[Show abstract][Hide abstract]ABSTRACT: Objectives
To determine clinical and echocardiographic correlates of acute heart failure, cardiogenic shock and in-hospital mortality in a large cohort of tako-tsubo cardiomyopathy (TTC) patients.
Despite good long-term prognosis, life-threatening complications due to hemodynamic instability can occur early in TTC patients.
The study population consisted of 227 patients (66.2 ± 12.2 years of age; females, 90.3%) enrolled in the Tako-tsubo Italian Network, undergoing transthoracic two-dimensional echocardiography on admission and at short-term follow-up (4.3 [4 to 6] weeks). Patients were divided into two groups according to the presence or absence of major adverse events, a composite of acute heart failure, cardiogenic shock, and in-hospital mortality.
Major adverse events occurred in 59 patients (25.9%). The variables for elderly patients ≥75 years of age (42.4 vs. 23.8%; p = 0.011): left ventricular (LV) ejection fraction (35.1 ± 5.9 vs. 38.4 ± 4.6%, p < 0.001), wall motion score index (1.9 ± 0.2 vs. 1.7 ± 0.2, p < 0.001), E/e′ ratio (13.5 ± 4.3 vs. 9.9 ± 3.3 [where E/e′ is ratio of mitral E peak velocity and averaged e′ velocity], p < 0.001), LV outflow tract obstruction (23.7 vs. 8.9%, p = 0.006), pulmonary artery systolic pressure (47.4 ± 12.3 vs. 38.0 ± 9.2 mm Hg; p < 0.001), right ventricular involvement (28.8 vs. 9.5%; p < 0.001), and reversible moderate-to-severe mitral regurgitation (49.1 vs. 11.9%; p < 0.001), were significantly different between groups and were associated with adverse events. At multivariate analysis, LV ejection fraction (HR: 0.92; 95% CI: 0.89 to 0.95; p < 0.001), E/e′ ratio (HR: 1.13; 95% CI: 1.02 to 1.24; p = 0.011), reversible moderate to severe mitral regurgitation (HR: 3.25; 95% CI: 1.16 to 9.10; p = 0.025), and age ≥75 years (HR: 2.81; 95% CI: 1.05 to 7.52; p = 0.039) were independent correlates of major adverse events.
Echocardiographic parameters provide additional information compared to other variables routinely used in clinical practice to identify patients at higher risk of hemodynamic deterioration and poor in-hospital outcome, allowing prompt institution of appropriate pharmacological treatment and adequate mechanical support.
Full-text · Article · Feb 2014 · JACC. Cardiovascular imaging
[Show abstract][Hide abstract]ABSTRACT: To describe the clinical characteristics and in-hospital outcomes of older adults with tako-tsubo cardiomyopathy (TTC).
Partially retrospective, partially prospective observational study.
Eleven Italian referral cardiac centers included in the Tako-tsubo Italian Network.
One hundred ninety consecutive individuals with TTC (92.1% female, mean age 66) were divided into three groups according to age (<65, n = 78; 65-74, n = 61; ≥75, n = 51).
Clinical findings and in-hospital outcomes were evaluated in each group.
Participants aged 65 and older had a greater prevalence of hypertension (P = .001) and a lower glomerular filtration rate (P < .001), and those aged 65 to 74 had a greater prevalence of psychiatric disorders (P = .01), ST-segment elevation on admission (P = .01) and a cerebrovascular disease (P = .003) than those younger than 65. Despite similar left ventricular ejection fraction (LVEF) on admission (P = .26), the oldest group had a lower LVEF at discharge (P = .03). Inotropic agents were used more frequently in older adults (P = .03). In-hospital composite adverse events (all-cause death, acute heart failure, life-threatening arrhythmias, stroke, and cardiogenic shock; P = .03) and overall complications (P = .004) were more common in participants aged 75 and older. Overall in-hospital mortality was low (2.8%) but was more prevalent in participants aged 75 and older (6.3%). On multivariate analysis, age of 75 and older (hazard ratio (HR) = 2.45, 95% confidence interval (CI) = 1.28-5.82, P = .04) and LVEF on admission (HR = 0.874, 95% CI = 0.81-0.95, P < .001) were the only independent predictors of in-hospital adverse events.
The clinical profile of participants aged 75 and older with TTC was different from that of those younger than 75 with TTC, and they had a higher in-hospital complication rate.
No preview · Article · Oct 2011 · Journal of the American Geriatrics Society
[Show abstract][Hide abstract]ABSTRACT: To evaluate the safety, reproducibility and pitfalls of an aortic valve re-implantation (AVRei) technique.
From June 2005 to December 2008, 30 patients underwent aortic valve-sparing re-implantation with Gelweave Valsalva prosthesis. Mean age was 66 +/- 7 years (range 47-81). Mean aortic root diameter was 49 +/- 6 mm (range 37-70) and 12 patients had an aortic insufficiency more than 2+. All the patients were elective, except three who underwent surgery for type A aortic dissection. Two patients had Marfan syndrome and one had a bicuspid aortic valve. Isolated aortic root replacement was performed in 26 patients, whereas hemiarch extension was required in four. All the survivors underwent serial echocardiographic assessment for functional results and multi-detector computed tomography (MDCT) for aortic root morphology evaluation.
There was one early death and one re-exploration for bleeding. Two patients suffered from a perioperative stroke and four required a pacemaker implantation because of a complete atrio-ventricular block. Mean follow-up was 12 +/- 10 months (range 1-42) with no late deaths, whereas freedom from reoperation was 100% and freedom from aortic insufficiency 2+ or more was 96.5%. MDCT aortic root reconstruction showed a pseudo-normalization of the neo-sinuses of Valsalva mimicking the human normal aortic root morphology.
AVRei with Valsalva conduit is a well-tolerated procedure both in elective and emergency situations. In well-selected patients, good functional and clinical results can be achieved, regardless of the cause of the aortic root disease. Application of simple surgical manoeuvres allows durable clinical efficacy to be obtained without the risk of major complications.
No preview · Article · Jul 2009 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract]ABSTRACT: Transthoracic Doppler echocardiography is a valuable tool to measure coronary flow reserve (CFR) and detect in-stent restenosis (ISR) after percutaneous coronary angioplasty in selected series of patients.
To assess the usefulness of coronary flow reserve measured by echocardiography in detecting significant (> or =70%) ISR of the left anterior descending coronary artery in a large unselected population.
Two hundred and twenty-three patients (age 61 +/- 10 years; 168 men) treated with left anterior descending stenting underwent CFR measurement by transthoracic Doppler echocardiography and venous adenosine infusion 24-72 h before control coronary angiography. Coronary-active drugs were continued, and patients with multiple risk factors and old anterior-apical myocardial infarction were included.
Significant ISR occurred in 56 patients (25%). Patients with ISR had higher basal coronary flow velocity (27 +/- 10 cm/s vs. 24 +/- 7 cm/s; P < 0.002) and lower CFR (1.5 +/- 0.5 vs. 2.7 +/- 0.6; P < 0.0001) than those without ISR. A linear relation was found between ISR and CFR (r = -0.73; P < 0.0001) and remained significant after adjustment for blood pressure and heart rate (r = -0.74; P < 0.0001). A CFR less than two identified significant ISR (sensitivity 88%, specificity 88%, area under the curve = 0.943; P < 0.001). In a multivariate model of CFR prediction, myocardial infarction and heart rate were slightly contributory (ss = -0.19, P < 0.01; ss = -0.16, P < 0.03, respectively), whereas ISR had a large influence (ss = -0.66; P < 0.0001). The inverse correlation between ISR and CFR persisted in patients with myocardial infarction (r = -0.64; P < 0.0001) and in those treated with beta-blockers (r = -0. 71; P < 0.0001).
Echocardiographic measurement of CFR detects significant left anterior descending ISR in unselected patients with multiple risk factors, old anterior-apical myocardial infarction, and taking beta-blockers.
Full-text · Article · Dec 2008 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract]ABSTRACT: Left cor triatriatum is a congenital heart disease characterized by an intra-atrial membrane determining obstruction and pressure gradient. We report an unusual case of cor triatriatum in a nonprofessional athlete presenting with effort dyspnoea. Although frequently diagnosed in the infant, it may also be a rare cause of effort dyspnoea in the adult.
No preview · Article · Oct 2008 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract]ABSTRACT: We report a case of transient tako-tsubo cardiomyopathy characterized by an unusual trigger in a woman victim of near-drowning syndrome. After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. Electrocardiogram changes and apical contraction abnormalities were reversed within 1 month. In conclusion, we hypothesize that hypoxemia related to near-drowning syndrome could have induced transient myocardial dysfunction mediated by a sympathetic nerve activation.
No preview · Article · Jun 2008 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract]ABSTRACT: Penetrating aortic ulcer (PAU) is defined as an ulcerating atherosclerotic lesion that disrupts the aortic wall layers, penetrating the internal elastic lamina. The natural history of the disease and the preferred treatment are still debated. We report a case of painless PAU in a 78-year-old man detected by transesophageal echocardiography at the level of proximal descending aorta as an incidental finding. The patient underwent endovascular stent-graft placement without any complications at early and late follow-up.
No preview · Article · Jan 2008 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract]ABSTRACT: Acute type A aortic dissection (TA-AAD) is a highly lethal clinical entity that can occur within a wide age range, associated with multiple aetiologies and various clinical presentations. In the very elderly type A aortic dissection frequently presents with non-specific symptoms and signs and is associated with high mortality and morbidity. Thus the clinician must have a high index of clinical suspicion in order to prompt the most appropriate diagnostic-therapeutic strategy. We report a nonagenarian women with TA-AAD, treated successfully with medical therapy.
Full-text · Article · Oct 2007 · Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo
[Show abstract][Hide abstract]ABSTRACT: The aim of the present study was to evaluate the prognostic significance of tissue Doppler echocardiography (TDE)-derived ventricular asynchrony in patients with left bundle branch block (LBBB) but not advanced heart failure.
Fifty-five patients (mean age 66 +/- 13 years; 33 male) with complete LBBB (QRS > 120 ms) hospitalized for an acute episode of decompensated heart failure and in New York Heart Association class II for at least 6 months before the study admission underwent standard Doppler echo and pulsed-wave TDE. Precontraction time (PCTm) from the beginning of Q wave of electrocardiogram to the onset of systolic myocardial velocity wave was evaluated in four different left ventricular (LV) basal myocardial segments (LV anterior, inferior, septal and lateral walls) and in one right ventricular (RV) lateral wall. Intraventricular activation delay (IntraV-del) was calculated by the difference of PCTm of each LV myocardial segment. Interventricular activation delay (InterV-del) was calculated by the difference of PCTm between the most delayed LV segment and RV lateral wall.
The mean value of EF was 40 +/- 9% and of InterV-del, IntraV-del was, respectively (97.4 +/- 46.7 and 57.9 +/- 35.5 ms). InterV-del was inversely related to EF (r = -0.68; P < 0001). During the follow-up (26 months, range 11-37 months) cardiac events were recorded in 23 (41%) patients: a worsening of heart failure (WHF) in 23 patients and cardiac death in ten patients. Cox proportional hazard multivariate analysis showed that age, and InterV-del [HR = 1.02 (P < 0.05) and 1.03 (P < 0005)] predicted mortality. A Receiver operating characteristic analysis showed that a cut-off value of InterV-del 100 ms (AUC = 0.86; P < 0001) predicted WHF and mortality with sensitivity and specificity of 75% and 90%; 81% and 84%, respectively.
TDE-derived interventricular asynchrony represents a prognostic indicator of major cardiac events at 2 years of follow-up in patients with LBBB but not advanced heart failure.
No preview · Article · Aug 2007 · Journal of Cardiovascular Medicine