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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.

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.

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.

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. 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). 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. 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). 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.

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. 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. 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). 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. [Display omitted]

Doppler of mitral and pulmonary vein flows are used to estimate left ventricular (LV) filling pressure. Mitral regurgitation (MR) makes unreliable these parameters by inducing changes of both mitral inflow and pulmonary vein flow. To evaluate whether Doppler tissue imaging (DTI) diastolic indices obtained at the level of LV lateral mitral annulus can provide accurate estimation of LV filling pressure in patients with MR. Forty-three patients (age 55 ± 11 years) with severe MR and mean LV ejection fraction (EF) 58 ± 13 were enrolled, 10 (23%) with LV EF <50% and 33 (77%) with LV EF >50%. Doppler signals from the mitral inflow, pulmonary venous flow, and DTI indices of the lateral mitral annulus were obtained. LV end-diastolic pressure (LVEDP) was measured invasively with fluid-filled catheter. In the overall population, the majority of standard Doppler and DTI indices correlated with LVEDP, but the multivariate analysis showed that the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/Em ratio) ( β = .87, P = .0001) was independent predictor of LVEDP ( R 2 = 0.74, SE = 4, P = .0001). An E/Em ratio >10 predicted an LVEDP >15 mm Hg (sensitivity 90%, specificity 83%). In both groups with LV EF >50% ( β = .77, P = .005; cumulative R 2 = 0.73, SE = 2.5, P = .0001) and <50% ( β = .89, P = .002; cumulative R 2 = 0.77, SE = 2.1, P = .002), multivariate analysis underscored again only E/Em ratio as independent predictor of LVEDP. The combination of DTI indices of the mitral annulus and mitral inflow velocities provides reliable parameters to predict LV filling pressure in patients with MR both in patients with LV EF >50% and <50%.

Razionale. La ricerca scientifica sull’applicazione clinica della terapia cellulare cardiaca mira a tradurre in efficacia i risultati ottenuti nell’ambito della ricerca di base. Da circa un decennio, si è passati dalla sperimentazione in vitro e su modelli animali a studi clinici su diverse categorie di pazienti cardiologici: pazienti con infarto miocardico acuto, pazienti con angina cronica refrattaria alle terapie convenzionali e pazienti con insufficienza cardiaca. Tuttavia i risultati non sono univoci. Precedenti studi hanno suggerito che l’iniezione di cellule staminali di derivazione midollare possa migliorare la perfusione miocardica e la funzione del ventricolo sinistro in pazienti affetti da ischemia miocardica cronica, altri studi hanno invece riportato risultati negativi.

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.