Left atrium: a forgotten biomarker and a potential target in cardiovascular medicine Emerging evidence shows the clinical usefulness of left atrium analysis in different fields of cardiovascular medicine in terms of diagnosis, prognosis and as a potential target for medical treatment. Left atrium structural and functional remodeling has been shown to be a sensitive marker able to detect high-risk individuals in the general population and in subjects with known cardiovascular diseases such as atrial fibrillation, heart failure, ischemic heart disease and valvular heart disease. This review aims to summarize the methods used to assess left atrium structure and function, focusing on its role to identify subclinical and clinical cardiovascular disease and to provide additional prognostic information for stratifying high-risk subjects.

Echocardiographic score for prediction of pulmonary hypertension at catheterization: the Daunia Heart Failure Registry Background Right heart catheterization (RHC) is recommended by guidelines for the diagnosis of pulmonary hypertension, the definition of hemodynamic impairment and responsiveness to drug therapy. However, RHC is an invasive test with associated risk of complications. Noninvasive echocardiographic tools, possibly predictive of pulmonary hypertension at RHC, could be therefore extremely useful. Methods Sixty-four consecutive patients with suspected pulmonary hypertension were enrolled in the study and assessed by echocardiography and RHC. Diagnosis of pulmonary hypertension was based on mean pulmonary artery pressure (≥25 mmHg) at RHC. Results Of 64 consecutive patients enrolled, 77% were diagnosed as having pulmonary hypertension after RHC. On the basis of significant differences between patients with pulmonary hypertension at RHC and those without on echocardiographic assessment, a multiple logistic regression model was constructed to predict the presence of pulmonary hypertension at RHC. The score was calculated using right atrium and ventricular diastolic area, tricuspid regurgitation Vmax, tricuspid regurgitation severity degree and left ventricular ejection fraction. The score area under the curve was therefore 0.786 (P = 0.0001), higher than for tricuspid regurgitation Vmax (P = 0.06). A score value more than 57 was associated with a 93% sensitivity, a 67% specificity, a 91% positive predictive power, a 73% negative predictive power, and an odds ratio 27 (P < 0.001) of pulmonary hypertension at RHC, significant even after correction at multivariable analysis. Accuracy of the prediction model was assessed in a validation cohort with comparable results (P = n.s.). Conclusion A simple noninvasive echocardiographic score can be useful in predicting the diagnosis of pulmonary hypertension at RHC and may be considered for the selection of patients who should undergo or could avoid RHC.

Multivariable models for the diagnosis of pulmonary hypertension No abstract available

Assessing bleeding in acute coronary syndrome using the Bleeding Academic Research Consortium definition Background The Bleeding Academic Research Consortium (BARC) definition was proposed to overcome the heterogeneity among the many bleeding definitions. The aim of this study-level meta-analysis was to explore the incidence of BARC-assessed bleeding in acute coronary syndrome (ACS) studies and to ascertain the relation between these events and variables related to bleeding risk. Methods and Results We searched the literature for studies that reported bleeding events according to BARC criteria in ACS patients. An analysis on heterogeneity between studies in bleeding reports was performed with I2 test. A meta-regression was conducted to explore the relation between different types of BARC bleedings and patient and procedural features. Nine studies were included in the analysis. Overall, BARC 2 rates were higher than BARC 3 or 5 rates (6.3 versus 2.6%). An extremely high level of heterogeneity was detected both for BARC 2 (I2 99.3%) and BARC 3 or 5 (I2 97.5%) bleedings. Increasing age [β coefficient 0.4% (0.2–0.6%); P < 0.001] and renal impairment [β coefficient 1 6.5% (1–32.1%); P  = 0.037] were associated with increased BARC 3 or 5 rates, whereas the use of glycoprotein IIb/IIIa inhibitors was the only factor related to an increased incidence of BARC 2 bleeding [β coefficient 2 2.3% (5.5–39%); P  = 0.009]. Conclusion The high level of heterogeneity in BARC bleeding reports only partially explained by bleeding risk profile suggests that a regulatory guidance to properly evaluate bleedings and to estimate the risk--benefit in clinical trials investigating different antithrombotic treatments in ACS patients is needed.

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis Purpose In the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis. Methods Twelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. Results Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients’ hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I–II. Conclusion The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results.

Transcatheter aortic valve implantation and patients excluded from clinical trials: previous mitral valve replacement No abstract available

Evidence of impaired longitudinal strain in pre-Fontan palliation in functional single left ventricle Background We evaluated two-dimensional speckle-tracking echocardiography longitudinal strain (L2DSE) in functionally single left ventricles (LV). Methods We retrospectively analyzed 21 patients with functionally single LV. We divided patients into two groups according to pre-Fontan cardiac catheterization data: group 1, adequate data for Fontan procedure and group 2, inadequate data. Results LV strain correlated with predicted pressure in the Fontan system (r = 0.64; P = 0.003), pressure in the Glenn system (r = 0.57; P = 0.010), and transpulmonary gradient (r = 0.59; P = 0.008), but not with left atrial pressure (r = 0.292; P = 0.226) or ejection fraction (r = 0.254; P = 0.294). In multiple regression analysis, four-chamber LV strain was correlated with predicted pressure in the Fontan (β = 0.642: P = 0.003), whereas no association was found with LV ejection fraction (β = 0.254; P = 0.294), or time from Glenn palliation (β = 0.082; P = 0.893). When dividing the population into two groups according to catheterization data, significantly lower four-chamber longitudinal 2DSE (−25.8 ± 3.2 vs.−19.5 ± 5.1; P = 0.004) was found to be not suitable for the Fontan procedure, as compared with those who underwent successful Fontan completion. Conclusion Regardless of ejection fraction, four-chamber L2DSE is associated with high predicted pressure in the Fontan system. Patients with hemodynamic data unsuitable for Fontan operation have significantly lower mean longitudinal strain parameters. 2DSE may represent a valuable tool in assessing patients with single LV physiology and might provide useful pre-Fontan information.

Midventricular Takotsubo cardiomyopathy complicated by a ventricular septal rupture: a surgical management No abstract available

Diagnostic ‘nightmares’ in an HIV patient with a cardiac mass and a previous history of tuberculosis No abstract available

A novel, transfemoral prosthesis designed to treat aortic valve regurgitation: technical aspects and procedural guide No abstract available