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Pulmonary arterial hypertension (PAH) in the elderly is often associated with left heart disease (LHD), prompting concerns about the use of pulmonary vasodilators. The PATRIARCA registry enrolled ≥70 year-old PAH or chronic thromboembolic pulmonary hypertension (CTEPH) patients at 11 Italian centers from 1 December 2019 through 15 September 2022. After excluding those with CTEPH, post-capillary PH at the diagnostic right heart catheterization (RHC), and/or incomplete data, 23 (33%) of a total of 69 subjects met the criteria proposed in the AMBITION trial to suspect LHD. Diabetes [9 (39%) vs. 6 (13%), p = 0.01] and chronic kidney disease [14 (61%) vs. 12 (26%), p = 0.003] were more common, and the last RHC pulmonary artery wedge pressure [14 ± 5 vs. 10 ± 3 mmHg, p < 0.001] was higher and pulmonary vascular resistance [5.56 ± 3.31 vs. 8.30 ± 4.80, p = 0.02] was lower in LHD than non-LHD patients. However, PAH therapy was similar, with 13 (57%) and 23 (50%) subjects, respectively, taking two oral drugs. PAH medication patterns remained comparable between LHD and non-LHD patients also when the former [37, 54%] were identified by atrial fibrillation and echocardiographic features of LHD, in addition to the AMBITION criteria. In this real-world snapshot, elderly PAH patients were treated with pulmonary vasodilators, including combinations, despite a remarkable prevalence of a LHD phenotype.

Background: Pulmonary hypertension (PH) is a life-threatening complication of connective tissue diseases (CTD); in this study, we aimed at investigating the potential role of inducible co-stimulator (ICOS) and its ligand (ICOS-L) as biomarkers of PH in CTD., Materials and Methods: We recruited 109 patients: 84 CTD patients, 13 patients with CTD complicated by pulmonary arterial hypertension (PAH), and 12 subjects with PAH alone. All recruited patients underwent a complete clinical and instrumental assessment along with quantitative measurement of serum ICOS and ICOS-L., Results: Independently of the underlying cause, patients with PAH were older and had a lower glomerular filtration rate. Interestingly, patients with both CTD-related and CTD-unrelated PAH had higher ICOS and ICOS-L serum concentrations than CTD patients (0.0001 for both). When compared to CTD patients, those affected by CTD-PAH showed higher ICOS (440 (240-600) vs. 170 (105-275) pg/mL, p = 0.0001) and ICOS-L serum concentrations (6000 (4300-7000) vs. 2450 (1500-4100) pg/mL; p = 0.0001). In a logistic regression, ICOS and ICOS-L were associated with a diagnosis of PAH, independently from age, gender, and renal function. The corresponding receiver operating characteristic (ROC) curves demonstrated a good diagnostic performance for both ICOS and ICOS-L., Conclusions: ICOS and ICOS-L are increased in patients with PAH, irrespectively from the underlying cause, and represent promising candidate biomarkers for the diagnostic screening for PAH among CTDs patients.

Pulmonary arterial hypertension (PAH) is a severe complication of connective tissue diseases (CTD). Its early diagnosis is essential to start effective treatment. In the present paper, we aimed to evaluate the role of plasma osteopontin (OPN) as a candidate biomarker of PAH in a cohort of CTD patients. OPN is a pleiotropic protein involved in inflammation and fibrogenesis and, therefore, potentially promising in this specific clinical context. We performed a cross-sectional observational study on a cohort of 113 CTD patients (females N = 101, 89.4%) affected by systemic sclerosis N = 88 (77.9%), mixed connective tissue disease N = 10 (8.8%), overlap syndrome N = 10 (8.8%) or undifferentiated connective tissue disease N = 5 (4.4%). CTD-PAH patients showed significantly higher OPN plasma values than patients with CTD alone (241.0 (188.8-387.2) vs. 200.7 (133.5-281.6) ng/mL; p = 0.03). Although OPN levels were directly correlated with age and inversely with glomerular filtration rate, they remained associated with PAH at multivariate analysis. In conclusion, OPN was significantly associated with PAH among patients with CTD, suggesting it may have a role as a non-invasive disease biomarker of PAH.

The early diagnosis of pulmonary arterial hypertension (PAH) is a major determinant of prognosis in patients affected by connective tissue diseases (CTDs) complicated by PAH. In the present paper we investigated the diagnostic accuracy of cardiopulmonary exercise testing (CPET) in this specific setting. We recorded clinical and laboratory data of 131 patients who underwent a CPET at a pulmonary hypertension clinic. Out of them, 112 (85.5%) had a diagnosis of CTDs; 8 (6.1%) received a diagnosis of CTDs-PAH and 11 (8.4%) were affected PH of different etiology. Among CPET parameters the following parameters showed the best diagnostic performance for PAH: peak volume of oxygen uptake (VO 2 ; AUC: 0.845, CI95% 0.767-0.904), ratio between ventilation and volume of exhaled carbon dioxide (VE/VCO 2 slope; AUC: 0.888, CI95%: 0.817-0.938) and end-tidal partial pressures (PetCO 2 ; AUC: 0.792, CI95%: 0.709-0.861). These parameters were comparable among CTDs-PAH and PH of different etiology. The diagnostic performance was even improved by creating a composite score which included all the three parameters identified. In conclusion, CPET is a very promising tool for the stratification of risk of PAH among CTDs patients; the use of composite measures may improve diagnostic performance.

Background: Few biomarkers are available for early identification of pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) in systemic sclerosis (SS) and scleroderma spectrum disorders (SSD)., Aims: To evaluate Gas6, sAxl, and sMer as biomarkers for cardiopulmonary complications of SS and SSD., Methods: In a cross-sectional observational study, we recruited 125 consecutive patients, affected by SS and SSD and referred to a tertiary-level pulmonary hypertension outpatient clinic. All patients underwent a comprehensive evaluation for identification of PAH and ILD. Gas6, sMer, and sAxl concentrations were measured with ELISA protocols, and concentrations were compared according to PAH or ILD., Results: Nineteen subjects had pulmonary hypertension (PH) (14 PAH), and 39 had ILD (6 severe). Plasma sMer was increased in PAH (18.6 ng/ml IQR [11.7-20.3]) with respect to the absence (12.4 [8.0-15.8]) or other form of pulmonary hypertension (9.6 [7.4-12.5]; K-W variance p < 0.04). Conversely, Gas6 and sAxl levels were slightly increased in mild ILD (25.8 ng/ml [19.5-32.1] and 24.6 [20.1-32.5]) and reduced in severe ILD (16.6 [15.0-22.1] and 15.5 [14.9-22.4]) in comparison to no evidence of ILD (23.4 [18.8-28.1] and 21.6 [18.1-28.4]; K-W, p ≤ 0.05). Plasma sMer ≥ 19 ng/ml has 50% sensitivity and 92% specificity in PAH identification (area under the ROC curve (AUC) 0.697, p < 0.03). Values of Gas6 ≤ 24.5 ng/ml and of sAxl ≤ 15.5 ng/ml have 100% and 67% sensitivity and 47% and 86% specificity, respectively, in identifying severe ILD (Gas6 AUC 0.787, p < 0.001; sAxl AUC 0.705, p < 0.05)., Conclusions: The assay of Gas6 sAxl and sMer may be useful to help in the identification of PAH and ILD in SS and SSD patients. The Gas6/TAM system seems to be relevant in cardiopulmonary complications of SS and SSD and merits further investigations., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2020 Mattia Bellan et al.)

Introduction/objective: In the present paper, we aimed to test the value of the red cell distribution width (RDW) coefficient of variation as a candidate biomarker for pulmonary arterial hypertension (PAH) in patients with connective tissue disorders (CTD), correlating it with the degree of cardiopulmonary impairment in these patients., Methods: The study population included N = 141 patients with CTD and N = 59 patients affected by pulmonary hypertension of other etiologies, all referred to the Pulmonary Hypertension Clinic of the Cardiology Division of an Academic Hospital in Northern Italy for evaluation (including right catheterization). Clinical, instrumental, and laboratory data were collected and related to RDW and other full blood count indexes., Results: Twenty out of 141 CTD patients (14%) received a diagnosis of PAH. In comparison to those without PAH, CTD patients with PAH displayed a larger RDW (14.9% (13.5-17.2) vs. 13.8% (13.1-15.0); p = 0.02) and a lower platelet count (205 (177-240) × 10 9 /l vs. 244 (197.5-304.2) × 10 9 /l; p = 0.005). Moreover, with respect to CTD patients without PAH, RDW was significantly larger also in PH of other etiologies. In contrast, the platelet count was significantly lower only in CTD-related PAH, with a value > 276 × 10 9 /l being 100% sensitive in ruling out PAH. Finally, RDW, but not the platelet count, was related directly to systolic pulmonary arterial pressure ( r = 0.381; p = 0.0008) and right ventricle diameter ( r = 0.283; p = 0.015) and inversely to diffusing capacity of the lung for carbon monoxide ( r = -0.325; p = 0.014)., Conclusion: RDW is a promising candidate biomarker for the screening and the prognostic stratification of PAH in CTD patients.

Aims: Increased right atrial size is related to adverse prognosis in pulmonary hypertension. The potential incremental value of right atrial function assessment is still unclear. We tested the relationship between right atrial two-dimensional speckle-tracking echocardiography impairment and hemodynamic, functional and clinical deterioration in patients with pulmonary hypertension., Methods: We prospectively evaluated 36 patients (27 female, 9 male; mean age 68 ± 13 years) with suspected pulmonary hypertension undergoing right heart catheterization and 16 matched controls. All patients underwent baseline evaluation by New York Heart Association functional class, 6-min walking test, brain natriuretic peptide (BNP), and standard two-dimensional echocardiography in less than 48 h of right heart catheterization. Right atrial two-dimensional speckle-tracking echocardiography was assessed by averaging all segments in standard four-chamber apical view., Results: Right atrial global integral strain was significantly lower in patients compared with controls (11.40 ± 5.22% vs. 25.72 ± 5.95 P < 0.001). Moreover, right atrial global strain, but not right atrial area or volume, was correlated with invasively measured cardiac index (CI) (r = 0.72; P < 0.0001) and pulmonary vascular resistances in all patients, even though stronger in subjects with precapillary pulmonary hypertension (r = -0.42, P = 0.018; r = -0.54, P = 0.007 respectively; P = 0.007). It was also correlated with New York Heart Association (P = 0.027), BNP (P = 0.002), and 6-min walking test (P = 0.006). After multivariate analysis including right atrial volume, tricuspid annular plane systolic excursion, left atrial strain, and BNP, right atrial global strain showed the strongest correlation with CI. Area under the curve optimal cutoff for predicting CI at least 2.4 l/min/m was 17% (area under the curve: 0.83, sensitivity: 90%, specificity: 54%)., Conclusion: Right atrial global strain can identify right atrial functional impairment before structural changes and may be implemented in a comprehensive, noninvasive right heart assessment for diagnosis and follow-up of pulmonary hypertension patients.

Chronic thromboembolic pulmonary hypertension is associated with adverse prognosis. Early diagnosis is important to better identify patients who would benefit from a well established therapeutic strategy. The purpose of our study was to evaluate long-term incidence of undiagnosed chronic thromboembolic pulmonary hypertension after acute pulmonary embolism and the utility of a long-term follow-up including an echocardiographic-based screening programme to early detect this disease. We evaluated retrospectively 282 patients discharged from the 'Maggiore della Carità' Hospital, Università del Piemonte Orientale, Novara, Italy, with diagnosis of acute pulmonary embolism between November 2006 and October 2009. One hundred and eleven patients underwent a clinical late echocardiographic screening programme after the acute event. Patients with suspected pulmonary hypertension based on echocardiographic evidence of systolic pulmonary artery pressure of at least 40  mmHg underwent complete work-up for chronic thromboembolic pulmonary hypertension assessment, including ventilation-perfusion lung scintigraphy and right heart catheterization. One hundred and eleven patients were included in the study. Pulmonary hypertension was suspected in 15 patients; five patients had chronic thromboembolic pulmonary hypertension confirmed by ventilation-perfusion lung scintigraphy, right heart catheterization and pulmonary angiography. Two patients with clinical class functionally advanced underwent surgical pulmonary endarterectomy and two asymptomatic patients underwent medical treatment. The prevalence of undiagnosed chronic thromboembolic pulmonary hypertension was 4.5%. Chronic thromboembolic pulmonary hypertension is a serious disease with a poor prognosis if not treated early. Surgical treatment is decisive. After surgery, the majority of patients have a substantial improvement in their functional status and in haemodynamic variables. Many patients are asymptomatic. Implementation of screening programmes may be helpful for an early diagnosis and early proper therapy.

Background: The level of atrial mechanical asynchrony may vary within the atrial fibrillation population and this may have pathophysiological relevance., Objective: We sought to verify whether the degree of left-atrial mechanical asynchrony associated with atrial fibrillation is a predictor of arrhythmia recurrence after restoration of sinus rhythm with electrical cardioversion., Methods and Results: Left atrial volume was calculated, whereas two-dimensional (2D) strain (speckle tracking technique) was used to estimate peak and standard deviation (SD) of time-to-peak of deformation of six segments arbitrarily identified along the perimeter of the cavity, imaged in apical four-chamber view. Left atrial mechanical asynchrony was quantified according to quartiles of time-to-peak SD assuming that larger values would identify higher grades of asynchrony. A total of 130 patients undergoing cardioversion for atrial fibrillation were prospectively enrolled. Time-to-peak SD was inversely related with peak strain (P < 0.001). No differences were observed among groups in terms of clinical, therapeutical and additional echocardiographic variables. At 1-year atrial fibrillation was observed in 53% of patients, with time-to-peak SD linearly related to atrial-fibrillation recurrence (P = 0.014). At multivariate analysis only time-to-peak SD (P = 0.032), but not atrial volume (P = 0.075), was identified as an independent predictor of fibrillation recurrence., Conclusion: This is the first study showing that left atrial asynchrony, quantified as time-to-peak SD of regional atrial strains before electrical cardioversion, is a major independent predictor of fibrillation recurrence in patients back to sinus-rhythm postprocedure.

Background: In healthy people the left ventricle presents a counter-clockwise apical rotation and a clockwise basal rotation ending in late systole. In early systole (during isovolumic contraction) there is a fast and inverse rotation (counter-clockwise at the base and clockwise at the apex). This opposite rotation between apex and base produces the systolic torsion of the left ventricle. The effect of permanent conventional pacing on this torsion is little known., Objectives: The aim of this study was to assess, by speckle tracking echocardiography, left ventricular rotation and torsion in patients conventionally paced at the apex of the right ventricle., Methods: Left ventricular apical and basal rotation and the consequent torsion were evaluated by means of speckle tracking echocardiography, in 13 paced patients, without ischemic or valvular disease, and in 17 healthy participants. Left ventricular dyssynchrony was evaluated by means of temporal uniformity of strain., Results: In the paced group there was a significant reduction in early-systolic clockwise torsion (-0.4 degrees +/- 1.2 vs. -1.5 degrees +/- 1.6; P = 0.04), and in late-systolic counter-clockwise torsion (15.1 degrees +/- 4.3 vs. 19.1 degrees +/- 5.5; P = 0.03). Circumferential temporal uniformity of strain averaged significantly lower in paced patients., Conclusions: Conventional pacing from the apex of the right ventricle alters both the torsional mechanic and the synchrony of the left ventricle.

Background: The standard deviation of time to peak strain (TPS-SD) has been proposed as an index of left ventricular (LV) dyssynchrony in patients to be resynchronized. However, TPS-SD is sensitive to noise, and the influence of outliers on TPS-SD is also relevant. Alternatively, dyssynchrony can be indexed by temporal uniformity of strain (TUS), whereby a time plot of regional strains, arranged for LV location, is subjected to Fourier analysis. If segments shorten simultaneously (synchronously), the plot appears as a straight line, with power only in the zero-order Fourier term, whereas regionally clustered dyssynchrony generates an undulating plot with higher power in the first-order term. TUS index reflects zero-order relative to first-order plus zero-order power., Methods: In this study, TUS and TPS-SD were computed in 68 patients (QRS duration >/= 120 ms; ejection fraction

Objectives: The aim of our study was to evaluate the feasibility, the safety, and hemodynamic improvements induced by permanent para-Hisian pacing in patients with chronic atrial fibrillation and narrow QRS who underwent atrioventricular (AV) node ablation., Background: Right ventricular apical pacing, inducing asynchronous ventricular contraction, may impair cardiac function; permanent para-Hisian pacing could preserve interventricular synchrony and improve left ventricular function., Methods: After AV node ablation, 16 patients were implanted with a dual-chamber pacemaker connected to a screw-in lead positioned in close proximity to the His bundle and to a right ventricular apical lead. Clinical and echocardiographic data were collected at baseline and after two randomized six-month periods (with para-Hisian and conventional pacing)., Results: During para-Hisian pacing, the interventricular electromechanical delay improved as well (34 +/- 18 ms) as during right apical pacing (47 +/- 19 ms), p < 0.05. Para-Hisian pacing allowed an improvement in New York Heart Association functional class (1.75 +/- 0.4 vs. 2.33 +/- 0.6 at baseline and 2.5 +/- 0.4 during apical pacing, p < 0.05 for both), in quality-of-life score (16.2 +/- 8.7 vs. 32.5 +/- 15.0 at baseline, p < 0.05), and in the 6-min walk test (431 +/- 73 m vs. 378 +/- 60 m at baseline and 360 +/- 71 m during apical pacing, p < 0.5 for both). Mitral and tricuspid regurgitation improved during para-Hisian pacing (1.22 +/- 0.8 and 1.46 +/- 0.5 index, respectively, vs. 1.68 +/- 0.6 [p < 0.05] and 1.62 +/- 0.7 [p = NS] index at baseline, respectively), with a slight worsening during apical pacing (1.93 +/- 1 and 1.93 +/- 0.7 index, respectively, p < 0.05 for both)., Conclusions: Permanent para-Hisian pacing is feasible and safe. Compared with conventional right apical pacing, it allows an improvement in functional and hemodynamic parameters over long-term follow-up.

We describe the prolonged follow-up of a 64-year-old female patient, with an ectopic intracardiac thyroid gland. The mass was first detected 14 years ago, during a routine echocardiographic examination. The patient suffered from episodes of palpitation and cardiac auscultation revealed a systolic murmur. At cardiac surgery a right ventricular mass penetrating most of the interventricular septum was found. The mass was also prolapsing into the pulmonary infundibulum and could not be removed. On histopathology examination, the presence of a normal tissue was demonstrated. Two main clinical events characterized the prolonged follow-up: the gradual development of a massive tricuspid insufficiency, probably due to the strict anatomic relationship between the septal tricuspid papillary muscle and the mass itself; frequent supraventricular arrhythmias, partially refractory to different pharmacologic regimens, which could be ascribed to the chronic overload of the right atrium. The mass size has been stable over the years, and no thyroid hormone derangement was ever found.

Effectiveness of dual-chamber pacing in patients with dilated cardiomyopathy is still controversial. Our study was performed: to select the most favorable individual atrioventricular (AV) delay; to compare hemodynamic short-term effects in each patient after 2 periods of DDD pacing and sinus rhythm (AV spontaneous); to assess hemodynamic long-term (1 year) effects after DDD pacing at optimum AV delay. In 1996, 9 patients (7 men, 2 women; mean age 69 +/- 5 years) with dilated cardiomyopathy (5 idiopathic, 4 ischemic), NYHA functional class III-IV, ejection fraction < 30%, end-diastolic volume > 60 ml/m2, mitral regurgitation +2/+3, PR interval > or = 200 ms, were enrolled. All patients were implanted with DDD pacemakers and monitored for: ejection fraction and end-diastolic volume (measured by echocardiography and radionuclide angiography); clinical conditions; exercise tolerance and maximum oxygen consumption (by Weber exercise protocol); neurohormonal activity (plasma renin, aldosterone, atrial natriuretic factor). Data were recorded: before DDD implantation; after 2 randomized, single-blind periods of 3 months in VVI mode (at ventricular "sentinel" rate of 50 b/min) and in DDD mode with the optimum AV delay, corresponding for each patient to the minimum end-diastolic volume measured by radionuclide angiography and to the highest cardiac output recorded by echocardiography; after 6 months of DDD pacing with most favorable AV delay. Three more patients died 6 months after (between sixth and twelfth month of follow-up), due to refractory heart failure; 1 patient dropped out because his pacemaker was programmed in VVI mode at low rate, due to intolerance of DDD pacing. Among the other 4 patients no clinical and laboratory parameters were significantly different after 1 year of follow-up. In conclusion, DDD pacing in selected patients with dilated cardiomyopathy showed disappointing results, despite a strict and laboratory monitoring; DDD pacing could be of major benefit in larger populations, according to Doppler mitral flow pattern: those patients with a larger A-wave amplitude could be more sensitive to DDD pacing than those with evidence of poor atrial systole. Moreover, biatral and/or biventricular pacing could also play a significant role.

Aortic valve disease is known to be the most frequent valvular disease in the elderly and aortic valve replacement is often the best therapeutic strategy. Hemodynamic performance of prostheses is critical in this subset of patients to ensure an optimal quality of life. Moreover, old patients with small aortic ostia are getting more and more common in clinical practice, making often necessary to implant small prostheses. If a significant pressure drop is not achieved, hypertrophy persists and left ventricular function may not improve. Such conditions have not yet been extensively studied in the elderly. The aim of this study was firstly to assess echocardiographically the performance of aortic prosthetic heart valves in old patients (> or = 70 years) and compare the results obtained in patients with prostheses of different type and size, and secondly to evaluate the postoperative changes in left ventricular hypertrophy and function in a subset of patients with isolated or prevalent aortic stenosis. One hundred fifty-one patients were initially considered; global mortality was 9.3% at 20 +/- 12 months from intervention. In the 75 patients with a postoperative echocardiogram, transprosthetic gradient was 27 +/- 12 (max) and 15.1 +/- 6.6 (mean) mmHg. Mean functional prosthetic area (FPA) was 1.5 +/- 0.5 cm2. No statistically significant differences could be demonstrated between mechanical and biological prostheses. Three groups were identified, according to prosthetic size (Group 1: diameter < 23 mm, Group 2: diameter 23 mm, Group 3: diameter > 23 mm). Among groups, max and mean gradients as well as FPA were found to be significantly different. Respectively max gradient was 33.2 +/- 13, 26 +/- 11, 20.2 +/- 7.2 mmHg (p < 0.05), mean gradient was 17.2 +/- 6.1, 15.4 +/- 7.6, 11.7 +/- 4.3 mmHg (p < 0.01) and FPA was 1.2 +/- 0.3, 1.5 +/- 0.3, 1.8 +/- 0.7 cm2 (p < 0.05 between Group 1 and Group 3). In a subgroup of 31 patients with isolated or prevalent aortic stenosis, a significant interventricular septal thickness reduction was found postoperatively (14.3 +/- 2.3 vs 12.6 +/- 8.0 mm, p < 0.001). Posterior wall thickness decreased similarly, but to a lesser extent; left ventricular diameters and myocardial mass also significantly decreased (left ventricular mass: 186 +/- 45 vs 146 +/- 38 g/m2, p < 0.001). When prosthetic size was considered, septal thickness reduction was more evident in Group 1 and Group 2 (p < 0.05 and p < 0.01). On the contrary, a significant improvement in left ventricular diameters was observed only in Group 3 (p < 0.05). Left ventricular mass decreased significantly in Group 2 and Group 3 (p < 0.01 and p < 0.05). Such improvements could be demonstrated only in those patients (79%) who showed at least a 50% reduction in the transvalvular gradient. In this subset, left ventricular function also significantly improved (fractional shortening: 29 +/- 0.7 vs 33 +/- 0.7%, p < 0.02). In conclusion, aortic valve replacement in the elderly is a safe and effective therapeutic strategy. In patients with small aortic prostheses, the transvalvular gradient was found to be slightly but significantly higher as compared to that of larger prostheses. However, left ventricular function was good and similar in all subgroups. No significant differences were found between mechanical and biological prostheses. In old patients with isolated or prevalent aortic stenosis a significant reduction in left ventricular hypertrophy and mass is observed within 2 years from intervention. An increase in myocardial contractility can also be expected, if at least a 50% reduction in transvalvular gradient is obtained.

Two-dimensional echocardiography is the technique of choice for identifying cardiac masses. Unfortunately, adjacent structures compressing the atrial wall may lead to misdiagnosis. Clinicians should promptly recognize this phenomenon and the related diagnostic features. The case of a 90-year-old woman presenting with a history of recent onset effort dyspnea is described. On transthoracic two-dimensional echocardiography a left atrial mass which closely mimicked an atrial myxoma was evident. A tomographic scan revealed a large sliding hiatus hernia, which was confirmed on traditional radiographic examination. The echocardiographic characteristics of the mass are described in detail, as well as a review of the literature for the purpose of a correct differential diagnosis.

A new bovine pericardial bioprosthesis (AMB bioprosthesis) with a bileaflet geometry was designed and developed, with the aim of achieving uniform stress distribution within the prosthesis. The ultimate goal was to limit tissue degeneration to a minimum by attaining optimum fluid dynamics, thereby obtaining an extended clinical durability. The two-leaflet, dome-shaped geometry with a central hinge allowed a very low profile, low ventricular projection in the mitral position, large effective orifice area and low gradients. The design of the thin Delrin stent and the centrally crossing bridge was developed using finite element analysis. Pre-clinical laboratory investigations showed very low trans-valvular gradients and no mechanical or tissue failure after 400 million cycle accelerated wear test. The final model of the prosthesis was manufactured by Baxter-Edwards CVS Division and tested in sheep with good results for up to five months. A limited clinical trial was started in January 1990 and stopped one year later encompassing 12 aortic and six mitral implants. The patients were followed clinically and by echocardiography three, six and 12 months, and four years after surgery. Mean gradients were 4 mmHg in the mitral and 10 mmHg in the aortic position with only minimum regurgitation and no tissue failure. We conclude that early and mid term results with this new pericardial bioprosthesis appear to be favorable and intend to closely monitor further outcome within the limited patient population.

The usefulness of the intravenous dipyridamole-echocardiography test (12-lead and two-dimensional [2-D] echo monitoring during dipyridamole infusion) in the diagnosis of coronary artery disease recently has been suggested. However, the intravenous form of dipyridamole is not available for clinical use in some countries and therefore the administration of oral dipyridamole has been employed in combination with echocardiography. In order to evaluate the relative usefulness of the oral (300 mg of pulverized tablets) vs the intravenous (up to 0.84 mg/kg in 10 min) dipyridamole-echocardiography test, we performed the two tests, on different days and in random order, in 28 inhospital patients: 21 had coronary artery disease (seven had one-vessel disease, eight had two-vessel disease, and six had three-vessel disease); seven patients had no significant coronary artery disease. For both tests, the diagnostic end-point was the development of a transient dyssynergy of contraction. Sensitivity was 95 percent for the intravenous and 52 percent for the oral dipyridamole-echocardiography test (p < 0.01); in positive cases, the dyssynergy after the dipyridamole administration appeared at 6.5 +/- 2.5 min for the intravenous and at 27.8 +/- 12.4 min for the oral test (p < 0.01). Specificity was 100 percent for both the intravenous and oral dipyridamole-echocardiography test. One or more extracardiac side effects (headache, gastrointestinal upset, flushing, etc) occurred in 61 percent of the intravenous and 68 percent of the oral tests (p = ns). Nine patients with a positive intravenous and oral dipyridamole-echocardiography test also had a positive exercise-electrocardiography test. A significant correlation between exercise time (ie, the time from onset of exercise and 0.1 m V of ST segment shift) and dipyridamole time (ie, the time from onset of dipyridamole administration and the development of frank dyssynergy) was present for the intravenous (r = 0.6, p < 0.05) but not for the oral test. We conclude that the oral dipyridamole-echocardiography test, in comparison with the intravenous dipyridamole-echocardiography test, has a lower sensitivity and requires a substantially longer imaging time. The dipyridamole time is related to exercise time for intravenous but not for the oral dipyridamole-echocardiography test.

Dipyridamole-echocardiography test response can be expressed not only in a black or white (positive vs negative) code but also, in positive tests, by a gray scale integrating the severity and extent of the dyssynergy as well as the ischemia-free stress time. The recognition of the dyssynergy is important to establish the diagnosis; however, the evaluation of the degree of the induced ischemia, stratified according to spatiotemporal coordinates, is even more important because it accurately predicts the coronary anatomical and functional situation, as well as the prognosis of the individual patient. Furthermore, the "shades of gray" in a positive response have proved useful in assessing the beneficial effects of several interventions: coronary angioplasty; coronary artery bypass surgery; thrombolysis; and medical antianginal therapy. Due to its excellent reproducibility, dipyridamole-echocardiography can play a pivotal role for simple, safe, fast, accurate, and objective assessment of therapeutic interventions, either mechanical or pharmacological, based upon the presence, timing, severity, and extent of dipyridamole-induced dyssynergy.

Background: We wished to assess whether dipyridamole echocardiography test (DET) can detect jeopardized myocardium after thrombolytic therapy., Methods and Results: Seventy-six consecutive patients with a first acute myocardial infarction (AMI) were treated with 2 million IU urokinase i.v. within 4 hours of the onset of AMI and underwent high-dose (as much as 0.84 mg/kg over 10 minutes) DET 8-10 days after AMI. The results were correlated to the anatomy of the infarct-related vessel (IRV). In patients with positive DET, we evaluated the wall motion score index (WMSI; a semiquantitative integrated estimation of extent and severity of the stress-induced dyssynergy). WMSI was derived by summation of individual segment scores divided by the number of interpreted segments. In a 13-segment model, each segment was assigned a score ranging from 1 (normal) to 4 (dyskinetic). Fifty-three patients had positive results on DET. Of these, 42 had dipyridamole-induced new wall motion abnormalities (WMAs) confined to the infarct zone or adjacent segments. In these patients, mean WMSI increased from 1.46 +/- 0.26 (at resting conditions) to 1.73 +/- 0.35 (at peak dipyridamole) (p less than 0.01), whereas no significant change was detected in negative patients (1.6 +/- 0.34 versus 1.57 +/- 0.34, p = NS). Coronary angiography showed a patent IRV (TIMI grade 2 or 3) in 53 patients and no or minimal reperfusion (TIMI grade 0 or 1) in 23 patients. A patent IRV with critical residual stenosis was found in 35 of 42 patients with dipyridamole-induced WMAs in the infarct zone and in 18 of 34 patients without WMAs (p less than 0.05). Among the 23 patients with occluded IRVs, nine had collateral flow to the distal vessel; six of these had a positive DET. Thus, the sensitivity and specificity for identifying a critically stenotic but patent IRV or the presence of a collateral-dependent zone were 66% and 93%, respectively. In a subset of nine patients with a positive DET in the infarct zone or adjacent segments, DET and a control coronary angiography were repeated 1-3 months after an angiographically successful (residual stenosis, 50% or less) coronary angioplasty in the IRV. The repeat DET was negative in eight patients (all with patent IRV at control angiography) and again positive in one patient, who showed restenosis at angiography. The WMSI, at resting conditions was similar before and after angioplasty, whereas it differed significantly at peak dipyridamole (1.7 +/- 0.2 versus 1.4 +/- 0.2, p less than 0.01)., Conclusions: DET can identify the anatomy of the IRV, and dipyridamole-induced WMAs within the infarct zone detect regions with jeopardized myocardium that may benefit from intervention.

Present paper reports on a patient referred for sustained, hemodynamically well tolerated, ventricular tachycardia, terminated by noninvasive temporary pacing. The tachycardia was refractory to chest tump and intravenous standard drugs (lidocaine and propafenone). Demonstration of spontaneous atrioventricular dissociation and ventricular capture during transesophageal atrial pacing allowed rapid and correct diagnosis. Overdrive with external noninvasive ventricular pacing proved effective in terminating ventricular tachycardia and converting it to sinus rhythm. These observations suggest that noninvasive approach to hemodynamically stable ventricular tachycardia can provide a safe and effective alternative to more aggressive medical management.

Dipyridamole echocardiography is gaining popularity as an exercise-independent diagnostic method in patients with suspected or demonstrable coronary artery disease. To assess its safety, feasibility, and diagnostic accuracy in patients recovering from uncomplicated acute myocardial infarction, 131 patients had the test before hospital discharge. The results were compared with those of maximum treadmill testing. We found that dipyridamole-induced transient asynergy remote from the infarct zone was more sensitive (74% versus 53%, p less than 0.05) and specific (97% versus 68%, p less than 0.01) than treadmill testing for detecting multivessel coronary artery disease. In a subgroup of 42 patients treated with thrombolytic therapy, dipyridamole echocardiography was able to detect in 27 the presence of jeopardized but viable myocardium in the infarct zone. An excellent correlation was found between dipyridamole echocardiography responses and infarct vessel patency. Finally, the prognostic impact of dipyridamole echocardiography on patients recovering from acute myocardial infarction was assessed in a consecutive series of 151 patients. Eighteen months of event-free survival was significantly different in patients with positive versus negative dipyridamole echocardiography results (76.1% versus 50.8%, p less than 0.01). The test was also superior to treadmill testing in predicting cardiac events. Thus, dipyridamole echocardiography performed early after acute myocardial infarction is safe, feasible, and accurate for predicting the extent of coronary artery disease and 18-month clinical outcome.

Background: Dipyridamole echocardiography test (DET: two-dimensional echocardiographic monitoring with dipyridamole infusion up to 0.84 mg/kg in 10 minutes) is a useful tool for the noninvasive diagnosis of coronary artery disease. Aims of the present study were to assess the effects of antianginal drugs on dipyridamole-induced ischemia and to evaluate whether drug-induced changes in DET response may predict variations in exercise tolerance., Methods and Results: Fifty-seven patients with angiographically assessed significant coronary artery disease (greater than 70% lumen reduction in at least one major coronary vessel) performed a DET and an exercise electrocardiography test (EET) in random order both off treatment and on antianginal drugs (beta-blockers, calcium antagonists and nitrates, alone or in various combinations). The criterion for DET positivity was a transient dyssynergy of contraction absent or of a lesser degree in the baseline examination. In DET, two parameters were evaluated: the dipyridamole time (i.e., the time from onset of dipyridamole infusion to obvious dyssynergy) and the wall motion score index. DET sensitivity was 91% off therapy and fell to 65% under therapy (p less than 0.01). In the 37 patients who had a positive DET both off and on therapy, the dipyridamole time increased from 6 +/- 3 (off therapy) to 8 +/- 3 minutes (on therapy) (p less than 0.01). The wall motion score index at peak dipyridamole went from 1.38 +/- 0.14 to 1.31 +/- 0.14 (p less than 0.01). EET and DET yielded concordant (positive versus negative) results in 41 of 57 (71%) patients off and in 35 of 57 (61%) on therapy (p = NS). In the subgroup of 38 patients with both positive DET and EET without treatment, the therapy-induced variations in exercise time were significantly correlated with the variations in dipyridamole time (r = 0.5; p less than 0.01), not with variations in wall motion score index (r = 0.3; p = NS)., Conclusions: 1) Antianginal therapy can protect from dipyridamole-induced ischemia and 2) the therapy-induced changes in DET response parallel variations in exercise tolerance and might be useful for the objective, exercise-independent assessment of the therapy efficacy.

To assess whether the different mechanical effects of intravenous dipyridamole were correlated with the location and distribution of the coronary arteries stenosis, 98 patients underwent high dose DET 8-10 days after an acute myocardial infarction. Left ventricular regional wall segments were identified in multiple views; a vascular territory was assigned to each coronary vessel. DET was positive in 68.4% of the patients (67/93), 59% (23/39) of those with single vessel disease, and 81% (44/54) of those with multivessel disease. Four different mechanical patterns of positivity of DET were observed: 1) marked worsening of wall motion in the same region showing asynergy (type I); 2) development of new wall motion abnormality adjacent to the infarct zone and located in the same vascular region (type II); 3) development of new wall motion abnormality adjacent to the infarct zone, but located in a different vascular region (type III); 4) development of transient remote asynergy (that is, a new wall motion abnormality in a region normal at rest and not directly adjacent to the infarct zone, type IV). Types I and II (asynergies in the infarct zone coronary bed) were found in patients both with single vessel disease or multivessel disease; by contrast, type III and IV were almost exclusively found in patients with multivessel disease (24/54 and 14/54 respectively) and occasionally in patients with single vessel disease (2/39 and 1/39 respectively). Thus, these two mechanical behaviours during dipyridamole infusion showed to be highly specific for predicting multivessel disease (95% and 97% respectively, sensitivity 44% and 26% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

To assess the role of high-dose (up to 0.84 mg/kg during 10 minutes) dipyridamole echocardiographic testing in the evaluation of coronary artery bypass graft patency early after surgery, 18 consecutive patients with angina underwent dipyridamole echocardiography and coronary angiography before and 7 to 10 days after bypass surgery. Coronary angiography showed 2- or 3-vessel disease in 7 and 11 patients, respectively. A total of 53 bypass grafts were performed. Before bypass surgery 14 patients had a positive and 4 a negative test result. No complication occurred during the test performed early after surgery. Of the 14 patients with positive dipyridamole echocardiographic results before surgery, 10 had negative and 4 had positive results after surgery. All 4 patients had negative results before and after surgery. In the 4 patients with positive results after dipyridamole echocardiographic testing before and after bypass surgery, dipyridamole time increased from 5.8 +/- 5 to 9.3 +/- 0.9 minutes (p = 0.3) after the procedure and wall motion score index at peak dipyridamole changed from 1.55 +/- 0.2 to 1.28 +/- 0.3 (p = 0.05). Forty-nine of 53 grafts were patent as seen on angiography. Dipyridamole echocardiographic results were positive in 4 of 5 patients who had at least 1 obstructed graft or native vessel obstructed distal to bypass graft insertion. The remaining patient had diagnostic electrocardiographic changes during dipyridamole infusion without wall motion abnormalities. Dipyridamole echocardiographic results were negative in all 13 patients who had complete revascularization. In the 4 patients with positive test results, the procedure correctly identified the localization of the diseased bypass graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Dual chamber pacing (DDD) maintains atrioventricular (AV) sequence; AV delay programmability modifies the relationship between atrial and ventricular contraction. To evaluate the hemodynamic effects of such a modification, ten patients with a DDD unit for complete AV block were studied by time-motion (M-mode) and Doppler echocardiography during inhibited ventricular pacing (VVI), atrial-triggered ventricular pacing (VDD) and atrioventricular sequential pacing (DVI) at different AV delay (90, 140, 190, 240 msec). A significant improvement in stroke volume (SV) (15%-20%, P less than 0.05) was seen during DDD versus VVI pacing; no changes, however, were observed in the same patient with different AV delay or during DVI versus VDD pacing. These data suggest that programming of AV delay does not affect systolic performance at rest; longer diastolic filling times recorded during DDD pacing with "short" AV delay (90-140 msec) do not seem to be a hemodynamically relevant epi-phenomenon of PM programming.