Search

Background: Echographic examination of the lung surface may reveal multiple "comet-tail images" originating from water-thickened interlobular septa. These images could be useful for noninvasive assessment of interstitial pulmonary edema. Study Objective: The purpose of this study was to assess the diagnostic accuracy of lung comet-tail images compared with chest radiography, wedge pressure, and extravascular lung water (EVLW) quantified by the indicator dilution method (PiCCO System, version 4.1; Pulsion Medical Systems; Munich, Germany). Methods and Patients: We enrolled 20 patients (mean age, 62.6 +/- 11.5 years [+/- SD]). Patients were studied before, immediately after, and 24 h following cardiac surgery with chest ultrasound, chest radiography, pulmonary artery catheterization, and the PiCCO system. Performing echo scanning (right and left hemithorax, from second to fourth intercostal space, from parasternal to midaxillary line), an individual patient comet score was obtained by summing the number of comets in each scanned space. Results: A total of 60 comparisons were obtained. Significant positive linear correlations were found between comet score and EVLW determined by the PiCCO System (r = 0.42, p = 0.001), between comet score and wedge pressure (r = 0.48, p = 0.01), and between comet score and radiologic lung water score (r = 0.60, p = 0.0001). Conclusions: The presence and the number of comet-tail images provide reliable information on interstitial pulmonary edema. Therefore, ultrasonography represent an attractive, easy-to-use, bedside diagnostic tool for assessing cardiac function and pulmonary congestion. [ABSTRACT FROM AUTHOR]

Abstract Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.

An abstract of the article "Long-term outcome of patients with ischemic mitral regurgitation according to the tethering pattern. preliminary results of an observational study," by E. Agricola and colleagues is presented.

An abstract of the article "Validation of real-time 3D echocardiography study protocol in identification of anatomic mitral regurgitant defect in patients with prolapse or flail," by E. Agricola is presented.

An abstract of the article "Possible mechanisms of dyspnea on effort in patients with normal left ventricular systolic function," by M. Pisani and colleagues is presented.

An abstract of the article "Stress-induced pulmonary edema assessed by chest ultrasound during exercise echocardiography: correlation with severity of ischemia and wedge pressure," by E. Agricola and colleagues is presented.

An abstract of the article "Tissue Doppler predicts left ventricular filling pressure better than standard Doppler in patients with mitral valve regurgitation," by E. Agricola, M. Galderisi, M. Oppizzi, G. Melisurgo, F. Airoldi, and A. Margonato is presented.

Background and Importance: Chest pain is a frequent cause of patient admissions in emergency departments (EDs). Clinical scores can help in the management of chest pain patients with an undefined impact on the appropriateness of hospitalization or discharge when compared to usual care., Objectives: The aim of this study was to assess the performances of the HEART score to predict the 6-month prognostic of patients presenting to the ED of a tertiary referral university hospital with non-traumatic chest pain., Design, Settings, and Participants: From 7040 patients presenting with chest pain from 1 January 2015 to 31 December 2017, after applying exclusion criteria (ST-segment elevation >1 mm, shock, absence of telephone number) we selected a sample of 20% chosen randomly. We retrospectively assessed the clinical course, definitive diagnosis, and HEART score according to ED final report. Follow-up was made by telephone interview with discharged patients. In hospitalized patients, clinical records were analyzed to evaluate major adverse cardiac events (MACE) incidence., Outcome Measure and Analysis: The primary endpoint was MACE, comprising cardiovascular death, myocardial infarction, or unscheduled revascularization at 6 months. We assessed the diagnostic performance of the HEART score in ruling out MACE at 6 months. We also assessed the performance of ED usual care in the management of chest pain patients., Results: Of 1119 screened, 1099 were included for analysis after excluding patients lost to follow-up; 788 patients (71.70%) had been discharged and 311 (28.30%) were hospitalized. Incident MACE was 18.3% ( n  = 205). The HEART score was retrospectively calculated in 1047 patients showing increasing MACE incidence according to risk category (0.98% for low risk, 38.02% for intermediate risk, and 62.21% for high risk). Low-risk category allowed to safely exclude MACE at 6 months with a negative predictive value (NPV) of 99%. Usual care diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% positive predictive value, and 99% NPV, with an overall accuracy of 98.00%., Conclusions: In ED patients with chest pain, a low HEART score is associated with a very low risk of MACE at 6 months., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice., Methods: We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort., Results: In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor)., Conclusions: Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients., Competing Interests: Conflict of Interest None reported., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aims: Aim of this study was to evaluate the impact of cardiological and echocardiographic evaluation in addition to a standard clinical and instrumental approach on diagnostic and prognostic accuracy in patients presenting in the emergency department (ED) with chest pain (CP). Acute coronary syndromes, pulmonary embolism and acute aortic syndromes (AAS) (triple-rule-out/TRO) were considered., Methods: From 7040 patients presenting with CP from 1 January 2015 to 31 December 2017, we randomly selected a sample of 1119. We retrospectively evaluated the clinical course and definitive diagnosis according to the ED final report. A 6-month follow-up to assess incident acute cardiovascular events was made by telephone interview in discharged patients; in hospitalized patients, clinical records were analyzed to evaluate the appropriateness of admissions. Diagnostic and prognostic accuracy wasd estimated through sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, according to the presence or absence of cardiological and echocardiographic consultation., Results: Complete information of 1099 patients out of 1119 was retrieved. Seven hundred and eighty-eight patients (71.70%) had been discharged, eight inappropriately (0.73%). Three hundred eleven (28.30%) had been hospitalized, 14 (1.27%) inappropriately. Diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% PPV and 99% NPV, with an overall accuracy of 98.00%. In patients evaluated by the cardiologist in addition to the ED physician (n = 387) we observed an improvement of sensitivity and NPV at the expense of specificity. Among improperly discharged patients, 7/8 had normal troponin, 7/8 normal ECG and only 1 was evaluated by a cardiologist. Only one inappropriately hospitalized patient was not evaluated by a cardiologist., Conclusions: Early consultation with a cardiologist and echocardiography improves clinical judgment in doubtful cases of CP, increasing diagnostic performance mainly by reducing inappropriate patient discharge and guaranteeing a low rate of inappropriate hospitalizations., (Copyright © 2022 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background Acute chest pain with mild troponin rise and inconclusive diagnosis after clinical evaluation represents a diagnostic challenge. Triple-rule-out (TRO) CT may exclude coronary artery disease (CAD), as well as acute aortic syndrome and pulmonary embolism, but cannot help identify other causes of myocardial injury. Purpose To investigate the diagnostic value of a comprehensive CT protocol including both an angiographic and a late contrast enhancement (LCE) scan in participants with troponin-positive acute chest pain. Materials and Methods In this prospective study, consecutive patients with troponin-positive acute chest pain or anginal equivalent and inconclusive diagnosis after clinical evaluation (symptoms, markers, electrocardiography, and echocardiography) who underwent TRO CT between June 2018 and September 2020 were enrolled. TRO CT was performed to evaluate the presence of obstructive CAD (stenosis ≥50%), acute aortic syndrome, and pulmonary embolism. If the findings on the TRO CT scan were negative, an LCE CT scan was acquired after 10 minutes to assess the presence and pattern of scar and quantify the myocardial extracellular volume fraction. CT-based diagnoses were compared with diagnoses obtained with reference standard methods, including invasive coronary angiography, cardiac MRI, and endomyocardial biopsy. Results Eighty-four patients (median age, 69 years [interquartile range, 50-77 years]; 45 men) were enrolled. TRO CT helped identify obstructive CAD in 35 participants (42%), acute aortic syndrome in one (1.2%), and pulmonary embolism in six (7.1%). LCE CT scans were acquired in the remaining 42 participants. The following diagnoses were reached with use of LCE CT: myocarditis (22 of 42 participants [52%]), takotsubo cardiomyopathy (four of 42 [10%]), amyloidosis (three of 42 [7.1%]), myocardial infarction with nonobstructed coronary arteries (three of 42 [7.1%]), dilated cardiomyopathy (two of 42 [4.8%]), and negative or inconclusive findings (eight of 42 [19%]). The addition of LCE CT improved the diagnostic rate of TRO CT from 42 of 84 participants (50% [95% CI: 38.9, 61.1]) to 76 of 84 (90% [95% CI: 82.1, 95.8]) ( P < .001). Conclusion A CT protocol including triple-rule-out and late contrast enhancement CT scans improved diagnostic rate in participants presenting with acute chest pain syndrome. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Nagpal and Bluemke in this issue.

Objectives: Aim of the study was to assess in-hospital survival rate and the degree of myocardial recovery after MCS treatment (IABP or IMPELLA) at discharge and at 6 months in patients with AMI-CS and planned early percutaneous revascularization., Background: All studies on MCS for acute myocardial infarction related cardiogenic shock (AMI-CS) focused on its impact on in-hospital mortality; however, few data about its role on myocardial recovery are available., Methods: Retrospective study on 64 patients: 36 patients (56%) received IABP and 28 (44%) Impella 2.5/CP., Results: Patients treated with Impella were sicker compared to those treated with IABP as shown by a higher need of catecholamines (93% Impella vs 57% IABP, P = 0.002) and higher inotropic score before procedure: 8 (5-15) versus 4.5 (0-9), P = 0.02. In-hospital survival and MCS-related complications were comparable; hemolysis was more frequent in the Impella group (32% vs 0%, P < 0.0001). Myocardial damage was lower in those patients who were implanted with IMPELLA before PCI: lower troponin peak [3831 ng/dL (1441-8436) vs 16 581 (7802-23 675), P = 0.004] and lower CPK peak [893 UI/L (584-4082) vs 5797 (2483-9292) P = 0.04]. Impella patients had higher LVEF at 6 months [45 (38-52) vs 40 (33-45)%, P = 0.04]. LVEF increase at 6 months was statistically significant in both groups (P < 0.0001), with higher myocardial recovery in patients supported with Impella (absolute delta-LVEF increase 20% vs 10% P = 0.005)., Conclusions: Cardiac unloading with IMPELLA in ACS-CS, especially if implanted before PCI, might provide lower myocardial damage and improved myocardial recovery which translates into significantly higher LVEF at 6 months., (© 2018 Wiley Periodicals, Inc.)

Aims: Renal dysfunction is common in heart failure. Recent evidence suggests a pivotal role for systemic venous congestion and functional tricuspid regurgitation (FTR) in the pathophysiology of renal dysfunction. We investigated the role of FTR as a determinant of renal dysfunction and a predictor of long-term prognosis in chronic systolic heart failure patients., Methods and Results: Four hundred and thirteen consecutive patients (mean age 74.2 ± 11 years) with chronic heart failure and left ventricular ejection fraction below 50% were enrolled. The FTR severity was quantified by transthoracic echocardiography. Renal function was evaluated with the estimated glomerular filtration rate measured by the simplified Modification of Diet in Renal Disease formula. The association between moderate/severe FTR and renal dysfunction, and its impact on heart failure episodes and overall mortality were also assessed. The median follow-up was 36 months (range 1-144 months). Through multivariate analysis, the interaction between moderate/severe FTR with tricuspid annular plane systolic excursion less than 16 mm was found to be an independent determinant of renal dysfunction [odds ratio 1.2, 95% confidence interval (CI) 1.1-1.5, P = 0.04]. Moderate/severe FTR (hazard ratio 1.3, 95% CI 1.2-2.7, P = 0.02) and tricuspid annular plane systolic excursion below 16 mm (hazard ratio 1.2, 95% CI 1.0-3.7, P = 0.01) were significantly related to the heart failure episodes. Moreover, the Kaplan-Meier analysis showed a worse outcome in patients with moderate/severe FTR (log-rank test 8.6, P = 0.003)., Conclusions: The combination of significant FTR and right ventricular dysfunction, but not FTR and right ventricular dysfunction alone, is independently associated with renal dysfunction. The presence of significant FTR is related to an excess event rate of heart failure and has significant impact on outcome.

Refractory angina pectoris (RAP) represents a clinical condition characterized by frequent episodes of chest pain despite therapy optimization. According to myocardial stunning and myocardial hibernation definitions, RAP should represent the ideal condition for systolic dysfunction development. We aim to investigate the evolution of left ventricular (LV) function in patients with RAP. A retrospective study which encompasses 144 patients with RAP referred to our institution from 1999 to December 2014 was performed. Of them, 88 met the inclusion criteria, and LV function was assessed by echocardiography. All of them had persistent angina episodes on top of optimal medical therapy and evidence of significant inducible myocardial ischemia and no further revascularization options. Nitrates consumption rate, time of angina duration, and the number of angina attacks were evaluated. In the whole population, ejection fraction (EF) was 44% ± 2. EF was significantly lower in patients with previous myocardial infarction (41% ± 1.5 vs 51% ± 1.8, p <0.0001). The duration time and the number of angina attacks did not correlate with EF in the whole population and in patients without previous myocardial infarction. In patients with previous myocardial infarction, the number of anginal attacks did not correlate with EF, but EF appeared higher in patients with angina duration >5 years (<5 years EF 37% ± 1 [n = 26]; >5 years 44% ± 2 [n = 44]; p 0.02). Long-term LV function in patients with RAP is generally preserved. A previous history of myocardial infarction is the only determinant in the development of systolic dysfunction. In conclusion, frequent angina attacks and a long-term history of angina are not apparently associated to worse LV function., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Right ventricular dysfunction (RVdysf) is a predictor of poor outcome in patients with heart failure and valvular disease. The aim of this study was to evaluate the evolution and the impact of RVdysf in patients with moderate-severe functional mitral regurgitation (FMR) successfully treated with MitraClip., Methods and Results: From October 2008 to July 2014, 60 consecutive high surgical risk FMR patients were evaluated and stratified into two groups: RVdysf group (TAPSE < 16 mm and/or S'TDI < 10 cm/s, 21 patients) and No-RVdysf group (38 patients). The overall mean age of patients was 73 ± 8 (83% male). Ischemic FMR etiology was present in 67%. Mean LVEF was 30 ± 10%. Overall mean time follow-up was 565 ± 310 days. The only significant difference between the two groups was a greater prevalence of stroke, ICD and use of aldosterone antagonist in RVdysf group. Acute procedural success was achieved in 90% of patients. At 6-month echo-matched analysis significant RV function improvement was observed in patients with baseline RVdysf (TAPSE 15 ± 3.0 vs. 19 ± 4.5, p = 0.007; S'TDI 7 ± 1.2 vs. 11 ± 2.8, p < 0.0001; baseline vs. 6-month, respectively). The mean improvement in the 6-min walking test was significant in both groups (120 and 143 m, RVdysf and No-RVdysf groups, respectively). At Kaplan-Meier analysis, the presence of RVdysf did not affect the outcome in terms of freedom from composite efficacy endpoint., Conclusions: This study shows that successful MitraClip implantation in patients with FMR and concomitant right ventricular dysfunction yields significant improvement of RV function at mid-term follow-up. Further data on larger population will be required to confirm our observations.

Atrial fibrillation (AF) is the most common clinically relevant cardiac arrhythmia. AF poses patients at increased risk of thromboembolism, in particular ischemic stroke. The CHADS2 and CHA2DS2-VASc scores are useful in the assessment of thromboembolic risk in nonvalvular AF and are utilized in decision-making about treatment with oral anticoagulation (OAC). However, OAC is underutilized due to poor patient compliance and contraindications, especially major bleedings. The Virchow triad synthesizes the pathogenesis of thrombogenesis in AF: endocardial dysfunction, abnormal blood stasis, and altered hemostasis. This is especially prominent in the left atrial appendage (LAA), where the low flow reaches its minimum. The LAA is the remnant of the embryonic left atrium, with a complex and variable morphology predisposing to stasis, especially during AF. In patients with nonvalvular AF, 90% of thrombi are located in the LAA. So, left atrial appendage occlusion could be an interesting and effective procedure in thromboembolism prevention in AF. After exclusion of LAA as an embolic source, the remaining risk of thromboembolism does not longer justify the use of oral anticoagulants. Various surgical and catheter-based methods have been developed to exclude the LAA. This paper reviews the physiological and pathophysiological role of the LAA and catheter-based methods of LAA exclusion.

Background: This observational study was designed to evaluate the prevalence of coronary microvascular dysfunction (CMD) in asymptomatic patients affected by systemic sclerosis (SSc), stratifying the results according to the limited (lcSSc) and the diffuse (dcSSc) forms of the disease., Methods and Results: We enrolled 19 consecutive asymptomatic patients with dcSSc (n=7) or lcSSc (n=12). In all subjects, coronary flow reserve (CFR) was assessed by measuring diastolic coronary flow velocities in the left anterior descending artery by pulsed wave Doppler at baseline and after dipyridamole infusion (0.84 mg·kg(-1)·6 min(-1)). Wall motion score index was evaluated at baseline and during stress. We enrolled 20 healthy subjects as controls. Mean CFR was 1.96±0.62 in patients and 2.69±0.47 in controls (P<0.001). Abnormal values of CFR (≤2) were significantly more prevalent in patients than in controls (10/19 vs. 0/20; P<0.001) and in the dcSSc subgroup than in the lcSSc subgroup (6/7 vs. 4/12; P=0.05). An inverse relationship between disease duration (from time of onset of Raynaud's phenomenon) and CFR value was observed in the lcSSc group (correlation coefficient -0.583; P=0.046). Neither patients nor controls had wall motion abnormalities during dipyridamole administration., Conclusions: A blunted CFR, most likely because of CMD, is more frequent in patients affected by the dcSSc form in the early stages of the disease, whereas it seems to appear later in lcSSc.

Background and Aim of the Study: The study aim was to evaluate whether, in patients with severe mitral regurgitation (MR), tricuspid valve remodeling was independent of the degree of functional tricuspid regurgitation (FTR) present. Whether any differences in the analysis remodeling, as assessed by two-dimensional (2D) and three-dimensional (3D) echocardiography, can be demonstrated was also addressed., Methods: A total of 188 patients (mean age 63.5 +/- 16.0 years) with severe organic or functional MR with or without associated FTR, and 30 normal controls (mean age 59.2 +/- 15 years) were enrolled in the study. Subsequently, both 2D and 3D transthoracic anatomic and functional parameters of the tricuspid valve were analyzed., Results: Patients and controls differed in all 2D and 3D parameters of tricuspid valve remodeling, except for the 2D end-diastolic annular diameter and circularity indices. The patients were then allocated to either group A (trivial/mild FTR) or group B (moderate/severe FTR). Significant differences were identified between groups A and B compared to controls in all tricuspid valve remodeling indices, except for the diastolic 2D annular diameter and circularity indices. Groups A and B had similar 2D and 3D parameters of tricuspid valve remodeling. The right ventricular end-diastolic diameter (RVEDD) (beta = 0.24, 95% CI: 0.11 to 0.22, p = 0.02) and fractional area change (beta = -0.48, 95% CI: -0.24 to 0.09, p = 0.0001, R2 = 0.22) were independent predictors of the tenting area, whereas the RVEDD was the only independent predictor of the diastolic 3D tricuspid annular area (beta = 0.53, 95% CI: 1.2 to 2.7, p = 0.0001, R2 = 0.28)., Conclusion: In patients with severe MR, tricuspid valve remodeling was also demonstrated in those with trivial/mild FTR, but was better characterized by 3D echocardiography. Tricuspid valve remodeling and right ventricular dilation were the main determinants of tricuspid valve regurgitation.

The aim of this study is to evaluate the role of contrast transesophageal echocardiography (cTEE) in the diagnostic characterization of acute aortic syndromes (AAS) [aortic dissection, intramural hematoma, penetrating ulcer]. We enrolled 66 non-consecutive patients with clinical suspicion of AAS. Standard transesophageal echocardiography and cTEE were performed prior to gated-CT angiography, which has been assumed as reference standard. cTEE was obtained with a single bolus of contrast agent injection. The definitive diagnosis of AAS was made in 48 patients by gated-CT angiography: 22 aortic dissections, 15 intramural hematomas and 11 penetrating aortic ulcers. Standard TEE and cTEE correctly diagnosed AAS in 87 and 100% (P = 0.03) cases respectively. Standard TEE correctly diagnosed aortic dissection in 20/22 (91%) and cTEE in 22/22 (100 %) (P = 0.5) cases. cTEE was superior than standard TEE in the visualization of false lumen entry tear (22/22 vs. 16/22, P = 0.03). Standard TEE correctly diagnosed intramural hematoma in 11/15 and cTEE 15/15 (P = 0.12) cases. Microtears were identified in 3 patients by cTEE an in 1 patient by standard TEE (P = 0.4). The presence of focal contrast enhancement was identified in 4 and 0 patients by cTEE and standard TEE respectively (P = 0.06). Both standard and cTEE correctly diagnosed penetrating aortic ulcer in 11/11 (100%) (P = 1.0) cases. cTEE provides additional value over standard TEE in the diagnosis and in the anatomic and functional characterization of AAS.

We describe the case of a young pregnant woman with moderate mitral regurgitation who was admitted to our department for dyspnea. The patient was treated with low-dose diuretic therapy and ventilatory support. At follow-up echocardiographic evaluation, a progressive improvement of mitral regurgitation and pulmonary artery pressure was observed. The most significant hemodynamic changes occurring during pregnancy are reviewed and discussed in the setting of associated mitral regurgitation.

Aims: The prognostic role of tricuspid regurgitation (TR) associated with organic left-sided valvular heart disease is well known. However, no data are available regarding the prognostic value of functional TR (FTR) in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction. The purpose of this study was to evaluate the prognostic role of FTR for occurrence of heart failure (HF) and mortality in patients with FMR., Methods and Results: We enrolled 373 consecutive patients (mean age 68±11 years) with LV dysfunction and at least mild FMR and with or without FTR, both quantitated by echocardiography. The median follow-up was 32 months (range 1-120 months); 132 (35.4%) and 97 patients developed HF or died, respectively. The incidence of HF at 3 and 6 years was 36±2% and 55±4%, respectively. Moderate to severe FTR [hazard ratio (HR) 1.4, 95% confidence interval (CI) 1.1-2.1, P = 0.01) was an independent determinant of HF. The incidence of HF was 41±5, 46±7, 57±7, and 65±8% for patients without, and with mild, moderate, and severe FTR respectively (P = 0.03). At 3 and 6 years the survival free of all-cause mortality was 77.5±2% and 60±3%, respectively. Moderate to severe FTR (HR 1.6, 95% CI 1.2-2.1, P = 0.01) was an independent determinant of overall mortality. At 6 years, survival free of all-cause mortality was 69±2.5, 67±2.1, 51±2.5, and 40±4.8% for patients without, and with mild, moderate, and severe FTR, respectively (P = 0.004)., Conclusions: Moderate or more FTR is independently associated with worse survival and a high incidence of HF episodes in patients with FMR.

Background: Although the prognostic impact of a moderate degree of ischemic mitral regurgitation (IMR) is well known, there are no data regarding the potential role of a mild degree of IMR. The aim of this study was to evaluate the impact of a mild degree (effective regurgitant orifice area < 20 mm(2)) of IMR on left ventricular (LV) remodeling and heart failure (HF)., Methods: A retrospective study was conducted in 35 patients with mild IMR that were propensity matched with 35 patients without IMR (controls). The population was evaluated between 3 and 6 months after first myocardial infarction and at 6 and 12 months, measuring LV volumes, ejection fraction, and the degree of mitral regurgitation. HF events requiring hospitalization were recorded., Results: The two groups were similar at baseline. During follow-up, patients with IMR showed significant increases in LV end-diastolic and end-systolic volumes and no change in ejection fractions, whereas controls did not show significant changes in volumes but did show increases in ejection fractions. Patients with IMR showed significantly higher end-systolic volumes at 6 months (P = .003) and 12 months (P = .007) and significantly higher end-diastolic volumes at 6 months (P = .048) and 12 months (P = .03) and lower ejection fractions at 6 months (P = .0001) and 12 months (P = .002) compared with controls. Patients with IMR experienced a significantly higher incidence of HF than controls (62% vs 23%, P = .001). At 6 months, in six patients mitral regurgitation degree changed from mild to moderate, and in one patient from mild to severe. Interestingly, 71.5% of patients who experienced increases in mitral regurgitation degree had no coronary revascularization (P = .04)., Conclusions: Mild IMR affects the LV remodeling process, increases its degree over time, and determines a higher rate of HF., (Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Background: Cardiac stem cell therapy is a field of scientific research with the goal to translate into clinical benefit the initial findings obtained in basic research laboratories. We have moved into clinical trials in different disease categories: acute myocardial infarction, chronic stable angina refractory to conventional therapy and heart failure. So far we have faced with contradictory results. Some previous studies suggested that bone marrow cell injection may improve myocardial perfusion and left ventricular function in patients with chronic myocardial ischemia., Methods: In this paper we present a brief review about stem cell use in clinical cardiology and describe our research protocol evaluating the effects of direct intramyocardial injection of autologous bone marrow cells (CD34+ selected cells versus all mononuclear cells) in patients with chronic myocardial ischemia., Results: Preliminary results show that this procedure seems to be safe and generally well tolerated by patients. An improvement in symptoms, in the first 6 months, appears to be achieved in approximately 50% of patients, with concomitant improvement of quantitative scintigraphic stress test imaging., Conclusions: Before drawing any definitive conclusions, we need to wait for the end of enrollment and unblinding of study randomization.