defibrillator, ICD) or arrhythmic storm or other indication of non-deferrable ablation]. The pacing and electrophysiological procedures urgent as they may be, less and less frequently represent situations of emergency, therefore for almost all cases, it is possible to perform a swab test to determine the positivity to COVID-19 of the patient. In cases where this is not possible, due to situations of emergency, the recommendations and procedures we have indicated are advisable, if not mandatory, in order to avoid the spreading of the virus to healthcare personnel and other patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

Infections by SARS CoV2 - COVID-19 became in a short time a worldwide health emergency. The present SARS-CoV-2 pandemic induced in a short time, an unprecedented impact on public health and on the pre-existing care pathways. In order to appropriately address this epidemiological emergency, urgent solutions were needed, such as remodelling or stopping hospitalization and deferrable clinical activities to avoid spreading the SARS-CoV-2 infection. After the first emergency lockdown phase, care pathways must guarantee healthcare to patients and preserve the safety of the healthcare personnel and of all the other subjects that refer to the cardiological surgeries. Rigorous prescriptive appropriateness of the requested exams with consequent reduction of unnecessary examinations is an essential requirement to preserve prioritized diagnostic and care pathways to patients in need, minimizing the risks connected to the SARS-CoV-2 contagion in hospitals. Telemedicine services represent a valid answer to cardiovascular disease patients' need for care and assistance, including those in quarantine and voluntary isolation. These services successfully contribute to fight the spread of the virus guaranteeing at the same time therapy and support through remote services that must therefore be considered a resource to be implemented and enhanced. This document has to be used by the healthcare personnel working in hospitals and in district offices, if applicable, and aims at managing patients, in complete safety and considered not suspect/not probable ('not at risk') of SARS-CoV-2 infection, eligible for diagnostic activity and subsequent therapy in outpatient surgeries. In particular, this document provides indications for patient evaluation to prevent COVID-19 exposure, gives general indications on managing appointments and waiting rooms, on how to strictly adhere to environmental safety measures, on the proper use of Individual Protective Equipment (IPE). It also provides specific indications for outpatient service procedures, like electrocardiogram, cardiologic examination, cardiologic checkup, Dynamic Holter Electrocardiogram, Transthoracic Echocardiography, Echo Stress, Transoesophageal Echocardiography, Bike Ergometer stress test, Ergospirometry, Outpatient Checkup of implantable electronic cardiac devices., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

Infections by SARS CoV2 - COVID-19 have become in a short time a worldwide health emergency. Due to cardiovascular implications of COVID-19 and to very frequent previous cardiovascular disorders of COVID-19 patients, it is presently crucial that Cardiologists are fully aware of COVID-19 related epidemiological, pathophysiological and therapeutic problems, in order to manage at best the present emergency by appropriate protocols developed on the basis of the competences acquired and shared on the field. The aim of this document is to propose algorithms for the management of cardiovascular diseases during COVID-19 emergency with the objective of providing patients with optimal care, minimizing contagion risk and appropriately managing personal protective equipment., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

The COVID-19 pandemic has become a global health emergency. In Italy, the number of people infected by SARS-COVID-2 is rapidly increasing and what emerges from the current data is that the majority do not present any symptoms or only minor flu-like symptoms. In about 20% of the patients, the disease progresses towards more complex forms (interstitial pneumonia to acute respiratory distress and multiple organ failure) with the need of hospitalization in CICU and advanced ventilator assistance. The transmission of the virus occurs very easily from the symptomatic patient s droplets from coughing and sneezing and from direct contact with persons or surfaces. In a patient presenting with ST elevation (STEMI) myocardial infarction or STEMI-like, if positive to COVID-19, the reperfusion therapeutic strategy depends on the local organization and on the possibility to access without delay a PCI COVID Center, on the basis, obviously, of the risk/benefit assessment of the individual case. However, we advise to try pursuing, in the first instance, the mechanical revascularization strategy, according to the available local possibilities., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions please email: journals.permissions@oup.com.)

Background: In adult patients with d-transposition of the great arteries after atrial switch operation, dysfunction of the systemic right ventricle (RV) is a well-known complication. Echocardiographic variables may provide adequate estimation of subpulmonary RV function, but their applicability to the subaortic RV is not straightforward. We evaluate the concordance between tricuspid annular plane systolic excursion (TAPSE) and magnetic resonance imaging-derived ejection fraction of the RV (MRI-RVEF) in these patients., Methods: Patients were recruited from those evaluated at the adult congenital clinic of our department between 2010 and 2012. All patients who had an echocardiographic assessment within 6 months of their MRI examination were selected. Patients clinically unstable, not in sinus rhythm, with a prosthetic systemic atrioventricular valve, permanent pacemaker, or more than moderate systemic atrioventricular valve regurgitation were excluded., Results: Eighteen Mustard-operated patients aged 22 ± 3.7 years were studied. The mean values of TAPSE and RVEF were 13.22 ± 1.7 mm and 49.7 ± 6%, respectively. TAPSE and RVEF were normal in 1 (5.5%) and 10 (55.5%) patients, respectively. Seventeen (94.4%) patients showed reduced TAPSE (12.9 ± 1.3 mm): RVEF was reduced in eight (47%) of these subjects, and normal in nine (53%). In patients with normal RVEF, both the MRI-RV end-diastolic and the MRI-RV end-systolic volumes were significantly lower than in patients with reduced RVEF. There were no other statistically significant differences between these patients. No correlation was found between TAPSE and both the MRI-RV end-diastolic and the end-systolic volumes. Globally, agreement between TAPSE and RVEF was slight (K = 0.09 ± 0.089)., Conclusions: Our results indicate that in these patients TAPSE is not a useful measure of RV function., (© 2013 Wiley Periodicals, Inc.)

The contribution of cardiac ultrasound in assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction was verified in a prospective study of serial echocardiograms (mean, 18.9 examinations per patient) obtained over a long-term period (1-72 months; mean, 38±12). The study population comprised 222 patients (162 men; age, 64±11 years) with a first anterior acute myocardial infarction, treated with thrombolysis (group A) or receiving no antithrombolic therapy (group B). Embolism occurred in a total of 12 patients (11 with a left ventricular thrombus; p<0.005) and was more frequent in group B (10 patients; p<0.04). Predictors of embolism were the absence of thrombolysis, detection of a left ventricular thrombus, protrusion or mobility of the thrombus, and morphologic changes in the thrombus over time. Patients in group A had a lower incidence of each of these predictors, and a higher thrombus resolution rate. An appropriate echocardiographic protocol is crucial to assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction and may help to identify candidates for aggressive antithrombotic therapy (c)2001 CHF, Inc.

The aims of this study were to optimize interlaboratory standardization of echocardiographic reporting (qualitative terms and quantitative parameters) and to evaluate the feasibility and clinical and research impact of collecting echocardiographic data in a standard computerized format over a geographical territory. In April 1992, a computer program of echocardiogram archiving and reporting (ARCE) was distributed at no cost to the 23 hospital echocardiographic laboratories operating in our region (Liguria). In April 1993 (1-year survey), 16 (70%) of the 23 hospital echo laboratories operating in our region were routinely using ARCE. In April 1997 (4-year survey ), 21 (87%) of the 24 echo laboratories were routinely using the system and 128,642 echocardiograms had been databased. ARCE is a powerful tool both for education and training in cardiac ultrasound and for undertaking multicenter studies by 95% of the users. Regarding the quality improvement process, we achieved 3 main goals: (1) a unique report format from 87% of Ligurian echo laboratories, which improved the communication between echocardiographers and other physicians; (2) development of specific, Ligurian population-based reference limits for M-mode and 2-dimensional quantitative parameters; and (3) interlaboratory comparison and standardization of both quantitative and semiquantitative evaluation of heart valve disease, left ventricular systolic and diastolic function, valve prosthesis function, and left ventricular hypertrophy. Regarding the scientific activity in Liguria, 9 multicenter studies in which 15 Ligurian echo laboratories took part were organized and completed in 5 years. Our 5-year experience shows that it is possible to create a large database of echocardiographic data that uses a fast, easy-access, and easy-to-use program of echo archiving and reporting that contains standardized variables. The use of this program on a regional territory scale appeared feasible and useful both for educational and training purposes. In addition, it stimulated the quality improvement process in echocardiography as well as performance of epidemiologic and clinical multicenter studies.

Left ventricular thrombosis is relatively common after acute myocardial infarction, especially in the anterior site, and represents a possible cause of potentially lethal peripheral embolization 1. Therefore, several studies have been performed in order to assess the efficacy of different antithrombotic drugs in resolving the detected thrombi or reducing their embolic potential. Fibrinolytic agents appear effective in this regard: in the majority of cases, they produce complete lysis and resolution of the thrombi. However, this treatment may itself cause embolic complications by producing a rapid fragmentation of thrombus and the subsequent emission of disrupted portions of the intracardiac mass into the systemic vascular bed [2]. This dramatic effect of thrombolysis has suggested the possibility that even the standard treatment of acute myocardial infarction with fibrinolysis implies a danger of embolization in those patients in whom a left ventricular thrombus may be present either from a previous myocardial infarction or from a very early thrombus development. However, this hypothesis has not yet been confirmed by direct observation. We report the case of a patient with a first acute anterior myocardial infarction, in whom the thrombolytic treatment induced lysis and embolization from a left ventricular thrombus present in an aneurysmatic dilatation of the infero-posterior wall due to a previous inferior myocardial infarction.

Background: Streptokinase reduces the incidence of left ventricular thrombosis after acute myocardial infarction. However, it is unknown whether a similar effect can be obtained with different thrombolytic agents and whether subcutaneous calcium heparin can have an additional efficacy., Methods and Results: To compare the effects of two different thrombolytic agents combined or not with heparin on the incidence and features of left ventricular thrombi and their related embolic events, we performed a GISSI-2 ancillary echocardiographic study (the first echocardiogram obtained within 48 hours of symptoms onset and the second before hospital discharge) that enrolled 180 consecutive patients (mean age, 63 +/- 11 years, 142 men) with a first anterior acute myocardial infarction. Patients were randomized into four groups of treatment: recombinant tissue-type plasminogen activator (rt-PA) (n = 47), rt-PA plus heparin (n = 45), streptokinase (n = 39), and streptokinase plus heparin (n = 49). Left ventricular thrombosis was observed in 51 of 180 patients (28%). No significant differences were found concerning the incidence of thrombi in the four treatment groups. Mural shape of left ventricular thrombi was found more frequently than the protruding shape (71% versus 29% at the first examination, 64% versus 36% at the second), particularly in heparin-treated patients (93% versus 7% at first examination, 70% versus 30% at the second). Only one embolic event (0.5%) occurred during the hospitalization., Conclusions: We conclude that 1) the rate of left ventricular thrombi does not differ in patients with acute myocardial infarction treated either with streptokinase or rt-PA, 2) subcutaneous heparin, when begun 12 hours after intravenous thrombolysis, does not appear to further reduce the occurrence of thrombi but seems to influence the shape of left ventricular thrombi, and 3) during the predischarge period, embolic events are rare in patients treated by thrombolysis.

To evaluate the relationship between the extent of left ventricular hypertrophy and ventricular or atrial arrhythmias, 77 patients with hypertrophic cardiomyopathy underwent two-dimensional echocardiography and 24-hour Holter monitoring. Antiarrhythmic treatment was discontinued before the study. Hypertrophy was septal in 33 patients, "extensive" (i.e., involving the septum and free wall) in 38 patients, and predominantly apical in six patients. Lown grade I and II ventricular arrhythmias were detected in 37% of patients, grade III in 21%, and grade IV in 29%. Atrial extrasystoles were seen in 52% of patients and chronic atrial fibrillation in 13%. More serious ventricular arrhythmias (Lown grades III and IV) occurred significantly more frequently in patients with extensive than in those with only septal hypertrophy (22/38 vs 11/33; p less than 0.001); similarly, chronic atrial fibrillation occurred more commonly in those with extensive hypertrophy (9/38 vs 1/33; p less than 0.01). During a mean follow-up period of 2.6 years, three patients died. All had a pattern of extensive hypertrophy. Two of them had ventricular tachycardia and the third had chronic atrial fibrillation. Results of this study suggest that an echocardiographic finding of extensive hypertrophy represents a useful marker for detecting patients at increased risk for serious ventricular and atrial arrhythmias.

Fifty-eight patients with transmural anterior myocardial infarction were prospectively studied with serial two-dimensional echocardiography to determine the clinical implications and prognostic significance of detection of left ventricular thrombus during acute myocardial infarction, the incidence of systemic embolization, and the possible occurrence of spontaneous regression of left ventricular thrombi. Patients were not treated with anticoagulants or platelet inhibitors during the acute phase of infarction or during follow-up. Two-dimensional echocardiograms were obtained within 24 hr of myocardial infarction, every 24 hr until day 5, every 48 hr until day 15, and every month for a follow-up of 2 to 11 months (mean 7), in the surviving patients; a total of 774 echocardiograms were obtained. Left ventricular thrombi were identified in 24 (41%) of the 58 study patients, and developed within 48 hr of infarction in 11 of these patients. Ten (91%) of the 11 patients with early thrombus formation died during hospitalization or during follow-up, while only two (15%) of the 13 who developed a thrombus after 48 hr of infarction died (p less than .005). Incidence of Killip class III or IV, total lactic dehydrogenase values, and extent of wall motion abnormalities were significantly higher in patients who developed a thrombus within 48 hr of infarction than in patients without thrombus. On the other hand, in patients who developed a thrombus after 48 hr of infarction, these parameters were not significantly different from those in patients who did not develop a thrombus. Spontaneous regression of thrombi was documented in three (20%) of the 15 patients who survived the acute phase of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

The ability of preoperative M-mode echocardiography to predict the clinical course and the decrease in left ventricular size was assessed in 42 patients after uncomplicated valve replacement for isolated aortic insufficiency. During follow-up study, one patient died of chronic heart failure. The New York Heart Association functional class of the 41 survivors improved from 2.4 to 1.2. All patients had a preoperative M-mode echocardiogram. Serial echocardiographic measurements, available in 33 patients, showed a sustained decrease in left ventricular end-diastolic dimension after the first postoperative year from 73 +/- 8 to 57 +/- 9 mm at 6 to 12 months and to 53 +/- 9 mm at 3 years postoperatively (p less than 0.01). Left ventricular cross-sectional area decreased from 31 +/- 8 to 26 +/- 7 cm2 and then to 23 +/- 5 cm2 at the latest follow-up study (p less than 0.01). At 3 years postoperatively, M-mode echocardiograms were available in 37 patients: 24 had a normal left ventricular dimension (group 1), while 13 still had an enlarged left ventricle (group 2). The clinical course in these two groups was similar. The best preoperative predictor of persistent left ventricular enlargement was the end-diastolic dimension (p less than 0.05), whereas fractional shortening and the end-diastolic radius/thickness ratio were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

This study evaluated the influence of thrombolysis followed by full anticoagulation on the frequency of left ventricular (LV) thrombi after acute myocardial infarction (AMI). Nineteen consecutive patients with a first anterior wall AMI who received 1,500,000 IU of streptokinase within 3 hours of symptom onset, followed by full anticoagulation, underwent echocardiographic studies within 24 hours of symptoms, and then on days 2, 3, 5, 7, 12, 30 and 90. Forty-four patients, with comparable clinical features and echocardiographic protocol but without antithrombotic therapy, served as the control group. LV thrombi developed in 4 of 19 (21%) treated patients and in 23 of 44 (52%) control subjects (p = 0.02). LV aneurysm or major wall motion abnormalities were noted in 8 of 19 (42%) treated patients and in 30 of 44 (68%) control subjects (p less than 0.05). No significant difference was found between treated and untreated patients when comparing the incidence of thrombi in the subgroups of patients with aneurysm or major wall motion abnormalities (3 of 8 vs 21 of 30) and in the subgroups with less extensive LV dysfunction. Thrombi disappeared during hospitalization in 3 of 4 treated patients, but in none of the controls. Fewer patients treated with intravenous streptokinase followed by full anticoagulation developed LV thrombi compared to patients treated with conventional therapy. This difference may be related to a reduced occurrence of major LV wall motion abnormalities. Resolution of thrombi frequently occurs in the hospital phase of AMI; therefore, only frequent echocardiographic examinations can assess the true frequency of LV thrombi.

Previous retrospective echocardiographic studies have reported a higher embolic potential of left ventricular thrombi with protruding configuration and patterns of mobility. The present study was performed to prospectively assess the shape and mobility patterns of left ventricular thrombi and their spontaneous changes with time. Two-dimensional echocardiograms were obtained in 109 consecutive patients with acute anterior myocardial infarction within 24 hr of the onset of symptoms, every 24 hr until day 5, every 48 hr until day 15, and then every month for a follow-up of 1 to 29 (mean 14 +/- 8) months in the survivors. None of the patients were treated with anticoagulants or platelet inhibitors during the study period. Left ventricular thrombi, detected in 59 patients (54%), appeared from 1 to 362 (mean 12 +/- 47) days after myocardial infarction. At first detection, the shape was mural in 21 patients and protruding in 38; patterns of mobility were present in eight patients. During follow-up, changes in the shape of the thrombi were noted in 24 patients (41%; from mural to protruding in nine, from protruding to mural in 15). These variations were encountered between 2 and 490 (mean 64 +/- 117) days after the first observation of the thrombus. Patterns of mobility, previously detected in eight patients, disappeared in five of eight within 2 to 28 (mean 14 +/- 11) days.(ABSTRACT TRUNCATED AT 250 WORDS)