75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
ORALI
CONCORSO GIOVANI RICERCATORI
O1
LEFT ATRIAL FUNCTION ANALYSIS AS INDEPENDENT PARAMETER TO PREDICT
LEFT VENTRICULAR END DIASTOLIC PRESSURE
MATTEO CAMELI (A), MASSIMO FINESCHI (A), STEFANIA SPARLA (A), MATTEO LISI
(A), FLAVIO D´ASCENZI (A), MAURIZIO LOSITO (A), MARTA FOCARDI (A), ROBERTO
FAVILLI (A), CARLO PIERLI (A), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA
BACKGROUND: Several noninvasive measurements are widely applied to estimate left
ventricular filling pressures (LVFP) and to establish a correct therapeutic strategy in a lot of cardiac
diseases, especially in patients with heart failure. Among these, left atrial (LA) deformation analysis
by speckle tracking echocardiography (STE), has recently demonstrated to be highly accurate to
estimate LVFP even in patients with advanced heart failure. The aim of this study was to examine the
accuracy of LA strain in predicting LVFP, analyzing its dependency from left ventricular parameters.
METHODS: A total of 87 stable patients with sinus rhythm undergoing cardiac catheterization were
studied. LV end diastolic pressure (LVEDP) was obtained during cardiac catheterization; peak atrial
longitudinal strain (PALS), left ventricular longitudinal strain (GLS) and mitral annular plane systolic
excursion (MAPSE) were measured in all subjects by another independent operator. PALS values
were obtained by averaging all segments (global PALS), and by separately averaging segments
measured in the 4-chamber and 2-chamber views.
RESULTS: Global PALS correlated significantly with LVEDP (r=-0.86; p<0.0001). Lower levels
of correlation were found for E/E’ ratio (r=0.57; p=0.01), GLS (r=0.40; p=0.05) and MAPSE (r=0.22; p=ns). Parameters of LV systolic analysis presented lower correlation in subgroup of patients
with lower LV ejection fraction. ROC analysis showed global PALS as the best predictor of increased
LVEDP (AUC: 0.83). In multivariate analysis, global PALS emerged as a determinant of the LVEDP,
independently on other confounding factors.
CONCLUSIONS: In comparison to E/E’ ratio and LV systolic parameters, LA strain is a strong and
independent parameter for non invasive prediction of LVEDP.
O2
PREVALENCE, CLINICAL CORRELATES AND
SUBAORTIC VENTRICULAR SEPTAL BULGE
LONGITUDINAL STUDY OF AGING)
FUNCTIONAL IMPACT OF
(FROM THE BALTIMORE
MARCO CANEPA (A, B, C), PIETRO AMERI (A), GIANPAOLO BEZANTE (A), MAJD
ALGHATRIF (B), JAMES STRAIT (B), EDWARD LAKATTA (B), LUIGI FERRUCCI (B),
THEODORE ABRAHAM (C), CLAUDIO BRUNELLI (A)
(A) CARDIOLOGY UNIT, DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF
GENOVA, IRCCS AOU SAN MARTINO IST, GENOVA, IT; (B) LONGITUDINAL STUDY
SECTION, TRANSLATIONAL GERONTOLOGY BRANCH NATIONAL INSTITUTE ON
AGING, NIH, BALTIMORE MD, USA; (C) HYPERTROPHIC CARDIOMYOPATHY UNIT
DIVISION OF CARDIOLOGY, JOHNS HOPKINS UNIVERSITY, BALTIMORE MD, USA
SIC | Indice Autori
1
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
BACKGROUND: A localized hypertrophy of the subaortic segment of the ventricular septum ventricular septal bulge (VSB, Figure 1) - has been frequently described in series of elderly persons,
but its prevalence with age, clinical correlates and impact on cardiac function and exercise capacity
remain uncertain.
METHODS: We explored these associations in a cross-sectional sample without known cardiac
disease from the Baltimore Longitudinal Study of Aging. We randomly selected 700 participants
(50% men, mean age 64±15, range 26-95 years) and reviewed their echocardiograms*.
RESULTS: We identified 28 men and 21 women with VSB (7% overall prevalence). The prevalence
of VSB significantly increased with age in both genders (Figure 2, p<.0001). In multivariate logistic
regression including hypertension and other cardiovascular risk factors, only age displayed a
significant independent association with VSB (OR 1.06 per year, 95% CI 1.03-1.10, p=0.0001). After
multiple adjustments, participants with VSB as compared to those without had enhanced global left
ventricular contractility (fractional shortening 41±1.3 vs. 38±0.3%, p=0.04; ejection fraction 71±1.6
vs. 67±0.4%, p=0.06; systolic velocity of the mitral annulus 8.4±0.1 vs. 8.9±0.3, p=0.06), and larger
aortic root diameters (3.3±0.06 vs. 3.1±0.02 cm, p=0.02). In subgroup of participants who completed
a maximal treadmill test (177 women and 196 men), those with VSB (19, 5.1%) had significantly
lower peak oxygen consumption than their counterparts (19.6±3.8 vs. 22.9±6.6 mL/kg per minute,
p=0.03). However this association was no longer significant after multiple adjustments.
CONCLUSIONS: The presence of VSB is independently associated with older age, determines
enhanced left ventricular contractility, without any evident impact on exercise capacity.
FIGURE 1. Example of VSB.
FIGURE 2. Prevalence of VSB
*From the two-dimensional parasternal long-axis view at end-diastole, the presence of VSB was
defined as i) a proximal focal area of localized septal hypertrophy with a dune-like structure
protruding in the left ventricular outflow tract, ii) a thickness ≥ 13 mm in men and ≥ 12 mm in
women, and iii) more than 50% greater than the thickness of the septum at its mid-distal-point.
SIC | Indice Autori
2
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O3
LEFT ATRIAL BLOOD FLOW VELOCITY DISTRIBUTION: A COMBINED 4D FLOW
MRI, T1 MAPPING MRI AND DOPPLER ECHOCARDIOGRAPHY STUDY
CARLA CONTALDI (A, B), BRADLEY ALLEN (C), LUBNA CHOUDHURY (B), DANIEL
C. LEE (B, C), PIM VAN OOIJ (C), SANDRO BETOCCHI (A), MICHAEL MARKL (C),
ROBERT O. BONOW (B)
(A) DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY
SCHOOL OF MEDICINE OF NAPLES, ITALY; (B) DEPARTMENT OF MEDICINE –
CARDIOLOGY, NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF MEDICINE,
CHICAGO, IL, USA; (C) DEPARTMENT OF RADIOLOGY, NORTHWESTERN UNIVERSITY
FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Background: New MRI techniques (T1-mapping, 4D flow MRI) provide quantitative assessment of
myocardial extracellular volume fraction (ECV) as a measure of fibrosis as well as the in-vivo
assessment of 3-directional blood flow within the entire heart including the atria.
Objectives: To investigate if alterations in left ventricular (LV) diastolic function in hypertrophic
cardiomyopathy (HCM) are associated with increases in LV ECV and alterations in left atrial (LA)
blood flow dynamics.
Methods: 4D flow MRI and T1-mapping MRI were performed in 22 HCM patients (mean 53±14
years) and 15 age matched controls (mean 56±5 years). For all 4D flow data, the LA was 3D
segmented and LA mean blood flow velocity was quantified. T1 values for each slice were acquired
pre and post contrast agent administration, by drawing contours along the endocardial and epicardial
borders and a region of interest in the left ventricular blood pool. ECV was calculated as reported by
Messroghli DR et all and it was averaged over the base, mid and apex to estimate whole heart ECV.
Diastolic function was assessed by echo-Doppler in 16 of the 22 HCM patients prior to MRI.
Results: All HCM patients were in sinus rhythm without history of paroxysmal atrial fibrillation
(AF); 6 patients had left ventricular outflow tract obstruction. LA mean velocities in HCM patients
(0.27±0.07 m/s) were significantly increased compared to controls (0.21±0.03 m/s, p=0.009) and
more heterogeneously distributed (Figure A), but were not significantly different in patients with and
without obstruction and with or without mild mitral regurgitation (MR) and moderate or severe MR.
There were significant correlations between LA velocities and ECV (r=0.48; p=0.02) (Figure B),
ECV and LA volume index (LAVI) (r=0.7; p<0.001), ECV and E/e’(r=0.5; p=0.04), LA velocities
and LAVI (r=0.55; p=0.02) and LA velocities and E/e’(r=0.67; p=0.04).
Conclusion: HCM patients showed a significant difference in 3D LA flow compared to controls. The
increased mean velocity may be an index of increased interstitial tissue and diastolic dysfunction in
these patients. These novel functional measures may be useful in assessing severity of HCM and risk
stratification, particularly the risk of future AF, and warrant further longitudinal investigation.
SIC | Indice Autori
3
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O4
TUTTE LE PROTEINE DEL SURFACTANTE SONO MARCATORI BIOLOGICI DI
DANNO DELLA MEMBRANA ALVEOLO-CAPILLARE NELL’INSUFFICIENZA
CARDIACA CRONICA?
PAOLA GARGIULO (A), CRISTINA BANFI (B), STEFANIA GHILARDI (B),
DAMIANO MAGRI (C), MARTA GIOVANNARDI (B), ELISABETTA SALVIONI (B),
ELISA BATTAIA (B), PASQUALE PERRONE-FILARDI (A), ELENA TREMOLI (E),
PIERGIUSEPPE AGOSTONI (B)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITA´ DEGLI
STUDI DI NAPOLI, FEDERICO II, NAPOLI, ITALIA; (B) CENTRO CARDIOLOGICO
MONZINO, IRCCS, MILANO, ITALIA; (C) DEPARTIMENTO DI MEDICINA CLINICA E
MOLECOLARE, “UNIVERSITA´ LA SAPIENZA“, ROMA, ITALIA; (D) DIPARTIMENTO DI
MEDICINA, UNIVERSITA´ DI VERONA, VERONA, ITALIA; (E) DIPARTIMENTO DI
SCIENZE FARMACOLOGICHE E BIOMOLECOLARI, UNIVERSITA´ DI MILANO,
MILANO, ITALIA; (F) DEPARTIMENTO DI SCIENZE CLINICHE E MEDICINA DI
COMUNITA´, UNIVERSITA´ DI MILANO, MILANO, ITALIA
Razionale: Nei pazienti affetti da insufficienza cardiaca cronica (ICC), la barriera alveolo-capillare
è frequentemente compromessa e la presenza di alterazioni funzionali e strutturali ha un riconosciuto
ruolo prognostico, oltre a rappresentare un interessante target terapeutico. Il recettore per i prodotti
avanzati di glicosilazione (RAGE) e le proteine del surfactante (SP), sebbene siano state proposte
come biomarcatori di danno polmonare, e più specificamente di alterazione della membrana
alveolocapillare, sono state poco studiate nell’ICC.
Obiettivo: Identificare nei pazienti affetti da ICC quale tra le SP e RAGE sia la proteina che meglio
identifichi la presenza di disfunzione della membrana alveolo-capillare, misurata mediante lo studio
della diffusione alveolo-capillare polmonare del monoossido di carbonio (DLCO).
Metodi: Abbiamo arruolato 89 pazienti affetti da ICC in stabile compenso da almeno 3 mesi e 17
controlli sani appaiati per sesso ed età. Tutti i soggetti sono stati sottoposti a ecocardiogramma
transtoracico con misura della frazione di eiezione del ventricolo sinistro (FEVS), a prelievo venoso
per il dosaggio dei comuni parametri biochimici e del peptide natriuretico (BNP), a DLCO e a test da
sforzo cardiopolmonare con misura del consumo di ossigeno al picco (VO2 di picco) e della pendenza
della relazione tra la ventilazione e ila produzione di anidride carbonica (VE/VCO2 spole). Abbiamo
dosato i livelli plasmatici della forma immatura della SP-B, della forma matura dell’SPB, di SP-A, di
SP-D e di RAGE.
Risultati: I livelli plasmatici della forma immatura di SP-B, di SP-A e di SP-D, ma non della forma
matura di SP-B e di RAGE sono risultati significativamente più elevati nei pazienti affetti da ICC
rispetto ai controlli (SP-B immatura: 15.6 AU (25°-75° range interquartile (RI): 10.1-23.3,) vs 11.1
(RI:5.9-12.4) (p = 0.000); SP-A: 29.9 ng/mg (RI: 22.0-42.1) vs 18.3 (RI:15.3-28.8 (p = 0.01); SP-D:
125 ng/mg (RI:85-172) vs 88 (RI:72-125) (p = 0.02); SP-B matura: 190 ng/mg (RI:148-288) vs 244
(RI:160-656) (p = ns); RAGE: 1485 pg/mg (RI:943-2082) vs 1236 (RI:1071-1641) (p = ns). Nei
pazienti affetti da IC, i livelli plasmatici della forma immatura di SPB, di SP-A e SP-D sono risultati
significativamente più alti nei pazienti in III e IV classe NYHA rispetto ai pazienti in I e II classe
NYHA. I livelli plasmatici della forma immatura di SPB, di SP-A, di SP-D e di RAGE sono risultati
significativamente correlati con i valori di DLCO, con i valori di VO2 di picco, con i valori della
VE/VCO2 spole e con i livelli plasmatici di BNP. I livelli plasmatici della forma matura di SP-B non
sono risultati correlati con nessuno di questi parametri. Confrontando i coefficienti di correlazione
tra i suddetti parametri e le singole proteine, la forza della correlazione tra i livelli plasmatici della
forma immatura di SPB e i valori di DLCO è risultata significativamente maggiore rispetto alla forza
delle correlazioni esistenti tra le altre proteine e i valori di DLCO. Questo risultato è stato confermato
all’analisi multivariata che ha dimostrato l’associazione indipendente tra i valori plasmatici della
SIC | Indice Autori
4
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
forma
immatura
di
SP-B
e
i
valori
di
DLCO.
Conclusione: La forma immatura di SP-B è il più affidabile marcatore biologico della funzione della
membrana alveolo-capillare nei pazienti affetti da ICC.
O5
PROGNOSTIC VALUE OF LOW PLASMA ABSOLUTE LYMPHOCYTE COUNT IN
PATIENTS ADMITTED FOR ACUTE HEART FAILURE
VALENTINA CARUBELLI (A), CARLO LOMBARDI (A), ANDREA ZANOLETTI (A),
VALENTINA LAZZARINI (A), FILIPPO QUINZANI (A), FEDERICA ZILIANI (A),
LEVI GUIDO (A), ANDREA VIGNONI (A), SARA PELLIZZARI (A),
ENRICO VIZZARDI (A), MARCO METRA (A)
(A) CATTEDRA DI CARDIOLOGIA UNIVRSITA´ E SPEDALI CIVILI DI BRESCIA
Background: Low relative lymphocyte count is an important prognostic marker in acute heart failure
(AHF), however it could be influenced by other abnormalities in white cells count. Our purpose is to
evaluate if low absolute lymphocyte count (ALC) is an independent predictor of events in patients
with AHF.
Methods: In a retrospective analysis, we included 309 patients with AHF, divided in 2 groups
according to the median value of ALC at admission (1,410 cells/mm3). The primary end point was
all-cause mortality within 1 year.
Results: Patients with low ALC were older and had more comorbidities, namely atrial fibrillation,
chronic kidney disease, chronic obstructive pulmonary disease (COPD) and anemia. Low ALC was
associated with higher all-cause mortality (27.1% vs 17.5%; p=0.020). In a multivariable model, the
independent predictors of mortality at one year were low ALC (HR 1.71; IC 95% [1.04-2.8];
p=0.035), systolic blood pressure at admission (HR 1.17; IC 95% [1.04-1.33]; p=0.009) and
glomerular filtration rate (HR 0.96; IC 95% [0.95-0.98]; p<0.001).
Conclusion: Low ALC in patients with AHF is an independent prognostic marker, underscoring that
the immune system derangement may play an important role in the pathophysiology of this disease.
SIC | Indice Autori
5
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O6
ALEXITHYMIA ON TOTAL ISCHEMIC TIME IN PATIENTS WITH ST-ELEVATION
MYOCARDIAL INFARCTION: A PRELIMINARY STUDY
VALENTINA PIPPIA (a), ROBERTA MONTISCI (a), FEDERICA SANCASSIANI (b),
MICHELA CONGIA (a), ROBERTO FLORIS (a), MANUELA CHERCHI (b), ANGELA
MARIA SANNA (b), MASSIMO RUSCAZIO (a), LUIGI MELONI (a)
(a) CLINICA CARDIOLOGICA, OSPEDALE SAN GIOVANNI DI DIO, UNIVERSITÀ DEGLI
STUDI DI CAGLIARI; (b) CONSULTATION PSYCHIATRY AND PSYCHOSOMATIC UNIT,
CAGLIARI
Purpose. During acute ST-elevation myocardial infarction (STEMI) early myocardial reperfusion is
the target therapy to salvage ischemic myocardium. Integrated STEMI-network reduces in-hospital
delay, but addresses only a part of the overall delay to reperfusion therapy. Thus, educational
campaigns to raise awareness in the presence of suspicious symptoms for STEMI have failed to
reduce the patients delay in decision-making. Alexithymia (AL) is a condition characterized by the
inability to perceive, recognize and describe the emotional states. The aim of our study was to assess
the role of AL on delay in seeking medical care and on total ischemic time (TIT) among STEMI
patients.
Methods. Ninety-five STEMI patients referred by the Emergency Medical Service (EMS) to our
department for primary PCI, mean age 60.8±11.5 yrs form the study population. Socio-demographic
and clinical characteristics, cognitive and emotional factors, AL (Toronto Alexithymia scale-20 item,
TAS-20) were evaluated. Time to presentation (TTP), first medical contact-to-balloon (FMCTB),
door-to-balloon (DTB) and TIT data were also collected.
Results. According to the TAS-20, we identified 27 patients with high AL ( AL group, AG) and 68
patients with low AL score (group no AL, No-AG). The two groups did not differ in age (mean age
64.3±11.9 vs 59.5±11.2,p=0.08), but in the AG mostly were female (37% vs 15%, p = 0.016) and AG
also showed a lower level of education (92.6% vs. 55.2%, p = 0.001). TTP (258.5 min vs 139 min,
p=0.0001) , FMCTB ( 101 min vs 78.5 min ,p=0.03) were significantly longer in AG than No-AG,
but no difference was found in DTB (50 min vs 40 min, p=0.99). Moreover, AG patients showed a
longer TIT than No-AG patients (258.5 min vs 139, p=0.0001). At Multi-variable analysis AL was
the only independent determinant of a TIT>120 min (p=0.037).
Conclusions. Our data showed that AL contributes to the pre-hospital delay to reperfusion in STEMI
patients, especially in women. These preliminary results address the need to act on psychological
factors to improve the patient's perception of symptoms, in order to reduce the TIT in the presence of
an efficient integrated STEMI-network
SIC | Indice Autori
6
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O7
RUOLO PROGNOSTICO DEL TRAP-TEST NELLO STUDIO DELLA REATTIVITA'
PIASTRINICA IN PAZIENTI SOTTOPOSTI AD ANGIOPLASTICA CORONARICA
PERCUTANEA. SOTTOSTUDIO PRODIGY.
SILVIA PUNZETTI (A), RITA PAVASINI (A), SIMONE BISCAGLIA (A),
GIANLUCA CAMPO (A), CLAUDIO CECONI (A)
(A) U.O. CARDIOLOGIA, AZIENDA OSPEDALIERA UNIVERSITARIA DI FERRARA FERRARA
INTRODUZIONE: Una spiccata reattività piastrinica (RP) è correlata ad un rischio aumentato di
eventi ischemici, come già dimostrato in numerosi studi; infatti la RP residua in pazienti in terapia
con clopidogrel è strettamente correlata agli ischemici e complicanze emorragiche in pazienti
trattati con angioplastica coronarica percutanea (PCI). Il
Multiplate Analyzer (Verum Diagnostica, Monaco,
Germania) è uno strumento in grado di saggiare,
attraverso l’uso di diversi agonisti piastrinici, le differenti
vie di attivazione piastrinica. Il suo TRAPtest (thrombin
receptor activating peptide, TRAP), finora scarsamente
utilizzato, riveste un potenziale vantaggio in quanto in
grado di determinare l’intera attività piastrinica, non
essendo vincolato in modo selettivo agli agenti
antipiastrinici (ad esempio acido arachidonico - aspirina o
adenosina difosfato - clopidogrel).
OBIETTIVO: Determinare il ruolo prognostico del TRAPtest in pazienti con cardiopatia
ischemica trattati con PCI.
METODI: Sono stati arruolati, in uno studio monocentrico prospettico, 715 pazienti con cardiopatia
ischemica trattati con PCI. I pazienti arruolati erano randomizzati a ricevere la duplice terapia
antiaggregante (aspirina+clopidogrel) per 6 o 24 mesi. Durante PCI è stata valutata la RP tramite
TRAPtest. I dati clinici, angiografici e di RP sono stati correlati con l’incidenza di eventi avversi
ischemici ed emorragici a 2 anni.
RISULTATI: I valori del TRAPtest non erano distribuiti secondo una curva di normalità (p<0.001),
e risultavano significativamente maggiori nei pazienti con ridotta clearance della creatinina (<60
ml/min) (1231 [1077-1440] vs. 1113 [951-1331], p=0.02, rispettivamente) e nei pazienti con diagnosi
di infarto miocardico con sopraslivellamento del tratto ST (STEMI) (1265 [1089-1491] vs. 1081
[928-1211], p=0.04, rispettivamente). Dall’analisi multivariata è emerso che, la clearance della
creatinina (HR: 0.98, 95%, CI: 0.97-0.99, p=0.03), la frazione di eiezione ventricolare sinistra (HR:
0.97, 95% CI: 0.95-0.98, p=0.04) ed il ricovero per STEMI (HR: 3, 95%, CI: 1.2-7, p=0.04)
rappresentavano fattori predittivi indipendenti di outcome. I valori di TRAPtest, inoltre, non
risultavano correlati con l’incidenza a due anni di morte, infarto miocardico ed eventi
cerebrovascolari (endpoint primario), o con le complicanze emorragiche. Analizzando invece i
pazienti che erano stati trattati con aspirina+clopidogrel per 6 mesi, si osservava che l’occorrenza
dell’endpoint primario era significativamente superiore nei pazienti con TRAPtest sopra la mediana
(18% vs. 10,5%, p = 0.04, rispettivamente per un significativo aumento degli eventi avversi dopo la
sospensione del clopidogrel al 6° mese. (p=0.02) Dall' analisi multivariata è emerso come il TRAPtest
rappresenti un fattore predittivo indipendente di complicanze ischemiche a 2 anni (HR: 1.8, 95%CI:
1.1-3.1, p=0.04). Lo stesso invece non risultava valido per gli eventi emorragici e per i pazienti
randomizzati a 24 mesi di aspirina + clopidogrel.
CONCLUSIONI: I valori di RP non predicono l’occorrenza di eventi avversi ischemici o emorragici,
ma dopo la sospensione del clopidogrel, essi son in grado di stimare un aumento delle complicanze
ischemiche nei pazienti in duplice terapia antiaggregante della durata di 6 mesi.
SIC | Indice Autori
7
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O8
PROGNOSTIC IMPACT OF BNP VARIATIONS IN PATIENTS ADMITTED FOR ACUTE
DECOMPENSATED HEART FAILURE WITH IN-HOSPITAL WORSENING RENAL
FUNCTION.
DAVIDE STOLFO (A), ELISABETTA STENNER (B), MARCO MERLO (A), ANDREA
GIUSEPPE PORTO (A), CRISTINA MORAS (A), GIULIA BARBATI (A),
ANETA ALEKSOVA (A), ALESSANDRA BUIATTI (A), GIANFRANCO SINAGRA (A)
(A) S.C. CARDIOLOGIA AZIENDA OSPEDALIERO-UNIVERSITARIA “OSPEDALI
RIUNITI“ DI TRIESTE; (B) LABORATORY MEDICINE DEPARTMENT, AZIENDA
OSPEDALIERO-UNIVERSITARIA, OSPEDALI RIUNITI DI TRIESTE
Objectives. Worsening renal function (WRF) during hospitalization is frequent in patients admitted
for acute decompensated heart failure (ADHF), but its prognostic impact is still debated. BNP inhospital trends may be helpful in order to estimate the congestive state of patients with ADHF. We
hypothesized that changes in BNP might identify patients with optimal diuretic responsiveness
resulting in transient WRF, not negatively affecting the prognosis.
Methods and Results. 122 patients admitted for ADHF were prospectively included. BNP and eGFR
were evaluated at admission and discharge. A 20% relative decrease in eGFR defined WRF, whereas
a BNP reduction ≥40% was considered significant. WRF occurred in 28 (23%) patients. Higher
variation in urea and hemoconcentration were more likely in these patients. There were no differences
in the primary outcome between patients with and without WRF (43 vs. 45%, p=0.597). A significant
reduction in BNP over the hospitalization occurred in 59% of the overall population and 71% of
patients with WRF. At a median follow-up of 13.0 (IQR 6–36) months, WRF patients with significant
BNP reduction had a lower rate of death/urgent heart transplantation/re-hospitalization if compared
with WRF patients without BNP reduction (30 and 75%, respectively; p=0.007). Favourable BNP
trends independently predicted the outcome both in the overall population (HR 0.301, 95% CI 0.1590.573, p<0.001), and WRF patients (HR 0.222, 95% CI 0.066-0.753, p=0.016).
Conclusions. WRF is not associated with a worst prognosis in ADHF. When associated with a
significant BNP in-hospital reduction, WRF identifies patients with adequate decongestion at
discharge and favourable outcome.
SIC | Indice Autori
8
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O9
MYOCARDIAL VENTRICULAR ADAPTATION TO PULMONARY HYPERTENSION IN
NON-ISCHEMIC DILATED CARDIOMYOPATHY: A STUDY PERFORMED BY
CARDIAC MAGNETIC RESONANCE
Roberta Ancona (a), Salvatore Comenale Pinto (a), Pio Caso (a), Fortunato Arenga (a), Maria
Gabriella Coppola (a), Raffaele Calabrò (a)
(a) Non invasive Cardiology, Chair of Cardiology, Department of Cardiology, Second University of
Naples
MANUEL DE LAZZARI (a), MARTINA PERAZZOLO MARRA (a), ALBERTO CIPRIANI (a),
FILIPPO ZILIO (a), ANGELA SUSANA (a), VERONICA SPADOTTO (a),
ANNACHIARA FRIGO (a), BENEDETTA GIORGI (b), GIUSEPPE TARANTINI (a),
FRANCESCO TONA (a), CRISTINA BASSO (a), RENATO RAZZOLINI (a),
SABINO ILICETO (a)
(a) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (b) INSTITUTE OF RADIOLOGY, UNIVERSITY OF PADUA
Background: The presence of pulmonary hypertension (PH) is a well-established prognostic factor
in heart failure (HF) in terms of increased mortality and hospitalization rates. The potent prognostic
impact of PH in HF suggests an important role for pre-clinical detection of signs indicating an ongoing
RV dysfunction due to its remodeling. Recently, several studies have highlighted the potential utility
of cardiac magnetic resonance (CMR) in patients with arterial pulmonary hypertension (PAH) after
discovering the presence of late gadolinium enhancement (LGE) in the RV junctional insertion point
of the interventricular septum in the majority of these patients.
Purposes: the aims of our study were: 1) to evaluate the presence and the prevalence of RV-LV
junctional LGE in patient with NIDC, 2) to evaluate the possible relationship between LGE and
hemodynamics obtained by a simultaneously right side catheterization, and 3) to evaluate the
prognostic significance of this pattern in terms of major events and specific heart failure outcome.
Methods: The study population included a consecutive series of patients with diagnosis of NIDC. To
be enrolled, patients had to have a depressed LV systolic function (LV EF <50%), absence of flowlimiting coronary artery disease. Exclusion criteria were: recent onset of heart failure (<1 month) and
contraindication to CMR. Diagnostic right heart catherization was performed in all patients. During
follow up the events collected were: hospitalization for decompensated heart failure, cardiac death or
heart transplantation and ventricular arrhythmias.
Results: 118 patients fulfilling the enrollment criteria. On post-contrast sequences, 38 (32%) showed
junctional LGE: in 29/38 patients, junctional LGE was associated with mid-wall interventricular
septal stria, in 8/38 patients LGE was confined only to the junctions points, and one patient had
junctional LGE associated with mid-wall stria on lateral free LV wall. In the junctional LGE group,
the patients had increased RV EDV (97 vs 90 ml/m2, p=0.03) and reduced RV EF (52 vs 57%;
p<0.01). Patients with junctional LGE showed a worse hemodynamic profile in terms of pulmonary
hypertension (61 vs 39%; p=0.027) and LVEDP (74 vs 55%; p=0.019); moreover, this group showed
an increased value of PCWP (55 vs 33%; p=0.018) with a mean value of 20 mmHg indicating a postcapillary pulmonary hypertension. During a median follow-up of 37 months Kaplan-Meier analysis
revealed a significant correlation between the junctional LGE presence and occurrence of episodes
of HF (p=0.03). On univariate Cox regression analysis, all right catheterization parameters indicating
a worse hemodynamics, including RV dysfunction/ dilation were associated with junctional LGE. On
multivariable analysis, only the increased LVEDP showed a trend for prediction of heart failure (HR
2.8; 95% CI 0.886-9.453, P= 0.079).
Conclusions: in this study we demonstrated that the presence of “junctional LGE” in the RV insertion
points is a frequent CMR finding in NIDC, up to 32% in our population. The strictly relationship with
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all hemodynamic parameters indicating the presence of PH complicating the NIDC with junctional
LGE makes this peculiar CMR pattern not specific for pre-capillary PH as herein demonstrated.
Finally, the junctional LGE pattern on follow-up was able in our study to identify the patients at risk
for developing HF, so assuming the role of an imaging marker of ventricular remodeling in patients
with NIDC complicated by PH.
O10
DOXORUBICIN IMPAIRS THE INSULIN-LIKE GROWTH FACTOR-1 AXIS IN H9C2
CELLS
PIETRO AMERI (A), PATRIZIA FABBI (A), PAOLO SPALLAROSSA (A),
CHIARA BARISIONE (A), SILVANO GARIBALDI (A), PAOLA ALTIERI (A),
BARBARA REBESCO (B), MARCO CANEPA (A), GIORGIO GHIGLIOTTI (A),
CLAUDIO BRUNELLI (A)
(A) CARDIOLOGY UNIT, DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF
GENOVA; (B) ANTIBLASTIC DRUG UNIT, AOU-IRCCS SAN MARTINO IST
Background and aims: Depletion of cardiac progenitor cells (CPCs) is central of to the pathogenesis
of chronic anthracycline cardiotoxicity. Insulin-like growth factor-1 (IGF-1) promotes the survival of
CPCs by activating type 1 IGF receptor (IGF-1R). Within the myocardium, IGF-1 action is modulated
by IGF binding protein-3 (IGFBP-3), which sequesters IGF-1 away from IGF-1R. Here, we
investigated the effect of doxorubicin on the IGF-1 system in the H9c2 cell model of cardiomyocytes
with proliferative and differentiative potential.
Results: At concentrations comparable to those observed in patients after bolus infusion (0.1-1 µM),
doxorubicin dose-dependently caused apoptosis of H9c2 cells. Exposure to the drug also resulted in
a dose-dependent decrease in IGF-1R levels (Figure, panels A and B). By contrast, IGFBP-3
expression increased (panels A and C). While IGF-1 was still capable to rescue H9c2 cardiomyocytes
from apoptosis triggered by 0.1 µM doxorubicin (panel D), it was no longer effective in the presence
of 1 µM doxorubicin (panel E). Consistent with previous reports, doxorubicin also dose-dependently
induced p53, which represses the transcription of IGF1R and induces the one of IGFBP3. Pretreatment with the p53 inhibitor, pifithrin-alpha (PFT-α), prevented the changes in IGF-1R and
IGFBP-3 in response to doxorubicin, suggesting that they were mediated by p53. Moreover, PFT-α
counteracted apoptosis initiated by doxorubicin. Of note, the decrease in IGF-1R and the increase in
IGFBP-3, as well as apoptosis, were also antagonized by pre-treatment with the antioxidant agents,
N-acetylcysteine, dexrazoxane, and carvedilol.
Conclusions: Doxorubicin down-regulates IGF-1R and up-regulates IGFBP-3 via p53 in H9c2 cells.
This translates into a relative resistance to IGF-1 pro-survival activity that may contribute to
apoptosis. Further studies are needed to confirm our findings in human CPCs and explore the
possibility of manipulating the IGF-1 axis to protect against anthracycline cardiotoxicity.
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Roma, 13 – 15 dicembre 2014
CARDIOLOGIA INTERVENTISTICA - TAVI
O11
ADDITIONAL TOOL TO ASSESS HEMODYNAMIC IMPROVEMENT AFTER
TRANSCATHETER AORTIC VALVE IMPLANTATION: ECHO-DOPPLER STUDY OF
THE CEREBRAL BLOOD FLOW
ANDREA ANCESCHI (A), SAVERIO MUSCOLI (A), VALERIA CAMMALLERI (A),
DOROTEA RUBINO (A), FRANCESCA DE PERSIS (A), MASSIMILIANO MACRINI (A),
MASSIMO MARCHEI (A), ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A),
EUGENIA MAIO (A), GIAN PAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Purpose: Aim of our study was to evaluate the arterial cerebral blood flow variation after
transcatheter aortic valve implantation (TAVI).
Methods: The study includes 56 patients who underwent TAVI for severe aortic stenosis (93%), pure
aortic insufficiency (2%) and surgical bioprosthesis degeneration (5%) from June 2013 to June 2014:
mean age 83.73±0.63year-old; trans-aortic velocity max 4.28±0.16 m/sec; mean gradient 49.59±2.75
mmHg; left ventricular ejection fraction 49.58±1.61%. Patients with significant stenosis of the left
common and internal carotid arteries (LICA) and previous endoarterectomy were excluded. Internal
diameter of the LICA was measured at baseline (0.73±0.08 cm); blood flow (BF), systolic peak
velocity (sPV) and mean acceleration time (mAT) were recorded as parameters of cerebral blood
flow. Diastolic and systolic systemic pressure and heart rate were monitored during the procedure.
All parameters were recorded at baseline, after balloon aortic valvuloplasty (BAV), and within 10
minutes after the device release.
Results: All procedures were performed in standard fashion using the transfemoral approach in 54
patients and left distal transaxillary route in 3 patient. The device success was 98%, 3 patients needed
acute valve-in-valve therapy for prosthesis malposition. The mean procedural and revalving time
were 55.69±2.68 and 5.54±1.07minutes, respectively. No intraprocedural death or major adverse
events occurred. Collected echo-Doppler data showed a significant improvement of the cerebral blood
flow after BAV and, subsequentially, after final release of the valve when compared to baseline. No
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statistically significant differences of systolic and diastolic pressure, and heart rate, were observed
after the procedure (Table 1).
Conclusions: Non invasive monitoring of echo-Doppler measurements (namely BF, sPV and mAT),
may be an useful additional tool to assess the hemodynamic improvement after TAVI, specifically
for the cerebral arterial district.
O12
COMPARISON BETWEEN 957 SELF-EXPANDABLE AND 947 BALLOONEXPANDABLE VALVES FOR PATIENTS UNDERGOING TRANSCATHETER AORTIC
VALVE IMPLANTATION: A META-ANALYSIS OF RANDOMIZED CONTROLLED
TRIALS AND ADJUSTED OBSERVATIONAL RESULTS
FRANCESCA GIORDANA (A), FABRIZIO D´ASCENZO (A), CLAUDIO MORETTI (A),
FEDERICO CONROTTO (C), MAURIZIO D´AMICO (C), STEFANO SALIZZONI (B),
MICHELE LA TORRE (B), MAURO RINALDI (B), SEBASTIANO MARRA (C),
FIORENZO GAITA (A)
(A) DIVISION OF CARDIOLOGY, CITTÀ DELLA SALUTE E DELLA SCIENZA,
UNIVERSITY OF TURIN, TURIN, ITALY; (B) DIVISION OF CARDIO-SURGERY, CITTÀ
DELLA SALUTE E DELLA SCIENZA, UNIVERSITY OF TURIN, TURIN, ITALY; (C)
DIVISION OF CARDIOLOGY, CITTÀ DELLA SALUTE E DELLA SCIENZA, TURIN, ITALY
Introduction. Two different devices, self- and balloon- expandable, have been developed for patients
undergoing transcatheter aortic valve implantation (TAVI), although contrasting data are reported
about their efficacy and safety.
Methods. Pubmed, Medline and Google Scholar were systematically searched for studies comparing
balloon expandable and self-expandable TAVI devices, with data derived from randomized
controlled trial or multivariate analysis. All cause death at 30-days and at follow up were the primary
end points, while post procedural moderate or severe aortic regurgitation, stroke, major vascular
complications, bleeding and pacemaker implantation the secondary ones.
Results. Six studies with 957 self-expandable and 947 balloon-expandable valves were included, one
randomized controlled trial and five observational study. Median age was 82 (81-83) years, with a
logistic EuroSCORE of 22% (21-22%); 50% (44-51%) of them were implanted with a 26 mm
prosthesis. At 30-days, the rate of death (OR 1.02 [0.94, 1.11]) and stroke (OR 1.23 [0.89, 1.69]) did
not significantly differ between the two valves. The self-expandable prosthesis has a lower rate of
major or life threatening bleeding (OR 0.86 [0.81, 0.91]) and major vascular complications (OR 0.88
[0.82, 0.94]), while the rate of PM implantation (OR 1.74 [1.45, 2.09]) and of moderate or severe
aortic regurgitation (OR 1.35 [1.18, 1.55]) was higher. After a follow up of 360 days (300-390), the
rate of all cause death did not significantly differ between the two groups (OR 1.00 [0.93, 1.08]). At
the meta-regression analysis, the benefit of balloon expandable valves has increased with annulus
diameter (beta 0.15, p<0.001).
Conclusions. The risk of moderate or severe aortic regurgitation and pace maker implantation was
lower in the balloon expandable devices, although with a more frequent rates of vascular and bleeding
complications. The between groups all cause of death at 30 and 360 days did not significantly differ.
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O13
EXPANDABLE SHEATH FOR TRANSFEMORAL TRANSCATHETER AORTIC VALVE
REPLACEMENT: PROCEDURAL OUTCOMES AND COMPLICATIONS
PAOLA ANGELA MARIA PURITA (A), ELISA COVOLO (A), MICHELA FACCHIN (A),
MARTA MARTIN (A), ERMELA YZERAJ (A), ROSARIA TENAGLIA (A),
FILIPPO ZILIO (A), AHMED AL MAMARY (A), MARCO MOJOLI (A),
GIANPIERO D´AMICO (A), ALBERTO BARIOLI (A), GILBERTO DARIOL (A),
BLERI CELMETA (A), VALERIA GASPARETTO (A), CHIARA FRACCARO (A),
DEMETRIO PITTARELLO (B), GIAMBATTISTA ISABELLA (A),
GIUSEPPE TARANTINI (A), MASSIMO NAPODANO (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) ANESTHESIOLOGY DEPARTMENT, UNIVERSITY OF PADUA
Aims: Among transfemoral Edwards transcatheter aortic valve implantation (TF TAVI), the
expandable sheath (e-sheath) has been described to present a lower rate of access complications,
compared to the fixed size sheath (f-sheath). Our aim was to compare the incidence of periprocedural
complications when using f-sheath vs. e-sheath during TAVI.
Methods: From September 2009 to May 2014, we included 141patients undergoing TF TAVI in our
center with the Edwards SAPIEN(™) /SAPIEN XT/ SAPIEN 3 balloon-expandable prosthesis
(Edwards Lifesciences Irvine, CA) utilizing the Novaflex , Novaflex+ and Commander delivery
systems; access closure was obtained with the Prostar system in all cases. E-sheath (18/19/16/14 F)
was used in 91 patients (64,5%), whereas f-sheath (18/19 F) was utilized in 50 patients. The crossover
technique was performed in 108 patients (79,4%). All complications were defined according to
Valvular Academic Research Consortium 2 (VARC-2) consensus.
Results: Out of 305 patients who underwent TAVI, 76 (54,7%) was female, mean age was 80.5 ± 6.5
years and logistic EuroSCORE was 20.7% ± 12.2. Mean minimal femoral artery diameter was 6.9 ±
1.4 in e-sheath group and 7.4± 0.8 mm f-sheath group, p 0.06. Mean outer diameter was 6.9 ± 0.4 in
e-sheath and 7.4 ± 0.1 in f-sheath group, p<0.001. Outer sheath diameter/artery ratio was 1.054 ±
0.275 in e-sheath group and 1.10 ± 0.104 in f-sheath group, p 0.4. VARC major vascular
complications rate were similar in the 2 groups: e- sheath 14 (15.6%) vs. f-sheath 6 (12.2%), p 0.62,
as well as minor vascular complications: 28 (31.5%) vs. 14 (29.2%), p 0.84. Similarly, bleeding
complications were comparable between e-sheath and f-sheath groups: life-threatening bleeding 2
(4.2%) vs. 2 (2.2%), major bleeding 19 (21.3%) vs. 13 (27.9%), and minor bleeding 29 (32.3%) vs.
9 (18.8%), p 0.35. By logistic regression analysis, no association was found between vascular
complication and sheath type, outer, minimal lumen diameter, or ratio of out of diameter to minimal
lumen ratio.
Conclusions: The use of expandable sheath did not reduce vascular and bleeding complications in
TF-TAVI. However the introduction of this approach allowed transfemoral TAVI in patients with
smaller femoral arteries (figure) probably limiting its potential benefits.
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O14
LONG TERM FOLLOW-UP OF PATIENTS UNDERGOING VALVULOPLASTY IN TAVI
ERA: A MULTICENTRIC RETROSPECTIVE STUDY
CLAUDIO MORETTI (A), LUDOVICA MARANGONI (A), ILARIA MEYNET (A),
SARA RETTEGNO (A), FABRIZIO D´ASCENZO (A), MAURIZIO D´AMICO (A),
STEFANO SALIZZONI (A), SEBASTIANO MARRA (A), FIORENZO GAITA (A)
(A) DIPARTIMENTO DI CARDIOLOGIA. A.O.U. CITTA´ DELLA SALUTE E DELLA
SCIENZA TORINO
Aims: The introduction of transcatheter aortic valve implantation (TAVI) has generated a renewed
interest in the treatment of high risk patients with severe aortic stenosis and serious contraindication
for aortic valve replacement. This study describes the indications and long-term outcomes of ballon
aortic valvuloplasty (BAV) in recent years.
Methods: All patients undergoing BAV in our centres from 2005 to 2013 were enrolled.
All cause death at follow-up were the primary end-point, while need of re-intervention,
myocardical infarction and stroke the secondary ones, along with BAV periprocedural complications
according to VARC criteria (death, bleeding, vascular complications, acute kidney injury)
Results: Among 586 consecutive patients, BAV as bridge to TAVI was performed in 277, (47,3%),
as bridge to surgical aortic valve replacement (SAVR) in 71 (12,1%) and as destination therapy in
238 (40,6%).Median age was of 82,1± 7,4,54,1% of them being female, with a median ejection
fraction of48,3%±15,8. In hospital mortality was 8,5%,5,2% after excluding patients presenting with
cardiogenic shock, being acute kidney injury (10,7%) the most frequent complication. cardiogenic
shock and a renal clearance below 60ml/min/m2 were independent predictors of all cause death in a
multivariate analysis. After a median follow-up of 240 days, 31,4% of patients, died, 5,6% were
rehospitalized for heart failure and 33,8% performed a new intervention (10,1% BAV, 71,2%TAVI ,
18,7% SAVR)
Echocardiography showed that the medium and peak transaortic gradients decreased after
valvuloplasty from 46mmHg(IC 44,3-48,2) to 39mmHg (IC 37,8-44), and from 78mmHg(IC 74,881,5) to 59mmHg (53-64) respectively. After 6 months medium gradient was 36mmHg (IC 28,738,1)and peak gradient 54mmHg (IC 46,4-62,9), showing durability of the valvuloplasty. Aortic valve
area (AVA) increased after valvuloplasty from 0,67cm2 (IC 0,64-0,69) to 1,50 cm2 (IC 1-1,9) and
0.95 cm2 (IC0.8-1) after 6 months
Conclusion: BAV is nowadays safe and effective, with a durable effect in the reduction of transaortic
valve gradient. Clinically, after 10 months follow up, no reintervention is needed in most of the
patients
O15
CLINICAL OUTCOME OF PATIENTS WITH AORTIC STENOSIS AND CORONARY
ARTERY DISEASE UNDERGOING INCOMPLETE TREATMENT STRATEGIES
GIUSEPPE DI GIOIA (A, B), MARIANO PELLICANO (A), ANGELA FERRARA (A),
GABOR TOTH (A), JULIEN ADJEDJ (A), WILLIAM WIJNS (A), IVAN DEGRIECK (A),
FILIP CASSELMAN (A), BERNARD DE BRUYNE (A), BRUNO TRIMARCO (B),
EMANUELE BARBATO (A, B)
(A) CARDIOVASCULAR CENTER AALST, OLV HOSPITAL, AALST (BELGIUM); (B)
UNIVERSITÀ DEGLI STUDI DI NAPOLI FEDERICO II. DIPARTIMENTO DI SCIENZE
BIOMEDICHE AVANZATE
Purpose: Current guidelines recommend aortic valve replacement (AVR) with coronary artery
bypass graft (CABG) in patients with moderate-to-severe aortic stenosis and significant coronary
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artery lesions. In real world, this is not always feasible due to advanced age and comorbidities. We
sought to evaluate the clinical outcome of patients treated not according to recommendations.
Methods: From 2002 to 2010, we retrospectively included 650 patients with moderate to severe aortic
stenosis and at least one significant coronary lesion (diameter stenosis>50%): 149 (23%) were treated
with medical therapy only (Gr 1), 107 (17%) with percutaneous coronary intervention (PCI) (Gr 2),
74 (11%) with AVR (Gr 3), and 320 (49%) with combined CABG and AVR (Gr 4). Primary endpoint
of the study was overall death up to 5 years.
Results: Patients’ characteristics like logistic euroSCORE (Gr 1: 18±13 vs. Gr 2: 15±15 vs. Gr 3:
16±14 vs. Gr 4: 11±10, p <0.01) and rate of severe aortic stenosis (Gr 1, 115 [77%] vs. Gr. 2, 57
[53%] vs. Gr 3, 72 [97%] vs. Gr 4, 292 [91%], p <0.01) were significantly different among the 4
groups. At a median follow-up of 59 months, overall death significantly decreased along the groups
(Gr 1, 101 [68%] vs. Gr 2, 47 [44%] vs. Gr 3, 25 [34%] vs. Gr 4, 74 [23%], p <0.01) (see figure).
Compared to Gr 1, Cox-regression analysis adjusted for potential confounders showed a significant
decrease in the risk of death of Gr 2 (HR: 0.61 [0.43-0.87], p <0.01), Gr 3 (HR: 0,59 [0.47-0.75], p
<0.01) and Gr 4 (HR: 0.63 [0.56-0.70], p <0.01).
Conclusions: In patients with aortic stenosis and at least one significant coronary lesion, we confirm
that medical therapy only is associated with the worst clinical outcome. Our data suggest that when
combined CABG/AVR is not feasible, PCI or AVR alone significantly improve long-term survival.
O16
PROTECTIVE IMPACT OF PRE-EXISTENT AORTIC REGURGITATION IN TAVI
PATIENTS DEVELOPING POST PROCEDURAL PARAVALVULAR LEAK
MICHELA FACCHIN (A), AUGUSTO D´ONOFRIO (A), ANDREA COLLI (A),
ELISA COVOLO (A), PAOLA ANGELA MARIA PURITA (A), MARTA MARTIN (A),
ERMELA YZEIRAY (A), MARCO MOJOLI (A), BLERI CELMETA (A),
ALBERTO BARIOLI (A), GIANPIERO D´AMICO (A), FILIPPO ZILIO (A),
GILBERTO DARIOL (A), AHMED AL-MAMARY (A), VALERIA GASPARETTO (A),
CHIARA FRACCARO (A), DEMETRIO PITTARELLO (A), MASSIMO NAPODANO (A),
GIAMBATTISTA ISABELLA (A), SABINO ILICETO (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA
Background: Even if trans-catheter aortic valve implantation (TAVI) is a safe and effective
technique in high-risk symptomatic severe aortic stenosis (SSAS) patients, the evidence of post
procedural paravalvular leak is common and it is associated with worse outcome.
Aim: we investigated the impact of pre-existent aortic regurgitation (AR) on cardiovascular mortality
in SSAS patients treated with TAVI, based on the degree of post-procedural paravalvular leak.
Methods: we prospectively evaluated the cardiovascular mortality in patients affected by SSAS
undergoing TAVI in our department between March 2009 to May 2014 with balloon-expandable
aortic valve (Edwars Sapien, Edwards Sapien XT and Edwards Sapien 3, Edwards Lifesciences
Irvine, CA). The presence and the degree of pre-procedural AR and PVL were assessed by Dopplermeasurements and stratified as absent (0/3), mild (1/3), and moderate/relevant (≥2/3).
Results: our study population included 243 consecutive patients with a mean age 80±6.7 years, 53%
were female, Euroscore logistic/II were 20±12/9±7, basal end diastolic volume of left ventricular
(LV) was 63 ml/mq and LV ejection fraction was 60%±12. The access was trans-femoral in 56.7%,
trans-apical in 40.8%, trans-subclavian in 0.4% and trans-aortic in 2% of patients. Seventy patients
(28.8%) had not baseline AR, 113 (46.5%) had a mild AR and 60 (24,7%) moderate/relevant AR.
After aortic valve implantation 139 patients (58.6%) did not show PVL, 84 (35.5%) had a mild PVL
and 14 (5.9%) had a moderate PVL. The Kaplan Meier analysis showed the presence of any grade of
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PVL was associated with an increase of cardiovascular mortality only in the patient without a preexisting AR (p=0.05) (see figure).
Conclusions: our findings seem to suggest a protective value on cardiovascular mortality of any grade
of the pre-existing AR in patients that developed a post-procedural moderate or relevant PVL.
IPERTENSIONE POLMONARE - 1
O17
EFFECTS OF MEDICAL TREATMENT FOR OPERABLE AND INOPERABILE
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION PATIENTS
ANDREA RINALDI (A), CRISTINA BACHETTI (A), FABIO DARDI (A), ENRICO GOTTI (A),
GAIA MAZZANTI (A), ALESSANDRA ALBINI (A), ENRICO MONTI (A),
CLAUDIA BERNABÉ (A), ELISA ZUFFA (A), CAROLINA BARBERI (A),
RACHELE BIONDI (A), MARGHERITA TIEZZI (A), MASSIMILIANO PALAZZINI (A),
ALESSANDRA MANES (A), NAZZARENO GALIÉ (A)
(A) DEPARTMENT OF SPECIALIZED, DIAGNOSTIC AND EXPERIMENTAL MEDICINE –
UNIVERSITY OF BOLOGNA - ITALY
Background: Pulmonary endoarterectomy (PEA) is the treatment of choice for chronic
thromboembolic pulmonary hypertension (CTEPH); specific PAH drugs therapy may improve
hemodynamics and exercise capacity in operable and inoperable patients. Purpose: to assess effects
of targeted PAH drugs in CTEPH patients.
Methods: between July 2003 and October 2013, 123 patients (mean age 65±16 years) with inoperable
CTEPH and 69 patients (mean age 57±16 years) with operable CTEPH received PAH specific drugs.
Six-minute walk test (6MWT) and right-heart catheterization data were collected at baseline and after
3-4 months of therapy in inoperable patients and at baseline, immediately before PEA and 6 months
after PEA in operated patients.
Results: In inoperable group 61 patients received phosphodiesterase type-5 inhibitors (PDE5-I), 36
endothelin receptor antagonists (ERA), 5 prostanoids and 21 combination therapy (CT); in operable
group 38 patients received PDE5-I, 21 ERA and 10 CT. In inoperable group targeted PAH drugs
reduced mean pulmonary arterial pressure (mPAP) from 48±11 to 44±11 (p<0.0001), pulmonary
vascular resistance (PVR) from 9.9±4.9 to 7.4±3.3 WU (p<0.001) and increased cardiac index (CI)
from 2.4±0.7 to 2.8±0.8 l/min/m² (p<0.001) and 6MWT from 360±137 to 419±129 m (p<0.001). In
operable group targeted PAH drugs reduced mPAP from 50±10 to 45±9 (p<0.001), PVR from 9.8±3.8
to 7.6±3.0 WU (p<0.001) and increased CI from 2.5±0.6 to 2.8±0.7 l/min/m² (p<0.0002) and 6MWT
from 394±135 to 442±127 m (p<0.001). After PEA mPAP decreased from 45±9 to 27±9 mmHg
(p<0.001), PVR decreased from 7.6±3.0 to 3.7±1.9 WU (p<0.001), CI increased from 2.8±0.7 to
3.0±0.5 l/min/m² (p=0.07) and 6MWT increased from 442±127 to 484±114 m (p<0.001).
Conclusions: PAH-approved drugs improve exercise capacity and hemodynamics in patients with
operable and inoperable CTEPH. Improvement of hemodynamics before PEA may favorably
influence surgical results in operable subjects.
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O18
DETERMINANTS AND PROGNOSTIC SIGNIFICANCE OF RIGHT VENTRICULAR
REVERSE REMODELING IN IDIOPATHIC PULMONARY ARTERIAL HYPERTENSION
RECEIVING SPECIFIC MEDICAL TREATMENT
ROBERTO BADAGLIACCA (A), MARIO MEZZAPESA (A), MARTINA NOCIONI (A),
BEATRICE PEZZUTO (A), ROBERTO POSCIA (A), FRANCESCA PESCE (A),
SILVIA PAPA (A), CRISTINA GAMBARDELLA (A), FRANCESCO FEDELE (A), CARMINE
DARIO VIZZA (A)
(A) DIP. SCIENZE CARDIOVASCOLARI E RESPIRATORIE - SAPIENZA UNIVERSITA´ DI
ROMA
Background. Survival in idiopathic pulmonary arterial hypertension (IPAH) is strongly associated
to the ability of the right ventricle (RV) to maintain its function in face of increased afterload. Cardiac
remodeling characterizes the natural history of the disease, and it has been suggested that some IPAH
patients receiving goal-oriented treatment could show a RV reverse remodeling (RVRR).
Objectives. To determine the predictors of RVRR in IPAH patients receiving specific therapy and its
impact on long-term prognosis.
Methods. In 102 consecutive IPAH patients RVRR was evaluated considering the main
echocardiographic parameters previously demonstrated to be prognostically relevant for risk
stratification: right atrium (RA) area, left ventricular systolic eccentricity index (LV-EIs) and RV end
diastolic area (RVEDA). All patients were re-evaluated after 12 months of treatment (mid-term
evaluation); survivors were followed for a mean of 358 ± 236 days. The first episode of clinical
worsening (CW) was taken into consideration for the analysis.
Results. Twenty one patients (20%) presented CW after mid-term evaluation, and other 30 patients
subsequently. In a univariate analysis, changes in RVEDA (HR 1.36, p=0.001), RA area (HR 1.5,
p=0.0001) and LV-EIs (HR 2.9, p=0.0001), resulted predictors of CW. Seventeen patients (17%)
showed significant changes in all 3 parameters: this was indicated as complete RVRR. At logistic
regression analysis, PVR reduction at mid-term follow-up resulted as independent predictor of
RVRR. Baseline cardiac index (HR 0.25, 95% CI: 0.12 to 0.51; p=0.0001), RVRR (HR 0.096, 95%
CI: 0.12 to 0.76; p=0.02) and changes in WHO functional class (HR 4.79, 95% CI: 2.1 to 10.6;
p=0.0001) resulted significantly predictive for CW (Chi2 39.11; p<0.0001). Patients with RVRR had
a significantly better long-term prognosis (p= 0.004). The event-free survival rates were, respectively,
94% and 94% versus 65% and 43% after 1 and 2 years of follow-up from mid-term re-evaluation, in
patients with and without RVRR.
Conclusions. RVRR significantly influences the prognosis of IPAH patients and changes in PVR
during follow-up resulted as independent predictors of RVRR.
O19
PREVALENCE OF THROMBOPHILIC MUTATION IN PATIENTS WITH ACUTE
PULMONARY EMBOLISM
MARCO ZUIN (A), CLAUDIO PICARIELLO (A), LUCA CONTE (A), DANIELA LANZA (A),
MASSIMO RINUNCINI (A), SILVIO AGGIO (A), KATIA D´ELIA (A), LORIS RONCON (A)
(A) SOC CARDIOLOGIA OSPEDALE DI ROVIGO
Purpose: Patients with pulmonary embolism (PE) have an increased frequency of thrombophilic
mutations (TMs) such as factor V Leiden G1691A (FVL), prothrombin G20210A (PT), or
methylenetetrahydrofolate reductase (MTHFR). We aimed to determine the prevalences of important
genetic causes of thromboembolism in a Veneto cohort.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Methods: We included 68 consecutive patients (29 male, 39 female, mean age 67.1914.90 years),
diagnosed with PE in Rovigo General Hospital, Department of Cardiology, between 2006 and 2010.
PE was objectively confirmed with computed tomography angiography (CTA) in all subjects.
Homocysteine concentration was determined using an enzymatic assay on the Hitachi 917 analyzer
(Roche Diagnostics) using reagents and calibrators from Catch, Inc. were considered subjects with
Hyper-homocysteinemia (H-Hcys) those having an homocysteinemia >14 g/dL. The sample were
genotyped using a multiplex Polymerase Chain Reaction with reverse line blot (mPCR/RLB)
hybridization assay .Collection of blood samples were performed at admission and before starting
treatment.
Results: Of the 68 patients, 11 (16.2%) had one or more mutations. H-Hcys was present in both
patients with thrombophilic mutation (TMs) and in patients without mutation (27.2% vs 15.3%,
p=ns). The frequencies, among TMs, of Factor V (FV) Leiden (FVL, G1691A), Factor II (FII
G20210A), methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C were 27.2%, 9%,
81.8%, and 18.1%, respectively. All patients with FVL and FII mutations were heterozygous. For
C677T, 8 patients were heterozygous and 1 homozygous, while all subjects with A1298C mutation
were heterozygous.
In the prevalence of the two MTHFR mutations examined there was a statistical significance (as
shown in Figure 1) Only in two cases were recorded two mutations simultaneously: the first between
FII and FV, while the second between MHTFR C677T and FV; in both cases were all heterozygous
genotype. There was no significant correlation between family history of thrombosis and presence of
a TMs.
Conclusions: MTHFR C677T and A1298C mutations in PE may be an important predisposing
factor in general population that needs to be tested routinely. Further studies related to cardiovascular
genetics in the Italian population are needed to confirm the genetic impact on PE.
Figure1. Prevalence of MHTFR mutations in the cohort.
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Roma, 13 – 15 dicembre 2014
O20
RV REMODELING PATTERN PREDICTS CLINICAL WORSENING IN IDIOPATHIC
PULMONARY ARTERIAL HYPERTENSION
ROBERTO BADAGLIACCA (A), MARTINA NOCIONI (A), MARIO MEZZAPESA (A),
SILVIA PAPA (A), BEATRICE PEZZUTO (A), ROBERTO POSCIA (A),
FRANCESCA PESCE (A), CRISTINA GAMBARDELLA (A), FRANCESCO FEDELE (A),
CARMINE DARIO VIZZA (A)
(A) DIP. SCIENZE CARDIOVASCOLARI E RESPIRATORIE - SAPIENZA UNIVERSITA´ DI
ROMA
Background. Prognosis in idiopathic pulmonary arterial hypertension (IPAH) is strongly associated
to right ventricular (RV) function.
Objectives. The aim of this study was to investigate whether RV concentric hypertrophy might be a
more favorable morphological pattern compared to eccentric hypertrophy.
Methods. In 75 consecutive IPAH patients RV morphological and functional features were evaluated
by echocardiography and magnetic resonance. The study population was divided into two groups by
the median value of RV mass/volume (M/V) ratio (0.47), allowing the distinction between RV
eccentric (≤0.47) and concentric hypertrophy (>0.47). The two groups were compared for RV
remodeling and systolic function parameters, WHO class, pulmonary hemodynamics and 6-minute
walk test (6MWT). Patients were followed for clinical worsening (CW).
Results. Despite similar afterload, patients with eccentric hypertrophy had advanced WHO class
(2.7±0.6 vs 2.4±0.5; p 0.007), worse 6MWT (394±110m vs 468±88m; p 0.002), worse remodeling
and systolic function parameters [RV fractional area change (34.2±9% vs 40.1±9%; p 0.01), RVESV
(107.1±48ml vs 85.5±34ml; p 0.032), RVEF (32.6±11% vs 38.3±10%, p 0.029), RV MASS
(70.8±26g vs 92.7±25g; p 0.0001)] compared to patients with concentric hypertrophy.
By Cox regression analysis, cardiac index (B -1.933; HR 0.145; CI 95% 0.056-0.375; p 0.0001),
pericardial effusion (B 0,957; HR 2,605; CI 95% 1,128-6,017; p 0,025), M/V ratio (B -1,349; HR
0.259; CI 0.085-0.789; p 0.017) resulted independent predictors of CW. The rate of CW at 6-months,
1-year and 2-year follow-up was 83%, 58%, 28% vs 94%, 89%, 85% respectively in patients with
eccentric compared to concentric hypertrophy.
Conclusions. Concentric hypertrophy might represent a more favorable RV adaptive remodeling
pattern to increased afterload in IPAH.
SINDROME CORONARICA ACUTA
O21
PATHOPHYSIOLOGY OF ACUTE CORONARY SYNDROME IN HIV POSITIVE
PATIENTS: INSIGHT FROM VIRTUAL HISTOLOGY ANALYSIS
ALESSANDRA ARMATO (A), ALESSANDRA CINQUE (A), NICOLÒ SALVI (A),
ANDERA CECCACCI (A), ANTONIO FUSTO (A), NOEMI BRUNO (A),
GENNARO SARDELLA (A), GABRIELLA D´ETTORRE (A), MASSIMO MANCONE (A),
VINCENZO VULLO (A), FRANCESCO FEDELE (A)
(A) “SAPIENZA“ UNIVERSITÀ DI ROMA
Introduction and Aim of the study: Numerous reports suggest, among HIV+ patients (pts), an
increased rate of acute coronary syndrome and cardiac death. However, the pathophysiologic
explanation of the increased rate of major cardiovascular events (MACE) in HIV+ is unknown. The
histological composition and plaque morphology represent the crucial determining factors to identify
unstable lesions. Virtual Histology intravascular ultrasound (VH-IVUS) is able to identify and
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
quantify 4 different types of atherosclerotic plaque components: necrotic, fibrous, fibro-fatty and
calcific tissue. The aim of our study is to assess coronary plaque morphology using VH-IVUS in
HIV+ patients in therapy with HAART and a low risk for cardiovascular events
Methods: Thirteen HIV-infected patients were enrolled from the Department of Cardiovascular,
Respiratory, Nephrology, Anesthesiology and Geriatric Sciences of the “Sapienza” University of
Rome (Italy). Patients, were part of population enrolled in a previous cross-sectional study, with an
indication to coronary angiography per protocol based on the evidence of coronary stenosis to a dualsource cardiac-CT. On the basis of VH-IVUS, plaque components were identified as dense calcium,
necrotic core, fibro-fatty tissue, or fibrous tissue, with the cross-sectional area and percentage of total
plaque area reported for each component. Such lesions were classified by means of radiofrequency
analysis as one of the following: thin-cap fibro-atheroma (TnCFA), thick-cap fibro-atheroma
(TkCFA), pathologic intimal thickening (PIT), fibrotic plaque (FP), or fibro-calcific plaque (FCP).
Results: All the patients presented a Framingham risk score <10%. The medium age was 53.3±4.1
years. The mean duration of highly active antiretroviral therapy was 12.9±2.4 years. Virtual
Histology-IVUS analysis, performed on 23 coronary plaque, showed an 87% (20/23) of TkCFA and
13% (3/23) TnCFA; no other plaque morphology was observed. All the plaque were rich in fibrous
tissue and necrotic tissue with a low percent of calcium (table 1).
Conclusions: Virtual Histology-IVUS analysis showed an high prevalence of unstable plaque
morphology rich in necrotic tissue. HIV related plaque seems to be different from general
population atherosclerotic plaque: less calcific; more necrotic and often with a thick-cap.
This suggest a peculiar pathophysiological mechanisms for HIV related atherosclerosis. Our
data show that this HIV+ population could be at increased risk of acute cardiovascular events
independently by traditional cardiovascular risk factors.
Fibrous tissue, mm3
Fibro-fatty volume, mm3
Necrotic core volume, mm3
Dense Calcium volume, mm3
64.9±36.8
18.5±11.3
24.2±16.5
5.0±3.5
Fibrous tissue, %
Fibro-fatty volume, %
Necrotic core volume, %
Dense Calcium %
58.3±5.2
16.2±3.1
21.1±4.3
4.0±1.6
O22
FRAILTY AND END-OF-LIFE IN ACS PATIENTS: IDENTIFICATION AND
PROGNOSTIC IMPACT
CLAUDIO MORETTI (A), MAURIZIO BERTAINA (A), GIORGIO QUADRI (A),
FABRIZIO D´ASCENZO (A), SEBASTIANO MARRA (A), GIUSEPPE MONTRUCCHIO (B),
MASSIMO PORTA (B), FRANCO VEGLIO (B), MARIO BO (B), CHIARA COLACI (A),
VIRGINIA DE SIMONE (A), FEDERICO GIUSTO (A), MARCO DI CUIA (A),
FIORENZO GAITA (A)
(A) CITTÀ DELLA SALUTE E DELLA SCIENZA; DIVISION OF CARDIOLOGY ; (B) CITTÀ
DELLA SALUTE E DELLA SCIENZA, DEPARTMENT OF INTERNAL MEDICINE; (C)
CENTRE FOR POPULATION HEALTH SCIENCES ,“PRIMARY PALLIATIVE CARE
RESEARCH GROUP“, EDIMBURGH´S UNIVERSITY, UK
INTRODUCTION: The role of Frailty and End of Life (EoL) in patients with Acute Coronary
Syndrome (ACS) remain to be determined.
METHODS: All consecutive unselected patients admitted to the Emergency Department (ED) of
two european hospital with a diagnosis of ACS during three different periods among 2011 and 2013
were included. Patients were divided according to positive or negative GSF (The Gold Standards
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Framework), which was calculated together with traditional cardiovascular risk scores (GRACE,
ACEF, New York PCI risk score) and the Clinical Frailty Scale. All cause death at one year followup was the primary outcome; cardiac and non cardiac death, all cardiovascular and all noncardiovascular events at one year were the co-primary end points .
RESULTS: 430 ACS patients were enrolled and 427 had a complete one year follow-up. 36 (8.4%)
had a positive GSF: they were older (77.6 ± 12.7 vs. 68.9 ± 11.8; p<0.001), with a lower BMI (23.18
± 4.1 vs. 26.3 ± 4.5;p=0.003), more frequently women (52.8% vs. 31.5%; p=0.015), less dyslipidemic
(22.2% vs. 56.9%; p<0.001) and had more comorbidities. They were also less angiographically
studied (66.7% vs. 92.9%; p=<0.001) and received less interventional procedures (47.2% vs. 72.8%;
p=0.002). At 12 months follow-up a positive GSF was associated with higher rate of all-cause death
(47.2% vs. 4.3%; p<0.001), cardiac death (13.9% vs. 2.6%;p=0.005), non cardiac death (33.3% vs.
1.8%; p<0.001) and all non-cardiovascular events (47.2% vs. 15.3%; p<0.001). The AUC for the
ROC curve for all-cause death was 0.803 (C.I. 95% 0.635-0.970). In the correlation analysis GSF had
good correlation only with the Clinical Frailty Scale (Pearson's correlation 0.499; p<0.001).
CONCLUSION: The prognostic indicator GSF can be a useful tool to identify EoL ACS patients,
being independently related to one year death and non cardiovascular events.
O23
HIGH SENSITIVITY TROPONIN HAS NO DIAGNOSTIC VALUE FOR MYOCARDIAL
INFARCTION IN STAGE IV-V OF RENAL INSUFFICIENCY
LUIGI MARZIO BIASUCCI (A), MASSIMO GUSTAPANE (A), GINA BIASILLO (A), MARIA
TERESA CARDILLO (A), MARIA GIULIA MARINI (A), CHIARA SONNINO (A),
MARTINA ZANINOTTO (B), MARIO PLEBANI (B), FILIPPO CREA (A)
(A) CATHOLIC UNIVERSITY OF THE SACRED HEART, ROME. ITALY; (B) UNIVERSITÀ
DEGLI STUDI DI PADOVA
Background: Renal insufficiency (RI) is a well known limiting factor in the evaluation of
myocardial infarction (MI) with troponin (Tn); this is particularly true for TnT. However it is
unknown in which amount the stage of RI influences Tn level. To this aim, we investigated the area
under the curve (AUC) of 3 different Tn assays (2 TnT and 1 TnI) according to the stage of RI.
Methods: 452 pts with chest pain were enrolled in the ER, 392 (86%) were discharged without
diagnosis of Acute Coronary Syndrome (ACS) and 60 (14%) with a diagnosis of ACS. We evaluated
3 different assays: cTnI LOCI (Siemens), Roche cTnT and Roche hsTnT. The population was
classified according to the glomerular filtration rate (GFR) level: GFR≥ 60 ml/min (stage I-II),
GFR<60>30 ml/min (stage III), GFR <30 ml/min (stage IV-V). The AUC was assessed either by
continuous values (Cont) and categorical values (Cat).
Results: Each Tn lost predictive value for MI with increasing stage of RI, in particular hsTnT in stage
IV-V had an AUC of 0.500 (see table).
Conclusions: Our study demonstrates that Tn levels have a poor performance in case of advanced
RI, in particular hsTnT use should be avoided because of its null discrimination power.
AUC cont
cTnI
LOCI(Siemens)
Roche cTnT
Roche hsTnT
0.819
0.804
0.865
AUC cat
All groups
0.795
0.784
0.780
GFR≥ 60 ml/min (stage I-II)
SE
SP
63%
96%
62%
77%
95%
80%
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cTnI
LOCI(Siemens)
Roche cTnT
Roche hsTnT
cTnI
LOCI(Siemens)
Roche cTnT
Roche hsTnT
cTnI
LOCI(Siemens)
Roche cTnT
Roche hsTnT
0.808
0.806
Roma, 13 – 15 dicembre 2014
64%
97%
0.772
0.770
56%
0.888
0.809
72%
GFR<60>30 ml/min (stage III)
0.835
0.806
68%
98%
90%
93%
0.824
0.808
93%
64%
0.788
64%
0.693
75%
GFR <30 ml/min (stage IV-V)
0.740
0.669
43%
91%
0.623
0.623
46%
-
0.584
0.500
71%
-
O24
LONG-TERM NATURAL HISTORY OF ACUTE CORONARY SYNDROMES: TIME
COURSE AND CAUSES OF DEATH
GIULIA NORSCINI (A), FABIO VAGNARELLI (A), GIULIA BUGANI (A),
ANNA CORSINI (A), LAURA CINTI (A), FRANCO SEMPRINI (A), SAMUELE NANNI (A),
NEVIO TAGLIERI (A), GIOVANNI MELANDRI (A), CLAUDIO RAPEZZI (A)
(A) ISTITUTO DI CARDIOLOGIA, POLICLINICO S.ORSOLA MALPIGHI, BOLOGNA
Aim: few data are available about mortality rates and their causes in the long-term follow up
of patients with acute coronary syndromes (ACS). The aim of this study was to evaluate the rates,
the time course and the causes of death in the long-term follow-up of unselected patients with STE
vs NSTE ACS.
Methods: we enrolled all 2046 consecutive ACS patients discharged between 2004 and 2006. 1703
had the complete 5-year follow-up (734 STEMI, 969 NSTEMI). We were able to obtain a
detailed description of mortality rates and their causes by either telephone interview or hospital
records consultation. Cardiovascular (CV) death was defined as a composite of death from cardiac
cause, sudden death, any death without another known cause, fatal stroke. Non-CV death was
classified into: cancer, infection, lung disease (LD), chronic kidney disease (CKD), fatal bleeding and
other.
Results: Mean age was 71.6 years. P-PCI was performed in 86.0% of STEMI and 70% of patients
with NSTEMI were managed invasively. The prescription of evidence-based medications in the
whole population was high. From hospital admission to 5-year follow-up, 737 patients died, with 487
of them experiencing a cardiovascular death (487/737, 66.1%). On the Kaplan-Meier estimates , the
5-year all-cause mortality was 36.4% for STEMI and 42.0% for NSTEMI, with STEMI patients
showing a trend boarding statistical significance towards a lower risk of mortality (HR = 0.88 95%
CI 0.76-1.02, p=.08, Figure 1). Landmark analysis demonstrated that STE-ACS patients disclosed a
higher risk of 30-day mortality (STE vs. NSTE HR = 1.53, 95% CI 1.16-2.06, p=.003) whereas the
risk allocated with NSTE-ACS markedly appeared after 1 year (STE vs. NSTE HR = 0.67, 95% CI
0.53-0.84, p=.001). 5-year all-cause death occurred in 737 patients, 296 in the STE group and 441 in
the NSTE group. Overall 487 patients (28.6%) died due to CV causes , 205 (27.9% ) in STE group
and 282 (29.1%) in NSTE group (p= 0.630). Non-CV death occurred in 250 patients (14.7%), 91
(12.4%) in STE group and 159 (16.4%) in NSTE group (p=0.630). The main causes of 5-y non-CV
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Roma, 13 – 15 dicembre 2014
death are shown in figure 2. Of note the contribution of non-CV has increased from 5% at 30-d to
34% at 5-year.
Conclusions: The dismal long-term outlook among the whole ACS population is affected by both
CV and non-CV causes as well. However the risk allocated with NSTE-ACS markedly appeared in
the long-run (after 1 year) when the role of non-CV causes of death becomes considerable.
O25
RELAZIONE TRA IL POLIMORFISMO GENETICO RS2036914 DEL FXI DELLA
COAGULAZIONE E L’OCCORRENZA DI EVENTI AVVERSI DOPO ANGIOPLASTICA
PERCUTANEA CORONARICA
RITA PAVASINI (A), SIMONE BISCAGLIA (A), SILVIA PUNZETTI (A),
GIANLUCA CAMPO (A), CLAUDIO CECONI (A)
(A) U.O. DI CARDIOLOGIA, AZIENDA OSPEDALIERO-UNIVERSITARIA DI FERRARA,
CONA (FE)
BACKGROUND: Il fattore XI della coagulazione (FXI) è una serin-proteasi che prende parte al
processo di amplificazione della genesi della trombina. I livelli plasmatici di FXI sono influenzati da
molteplici fattori genetici e ambientali. In particolare il comune polimorfismo rs2036914 della
regione intronica del gene del FXI ha dimostrato di avere una relazione forte con i livelli plasmatici
dell’antigene e dell’attività del FXI. Inoltre tale polimorfismo correla con il valore del tempo di
tromboplastina parziale attivata (aPTT). Elevati livelli plasmatici di FXI sono associati ad un elevato
rischio di trombosi venosa profonda, invece una chiara associazione tra FXI e l’incidenza di infarto
miocardico (IM) non è nota. Al momento non sono disponibili dati circa l’occorrenza di eventi avversi
in presenza del polimorfismo rs2036914 del FXI in pazienti trattati con angioplastica percutanea
(PCI).
OBIETTIVO: Determinare il valore prognostico del polimorfismo rs2036914 del fattore XI
sull’outcome a due anni di pazienti trattati con PCI. In secondo luogo, valutare la relazione
intercorrente tra questo polimorfismo e il valore di aPTT e l’insorgenza di un IM peri-procedurale.
METODI: Sono stati arruolati 812 pazienti trattati con PCI. In tutti i pazienti è stato valutato il
polimorfismo rs2036914 del fattore XI e dosato l’aPTT (prima della PCI, alla dimissione e dopo 6
mesi dalla procedura), è stata poi osservata l’incidenza di complicanze ischemiche e di
sanguinamento a due anni.
RISULTATI: FXI rs2036914 si è dimostrato significativamente associato con i valori di aPTT,
indipendentemente dal momento in cui era stato dosato (p<0.01). FXI rs2036914 non è correlato con
la variazione dell’incidenza dell’endpoint composito di morte e d’infarto miocardico (CC omozigoti
13.3% vs CT eterozigoti 11% vs. TT omozigoti 10.6 %, p=0,6). Non è stata trovata alcuna relazione
con l’incidenza di trombosi di stent. L’incidenza di infarto peri-procedurale tipo 4a differiva invece
significativamente tra i vari sottogruppi di FXI rs2036914 (CC omozigoti 22% vs. CT eterozigoti
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14% vs. TT omozigoti 9.9%, p<0.01). FXI rs2036914 è risultato essere un predittore indipendente di
rischio di infarto peri-procedurale (CC vs. T portatori, HR 1.12, 95%CI 1.04-1.21, p<0.01). Infine,
FXI rs2036914 è significativamente associato con l’incidenza di complicanze dovute a
sanguinamento superficiale (BARC 1 and Bleedscore 1-2).
CONCLUSIONI: In pazienti sottoposti a PCI e stenting, la presenza del polimorfismo rs2036916
del FXI non ha dimostrato di essere un fattore predittivo di morte, reinfarto e trombosi di stent a 2
anni, associandosi invece a una più elevata incidenza d’infarto peri-procedurale. Inoltre FXI
rs2036916 ed è un predittore indipendente del rischio di complicanze dovute a sanguinamento
superficiale.
O26
ANALISI METABOLOMICA IN PAZIENTI CON ISCHEMIA MIOCARDICA
INDUCIBILE SOTTOPOSTI A STUDIO CORONAROGRAFICO. ADMA, PROFILO
METABOLICO DEL SANGUE CORONARICO, CORONAROPATIA
ATEROSCLEROTICA E MICROVASCULOPATICA
FEDERICA ASCEDU (A), MARTINO DEIDDA (A), CHRISTIAN CADEDDU (A),
DAMIANA CONGIA (C), CLAUDIA DEPAU (A), GIORGIO LAI (D),
MAURO CADEDDU (D), GIANFRANCO DE CANDIA (D), RAIMONDO PIRISI (D),
GIUSEPPE MERCURO (A)
(A) DIPARTIMENTO DI SCIENZA MEDICHE “M. ARESU“ - UNIVERSITÀ DEGLI STUDI DI
CAGLIARI; (B) DIPARTIMENTO DI SCIENZE BIOMEDICHE - UNIVERSITÀ DEGLI STUDI
DI CAGLIARI; (C) U.O.C. DI CARDIOLOGIA - AO BROTZU - CAGLIARI; (D)
LABORATORIO DI EMODINAMICA - P.O. SAN GIOVANNI DI DIO - A.O.U. DI CAGLIARI
Background: La disfunzione endoteliale rappresenta un punto fondamentale nello sviluppo di
aterosclerosi ed è coinvolta nella progressione della placca e nell'insorgenza delle complicanze della
patologia aterosclerotica (ATS). Per tale ragione, i biomarker di disfunzione endoteliale , tra i quali
la dimetilarginina asimmetrica (ADMA) sono oggetto di interesse crescente. La metabolomica, una
tecnica altamente sensibile ed in grado di identificare cluster metabolici specifici di stato di salute o
malattia, potrebbe costituire un’efficace tool nello studio delle diverse estrinsecazioni
fisiopatologiche della ATS e delle lore fingerprint metaboliche.
Materiali e Metodi: Abbiamo arruolato 11 soggetti (7 uomini, 4 donne; età: 66±12.87 anni) risultati
positivi per ischemia miocardia inducibile ad un ecostress con dobutamina e sottoposti a
coronarografia, nel corso della quale sono stati effettuati prelievi di sangue coronarico; su questo sono
stati dosati i livelli di ADMA ed effettuata una spettroscopia 1H-RMN per l’analisi metabolomica.
Risultati: Sulla base dell’esame coronarografico è stato possibile evidenziare la presenza di malattia
coronarica stenosante (MCS) in 6 pazienti e assenza di coronaropatia angiograficamente evidente in
5 pazienti, pertanto considerati affetti da disfunzione microcircolatoria (DMC). I livelli di ADMA
non sono risultati differenti nelle due classi di pazienti (MCS vs DMC rrispettivamente: CDx:
0.54±0.08 vs 0.55±0.05, p=0.87; CSn: 0.56±0.09 vs 0.56±0.02; p=0.95).
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L’analisi OPLS-DA a due classi ha permesso di clusterizzare nettamente e in maniera statisticamente
significativa i pazienti affetti da patologia stenosante rispetto a quelli affetti da patologia del
microcircolo (R2=0.994; Q2=0.905; ANOVA per Cross validation: p=0.01). In tal modo è stato
possibile identificare due pattern metabolici differenti corrispondenti a due distinte entità
fisiopatologiche: l’ATS stenosante e l’alterata funzione del microcircolo. L’analisi delle variabili più
importanti nel determinare la clusterizzazione ha consentito di individuare un ristretto numero di
metaboliti: l’alanina, la betaina, il citrato, il lattato, il malonato, la N,N-dimetilglicina (DMG), il
piruvato e il succinato. La successiva analisi univariata ha evidenziato la presenza di differenze
statisticamente significative nei livelli di betaina e di DMG (rispettivamente 0.3573±0.2324 μM vs
0.1340±0.1040 μM, p<0.03, e 0.0064±0.0032 μM vs 0.0030±0.0014 μM, p<0.02) nel gruppo di
pazienti con coronarie angiograficamente normali rispetto a quelli con patologia stenosante.
Conclusioni: L’ADMA non si è dimostrata in grado di discriminare tra diverse manifestazioni della
ATS coronarica. Al contrario la metabolomica ha identificato due diversi profili metabolici
corrispondenti ai due diversi quadri angiografici. Il riconoscimento di pattern metabolici distinti nel
microambiente coronarico in presenza o assenza di placche aterosclerotiche significative offre
interessanti spunti nel poter definire la differente modulazione della funzione dell’endotelio
coronarico. Inoltre l’identificazione delle molecole più importanti nel determinare un’evoluzione
piuttosto che un’altra, con particolare riferimento a betaina e DMG, dotate di azione
antinfiammatoria, catabolica nei confronti dell’omocisteina e protettiva contro lo stress ossidativo,
potrebbe costituire la base per nuovi approcci in ambito di ricerca sia fisiopatologia che
farmacologica.
ESPOSIZIONE DELLA SINTESI DEI LAVORI DA PARTE DEI VINCITORI
DELLE BORSE DI STUDIO SIC
O27
BREATH HOLD TESTING FOR PULMONARY ARTERIAL HYPERTENSION AND
HEART FAILURE
MARTINO CHELI (A), MANRICO BALBI (A), CLAUDIO BRUNELLI (A),
MARCO VICENZI (B), JEAN LUC VACHIERY (B)
(A) DIPARTIMENTO MEDICINA INTERNA, U.O. CARDIOLOGIA, UNIVERSITA DI
GENOVA; (B) PULMONARY VASCULAR DISEASES AND HEART FAILURE CLINIC,
DEPARTMENT OF CARDIOLOGY CUB-HÔPITAL ERASME, BRUSSELS
Background: Breathlessness is frequently the earliest and the most recurrent symptom in patients
affected by pulmonary arterial hypertension (PAH) or heart failure (HF). Several semiquantitative
scales for grading dyspnoea, such as the WHO functional class at rest and Borg index at effort, have
shown adequate consistency to predict prognosis, but assessment of symptoms is considerably
influenced by subjective variability and environmental factors. We sought to explore whether breath
hold duration (BHD) could provide an objective estimate of dyspnoea and insights on exercise
capacity and chemosensitivity through comparison with standard functional tests.
Material and Methods: In this single centre, prospective study, 15 consecutive patients with
heritable/associated forms of PAH and 23 HF patients were recruited between the 1st January and the
30th April 2014. Exclusion criteria were pulmonary disease and/or clinical instability within 1 month.
All tests were performed in the fasting state, in a quiet environment with steady temperature. Breath
hold duration was evaluated at approximately 85% of vital capacity and at functional residual
capacity. Peripheral saturation and PETCO2 were continuously monitored. Two assays separated by
at least 5’ were performed for each modality and averaged; tests were repeated if incorrectly
performed.
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Results: Patient characteristics were similar among PAH and HF patients in terms of age,
anthropometrics, NT pro BNP levels, WHO functional class and exercise capacity, as expressed by
peakVO2, workload and effort attitude. Male gender was slightly more prevalent in HF (73% vs 47%,
p= ns). BHD was significantly shorter in PAH than HF patients for both testing modalities (27.7s vs
43.6s, p< 0.01, and 17.3s vs 25.1s, p<0.05, at 85% of vital capacity and at functional residual capacity,
respectively). Compared to HF, PAH patients had lower baseline peripheral saturation (88.9% vs
97.1%, p <0.0001), steeper VeVCO2 slope (46.9 vs 33.7, p<0.05) and lower baseline PETCO2 (28.2
vs 33 mmHg, p<0.01). In PAH, BHD was significantly related to WHO FC (r -0.69, p<0.005) and
six minute walk distance (r 0.77, p<0.05), but not to peak VO2. Conversely, in HF, BHD was
correlated with peak VO2 (r 0.75, p<0.01), but not to WHO FC. BHD was not associated with NT
pro BNP levels in either subgroup. Breath hold testing was well tolerated in all subjects; no adverse
events occurred.
Conclusions: Patients with PAH show reduced breath holding ability as compared to HF patients
with similar functional class and exercise capacity. This could be related to a more deranged
chemosensitivity. BHD might provide complementary functional assessment in PAH patients whose
exercise capacity is limited by peripheral musculoskeletal disease.
O28
ASSOCIATIONS BETWEEN ALTERED MYOCARDIAL EXTRACELLULAR VOLUME
FRACTION AND AORTIC HEMODYNAMICS IN HYPERTROPHIC
CARDIOMYOPATHY: COMBINED 4D FLOW AND T1-MAPPING MRI
CARLA CONTALDI (A, B), PIM VAN OOIJ (C), BRADLEY D. ALLEN (C), DANIEL
C. LEE (C), LUBNA CHOUDHURY (B), ALEX J. BARKER (C), MICHAEL MARKL (C, D),
ROBERT O. BONOW (B)
(A) DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY
SCHOOL OF MEDICINE OF NAPLES, ITALY; (B) DEPARTMENT OF MEDICINECARDIOLOGY, NORTHWESTERN UNIVERSITY, CHICAGO, IL, USA; (C) DEPARTMENT
OF RADIOLOGY, NORTHWESTERN UNIVERSITY, CHICAGO, IL, USA; (D)
DEPARTMENT OF BIOMEDICAL ENGINEERING, NORTHWESTERN UNIVERSITY,
CHICAGO, IL, USA
Introduction: Diagnosis of obstructive hypertrophic cardiomyopathy (HCM) is based on the peak
pressure gradient (∆P>30 mmHg at rest) over the left ventricular outflow tract (LVOT) by Doppler
echocardiography. However this technique has limitations,
such as single-direction measurement of velocities and
misclassification due to simplified Bernoulli equation.
Recently, the irreversible energy loss (EL'), due to viscous
dissipation, estimated by 4D flow Magnetic Resonance
Imaging (MRI), has been proposed as a method to measure
increased LV afterload in the presence of complex 3D flow
fields. The aim of this study is to investigate the benefit of
energy loss quantification in the LVOT of HCM patients,
by examining the relationship between EL' with the
expansion of the myocardial extracellular volume (ECV), obtained from T1-mapping MRI, as a
marker for LV remodeling.
Methods: Navigator and prospectively cardiac gated 4D Flow measurements in the 3-Chamber view
were performed in 35 HCM patients (mean age 54±15 years) and 11 healthy controls (mean age
43±14 years) at 1.5T and 3T. Time-averaged 3D PC-MR angiogram images were used for 3D
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Roma, 13 – 15 dicembre 2014
segmentation of LVOT geometry (MIMICS, Materialise). As reported by Barker at al, EL' in the
LVOT was calculated as:
where µ is the dynamic viscosity of blood, N is the number of
voxels, V is the volume of a voxel and is the viscous dissipation, as given by:
in which i and j are the principal directions x, y, z. T1-mapping was performed in 23 of the 35 HCM
patients (mean age 50±15 years) using modified look-locker inversion recovery (MOLLI) sequences.
T1 values for each slice were acquired pre (T1pre) and post (T1post) contrast administration, by drawing
contours along the endocardial and epicardial borders and a region of interest in the LV blood pool.
The myocardial ECV was calculated using: ECV=(1-hematocrit)x(∆R1myocardium/∆R1blood; ∆R1=1/∆T1 and ∆T1 = difference of T1pre and T1post.
It was averaged over the base, mid and apex to estimate whole heart ECV.
Results: Figure shows streamlines, peak systolic velocity magnitude and EL' in the LVOT of a control
(top) and a HCM patient (below). The difference in EL' between HCM patients and controls was
significant (4.0±2.7 mW vs. 1.5±0.6 mW; p<0.005). EL' showed a strong correlation with LVOT
gradient (R2=0.86; p<0.001), by 4D Flow MRI, and a good correlation with ECV (R2=0.46; p<0.001).
Conclusion: Increased EL' in HCM patients may indicate LVOT obstruction and both indicate and
lead to remodeling of the left ventricle. Energy loss may help drive myocardial fibrosis in these
patients. 4D Flow MRI analysis of the LVOT and EL' may be useful in HCM severity assessment and
risk stratification, without the limitations associated with gradient estimation.
O29
PLATELET REACTIVITY AND CLINICAL OUTCOMES IN PATIENTS TREATED
WITH EITHER TICAGRELOR ALONE OR DUAL ANTIPLATELET THERAPY AFTER
SECOND-GENERATION DRUG ELUTING STENT IMPLANTATION
ROBERTO DILETTI (A)
(A) INTERVENTIONAL CARDIOLOGY, THORAXCENTER, ERASMUS MC, ROTTERDAM
Background The relation between platelet reactivity and clinical adverse events after coronary artery
interventions has been incompletely characterised.
The primary aim of the present investigation is to determine the impact of high on-treatment platelet
reactivity, patients treated with either very short or standard (1 year) dual antiplatelet therapy after
coronary intervention.
Methods This is a Sub-study of GLOBAL LEADERS randomized controlled trial. A total of 2455
patients will be evaluated in this analysis.
Patients undergo a single venous blood sampling during the 3-month clinical follow-up (or later)
visit per-protocol planned in the above-mentioned trial, and platelet function is assessed locally.
Main study parameter is the evaluation of platelet reactivity assessed with VerifyNow P2Y12 and
VerifyNow Aspirin assays respectively. In the VerifyNow P2Y12 assay results are expressed in
P2Y12 reaction units (PRU). Poor responders to clopidogrel or ticagrelor are identified in case of a
PRU value >208. Using the VerifyNow Aspirin assay, results are expressed in terms of aspirin
reaction unit (ARU). Patients are identified as aspirin poor responders in case of an ARU value
>550
Primary endpoint of the present investigation is the evaluation of the composite of cardiac death,
any myocardial infarction, target vessel revascularization and stent thrombosis at 2 years post
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procedure, in patients poor responders to clopidogrel or ticagrelor (PRU >208) compared to patients
with optimal response to treatment (PRU<208). Secondary endpoint is the comparison of bleeding
events (BARC 2 or superior, according to BARC definitions) at 2 years post procedure in patients
with either aspirin reaction unit values superior or inferior to 550 ARU.
Results Explorative results will be available at the time of the presentation.
Conclusions Preliminary conclusions will be based on hypothesis generating data.
O30
NATURAL HISTORY OF LEFT VENTRICULAR DYSFUNCTION IN SENILE SYSTEMIC
AMYLOIDOSIS: NEW INSIGHTS BY MEANS OF SPECKLE TRACKING
ECHOCARDIOGRAPHY
CANDIDA CRISTINA QUARTA (A, B), CLAUDIO RAPEZZI (A), RODNEY H FALK (B),
SCOTT D SOLOMON (C)
(A) ISTITUTO DI CARDIOLOGIA, POLICLINICO S.ORSOLA-MALPIGHI, UNIVERSITA´ DI
BOLOGNA, ITALIA; (B) CARDIAC AMYLOID PROGRAM, BRIGHAM AND WOMEN´S
HOSPITAL, HARVARD MEDICAL SCHOOL, BOSTON, USA; (C) CARDIOVASCULAR
DEPARTMENT, BRIGHAM AND WOMEN´S HOSPITAL, HARVARD MEDICAL SCHOOL,
BOSTON, USA
Background. Unlike the other forms of cardiac amyloidosis, senile systemic amyloidosis (SSA) which is due to wild-type transthyretin (TTR)-related amyloid infiltration- is, to all intents and
purposes, exclusively limited to the heart and presents as inexorably progressive congestive heart
failure almost exclusively in elderly men. The natural history of SSA has been poorly described. The
determination of progression of cardiac disease by standard echocardiography may be difficult, as
measurements such as ejection fraction and mean ventricular wall thickness are subject to
considerable inter- and intra-observer variability, even in skilled laboratories.
Aims. In order to refine a definition of progression of LV dysfunction in SSA, we assessed the effect
of SSA on cardiac structure and function over 12 to 24 month period by means of both conventional
and newer two-dimensional speckle-tracking echocardiography. Furthermore, we compared data
from these patients with those from patients affected by SSA currently under off-label treatment with
Tafamidis, a TTR stabilizer, in order to study the effects of the drug on the progression of heart
disease.
Results. We included in the analysis 24 SSA patients; age 77 [73-80] years, 23 (96%) males, presence
of atrial fibrillation in 29%. Eleven patients were treated with standard treatments for heart failure
and arrhythmias, including diuretics, small doses of ace-inhibitors and beta-blockers, and
amiodarone. Thirteen patients were also under off-label treatment with Tafamidis 20 mg/die. The
table summarizes the changes over a 2 years period of the main conventional and speckle tracking
derived echocardiographic parameters.
Conclusions. Functional echocardiographic parameters (either conventional or speckle-tracking
derived) disclosed a greater progression of cardiac disease than morphological ones in SSA patients.
Despite the small sample size, we were not able to disclose differences in the progression of LV
dysfunction over time between patient treated and those untreated with Tafamidis.
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Table
Untreated patients
(n=11)
Echocardiographic parameter
Baseline 2 years
LV wall thickness, cm
1.8±0.2 1.9
LV mass, g
340±75 384±82
LV diameter in diastole, cm
4.4±0.5 4.4±0.6
Left atrial volume, mL
112±39 112±35
LV volume in diastole, mL
101±22 95±21
LV ejection fraction, %
55±8
48±9
E/E’ ratio
15±8
14±5
Global LV longitudinal strain
-12±3
-10±4
Apical LV longitudinal strain
-22±6
-16±4
Mid-ventricular LV longitudinal strain -8±4
-8±3
Basal LV longitudinal strain
-7±3
-7±3
LV circumferential strain
-24±7
-17±5
Patients under Tafamidis
(n=13)
Baseline 2 years
1.9±0.3 1.8±0.2
348±114 350±95
4.1±0.5 4.2±0.6
112±59 97±36
102±27 94±24
50±10
48±10
13±5
15±5
-11±3
-9±2
-19±7
-17±5
-7±3
-5±2
-7±4
-4±3
-22±5
-18±7
p
0.35
0.88
0.1
0.75
0.97
0.11
0.31
0.16
0.09
0.45
0.79
0.62
O31
NOX4 PROMUOVE LA SOPRAVVIVENZA CARDIOMIOCITARIA DURANTE
DEPRIVAZIONE ENERGETICA ED ISCHEMIA ATTRAVERSO L’ATTIVAZIONE
DELL’AUTOFAGIA
SEBASTIANO SCIARRETTA (A, B), PEIYONG ZHAI (B), MASSIMO VOLPE (A),
JUNICHI SADOSHIMA (B)
(A) DIVISION OF CARDIOLOGY, DEPARTMENT OF CLINICAL AND MOLECULAR
MEDICINE, FACULTY OF MEDICINE AND PSYCHOLOGY, UNIVERSITY “SAPIENZA“,
ROME, ITALY; (B) CARDIOVASCULAR RESEARCH INSTITUTE, DEPARTMENT OF CELL
BIOLOGY AND MOLECULAR MEDICINE, RUTGERS NEW JERSEY MEDICAL SCHOOL,
NEWARK, NEW JERSEY, USA
Nox4 e’ la principale isoforma dell’enzima NADPH ossidasi nei cardiomiociti insieme a Nox2. La
NADPH ossidasi e’ il solo enzima cellulare devoto alla produzione di radicali liberi dell’ossigeno
(ROS) in maniera regolata e per tale funzione prende parte alla regolazione dei processi cellulari nei
quali i ROS agiscono come molecole di segnale. Studi precedenti hanno dimostrato come Nox4
svolga delle funzioni adattative in resposta a stress cellulare, in particolare ad ipossia. Per la prima
volta abbiamo testato se Nox4 fosse coinvolto nella regolazione dell’autofagia in risposta a
deprivazione energetica cardiomiocitaria.
Abbiamo trovato che i livelli di espressione di Nox4 ma non di Nox2 sono aumentati nei cardiomiociti
durante deprivazione di glucosio in vitro. I livelli di ROS valutati attraverso fluorescenza cellulare
dopo incubazione con DHE, DCF ed Amplex Red erano ugualmente aumentati durante deprivazione
di glucosio in maniera dipendente da Nox4, suggerendo quindi che l’aumento dei ROS durante
deprivazione energetica cardiomiocitaria sia mediato dall’attivazione di Nox4.
Di interesse, abbiamo osservato che i livelli e l’attivita’ di Nox4 e i livelli dei ROS sono aumentati
nel reticolo endoplasmatico (RE) ma non nei mitocondri dei cardiomiociti messi in cultura in assenza
di glucosio, suggerendo che Nox4 produca ROS selettivamente nel RE durante la deprivazione di
glucosio.
Successivamente abbiamo osservato che l’inibizione di Nox4 inibisce sia la formazione degli
autofagosomi che in parte la loro fusione con i lisosomi nei cardiomiociti deprivati di glucosio,
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suggerendo che Nox4 sia importante per l’attivazione del processo autofagico durante deprivazione
energetica. Dal punto di vista meccanicistico, abbiamo scoperto che Nox4 regola l’autofagia durante
deprivazione energetica attraverso la cascata trasduzionale PERK/eIF-2α/ATF4.
Importante, abbiamo osservato che l’attivazione di Nox4 nel RE durante deprivazione energetica e’
un meccanismo protettivo. Infatti, l’inibizione di Nox4 riduceva la sopravvivenza cardiomiocitaria
durante deprivazione di glucosio che veniva ristabilita invece dalla riattivazione concomitante
dell’autofagia, indicando che Nox4 promuove la sopravvivenza cellulare favorendo l’attivazione
dell’autofagia.
Abbiamo quindi confermato i nostri risultati in vivo, osservando che topi con delezione del gene
Nox4 selettivamente nei cardiomiociti mostrano un’inibizione dell’autofagia durante sia deprivazione
di nutrienti che ischemia miocardica. Inoltre, questi topi knockout per Nox4 mostravano una
significativa riduzione della funzione cardiaca durante deprivazione di nutrienti ed un aumentato
infarto del miocardio dopo ischemia miocardiaca prolungata conseguente a legatura dell’arteria
discendente anteriore.
In conclusione, il nostro studio dimostra che l’attivazione di Nox4 promuove la sopravvivenza
cardiomiocitaria durante deprivazione energetica ed ischemia attraverso l’attivazione dell’autofagia.
LA TC CARDIACA NELLO STUDIO DELLE CORONARIE
O32
HIGH REMODELING INDEX AND LOW ATTENUATION PLAQUE AT CARDIAC CT AS
RISK FACTORS FOR ACUTE CORONARY SYNDROME IN A POPULATION WITH
NON-OBSTRUCTIVE CORONARY ARTERY DISEASE: A RETROSPECTIVE CASECONTROL STUDY
EDOARDO CONTE (A), SAIMA MUSHTAQ (A), CHIARA SEGURINI (A),
ERIKA BERTELLA (A), ANDREA BAGGIANO (A), MONICA LOGUERCIO (A),
ANDREA ANNONI (A), ALBERTO FORMENTI (A), MARIA PETULLÀ (A),
VIRGINIA BELTRAMA (A), GIANLUCA PONTONE (A), DANIELE ANDREINI (A, B),
MAURO PEPI (A), CESARE FIORENTINI (A, B)
(A) CENTRO CARDIOLOGICO MONZINO, IRCCS, MILAN, ITALY; (b) DEPARTMENT OF
CLINICAL SCIENCES AND COMMUNITY HEALTH, CARDIOVASCULAR SECTION,
UNIVERSITY OF MILAN, MILAN, ITALY
Background: Obstructive coronary artery disease leading to myocardial ischemia is known to be
associated with increased incidence of major cardiovascular events (MACE). Recent studies have
suggested that even non-obstructive plaques increases cardiovascular events at long-term follow-up.
However, how to discriminate patients at higher risk of acute coronary syndrome (ACS) among a
population with non-obstructive coronary artery disease (CAD) is still unclear. Aim of this
retrospective case-control study is to identify plaque characteristics at coronary computed
tomography angiography (CCTA) associated with high risk of ACS in a non-obstructive CAD
population.
Methods: Thirteen patients exhibiting ACS as first symptoms of CAD (3 STEMI, 4 NSTEMI, 6 UA)
and thirteen controls without ACS during follow-up, identified from a registry of 500 patients who
underwent CCTA between September 2006 and December 2008 for suspected but unknown CAD at
the time of scan and who were found to have non obstructive disease at CCTA were enrolled in the
study. HeartScore was calculated for every single patients. For each coronary plaque detected,
coronary arterial remodeling index (RI) by using vessel diameter (RIdiam = lesion diameter/reference
diameter) and vessel area (RIarea = lesion area/reference area), HU attenuation for evaluation of
plaque composition and stenosis severity (lesion lumen area/reference lumen area) were measured.
Patients were finally classified as RI positive if RIdiam was > 1,4 and RIarea was > 1,5; low
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attenuation plaque (LAP) was identified if HU was < 150 and higher degree coronary stenosis was
identified if lumen stenosis was >50%.
Results: Cases and controls have similar HeartScore, (median: 2% vs 2%, respectively; p=0.2855)
and coronary artery stenosis severity was not different between these two groups (mean: 35% vs 30%,
respectively; p=0.0764). Otherwise cases have significatively higher degree of RIarea (median: 1.76
vs 1.21; p=0.0007), higher degree of RIdiam (median: 1.49 vs 1.25; p<0.0001) and lower HU plaque
(median 425 vs 532; p=0.049). Among these features, positive RIarea (odds ratio OR = 7.5;
confidence interval CI: 1.30 - 43.02 p=0.0238), and the combination of lower attenuation plaque and
positive RIarea on a the same plaque (OR = 10; CI: 1.01 - 103.95; p= 0.0483) are the most useful
tools for indentifying patients at higher risk of ACS.
Conclusions: CCTA high remodeling index and low attenuation plaque appears to be a promising
tool for risk stratification in patients with non-obstructive CAD.
O33
RUOLO EMERGENTE DELLA PERFUSIONE MIOCARDICA DINAMICA MEDIANTE
TC
RUOLO EMERGENTE DELLA PERFUSIONE MIOCARDICA DINAMICA MEDIANTE
TC
CAMILLA ZAWAIDEH (B), GIAN PAOLO BEZANTE (B), MARGHERITA CASTIGLIONE
MORELLI (A), CARLO FERRO (A), BASSAM DIB (C), GIANLUCA SECCHI (B),
SARA BOCCALINI (A), IRILDA BUDAJ (A), ATHENA GALLETTO (A), JERIES
PAOLO ZAWAIDEH (B), SELENE CAPITANIO (C), CECILIA MARINI (D),
GIANMARIO SAMBUCETI (C), CLAUDIO BRUNELLI (B), SARA SEITUN (A)
(A) IRCCS AZIENDA OSPEDALIERA UNIVERSITARIA SAN MARTINO – IST U.O.
RADIOLOGIA; (B) IRCCS AZIENDA OSPEDALIERA UNIVERSITARIA SAN MARTINO –
IST U.O. CLINICA DI MALATTIE DELL’APPARATO CARDIOVASCOLARE E UTIC; (C)
IRCCS AZIENDA OSPEDALIERA UNIVERSITARIA SAN MARTINO – IST U.O. MEDICINA
NUCLEARE; (D) CNR INSTITUTE OF MOLECULAR BIOIMAGING AND PHYSIOLOGY,
MILAN, SECTION OF GENOA, GENOA, ITALY
Obiettivo: Valutare il ruolo emergente della
perfusione miocardica dinamica mediante TC nel
management dei pazienti con sospetta cardiopatia
ischemica mediante l'individuazione di ischemia
inducibile e di aree di necrosi-fibrosi.
La nostra esperienza: La coronarografia TC è un
esame accurato nella valutazione non invasiva
dell’aterosclerosi coronarica, tuttavia, in base alle sole caratteristiche morfologico-anatomiche, non è
possibile determinare il significato fisiopatologico della lesione coronarica aterosclerotica.
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Nella pratica clinica, le informazioni
morfologiche dell'albero coronarico
ottenute con la coronarografia TC sono
spesso integrate da esami di imaging
funzionale quali ECO-Stress, SPECT,
PET o RM. Con apparecchiature TC di
ultima generazione è possibile
eseguire studi di perfusione-TC
dinamici mediante uno stimolo
farmacologico
iperemico
(dipiridamolo) e quindi combinare il
dato funzionale a quello anatomico in
una stessa seduta d’esame.
Attraverso una revisione della nostra casistica
preliminare, la metodica TC di perfusione miocardica
dinamica ha dimostrato buona sensibilità, specificità, VPP e
VPN nei confronti della SPECT, della perfusione RM e della
misurazione invasiva della FFR alla coronarografia.
Conclusioni: La perfusione miocardica dinamica mediante
TC è una metodica promettente in grado di migliorare
l’accuratezza diagnostica e la specificità dell’esame
coronarografico TC, combinando in un unico esame il dato
morfologico a quello funzionale.
O34
IMPACT OF INTRA-CYCLE MOTION CORRECTION ALGORITHM ON OVERALL
EVALUABILITY AND ACCURACY IN 160 NOT-EVALUABLE CONSECUTIVE
PATIENTS STUDIED BY COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY
FOR SUSPECTED CAD
ERIKA BERTELLA (A), ANDREA BAGGIANO (A), SAIMA MUSHTAQ (A),
MONICA LOGUERCIO (A), DANIELE ANDREINI (A, B), MARIA PETULLÀ (A),
CHIARA SEGURINI (A), EDOARDO CONTE (A), VIRGINIA BELTRAMA (A),
GIANLUCA PONTONE (A)
(A) CENTRO CARDIOLOGICO MONZINO, IRCCS; (B) DEPARTMENT OF
CARDIOVASCULAR SCIENCES AND COMMUNITY HEALTH, UNIVERSITY OF MILAN
Background: Computed tomography coronary angiography (CTCA) has emerged in the last decade
as a robust tool for the evaluation of coronary artery disease (CAD). However, despite the evolving
technology, the motion artifacts due to the limited temporal resolution are still a challenge. Recently,
a novel intra-cycle motion correction algorithm to reduce motion artifacts has been introduced. The
aim of this study is to evaluate the impact of this new reconstruction algorithm on image quality,
overall evaluability and diagnostic accuracy in consecutive not-evaluable patients for artifacts
evaluated by CTCA in comparison with standard reconstruction algorithm.
Methods and Materials: From a cohort of 900 consecutive patients referred to our hospital to
perform CTCA for suspected CAD, 160 (18%) patients (mean age 65.3±11.7 yo, 101 male) with at
least one coronary segment with diameter2 mm classified as not evaluable for motion artifacts were
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enrolled in this study and evaluated on dedicated post-processing workstation (AW version 4.5, GE
Healthcare) using standard reconstruction algorithm (Group 1) and intra-cycle motion correction
algorithm (Group 2) by two blinded expert reader. The Likert image quality, defined as 1 (notevaluable) to 4 (no artifacts, unrestricted evaluation), and overall evaluability were estimated and
compared among groups. Finally, a sub-group of 45 patients was referred to invasive coronary
angiography as reference and sensitivity (Se), specificity (Sp), negative predictive value (NPV),
positive predictive value (PPV) and accuracy (Ac) of CTCA were evaluated, censoring as positive
the not-evaluable segments, and compared among groups.
Results: Group 2 showed a higher Likert score (3.10.9 vs. 2.51.1, p<0.001) and overall evaluability
(94% vs. 79%, p<0.001) in comparison with Group 1, respectively. In a segment based-model and in
a vessel-based model, Sp, PPV and Ac were higher in Group 2 vs Group 1 (87% vs 73%, 50% vs
34%, 85% vs 73%, p<0.001 and 62% vs 28%, 66% vs 51% and 75% vs 57%, p<0.001,
respectively). The Group 2 showed a higher accuracy vs group 1 in a patient based model (93% vs
75%, p<0.05). Finally, 96 out of 160 patients enrolled in the study became fully evaluable after intracycle motion correction algorithm reducing the prevalence of not-evaluable patients form 18% up to
7% of overall population studied by CTCA.
Conclusions: In the routine clinical practice the intra-cycle motion correction algorithm is able to
improve the image quality, the overall evaluability and the diagnostic accuracy of CTCA.
O35
LONG-TERM PROGNOSTIC IMPACT OF CORONARY ATHEROSCLEROTIC
BURDEN: VALIDATION OF THE CT-LEAMAN SCORE. PROGNOSTIC VALUE OF CTLEAMAN SCORE
EDOARDO CONTE (A), SAIMA MUSHTAQ (A), PEDRO DE ARAUJO GONÇALVES (B),
HECTOR M. GARCIA-GARCIA (C), GIANLUCA PONTONE (A),
ANTONIO BARTORELLI (A, D), ERIKA BERTELLA (A), CARLOS M. CAMPOS (C),
MAURO PEPI (A), PATRICK W. SERRUYS (C, E), DANIELE ANDREINI (A, D),
CESARE FIORENTINI (A, D)
(a) CENTRO CARDIOLOGICO MONZINO, IRCCS, MILAN, ITALY; (b) HOSPITAL DE
SANTA CRUZ, CARDIOLOGY DEPARTMENT, CHLO, LISBON, PORTUGAL; HOSPITAL
DA LUZ, CARDIOVASCULAR CENTER, ESS, LISBON, PORTUGAL; CEDOC, CHRONIC
DISEASES RESEARCH CENTER, FCM-NOVA, LISBON, PORTUGAL; (c)
THORAXCENTER, ERASMUS MC, ROTTERDAM, THE NETHERLANDS; (d)
DEPARTMENT OF CLINICAL SCIENCES AND COMMUNITY HEALTH,
CARDIOVASCULAR SECTION, UNIVERSITY OF MILAN, ITALY; (e) DEPARTMENT OF
CARDIOLOGY, IMPERIAL COLLEGE LONDON
Objectives: To evaluate CT-adapted Leaman score (CT-LeSc) long-term prognostic value in patients
with suspected coronary artery disease (CAD).
Background: CT-LeSc was developed to quantify coronary CT angiography (CCTA) information
regarding atherosclerotic burden (lesion localization, stenosis degree and plaque composition).
Methods: Single-center prospective registry including 1304 consecutive patients undergoing CCTA
for suspected CAD. High CT-LeSc was defined by upper tercile (score >5) cut-off. Segment
involvement score (SIS) and segment stenosis score (SSS) were also evaluated. Hard cardiac events
(cardiac death and non-fatal acute coronary syndromes) were considered for analysis. Different Cox
regression models were used to identify independent event predictors. Kaplan-Meier event-free
survival was evaluated in 4 patient subgroups stratified by obstructive (≥50% stenosis) vs. nonobstructive CAD and a high (>5) vs. low (≤5) CT-LeSc.
Results: Of 1196 patients included in the final analysis (mean follow-up of 52±22 months), 125
patients experienced 136 hard events (18 cardiac deaths; 118 nonfatal acute coronary syndromes).
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All atherosclerotic burden scores were independent predictors of cardiac events (HRs of 3.09 for SIS,
4.42 for SSS and 5.39 for CT-LeSc). Cumulative event-free survival was 76.8% with high CT-LeSc
and 96.0% with low CT-LeSc. Event-free survival in non-obstructive CAD with high CT-LeSc
(78.6%) was similar to obstructive CAD with high CT-LeSc (76.5%) but lower than obstructive CAD
with low CT-LeSc (80.7%).
Conclusions: CT-LeSc is an independent long-term predictor of hard cardiac events. Patients with
non-obstructive CAD and high CT-LeSc had hard event-free survival similar to patients with
obstructive CA
CARDIOMIOPATIA TAKOTSUBO
O36
RIGHT VENTRICULAR INVOLVEMENT IN A LARGE COHORT OF TAKOTSUBO
CARDIOMYOPATHY
RODOLFO CITRO (e), GUIDO PARODI (b), GENNARO PROVENZA (c),
MARCO MARRANI (b), ANGELO SILVERIO (a), COSTANTINA PROTA (a),
BENEDETTA BELLANDI (b), EDUARDO BOSSONE (d), FEDERICO PISCIONE (a), Jorge
Salerno URIARTE (e)
(a) UNIVERSITY HOSPITAL SAN GIOVANNI DI DIO E RUGGI D´ARAGONA,
DEPARTMENT OF CARDIOLOGY, SALERNO, ITALY ; (b) CAREGGI UNIVERSITY
HOSPITAL (AOUC), DEPARTMENT OF CARDIOLOGY, FLORENCE, ITALY ; (c) CIVIL
HOSPITAL, DIVISION OF CARDIOLOGY, VILLA D´AGRI, POTENZA, ITALY ; (d) CAVA
DE´TIRRENI-AMALFI COAST HOSPITAL, DIVISION OF CARDIOLOGY, CAVA DE´
TIRRENI, SALERNO, ITALY; (e) DEPARTMENT OF HEART SCIENCES, CIRCOLO
HOSPITAL AND MACCHI FOUNDATION, UNIVERSITY OF INSUBRIA, VARESE, ITALY.
AIM OF THE STUDY: Is to describe the prevalence, clinical findings, echocardiographic features
and in-hospital course of patients with tako-tsubo cardiomiopathy (TTC) and right ventricular
involvement (RVi).
MATERIAL AND METHODS: The study population consisted of 495 consecutive pts (mean age
69.1 ± 11.5 years, 91% female) prospectively enrolled in Tako-tsubo Italian Network (TIN). Clinical
and demographic characteristics, as well as, ECG and serum findings was collected. Transthoracic
echocardiography was performed within 6 hours of hospital admission and right ventricular systolic
function was assessed visually from all available echocardiographic windows. Patients (pts) were
divided into two groups according to the presence (group A) or absence (group B) of RVi.
RESULTS: RVi was detected in 53 pts (10.7 %: mean age 68.2 ± 13.9 years, 92% female). At
admission, no significantly differences were found in systolic blood pressure (123.8 ± 22.9 vs 126.2
± 24.6 mmHg ; p = 0.542), diastolic blood pressure (74.6 ± 14.0 vs 74.6 ± 13.5 mmHg; p = 0.983 )
and heart rate (88.7 ± 17.2 vs 83.8 ± 18.3 bpm ; p = 0.073) between the two groups. The association
of chest pain with dyspnea was more prevalent in group A (25 vs 5%; p < 0.001), whereas chest pain
was the most common presenting symptom in patients without RVi (group B: 55 vs 74%; p = 0.003).
Any significant difference concerning the ECG changes at admission was found between the two
groups. Left ventricular ejection fraction (35.7 ± 6.6 vs 36,8 ± 7.1 % ; p = 0.306) and E/e’ ratio (11.6
± 4.1 vs 10.9 vs 3.9 p = 0.405) were not significantly different between the two groups. Tricuspid
annular plane systolic excursion (16.7 ± 4.3 vs 19.6 ± 4.0 ; p = 0.003) was lower and pulmonary artery
systolic pressure was higher (43.7 ± 14.6 vs 39.6 ± 9.8; p = 0.034) in patients of group A. RV area
change was significantly lower in group A compared to group B ( 26.7 ± 4.2 vs 41.1 vs 4.33; p <
0.001). Moderate to severe mitral regurgitation (36 vs 18%; p = 0.02), major adverse events (acute
heart failure and cardiogenic shock) were prevalent in group A pts (37 vs 17% , p = 0.001). COPD
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Roma, 13 – 15 dicembre 2014
(23 % vs 15%; p = 0.006), other non-acute cardiac disease (27 vs 13 %; p = 0.008) and actual or past
history of cancer, included previous treatment with chemotherapic agent (19 vs 9%: p = 0.034) were
more prevalent in patients with RVi. Furthermore total associated comorbidities were more frequent
in group A (1.25 vs 0.89 ; p= 0.032).
CONCLUSION: Patients with TTC and RVi have a different clinical profile and represent a subset
of patients at higher risk of in-hospital complications such as acute heart failure and cardiogenic
shock; thus aggressive therapeutic strategies should not be neglected or postponed in this setting.
O37
STUDIO DEL MICROCIRCOLO CORONARICO,VALUTATO TRAMITE IL TIMI
FRAME COUNT, IN PAZIENTI CON CARDIOMIOPATIA TAKO-TSUBO E ANGINA
MICROVASCOLARE
SALVATORE RIZZO (A), SALVATORE GIAMBANCO (A), ANGELO QUAGLIANA (A),
MARIA CRISTINA TERI (A), FRANCESCO GIAMBANCO (B), SALVATORE EVOLA (A),
SALVATORE NOVO (A), PASQUALE ASSENNATO (A), GIUSEPPINA NOVO (A)
(A) CATTEDRA E DIVISIONE DI CARDIOLOGIA, UNIVERSITÀ DI PALERMO; (B)
DIVISIONE DI CARDIOLOGIA, OSPEDALE INGRASSIA, PALERMO
Background. La cardiomiopatia tako-tsubo (CT) è una sindrome caratterizzata da disfunzione
sistolica, acuta e reversibile, coinvolgente più frequentemente in maniera circonferenziale i segmenti
basali ed apicali del ventricolo sinistro. La presentazione clinica ed elettrocardiografica mima spesso
una sindrome coronarica acuta, smentita un quadro coronarografico negativo per stenosi significative,
occlusione o rottura acuta di placca. Persistono incertezze sulle basi patogenetiche della sindrome;
fra le ipotesi avanzate in letteratura vi sono il danno epicardico multivasale coronarico, la
cardiotossicità catecolaminergica, lo stunning neurogeno miocardico e la presenza di alterazioni del
microcircolo coronarico.
Obiettivi. Scopo del nostro studio è stato quello di verificare la presenza di una disfunzione del
microcircolo coronarico in un gruppo di pazienti affetti da CT, confrontandoli con pazienti a coronarie
del tutto sane e privi di fattori di rischio cardiovascolare e con pazienti aventi una malattia del
microcircolo conclamata come l’angina microvascolare (MVA).
Materiali e Metodi. Sono stati valutati 71 pazienti affetti da CT, ricoverati presso le UTIC del
Policlinico Universitario e dell’AO Ingrassia di Palermo fra il 2007 e il 2014.La valutazione della
disfunzione microvascolare è stata ottenuta sulle immagini angiografiche attraverso il calcolo del
TIMI Frame Count (TFC), come stabilito dal gruppo di Gibson. La stessa valutazione è stata eseguita
in un gruppo di controllo costituito da 35 pazienti privi di fattori di rischio cardiovascolari e non
ischemici, sottoposti a CVG preoperatoria di routine per valvulopatia durante il medesimo periodo di
osservazione. Inoltre i pazienti con CT sono stati confrontati con una popolazione di 71 pazienti affetti
da MVA paragonabile per età, sesso e fattori di rischio.
Risultati. L'analisi del TFC ha mostrato valori significativamente alterati nei pazienti affetti da CT
rispetto ai controlli sani in ogni vaso coronarico considerato (IVA 25,16 ± 6,91 vs 17,3 ± 3,76,
p<0,001; CX 25,48 ± 6,1 vs 17,05 ± 4,6, p<0,001; CD 26,43 ± 8,95 vs 15,74 ± 4,27, p<0,001). Lo
stesso risultato è stato confermato sulla media dei valori riscontrati (TFC medio 25,7 ± 5,34 vs 16,7
± 3,26; p<0,001). L'entità della disfunzione microcircolatoria dei soggetti con CT, tuttavia, non ha
raggiunto i cut-off comunemente riconosciuti come patologici. L'analisi delle curve ROC ha
dimostrato che un TFC >20 frame è in grado di discriminare i pazienti con CT dai controlli sani con
specificità pari al 88,57% e sensibilità pari al 85,92% (AUC 0,927; p<0,0001). La disfunzione
microvascolare riscontrata è diffusa, non essendovi differenze statisticamente significative nel
confronto fra i tre vasi principali. Inoltre, considerando l’intera popolazione di pazienti con CT,
l’80,3% ha mostrato valori di TFC sopra il cut-off stabilito su almeno due vasi. La popolazione di
pazienti affetti da CT è stata quindi confrontata con una popolazione di pazienti affetti da MVA. I
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Roma, 13 – 15 dicembre 2014
pazienti con MVA hanno presentato TFC significativamente più alterati rispetto ai CT (TFC medio
in CT 25,7 ± 5,34 vs 28,25 ± 9,3 in MVA; p<0,001).
Conclusioni. I pazienti con CT mostrano una disfunzione microcircolatoria lieve e diffusa, non
rilevabile dai cut-off di normalità comunemente considerati. L'entità delle alterazioni è risultata
comunque inferiore rispetto ai pazienti con una malattia del microcircolo conclamata, come quelli
affetti da MVA. Le alterazioni del microcircolo nei pazienti con CT potrebbero esserne più che una
causa, un semplice epifenomeno dello stunning miocardico, peculiare nella fase acuta di malattia.
O38
I LIVELLI SIERICI DELLA CREATININA PREDICONO LA DURATA
DELL’OSPEDALIZZAZIONE E GLI EVENTI AVVERSI AL FOLLOW-UP IN PAZIENTI
CON CARDIOMIOPATIA TAKOTSUBO
FRANCESCO SANTORO (A), RICCARDO IEVA (A), ARMANDO FERRARETTI (A),
FRANCESCO MUSAICO (A), LUIGI FLAVIO MASSIMILIANO DI MARTINO (A),
GIUSEPPE TRIGGIANI (A), ANTONIO CENTOLA (A), NATALE DANIELE BRUNETTI (A),
MATTEO DI BIASE (A)
(A) DIPARTIMENTO DI CARDIOLOGIA, UNIVERSITA´ DI FOGGIA
Introduzione: Il ruolo prognostico della compromissione della funzione renale nella stratificazione
precoce del rischio nei soggetti con cardiomiopatia Takotsubo (CTT) è noto in misura estremamente
limitata. L’obiettivo di questo studio è stato pertanto valutare eventuali correlazioni tra i livelli della
creatinina sierica ed il follow-up a breve e lungo termine in soggetti con CTT.
Metodi: Settantotto soggetti consecutivi ricoverati per un episodio di CTT sono stati arruolati e
seguiti con un follow-up medio di 456 giorni. I livelli sierici della creatinina sono stati dosati
all’ingresso, per i primi 4 giorni di ricovero ed alla dimissione. Sono stati inoltre registrati la durata
dell’ospedalizzazione, l'incidenza di morte, riospedalizzazione per eventi cardiovascolari e recidiva
di CTT al follow-up.
Risultati: La degenza media ospedaliera è stata di 8,5 giorni; il 17% dei soggetti arruolati è incorso
in eventi avversi durante follow-up. I livelli sierici della creatinina al momento del ricovero erano
direttamente proporzionali alla durata del ricovero ospedaliero. (r 0,27, p <0,05).
L’incidenza di eventi avversi e la mortalità durante il follow up erano proporzionali ai valori di
creatinina all’ingresso (r 0,28, p<0.05 in entrambi i casi) ed ai valori di picco durante i primi 4 giorni
di ricovero (r 0,40 – 0,41, p<0,001).
Valori della creatinina <1.18 mg/dl escludevano l’incidenza di eventi al follow up con un potere
predittivo dell’88%
Conclusioni: Livelli aumentati della creatinina all’ingresso e durante i primi giorni di ricovero sono
associati ad una maggiore durata dell’ospedalizzazione e ad una maggiore incidenza di eventi avversi
durante il follow up. La creatinina potrebbe rappresentare un potenziale marker per la stratificazione
precoce del rischio nei soggetti con CTT.
O39
RISONANZA MAGNETICA CARDIACA NELLA DIAGNOSI DIFFERENZIALE DELLA
CARDIOMIOPATIA DI TAKO TSUBO.
GRAZIA CASAVECCHIA (A), ANTONIO TOTARO (A), MATTEO GRAVINA (B),
RICCARDO IEVA (A), NATALE DANIELE BRUNETTI (A), LUCA MACARINI (B),
MATTEO DI BIASE (A)
(A) DIPARTIMENTO DI CARDIOLOGIA, UNIVERSITÀ DEGLI STUDI DI FOGGIA; (B)
DIPARTIMENTO DI RADIODIAGNOSTICA, UNIVERSITÀ DEGLI STUDI DI FOGGIA
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Premessa: La cardiomiopatia Tako Tsubo (CTT) è una forma transitoria di scompenso cardiaco acuto
scatenata da stress fisici e/o emotivi che si presenta con una tipica disfunzione ventricolare sinistra
tipo apical ballooning. Lo studio del cuore con risonanza magnetica cardiaca (RMC) può essere utile
nella diagnosi di questa sindrome, particolarmente quando la diagnosi differenziale con la sindrome
coronarica acuta (SCA) non è semplice.
Metodi: Riportiamo due casi in cui, per la presentazione clinica sovrapponibile e per la presenza di
coronarie normali, si poneva il problema della diagnosi differenziale tra CTT e SCA. È stata eseguita
la RMC per distinguere queste due entità cliniche.
Risultati: La presenza di edema localizzato nei segmenti medio-basali della parete laterale e la
presenza di late enhancement nei segmenti basali della parete infero-laterale nel caso 1, erano
indicative di infarto miocardico con coronarie epicardiche normali e disfunzione del microcircolo. La
tipica localizzazione dell’edema ai segmenti medio-apicali del ventricolo sinistro in assenza di late
enhancement nel caso 2 era indicativa di CTT. La valutazione con RMC dell’edema miocardico e
della fibrosi miocardica può permettere la distinzione tra SCA e CTT.
Conclusioni: La RMC può fornire informazioni sulla caratterizzazione tissutale ed importanti
informazioni funzionali, che possono essere utili nella diagnosi di CTT e nella diagnosi differenziale
di SCA.
O40
TIME COURSE OF ELECTROCARDIOGRAPHIC AND ECHOCARDIOGRAPHIC
CHANGES IN TAKO-TSUBO CARDIOMYOPATHY.
RODOLFO CITRO (a), GUIDO PARODI (b), GENNARO PROVENZA (c),
MARCO MARRANI (b), COSTANTINA PROTA (a), ANGELO SILVERIO (a),
BENEDETTA BELLANDI (b), ARMANDO UGO CAVALLO (a), GIOVANNI VITALE (a),
CESARE BALDI (a), EDUARDO BOSSONE (d), FEDERICO PISCIONE (a)
(a) UNIVERSITY HOSPITAL SAN GIOVANNI DI DIO E RUGGI D´ARAGONA,
DEPARTMENT OF CARDIOLOGY, SALERNO, ITALY ; (b) CAREGGI UNIVERSITY
HOSPITAL (AOUC), DEPARTMENT OF CARDIOLOGY, FLORENCE, ITALY ; (c) CIVIL
HOSPITAL, DIVISION OF CARDIOLOGY, VILLA D´AGRI, POTENZA, ITALY ; (d) CAVA
DE´TIRRENI-AMALFI COAST HOSPITAL, DIVISION OF CARDIOLOGY, CAVA DE´
TIRRENI, SALERNO, ITALY
PURPOSE: Tako-tsubo cardiomyopathy (TTC) is characterized by transient myocardial dysfunction
and electrocardiographic (ECG) dynamic changes considered generally reversible within few weeks.
Aim of the study was to compare the time course of ECG and echocardiographic changes in patients
with TTC.
METHODS: Study population consisted of 55 patients (pts, mean age 64.9 ± 13.9 years, 91% female)
with TTC consecutively enrolled in two Italian hospitals according to Tako-Tsubo Italian Network
criteria. Data collection includes demographic, clinical and laboratory data. ECG and
Echocardiography were performed at admission, at discharge and at 2-month follow up. Patients with
(Group A) and without (Group B) ECG normalization at 2-months follow up were compared.
RESULTS: At 2-months follow up, most of pts (78.2%) completely recovered the wall motion
abnormalities previously detected at admission by echocardiography. No persistence of ST-segment
deviation was detected in the overall population while only a minority (36.3%) had no more ECG
changes of ventricular depolarization (Group A). The remaining 35 (63.7%) had persisting T-wave
inversion (Twi) with higher prevalence in anterior (p<0.001), antero-lateral (p<0.004) and inferior
(p<0.003) leads (Group B). No significant differences in age, sex prevalence, left ventricular ejection
fraction, peak troponin level, ballooning localization and in-hospital complication between the two
groups were detected. In group B only 11 patients (31.4%) had concomitant wall motion
abnormalities but in 24 patients (68.6%) normal regional myocardial contraction despite the
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persistence of Twi was appreciated. Interestingly, some ECG findings at admission such as wide STsegment elevation in V3 (1.39±1.24 vs 0.6±1.02; p=0.023), or at discharge, such as Twi in precordial
leads (94% vs 55%, p<0.001) were prevalent in group B compared with group A and seem to be
associated to delayed ECG recovery.
CONCLUSIONS: Despite complete functional normalization in the vast majority of patients, at 2
months follow-up an "uncoupling" between electrical and mechanical recovery of abnormalities may
occur in a significant proportion of TTC patients. ECG findings at admission are able to predict longterm persistence of electrocardiographic abnormalities.
O41
TROPONIN I/ EJECTION FRACTION RATIO: A NEW INDEX TO DIFFERENTIATE
TAKOTSUBO CARDIOMYOPATHY FROM MYOCARDIAL INFARCTION
SALVATORE GIAMBANCO (A), MARIA RITA SUTERA (A), VITO BONOMO (A),
FRANCESCO GIAMBANCO (B), ANTONINO ROTOLO (A), SALVATORE EVOLA (A),
PASQUALE ASSENNATO (A), SALVATORE NOVO (A), GIUSEPPINA NOVO (A)
(A) CATTEDRA E DIVISIONE DI CARDIOLOGIA, UNIVERSITÀ DI PALERMO; (B)
DIVISIONE DI CARDIOLOGIA, OSPEDALE INGRASSIA, PALERMO
Background: Takotsubo cardiomyopathy (TC) is a frequently stress-induced cardiac disorder, whose
symptoms resemble those of acute myocardial infarction (AMI).
Aim of our study was to investigate whether a non invasive tool, the ratio peak troponin I and ejection
fraction, could be useful to distinguish TC from AMI.
Methods: We enrolled 53 cases of TC and as a control group 53 AMI patients, both STEMI and
NSTEMI, matched for ejection fraction (EF), admitted to our institution between 2007 and 2014.
For each patient cardiovascular risk factors were recorded, a cardiological evaluation including
electrocardiogram and transthoracic echocardiogram was performed and serial troponin I levels were
measured. Moreover, the ratio between peak troponin I and left ventricular ejection fraction (LVEF)
at admission was calculated (TEFR).
Results: The peak troponin I level was significantly lower in patients with TC than in the AMI group
(6.52 ± 7.25 vs. 91.11 ± 117.91 ng/dl, p< 0.001). The TEFR was 16.31 ± 19.58 in TC and 230.83 ±
323.74 in AMI patients (p< 0.001). A TEFR value ≤ 60, derived from the receiver operating
characteristic (ROC) curve analysis, was the cut-off value with the best sensitivity (96.23%) and
specificity (84.91%) to differentiate TC from AMI.
Conclusions: The TEFR could be useful in differentiating TC from AMI at an early stage.
RESINCRONIZZAZIONE CARDIACA
O42
LA RIDUZIONE DELLE APNEE DI TIPO CENTRALE COME MARKER DI RISPOSTA
ALLA TERAPIA DI RESINCRONIZZAZIONE CARDIACA NEI PAZIENTI CON
SCOMPENSO CARDIACO CRONICO
MARIA VITTORIA MATASSINI (A), ALESSIA URBINATI (A), FEDERICO GUERRA (A),
MARIA AGNESE LATINI (A), SILVIA CESINI (A), ALESSANDRO CAPUCCI (A)
(A) CLINICA DI CARDIOLOGIA ED ARITMOLOGIA, OSPEDALI RIUNITI DI ANCONA,
UNIVERSITÀ POLITECNICA DELLE MARCHE
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Background: I disturbi respiratori del sonno (DRS) sono una comorbidità di frequente riscontro nei
pazienti con Scompenso Cardiaco (SC) e contribuiscono alla progressione dello stesso mediante
attivazione neuro-ormonale, alterazioni emodinamiche, promozione dello stress ossidativo e della
cascata infiammatoria. La terapia elettrica di resincronizzazione cardiaca (CRT) rappresenta uno dei
capisaldi di trattamento dello SC; tuttavia, circa il 30% non trae benedicio da tale scelta terapeutica.
Scopo dello studio è stato di valutare l’impatto dei DRS in termini di risposta clinica ed
ecocardiografica alla CRT nei pazienti con SC avanzato.
Metodi: 63 pazienti (60% M, età media 70 anni) con SC e indicazione ad impianto di CRT (35%
cardiopatia ischemica) sono stati arruolati e sottoposti a valutazione basale, a 6 e 12 mesi
dall’impianto di CRT mediante monitoraggio cardiorespiratorio, ECG a 12 derivazioni,
ecocardiogramma, dosaggio del BNP, questionario di Epworth per valutazione della sonnolenza
(ESSQ), questionario “Minnesota Living with Heart Failure Questionnaire” (MLHFQ), 6 min
walking test (6MWT). I pazienti sono stati divisi in due gruppi sulla base della presenza/assenza dei
DRS alla valutazione basale.
Risultati: Il 28% della popolazione in studio era affetto da apnee di tipo ostruttivo (OSAS) mentre il
32% da apnee di tipo centrale (CSA). I pazienti con CSA più frequentemente presentavano
comorbidità come ipertensione (94%), diabete (33%) ed insufficienza renale cronica (56%) ed
mostravano una maggiore compromissione della classe funzionale (67% in classe NYHA≥III). La
terapia di CRT ha determinato una significativa riduzione dell’incidenza e della severità delle CSA a
6 mesi fino alla totale scomparsa delle stesse a 12 mesi (p=0.014) con consensuale miglioramento
dello score di sonnolenza (ESSQ). Al contrario nessun effetto si è verificato nei confronti delle apnee
di tipo ostruttivo. Nel corso dello studio non si è evidenziata nessuna differenza tra i due gruppi in
termini di parametri elettrici (durata del QRS), ecocardiografici (volumi ventricolari e frazione
d’eiezione), classe funzionale NYHA e performance al 6MWT, con progressivo miglioramento di
tali parametri nella popolazione generale, come in ciascun sottogruppo di studio.
La percezione della qualità della vita valutata mediante MLHFQ è risultata, tuttavia, superiore nei
pazienti con CSA o senza DRS rispetto ai pazienti con OSA (p=0.027 e p=0.038, rispettivamente).
Conclusioni: la presenza di DRS non inficia la risposta clinica ed ecocardiografica alla CRT.
Tuttavia, la terapia elettrica di resincronizzazione riduce l’incidenza e la severità esclusivamente delle
apnee di tipo centrale e i pazienti con tale tipologia di DRS presentano una migliore percezione della
qualità della vita rispetto ai pazienti con OSAS.
O43
MIGLIORAMENTO A BREVE TERMINE DELL’ELASTANZA VENTRICOLARE
SINISTRA DOPO TERAPIA DI RESINCRONIZZAZIONE.
FRANCESCO MARIA ANGELO BRASCA (A), GIOVANNI BATTISTA PEREGO (A),
VALERIA RELLA (A, B), GABRIELLA MALFATTO (A), GIANFRANCO PARATI (A, B)
(A) DIVISIONE DI CARDIOLOGIA, OSPEDALE SAN LUCA, ISTITUTO AUXOLOGICO
ITALIANO IRCCS, MILANO; (B) DIPARTIMENTO DI MEDICINA CLINICA,
PREVENZIONE E BIOTECNOLOGIE SANITARIE, UNIVERSITÀ DI MILANO-BICOCCA
Premesse: La terapia di resincronizzazione cardiaca (CRT) migliora qualità di vita e capacità di
esercizio e riduce mortalità e ospedalizzazioni, ma con alta percentuale di “non responders” (fra 30%
e 50%). Alcuni parametri ecocardiografici di funzione sistolica e diastolica in basale sono stati
identificati come predittori di outcome, e le loro variazioni dopo CRT si associano a miglioramento
della prognosi. In particolare, CRT determina entro 6-12 mesi un miglioramento della funzione
diastolica. L’elastanza diastolica (KLV) è stata proposta per la valutazione dei pazienti sottoposti a
CRT. KLV è calcolabile non invasivamente, tramite il deceleration time dell’onda E mitralica, con la
formula di Little et al.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Scopo dello studio: Valutare se KLV basale o la sua variazione a 6 mesi predicano l’outcome a mediolungo termine di pazienti dopo CRT.
Materiali e Metodi: Abbiamo studiato 63 pazienti [pz: 75±9 anni; 26% donne; 53% eziologia
ischemica; 52% ipertesi; 29% diabetici; 41% storia di FA; 62% NYHA≥III; FE 30±7%]. Sono stati
esclusi pz: (1) deceduti entro 6 mesi dall’impianto (2) in FA durante ecocardiografia basale, (3) con
valvulopatia severa. In basale sono stati raccolti i dati ecocardiografici e clinici; a 6 mesi dall’impianto
sono state valutate le variazioni dei parametri ecocardiografici. L’incidenza cumulativa di mortalità
e ospedalizzazioni (M+O) è stata considerata come outcome. La relazione tra variazione di KLV ed
outcome è stata valutata con regressione di Cox.
Risultati: Al followup mediano di 36 mesi (range 12-48) l’incidenza di M+O è stata 61.7%. I 3 pz
deceduti hanno avuto almeno un’ospedalizzazione prima del decesso. KLV basale era 0.24 mmHg/mL,
maggiore in pz con storia di scompenso cardiaco acuto (0.28 vs 0.20 mmHg/mL; p < 0.05). KLV
basale risultava significativamente correlata con: volume telesistolico del ventricolo sinistro (VTS),
pressione polmonare (PAPs) e grado di insufficienza mitralica e tricuspidale. Nessuno dei parametri
basali considerati prediceva il successivo andamento clinico. A 6 mesi da CRT, nell’intera
popolazione si rilevava un trend di riduzione di KLV (0.20 vs 0.24 mmHg/mL; p = 0.06). La
regressione di Cox evidenziava significativa correlazione tra outcome ed entità della riduzione di KLV
a 6 mesi (p=0.027). Il miglioramento di FE e/o VTS non era predittivo di outcome. La sopravvivenza
libera da eventi nei pz con riduzione ( KLV<0) o aumento ( KLV>0) di KLV al FU è riportata in
Figura.
Conclusioni: Il nostro studio mostra come, nel followup di pazienti sottoposti a CRT, una riduzione
della rigidità del ventricolo sinistro si associ ad un miglior outcome a medio termine.
O44
POTENTIAL ROLE OF P WAVE DURATION AS A DETERMINANT OF THE OPTIMAL
ATRIO-VENTRICULAR DELAY IN CARDIAC RESYNCHRONIZATION THERAPY
ALESSIA AGRESTA (A), GIUSEPPE STABILE (B), SALVATORE IVAN CAICO (D, D),
PATRIZIA PEPI (E), MICHELE ACCOGLI (I), ANTONIO DE SIMONE (C),
ANTONIO D´ONOFRIO (G), LUIGI PADELETTI (F), MASSIMILIANO MARINI (J),
GIUSEPPE ARENA (K), GIAMPIERO MAGLIA (L), GENNARO MARESCA (A), GIOVANNI
LUCA BOTTO (M), EMANUELE BERTAGLIA (N), MAURIZIO MALACRIDA (H),
ANTONIO RAPACCIUOLO (A)
(A) DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY
OF NAPLES, ITALY; (B) CLINICA MEDITERRANEA, NAPOLI, ITALY; (C) CLINICA SAN
MICHELE, MADDALONI (CE), ITALY; (D) OSPEDALE SANT´ANTONIO ABATE,
GALLARATE (VA), ITALY; (E) OSPEDALE CARLO POMA, MANTOVA, ITALY; (F)
OSPEDALE CAREGGI, UNIVERSITÀ DI FIRENZE, FIRENZE, ITALY; (G) OSPEDALE
MONALDI, NAPOLI, ITALY; (H) BOSTON SCIENTIFIC ITALIA, MILANO, ITALY; (I)
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75° CONGRESSO NAZIONALE
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Roma, 13 – 15 dicembre 2014
OSPEDALE PANICO, TRICASE (LE), ITALY; (J) OSPEDALE SANTA CHIARA, TRENTO,
ITALY; (K) OSPEDALE SS GIACOMO E CRISTOFORO, MASSA, ITALY; (L) AO
PUGLIESE-CIACCIO, CATANZARO, ITALY; (M) AO SANT’ANNA, SAN FERMO DELLA
BATTAGLIA (CO), ITALY; (N) UNIVERSITA´ DI PADOVA, PADOVA, ITALY
Aims: Optimization of the atrioventricular (AV) delay may result in enhanced cardiac
resynchronization therapy (CRT) effectiveness.
Since the implantable device senses electrical activity in the right chambers of the heart, the
programmed AV delay determines the right heart AV timing, which may be significantly different
from the left heart AV timing in the presence of prolonged P-wave duration (PWd).
The aim of the study was to characterize the P-wave during spontaneous activation in an unselected
population undergoing CRT.
Methods: All baseline ECG were centrally analyzed and following variables were calculated: PWd,
End-P to Onset-QRS interval (EPQI), PR interval, P/PR ratio and the presence of a negative
component (NC) in lead V1. All interval measurements were made with digital calipers at a sweep
speed of 50 mm/s. As previously defined, we use PWd≥120ms and NC>1mm2 as cut-off values.
Results: A total of 470 consecutive patients in sinus rhythm were enrolled (male 69%, age
69±10years, 96% NYHA II/III, 48% ischemic etiology, 14% history of AF, 85% LBBB, left atrium
diameter 46±9mm).
Mean ECG characteristics were: PWd 98±23ms, PWd≥120ms in 24% of patients, EPQI 96±56ms,
PQ 193±60, P/PR 0.52±0.13, 60% of patients with a NC>1mm2. We found that longer PWd
(≥120ms) were associated both with longer EPQI (106±80 ms vs. 92±44ms, p=0.02) and with higher
NC≥1mm2 prevalence (71% vs. 56% 44ms, p=0.005). Higher P/PR were associated with longer PWd
(0.58±0.12 vs. 0.51±0.12 with PWd<120ms,
p<0.0001) and with NC≥1mm2 (0.54±0.11 vs. 0.50±0.13 with NC<1mm2, p<0.0001).
Conclusion: The suboptimal programming of the AV delay can lead to persistent AV dyssynchrony,
diastolic mitral regurgitation, and a reduction in cardiac output with attenuated CRT. Our results
suggest that the PWd has a significant impact on the PR interval, especially in patients with a PWD≥
120ms.
A longer PWd can lead the device in a late sensing of intrinsic P-waves. Moreover the electrical and
mechanical contraction of the atria could not be followed by a consistent AV coupling. Particular
attention should be paid to the AVD optimization in order to maximize the effectiveness of
biventricular pacing.
O45
IS THERE AN UPPER LIMIT OF QRS DURATION IN LEFT BUNDLE BRANCH BLOCK
ABOVE WHICH CARDIAC RESYNCHRONIZATION THERAPY FAILS TO PROVIDE
BENEFIT?
MATTEO BELTRAMI (A), LUIGI PADELETTI (A), SIMONA GAMBETTI (B),
MATTEO BERTINI (C), GIOSUÈ MASCIOLI (D), SABRINA BRESSAN (B),
GIUSEPPE FUCÀ (B), ALESSANDRO PAOLETTI PERINI (A), FEDERICO PACCHIONI (B),
MARIO PEDACI (B), FEDERICA MICHELOTTI (D), LETIZIA BACCHI REGGIANI (E),
BIAGIO SASSONE (B)
(a) INSTITUTE OF INTERNAL MEDICINE AND CARDIOLOGY, UNIVERSITY OF
FLORENCE, CAREGGI HOSPITAL, FLORENCE, ITALY; (b) CARDIOLOGY UNIT, SS.
ANNUNZIATA HOSPITAL, AUSL FERRARA, CENTO (FE), ITALY; (c) DEPARTMENT OF
CARDIOLOGY, UNIVERSITY OF FERRARA, S. ANNA HOSPITAL, FERRARA, ITALY; (d)
DEPARTMENT OF ARRHYTHMOLOGY, CLINICHE HUMANITAS GAVAZZENI,
BERGAMO, ITALY; (e) INSTITUTE OF CARDIOLOGY, UNIVERSITY OF BOLOGNA,
POLICLINICO S. ORSOLA-MALPIGHI, BOLOGNA, ITALY
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Aims. Left bundle branch block (LBBB) is the most reliable electrocardiographic predictor of
response to cardiac resynchronization therapy (CRT). However not all patients with LBBB will
respond to CRT. Our aim was to investigate the interaction between QRS duration, LBBB type
morphology and the response to CRT.
Methods and Results. We retrospectively analysed electrocardiograms of 243 patients who
underwent CRT implantation according to current clinical indications. A 6 month reduction of left
ventricular end-systolic volume >15% was used to identify CRT responders. The clinical endpoint
consisted of death, hospitalization for heart failure and sustained rapid ventricular tachyarrhythmias.
An LBBB morphology was present in 169 patients (70%) and 101 of these (60%) were responders to
CRT. Analysing the interaction between QRS duration and CRT response in LBBB patients a “U
shaped” distribution resulted, with nonresponders clustered between 120 and 130 ms and above 180
ms. The receiver operating characteristic curve analysis identified 178 ms as the optimal cut-off value
of QRS to predict a nonresponse to CRT [AUC = 0.67 (95% confidence interval 0.57 to 0.76)]. At
multivariate analysis only an ischaemic etiology and a QRS ≥178 ms were independent predictors of
non-responsiveness to CRT (AUC=0.75). LBBB patients with QRS ≥178 ms had greater likelihood
of adverse clinical events during a mean follow-up of 32 months (p=0.049).
Conclusions. In CRT patients with LBBB a marked QRS widening (i.e. ≥178 ms) is related to worse
echocardiographic response and lower event free survival rate as compared to patients with an
intermediate QRS widening.
O46
IDENTIFICAZIONE PRECOCE DEI RESPONDERS ALLA CRT
PATRIZIA CARITÀ (A), GIUSEPPE COPPOLA (A), EGLE CORRADO (A),
CINZIA NUGARA (A), ANGELA NOGARA (A), GIANFRANCO CIARAMITARO (A),
FEDERICA MICHELOTTI (B), SALVATORE NOVO (A), GIOSUÈ MASCIOLI (B),
PASQUALE ASSENNATO (A)
(a) POLICLINICO UNIVERSITARIO PAOLO GIACCONE PALERMO; (b) CLINICHE
HUMANITAS GAVAZZENI, BERGAMO
BACKGROUND: la resincronizzazione cardiaca (CRT) è una terapia elettrica ormai
convalidata in pazienti con scompenso cardiaco avanzato. Sfortunatamente nonostante i criteri
di selezione circa il 30 - 50% dei pazienti non risponde come previsto.
METODI: l’obiettivo del nostro studio è stato identificare predittori elettrocardiografici
precoci (post-impianto) di rimodellamento inverso dopo CRT. Abbiamo analizzato
retrospettivamente i dati riguardanti 100 pazienti consecutivi (67 ± 9 anni) sottoposti in due
centri ospedalieri a impianto di CRT (con o senza ICD) secondo le indicazione delle attuali
linee guida. Essi erano in classe NYHA II-IV, con FE del VS (LVEF) ≤ 35%,
indipendentemente dall’eziologia, e QRS largo. La “risposta” alla resincronizzazione è stata
definita come riduzione ≥ 10% del volume telesistolico sinistro (LVESV) al follow-up di sei
mesi. In accordo con precedenti studi, abbiamo utilizzato come predittore elettrocardiografico
di successo della CRT il QRS-index (QI) che indica la percentuale di variazione della durata
del QRS dopo stimolazione biventricolare (QRS post – pre / pre *100).
RISULTATI: il rimodellamento inverso ecocardiografico è stato riportato nel 72% dei
pazienti, con una riduzione del LVESV del - 31 ± 18% (- 47 ± 31 ml) [vs. + 9 ± 18% (10 ± 27
ml) nel gruppo dei non responder [p < 0.0001]. Il QI era significativamente più basso (valori
più negativi) nel gruppo responder (-16 ± 8, p=0.03) e significativamente correlato con la
percentuale di variazione del LVESV (YU index, r= +0.32). La curva ROC del QI e della
risposta alla CRT ha stimato un’AUC di 0.63 e ci ha permesso di identificare un QI < -10.67
quale valore cut-off con migliore rapporto tra sensibilità e specificità (rispettivamente 76% e
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
50%). Nel modello di regressione logistica il QI è risultato associate significativamente alla
risposta [1.24 (1.1 – 1.2), p=0.05].
CONCLUSIONI: a nostro avviso l'elettrocardiogramma periprocedurale (esame di facile accesso e
basso basso costo) attraverso il calcolo del QI può aiutare ad identificare un gruppo di pazienti
resincronizzati ad elevata probabilità di non risposta al follow-up. Tali pazienti andrebbero sottoposti
ad attento monitoraggio e all'ottimizzazione del dispositivo già nelle prime fasi post-impinato.
O47
RISULTATI PRELIMINARI DI UNO STUDIO IN ACUTO SULLA VARIAZIONE DEI
PARAMETRI EMODINAMICI DURANTE MULTI POINT PACING (MPP) RISPETTO
ALLA STIMOLAZIONE BIVENTRICOLARE TRADIZIONALE
LORENZA INAMA (A), MANUEL CERINI (A), MARCO BELOTTI (A),
FRANCESCA SALGHETTI (A), ALESSANDRO LIPARI (A),
FRANCESCA VASSANELLI (A), DAVIDE CASTAGNO (B), CHIARA SICILIANO (C),
MARCO PANUCCIO (D), LUCA BONTEMPI (A), ANTONIO CURNIS (A)
(A) DIVISIONE E CATTEDRA DI CARDIOLOGIA, SPEDALI CIVILI-UNIVERSITÀ DEGLI
STUDI, BRESCIA; (B) CATTEDRA DI CARDIOLOGIA, UNIVERSITÀ DEGLI STUDI DI
TORINO, TORINO; (C) CATTEDRA DI CARDIOLOGIA, UNIVERSITÀ DEGLI STUDI DI
PADOVA, PADOVA; (D) DIPARTIMENTO DI SCIENZE CARDIOVASCOLARI,
UNIVERSITÀ LA SAPIENZA, ROMA
Background: La stimolazione biventricolare nel corso degli anni, e attraverso i numerosi studi nei
quali sono stati arruolati più di dieci mila pazienti, si è dimostrata efficace nel determinare un
miglioramento emodinamico nonchè clinico significativi nel paziente affetto da scompenso cardiaco
cronico refrattario alla terapia medica ottimizzata. Tale risultato , nonostante gli sforzi finalizzati alla
selezione sempre più accurata dei pazienti e delle migliorie delle tecniche e dei materiali di impianto,
si limita ad a circa 60- 70 % della popolazione trattata.Al fine di ridurre la percentuale di pazienti
non-responder è stata introdotta una nuova modalità di stimolazione ventricolare sinistra : multi point
pacing (MPP). In tale stimolazione si utilizza un elettrocatetere ventricolare sinistro (LV)
quadripolare (Quartet model 1458Q, St.Jude Medical) connesso ad un device (Quadra Assura MP,
St. Jude Medical) in grado di erogare stimoli in diverse configurazioni e in diversi punti del ventricolo
sinistro contemporaneamente .
Il defibrillatore impiantabile è inoltre dotato di algoritmo MPP che fornisce indicazioni riguardo la
miglior configurazione di stimolazione per il paziente. Prime evidenze scientifiche hanno dimostrato
la superiorità della stimolazione MPP, valutate in acuto ed al follow-up medio breve, rispetto alla
CRT standard
Scopo dello studio: Valutare la variazione dei parametri emodinamici in diverse configurazioni di
stimolazione, Biventricolare standard (Biv) e Multipoint pacing (MPP).
Pazienti e Metodi: In 9 dei 10 pazienti candidati alla CRT (100% maschi, età 73 ± 6, classe NYHA
III-IV) ed impiantati con dispositivo biventricolare MPP sono stati valutati parametri emodinamici
usando il sistema Most Care ( Pressure Recording Analytical Method, PRAM; Vytech Health,
Padova, Italia).
In particolare sono stati analizzati :maximal pressure /time ratio ( dP/dT )- Cardiac output index (Coi)
-Stroke Volume index ( SVi) in diverse configurazioni di stimolazione Biv ed MPP, suggerite dal
dispositivo sulla base dei segnali elettrici.
Risultati: Tutti i valori ottenuti in acuto
nelle diverse configurazioni MPP risultano
significativamente migliorati rispetto al basale e alla stimolazione CRT tradizionale :
- dP/dT (mmHg/msec.): 14,65±14,72 in MPP vs 3,36%±4,81% in Biv ; p=0.043.
- Coi (l/minm2 ) (%): 26.44%±11.64 in MPP vs 15.31%±12.27 in Biv; p=0.028.
- SVi (ml/m2)(%) :15.83%±7.66in MPP vs 9.22%±6.62 in Biv ; p=0.046.
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Conclusioni: La stimolazione MPP, ottenuta attraverso un elettrocatetere quadripolare sinistro ed
ottimizzata permette di migliorare in maniera significativa l’emodinamica rispetto alla stimolazione
CRT tradizionale in acuto.
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 1
O48
HIGH-DOSE ATORVASTATIN PRE-TREATMENT IN PATIENTS UNDERGOING
PERCUTANEOUS CORONARY INTERVENTION: LONG-TERM FOLLOW-UP OF THE
ARMYDA (ATORVASTATIN REDUCTION FOR MYOCARDIAL DAMAGE DURING
ANGIOPLASTY) STUDIES.
ELISABETTA RICOTTINI (A), ANNUNZIATA NUSCA (A), ANNALISA GURRERI (A),
GIUSEPPE PATTI (A), MARCO MIGLIONICO (A), VINCENZO PASCERI (A),
GIUSEPPE COLONNA (A), GERMANO DI SCIASCIO (A)
(A) CAMPUS BIO-MEDICO UNIVERSITY OF ROME
Purpose: Statins exert significant “pleiotropic” effects such as improvement of endothelial function,
reduction of vascular inflammation and oxidative stress. On the basis of these evidences, the
ARMYDA (Atorvastatin Reduction for MYocardial Damage during Angioplasty) group designed a
series of randomized studies to investigate the benefits of statins in patients undergoing percutaneous
coronary intervention (PCI). In the ARMYDA and ARMYDA-ACS studies, a reduced incidence of
peri-procedural myocardial damage has been demonstrated in patients with both stable and unstable
syndromes receiving high-dose statin pre-treatment. In the ARMYDA-RECAPTURE trial, an acute
atorvastatin reload, in patients already on statin therapy at the time of PCI, was associated with a
significant 30-day clinical improvement. However, nowadays, no data are available on the possible
beneficial effects of pre-PCI high-dose statin treatment on long-term outcomes. Thus, the aim of this
analysis was to investigate this issue performing a clinical follow-up of all these above-mentioned
trials.
Methods: 237 patients receiving high-dose atorvastatin pre-treatment and 242 placebo were included
in this analysis. The specific trials’ design was previously reported. On long-term follow-up, the
occurrence of major adverse cardiac events (MACE), defined as death, acute myocardial infarction,
target vessel revascularization and coronary artery bypass graft, was evaluated. As secondary end
point, we analyzed the incidence of clinically driven in-stent restenosis (ISR).
Results: Clinical follow-up (mean 7818 months) was successfully completed in 396 patients (83%).
The primary composite end-point occurred in 20% (48) of patients receiving statin treatment at the
time of coronary stenting and in 31% (75) of those not pre-treated (p=0.007). The incidence of ISR
was 8% in the atorvastatin group vs 18% in the placebo arm (p=0.0015). Furthermore, the KaplanMeier curves showed an event-free survival of 78% in patients undergoing high-dose statin therapy
and 66% in controls (p=0.035).
Conclusions: according to the ARMYDA trials, high-dose atorvastatin therapy before PCI may be
associated also to a significant improvement also on long-term follow-up, with a reduced incidence
of MACEs and ISR. All these evidences should definitely influence clinical practice and warmly
support early initiation of statin therapy before PCI.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O49
CORRELATION BETWEEN
CARDIOVASCULAR RISK.
RHEUMATIC
AUTOIMMUNE
DISEASES
AND
FRANCESCA DE PASCALIS (A), PIETRO SCICCHITANO (A), FRANCESCA CORTESE (A),
MICHELE GESUALDO (A), ANNAPAOLA ZITO (A), GABRIELLA RICCI (A),
SANTA CARBONARA (A), ROBERTA RICCARDI (A), CINZIA ROTONDO (B),
LAURA COLADONATO (B), ANTONELLA NOTARNICOLA (B),
FLORENZO IANNONE (B), MARCO MATTEO CICCONE (A)
(A) CARDIOVASCULAR DISEASES SECTION, DEPARTMENT OF EMERGENCY AND
ORGAN TRANSPLANTATION (DETO), UNIVERSITY OF BARI, BARI, ITALY.; (B)
INTERDISCIPLINARY DEPARTMENT OF MEDICINE -RHEUMATOLOGY UNIT, SCHOOL
OF MEDICINE, UNIVERSITY OF BARI, BARI, ITALY.
Purpose: the aim of the study is to investigate whether rheumatic autoimmune diseases are associated
with an increased in Carotid Intima-Media Thickness (C-IMT) and to evaluate possible discrepancies
between different connective tissue diseases (CTD).
Methods: A total of 108 patients (93 females), mean age 51 ± 14 years suffering from CTD were
consecutively enrolled. Patients were subdivided in the following two groups: 1) Systemic Sclerosis
(SSc, 60 patients); 2) non-Systemic Sclerosis (NoSSc, 48 patients). All patients underwent structured
clinical interview, physical examination, laboratory evaluation and two-dimensional echo-color
Doppler of the carotid arteries in order to measure C-IMT and atherosclerotic plaques. Framingham
risk score was also calculated. We also enrolled 108 healthy controls (HC), matched by sex and age.
Results: There were no significant differences between SSc and NoSSc patients regarding any of the
demographics and traditional cardiovascular risk factors. Mean C-IMT was not significantly different
between the whole CTD patients (0.86 ± 0.13 mm) and HC (0.83 ± 0.13 mm). C-IMT was
significantly higher in SSc than in NoSSc group (0.91 ± 0.1 mm vs 0.80 ± 0.14 mm, p < 0.001).
Furthermore, C-IMT in SSc group was significantly higher than C-IMT in controls (0.91 ± 0.1 mm
vs 0.83 ± 0.13 mm, p< 0.001). C-IMT did correlate neither with disease activity nor with drug intake.
Conclusion: SSc patients had a significant increase in C-IMT as compared to NoSSc patients and
healthy controls.
O50
IMPATTO PROGNOSTICO DELL'INFARTO MIOCARDICO PERIPROCEDURALE
SECONDARIO AD ANGIOPLASTICA CORONARICA PERCUTANEA.
SEBASTIANO GILI (A), FABRIZIO D´ASCENZO (A), CLAUDIO MORETTI (A),
PIERLUIGI OMEDÉ (A), FILIPPO SCIUTO (A), FRANCESCA GIORDANA (A),
ANNA GONELLA (A), FRANCESCO COLOMBO (A), ENRICO CERRATO (A),
FLAVIA BALLOCCA (A), MARCO DI CUIA (A), GIADA LONGO (A), CHIARA COLACI (A),
ILARIA VILARDI (A), MAURIZIO BERTAINA (A), DAVIDE SALERA (A),
ALESSIO RAVIOLA (A), ELISA MISTRETTA (A), UMBERTO ANNONE (A),
GIUSEPPE BIONDI ZOCCAI (A), IMAD SHEIBAN (A), FIORENZO GAITA (A)
(A) DIVISIONE DI CARDIOLOGIA, CITTÀ DELLA SALUTE E DELLA SCIENZA TORINO
Introduzione. Diverse definizioni di infarto miocardico (IM) periprocedurale secondario ad
angioplastica coronarica percutanea (PCI) sono state proposte, ma il loro impatto prognostico non è
stato ancora univocamente definito.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Metodi. I dati procedurali di pazienti consecutivi sottoposti a PCI dal 2009 al 2011 sono stati rivisti
allo scopo di assegnare la diagnosi di IM periprocedurale in base all’incremento di CK-MB (>3 x
limite superiore della norma [LSN] e >5 x LSN), all’incremento di troponina T (> 3 x 99° percentile
LSN e > 5 x 99° percentile LSN) e in base alle recenti definizioni della Task Force 2012 per la
definizione universale di IM e della SCAI (Society for Cardiovascular Angiography and
Interventions). I MACE (eventi cardiovascolari avversi maggiori, cioè morte, reinfarto o rePCI) al
follow up costituivano l’end-point primario.
Risultati. 712 pazienti sono stati arruolati; dopo un follow up mediano di 771 giorni, 115 (16,7%)
sono andati incontro a MACE. La diagnosi di IM periprocedurale è stata assegnata in 190 pazienti in
base all’incremento di troponina T > 5 x 99° percentile del LSN. Applicando la definizione della Task
Force 2012 a tali pazienti, per 46 la diagnosi di IM periprocedurale è stata esclusa e di questi l’1,4%
ha sperimentato MACE (lo 0,3% è deceduto), mentre tra i 144 in cui la diagnosi di IM periprocedurale
è stata confermata, il 2,9% ha riportato MACE e l’1,3% è deceduto. In seguito all’applicazione della
definizione SCAI, 176 sono stati esclusi dalla diagnosi di IM periprocedurale (di questi, il 3,8% con
MACE e l’1,4% deceduti), mentre tra i 14 con la conferma della diagnosi di IM periprocedurale, lo
0,5% ha sperimentato MACE e lo 0,1% è deceduto. Simili limitate performance prognostiche sono
state riscontrate con le definizioni basati sul rialzo di CK-MB e sul rialzo di troponina T > 3 x 99°
percentile LSN. All’analisi multivariata, nessuna definizione è risultata correlare con eventi avversi
al follow up.
Conclusioni. L’IM periprocedurale rappresenta una frequente complicanza per i pazienti sottoposti
a PCI. Allo stato attuale, tutte le definizioni sperimentate presentano una risoluzione prognostica non
soddisfacente nel discriminare i pazienti con e senza eventi avversi al follow up, rendendo evidente
la necessità di introdurre definizioni più accurate.
O51
MILD THERAPEUTIC HYPOTHERMIA AFTER OUT-OF-HOSPITAL CARDIAC
ARREST SECONDARY TO MYOCARDIAL INFARCTION: ECHOCARDIOGRAPHIC
DATA
MATTEO CAMELI (A), BENEDETTA MARIA NATALI (A), STEFANO LUNGHETTI (A),
FLAVIO D´ASCENZI (A), RAFFAELLA DE VITO (A), ROMINA NAVARRI (A),
CRISTINA DI TOMMASO (A), CARLO PIERLI (A), ROBERTO FAVILLI (A),
SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA
Background: The use of Terapeutic Hypothermia (TH) in patients presenting with cardiac arrest due
to acute myocardial infarction has been reported in the literature of last years. Among many
physiologic effects of hypothermia, the potential to improve cardiac function and hemodynamics and
reduce end-organ damage from prolonged hypoperfusion could be the most relevant. Some studies
demonstrated hypothermia seems to be associated to a reduction of infarct size in myocardial
infarction. The aim of this study is to show left ventricular (LV) performance during and after
induction of mild hypotermia in patients admitted after successful resuscitation from out-of-hospital
cardiac arrest secondary to acute ST-elevation myocardial infarction (STEMI).
Methods: 11 consecutive patients (mean age 63 ± 8 years) admitted after successful resuscitation
from out-of-hospital cardiac arrest secondary to anterior STEMI were enrolled. Hypotermia was
performed via intravascular cooling by rapid infusion of cold saline (34°C), maintained for 24 hours.
All patient underwent successful percutaneuos revascularization. Transthoracic eco Doppler was
performed in all patients during TH and 48 h after the end of TH. The echocardiographic images were
analyzed off-line to calculate global longitudinal strain (GLS), obtained by averaging 4-, 2- and 3chamber view longitudinal strain values.
Results: Rewarming induced a significant increase in heart rate from 61 to 71 beats per minute.
Despite the increase of LV end diastolic diameter and volume (from 45 ± 8.2 to 51 ± 8.0 mm, p=0.07
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
and 48 ± 11.0 to 62 ± 12 ml, p=0.001, respectively), after rewarming was evident an increase of LV
ejection fraction and in particular of GLS (from 42.5 ± 4.3 to 51.9 ± 4.3%, p=0.01 and -9.0 ± 2.1 to 14.7 ± 2.2%, p<0.0001, respectively) and a reduction of E/A ratio (from 1.8 ± 0.9 to 1.3 ± 0.8,
p=0.001).
Conclusions: LV systolic and diastolic function improve in patients with out-of-hospital cardiac
arrest secondary to STEMI treated with TH after a successful reperfusion therapy.
O52
POSSIBILE RUOLO DELL'ANALISI DEL LONGITUDINAL STRAIN GLOBALE E SUBENDOCARDICO
IN
CORSO
DI
ECOSTRESS
CON
DOBUTAMINA
NELL'IDENTIFICAZIONE DEI SEGMENTI ISCHEMICI
SALVATORE FARCI (A), CHIARA DE TONI (A), FABIO PAU (A), STEFANO BANDINO (A),
FABIO ORRÙ (A), MARTINO DEIDDA (A), CHRISTIAN CADEDDU (A),
GIUSEPPE MERCURO (A)
(A) DIPARTIMENTO DI SCIENZE MEDICHE “M. ARESU“ - UNIVERSITÀ DEGLI STUDI DI
CAGLIARI
Scopo: lo strain bidimensionale derivato dall’analisi speckle tracking si è mostrato fattibile e accurato
nella stima quantitativa dell’ischemia miocardica in corso di ecocardiografia da stress. Recentemente
l’analisi dello strain longitudinale selettiva dei layers subendocardici si è rivelata fattibile durante
ecocardiografia da sforzo. Abbiamo voluto confrontare l’accuratezza dell’analisi segmentale a tutto
spessore nell’individuare ischemia miocardica con una valutazione specifica dello strato
subendocardico in 20 pazienti sottoposti a ecocardiogramma da stress con dobutamina e studio
angiografico coronarico.
Metodi e Risultati: lo strain longitudinale 2D è stato misurato nelle tre proiezioni apicali a riposo,
in corso di infusione di Dobutamina a bassa dose e al picco dello stress. Il picco di strain longitudinale
globale (G-Ɛ) e subendocardico (Endo- Ɛ) è stato misurato off line a riposo, a bassa dose e al picco
dello stress; i risultati sono stati confrontati con l’analisi qualitativa del wall motion e con la presenza
di malattia coronarica significativa (CAD con stenosi > 70% del diametro coronarico alla
coronarografia). 112 segmenti ischemici sono stati confrontati con 166 segmenti non ischemici. Le
variazioni dello strain longitudinale dal basale alla bassa dose e infine all’alta dose sono state
confrontate entrambe per l’analisi transmurale e subendocardica.
Sono stati ricavati i cut-off ottimali, la sensibilità e la specificità dalle curve ROC per i segmenti
ischemici. L’analisi segmentale del subendocardio ad alta dose si è mostrata in grado di aumentare in
maniera significativa l’accuratezza del test nell’individuare i segmenti ischemici (sens [95% IC]
90.2% [da 81.68% a 95.69%] vs 85.4% [da 75.83% 92.20%]; spec [95% IC] 93.1% [da 86.9% a 97%]
vs 92.2% [da 85.8% a 96.4%]). Per di più l’analisi segmentale dello strato subendocardico a bassa
dose di dobutamina ha mostrato di essere in grado di aumentare significativamente soprattutto la
specificità del test (sens [95% CI] 69.6% [da 58.4% a 79.2%] vs 68.3% [da 57,08% a 78,13%]; spec
[95% CI] 92.2% [da 85.8% a 96.4%] vs 86.2 [da 78.6% a 91,9%]). In particolare l’analisi segmentale
dello strain longitudinale del subendocardio a bassa dose ne ha incrementato la
specificità, raggiungendo quella ottenuta dall’analisi segmentale dello strain transmurale al picco
dello stress.
Conclusioni: la misurazione dello strain longitudinale segmentale con speckle tracking durante
infusione di dobutamina è fattibile e in grado di aumentare l’accuratezza del test. Inoltre l’analisi
specifica dello strain subendocardico in corso di DSE è in grado di raggiungere un’elevata specificità
per ischemia miocardica anche alle basse dosi di dobutamina.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O53
INFLUENZA DELLA RIASSEGNAZIONE CHIRURGICA E FARMACOLOGICA DEL
SESSO SUL PROFILO DI RISCHIO CARDIOVASCOLARE DEI SOGGETTI
TRANSESSUALI
GABRIELLA RICCI (A), PIETRO SCICCHITANO (A), FRANCESCA CORTESE (A),
MICHELE GESUALDO (A), ANNAPAOLA ZITO (A), SANTA CARBONARA (A),
MICHELE MONCELLI (A), ILARIA DENTAMARO (A), FRANCESCA L´ABBATE (A),
GIUSEPPE PARISI (A), GIUSEPPE LOVERRO (B), MARCO MATTEO CICCONE (A)
(A) DETO, SEZIONE DI MALATTIE DELL’APPARATO CARDIOVASCOLARE,
UNIVERSITÀ DEGLI STUDI DI BARI; (B) DIPARTIMENTO DI GINECOLOGIA ED
OSTETRICIA, UNIVERSITÀ DEGLI STUDI DI BARI
Obiettivo: valutare gli effetti cardiovascolari del cambiamento di sesso sia farmacologico che
chirurgico nei soggetti transessuali.
Metodi: abbiamo arruolato 13 soggetti transizionanti da femmina a maschio (FtM), 8 soggetti operati
da maschio a femmina (oMtF), 10 soggetti transizionanti da maschio a femmina non operati (noMtF)
e due gruppi controllo [il primo composto da 11 maschi (MC) ed il secondo da 17 femmine (FC)].
Gli MtF erano in trattamento sia estrogenico che di deprivazione androgenica, mentre gli FtM erano
trattati con testosterone. Tutti i soggetti sono stati sottoposti ad una valutazione antropometrica,
laboratoristica ed ultrasonografica [spessore intima-media carotideo (C-IMT) e vasodilatazione
flusso-mediata (FMD) dell'arteria brachiale]. Abbiamo confrontato: FtM vs MC, oMtF e/o noMtF vs
FC.
Risultati: i valori di C-IMT di sinistra erano significativamente più bassi negli FtM rispetto al gruppo
MC (0.56±0.05 mm vs 0.64±0.05 mm; p =0.025). Nessuna differenza statisticamente significativa è
stata trovata tra questi gruppi per quanto riguarda i valori di FMD (p =0.791). Sebbene gli oMtF
hanno mostrato uno stato infiammatorio sistemico rispetto al gruppo FC (livelli più elevati di leucociti
[7.3±0.8 x103/μL vs 6.0±0.5 x 103/μL; p=0.009] e di proteina C-reattiva [3.75±1.63 mg/dl vs
1.28±0.36 mg/dl; p =0.012]), non sono state trovate differenze statisticamente significative tra i due
gruppi per quanto concerne i valori di FMD e C-IMT di destra e sinistra (p =0.147, p =0.364 e p
=0.172, rispettivamente). Infine, gli noMtF hanno mostrato valori più bassi di FMD rispetto ai
controlli FC (6.4±1.1 vs 10.5±1.6; p<0,001).
Conclusioni: la riassegnazione farmacologica e chirurgica del sesso potrebbe influenzare il profilo
di rischio cardiovascolare degli individui, e l'intervento chirurgico di riassegnazione sessuale
potrebbe esercitare un ruolo protettivo (gli oMtF non hanno mostrato differenze nei valori di FMD
rispetto ai controlli, mentre gli noMtF hanno mostrato una riduzione della funzione endoteliale).
Tabella. Confronto tra valori di FMD dell'arteria brachiale e IMT carotideo in soggetti transizionanti da femmina a
maschio, operati da maschio a femmina e transizionanti da maschio a femmina non operati con controlli maschi e
femmine.
FtM
Controlli femmine
p
FMD
8.1 ± 1.3%
0.56 ± 0.05 mm
0.60 ± 0.07 mm
oMtF
7.9 ± 3.7%
0.585 ± 0.09 mm
0.585 ± 0.10 mm
noMtF
6.4 ± 1.1%
IMT sx
0.64 ± 0.13 mm
0.64 ± 0.05 mm
0.988
IMT dx
0.56 ± 0.09 mm
0.63 ± 0.06 mm
0.158
FMD
IMT sx
IMT dx
FMD
IMT sx
IMT dx
10.5 ± 1.6%
0.53 ± 0.04 mm
0.55 ± 0.04 mm
Controlli maschi
7.9 ± 1.7%
0.64 ± 0.05 mm
0.63 ± 0.06 mm
Controlli maschi
7.9 ± 1.7%
0.053
0.406
0.127
p
0.977
0.266
0.537
p
0.151
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
FtM: soggetti transizionanti da femmina a maschio; oMtF: soggetti operati da maschio a femmina; noMtF: soggetti transizionanti da
maschio a femmina non operati, FMD: flow mediated dilation; dx: destra; sx: sinistra; IMT: intima media thickness.
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 2
O54
IMPACT OF NEUTHROPHIL TO LYMPHOCYTE RATIO ON CORONARY ARTERY
DISEASE AND PLATELET AGGREGATION AMONG DIABETIC PATIENTS
MONICA VERDOIA (a), LUCIA BARBIERI (a), ALON SCHAFFER (a), GABRIELLA DI
GIOVINE (a), MATTEO NARDIN (a), PAOLO MARINO (a), GIUSEPPE DE LUCA (a)
(a) CLINICA CARDIOLOGICA, AOU MAGGIORE DELLA CARITA´, UNIVERSITA´ DEL
PIEMONTE ORIENTALE
Background. Coronary artery disease is the leading cause of mortality among diabetic patients.
Neutrophil to Lymphocyte Ratio (NLR) has recently emerged among inflammatory parameters as a
potential indicator of vascular complications and worse outcome in diabetics. Aim of our study was
to evaluate the impact of diabetes on NLR and its role in the extent of coronary artery disease (CAD)
and platelet aggregation in a large cohort of patients undergoing coronary angiography.
Methods. Consecutive patients undergoing coronary angiography were included. Diabetic status and
main chemistry parameters were assessed at admission. Significant CAD was defined as at least 1
vessel stenosis > 50%, while severe CAD as left main and/or trivessel disease, as evaluated by QCA.
Platelet function was assessed by PFA-100.
Results. Among 3756 patients, the 1377 (36.7%) diabetics were older and displayed a higher
cardiovascular risk profile and more complex coronary disease. Diabetic status was associated to a
significant increase in NLR levels (p=0.004). Among diabetics, higher NLR tertiles values were
related to ageing (p<0.001), dyslipidemia (p<0.001), renal failure (p<0.001), Body Mass Index
(p<0.001), previous percutaneous coronary revascularization (p=0.004) and cerebrovascular events
(p=0.003), acute presentation (p<0.001), therapy at admission with beta-blockers, statins, ASA
p<0.001, respectively), diuretics (p=0.01) and clopidogrel (p=0.04), platelets count (p=0.03), white
blood cells count, creatinine, glycemia, C reactive protein (p<0.001), while inversely with
haemoglobin, triglycerides levels (p<0.001) and smoke (p=0.03). NLR was associated with
multivessel disease (p<0.001), the percentage of stenosis (p=0.01), type C lesions (p=0.02), coronary
calcifications and intracoronary thrombus (p<0.001) but inversely with instent restenosis (p=0.003)
and TIMI flow (p=0.02). NLR was directly related with the prevalence of coronary artery
disease (p<0.001; adjusted OR[95%CI]=1.62[1.27-2.07], p<0.001) and with severe CAD (p<0.001;
adjusted OR[95%CI]=1.19 [1-1.43], p=0.05). Moreover, a direct relationship was found between
NLR and platelet aggregation, as evaluated by PFA-100.
Conclusion. Neutrophil to lymphocyte ratio is increased among diabetic patients. In diabetics, NLR
elevation is independently associated to the prevalence and severity of coronary artery disease and to
platelet reactivity.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O55
PEAK OXYGEN CONSUMPTION PREDICTS OUTCOME IN HYPERTROPHIC
CARDIOMYOAPATHY
CARLA CONTALDI (A), RAFFAELLA LOMBARDI (A), ALESSANDRA GIAMUNDO (A),
ELENA CHIACCHIO (A), SANDRO BETOCCHI (A)
(A) DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY
SCHOOL OF MEDICINE OF NAPLES, ITALY
Background: In Hypertrophic cardiomyopathy (HCM) cardiopulmonary exercise testing has proved
useful in the assessment of functional capacity, that is often reduced in HCM patients. While in
systolic heart failure peak oxygen consumption (VO2) is a strong and independent determinant of
prognosis, data to support a prognostic role of peak VO2 in HCM are lacking.
Objectives: The aim of this study is to assess if peak VO2 is a long-term predictor of outcome in
HCM patients.
Methods: We studied 92 HCM patients (40 ±15 years; 77% men). We excluded from the study
patients in dilative end-stage, with other associated heart diseases and non cardiac conditions
affecting exercise tolerance. All patients were off drugs at the time of protocol and underwent
symptom-limited exercise, soon after echocardiography. Peak VO2 was expressed in ml/min/Kg and
as percentage of the predicted value (calculated by using Wasserman and Hansen equations in order
to rule out the influence of age, sex, body weight, and the different kind of exercise). Clinical,
echocardiographic and cardiopulmonary exercise baseline variables were recorded. Patients were
followed up for 76±57 months. The primary endpoint was a composite one including atrial fibrillation
(AF), progression to NYHA class III or IV, myotomy-myectomy, heart transplantation, and cardiac
death. An ancillary endpoint included markers of heart failure (progression to NYHA class III or IV,
myotomy-myectomy, heart transplantion).
Results: At baseline, 62% of patients were asymptomatic, 35% was NYHA class II and only 3% was
NYHA class III; 26 % of patients presented with LVOT obstruction at rest. During follow up, 30
patients met the primary endpoint. The breakdown of individual endpoints was: 19 AF, 10
progressions to NYHA class III or IV, 6 myotomy-myectomies, 6 cardiac deaths, and 2 heart
transplantations. Of note, 27 mildly symptomatic or asymptomatic patients had events. Exercise
tolerance helps stratify these patients: 19% of these patients with percent predicted peak VO2 >80%
had events, as opposed to 53% of them with percent predicted peak VO2 < 55% (p= 0.04).
By multivariate Cox survival analysis, maximum LA diameter (hazard ratio (HR): 0.11; 95%
confidence interval (CI): 1.03 to 1.20), maximal wall thickness (MWT) (HR: 0.14; 95% CI: 1.03 to
1.28) and peak VO2 (HR: -0.10; 95% CI: 0.83 to 0.98) were determinant of prognosis; in the second
model, maximum LA diameter (HR: 1.12; 95% CI: 1.04 to 1.22), MWT (HR: 0.14; 95% CI: 1.04 to
1.28) and percent predicted peak VO2 (HR: -0.03; 95% CI: 0.95 to 0.99)(overall, p<0.0001)
independently predicted outcome. Kaplan-Meyer event-free survival for both endpoints was
significantly lower in patients with peak VO2< 15 ml/min/Kg as compared to those with peak VO2
between 15 and 20, and those with peak VO2 > 20 ml/min/Kg. In addition, event-free survival for
both endpoints was significantly lower in patients with a percent predicted peak VO2< 55% as
compared to those with percent predicted peak VO2 between 55 and 80, and >80%.
Conclusion: We found that severe exercise intolerance is often present in patients with mild or no
symptoms and may precede clinical deterioration. In HCM patients, peak VO2 provides excellent risk
stratification with a high event rate in patients with percent predicted peak VO2 <55%.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O56
HIGH PREVALENCE AT COMPUTED CORONARY TOMOGRAPHY OF NONCALCIFIED PLAQUES IN ASYMPTOMATIC HIV PATIENTS TREATED WITH HAART
ENRICO CERRATO (A), FABRIZIO D´ASCENZO (A), MARTINA PIANELLI (A),
MARGHERITA CANNILLO (A), FLAVIA BALLOCCA (A), UMBERTO BARBERO (A),
SEBASTIANO GILI (A), ELISA MISTRETTA (A), ALESSIO RAVIOLA (A),
DAVIDE SALERA (A), GIUSEPPE BIONDI-ZOCCAI (C), PIERLUIGI OMEDE´ (A),
MASSIMO MANCONE (B), WALTER GROSSO MARRA (A), CLAUDIO MORETTI (A),
FIORENZO GAITA (A)
(A) CITTA´ DELLA SALUTE E DELLA SCIENZA DI TORINO, UNIVERSITA´ DEGLI STUDI
DI TORINO.; (B) POLICLINICO UMBERTO I “SAPIENZA”, UNIVERSITA DI ROMA; (C)
DEPARTMENT OF MEDICO-SURGICAL SCIENCES AND BIOTECHNOLOGIES, SAPIENZA
UNIVERSITA´ DI ROMA, LATINA
Introduction. Prevalence and features of coronary plaques in HIV asymptomatic patients remain to
be determined.
Methods. Pubmed, Cochrane and Google Scholar were searched for articles evaluating asymptomatic
HIV patients evaluated with coronary computed tomography. The primary end point was prevalence
of coronary stenosis (more than 30%), while prevalence of coronary stenosis (more than 50%), of
calcified coronary (CCP), non-calcified coronary plaques (NCP) and of Coronary Artery
Calcification Score (CAC) more than 0 were the secondary ones.
Results. 9 studies with 1229 HIV patients and 1029 controls were included. HIV patients were more
frequently of male gender, with higher rates of diabetes mellitus and of hypertension (although not
significant). Prevalence of significant coronary stenosis (>30%) did not differ between HIV+ and
HIV- patients [42% (37-44) and 46% (35-52) with an Odds Ratio (OR) of 1.38 (0.86-2.20)]. Similarly
prevalence of coronary stenosis above 50% (15% 9-21 and 14% 7-22 with an OR of 1.11 [0.81-1.52]),
of CCP(31% 24-32 and 21% 14-30 with an OR of 1.17 [0.63-2.16] and of CAC above zero (43% 3948 and 46 26-56 with an OR of 0.88 [0.43-1,79] did not differ among HIV+ and HIV- patients. On
the contrary rates of NCP were significantly higher in HIV-positive patients [58% (48-60) and 17%
(14-27) with an OR of 3.26 (1-30-8.18)], with an inverse relationship with Cd4 cell count at metaregression (Beta -0.20 -0.35-0.18 p 0.04).
Conclusion. Asymptomatic HIV patients present with higher rates of non-calcific coronary plaques
at computed tomography, especially those with low Cd4 cell counts.
O57
TRANSCORONARY GRADIENT OF CIRCULATING MICRORNAS IN HEART FAILURE
JOLANDA SABATINO (A), SALVATORE DE ROSA (A), OVIDIO DE FILIPPO (B),
CLARICE GARERI (A), GENNARO MARESCA (B), ALESSIA AGRESTA (B),
ELISA KOCI (B), ANNUNZIATA CERRONE (B), ANTONIO CURCIO (A),
ANTONIO RAPACCIUOLO (B), CIRO INDOLFI (A)
(A) LABORATORIO DI CARDIOLOGIA MOLECOLARE E CELLULARE, UNIVERSITÀ
MAGNA GRAECIA, CATANZARO; (B) CARDIOLOGIA, UNIVERSITÀ FEDERICO II,
NAPOLI
Background. Circulating levels of microRNA (miRs) are emergent promising biomarkers for
cardiovascular disease. In particular, altered expression of miRs has been related to heart failure and
cardiac remodeling. To identify the heart as a potential source for miRs released into the circulation,
we measured the concentration gradients across the coronary circulation for the miR-34a, whose
levels have been associated to LV-remodeling and prognosis, miR-126, whose decrease has been
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
associated to an impaired cardiac repair capacity, and the miR-21*, that was recently shown to be
actively involved in mediating HF and LV-hypertrophy.
Methods and Results. Circulating miRs were measured by TaqMan polymerase chain reaction in
EDTA-plasma simultaneously obtained from the aorta (Ao) and the coronary venous sinus (CVS) in
patients with non-ischemic heart failure (nonICM-HF, n=6), or ischemic heart failure (ICM-HF)
(n=6). Circulating levels of the miR-34a (4.3-fold) and the miR-21* (1.5-fold) were increased in
nonICM-HF compared to ICM-HF patients. On the contrary circulating levels of miR-126 were
substantially decreased in nonICM-HF as compared to ICM-HF patients. Interestingly, there was a
significant increase in circulating levels of miR-34a and miR-21* across the coronary circulation in
our HF population, suggestive of a release into the coronary circulation during myocardial injury.
Moreover, an 8-fold increase in circulating levels of miR-126 across the coronary circulation was
specifically observed in the nonICM-HF patients group.
Discussion and Conclusions. Circulating levels of miR-34a and miR-21* are increased, while miR126 levels are decreased, in non-ischemic Heart Failure patients compared to HF of ischemic origin.
Interestingly, miR-34a and miR-21* are seemingly released from the heart into the coronary
circulation in Heart Failure patients, as their levels in the CVS are higher than in the Ao. Interestingly,
a substantial release of the miR-126 into the coronary circulation was specifically found in nonischemic HF. The differential regulation of circulating miRs during the transcoronary passage in HF
might provide important information to better understand their role in HF and foster their use as
cardiac biomarkers
IMAGING CARDIOVASCOLARE - CUORE D'ATLETA
O58
P-WAVE MORPHOLOGY IS UNAFFECTED BY BIATRIAL SIZE: A LONGITUDINAL
STUDY EVALUATING BIATRIAL SIZE, BIATRIAL STIFFNESS, AND ECG CRITERIA
FOR BIATRIAL ENLARGEMENT IN ATHLETES AND CONTROL SUBJECTS
FLAVIO D´ASCENZI (A), MICHELE BIAGI (A), FRANCESCO CASSANO (A),
MATTEO CAMELI (A), MARCO SOLARI (A), MARTA FOCARDI (A),
MARGHERITA PADELETTI (A), MARCO BONIFAZI (B), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA, SIENA,
ITALY; (B) DEPARTMENT OF MEDICINE, SURGERY, AND NEUROSCIENCE,
UNIVERSITY OF SIENA, SIENA, ITALY
Background. Biatrial enlargement is common in athletes and a further increase in biatrial size can
occur in response to training during the competitive season. P-wave mophology seems to be
unaffected by atrial size, however few studies have been conducted and no specific data based on inseasonal repeated measures are available in top-athletes. Thus, the aim of this study was to investigate
whether biatrial enlargement occurring in response to training is able to change the ECG pattern in
athletes.
Methods. Thirty-three professional, top-level athletes were evaluated at the beginning of the
competitive season and after 6 months of training. Twenty-two sedentary subjects were used as
controls. Athletes and controls were evaluated by ECG and both standard and 2D speckle tracking
echocardiography.
Results. As expected, athletes had greater left atrial (LA) and right atrial (RA) size as compared with
controls (p<.0001). After 6 months of training, a further increase in left and right atrial size was
observed (p=.002 and p=.005, respectively). The increase in biatrial size was accompanied by an
increase in both left and right ventricular dimensions (p<.001 and p<.05, respectively). Neither
athletes nor controls fulfilled the criteria for RA enlargement. No significant differences exist
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between athletes and controls for criteria for LA enlargement, although 6% of athletes fullfilled the
ECG criteria for LA enlargement. After training, despite an increase in LA size, the percentage of
athletes fulfilling the criteria for LA enlargement did not vary. Of note, biatrial stiffness was normal
both in athletes and in controls.
Conclusions. Despite a greater biatrial size as compared with controls and despite a further traininginduced increase in biatrial dimensions during the season, in top-level athletes ECG criteria for
biatrial enlargement do not significantly vary during the season. The finding of a normal biatrial
stiffness suggests that, in absence of intra-atrial delay and in presence of a physiological global
remodelling, no pathological findings can be detected at 12-lead ECG. Thus, our findings suggest
that, when biatrial enlargement is identified at 12-lead ECG at pre-participation screening, further
investigations are needed to exclude underlying cardiac diseases.
O59
DIFFERENZE INTERETNICHE NELLA STRUTTURA E NELLA FUNZIONE DEL
CUORE DI ATLETI ADOLESCENTI: STUDIO CON ECOCARDIOGRAFIA DOPPLER
TISSUTALE
ANTONIO CROCAMO (A), MARGHERITA ILARIA GIOIA (A), MARINA GIANFREDA (A),
MAURO LI CALZI (A), ELEONORA MOCCIA (A), LUISA MUSIARI (A),
MATTEO GOLDONI (A), ALBERTO MONTANARI (A), GIOVANNA PELÀ (A)
(A) DIPARTIMENTO DI MEDICINA CLINICA E SPERIMENTALE
Come già dimostrato da un recente studio del nostro gruppo, l'etnia è un fattore determinante per gli
adattamenti morfologici del ventricolo sinistro (VS) indotti dall'esercizio fisico anche in atleti
adolescenti amatoriali: gli atleti adolescenti di etnia africana (A), mostrano, rispetto ai coetanei
caucasici (C), valori di massa (LVM), spessori del setto interventricolare (SIV) e della parete
posteriore (PP) maggiori con un rimodellamento concentrico, senza variazioni significative
dei parametri sistolici e diastolici stimati con tecnica convenzionale. Lo scopo del nostro lavoro è
stato quello di studiare le eventuali differenze funzionali del cuore di atleti adolescenti di diversa etnia
mediante l’Ecocardiografia Doppler Tissutale (EDT), applicata non solo allo studio del VS ma anche
destro (VD). Abbiamo esaminato 72 atleti adolescenti (età media 13.8+1.7, 12-17), 54 C e 18 A, di
sesso maschile, impegnati in attività agonistiche di tipo aerobico, con simili protocolli di allenamento.
Tutti i partecipanti sono stati sottoposti a valutazione clinica, ECG e ad ecocardiogramma, con misura
degli spessori, dei diametri, della LVM del VS, utilizzando il “relative wall thickness” (RWT) quale
indice di geometria. L’EDT è stata eseguita analizzando le escursioni dell’anello mitralico a livello
del SIV, della PP e della parete laterale (PL), per lo studio del VS, e quelle dell’anello tricuspidalico
per il VD. In ogni sede sono stati ricavati le velocità di picco (pv) e gli integrali (int) dell'onda sistolica
(S) e delle onde diastoliche (E' ed A'). I due gruppi non differivano per età, massa corporea (BSA),
pressione arteriosa sistolica (PAS) e diastolica e frequenza cardiaca (FC). Gli A, in assenza di
differenze significative per diametri, volumi, frazione d'eiezione, presentavano maggiori spessori del
VS, con più elevati LVM ed RWT, a conferma di un preferenziale rimodellamento concentrico
dipendente dall’etnia. La funzione diastolica, basata sullo studio doppler dei flussi transmitralico e
transtricuspidalico, era sovrapponibile nei due gruppi. Tuttavia, all’EDT si rilevavano onde E’
significativamente inferiori negli A rispetto ai C nelle diverse sedi, sia nel VS (SIV pv:13+2 vs 15+3
cm/s, p<0.01; int:1.28+0.31 vs 1.52+0.38 cm, p <0.05; PL pv: 19+4 vs 23+4 cm/s, p=0.001; int:
1.64+0.36 vs 1.92+0.45 cm, p<0.05; PP pv:17+4 vs 20+5 cm/s, p<0.01), sia nel VD (pv: 14+4 vs
17+4 cm/s, p < 0.05). L’onda S era lievemente ridotta negli A in tutte le sedi del VS con valori
significativi degli integrali ricavati a livello del SIV (1.64+0.36 vs 1.85+0.30 cm, p<0.05) e della PL
(1.82+0.29 vs 2.13+0.54 cm, p<0.05) ma non nel VD. All'analisi di regressione lineare multipla,
considerando come variabili indipendenti etnia, età, PAS, FC, BSA e diametro diastolico del VS
(DTD), l'etnia risultava essere l’unico predittore dell’onda E' ricavata sul SIV (E’pv: p=0.011; E’int:
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Roma, 13 – 15 dicembre 2014
p=0.047) e sulla PL (E’pv: p=0.002; E’int: p=0.044); in quest’ultima sede si osservava tuttavia anche
un effetto del DTD sull’int E’ (p<0.05). Simile dipendenza da etnia e DTD si osserva sul pv di E’ a
livello della PP del VS (p=0.011, p=0.016, rispettivamente). L’etnia anche era l’unica
determinante dell’onda S sulla PL (p=0.034) e, insieme alla FC (p<0.01), prediceva l’onda S sul
SIV (p=0.011). Anche sul VD solo l’etnia prediceva E’ (p=0.040). Conclusioni: Il cuore degli atleti
adolescenti d'etnia africana, rispetto ai coetanei caucasici, presenta, oltre ad una maggior ipertrofia
concentrica, una riduzione delle onde tissutali, in particolare quelle diastoliche. L’etnia africana
determina quindi, non solo un peculiare rimodellamento strutturale del VS con maggiore ipertrofia
concentrica, ma anche modificazioni nella funzione diastolica di ambedue i ventricoli, con minore
rilasciamento.
O60
GLOBAL AND SEGMENTAL VALUES AND DETERMINANTS OF SPECKLE
TRACKING AFI LONGITUDINAL SYSTOLIC STRAIN IN NORMAL SUBJECTS
P BARBIER (A), O MIREA (B), M GUGLIELMO (A), G SAVIOLI (C), C CEFALÙ (A),
A MALTAGLIATI (A)
(A) CENTRO CARDIOLOGICO MONZINO, IRCCS, MILANO, ITALY ; (B) EMERGENCY
COUNTY HOSPITAL, DEPARTMENT OF CARDIOLOGY, CRAIOVA, ROMANIA; (C)
FOUNDATION IRCCS POLYCLINIC SAN MATTEO, MEDICAL CLINIC II - UNIVERSITY
OF PAVIA, PAVIA, ITALY
Purpose. Echocardiographic 2D speckle tracking left ventricular (LV) peak systolic longitudinal
strain (PSLS, %) has been proposed as an index of LV systolic function to detect “pre-clinical”
(normal ejection fraction, EF) LV dysfunction, given it can easily be calculated online using
Automated Function Imaging (AFI) technology. However, availability of normal values is limited
especially at segmental level, and knowledge of determinants of PSLS is poor.
Methods. We studied 100 normal subjects (including normal stress echocardiography; age: 43±14 y,
range 14-87 y; HR: 67±12, 45-114 bpm) undergoing comprehensive 2D and Doppler
echocardiography using GE Vivid7/9 systems and onboard AFI (v112) strain analysis derived by LV
wall tracking of the 18 myocardial segments in the 3 apical views.
Results. Normal mean LV global AFI-derived PSLS was -21±2% (5-95% CI= -25, -17), with lowest
values in the basal septum and anterior wall, and highest in the apical septum and inferior wall
(Table); on average, PSLS increased significantly from base to apex (p<.001). At multiple regression
analysis, global PSLS was positively determined by mitral valve peak E wave, LV ejection fraction,
right ventricular TAPSE, left atrial compliance (maximum LA volume – minimum / minimum x 100),
and tissue Doppler peak mean mitral annuls systolic velocity, and negatively influenced by LV
myocardial performance index (TEI), BSA and mitral E/A peak ratio (r=.77, r2= 0.6, p<.001). Of
note, at factorial ANOVA analysis, increasing image resolution (Vivid 9 vs. 7 imaging) increased
global PSLS (p= .002). Age and heart rate did not influence PSLS in our normal subjects.
Conclusions. Normal AFI-derived peak systolic strain shows significant segmental and base to apex
heterogeneity. Normal LV global systolic strain is influenced by a complex interaction of LV systolic
and diastolic function, RV systole (mediated by the septum) and left atrial compliance, with
ultrasound system dependent image resolution also playing a role.
Table. Normal segmental values for AFI peak systolic strain.
mean±SD %
Base
Septum inf.
Septum ant.
Anterior
Lateral
Posterior
Inferior
‐18±3
‐18±3
‐18±4
‐20±4
‐20±4
‐21±4
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Papillary
Apex
Roma, 13 – 15 dicembre 2014
‐21±3
‐22±3
‐21±4
‐20±3
‐20±4
‐23±3
‐26±5
‐24±5
‐23±5
‐23±5
‐22±4
‐26±4
O61
STUDIO DEL METABOLISMO MIOCARDICO CON SPETTROSCOPIA A RISONANZA
MAGNETICA: CARDIOMIOPATIA IPERTROFICA (CMI) VERSUS CUORE D’ATLETA
FRANCESCO SECCHI (A), RICCARDO SPAIRANI (A), MARCELLO PETRINI (A),
GIOVANNI DI LEO (A), FRANCESCO SARDANELLI (A), MASSIMO LOMBARDI (A)
(A) IRCCS POLICLINICO SAN DONATO
Scopo: Valutare il metabolismo energetico miocardico in pazienti affetti da CMI e in atleti rispetto a
soggetti sani non allenati attraverso spettroscopia al fosforo (31P-MRS) e all’idrogeno (1H-MRS).
Materiale e Metodi: Sono stati eseguiti studi di RM cardiaca (1.5-T) in 24 soggetti: 10 atleti (A), 7
pazienti con CMI (H) e 7 volontari sani (V). Sono state acquisite sequenze cinetiche, 1H-MRS e 31PMRS. La funzione ventricolare è stata calcolata segmentando le immagini cinetiche (Syngo-Argus
software). Gli spettri di 1H-MRS sono stati analizzati con il software jMRUI mentre quelli di 31PMRS con il software Spectroscopy-Argus. Sono stati utilizzati i test di Kruskal-Wallis e JonckheereTerpstra. I dati sono riportati come mediane (intervallo interquartile).
Risultati: La frazione di eiezione (%), il volume telediastolico (ml/m2), il volume telesistolico
(ml/m2), la massa (g/cm2) e lo spessore settale (mm) sono risultati di 68, 95, 30, 72 e 10 per il gruppo
A, rispettivamente; 68, 73, 20, 81 e 18 per il gruppo H, rispettivamente; 63 (p=0.865), 78 (p=0.011),
29 (p=0.013), 45 (p=0.008) e 6 (p<0.001) per il gruppo V, rispettivamente. La PCr, γATP e il Pi sono
risultati di 25, 5.3, 0.3 per il gruppo A, rispettivamente; 22, 5.4, 0.4 per il gruppo H, rispettivamente;
27 (p=0.428), 6.2 (p=0.701), and 0.0 (p=0.114) per il gruppo V, rispettivamente. Il rapporto
PCR/γATP era di 5.2 nel gruppo A, 3.7 nel gruppo H e 4.2 nel gruppo V (p=0.307); la creatina totale
era di 0.7, 0.6, e 0.0, rispettivamente (p=0.037); i lipidi erano di 0.0, 1.5, e 0.2, rispettivamente
(p=0.042).
Conclusioni: Si conferma l’esistenza di un’alterazione del metabolismo energetico cardiaco nei
pazienti affetti da CMI rispetto ai soggetti sani ed agli atleti
O62
EXERCISE-INDUCED LONGITUDINAL CHANGES IN LEFT VENTRICULAR STRAIN
IN TOP-LEVEL ATHLETES: A NOVEL COMPONENT OF ATHLETE'S HEART
FLAVIO D´ASCENZI (A), FEDERICO ALVINO (A), VALENTINA ANDREI (A),
CAMELI MATTEO (A), ANTONELLA LOFFRENO (A), MATTEO LISI (A),
MARCO SOLARI (A), STEFANO LUNGHETTI (A), ALESSANDRO ZORZI (B),
MARTA FOCARDI (A), MARCO BONIFAZI (C), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA, SIENA,
ITALY; (B) DIVISION OF CARDIOLOGY, DEPARTMENT OF CARDIAC, THORACIC AND
VASCULAR SCIENCES, UNIVERSITY OF PADOVA, PADOVA, ITALY; (C) DEPARTMENT
OF MEDICINE, SURGERY, AND NEUROSCIENCE, UNIVERSITY OF SIENA, SIENA,
ITALY
Purpose. Left ventricular (LV) longitudinal strain, a recognized marker of LV function in several
cardiomyopathies, has recently been investigated in the setting of athlete’s heart. Although it
represents a useful tool to differentiate between athlete’s heart and cardiomyopathies, longitudinal
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
data characterizing the impact of training on LV longitudinal strain in a large cohort of top-level
athletes have not yet been reported.
Methods. 87 top-level athletes practising football, basketball, and volleyball were enrolled. Athletes
were studied at the beginning of the season and after 16±2 weeks of a supervised, intensive training
program, >15 hours per week. Athletes were excluded from the final analysis if they withdrew from
the training program >2 weeks for musculoskeletal injuries of if they were moved to other club before
the post-training measurement. For these reasons, 6 athletes were excluded and the final study
population consisted of 81 athletes (age: 27±3 years, 66% male).
Results. After training a significant increase in LV mass (81.8±19.9 vs. 92.6±22.7 g/m2, p<.0001)
and in LV end-systolic volume (22.4±6.4 vs. 25.7±6.2 mL/m2, p<.0001) was found, while neither LV
end-diastolic volume (59.9±11.8 vs. 61.1±13.6 mL/m2, p=.263) nor LV ejection fraction (63.1±5.9
vs. 62.7±5.3 %, p<.0001) did change after training. Conversely, a significant increase in LV
longitudinal strain was found after training (-19.0±3.6 vs. -20.2±2.1, p=.001).
Conclusions. Participation in an intensive training program was associated with significant changes
in LV longitudinal strain. These findings suggest that the increase in LV strain is a novel component
of exercise-induced adaptations of the athlete’s heart and the in-seasonal changes in LV strain need
to be taken into account when evaluating an athlete for cardiomyopathies.
O63
LEFT VENTRICULAR CONTRACTILE RESERVE AS A NEW PROGNOSTIC FACTOR
IN SYSTEMIC SCLEROSIS PATIENTS
STEFANIA PALMAS (A), GIUSEPPINA GIAU (A), ROBERTA PIRAS (A),
CHRISTIAN CADEDDU (A), MARTINO DEIDDA (A), ANNA MARIA SETTEMBRINI (A),
FRANCESCA NONNE (A), MARIO MURA (A), STEFANO DEL GIACCO (A), PAOLO
EMILIO MANCONI (A), GIUSEPPE MERCURO (A)
(A) DIPARTIMENTO DI SCIENZE MEDICHE “M. ARESU“ - UNIVERSITÀ DEGLI STUDI DI
CAGLIARI
Introduction. Several studies evidenced high prevalence of myocardial systolic and diastolic
dysfunction among patients with systemic sclerosis, related either to myocardial fibrosis or in some
cases to a myocardial microvascular dysfunction. Exercise echocardiography has been used to
identify a subset of SS patients with an inappropriate exercise-induced increase in PASP but the
diagnostic and prognostic role of this test is still unclear.
The aim of our study was to evaluate left ventricle impairment under exercise and its prognostic value
among patients with systemic sclerosis.
Methods. We studied 25 patients (age 62,1±10 years; 2 male, 23 female) with systemic sclerosis.
Patients with Interstitial Lung Disease were excluded from the study. All patients performed a clinical
evaluation, a 2D echocardiography associated with Tissue Doppler (TD) and speckle tracking (ST)
imaging to evaluate left ventricular deformation indexes, an exercise echocardiography to evaluate
left ventricle contractile reserve (LVCR) and exercise pulmonary pressures, and a 6 minute walking
test (6MWT) to evaluate the exercise tolerance was performed. All patient performed a clinical
evaluation and a 2D echocardiography associated with TD and ST at follow up of 4,2 ± 0,2 years.
Results. We evidenced a significant correlation between S-GLS and the 6MWT (r 0.63; p<0.001)
and Δ PASP (r -0.53; p<0.01). Moreover a S-GLS cutoff <17.2%, computed with ROC analysis,
identified SSc patients who showed a decrease in exercise tolerance at follow up [AUC 0.81 (95% CI
0.67 to 0.94), sensitivity 78% (95% CI 63–92), specificity 71% (95% CI 50–91)].
Moreover patients with S-GLS <18% demonstrated lower pulmonary pressures at FU (PAPS
34,8±8,4 vs 26±3 mmHg; p<0,05).
Conclusions. Our data demonstrated that in SS patients a reduced LVCR showed to be strictly related
to an inappropriate pulmonary pressure response to exercise and a reduced exercise tolerance.
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Moreover a reduced LVCR showed to be able to identify SSc patients who show a decrease in
exercise tolerance at follow up with higher pulmonary pressures.
RIVASCOLARIZZAZIONE MIOCARDICA PERCUTANEA
O64
RADIAL COMPRESSION GUIDED BY INVERSE BARBEAU TEST VERSUS STANDARD
COMPRESSION WITH A PNEUMATIC DEVICE
LUIGI DI SERAFINO (A), MAURIZIO TURTURO (A), SAVERIO LANZONE (A),
PAOLINO BRINDICCI (A), NICOLA GRIMALDI (A), LUIGI DI GIOIA (A), VITO
ALESSANDRO ANGELILLI (A), CARLO D´AGOSTINO (A)
(A) UOC CARDIOLOGIA - PO DI VENERE BARI
Background. Trans-radial access has become the approach of choice for diagnostic coronary
angiography or percutaneous coronary interventions (PCI) because of its lower vascular complication
rate. However, it has been shown to be associated with a higher rate (5–10%) of asymptomatic radial
artery (RA) occlusion which is in turn also associated with the occlusion of the radial artery during
compression.
Methods and Results. We conducted a prospective, controlled, single-center trial study. We
investigated whether pneumatic compression of RA guided by the “Inverse Barbeau test” (IBT)
(group A) is efficient in reducing radial occlusion during compression in patients undergoing
coronary procedures by trans-radial access as compared to the use of standard procedure (group B,
15 ml of air into the device). Pulse oximetry was used for RA flow evaluation and IBT was performed
with the patient wearing the pneumatic compression device. IBT was performed in two occasions: 1)
Before the procedure, in order to evaluate the amount of air to be inflated into the compression device
and 2) up to 30 minutes after the procedure, in order to evaluate the RA patency during compression.
Clinical follow up was performed at 30 days. We enrolled a total of 100 patients and no significant
difference was found between the two group of patients in terms of clinical and angiographic
characteristics. Group A showed significantly lower rate of RA occlusion during pneumatic RA
compression than Group B (respectively 0% vs 23%, p<0.01) without significant differences in the
rate of other complications. Nevertheless, at one month follow up no significant difference was found
between the two groups in terms of RA occlusion at physical examination (respectively 0% vs 8%,
p=0.10).
Conclusions. Pneumatic compression device guided by IBT is safe and efficient, and might
contribute to reduce the incidence of radial artery occlusion.
O65
I LIVELLI DI PRO-BNP ALL'ARRIVO DEI PAZIENTI CON STEMI PREDICONO
L'OSTRUZIONE MICROVASCOLARE E L'EMORRAGIA INTRACARDIACA POST-PCI
PRIMARIA
ALESSANDRO DURANTE (A, C), FRANCESCO DE COBELLI (B, C),
PIETRO LAFORGIA (C), ANTONIO ESPOSITO (B, C), GIUSEPPE PIZZETTI (B),
GIULIA BENEDETTI (B, C), ANNA DAMASCELLI (B, C), MARIANGELA CAVA (B, C),
CLAUDIA BORGHI (A), GIOVANNI CORRADO (A), ANTONIO COLOMBO (B),
ALBERTO MARGONATO (B, C), ORNELLA E. RIMOLDI (D), PAOLO G. CAMICI (B, C)
(A) OSPEDALE VALDUCE, COMO; (B) OSPEDALE SAN RAFFAELE, MILANO; (C)
UNIVERSITÀ VITA-SALUTE SAN RAFFAELE, MILANO; (D) IBFM CNR, MILANO
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Introduzione: La presenza di ostruzione microvascolare (MVO) dopo angioplastica primaria (pPCI)
nei pazienti con infarto miocardico acuto con sopralivellamento del tratto ST (STEMI), rappresenta
il criterio diagnostico del no reflow utilizzato nella valutazione con risonanza magnetica cardiaca
(CMR). Oltre al MVO, la presenza di emorragia intramiocardica (IMH) alla CMR è stata correlata
sia al fenomeno del no reflow che alla presenza di MVO, seppur con una incidenza variabile.
Attualmente non sono noti parametri bio-umorali precoci in grado di predire l’occorrenza di MVO e
IMH. Scopo del nostro studio era di valutare l’incidenza di IMH e di individuare predittori bioumorali sia di MVO che di IMH.
Materiali e Metodi: Studio prospettico, arruolati 70 pazienti consecutivi con STEMI trattati con
pPCI entro 12 ore dall’insorgenza dei sintomi, successivamente sottoposti a CMR entro 5 giorni
dall’evento indice. Prelievo ematico all’arrivo e prelievi seriati durante la degenza per chimica clinica,
TroponinaT (TnT) e NT-proBNP . CMR con sequenze T2 pesate STIR ha misurato l’estensione
dell’area a rischio e la presenza di IMH. Per mezzo di sequenze T1 pesate IR dopo 4 (precoci) oppure
15 minuti (tardive) dalla somministrazione di 0.15 mmol/kg di Gadobutrol sono stati misurate
l’estensione dell’infarto (LGE come % della massa del ventricolo sinistro (VS)) e MVO.
Risultati: Quarantasei pazienti (66%) hanno presentato MVO, e di questi 22 hanno presentato IMH
(31% della popolazione totale, 48% dei pazienti con MVO).
I pazienti con MVO hanno presentato, rispetto ai pazienti senza MVO, maggiori dimensioni
dell’infarto, sia al picco di TnT (8.24±5.31 vs 2.62±2.28 µg/l, p<0.0001) che alla misura CMR
(31.5±10.6 vs 19.6±10.3% VS , p<0.0001).
Similmente, i pazienti con IMH, rispetto ai pazienti senza IMH, avevano un picco di TnT maggiore
(9.63±5.24 vs 4.31±3.25 µg/l, p<0.0001) e una area di LGE più estesa (32.3±10.4 vs 19.8±10.7% LV
, p<0.0001).
Il livello di NT-proBNP al momento del ricovero è risultato essere direttamente correlato al picco
(r=0.641, p<0.0001) e all’area di LGE (r=0.451, p<0.001). Il livello di NT-proBNP è risultato essere
un predittore sia di MVO (p=0.01) che di IMH (p=0.02). La stratificazione dei pazienti in quartili a
seconda dei livelli di proBNP ha indicato che tutti I pazienti nell’ultimo quartile (>2049 pg/ml) hanno
presentato sia MVO che IMH.
Conclusioni: Il nostro studio prospettico ha mostrato una alta incidenza di no reflow alla valutazione
tramite CMR, pari a due terzi della popolazione in studio; inoltre, circa la metà dei pazienti con MVO
ha presentato anche IMH. Infine, i livelli di NT-proBNP all’arrivo del paziente sono risultati essere
predittivi di MVO e IMH.
O66
SAFETY AND EFFICACY OF TREATMENTS FOR IN STENT RESTENOSIS: A
NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
JACOPO PERVERSI (A), CLAUDIO MORETTI (A), FABRIZIO D´ASCENZO (A),
PIERLUIGI OMEDÈ (A), FRANCESCO COLOMBO (A), ENRICO CERRATO (A),
ADNAN KASTRATI (B), GREGG STONE (C), REMO ALBIERO (E), OLUSEUN
O. ALLI (F), HARALD RITTGER (G), BRUNO SCHELLER (H),
BERNARD CHEVALIER (I), PASCAL MEIER (J), FIORENZO GAITA (A)
(A) DIVISION OF CARDIOLOGY, “CITTÀ DELLA SALUTE E DELLA SCIENZA“
HOSPITAL, UNIVERSITY OF TURIN; (B) DEUTSCHES HERZZENTRUM, TECHNISCHE
UNIVERSITÄT, MUNICH, GERMANY; (C) COLUMBIA UNIVERSITY MEDICAL CENTER,
COLUMBIA, UNITED STATES; (D) HOSPITAL UNIVERSITARIO DE LA PRINCESA,
MADRID, SPAIN; (E) ISTITUTO CLINICO SAN ROCCO, OME, ITALY; (F) UNIVERSITY OF
ALABAMA, BIRMINGHAM, UNITED STATES; (G) UNIVERSITÄTSKLINIKUM,
ERLANGEN, GERMANY; (H) UNIVERSITATSKLINIKUM DES SAARLANDES HOMBURG,
HOMBURG, GERMANY; (I) INSTITUT CARDIOVASCULAIRE PARIS-SUD, MASSY,
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
FRANCE; (J) UNIVERSITY COLLEGE LONDON HOSPITALS, LONDON, UNITED
KINGDOM
Aims. The optimal treatment for patients presenting with in-stent restenosis remains to be defined,
given the large spectrum of alternative strategies. We performed a network meta-analysis of
randomized controlled trials to compare safety and efficacy of the different treatments for in-stent
restenosis
Methods and Results. All randomized controlled trials investigating different treatments for patients
presenting with in-stent restenosis were included. Major adverse cardiac events (a composite endpoint
of death, myocardial infarction, target lesion revascularization, myocardial infarction and stent
thrombosis) were the primary endpoint, while its components the secondary ones and where appraised
within a hierarchical Bayesian model computing odds ratios. Non compliant/semi compliant balloons
were evaluated in 11 studies with 1149 patients, bare metal stent in one study with 224 patients,
rotablator in one study with 146 patients, sirolimus eluting stent in 9 with 1017 patients, paclitaxel
eluting stent in 7 with 1048 patients, paclitaxel coated balloon in 4 studies with 282 patients,
everolimus eluting stent in 1 study with 32 patients, and brachytherapy in 5 with 716 patients. After
a median of 12 months (10-14), paclitaxel coated balloon performed not inferior to sirolimus eluting
stent, paclitaxel eluting stent and everolimus eluting stent, all of them being superior to non compliant
and cutting balloon. This reduction in major adverse cardiac events was mainly driven by reduction
in target lesion revascularization obtained by paclitaxel coated balloon, paclitaxel eluting stent,
sirolimus eluting stent when compared to other strategies. Rates of myocardial infarction did not
differ between various treatments, as those of stent thrombosis, apart from a reduction of stent
thrombosis offered by paclitaxel coated balloon when compared to cutting balloon (odds ratio 0.28:
0.02-0.9, all confidence interval 95%).
Conclusions. Paclitaxel coated balloon performed similar to first generation drug eluting stent for
treatment of in-stent restenosis, being superior to cutting and non compliant balloon.
O67
PERIPROCEDURAL MYOCARDIAL INFARCTION PREDICTS WORSE CLINICAL
OUTCOME
IN
PATIENTS
UNDERGOING
PERCUTANEOUS
CORONARY
INTERVENTIONS OF CHRONIC CORONARY TOTAL OCCLUSION
LUIGI DI SERAFINO (A, E), FRANCESCO BORGIA (C, D), JOREN MAEREMANS (B),
STYLIANOS A. PYXARAS (E), BERNARD DE BRUYNE (E), WILLIAM WIJNS (E), GUY
R. HEYNDRICKX (E), JO DENS (B), CARLO DI MARIO (C), EMANUELE BARBATO (E)
(A) UOC CARDIOLOGIA - PO DI VENERE BARI; (B) DEPARTMENT OF CARDIOLOGY –
OOST-LIMBURG HOSPITAL, GENK; (C) NATIONAL INSTITUTE OF HEALTH RESEARCH
CARDIOVASCULAR BRU ROYAL BROMPTON HOSPITAL & IMPERIAL COLLEGE,
LONDON; (D) CATTEDRA DI CARDIOLOGIA - AOU FEDERICO II NAPOLI; (E)
CARDIOVASCULAR CENTER AALST, OLV CLINIC, AALST
Background. Periprocedural myocardial infarction (PMI) after percutaneous coronary intervention
(PCI) has been associated with higher mortality. PMI might occur more frequently during challenging
procedures such as PCI of chronic coronary total occlusion (CTO). However, the prognostic
implication of PMI in CTO-PCI remains unclear.
Methods and Results. From January 2006 to September 2012, 715 consecutive patients (pts)
undergoing PCI of CTO in major native coronary arteries were screened for this registry at 3 centers.
Only pts with available pre- and post-PCI troponin (cTn) were finally included (n=442). PMI was
defined as an elevation of cTn >5 times URL in pts with normal baseline values or a rise of cTn >20%
if baseline values were elevated. Pts were grouped into: a) successful CTO-PCI and no-PMI (Group
A, n=195); b) successful CTO-PCI with PMI (Group B, n=133); failed CTO-PCI (Group C, n=114).
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Major adverse cardiovascular events (MACE: composite of overall death plus non-fatal myocardial
infarction plus target vessel revascularization) were assessed in 431 patients (97%) at a median
follow-up of 25 months (10-37). The 3 groups did not differ significantly with respect to clinical
characteristics. MACE rate was significantly lower in pts treated with successful CTO-PCI without
PMI, and progressively increased in case of PMI or failed CTO-PCI (Group A= 9%, Group B= 15%,
Group C= 28%, HR: 1.57 (1.24-2.18), p<0.01). MACE-free survival was also significantly higher in
Group A at Kaplan-Mayer analysis (Log-Rank: 7.17, p<0.01).
Conclusions. Occurrence of PMI during PCI of CTO is associated with worse clinical outcome, yet
superior to patients with failed CTO recanalization
O68
EOSINOPHILS COUNT AND PERIPROCEDURAL MYOCARDIAL INFARCTION IN
PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTIONS
MONICA VERDOIA (a), ALON SCHAFFER (a), LUCIA BARBIERI (a), GABRIELLA DI
GIOVINE (a), MATTEO NARDIN (a), PAOLO MARINO (a), GIUSEPPE DE LUCA (a)
(a) OSPEDALE MAGGIORE DALLA CARITA´, UNIVERSITA´ DEL PIEMONTE
ORIENTALE
Eosinophils have been involved in a wide spectrum of pro-inflammatory and pro-thrombotic
conditions, with the development of cardiovascular complications in a significant proportion of
hypereosinophilic patients. However, no study has so far evaluated the impact of eosinophils levels
on periprocedural myocardial infarction (PMI) in patients undergoing non- urgent percutaneous
coronary interventions (PCI), that was, then, aim of current study.
Methods: In a consecutive cohort of patients, myonecrosis biomarkers were dosed at intervals from
6 to 48 hours after PCI. Periprocedural myonecrosis was defined as troponin I increase by 3 times the
ULN or by 50% of an elevated baseline value, whereas PMI as CKMB increase by 3 times the ULN
or 50% of baseline.
Results: Our population is represented by 1543 patients who were divided according to tertiles of
absolute eosinophils count (AEC <0.1; 0.1-0.2; > 0.2 x 10^3/ml). Higher AEC was related to male
gender (p=0.002), arterial hypertension (p=0.02), diabetes (p=0.001), previous coronary
revascularization (p=0.003 for PCI, p=0.03 for CABG), treatment with ARBs, beta-blockers,
diuretics and ASA (p<0.001), statins (p=0.02), calcium antagonists (p=0.05),
glycosylated haemoglobin (p<0001), creatinine levels (p=0.001) and platelet count (p=0.01), while
inversely with acute presentation (p<0.001), glycaemia (p=0.03), HDL-cholesterol and C-reactive
protein (p=0.02). AEC related with multivessel coronary artery disease (p=0.05), lesion length
(p=0.01), drug eluting stents implantation (p=0.001) and use of kissing balloon technique (p=0.05),
while inversely to intracoronary thrombus (p<0.001) and thrombectomy (p=0.04).
AEC did not influence the occurrence of PMI (p = 0.06, adjusted OR [95%CI] = 1.06 [0.86-1.31], p
= 0.57) or myonecrosis (p = 0.15, adjusted OR[95%CI] = 1.06 [0.88-1.27], p=0.53). Results were
confirmed at subgroup analysis in higher-risk subsets of patients.
Conclusion: In patients undergoing non-urgent PCI,
eosinophils levels are not associated with the occurrence of
periprocedural myocardial infarction or myonecrosis.
.
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O69
ANGIOPLASTICHE COMPLESSE CON ACCESSO RADIALE 7 FRENCH: REGISTRO
PROSPETTICO
SIMONE BISCAGLIA (A), RITA PAVASINI (A), SILVIA PUNZETTI (A),
GIANLUCA CAMPO (A), CLAUDIO CECONI (A)
(A) AZIENDA OSPEDALIERO - UNIVERSITARIA SANT´ANNA CONA - FERRARA
E’ convinzione diffusa che procedure di angioplastica coronarica (PCI) complessa richiedano
l’accesso femorale, anche per la necessità di utilizzare introduttori più grandi (7F). L’introduttore 7F
permette, infatti, un migliore supporto e un delivery ottimale dei materiali. I dati relativi all’utilizzo
di introduttori 7F nell’accesso radiale sono scarsi e di natura retrospettiva. Il nostro studio prospettico
monocentrico si è perciò posto un duplice scopo: valutare fattibilità e sicurezza di procedure di PCI
eseguite tramite accesso radiale con introduttore 7F e verificare la percentuale di occlusione
dell’arteria radiale (AR) a 6 mesi dalla procedura. Da giugno 2010 a giugno 2013, 4465 pazienti sono
stati riferiti presso il nostro Istituto per eseguire coronarografia ed eventuale PCI. 3530 pazienti hanno
completato la coronarografia diagnostica tramite introduttore radiale 6F. In 2631 pazienti (75%) è
stata eseguita PCI on-line; in 175 di questi il primo Operatore ha deciso di utilizzare l’introduttore
radiale 7F per la PCI, a causa della complessità della procedura (n=25: lesioni su biforcazione con
ramo collaterale > 2 mm; n=54: tronco comune non protetto; n=42: occlusione cronica totale; n=34:
aterotomia rotazionale; n=15: STEMI con elevato carico trombotico; n=5: shock cardiogeno
all’esordio). I pazienti sono stati seguiti prospetticamente ed è stata valutata da un operatore in cieco
l’occorrenza di occlusione tardiva dell’AR a 6 mesi dalla procedura, mediante valutazione clinica
(polso arterioso) ed esame eco-Doppler. Non sono stati eseguiti né test di Allen, né pletismografia
pre-procedura, poiché non rientrano nella nostra pratica quotidiana. In tutti i 175 pazienti la procedura
è stata completata con successo. In nessun caso è stato necessario effettuare un crossover dall’accesso
radiale a quello femorale. Il follow-up a 6 mesi è disponibile in 165 pazienti, in quanto 10 pazienti
(5.7%) sono deceduti prima della visita di controllo. Alla valutazione del polso arterioso, l’AR era
palpabile in 155 pazienti (93.9%), mentre all’esame Doppler si presentava pervia in 153 pazienti
(92.7%). Non abbiamo riscontrato differenze significative a livello di caratteristiche basali,
angiografiche o procedurali, tra pazienti con e senza occlusione dell’AR. Nel post-procedura solo un
paziente ha riferito dolore alla mano, in assenza di segni indicativi di ischemia dell’arto. Il nostro
studio rappresenta la più numerosa casistica di pazienti trattati con PCI mediante accesso radiale con
introduttore 7F e l’unica a riportare prospetticamente la pervietà dell’AR a lungo-termine. I nostri
dati mostrano che tale approccio è fattibile e sicuro. Le principali novità della nostra casistica rispetto
ai dati pubblicati in precedenza da Egred sono: la numerosità (175 contro i 77 pazienti di Egred), la
valutazione prospettica e l’esecuzione di eco-Doppler a 6 mesi in tutti i pazienti (il follow-up a lungo
termine era presente solo nel 30% dei pazienti tramite valutazione del polso arterioso). Nel nostro
studio abbiamo osservato una percentuale di occlusione dell’AR a 6 mesi del 6% (95%CI 3%-11%)
alla valutazione del polso arterioso, mentre del 7% (95%CI 4%-12%) all’esame Doppler, valori non
differenti rispetto a quelli riportati negli studi precedenti (variabili tra il 5 e il 38%), in cui veniva
utilizzato un introduttore 6F. Il nostro tasso di occlusione dell’AR è stato perciò minore rispetto alle
attese. In conclusione, i dati disponibili ad oggi e la nostra valutazione prospettica suggeriscono che
le procedure eseguite tramite accesso radiale 7F sono fattibili e sicure. Ne consegue che la dimensione
dell’introduttore non debba più essere considerata una limitazione nella selezione dell’accesso radiale
rispetto a quello femorale
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O70
ACEF SCORE TO RISK STRATIFY PATIENTS UNDERGOING PERCUTANEOUS
CORONARY INTERVENTIONS OF CORONARY CHRONIC TOTAL OCCLUSION
LUIGI DI SERAFINO (A, B), FRANCESCO BORGIA (E, F), JOREN MAEREMANS (D),
STYLIANOS A. PYXARAS (B), BERNARD DE BRUYNE (B), WLLIAM WIJNS (B), GUY
R. HEYNDRICKX (B), JO DENS (D), CARLO DI MARIO (F), EMANUELE BARBATO (B)
(A) UOC CARDIOLOGIA - PO DI VENERE BARI; (B) CARDIOVASCULAR CENTER
AALST, OLV CLINIC, AALST; (C) 1NATIONAL INSTITUTE OF HEALTH RESEARCH
CARDIOVASCULAR BRU ROYAL BROMPTON HOSPITAL & IMPERIAL COLLEGE,
LONDON ; (D) DEPARTMENT OF CARDIOLOGY – OOST-LIMBURG HOSPITAL, GENK ;
(E) CATTEDRA DI CARDIOLOGIA - AOU FEDERICO II NAPOLI; (F) NATIONAL
INSTITUTE OF HEALTH RESEARCH CARDIOVASCULAR BRU ROYAL BROMPTON
HOSPITAL & IMPERIAL COLLEGE, LONDON
Background. The Age, Creatinine, and Ejection Fraction (ACEF) score can reliably predict clinical
outcomes in patients (pts) undergoing elective percutaneous revascularization (PCI) of non-occlusive
coronary stenoses. We aimed at assessing the prognostic value of the ACEF score in pts undergoing
successful PCI of coronary chronic total occlusion (CTO).
Methods and Results. ACEF score was calculated in 587 consecutive pts treated with PCI of CTO
that was successful in 433 (74%) pts (success group) and failed in 154 (26%) pts (failure group). Pts
from both groups were divided according to the following ACEF score tertiles: 1st ACEF<0.950, 2nd
ACEF from 0.95 to 1.207, 3rd ACEF tertile>1.207. Clinical endpoints up to 24 months follow-up
were major adverse cardiac events (MACE), overall death, non-fatal myocardial infarction (MI) and
clinically driven target vessel revascularization (TVR). Median follow-up, available in 558 pts (95%),
was 24 months (8-24 months). In the success group, higher MACE rate was significantly associated
with increasing ACEF score tertile (1st ACEF=7%, 2nd ACEF=13%, 3rd ACEF=18%, p=0.02).
MACE-free survival was significantly decreased with increasing ACEF tertile (Log-Rank: 5.58,
p=0.018). In the failure group, lower MACE rate was significantly associated with increasing ACEF
tertile (p=0.042). This was mainly driven by significant decreasing rate of TVR along the ACEF
tertiles (1st ACEF=34%, 2nd ACEF=19%, 3rd ACEF=10%, p=0.007). Compared to the success
group, in the failure group MACE rate was significantly higher in the 1st ACEF tertile (p<0.001),
and similar in the 3rd ACEF tertile (p=0.57).
Conclusions. ACEF score represents a simple tool in the prognostication of patients successfully
treated with PCI of CTO. In addition, it identifies those patients who would not derive any significant
clinical harm despite failed percutaneous revascularization of the CTO.
O71
Functional tricuspid regurgitation in patients with left ventricular dysfunction: its contribution
to renal dysfunction and long-term prognosis.
Claudia Marini (a), Stefano Stella (a), Alberto Monello (a), Vincenzo Tufaro (a), Andrea Fisicaro
(a), Michele Oppizzi (a), Alberto Margonato (a), Eustachio Agricola (a)
(a) Division of Non Invasive Cardiology, San Raffaele Hospital, IRCCS, Milan, Italy.
Background and aim: The prognostic role of renal impairment in heart failure (HF) is well known,
while the pathophysiology of impaired renal function in patients with left ventricular dysfunction is
debated. As the low cardiac output and the consequent impaired kidney perfusion was the most
accepted underlying theory, recent evidences suggest an outstanding role of systemic venous
congestion. Functional tricuspid regurgitation (FTR) plays an important role in increasing systemic
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
venous pressure, leading to renal vascular congestion. The aim of the study was to assess the
contribution of FTR to renal dysfunction and long-term prognosis in patients with systolic HF.
Methods: We enrolled 413 consecutive patients (mean age 74.2+11 years, 76% men) with systolic
HF, defined as an ejection fraction (EF)<50%, with or without FTR. TR severity was graded using
the vena contracta and the jet area/right atrial area methods. Renal function was evaluated by serum
creatinine values and the estimated glomerular filtration rate (eGFR) using sMDRD formula. Renal
failure (RF) was defined with an eGFR<60 mL/min/m2. The end-points were HF episodes requiring
hospitalizations and the overall mortality. Patients were followed up with outpatient visits or periodic
telephone interviews. Univariate and multivariate Cox proportional hazard regression analysis was
used to identify the predictors HF episodes and overall mortality. Univariate and multivariate
predictors of renal function were assessed by logistic regression analysis.
Results: The median follow-up was 43.2+36 months (range 1-144). 101 patients developed HF
episodes; 161 patients died (62% cardiac deaths). Mean EF and NYHA class were 34.8+10.4% and
2±0.8 respectively. FTR was absent or mild in 68.5% of patients, moderate in 21.5% and severe in
10%. Patients with moderate/severe FTR had higher PAPs (43.2+15.5 vs. 31.6+12.3 mmHg,
p=0.0001), right atrial area (22.6+7 vs. 17.8+6.0 cm2, p=0.0002) and right ventricular diameter
(35.3+5.4 vs. 33.8+4.1 mm, p=0.009), NT-proBNP values (9578.7+13125.4 vs. 5203+8178.1 pg/ml,
p=0.004) and lower TAPSE (20.9+4 vs. 21.9+3.7 mm, p=0.02) compared with those with absent/mild
FTR. At 1, 5 and 9 years the survival was 88%, 65%, 48% for absent/mild and 82%, 47%, 20% for
moderate/severe FTR (p=0.0001) respectively. At 1, 5 and 9 years the survival was 84%, 50%, 20%
and 89%, 68%, 62% in patients with (51.6%) and without RF (p=0.0001) respectively. At the
univariate analysis moderate/severe FTR (OR 1.5, CI 1.0-2.3, p=0.03), increased PAPs (OR 1.1, CI
1.0-1.2, p=0.002), atrial fibrillation (AF) (OR 1.9, CI 1.2-3.0, p=0.003), NYHA class III/IV (OR 1.6,
CI 1.1-2.4, p=0.02) and age (OR 1.1, CI 1.0-1.1, p=0.0001) were associated to RF. At multivariate
analysis, the interaction between moderate/severe FTR and TAPSE<16 mm (OR 1.2, CI 1.0-1.5,
p=0.04), AF (OR 1.8, CI 1.2-3.0, p=0.005), NYHA class III/IV (OR 1.3, CI 1.1-2.1, p=0.02) and age
(OR 1.03, CI 1.0-1.05, p=0.0001) were independent determinants of RF. The presence of RF (HR
2.3, CI 1.1-6.1, p=0.04), moderate/severe MR (HR 1.6, CI 1.2-4.7, p=0.001), NYHA class III/IV (HR
2.7, CI 1.2-7.3, p=0.03), AF (HR 1.4, CI 1.1-3.5, p=0.01), and ICD (HR 0.18, CI 0.05-0.6, p=0.008)
were independent determinants of mortality.
Conclusions: Patients with systolic HF and moderate to severe FTR had a significantly higher
mortality and morbidity than patients with absent or mild FTR. Systemic venous congestion due to
FTR associated with right ventricular dysfunction is an independent predictor of RF and plays a
pathophysiological role in impaired renal function.
MECCANISMI DI RIPARAZIONE MIOCARDICA - 1
O72
INHIBITION OF THE CRYOPYRIN INFLAMMASOME IMPROVES CARDIAC
REMODELING AFTER SEVERE ISCHEMIC AND NON-ISCHEMIC INJURY: A NEW
STRATEGY TO PREVENT HEART FAILURE
STEFANO TOLDO (A), CARLO MARCHETTI (A), ELEONORA MEZZAROMA (A),
SALVATORE CARBONE (A), ANDREA NORDIO (A), CHIARA SONNINO (A), ADOLFO
G. MAURO (A), MASSIMO FEDERICI (B), BENJAMIN W. VAN TASSELL (A),
ANTONIO ABBATE (A)
(A) VIRGINIA COMMONWEALTH UNIVERSITY; (B) UNIVERSITA´ DI ROMA TOR
VERGATA
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Introduction. The formation of the cryopyrin inflammasome during injury to the heart amplifies the
inflammatory response and mediates further damage. An inhibitor of the cryopyrin inflammasome
was shown to reduce ischemia/reperfusion injury in the mouse.
Hypothesis. We hypothesize that the cryopyrin inflammasome inhibitor would limit left ventricular
(LV) remodeling and dysfunction following severe ischemic (non-reperfused myocardial infarction
[MI]) and non-ischemic (doxorubicin-induced) injury to heart.
Methods. Adult male CD-1 male mice underwent permanent ligation of the left anterior descending
coronary artery to induce a large non-reperfused MI (ischemic model) or injection of doxorubicin
10mg/kg to induce LV systolic dysfunction (non-ischemic model). The cryopyrin inflammasome
inhibitor (16673-34-0, 100 mg/kg) or vehicle (N=6-8 per each group) were administered
intraperitoneally daily for 7 days. Transthoracic echocardiography was performed to measure LV
end-diastolic diameter (EDD) and LV fractional shortening (FS). We used Masson’s Trichrome stain
to measure infarct size (ischemic model) or interstitial fibrosis (non-ischemic model).
Results. Permanent coronary ligation led to a large non-reperfused MI and a significant increase in
LVEDD and a reduction in LVFS (ischemic model). When compared with vehicle, treatment with
the cryopyrin inflammasome inhibitor significantly limited LV enlargement (4.53±0.14 vs vehicle
4.95±0.04mm, P=0.006) and limited systolic dysfunction after AMI (Figure). A significant increase
in interstitial fibrosis and reduction in LVFS was seen after doxorubicin treatment (non-ischemic
model), and treatment with the inhibitor significantly reduced interstitial fibrosis (0.73%±0.14 vs
vehicle 3.35%±0.83, P=0.001) and preserved LVFS (Figure).
Conclusion. Inhibition of the cryopyrin inflammasome using a small molecule, 16673-34-0, reduces
cardiac injury and limits LV systolic dysfunction following ischemic and non-ischemic injury.
O73
ADVANCED OXIDATION PROTEIN PRODUCTS-MODIFIED ALBUMIN AND
FIBRINOGEN INDUCE DIFFERENTIATION OF RAW264.7 MACROPHAGE CELL LINE
INTO DENDRITIC-LIKE CELLS: EFFECT OF N-ACETYL CYSTEINE
CHIARA BARISIONE (A), GIORGIO GHIGLIOTTI (A), PATRIZIA FABBI (A),
CLAUDIO BRUNELLI (A), SILVANO GARIBALDI (A)
(A) DIVISION OF CARDIOLOGY, IRCCS UNIVERSITY HOSPITAL SAN MARTINO,
RESEARCH CENTRE OF CARDIOVASCULAR BIOLOGY, UNIVERSITY OF GENOA,
ITALY
SIC | Indice Autori
64
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Background: Innate and adaptive immunity play key roles in multiple steps of onset and progression
of atherosclerotic damage. Circulating and local prooxidants promote inflammation in arterial vessel
walls. Advanced Oxidation protein Products (AOPP) include oxidative modifications of proteins that
mainly (even not exclusively) occur through myeloperoxidase (MPO)-derived hypochlorite
production. Circulating proteins enriched in AOPP affect activity of leukocytes and other cells.
Moreover, hypochlorite modified proteins have been found in atherosclerotic lesions.
Recent identification of dendritic cells (DCs) in atherosclerotic plaques raised great interest, since the
functions of DCs include lipid uptake, efferocytosis, inflammation resolution, antigen presentation
and activation of T cells.
Aim: aim of this work is to evaluate whether the oxidative modifications of two circulating proteins,
albumin and fibrinogen, modulate activation and differentiation of mature macrophages into dendritic
cells in vitro. The preventive role of antioxidant treatment has also been tested.
Methods: AOPP-proteins were prepared by in vitro incubation of either proteins at concentrations
near to the physiological range with HOCl. Mouse macrophage-like RAW264.7 were treated with
different concentrations of AOPP-proteins for 48 hours with/without N-Acetyl Cysteine (NAC).
Results: AOPP-enriched albumin and fibrinogen induced differentiation of RAW264.7 cells into a
dendritic-like phenotype, as shown by a dose-dependent increase in the number of cells with dendritic
morphology and by surface exposure of markers of dendritic lineage and activation: CD86, MHC
classII, CD1d. Fibrinogen is more susceptible to oxidation than albumin, and Fibrinogen-AOPP
induced DC differentiation at lower protein concentration. NAC (400microM) prevented the
RAW264.7 differentiation into dendritic cells.
Conclusions: our preliminary results highlight that oxidized plasma proteins may participate in the
modulation of immune responses. Because T cell subsets regulate atherosclerotic process in different
ways either promoting or suppressing atherogenesis, the modulating effect of DCs on T cell activation
may affect steps of the atherosclerotic process and may represent a new avenue in this research area.
O74
AGE-DEPENDENT IMPAIRMENT OF NUMBER AND ANGIOGENIC POTENTIAL OF
ADIPOSE TISSUE-DERIVED PROGENITOR CELLS
FRANCESCA RENNA (B), ROSALINDA MADONNA (B), MARIA ANNA TEBERINO (B),
GAIA GIOVANNELLI (B), PAMELA CONFALONE (B), ROBERTO COTELLESE (A),
PAOLO INNOCENTI (A), RAFFAELE DE CATERINA (B)
(A) DIVISION OF GENERAL SURGERY, DEPARTMENT OF SURGICAL SCIENCES, “G.
D’ANNUNZIO UNIVERSITY – CHIETI, ITALY; (B) INSTITUTE OF CARDIOLOGY, “G.
D’ANNUNZIO” UNIVERSITY – CHIETI, ITALY
Background: Adipose tissue-Derived Stromal Cells (ADSCs) are being recognized as a source of
stem cells potentially useful for cardiovascular repair. We analyzed the effect of aging on the number
and angiogenic activity of adipose tissue-derived Progenitor Cells (PCs).
Materials and Methods: Fifty-two subjects (aged 68 ± 13 years) with variable degrees of
cardiovascular risk underwent abdominal surgery for intercurrent diseases. Visceral adipose tissue (3
± 1 g/patient) was processed with type 1 collagenase to obtain ADSCs. Adipose tissue-derived PCs
were quantified by flow cytometry as % CD45‾/CD34+/CD133+ cells of total ADSCs. Matrigel
angiogenesis assay was used to analyze the ability of ADSCs to form tubes or networks.
Results: We found that increasing age significantly and inversely correlated with levels of adipose
tissue-derived CD45‾/CD34+/CD133+ cells (r = -0.31, P<0.05) and tubulization in the Matrigel
assay (r= -0.29, P<0.05) We found no effect of other quantitative risk parameters (total cholesterol,
low density lipoprotein cholesterol, high density lipoprotein cholesterol, waist circumference, body
mass index, systolic and diastolic arterial pressure) on the number and function of PCs.
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Conclusions: Aging may alter the availability and angiogenic capacity of adipose tissue-derived
CD45‾/CD34+/CD133+ cells. Aging may therefore impair the use of adipose tissue as a source of
autologous PCs in elderly patients.
O75
BETA-BLOCKING TREATMENT IN HEART FAILURE PATIENTS CORRELATES
WITH SUCCESSFUL ISOLATION OF RESIDENT CARDIAC PROGENITOR CELLS AND
AFFECTS THEIR PHENOTYPE IN VITRO
ISOTTA CHIMENTI (A), FRANCESCA PAGANO (A), ELENA CAVARRETTA (A),
CAMILLA SICILIANO (A), GIORGIO MANGINO (A), PIERGIUSTO VITULLI (A),
SARA IZZO (A), ELENA DE FALCO (A), ERNESTO GRECO (B),
MARIANGELA PERUZZI (A), GIUSEPPE BIONDI ZOCCAI (A), ANTONINO MARULLO (A),
GIACOMO FRATI (A)
(A) DIPARTIMENTO SCIENZE E BIOTECNOLOGIE MEDICO CHIRURGICHE,
UNIVERSITÀ DI ROMA “SAPIENZA“; (B) DIPARTIMENTO DI SCIENZE
CARDIOVASCOLARI, RESPIRATORIE, NEFROLOGICHE, ANESTESIOLOGICHE E
GERIATRICHE, UNIVERSITÀ DI ROMA “SAPIENZA“
BACKGROUND. Cardiovascular disease is a leading cause of mortality and morbidity, mostly due
to myocardial infarction incidence and survival, and consequent epidemic heart failure (HF). Despite
remarkable pharmacological efficacy and advancements, end-stage HF patients only have the option
of transplantation, creating the urgent need for alternative therapies. Cardiac stem cell (CSC) therapy
offers new promises for regenerative medicine approaches, based on successful pre-clinical and
clinical data, and CSCs isolated as spontaneous 3D cardiospheres (CSs) represent the most promising
resident population under clinical investigation. The impact of the patient’s medical and
pharmacological history on the biology of his/her own resident CSCs represents a key issue to be
considered in the quality and potency of the final cell product for autologous protocols. Aim. To
investigate the influence of multiple clinical parameters on CSCs isolation efficiency, and in
particular the effects of beta-signaling on their biology.
METHODS AND RESULTS. Twenty adult HF patients undergoing cardiac surgery have been
enrolled. Multiple medical parameters have been collected in a database, such as: sex, age, BMI,
diagnosis, surgical intervention, cardiopulmonary bypass time, glicemia, cholesterol, AST, ALT,
diabetes, smoking habits, IMA, drug prescriptions, etc. Corresponding CSC biological data
concerning CSs isolation timing and efficiency for each patient have been matched. We observed a
positive statistical correlation between beta-blocker assumption by donors and both successful
primary explant growth and CS formation (P<0.05 for both) from cell cultures of corresponding
bioptic samples. Considering that beta-blockers represent one of the elective HF pharmacological
treatments, and that multiple evidences suggest a connection between mechanical/pharmacological
stress reduction and CSC biology, we next investigated the role of beta-signaling in CSs. CSs and
CS-derived cells express adrenergic beta-receptors 2 and 1 (ADRB), as detected by realtime PCR and
immunofluorescence staining, with a trend towards increasing gene expression levels during cell
culture progression. These results support the ability of CSs to respond to beta-adrenergic stimulation,
both in vivo and in vitro. Our preliminary experiments showed that 6 days of 5uM clembuterol (CLE,
beta2 agonist) treatment increased gene expression levels of nkx2.5, MHC and ADRB2 versus
untreated cells, while cells treated with 25uM butoxamine (BUT, beta2 antagonist) or both,
consistently displayed downregulation of the same genes. Gene levels of smooth muscle,
mesenchymal or endothelial lineages were unaffected. Also, cytofluorimetry analysis of CLE treated
cells detected a slight reduction in the ckit+ subpopulation among CDCs, compared to the other
treatments. Dose-response proliferation time-course up to 4 days did not detect any toxic effect of
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pharmacological treatments up to 10uM CLE and/or 25uM BUT, also supported by no detectable
gene expression modulation of heat shock protein 70 after treatments.
CONCLUSIONS. Overall our preliminary data suggest that beta-blocker treatment might have a role
in sparing the resident CSC pool, as suggested by the positive correlation with successful CSs
isolation in patients treated with beta-blockers versus non treated, while conversely beta stimulation
might favor commitment/differentiation, and thus extinction, of the resident CSCs pool, as also
suggested by increased expression of cardiac genes and reduction of the putative c-kit+ stem
subpopulation.
O76
INDUCTION OF MANGANESE SUPEROXIDE DISMUTASE BY (1-3) BETA-D-GLUCAN
PROMOTES ANGIOGENESIS UNDER OXIDATIVE MICROENVIRONMENT IN VITRO
AND IN VIVO
SILVIA AGOSTINI (A), ELENA CHIAVACCI (C), MARCO MATTEUCCI (A),
MICHELE TORELLI (D), LETIZIA PITTO (C), VINCENZO LIONETTI (C)
(A) LABORATORIO DI SCIENZE MEDICHE, ISTITUTO DI SCIENZE DELLA VITA,
SCUOLA SUPERIORE SANT´ANNA, PISA, ITALIA; (B) FONDAZIONE TOSCANA “G.
MONASTERIO“, PISA, ITALIA; (C) ISTITUTO DI FISIOLOGIA CLINIA, CNR, PISA,
ITALIA; (D) PASTIFICIO ATTILIO MASTROMAURO, CORATO, BARI, ITALIA
Introduction: Angiogenic response of adult endothelial cells can significantly improve the repair
potential of failing myocardium; however, it is challenging to promote it in the presence of oxidative
stress, which plays a pivotal role in chronic heart failure. Therefore, the identification of novel
effective angiomodulators is a desirable achievement. Barley-derived (1.3)beta-D-glucan (β-Dglucan) is a water-soluble chain of D-glucose polysaccharide with antioxidant properties, but its
angiogenic effect is still unknown.
Hypothesis: The treatment of adult endothelial cells with (1-3)β-D-glucan enhances the angiogenic
response in the presence of oxidative microenvironment.
Methods: In vitro, human umbilical vein endothelial cells (HUVECs) chronically exposed to H2O2
(50uM for 24h) were cultured with or without 3% w/v β-D-glucan, then tested for cell viability and
tube formation. p-eNOS/eNOS ratio, pAkt/Akt ratio, HIF1-alpha and MnSOD expression, and the
level of anion superoxide was evaluated. In vivo, Tg(kdrl:EGFP)s843Tg transgenic zebrafish
embryos were treated for 24h with 3% w/v β-D-glucan under oxidative microenvironment prior
angiogenesis assay.
Results: HUVECs treatment with β-D-glucan prevented cell death by 87.41±14% (P≤0.004) and
significantly increased tube formation activity by 11±4% under oxidative microenvironment. At the
cellular level such effects seem to be mediated by a significant induction of MnSOD expression
through reduction of anion superoxide level. Finally, similar dose of β-D-glucan was confirmed to
prevent vascular depletion in zebrafish embryos chronically exposed to oxidative microenvironment.
Conclusions: Our study revealed, for the first time, that barley-derived β-D-glucan promotes adult
angiogenesis under oxidative microenvironment through increased expression of MnSOD. These
findings uncover a novel and unexpected role for dietary β-D-glucan as a critical activator of
antioxidant activity governing adult angiogenic response.
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O77
DOXORUBICIN CARDIOMYOPATHY IS PREVENTED BY THE ADMINISTRATION OF
RANOLAZINE AT THE END OF ANTINEOPLASTIC TREATMENT IN MODEL MOUSE
CARMELA COPPOLA (A), GIOVANNA PISCOPO (A), FRANCESCA GALLETTA (A),
CARLO MAUREA (A), DOMENICA REA (B), NICOLA MAUREA (A)
(A) DEPARTMENT OF CARDIOLOGY, NATIONAL CANCER INSTITUTE PASCALE
FOUNDATION - NAPLES; (B) ANIMAL FACILITY, NATIONAL CANCER INSTITUTE
PASCALE FOUNDATION - NAPLES
Purpose: Anthracyclines (A) are first line drugs against cancer, but produce a well-known
cardiomyopathy; the main mechanism that determines this damage is the production of reactive
oxygen species (ROS) that hyperactivate protein kinase 2 calcium-calmodulin-dependent (CaMKII)
and inhibite SERC2a; by this mechanism they activate the late sodium current (INa), target of
Ranolazine (R), that results in calcium overload. Here, we aim at assessing whether R, diminishing
intracellular Ca2+ through its inhibition of late INa, blunts A cardiotoxicity.
Methods: To evaluate cardiac function in vivo, fractional shortening (FS) and ejection fraction (EF)
were measured by M/B mode echocardiography and radial and longitudinal strain (RS and LS) were
measured using 2D speckle-tracking echocardiography, in C57/BL6 mice, 2-4 mo old, at day 0, and
after 2 and 7 days of daily administration of D (2.17 mg/kg/day, ip). These measurements were
repeated after 5 days of R treatment (305 mg/Kg/day, gavage, dose comparable with that used in
humans of 750 mg twice) initiated at the end of D treatment.
Results: In our in vivo studies, after 7 days with D, FS decreased to 50.5±8.4%, p<0.05 vs 61.5±1%
(sham), EF to 82.2±8.1%, p<0.05 vs 91.3±0.5% (sham), RS to 14.3±4.7%, p<0.01 vs 40.5±4.8%
(sham), and LS to -16.6±7.9%, p<0.01 vs -38.8±6% (sham). In mice treated with R for 5 days after
D treatment, the indices of cardiac function recovered: FS was 61.5±1.1%, EF was 91.25±1.1%,
p<0.01; RS was 29.5±3.4%, p<0.05 vs D+R. However the alteration of LS persists after treatment
with R (-25.5±6.3%, p<0.01 vs sham).
Conclusions: R post-treatment blunts cardiotoxic effects due to A, as demonstrated by the
normalization of the values of FS, EF and RS. The explanation for the persistent abnormalities of LS
could be that the subendocardial fibers, responsible for the alteration of LS, have a more delayed
recovery.
ARITMOLOGIA - 1
O78
CORRELAZIONE TRA DATI EMODINAMICI DERIVANTI DALL’IMPEDENZA
TRANSVALVOLARE ED INDICI ECOCARDIOGRAFICI IN PAZIENTI PORTATORI DI
PACEMAKER VDD
MARICA CAIVANO (A), PIER LUIGI PELLEGRINO (A), ANTONIO NARDELLA (A),
MARIA TERESA TUCCIARIELLO (A), GIROLAMO D´ARIENZO (A),
FRANCESCO SANTORO (A), NATALE DANIELE BRUNETTI (A), MATTEO DI BIASE (A)
(A) CARDIOLOGIA UNIVERSITARIA OSPEDALI RIUNITI FOGGIA; (b) OSPEDALE
MIULLI ACQUAVIVA BARI
Introduzione: Le modificazioni strutturali e geometriche del ventricolo destro che si realizzano
durante il ciclo cardiaco determinano variazioni cicliche dell’impedenza, che potrebbero essere
utilizzate come indicatori della funzione contrattile destra. L’impedenza transvalvolare (TVI) che
viene rilevata tra atrio e ventricolo destro in alcuni modelli di pacemaker bicamerali (Medico SPA) è
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una delle metodiche proposte per la valutazione dell’impedenza cardiaca. Lo scopo di questo studio
è stato pertanto quello di valutare eventuali correlazioni tra TVI e parametri ecocardiografici (TAPSE,
E/A, deceleration time) in grado di valutare la funzione ventricolare destra.
Materiali e Metodi: tra agosto 2012 e marzo 2013 sono stati arruolati 20 pazienti, la metà dei quali
sottoposti a impianto e la restante metà a sostituzione elettiva di pacemaker VDD modello Medico
Sophos 440. I pazienti sono stati sottoposti a controllo del pacemaker e a concomitante
ecocardiografia – ecocolordoppler. I valori dell’impedenza transvalvolare e dei parametri
ecocardiografici TAPSE, rapporto E/A e deceleration time sono stati misurati per una serie di
intervalli AV stabiliti a priori, ossia 112 ms, 128 ms, 144 ms, 168 ms, 200 ms, 216 ms. Per la TVI il
programmatore forniva separatamente i valori telediastolici (EDV), telesistolici (ESV), l’Ampiezza,
l’intervallo di latenza, il tempo di salita e il tempo di inizio discesa.
Risultati: sono state valutate le eventuali correlazioni per ogni intervallo AV tra i valori della TAPSE
e l’impedenza transvalvolare telediastolica EDV-TVI, l’impedenza transvalvolare telesistolica ESVTVI, l’ampiezza del segnale TVI (ESV-EDV), l’ampiezza normalizzata per il valore di partenza
(rapporto ampiezza TVI/ESV). La correlazione tra i suddetti parametri è risultata statisticamente
significativa per intervalli AV di 168 ms (EDV-TVI: p=0,023; ESV-TVI: p=0,028), 200 ms (EDVTVI: p=0,006; ESV-TVI: p=0,010) e 216 ms (EDV-TVI: p=0,030; ESV-TVI: p=0,043). Anche il
rapporto E/A e il deceleration time sono stati analizzati agli intervalli AV suddetti, riscontrandosi un
aumento progressivo di entrambi i valori procedendo dagli AV delay più bassi a quelli più alti. Le
correlazioni diventavano significative all’aumentare dell’AV delay (168, 200 e 216 millisecondi per
la prima; 200 e 216 per la seconda).
Conclusioni: la TVI si correla ai parametri ecocardiografici, in particolare agli intervalli AV più alti.
La valutazione dei valori della TVI potrebbe essere utilizzata per la ottimizzazione della funzione
ventricolare destra nei pazienti portatori di pacemaker
O79
MULTIDISCIPLINARY “CARDIO-THORACIC-VASCULAR” APPROACH IN THE
TREATMENT OF CRT FAILURES
PATRIZIA PEPI (A), ANDREA DROGHETTI (B), ALBINO REGGIANI (A),
LUCA TOMASI (A), VALENTINA CHIARINI (A), MAURIZIO MALACRIDA (C),
MAURIZIO COVINI (C), GIOVANNI MURIANA (B), ROBERTO ZANINI (A)
(A) DIVISION OF CARDIOLOGY MANTUA, ITALY; (B) THORACIC SURGERY MANTUA,
ITALY; (C) BOSTON SCIENTIFIC, MILAN, ITALY
Purpose: Cardiac resynchronization therapy (CRT) is a complex therapeutically approach, associated
with an non-negligible rate of failures occurring during left ventricular (LV) lead implantation (failure
to consulate coronary sinus (CS), unsuccessful achievement of the target area, phoenix nerve
stimulation, inadequate pacing threshold) and during follow-up (lead dislodgment or malfunction).
We describe the multidisciplinary approach adopted in our center to apply alternate methods for LV
lead implantation with the aim of increasing CRT success.
Materials and Methods: Patients referred to our center after intraoperative or chronic LV lead failure
are routinely managed as it follows. 1. Re-assessment of CRT indications 2. Preoperative anesthetic
and pulmonary function assessment 3. Video-thoracic surgery (VTS) 4. Pacing site selection by the
cardiologist 5. Clinical and ECG evaluation 6. Echo/EP/HF evaluation at 3-months. The team is
composed of: surgeon, cardiologist, radiologist, speleologist, heart failure, cardiac imaging and
device specialists.
Results: 26 patients (mean age 67±10 years, male 62%, EF 25±6%, ischemic etiology 70%, NYHA
III/IV 77%) were evaluated over 3 years. The median time from the previous LV lead implantation
attempt was 94 days. Implant failure was due to: failed coronary vein access (31%), non-satisfactory
lead positioning (38%) and CS dissection (4%). Long-term failures were caused by: lead dislodgment
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(8%), malfunction (8%) and increased pacing threshold (8%). The VTS was successful in all patients,
and a target poster-lateral position was always achieved with a basal (40%), mid (40%) and apical
(20%) lead positioning. The inter-electronic RV to LV distance was 94.8±23 mm. Pacing threshold
was1±[email protected]. QRS duration after biventricular pacing was 141±19ms. Procedural time was
100±17min while the average hospitalization time was 4±2 days. All the measures were found to be
stable at an average follow-up of 431 days.
Conclusion: LV lead implantation is a complex procedure with a considerable risk of both short and
long-term complications. VTS within a multidisciplinary approach represents an effective strategy to
manage CRT failures.
O80
ARRHYTHMIC RISK STRATIFICATION IN PATIENTS WITH IDIOPATHIC DILATED
CARDIOMYOPATHY AND NO CONVENTIONAL INDICATIONS FOR IMPLANTABLE
CARDIAC DEFIBRILLATOR
FABRIZIO PIROZZI (A), DAVIDE STOLFO (A), GIANLUCA D´ANGELO (A),
MARCO ALONGE (A), MARTA GIGLI (A), SARA SCAPOL (A), MILENA DI NUCCI (A),
GIULIA BARBATI (A), MASSIMO ZECCHIN (A), MARCO MERLO (A),
GIANFRANCO SINAGRA (A)
(A) UNIVERSITA’ DEGLI STUDI DI TRIESTE
Background: primary prevention of major ventricular arrhythmias (MVA) in patients with idiopathic
dilated cardiomyopathy (IDCM) is primarily based on left ventricular ejection fraction (LVEF)
assessment. Nonetheless, unexpected MVA still affect patients considered at low-risk (LR), attesting
the limitation of the current risk stratification. We sought to identify the clinical predictors of MVA
in patients with IDCM and no conventional indications for implantable cardioverter defibrillator
(ICD).
Methods: in this retrospective, case-control study, among 922 patients enrolled in the Heart Muscle
Disease Registry of Trieste from 1988 to 2013, we analyzed 414 IDCM patients considered at LR
according to the following criteria: LVEF≥36% and no previous episodes of MVA (sustained
ventricular tachycardia/non-fatal ventricular fibrillation (SVT/VF), appropriate ICD intervention and
sudden cardiac death (SD)). Data were recorded at the last available medical examination before the
index event. Patients were optimally treated at the time of index evaluation (87% and 84% of ACEinhibitors/sartans and beta-blockers, respectively).
Results: over a median follow-up of 43 (IQR 16-116) months, 45 patients (11 % of patients at LR;
31% of the all MVA in whole IDCM population) experienced MVA. The mean age at the time of
event was 51±14 years. They were characterized by a previous history of syncope in 10 patients
(22%), LVEF of 42±6% with a normal value (>50%) in 10 patients (22%), significant LV dilation
(VTDi>90ml/m2 bundle branch block 12 patients (27%). Independent risk factors for MVA in LR
subgroup were previous history of syncope (OR 3.41, 1.45-8.03, p=0.004), larger left ventricular
dilation (OR 2.62, 1.72-3.99, p<0.0001) and longer duration of disease (OR 1.39, 1.42-2.63,
p<0.0001).
Conclusions: in a large cohort of IDCM patients nearly one‐third of the MVA occurred in a population apparently at LR of events. History of syncope, larger LV dilatation and significant duration of disease emerged as strong predictors of MVA and should be considered in the arrhythmic risk stratification of patients without conventional criteria for SD primary protection.
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O81
CHARACTERISTICS AND OUTCOME OF POLYMICROBIAL INFECTIONS OF
CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES
ZEFFERINO PALAMÀ (A), ROBERTA TROTTA (A), COSIMO MANDURINO (A),
CLAUDIA FABRIZIO (B), GIUSEPPE BRUNO (B), ADRIANA MOSCA (C),
MICHELINA BATTISTA (C), FRANCESCO VENANZIO NAPOLI (A),
SERGIO CARBONARA (B), GIOVANNI LUZZI (A), GIUSEPPE MIRAGLIOTTA (C),
GIOACCHINO ANGARANO (B), STEFANO FAVALE (A)
(A) U.O. CARDIOLOGIA UNIVERSITARIA, DIPARTIMENTO DELL´EMERGENZA E DEI
TRAPIANTI DI ORGANO, UNIVERSITA´ DEGLI STUDI DI BARI; (B) CLINICA MALATTIE
INFETTIVE, UNIVERSITÀ DEGLI STUDI DI BARI ; (C) SEZIONE DI MICROBIOLOGIA,
DIPARTIMENTO INTERDISCIPLINARE DI MEDICINA, UNIVERSITÀ DI BARI
Background: Cardiovascular implantable electronic devices (CIED) infections present with a
polymicrobial aetiology in up to 22% of cases. However, characteristics and optimal therapy of
polymicrobial infections (PIs) are not clearly defined thus far. The aim of our study was to describe
the characteristics and outcomes of CIED-PIs.
Methods: Patients with suspected CIED infection observed at the Clinic of Infectious Diseases,
University Hospital of Bari (Italy) routinely undergo extensive microbiological investigation from
multiple sites (blood, pocket swabs/biopsies, swabs and/or biopsies, lead tips) both before and during
the CIED extraction. In this prospective single-centre observational study conducted from November
2012 to October 2013, all patients with polymicrobial, clinically significant isolates were enrolled.
Demographic, clinical, instrumental, laboratory, microbiological, treatment and outcome data were
recorded.
Results: Ten cases of CIED-PIs (8 males; age 60-84 years; 6 pacemaker, 4 implantable cardioverterdefibrillator) were observed. A lead infection was microbiologically documented in all patients (6
with lead vegetations, 2 of whom also had valvular endocarditis), bacteraemia in 4 patients, pocket
infection in 8 patients. All ten cases had isolates from >=2 different sites, and four of them from 3
sites. At least 2 microbial species were isolated in all patients, 3 in three patients, and 4 in one patient.
Strains belonging to the same species but with different patterns of drug-resistance were cultured
from three subjects; two of them had also isolates of other species. Either diverse species or strains
of the same species were detected from different sites as well as from the same site in 6/10 patients,
from different sites only in 3 patients, from the same site only in 1 patient. Pathogens were mainly
Gram-positive bacteria: S. hominis (4 subjects), S. epidermidis (7), S. capitis (4), S. haemolyticus (1),
S. simulans (1), S. aureus (1), E. faecalis (1), Micrococcus spp. (1), S. viridans (1). C. freundi was
detected in 1 case. Daptomycin constantly showed in-vitro efficacy versus Gram-positive bacteria, in
contrast to most other antibiotics tested. Eight patients were treated with daptomycin-based (8
mg/kg/day) regimens throughout the treatment; in the remaining 2 subjects, daptomycin was switched
to oxacillin following detection of oxacillin-susceptible Staphylococcus spp. A clinical and
microbiological success was recorded in all cases (follow-up 12-48 weeks, available for 7/10
subjects).
Conclusion: CIED-PIs can be caused by different species of mostly Gram-positive bacteria, as well
as by strains of the same species with different patterns of drug-resistance. The pathogen diversity
can be detected either from different infection sites or from a same site, by thorough microbiological
investigation. Daptomycin, based on its constant in vitro and in vivo effectiveness against Grampositive bacteria shown in our patients, may represent a valuable therapeutic option in CIED-PIs.
Further studies are warranted to define both the characteristics and the optimal management of CIEDPIs
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O82
APPROCCIO VENOSO ECO-GUIDATO PER GLI IMPIANTI DI ELETTROCATETERI
DA STIMOLAZIONE E DEFIBRILLAZIONE CARDIACA
MATTIA LICCARDO (A), PASQUALE NOCERINO (A), ANDREA CAROL RUSSO (D),
ANTONIETTA BORRINO (A), CRISINA CARBONE (A), PAOLA FOLLERO (A),
CARMINE CIARDIELLO (B), LUCA PRATO (C), GAIA SALZANO (C)
(A) OSPEDALE SANTA MARIA DELLE GRAZIE POZZUOLI NAPOLI; (B) H.T.MED ; (C)
BOSTON SCIENTIFIC, ITALY; (D) UNIVERSITY OF SYRACUSE, NEW YORK
Introduzione. Tradizionalmente le tecniche principalmente utilizzate per l’accesso venoso per
l’impianto di elettrocateteri da stimolazione e defibrillazione cardiaca sono la puntura della succlavia
e la venotomia della vena cefalica. Negli ultimi anni sempre più interessante e studiato risulta essere
l’approccio alla vena ascellare /succlavia extratoracica.
Scopo del lavoro è valutare il rate di successo e le complicanze correlate dell’ approccio ascellare
rispetto alla classica puntura della succlavia.
Tecnica. Dopo disinfezione della cute nella regione clavicolare e preparazione di campo sterile
veniva utilizzato un copri sonda sterile per rivestire la sonda cardiologica che veniva precedentemente
ricoperta di gel non sterile. Per migliorare la visualizzazione delle immagini e ridurre l’aria
nell’interfaccia cute-copri sonda si utilizzava soluzione fisiologica. L’operatore destrimano
impugnava la sonda con la mano sinistra e la siringa con l’ago con la mano destra. Si individuava la
regione anatomica sotto-clavicolare extra-toracica della vena succlavia /ascellare che veniva punta,
previa anestesia locale nella zona d’interesse, con tecnica di Seldinger; la progressione dell’ago
veniva poi guidata dall’ecografia.
Metodi. Dopo un periodo di apprendimento della tecnica eco-guidata sono stati arruolati 90 pazienti
consecutivi in cui, in maniera randomizzata 1:1, veniva scelto l’approccio iniziale (eco o succlavia).
Se in un tempo massimo di 5 minuti il primo approccio falliva nella cannulazione si passava al
secondo approccio.
Risultati. Nel periodo di apprendimento di circa tre mesi la frequenza di insuccesso risulta minore
del 30%. Nel periodo di arruolamento randomizzato, la frequenza di successo al primo tentativo
dell’approccio eco è confrontabile con quello per succlavia (42/45, 93.3% vs 43/45, 95.6%). Non
sono riportati eventi maggiori all’impianto e nel post-operatorio. Sono registrati eventi minori quali:
sposizionamento durante procedura e/o innalzamento di soglia post-procedura in maniera
paragonabile nei due gruppi (Eco: 2.2% vs Succlavia 6.7%).
Conclusioni. La tecnica proposta sembra efficace e sicura al pari della tecnica classica per succlavia,
inoltre presenta il vantaggio di essere scevra da rischi di pneumotorace e di rottura di elettrocateteri.
Valutazioni su un follow-up a medio e lungo termine sono in atto per valutarne l'affidabilità. Studi
con un numero adeguato di pazienti sarebbero auspicabili per confermare i nostri risultati preliminari.
O83
PATIENT DESTINY AFTER CIED EXTRACTION: REIMPLANTATION OR NOT?
COSIMO MANDURINO (A), ROBERTA TROTTA (A), ZEFFERINO PALAMÀ (A),
CLAUDIA FABRIZIO (B), SERGIO CARBONARA (B), GIOVANNI LUZZI (A),
GIOACCHINO ANGARANO (B), STEFANO FAVALE (A)
(A) U.O. CARDIOLOGIA UNIVERISTARIA, DIPARTIMENTO DELL´EMERGENZA E DEI
TRAPIANTI D´ORGANO, UNIVERSITA´ DEGLI STUDI DI BARI; (B) CLINICA MALATTIE
INFETTIVE, UNIVERSITÀ DEGLI STUDI, BARI
Introduction: Infection and lead malfunction are frequent cardiac implantable electronic device
(CIED) complications. Sickness progression and patient conditions changes can modify indications
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to reimplant. In order to optimize management of these patients we examined our experience in
treating them before and after lead extraction.
Methods: We enrolled 115 consecutive cases of CIED removal (mechanical dilatation technique)
from November 2009 to May 2014. Patients were clinically evaluated after lead extraction to assess
reimplant indication according to current European Society of Cardiology guidelines. Subjects were
classified in two groups: same type versus upgrading, downgrading or no CIED reimplant.
Results: Table 1 resumes population characteristics. CIED were removed (239 leads) because of
pocket infection (70), endocarditis (23) and lead malfunction (22). Explanted CIED were: 6 single
chamber pacemaker (PM); 27 dual chamber PM; 1 biventricular PM; 14 single chamber defibrillator
(ICD); 34 dual chamber ICD; 33 biventricular ICD. Average first-implant-to-removal elapsed time
was 66±59 months, comparison between the two aforementioned groups was 58±51 vs 81±67 months
(p= 0.051).
Conclusions: A third of our cohort did not require a same-type device after CIED extraction and
there was no significant difference between the two groups of patients in first-implant-to-removal
interval. Formerly preferred conservative approach could explain consistent standard deviation in
elapsed time since first implant until CIED removal. Therefore it is ought to reevaluate indication to
a new device according to current guidelines and present conditions of patient.
O84
ROLE OF 123-IODINE METAIODOBENZYLGUANIDINE (MIBG) IMAGING IN
GUIDING REIMPLANTATION OF ICD IN PATIENTS UNDERWENT DEVICE
EXTRACTION
NICOLÒ SALVI (A), NOEMI BRUNO (A), PAOLA SCARPARO (A),
CAMILLA CALVIERI (A), ALESSANDRA CINQUE (A), MANFREDI ARIOTI (A),
ALESSANDRA ARMATO (A), PASQUALINA BRUNO (A), MASSIMO MANCONE (A),
GIUSEPPE DE VINCENTIS (A), FRANCESCO FEDELE (A)
(A) “SAPIENZA“ UNIVERSITÀ DI ROMA
Background: According to guidelines, implantable cardioverter defibrillator (ICD) is recommended
for the prevention of sudden cardiac death (SCD) in heart failure (HF) patients (pts) with an ejection
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fraction (EF) ≤ 35%, a NYHA class II or III and in full medical therapy. Moreover, numerous patients
treated with ICD experienced complications needing ICD removal. In this setting it is difficult to
decide the timing or the indication to ICD re-implantation, especially in pts who never experienced a
malignant arrhythmia, since EF has a low sensibility and specificity. Recently, 123-iodine
metaiodobenzylguanidine imaging (123-I MIBG) has shown the possibility to identify, among pts
who are candidates for ICD implantation and independently from EF, a cohort at high risk of SCD
defined as: heart/ mediastinum (H/M) ratio ≤ 1.6 and a summed score at SPECT (SS)> 26.
Aim: The aim of our study is to evaluate, in a real world registry, the role of 123 I-MIBG imaging,
in guiding re-implantation of ICD in patients who underwent device extraction.
Methods: We enrolled 24 pts consecutively admitted to our hospital with a diagnosis of HF and EF
≤ 35%, undergone ICD extraction for device infections. Patients were divided in two groups: (G1)
group-1 not re-implanted ICD patients, including pts without appropriate shocks in the previous 5
years, H/M ratio >1.6 and SS < 26; (G2) group-2 re-implanted ICD patients, including pts with ≥1
appropriate shock, H/M ratio ≤ 1.6 and SS > 26. All patients underwent 1 year follow-up.
Results: Eight pts in G1 and 16 pts in G2 were enrolled. No significant differences were observed
between the groups in term of baseline characteristics. All patients were on optimal medical therapy
according to current guidelines. In G1 the H/M ratio was 1.75 ± 0.15 vs 1.39±0.14 in G2 (p<0.001),
SS was 13.5 ± 8.2 in G1 vs 25.4 ±10.9 in G2 (p<0.05) and EF was 30.44 ± 5.07 in G1 vs 25.94 ±.5.86
in G2 (p=0.62). At 12 months follow-up all G1 pts were alive and without re-hospitalization episodes.
In G2 we recorded 6 episodes of appropriate shocks vs 0 episodes in G1 (0.045).
Conclusion: Our results showed that 123-I MIBG could be a useful tool to better identify patients
who need ICD reimplantation, independently from ejection fraction. Further studies, in wider
populations, are needed to confirm our findings.
O85
ARRESTO CARDIACO EXTRAOSPEDALIERO: VALIDAZIONE DI UN PROTOCOLLO
GESTIONALE MULTIDISCIPLINARE DEI PAZIENTI POST ROSC
RITA BELFIORE (A), SERENA RAKAR (A), SARA SCAPOL (A), LAURA MASSA (A),
VITTORIO ANTONAGLIA (B), VINCENZO CAMPANILE (C), ANDREA PERKAN (A),
GIANCARLO VITRELLA (A), ALESSANDRO SALVI (A), GIANFRANCO SINAGRA (A)
(A) AZIENDA OSPEDALIERO-UNIVERSITARIA “OSPEDALI RIUNITI”, DIPARTIMENTO
CARDIOVASCOLARE –SCUOLA DI SPECIALIZZAZIONE IN MALATTIE
CARDIOVASCOLARI, TRIESTE ; (B) CENTRALE OPERATIVA 118, ASS 1 TRIESTINA,
TRIESTE; (C) ANESTESIA-RIANIMAZIONE E TERAPIA ANTALGICA, AZIENDA
OSPEDALIERO-UNIVERSITARIA “OSPEDALI RIUNITI”, TRIESTE
BACKGROUND: L’arresto cardiaco extraospedaliero (OHCA) rappresenta una problematica
sanitaria ad elevato tasso di letalità. Indipendentemente dal tipo di ECG post ROSC (ripristino del
circolo spontaneo), la patologia coronarica sottende fino al 70% dei casi di OHCA e l’angioplastica
coronarica (PCI) precoce sembra correlarsi ad un outcome migliore, tanto più se nei pazienti (pz)
comatosi associata all’ipotermia terapeutica (HT), che limita i danni neurologici della sindrome postarresto.
MATERIALI E METODI: Nel 2011 abbiamo redatto un protocollo provinciale sulla gestione
multidisciplinare dell’OHCA, cui hanno partecipato 118, Pronto Soccorso (PS), Cardiologia ed
Anestesia-Rianimazione della nostra città. In base all’ECG post ROSC, distinto in STEMI o noSTEMI, i pz arrivavano direttamente in sala di emodinamica (SE) per la coronarografia (CFG)
emergente o indirettamente, dopo una valutazione multidisciplinare in PS, per escludere una causa
extracoronarica. Tutti i pz dovevano essere trattati quanto prima con HT. A 2 anni abbiamo analizzato
retrospettivamente i risultati di tale percorso.
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RISULTATI: Dal 2011 al 2013 sono stati ammessi al nostro ospedale 55 pz sopravvissuti ad OHCA
(62% M, età media 67.6±15.9 anni, 55% con ritmo d’esordio FV/TV, 87% con OHCA testimoniato,
96% comatosi). L’ECG post ROSC era STEMI nel 36% dei pz, no-STEMI nel 58% e non disponibile
nel 6%. La CGF emergente è stata eseguita in 34 pz (62%; 20 pz, 59% con ECG STEMI e 14 pz,
41% no-STEMI), l’HT in 35 pz (64%), contemporaneamente CGF-HT in 26 pz (47%). Tra le CGF
la maggior parte dei pz (20 pz, 59%) ha avuto un accesso diretto in SE ed è stata studiata per approccio
radiale (26 pz, 76%). La maggior parte dei pz studiati (23 pz, 67%) aveva una malattia
coronarica>50% e la metà (17 pz, 50%) è stata rivascolarizzata con PCI, 7 pz (41%) su lesione della
discendente anteriore e 12 pz (71%) con impianto di stent. 14 (41%) dei pz con malattia coronarica
presentavano un’occlusione totale, in 3 casi sottesa da un ECG no-STEMI; mentre la metà di tutti di
pz con ECG no-STEMI (14 pz) presentava una stenosi coronarica>50%. I pz dimessi vivi
dall’ospedale erano 23 (42%), 19 (34.5%) con buona performance cerebrale (CPC²2) e 5 (9%) trattati
con ICD. Cinque pz sono rimasti lungodegenti a causa di gravi complicanze neurologiche. Ad 1 anno
erano vivi complessivamente 26 pz (47.2%). La strategia combinata CGF-HT incideva sulla
sopravvivenza alla dimissione (p 0.04) e ad 1 anno (p 0.01), ma non sullÕoutcome neurologico (p
0.482).
CONCLUSIONI: La malattia coronarica si è rilevata anche nella nostra casistica la causa principale
dellÕOHCA. La strategia combinata CGF-HT si è dimostrata fattibile, a dispetto del ritmo di
presentazione, prevalentemente ma non esclusivamente FV/TV, e dell’ECG post ROSC, non sempre
indicativo di malattia-occlusione coronarica. Il protocollo nel complesso è stato di facile applicabilità,
ma necessariamente il percorso va implementato alla luce dei nostri dati di outcome e delle nuove
evidenze sull’HT.
ARITMOLOGIA - 2
O86
ACUTE HEMODYNAMIC DECOMPENSATION DURING CATHETER ABLATION OF
SCAR-RELATED VT: INCIDENCE, PREDICTORS AND IMPACT ON MORTALITY
DANIELE MUSER (A), PASQUALE SANTANGELI (C), SILVIA MAGNANI (B),
ERICA ZADO (C), MATHEW HUTCHINSON (C), GREGORY SUPPLE (C),
DAVID FRANKEL (C), FERMIN GARCIA (C), RUPA BALA (C), MICHAEL RILEY (C),
EDUARDO RAME (C), SANJAY DIXIT (C), GIANFRANCO SINAGRA (B),
ALESSANDRO PROCLEMER (A), FRANCIS MARCHLINSKI (C), DAVID CALLANS (C)
(A) AZIENDA OSPEDALIERO-UNIVERSITARIA DI UDINE; (B) AZIENDA OSPEDALIERO
UNIVERSITARIA DI TRIESTE; (C) HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA
Introduction: The occurrence of periprocedural acute hemodynamic decompensation (AHD) in
patients (pts) undergoing catheter ablation (CA) of scar-related VT has not been previously
investigated.
Methods: Using logistic regression analysis we identified predictors of AHD in 148 consecutive pts
undergoing CA of scar-related VT. Periprocedural AHD was defined as persistent hypotension
(systolic blood pressure <80-90 mmHg) despite vasopressors and requiring mechanical support
and/or procedure discontinuation. A risk score was created from the rounded univariate odds ratios
(OR).
Results: Periprocedural AHD occurred in 19 (13%) pts, and was predicted by 6 factors: ischemic
cardiomyopathy (OR=6.12 [1.36-27.60], P=0.018), EF <25% (OR=2.97 [1.10 7.98], P=0.031),
NYHA class III or IV (OR=6.84 [2.39-19.53], P<0.001), COPD (OR=3.84 [1.33-11.12], P=0.013),
VT storm (OR=5.09 [1.41-18.32], P=0.013), and general anesthesia (OR=7.23 [2.43-21.53],
P<0.001). When applying the risk score derived from the ORs of the predictors (Figure), the risk of
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AHD was 2%, 5% and 44%, respectively for increasing risk score tertile. At 20±8 months follow-up,
the mortality rate in the AHD group was 58% vs. 14% in the rest of the population (P<0.001).
AHD was associated with increased risk of 6-month (OR=6.36, P=0.008) and 1-year (OR=5.05,
P=0.008) mortality, independently of the risk score.
Conclusions: Periprocedural acute hemodynamic decompensation occurs in 13% of patients
undergoing catheter ablation of scar-related VT and is associated with increased risk of mortality. A
risk score comprising 6 factors can be used to identify these patients..
O87
EFFICACIA E SICUREZZA A LUNGO TERMINE DELL’ABLAZIONE MEDIANTE
RADIOFREQUENZE DI TACHICARDIE SOPRAVENTRICOLARI CON APPROCCIO
SEMPLIFICATO
Pier Luigi Pellegrino (a), Massimo Grimaldi (a, b), Luigi Di Martino (a), Francesco Santoro (a),
Marica Caivano (a), Mauro Ciavarella (a), Natale Daniele Brunetti (a), Matteo Di Biase (a)
(a) CARDIOLOGIA UNIVERSITARIA OSPEDALI RIUNITI FOGGIA; (b) OSPEDALE
MIULLI ACQUAVIVA BARI
Background: L’ablazione transcatetere mediante radiofrequenze (ATC) viene utilizzata con
successo nel trattamento delle tachicardie da rientro dagli anni ’90. In genere la procedura richiede
l’uso di 5 cateteri, sebbene alcuni operatori effettuino la procedura con un numero ridotto di cateteri.
Lo studio si propone pertanto di valutare i risultati in termini di efficacia e sicurezza a breve e lungo
termine di un approccio semplificato con l’uso di 2/3 cateteri.
Materiali and Metodi: 274 pazienti consecutivi con tachicardie parossistiche ed evidenza ECG di
tachicardia a QRS stretto come da AVNRT o AVRT da via accessoria sono stati sottoposti a studio
elettrofisiologico (EPS) e ATC presso la Cardiologia Universitaria degli Ospedali riuniti di Foggia
dal 2004 al 2012. 195 pazienti sono stati trattati per AVNRT, 79 per AVRT (65 manifesta, 13 occulta).
Il follow-up medio è stato di 86±32 (24-132) mesi. Un approccio a 2 cateteri è stato utilizzato di
routine sia per l’EPS che per l’ARF. E’ stato aggiunto un terzo catetere in caso di ATC da vie
accessorie sinistre.
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Risultati: La procedura ha avuto una percentuale di efficacia in acuto del 99.6%. 15 soggetti (5.56
%) hanno avuto recidiva di aritmia: 7 (2.57 %) con AVRT, 8 (2.94 %) con AVNRT (tutte forme
tipiche). Una seconda seduta è stata effettuata in 8 soggetti, con efficacia in tutti i casi. 2 (0.73%)
soggetti hanno avuto complicanze maggiori (blocco AV completo, uno con necessità di impianto di
pacemaker). Non sono state osservate altre complicanze maggiori. Complicanze vascolari sono state
osservate in 4 soggetti (1.43%): trombosi parziale della vena femorale (3 pz) senza complicanze
emboliche, fistola femorale artero-venosa (1 pz). Un minimo versamento pericardico è stato osservato
in 6 pazienti (2.2%).
Conclusioni: La ATC delle AVNRT con approccio semplificato e numero ridotto di cateteri può
essere efficace e sicuro in maniera sovrapponibile all’approccio tradizionale.
O88
FLUOROLESS
ABLATION
OF
ACCESSORY
PATHWAYS
USING
ELECTROANATOMIC MAPPING SYSTEM IN CHILDREN AND ADOLESCENTS
ELISA EBRILLE (A), DOMENICO CAPONI (B), PAOLO DI DONNA (B),
ALESSANDRA SIBOLDI (C), GIOVANNI BERTERO (C), FULVIO GABBARINI (D),
FRANCESCA DI CLEMENTE (B), CRISTINA RAIMONDO (A), MAURIZIO MARASINI (C),
FIORENZO GAITA (A), MARCO SCAGLIONE (B)
(A) CARDIOLOGY DIVISION, DEPARTMENT OF MEDICAL SCIENCES, UNIVERSITY OF
TURIN, TURIN, ITALY; (B) CARDIOLOGY DIVISION, CARDINAL G. MASSAIA
HOSPITAL, ASTI, ITALY; (C) PEDIATRIC CARDIOLOGY DEPARTMENT, G. GASLINI
INSTITUTE, GENOVA, ITALY; (D) CARDIOLOGY DEPARTMENT, OIRM PEDIATRIC
HOSPITAL, TURIN, ITALY
Purpose. Fluoroscopic catheter ablation of cardiac arrhythmias in pediatric patients is a challenging
procedure and, because of radiation sensitivity and longer life expectancy, is associated with potential
adverse events. We evaluated the feasibility, safety and efficacy of accessory pathway (AP) ablation
guided by 3D electroanatomic mapping (EAM) system in order to reduce X-Ray exposure in pediatric
patients affected by Wolff-Parkinson-White syndrome both with cryoenergy and radiofrequency (RF)
energy.
Methods e Results. We included 44 patients (mean age 13.1 ± 3.3 years). Nine out of 44 were
affected by concealed AP. An electrophysiological study with a 3D EAM reconstruction was
performed in every patient with a transfemoral venous direct right atrium approach or an arterial
retrograde approach. In 2 patients with left-sided AP, a patent foramen ovale allowed left atrium
access. At the electrophysiological study a total of 47 AP were present. AP was left-sided in 45%
(21/47) of patients (15 lateral, 1 anterior, 3 postero-septal, 2 postero-lateral) and right sided in 55%
(26/47) (1 anterior, 3 antero-lateral, 1 postero-lateral, 3 lateral, 5 para-Hisian, 12 postero-septal, 1
antero-septal). Ablation was successfully performed in every patient, in 33 with RF and in 11 with
cryoenergy completely without the use of fluoroscopy. No complication occurred. At a mean followup of 16.0 ± 11.7 months we observed 7 recurrences, 3 successfully re-ablated without fluoroscopy.
In 1 case cryoablation for a para-Hisian AP wasn’t able to control the arrhythmia in the long-term.
Conclusion. 3D EAM allowed performing a safe and effective fluoroless AP ablation procedure in a
pediatric population both with RF and cryoenergy.
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O89
LA TERAPIA DI COMBINAZIONE CON FLECAINIDE E METOPROLOLO RIDUCE LE
RECIDIVE DI FIBRILLAZIONE ATRIALE AD UN ANNO MIGLIORANDO LA QUALITÀ
DI VITA
FEDERICO GUERRA (A), LUCA PIANGERELLI (A), JENNY RICCIOTTI (A),
FEDERICA RAGNO (A), ALESSANDRO CAPUCCI (A)
(A) CLINICA DI CARDIOLOGIA ED ARITMOLOGIA, OSPEDALI RIUNITI DI ANCONA,
UNIVERSITÀ POLITECNICA DELLE MARCHE
Background: la fibrillazione atriale (FA) rappresenta l' aritmia di piu comune riscontro nella pratica
clinica con una prevalenza che sfiora il 2% della popolazione mondiale. La flecainide, anti-aritmico
di classe IC, rappresenta un farmaco di prima scelta nei pazienti con cardiopatia non ischemica e
frazione di eiezione conservata ed è causa di numerosi effetti collaterali, spesso invalidanti, che
conducono ad una prematura sospensione del farmaco o al sottodosaggio. Per ovviare a tali
limitazioni e'stato proposta l'associazione di basse dosi di beta-bloccante per sfruttare un potenziale
effetto sinergico e per limitare la comparsa di eventi avversi. Scopo di questo studio è determinare
l'efficacia nel mantenimento del ritmo sinusale di un associazione flecainide-metoprololo rispetto lla
flecainide in monoterapia durante un follow-up di un anno.
Metodi: studio monocentrico, prospettico, randomizzato. su 152 pazienti, di cui 80 assegnati a
ricevere la terapia di combinazione e 72 flecainide in monoterapia. Entrambi i gruppi sono stati
valutati lungo un follow-up di 1 anno mediante visita a 3, 6 e 12 mesi. Criteri di inclusione: FA
parossistica o persitente con recente passaggio a ritmo sinusale e consenso informato. Cirteri di
esclusione: recente infarto del miocardio (6 mesi), scompenso NYHA III-IV, severa disfunzione
sistolica (<40%), blocchi di branca, bradicardia severa (<40), malattia del nodo seno-atriale,
ipotensione, disfunzione tiroidea ed insufficienza severa renale, epatica o polmonare. Tutti i pazienti
hanno iniziato con una dose di 50 mg per os b.i.d. di flecainide, successivamente titolata a 75 mg
b.i.d. ad 1 mese e 100 mg b.i.d. a 3 mesi o fino alla massima dose tollerata. I pazienti nel gruppo B
hanno inoltre ricevuto una dose di metoprololo fino a 50 mg b.i.d. Endpoint primario dello studio
e'stata la valutazione di recidive aritmiche lungo il corso dell'anno di follow-up, definite come episodi
sintomatici di FA (durata almeno 5 minuti) o documentati durante visita. Endpoint secondario e' stata
la valutazione della qualita di vita (QoL), valutata mediante i questionari SF-36 e AFSS.
Risultati: i due gruppi sono risultati omogenei in termini di eta',genere, caratteristiche
ecocardiografiche o fattori di rischio cardiovascolare. La terapia di combinazione ha ridotto le
recidive aritmiche ad un anno in modo significativo con un ARR del 21% ed un RR del 37% .
Valutando la popolazione per tipologia di FA si e'inoltre osservato che la terapia di combinazione ha
ridotto gli eventi nei pazienti con forma persistente rispetto a quelli con forma parossistica dove non
risulta superiore alla terapia con sola flecainide. I pazienti in terapia di associazione hanno inoltre
mostrato un miglioramento della qualita' di vita rispetto a quelli in monoterapia. Il questionario SF36 ha mostrato un incremento sia nei valori sia del physical che del mental score. L'AFSS ha inoltre
confermato un miglioramento nel benessere generale senza differenze significative dei restanti
parametri valutati.
Conclusioni: l'aggiunta del metoprololo alla terapia con flecainide ha migliorato l'efficacia nel
mantenimento del ritmo sinusale con riduzione delle recidive aritmiche fino al 37% durante 1 anno
di follow-up nei pazienti con FA permanente. La riduzione del dosaggio della Flecainide ha inoltre
incrementato la sicurezza e la tollerabilita' del farmaco con riduzione degli eventi avversi e maggiore
compliance alla terapia. La terapia di combinazione ha inoltre migliorato la qualita' di vita dei
pazienti.
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O90
VALORE PREDITTIVO DELLA VELOCITA' DI PROPAGAZIONE AL COLOR M-MODE
NELLA RECIDIVA DI FIBRILLAZIONE ATRIALE DOPO CARDIOVERSIONE
ELETTRICA
DIEGO ALBERTI (a), JACOPO SENES (a), SARA ONETO (a), GIOVANNI BERTERO (a)
(a) CARDIOLOGIA UNIVERSITARIA OSPEDALE SAN MARTINO DI GENOVA
La correlazione tra disfunzione diastolica e recidiva di fibrillazione atriale è nota.
Ma quale parametro ecocardiografico di disfunzione diastolica può essere agevolmente utilizzato per
valutare il rischio di recidiva nei pazienti con fibrillazione atriale dopo cardioversione
elettrica(CVE)?
In questo studio abbiamo testato il parametro Velocità di propagazione al color m-mode (Vp) in 30
pazienti sottoposti a CVE c/o il nostro centro. Abbiamo rivalutato i pazienti dopo 30 giorni: 18
avevano mantenuto il ritmo sinusale e 12 avevano recidivato. Abbiamo riscontrato che i pazienti che
avevano Vp > 40 cm/s mantenevano il ritmo sinsuale nel 90 % dei casi, mentre quelli che avevano
Vp < 40 cm/s recidivavano in più del 50 % dei casi. I pazienti in ritmo sinusale e quelli che avevano
recidivato non differivano per frazione d’eiezione, età, fattori di rischio cardiovascolari, per volume
atriale e per terapi antiaritmica. E’ stato testato il Vp anche in differenti condizioni di carico (Valsava
e hand-grip) e si è mantenuto invariato. Il Vp si è dimostrato indipendente dal carico, indipendente
dal ritmo e un buon predittore di recidiva di fibirllazione atriale. A differenza del rapporto E/E’ che
è spesso difficile da calcolare con precisione e necessita di tempo per calcolarlo, il Vp è semplice e
velocee può essere agevolmente utilizzato nella pratica clinica.
O91
ANEURISMA DEL SETTO INTERATRIALE E ARITMIE SOPRAVENTRICOLARI: IL
RUOLO DEL RITARDO ELETTROMECCANICO ATRIALE
VINCENZO RUSSO (a), ANNA RAGO (a), ANDREA ANTONIO PAPA (a), FEDERICA DI
MEO (a), ANNA CRISTIANO (a), MARIA GIOVANNA RUSSO (a),
RAFFAELE CALABRO’ (a), GERARDO NIGRO (a)
(a) DIPARTIMENTO DI SCIENZE CARDIO-TORACICHE E RESPIRATORIE, SECONDA
UNIVERSITÀ DEGLI STUDI DI NAPOLI, AORN OSPEDALI DEI COLLI, MONALDI,
NAPOLI
Introduzione: I pazienti con aneurisma del setto interatriale (ASA) presentano un’ elevata incidenza
di crisi parossistiche di tachiaritmie atriali. Scopo del nostro studio è stato valutare, nei soggetti con
ASA senza shunt interatriale e normale funzione cardiaca, gli indici non invasivi elettrocardiografici
(durata e dispersione dell’ onda P) ed ecocardiografici (ritardo elettromeccanico atriale) di
eterogeneità della conduzione atriale e il ruolo predittivo di aritmie sopraventricolari (SV) del ritardo
elettromeccanico atriale in questa popolazione.
Materiale e Metodi: Abbiamo arruolato nel nostro studio una popolazione selezionata di 100 soggetti
con ASA (41 M, età media 32.5 ± 8 anni) ed un gruppo controllo di 100 soggetti sani appaiati per
sesso ed età. Ogni soggetto arruolato è stato sottoposto, durante un periodo di osservazione di 4 anni,
a monitoraggio per 30 giorni mediante Loop Recorder esterno, effettuato con cadenza trimestrale, per
la valutazione dell’ eventuale insorgenza di aritmie atriali. La diagnosi di ASA è stata effettuata
mediante ecocardiogramma transtoracico sulla base dei seguenti criteri: minima base aneurismatica
≥ 15 mm ed escursione ≥ 10 mm. Il ritardo elettromeccanico intra ed interatriale è stato misurato per
entrambi gli atri attraverso ecocardiografia con Doppler tissutale. La dispersione dell’ onda P (PD)
è stata accuratamente misurata utilizzando elettrocardiogramma a 12 derivazioni.
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Roma, 13 – 15 dicembre 2014
Risultati: Il gruppo di pazienti con ASA presentava un incremento statisticamente significativo del
ritardo elettromeccanico interatriale (48.7 ± 19.8 ms vs 34.8 ± 9.7 ms P=0.001), del ritardo
elettromeccanico intra-atriale sinistro (42.8 ± 16.7 ms vs 28.9 ± 10.1 ms, P=0.001), della durata
massima dell’ onda P (100.4 ± 6.2 vs 90.4 ± 7.5 ms, P = 0.03) e della PD (30.5 ± 10 vs 14.9 ± 3.1 ms,
P = 0.003) rispetto al gruppo controllo. Dividendo il gruppo ASA in 2 sottogruppi (pazienti con e
senza aritmie SV), i valori di ritardo elettromeccanico interatriale (61.5 ± 18.8 ms vs 44.1 ± 19.8,
P=0.001), ritardo elettromeccanico intra-atriale sinistro (54.7 ±15.1 ms vs 38.2 ± 14.6, P=0.001), P
max (101.1 ± 7.4 vs 87.1 ± 7.2 ms, P=0.002) e PD (32.5 ± 8.5 ms vs 26.2 ± 7.2 ms, P=0.002) erano
significativamente più elevati nel sottogruppo con aritmie SV rispetto al sottogruppo senza aritmie
SV. I ritardi elettromeccanici intra-atriale sinistro e interatriale risultavano significativamente
correlati con la PD (R=0.79, P=0.01, R=0.74, P=0.01, rispettivamente). Il valore cut off del ritardo
elettromeccanico intra-atriale sinistro pari a 40.1 ms aveva una sensibilità del 82% ed una specificità
del 83% nell’identificare pazienti con ASA a rischio di insorgenza di aritmie SV.
Conclusioni: I nostri risultati dimostrano che gli indici di ritardo elettromeccanico atriale (inter e
intra-atriale sinistro) e la PD sono significativamente incrementati nei soggetti con ASA senza shunt
interatriale. PD e ritardo elettromeccanico atriale rappresentano parametri semplici, non invasivi,
poco costosi e utili per la valutazione del rischio di aritmie SV nei pazienti con ASA senza shunt
interatriale e normale funzione cardiaca.
INSUFFICIENZA CARDIACA ACUTA
O92
MIGLIORAMENTO DELL'ELASTANZA VENTRICOLARE SINISTRA INDOTTO DA
UNA SINGOLA SOMMINISTRAZIONE DI LEVOSIMENDAN
GABRIELLA MALFATTO (A), MATTEO OLDANI (A, B), BENEDETTA ORTIS (B),
ALESSANDRA VILLANI (A), VALERIA RELLA (A, B), GIANFRANCO PARATI (A, B)
(A) DIVISIONE DI CARDIOLOGIA, OSPEDALE SAN LUCA, ISTITUTO AUXOLOGICO
ITALIANO IRCCS, MILANO; (B) DIPARTIMENTO DI MEDICINA CLINICA,
PREVENZIONE E BIOTECNOLOGIE SANITARIE, UNIVERSITA´ DI MILANO-BICOCCA,
MILANO
Premesse: La comparsa di disfunzione diastolica segna un peggioramento della prognosi nello
scompenso cardiaco. La definizione della diastole ventricolare è difficile, perché essa deriva
dall’equilibrio tra pressioni di riempimento e proprietà passive ventricolari. Secondo un modello
matematico, la diastole passiva (elastanza ventricolare sinistra KLV, mmHg/ml) è stimabile
noninvasivamente come (a) KLV = (70 / [DT-20])2 mmHg/ml, ove DT è il tempo di decelerazione del
flusso Doppler transmitralico. Un’elevata KLV indica quindi maggiore rigidità e minor compliance
ventricolare. Il levosimendan (LEVO) è un inodilatatore che modifica favorevolmente la diastole
attiva (load-dependent) agendo sul post-carico e sulle pressioni di riempimento, ma il cui effetto sulle
proprietà passive della diastole è meno noto ed è stato studiato solo in modo invasivo.
Scopo dello studio: Valutare se la stima noninvasiva di KLV potesse definire l’effetto di un’infusione
di LEVO sulle proprietà passive della diastole ventricolare in pazienti (pz) con scompenso cardiaco
avanzato (SCC).
Materiali e Metodi: Abbiamo studiato 35 pz con SCC [71±5 anni; 13% donne; 55% ischemici;
NYHA 3.02±0.03; FE 29±6%] in cui era eseguita un’infusione di LEVO (12.5 mg/ totale) senza bolo
iniziale e senza restrizioni di tempo. Prima e dopo l’infusione si effettuava un ecocardiogramma
colorDoppler con definizione del tempo di decelerazione del flusso transmitralico (DT, deceleration
time), della frazione di ejezione (FE), della pressione polmonare (PAP), del rapporto E/E’ con eco
TDI. Era inoltre ottenuto un valore di BNP. Dal DT, KLV era derivata con la formula (a).
SIC | Indice Autori
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Risultati: Non si sono verificati eventi avversi nè aritmie ventricolari. Dopo l’infusione di LEVO, si
osservava il prevedibile miglioramento di FE (15±3%, p<0.001), PAPs (-18±4%, p<0.001), E/E’ (29±5%, p<0.001) e del BNP plasmatico (-35±9%, p<0.001). Si osservava inoltre una sensibile
riduzione della rigidità diastolica, come mostrato dalla riduzione di elastanza KLV da 0.243±0.099 a
0.169±0.069 mmHg/ml (-26±4%, p<0.001). L’entità della riduzione di KLV era inversamente
correlata al valore iniziale con andamento esponenziale (R= 0.69, p< 0.01): tanto più il ventricolo era
rigido tanto maggiore era il miglioramento osservato (Figura).
Conclusioni: Il Levosimendan migliora significativamente le proprietà passive della diastole
ventricolare, probabilmente attraverso il suo peculiare effetto Ca++ sensibilizzante nei confronti della
Troponina C.
O93
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) COME RESCUETHERAPY NELLO SHOCK CARDIOGENO REFRATTARIO: L’ESPERIENZA DI
PADOVA
GIACOMO BORTOLUSSI (A), VINCENZO TARZIA (A), ROBERTO BIANCO (A),
JONIDA BEJKO (A), MASSIMILIANO CARROZZINI (A), SABINO ILICETO (B),
LUISA CACCIAVILLANI (B), TOMASO BOTTIO (A), GINO GEROSA (A)
(A) CARDIOCHIRURGIA, DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE
E VASCOLARI, UNIVERSITÀ DI PADOVA; (B) CARDIOLOGIA, DIPARTIMENTO DI
SCIENZE CARDIOLOGICHE, TORACICHE E VASCOLARI, UNIVERSITÀ DI PADOVA
Introduzione: Lo shock cardiogeno refrattario è una condizione potenzialmente mortale e ascrivibile
a molteplici eziologie. Nonostante i progressi nelle strategie di trattamento, la prognosi rimane
estremamente infausta se non si ricorre a sistemi di supporto meccanico al circolo. Data l’instabilità
emodinamica con cui si presenta la maggior parte di questi pazienti, l’ECMO rappresenta la soluzione
più pratica per la sua facilità di trasporto, impianto, e gestione. Lo studio proposto si prefigge di
valutare l’impatto dell’ECMO sulla sopravvienza nel paziente affetto da shock cardiogeno refrattario.
Metodi: Tra gennaio 2009 e maggio 2014, 91 pazienti (79% maschi, età media 51±15 anni) con shock
cardiogeno refrattario sono stati trattati con supporto ECMO periferico.
L’eziologia dello shock comprendeva l’IMA nel 37% dei casi, miocardite (6%), embolia polmonare
(7%), e peggioramenti acuti in un quadro di scompenso “cronico”: cardiopatie dilatative primitive
(31%), post-ischemiche (9%), o in patologie congenite (2%).
Nel 49% dei casi, l’ECMO è stato impiantato con tecnica percutanea, al letto del paziente. Nel 27%
dei casi l’impianto è avvenuto durante massaggio cardiaco esterno.
Risultati: La durata media del supporto ECMO è stata di 8±8 giorni. La mortalità in ECMO è stata
del 17.6%. Il 27.5% ha ottenuto un recupero della funzione cardiaca sufficiente allo svezzamento dal
supporto meccanico. Quattro pazienti sono stati sottoposti ad intervento chirurgico tradizionale
(CABG, ventricoloplastica). Il 14% è stato sottoposto a trapianto cardiaco ortotopico direttamente
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Roma, 13 – 15 dicembre 2014
dall’ECMO. Più di un terzo dei pazienti (36.3%) sono invece transitati verso una forma di assistenza
ventricolare, paracorporea o impiantabile, e con finalità diversa a seconda della candidabilità o meno
al trapianto cardiaco.
La sopravvivenza a 30 giorni è stata del 71.4%, mentre la sopravvivenza alla dimissione,
considerando i diversi percorsi terapeutici, è stata del 50%. Tra i pazienti dimessi, si è registrata una
sopravvivenza vicina al 90% al follow-up di 48 mesi.
Conclusioni: Nella nostra esperienza, l’ECMO si è dimostrato un valido strumento per il trattamento
dello shock cardiogeno refrattario alla terapia convenzionale, permettendo di sostenere acutamente le
funzioni vitali, finchè la miglior strategia terapeutica viene individuata. In tal senso l’ECMO può
quindi essere definito un “Bridge-to-Life”. Tra i pazienti dimessi dall’ospedale, si è dimostrata
un’ottima sopravvivenza al follow-up.
O94
ACUTE HEART FAILURE AS A CLINICAL PRESENTATION OF ACUTE AORTIC
SYNDROMES: FREQUENCY, MISDIAGNOSTIC IMPLICATION AND PROGNOSTIC
EFFECT
GIULIA BUGANI (A), FABIO VAGNARELLI (A), ANNA CORSINI (A),
SIMONE LONGHI (A), MADDALENA GRAZIOSI (A), ELENA BIAGINI (A),
GIOVANNI MELANDRI (A), CLAUDIO RAPEZZI (A)
(A) ISTITUTO DI CARDIOLOGIA, POLICLINICO S.ORSOLA MALPIGHI, BOLOGNA
Background: Acute heart failure (AHF) is a potential complication of acute aortic syndrome (AAS)
but its clinical and prognostic implications are not well understood. Therefore, the aims of this study
were to describe the frequency of AHF presentation in AAS and to explore its impact on diagnostic
delay and in-hospital mortality.
Methods: all patients referred to our institution from 2000 to 2013 who received a final diagnosis of
spontaneous AAS were enrolled. The registry collects data on “acute” aortic syndromes only, ie
patients presenting within 14 days of symptoms onset. AAS comprised “classic” aortic dissection,
penetrating ulcer, intramural hematoma and was defined according to the Stanford classification.
We also used detailed reviews of patients’ original presentation, CT scans, magnetic resonance
imaging examinations, transesophageal and transthoracic echocardiographic recordings and
electrocardiograms. All available echocardiographic recordings were blindely reviewed by a team of
3 expert echocardiographers who noted the anatomic details of AAS. Magnetic resonance imaging
and CT scans were reviewed by 2 expert cardiovascular radiologists.
AHF presentation comprised: congestive heart failure or cardiogenick shock (defined as sustained
hypotension systolic blood pressure < 90 mm Hg for > 30 min accompanied by clinical signs
indicating peripheral/cerebral hypoperfusion due to cardiac failure, except for cardiac tamponade).
Results: of the 398 patients enrolled, 44 (11%) presented with AHF (34 in Stanford type A, 10 in
type B). Patients with AHF showed more often dyspnea as a symptom (27,3% vs. 13,0%,p = 0.021)
ACS-like ECG findings (47,7% vs.22,9%, p = 0.001), pleural effusion (40,9% vs. 22,9%, p = 0.015),
moderate/severe aortic regurgitation (31,8% vs. 16,4%, p = 0.021), coronary osthia involvement
(22,7% vs. 3,4%, p = 0.001). AHF presentation did not imply a longer median in-hospital diagnostic
times and was not associated with increased risk of long (> 75th percentile) in-hospital delay (OR
0.63, 95% CI 0.28-1.41, p = 0.26). In-hospital mortality was higher in patients presenting with AHF
compared to those without AHF (40% vs. 19,5%, p = 0.002). After multivariate analysis, AHF was
confirmed to be independently associated with increased risk of death (adjusted OR 2.56 95% CI
1.26-5.19, p = 0.009, Table).
Conclusions: up to 10% of patients with AAS presented with AHF which was independently
associated with increased mortality.
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Roma, 13 – 15 dicembre 2014
Table Independent predictors of in-hospital mortality
Variable
Multivariate analysis
OR (95% CI)
P
Acute heart failure
2.56 (1.26-5.19)
.009
Cardiac tamponade
2.42 (1.14-5.12)
.021
Pleural effusion
1.67 (0.96-2.88)
.067
ACS-like ECG
1.93 (1.12-3.34)
.017
Age (for each 10 year
1.36 (1.14-1.58)
.001
increase)
O95
L'ECMO COME RESCUE-THERAPY NELLO SHOCK CARDIOGENO TERMINALE: IL
RUOLO DELL'UTIC
ERVIS HISO (A), CHIARA SALOTTI (A), ELENA ROSSI (A), NICOLA GASPARETTO (A),
MARTINA PERAZZOLO MARRA (A), GIACOMO BORTOLUSSI (A),
VINCENZO TARZIA (A), TOMASO BOTTIO (A), ROBERTO BIANCO (A),
LUISA CACCIAVILLANI (A), SABINO ILICETO (A), GINO GEROSA (A)
(A) DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE E VASCOLARI.
UNIVERSITÀ DI PADOVA
Presupposti e Scopo dello studio: lo shock cardiogeno e lo scompenso cardiaco cronico refrattario
sono condizioni cliniche con un tasso di mortalità tuttora elevato. Nei casi più critici, refrattari sia a
terapia con inotropi che all’utilizzo del contropulsatore intraaortico (IABP), spesso l’ECMO
(Ossigenazione Extracorporea a Membrana) costituisce l’unica opzione per la sopravvivenza. In
passato l’utilizzo di tale device è stato prerogativa esclusiva della rianimazione cardiochirurgica; ad
oggi è diventato uno strumento importante anche per il cardiologo intensivista nell’ambito dell’Heart
Failure Team.
Scopo di questo studio è valutare complicanze ed outcome in un gruppo di pazienti con shock
cardiogeno refrattario sottoposti a posizionamento di ECMO e gestiti da personale medico ed
infermieristico della terapia intensiva cardiologica (UTIC) di un centro di I livello in stretta
collaborazione con cardiochirurghi, perfusionisti ed emodinamisti.
Materiali e Metodi: tutti i pazienti ricoverati in UTIC e sottoposti a posizionamento ECMO venoarterioso per shock cardiogeno da gennaio 2010 a maggio 2014. Sono stati raccolti i dati clinici ed
emodinamici dei pazienti, le complicanze insorte durante il periodo di assistenza e i dati relativi a
durata dell’ECMO, mortalità durante trattamento ECMO, mortalità intraospedaliera.
Risultati: 38 pz (27 maschi, 11 femmine) con età media 51 ± 16 anni; durata media dell’assistenza
ECMO: 10 ± 10 giorni. 23 pz (61%) sono andati incontro ad intubazione oro-tracheale prima del
posizionamento del device e 10 pz (26%) hanno mantenuto contemporaneamente sia supporto ECMO
che IABP. 13 pz (34%) presentavano severa compromissione della funzionalità renale con necessità
di ultrafiltrazione venosa continua (CVVH) prima del posizionamento di ECMO; nel 46% di questi
vi è stato recupero della funzione renale. Tra i pazienti in ECMO non sottoposti a CVVH il 16% ha
sviluppato insufficienza renale acuta. In 15 pz (39%) è stata riscontrata la comparsa di emorragie
minori e maggiori (definite secondo i criteri TIMI) che hanno richiesto trasfusioni multiple. 8 pz
(21%) in ECMO hanno sviluppato Multi-Organ-Failure. 5 pz (13%) hanno presentato sepsi; 1 pz
ARDS. 5 pz (13%) hanno sviluppato aritmie ventricolari sostenute associate ad instabilità
emodinamica. 2 pz (5%) hanno avuto ischemia d’arto in sede di posizionamento della cannula con
necessità di trattamento.
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Follow up: 11 pazienti (29%) sono deceduti durante assistenza ECMO; dei rimanenti nel 37% dei
casi (10/27) vi è stato recupero della funzione contrattile; nel 44% (12/27) l’ECMO è stato utilizzato
come bridge to VAD e in 3 casi vi è stato un successivo trapianto cardiaco. Il 18% dei pazienti (5/27)
è andato incontro direttamente a trapianto cardiaco. La mortalità intraospedaliera complessiva è stata
del 50% (19/38).
Conclusioni: l’ECMO rappresenta una valida opzione terapeutica nei pazienti affetti da shock
cardiogeno refrattario. I risultati di questo trattamento sono direttamente correlati alla corretta
selezione del paziente ed al timing di impianto oltre che alla presenza di una rete intraospedaliera
coinvolgente diverse competenze al fine di ridurre le complicanze, siano esse di tipo emodinamico,
infettivo, ischemico ed emorragiche. Per tale motivo l’approccio multidisciplinare guidato dall’Heart
Failure Team è il modello che noi proponiamo per ottimizzare l’outcome dei pazienti
indipendentemente dal reparto di cure intensive in cui sono ricoverati.
O96
GESTIONE CLINICO TERAPEUTICA DELLO SHOCK CARDIOGENO POST
ISCHEMICO: L'ESPERIENZA DELLA CARDIOLOGIA DEL POLICLINICO TOR
VERGATA
FABIANA COZZA (A), SIMONA ALUIGI (A), ORIANA SERGNESE (A), LUCIANO E. DI
BATTISTA (A), SAVERIO MUSCOLI (A), CINZIA RAZZINI (A), FRANCESCO ROMEO (A)
(A) CATTEDRA DI CARDIOLOGIA, POLICLINICO TOR VERGATA, ROMA
Introduzione: Lo shock cardiogeno (SC) rappresenta una delle complicanze più drammatiche dell’
infarto acuto del miocardio (STEMI – NSTEMI) con un’incidenza pari al 7- 10% dei pazienti
ricoverati per IMA e un tasso di mortalità intra-ospedaliera che si attesta a tutt’oggi al 50%.
Obiettivi: Lo scopo del nostro studio è stata l’analisi della gestione clinico - terapeutica del paziente
affetto da shock cardiogeno post ischemico, la valutazione dei tassi di mortalità intra-ospedaliera e la
sopravvivenza a trenta giorni e a sei mesi dalla dimissione.
Materiali e Metodi: Nel periodo che va dal gennaio 2008 a maggio 2014 sono stati arruolati 75
pazient ricoverati presso l’UTIC del policlinico Tor Vergata con diagnosi di shock cardiogeno post
ischemico. E’ stato eseguito il monitoraggio clinico dei pazienti e sono stati effettuati dei follow up
a 30 giorni ed a 6 mesi dalla dimissione. E’ stata individuata la sottopopolazione dei pazienti deceduti
in ospedale e ne sono state analizzate le principali caratteristiche.
Risultati: L’età media dell’intera popolazione è risultata di 65 anni. L’ipertensione rappresenta il
fattore di rischio principale (61,3%). Il 64% della popolazione totale e il 70% del sottogruppo dei
pazienti deceduti in ospedale presentava STEMI ANTERIORE in cui, il 48% del totale ed il 50% dei
decessi intraospedalieri presentava all’esame coronarografico una malattia bivasale. Il 94, 6% dei
pazienti è stato sottoposto ad intervento di rivascolarizzazione percutanea precoce (PCI primaria),
con trattamento della culprit lesion in fase acuta e successivamente ad ulteriori rivascolarizzazioni
(PCI staged), quando necessario, dopo il raggiungimento della stabilizzazione emodinamica. Durante
l’intervento in sala di emodinamica il 28% della popolazione totale ha avuto la necessità di
intubazione oro tracheale mentre il 32% ha sviluppato complicanze aritmiche. In media, la durata
della contropulsazione è risulta essere di 3 giorni con una degenza media di 10 giorni.
Il tasso di mortalità intraospedaliera registrato è stato del 13%, mentre al follow up dei 30 giorni è
stato del 7% e a 6 mesi del 4%.
Conclusioni: La riduzione del tasso di mortalità intra ospedaliera che abbiamo riscontrato nei nostri
pazienti rispetto ai trials clinici presenti in letteratura è stata ottenuta grazie alla gestione dello shock
cardiogeno postischemico che viene attuata nel nostro centro, che prevede quando possibile la
strategia di rivascolarizzazione precoce, l’adeguato supporto inotropo e il supporto meccanico al
circolo (quando necessario). Questi dati sono ancora preliminari ed è tutt’ora in corso il monitoraggio
e il follow up dei nostri pazienti in shock cardiogeno.
SIC | Indice Autori
84
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O97
ASSISTENZA VENTRICOLARE SINISTRA NEI PAZIENTI AFFETTI DA SCOMPENSO
CARDIACO TERMINALE: L’ESPERIENZA DI PADOVA.
GIACOMO BORTOLUSSI (A), VINCENZO TARZIA (A), ROBERTO BIANCO (A),
MICHELE GALLO (A), MARINA COMISSO (A), VALENTINA PENZO (A),
JONIDA BEJKO (A), TOMASO BOTTIO (A), GINO GEROSA (A)
(A) CARDIOCHIRURGIA, DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE
E VASCOLARI, UNIVERSITÀ DI PADOVA
Introduzione: Lo scompenso cardiaco terminale è una condizione gravata da alta mortalità e
morbidità, che comporta frequenti ricoveri, e costi elevati. Negli anni si sta assistendo ad un continuo
incremento del numero di pazienti affetti da tale patologia, il cui gold-standard terapeutico rimane il
trapianto cardiaco. Tuttavia, il numero di donatori idonei è in riduzione, ragione per cui diventa
necessario individuare strategie di trattamento alternative. In tale contesto, diventa sempre più
importante il ruolo dell’assistenza ventricolare sinistra (Left Ventricular Assist Device, LVAD)
impiantabile, capace di migliorare non solo la sopravvivenza, ma anche la qualità della vita. Scopo
di questo studio è valutare l’impatto del LVAD impiantabile sulla sopravvivenza a breve e medio
termine dei pazienti con scompenso cardiaco terminale.
Metodi: Tra dicembre 2008 e maggio 2014, 60 pazienti con scompenso cardiaco terminale (età media
50±17 anni; 84% maschi) sono stati trattati mediante impianto di LVAD presso il nostro centro.
La cardiopatia responsabile era di eziologia ischemica nel 33% dei casi, dilatativa primitiva nel 57%,
e dovuta ad altre cause nel 10%.
I dispositivi utilizzati sono entrambi a flusso continuo: il Jarvik2000, una pompa assiale, e
l’HeartWare HVAD, una pompa centrifuga. La tecnica di impianto convenzionale comprende la
sternotomia mediana (20%) e la toracotomia sinistra (27%), mentre più recentemente si adotta quando
possibile un approccio mininvasivo, attraverso minitoracotomia anteriore sinistra abbinata a
ministernotomia (45%) o a minitoracotomia destra in II spazio (8%). La gran parte dei casi (90%) è
stata eseguita senza ausilio della circolazione extracorporea.
Risultati: La finalità dell’impianto è stata Bridge-to-Transplant nel 57% dei casi, Bridge-toCandidacy nel 20%, e Destination therapy nel 23%. I pazienti trapiantati sono stati finora 15 (25%).
La durata mediana del supporto è stata di 124 giorni (media 263±332 giorni). La sopravvivenza ad 1
anno è stata del 70%, registrando una mortalità precoce a 30 giorni del 18%, e a medio termine (oltre
i 30 giorni) di un ulteriore 12%. Tra le cause di morte si sono verificate disfunzione ventricolare
destra (20%), eventi emorragici cerebrali (6.6%) e toracici (5%), complicanze intestinali (6.4%).
Conclusioni: Il supporto con LVAD ha dimostrato di garantire una buona percentuale di
sopravvivenza a breve e medio termine, in una popolazione altrimenti gravata da alto tasso di
mortalità e morbidità.
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85
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
CARDIOPATIE CONGENITE
O98
BASELINE HEMODYNAMICS OF PATIENTS DEVELOPING PULMONARY ARTERIAL
HYPERTENSION AFTER SHUNT CLOSURE
EMANUELE ROMEO (A), MICHELE D´ALTO (A), PAOLA ARGIENTO (A), GIOVANNI
MARIA DI MARCO (A), GIUSEPPE SANTORO (A), GIANPIERO GAIO (A),
BERARDO SARUBBI (A), GIANCARLO SCOGNAMIGLIO (A), ANNA CORRERA (A),
NICOLA GRIMALDI (A), MARIA GIOVANNA RUSSO (A)
(A) SECOND UNIVERSITY OF NAPLES - MONALDI HOSPITAL, DEPARTMENT OF
CARDIOLOGY, NAPLES, ITALY
Background: Pulmonary arterial hypertension (PAH) after shunt closure is associated with a poor
prognosis. The aim of this study was to assess retrospectively the hemodynamics of patients
developing PAH after shunt closure.
Methods: Hemodynamic data obtained by right heart catheterization (RHC) performed at baseline
and after shunt closure were analyzed.
Results: Twenty-two patients, 13 with atrial septal defect (ASD), 6 with ventricular septal defect
(VSD), 1 with both ASD and VSD, 1 with patent ductus arteriosus, and 1 with complete atrioventricular canal have been considered. The mean age at closure was 25.3±20.1 years (range 3 months
to 56.7 years), and the mean age at PAH diagnosis was 37.0±20.8 years (range 5 to 61.2 years). The
time delay between shunt closure and PAH diagnosis was 140.2±100.2 months. At baseline RHC,
hemodynamic data were as follows: pulmonary vascular resistance (PVR) 8.6±2.6 Wood units, PVR
index (PVRi) 10.1±2.7 Wood units*m2, mean pulmonary arterial pressure 43.7±9.7 mmHg, PVR to
systemic vascular resistance ratio (PVR/SVR) 0.70±0.23, and Qp/Qs 1.6±0.4. In particular, 18/22
(81%) had PVR ≥5 Wood units, 21/22 (95%) PVRi ≥6 Wood units*m2, 21/22 (95%) PVR/SVR
≥0.33, and 11/22 (50%) Qp/Qs ≤1.5. During the follow-up, 5/22 (22%) patients died and one patient
underwent successful double lung transplantation.
Conclusions: High baseline values of PVR (≥5 Wood units), PVRi (≥6 Wood units*m2) and
PVR/SVR (≥0.33) are common findings in patients who develop PAH late after shunt closure. A
Qp/Qs >2 may be considered reassuring before shunt closure. PAH may develop or become clinically
manifest years after shunt repair. The clinical course of PAH in previously repaired defects was not
benign, showing a high mortality rate. Large prospective clinical trials are needed to establish the safe
limits for shunt closure.
O99
PROGNOSTIC ROLE OF N-TERMINAL PRO-B-TYPE NATRIURETIC PEPTIDE IN
ADULTS WITH CONGENITAL HEART DISEASE: A SINGLE-CENTER EXPERIENCE.
ASSUNTA MEROLA (A), SCOGNAMIGLIO GIANCARLO (A), BERARDO SARUBBI (A),
NUNZIA BORRELLI (A), MICHELE D´ALTO (A), GIANGIACOMO DI NARDO (A),
MICHELA PALMA (A), EMANUELE ROMEO (A), DIEGO COLONNA (A),
ANNA CORRERA (A), NICOLA GRIMALDI (A), MARIA GIOVANNA RUSSO (A)
(A) CARDIOLOGY SECOND UNIVERSITY OF NAPLES, GUCH UNIT, AORN DEI COLLI,
MONALDI HOSPITAL
Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a reliable, well-established
marker of outcome in acquired heart failure. Little is known on its prognostic value in the expanding
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subset of adult patients with congenital heart disease (ACHD). Aim of the present study is to assess
the relationship between NT-proBNP levels and clinical outcome in an outpatient ACHD population.
Methods and Results: Circulating NT-proBNP levels were measured in 358 stable ACHD patients
(age 28.7 ± 12 years, 56% male) attending our tertiary centre between years 2008 and 2013. Median
NT-proBNP value was 87 pg/ml (IQR: 38-201), with 151 (42.2%) patients showing at least one value
>125 pg/ml during the study period. Higher values of NT-proBNP were observed in patients with
complex lesions such as Fontan circulation (median 149.5 pg/ml [IQR 53.2 -336.1]) and systemic
right ventricle (median 141 pg/ml [IQR 106 -246]) and the lowest levels were seen in patients with
aortic coarctation (median 28.3 pg/ml [IQR 11.1 -59.5]) During a median follow-up of 24 months
(IQR 6.0 - 36.5), deaths or hospitalizations due to cardiac causes, i.e. arrhythmias, surgical or
percutaneous interventions, decompensated heart failure, occurred in 90 patients (25.1%). In patients
experiencing an adverse event, median NT-proBNP values at baseline were significantly higher (203
pg/ml [IQR 93.2-452.7] vs 67.4 pg/ml [IQR 30.1-142.7], p<0.0001). On Cox regression analysis, NTproBNP emerged as a powerful predictor of outcome (HR: 1.7, 95% CI: 1.4-2.0, p<0.0001) and
remained significant after adjustment for age, QRS duration, NYHA class, systemic ventricular
ejection fraction, renal function and VO2 peak. Receiver-operator characteristic (ROC) analysis
identified an optimal cut-off value of 132 pg/ml (area under the curve 0.73, p <0.0001). Patients with
NT-proBNP > 132 pg/ml had 3-fold higher risk of adverse events (HR=3.0, 95% CI 2.0-4.7,
p<0.0001).
Conclusion: NT-proBNP is a simple, powerful marker of outcome in contemporary ambulatory
ACHD patients and, therefore, should be included in the risk stratification and periodic assessment
of this population.
O100
CARDIOPATIA MATERNA ED ESITI AVVERSI MATERNI, OSTETRICI E FETALI.
ESPERIENZA DI UN TEAM MULTIDISCIPLINARE
VALENTINA BENETTI (A), MARIA ANTONIA PRIOLI (A), LUCIA ROSSETTI (A),
MICOL REBONATO (A), ELENA GIULIA MILANO (A), GIULIA DOLCI (A),
DEBORA BALESTRIERI (B), FRANCA BETTINAZZI (B), PAOLA PILLONI (C),
CORRADO VASSANELLI (A)
(A) CARDIOLOGIA - D.U.; DAI CARDIOVASCOLARE E TORACICO; AZIENDA
OSPEDALIERA UNIVERSITARIA INTEGRATA VERONA; (B) OSTETRICIA E
GINECOLOGIA - D.U.; DAI MATERNO INFANTILE; AZIENDA OSPEDALIERA
UNIVERSITARIA INTEGRATA VERONA; (C) ANESTESIA E RIANIMAZIONE - D.U.; DAI
EMERGENZA E TERAPIE INTENSIVE; AZIENDA OSPEDALIERA UNIVERSITARIA
INTEGRATA VERONA
complicanze complicanze Introduzione: Nei Paesi Occidentali la
patologia cardiovascolare più frequente che
OSTETRICHE
FETALI
interessa donne che intraprendono una
Aborto
Small for
gestional age gravidanza è la cardiopatia congenita. Negli
ultimi anni, l’immigrazione da aree in cui
Aritmie
Taglio cesareo
Pretermine
l’incidenza della cardite reumatica (CR) è ancora
Peggioramento Ipertensione
Ricorrenza
elevata ha generato un incremento di donne
cardiopatia
gestazionale
cardiopatia
straniere con valvulopatia che affrontano la
Intervento
Preeclampsia
Nati morti
gravidanza nel nostro Paese.
CCH
Materiali e Metodi: Abbiamo analizzato dati
Farmaci
relativi
a complicanze materne, ostetriche e fetali
Morte materna
(tabella 1) in 189 gravidanze di 92 pz
cardiopatiche: 14 pz con cardiopatia complessa (CC), 72 con cardiopatia semplice (CS) e 6 pz con
complicanze
MATERNE
Scompenso
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esiti di CR (tabella 2). 70 erano in buon compenso di circolo prima della gravidanza mentre 22
avevano uno status NYHA = 2 pre-gravidico.
Risultati: L’incidenza di complicanze materne, ostetriche e fetali è stata maggiore in pz con CC
rispetto a pz con CS o CR (tabella 3.). Tuttavia ipertensione gestazionale e preeclampsia hanno avuto
un’incidenza maggiore in donne con CS (13% in CS vs 5% in CC; p value < 0,01) ed in particolare
in donne con aorta bicuspide (AoB). Nelle stesse la gravidanza sembra inoltre aumentare la
progressione della dilatazione della radice aortica. Pz con CS o CR con status NYHA = 2 pregravidico hanno avuto outcome materni, ostetrici e fetali peggiori rispetto a pz con CS o CR ma con
un buono stato di compenso pregravidico (tabella 3). Il team cardiologo-ostetrico-anestesista ha
consentito un’adeguata gestione pre e post-parto delle pz con CC quali intervento di Fontan, Rastelli
e Senning.
Conclusioni: Pz con CC presentano maggiore incidenza di esiti avversi materni, ostetrici e fetali. Gli
esiti peggiori in pz con CS o CR si sono registrati in pz in classe NYHA = 2 pregravidica. Le pz con
AoB sono particolarmente a rischio per dilatazione aortica ed anche per ipertensione gestazionale e
preeclampsia. Un team multidisciplinare e la conoscenza della fisiopatologia della gravidanza sono
elementi indispensabili nei centri di terzo livello per un’adeguata gestione delle pazienti più
complesse.
CC
Tetralogia di Fallot
Esiti Fontan
TGA (Senning,
Rastelli)
Malattia di Ebstein
CS
DIA/DIV
Difetti
valvolari
AoB
CR
SAo
SM
Prolasso
mitralico
Protesi
CS
Complicanze MATERNE
Complicanze OSTETRICHE
Complicanze
FETALI
IM
CC
p
CS
CS
p
stabili instabili
37% 62% 0,05 29%
91% 0,01
49% 82% 0,01 45%
80% 0,05
36% 81% 0,01 41%
73% 0,05
O101
ALTERED AORTIC UPPER WALL TDI VELOCITY INFLUENCES NEGATIVELY LEFT
VENTRICULAR DIASTOLIC FUNCTION IN OPERATED TETRALOGY OF FALLOT
PIER PAOLO BASSAREo (a), ANDREA RAFFAELE MARRAS (a), GIUSEPPE MERCURO (a)
(a) DIPARTIMENTO DI SCIENZE MEDICHE “M.ARESU“ - UOC CARDIOLOGIA ED
ANGIOLOGIA - UNIVERSITA´ DI CAGLIARI
Background. Postoperative Tetralogy of Fallot (TOF) patients often develop a progressive aortic
root dilatation due to an impairment in aortic elastic properties. Aims: 1) to assess aortic elasticity at
the level of the aortic upper wall by tissue Doppler imaging (TDI); 2) to evaluate the influence of
aortic stiffness on left ventricular (LV) diastolic function of TOF patients.
Methods. 28 postoperative TOF patients (14 males, 14 females. Mean age: 25.7 ± 1.6 years) and 28
age- and sex-matched normal subjects were examined. Aortic distensibility and stiffness index were
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calculated. Aortic wall systolic and diastolic velocities, LV systolic and diastolic parameters were
assessed by TDI.
Results. Aortic distensibility was significantly lower (p<0.01), and aortic stiffness index was
significantly higher (p< 0.01) in TOF patients than in controls. E/El was significantly higher in the
TOF than in control group (p<0.001). Aortic upper wall early diastolic velocity (AWEDV) was
significantly correlated with aortic stiffness index (r: –0.53, p =0.004), aortic distensibility
(r=0.46, p=0.01), E/El ratio (r= –0.48; p=0.01). The latter relationship was still significant even when
excluding the influence of age at surgery (r= –0.36; p =0.05).
Conclusions. Aortic elastic properties can be directly assessed by measuring AWEDV by
TDI. Aortic elasticity is significantly lower in postoperative TOF patients, and this issue affects
negatively even their LV diastolic function, with a potential long-term influence on their clinical
status.
O102
N-TERMINAL PRO-B-TYPE NATRIURETIC PEPTIDE AS A PREDICTIVE MARKER OF
ARRHYTHMIAS IN ADULTS WITH CONGENITAL HEART DISEASE
ASSUNTA MEROLA (A), GIANCARLO SCOGNAMIGLIO (A), BERARDO SARUBBI (A),
NUNZIA BORRELLI (A), MICHELE D´ALTO (A), GIANGIACOMO DI NARDO (A),
MICHELA PALMA (A), ANNUNZIATA MORMILE (A), GIOVANNI MARIA DI MARCO (A),
ANNA CORRERA (A), NICOLA GRIMALDI (A), MARIA GIOVANNA RUSSO (A)
(A) CARDIOLOGY SECOND UNIVERSITY OF NAPLES, GUCH UNIT, AORN DEI COLLI,
MONALDI HOSPITAL
Background: Arrhythmic events are associated with an increased mortality risk and represent the
leading cause of hospital admission in adult patients with congenital heart disease (ACHD). However,
to date, no perfect risk-stratification scheme has emerged, although several clinical variables with
modest prognostic value have been identified. Aim of the present study is to assess the relationship
between NT-proBNP levels and the arrhythmic risk in an outpatient ACHD population.
Methods and Results: Our study involved 358 ACHD patients (age 28.7 ± 12 years, 56% male)
attending our tertiary centre between years 2008 and 2013. During a median follow-up of 24 months
(IQR 6.0 - 36.5), documented arrhythmic events requiring hospitalization occurred in 44 patients
(12,3%). The following arrhythmias were observed: ventricular tachycardia (n: 15, 34,1%), atrial
fibrillation (n: 5, 11,3%), sustained supraventricular tachycardia (n: 15, 34,1%), advanced atrioventricular block (n: 4, 9,1%) and sinus node dysfunction (n: 5, 11,3%). Permanent PMK implantation
was required in 4 patients. A higher incidence of arrhythmias was encountered in patients with
Tetralogy of Fallot (n: 16, 17,4% of 92 patients) and Ebstein's anomaly (n: 4, 16% of 25 patients).
In patients experiencing an arrhythmic event, median NT-proBNP values at baseline were
significantly higher (206,5 pg/ml [IQR 118,7-486,9] vs 69 pg/ml [IQR 31-151], p<0.0001). The
strongest and most significant correlation was found between NT-proBNP and left atrial volume
index (R = 0,75, p< 0,0001); a positive correlation with age (R = 0,32, p < 0,0001) and a negative
correlation with creatinine clearance (R= - 0,2 , p < 0,0001) was also demonstrated. On Cox
regression analysis, NT-proBNP emerged as a powerful predictor of arrhythmias (HR: 1,7, 95% CI:
1.2-2,4, p<0,003), with a prognostic value even stronger than age (HR: 1,03, 95% CI: 1.008-1,066,
p<0,01) and QRS duration (HR: 1,02, 95% CI: 1.007-1,033, p<0,002). Receiver-operator
characteristic (ROC) analysis identified an optimal cut-off value of 138 pg/ml (area under the curve
0.74, p <0.0001). Patients with NT-proBNP > 138 pg/ml had more than 2,5-fold higher risk of
adverse events (HR=2,7, 95% CI 1.2-6,1, P<0.01).
Conclusion: NT-proBNP, being a simple and reliable predictive marker of arrhythmias in ACHD
patients, should be routinely assessed during the follow-up and included in the arrhythmic riskstratification for this population.
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O103
MTHFR GENE MUTATIONS IN PFO POPULATION: ONE MORE REASON FOR
TRANSCATHETER CLOSURE OF PATENT FORAMEN OVALE
EUGENIA MAIO (A), VALERIA CAMMALLERI (A), SAVERIO MUSCOLI (A),
ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A), DOROTEA RUBINO (A),
FRANCESCA DEPERSIS (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), GIANPAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
BACKGROUND: MTHFR gene is considered as a risk factor for thrombotic events. Two common
polymorphisms have been identified and in particular the C677T mutation. Patent foramen ovale
(PFO) is identified in 25% of the general population.
AIM: The aim of our study was to obtain the rate of C677T MTHFR gene mutations in 104 patients
admitted to close the PFO.
METHODS: Between March 2012 and May 2014, all patients with ischemic lesions and the presence
of a patent foramen ovale were submitted to transcatheter closure. Before surgery, genetic analyzes
were performed on DNA extracted from peripheral blood leukocytes. By gene amplification and
typing by PCR-SSO, we studied mutations in the MTHFR gene.
RESULTS: In our population, 38 of 104 (36,5%) are heterozygous at the gene MTHFR C677T and,
in comparison to the data obtained by prevalence of the heterozygous gene in the European area
(43%) multiplied with the prevalence of PFO in the same population (25%), represent for us a rate
higher than expected (36,5% vs 10,7%). With regard to homozygotes, 8 of 104 are 7,7% of our sample
that is also greater than known data (7,7% vs 2.75% in general population).
CONCLUSIONS: The high number of patients with PFO, thrombotic risk of genetic origin and signs
of ischemic lesions on MRI suggests that the indication at transcatheter closure is more justified by
the prevention of new cerebrovascular events.
MECCANISMI DI RIPARAZIONE MIOCARDICA - 2
O104
PROTECTION AGAINST DOXORUBICIN-INDUCED CARDIOMYOPATHY BY
BERGAMOT POLYPHENOLS THROUGH MYOCYTE SURVIVAL AND CARDIAC
STEM CELL ACTIVATION
CRISTINA CARRESI (A), IOLANDA AQUILA (B), FABIOLA MARINO (B),
VINCENZO MUSOLINO (A), CHRISTELLE CORREALE (B),
FRANCESCA OPPEDISANO (A), CONCETTA DAGOSTINO (A), MICAELA GLIOZZI (A),
BERNARDO NADAL-GINARD (C), CIRO INDOLFI (B), DANIELE TORELLA (B),
VINCENZO MOLLACE (A)
(A) LABORATORY OF ENVIRONMENTAL, CELLULAR AND MOLECULAR
TOXICOLOGY MAGNA GRAECIA UNIVERSITY OF CATANZARO, CATANZARO, ITALY;
(B) LABORATORY OF CELLULAR AND MOLECULAR CARDIOLOGY MAGNA GRAECIA
UNIVERSITY OF CATANZARO, CATANZARO, ITALY ; (C) KING´S COLLEGE LONDON,
LONDON, UNITED KINGDOM
Purpose: The clinical use of Doxorubicin (DOX) has the serious drawback of cardiotoxicity, which
over time causes a cardiomyopathy leading to heart failure. The molecular pathogenesis of
anthracycline cardiotoxicity remains highly controversial. Recently, it has been suggested that
resident endogenous cardiac stem/progenitor cell (eCSC) depletion contributes to DOX-induced
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cardiomyopathy. Dietary polyphenols play a beneficial cardiovascular protecting role due to their
pleiotropic anti-oxidative/inflammatory effects. Thus, we have investigated whether a mixture of
flavonoids extracted from Bergamot (Citrus Bergamia, an endemic plant from Southern Italy), the
bergamot-derived polyphenolic fraction (BPF), could attenuate myocyte damage and improve
myocyte regeneration through eCSC activation in DOX-induced cardiomyopathy.
Methods: We first assessed BPF’s effects on DOX-induced damage in CSCs in vitro. For in vivo
studies, Wistar male rats (n=36) were randomly assigned to receive intra-peritoneal injection of saline
(that served as controls, CTRL, n=6), BPF (20mg/kg daily, n=10), DOX (6 doses of 2,5mg/Kg from
day 1 to day 14, n=10), and DOX+BPF (n=10). To track new cardiac cell formation all animals were
implanted with subcutaneous micro-pumps to systemically release BrdU over 21 days when the rats
were sacrificed.
Results: BPF significantly reduces reactive oxygen species (ROS) accumulation and apoptotic death
in CSCs in vitro. Intriguingly, BPF enhanced CSC specification into beating cardiomyocytes in vitro.
Importantly, BPF in vivo treatment was able to prevent DOX-induced LV impairment.
Echocardiography imaging demonstrated that DOX+BPF group had a significantly improved ejection
fraction, fractional shortening and myocardial strain when compared to DOX-treated rats. DOX
caused significant myocyte apoptosis with reactive myocyte hypertrophy when compared to CTRL.
c-kit+ eCSC number was not significantly higher in DOX compared to CTRL. Only rare BrdU
labelled cardiac cell nuclei but no BrdU+ myocytes were identified in DOX-induced cardiomyopathy,
showing a lack of myocardial regeneration. On the contrary, BPF significantly reduced myocyte loss
and myocyte hypertrophy by DOX. This improvement was associated with an increased number of
activated BrdU+ eCSCs and differentiating newly-formed BrdU+ cardiomyocytes.
Conclusions: BPF reduces DOX-induced cardiotoxicity decreasing myocyte loss and enhancing CSC
activation and cardiomyocyte replacement. These data suggest that a BPF-supplemented diet could
have beneficial effects in attenuating cardiotoxicity in patients requiring anthracycline
chemiotherapy.
O105
C-KIT EXPRESSION IDENTIFIES TRUE CARDIAC PROGENITORS AT MESODERMAL
INDUCTION FROM HUMAN PLURIPOTENT STEM CELLS
MARIANGELA SCALISE (c), CARLA VICINANZA (c), IOLANDA AQUILA (c),
FABIOLA MARINO (c), CHRISTELLE CORREALE (c), GIOVANNI CUDA (a), GEORGINA
MAY ELLISON (b), BERNARDO NADAL-GINARD (b), DANIELE TORELLA (c),
CIRO INDOLFI (c)
(a) LABORATORY OF PROTEOMICS, MAGNA GRAECIA UNIVERSITY, CATANZARO,
ITALY; (b) STEM CELL AND REGENERATIVE BIOLOGY INSTITUTE, KING’S COLLEGE
LONDON, LONDON, UK; (c) MOLECULAR AND CELLULAR CARDIOLOGY, MAGNA
GRAECIA UNIVERSITY, CATANZARO, ITALY
Background: The adult heart harbours a population of endogenous resident cardiac stem/progenitor
cells (eCSCs). These cells have been detected, isolated and characterized to be clonogenic, selfrenewing and multipotent in vitro and in vivo. However, multiple markers have been employed for
their detection and isolation. The first marker to be used has been c-kit, the receptor for the stem cell
factor. While extensive and reproducible data over 10 years of intense research have demonstrated
the characteristics and the robust regenerative potential of c-kitpos eCSCs, recent findings claimed that
these cells have the prototypical characteristics of tissue specific stem cells but their functional role
in vivo is minimal at best. Embryonic stem cells (ESCs) and induced pluripotent stem cells (hiPSCs)
are undoubtedly the most studied stem cells whose pluripotent differentiation potential has never been
questioned. Concurrently, these pluripotent stem cells have been fundamental to derive all tissue
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specific stem cells. Thus, in the study we have tested whether c-kitpos cells are true cardiac stem
progenitors during cardiac cells differentiation from human pluripotent stem cells.
Methods: The NIH-approved human Embryonic stem cell (ESC) clone H9 was obtained from the
Wisconsin International Stem Cell (WISC) Bank and used in this study. Human iPS cultures were
reprogrammed from human fibroblasts (HDF) using the non-integrating CytoTune™-Sendai viral
vector kit. Characterization of bona fide hiPSCs was performed by RT-PCR, immunostaining and
FACS analysis. A dedicated conditioned culture medium was used to induce ESC and iPS
commitment to mesodermal lineage progenitors. c-kitpos cells were sorted at different stages by FACS
and expanded in hCSC media. These hESC- and hiPSC-derived c-kitpos cells were analysed for
markers of stemness and cardiac lineages by RT-PCR, FACS and immunocytochemistry and for their
differentiation potential in all cardiac lineages in vitro.
Results: We have generated iPS colonies from HDF and shown their ES-like phenotype. hiPSCs
stably expressed endogenous transcripts of stemness and pluripotency genes by RT-PCR and scored
positive for OCT4, SOX2, NANOG, KLF4, hTERT, and MYC by FACS and immunocytochemistry.
The hiPS and also hESCs were grown then as cell colonies in hanging drops in vitro. After induction
to mesodermal lineage, hESCs and hiPSCs reduced the expression of pluripotency genes and turned
on the expression of the primordial embryonic cardiac precursor genes. Indeed, these cells expressed
both Brachury T and Mesp1, key regulators of the earliest step of cardiac development. c-kit
expression was investigated at different time points after mesodermal induction and gradually
increased during the first week in culture. Sorted c-kitpos cells show a stable cardiac stemness
phenotype and expressed also known cardiac specific transcription factors, like GATA4, MEF-2C
and NKX 2.5. These hESC- and hiPSC-derived cells were clonogenic, self-renewing and multipotent
in vitro being able to differentiate in cardiomyocytes, smooth muscle and endothelial cells similarly
to control adult hCSCs. When analysed by RNA-seq hiPS-derived c-kitpos cells were practically
undistinguishable from adult and foetal c-kitpos hCSCs. Importantly, when c-kitpos cells were removed
at mesodermal stage induction from ESC and iPS colonies no beating cardiomyocyte progeny was
observed.
Conclusions: We have for the first time established that c-kit positive cells are true cardiac
stem/progenitor cells that are necessary for cardiomyogenic induction from human pluripotent stem
cells.
O106
MEGESTROL ACETATE REDUCES WASTING THROUGH AUTOPHAGIC
MODULATION AND IMPROVES CARDIAC FUNCTION IN A MODEL OF CANCERCACHEXIA INDUCED CARDIOMYOPATHY
VINCENZO MUSOLINO (A, B), MICAELA GLIOZZI (A), CRISTINA CARRESI (A),
ANIKA TSCHIRNER (B), CATHLEEN DRESCHER (B), SANDRA PALUS (B),
FRANCESCA OPPEDISANO (A), CONCETTA DAGOSTINO (A),
ANTONINO SCARCELLA (A), ERNESTO PALMA (A), DANIELE TORELLA (C, D),
JOCHEN SPRINGER (B, E), STEFAN ANKER (B, F), VINCENZO MOLLACE (A, F)
(A) INSTITUTE OF RESEARCH FOR FOOD SAFETY & HEALTH (IRC-FSH), UNIVERSITY
OF CATANZARO “MAGNA GRAECIA”, CATANZARO, ITALY; (B) APPLIED CACHEXIA
RESEARCH, DEPARTMENT OF CARDIOLOGY, CHARITÉ MEDICAL SCHOOL, BERLIN,
GERMANY; (C) LABORATORY OF MOLECULAR AND CELLULAR CARDIOLOGY,
DEPARTMENT OF MEDICAL AND SURGICAL SCIENCES,UNIVERSITY OF CATANZARO
“MAGNA GRAECIA”, CATANZARO, ITALY; (D) STEM CELL AND REGENERATIVE
BIOLOGY UNIT (BIOSTEM), LIVERPOOL JOHN MOORES UNIVERSITY, LIVERPOOL L3
3AF, UK; (E) NORWICH MEDICAL SCHOOL, UNIVERSITY OF EAST ANGLIA, NORWICH,
UK; (F) CENTRE FOR CLINICAL AND BASIC RESEARCH, IRCCS SAN RAFFAELE
PISANA, ROME, ITALY
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Background: Cachexia is a complex metabolic syndrome associated with underlying chronic illness,
i.e. cancer. One of the features of cachexia is the loss of muscle mass, characterized by disbalance of
protein synthesis and protein degradation. Muscle atrophy is due to hyperactivation of the main
cellular catabolic pathways, including autophagy. Cachexia also affects cardiac muscle and the
atrophy of the heart impairs cardiac function and is likely to contribute to mortality. Anti-cachectic
therapy in patients with cancer cachexia is so far limited to nutritional support and anabolic steroids.
Methods: The use of the appetite stimulant megestrol acetate (MA) has been discussed as a treatment
for cachexia. In this study the effects of MA (100 mg/kg) were tested in cachectic tumour-bearing
rats (Yoshida AH-130 ascites hepatoma). Rats were treated with 100mg/kg/d MA or placebo starting
one day after tumor-inoculation for 16 days. Body weight and body composition were assessed at
baseline and at the end of the study. Cardiac function was analyzed by echocardiography at baseline
and day 11. Autophagic markers were assessed in gastrocnemius muscle and heart by western blot
analysis.
Results: MA decreased the loss of body weight (p<0.05) compared to placebo animals. Cardiac
wasting was showed as evidenced by a reduction in absolute heart weight and left ventricular mass
in tumor-bearing vs sham rats (p<0.001). Tumor-bearing rats displayed cardiac dysfunction. LVEF,
LVFS and LVSV were significantly reduced in tumor-bearing rats compared to sham. Megace
significantly improved LVEF and LVFS. Western blotting analysis showed an upregulation of the
autophagic pathway in gastrocnemius and hearts of tumor-bearing rats compared to sham. MA was
able to modulate the autophagic markers in the gastrocnemius and in the hearts of tumor-bearing rats.
Conclusions: Megace is good candidate for muscle wasting treatment. Besides improving survival
and protecting fat mass and lean mass, through a marked downregulation of autophagy in the muscles
and in the heart, the cardiac function was significantly improved by megestrol acetate. Hence, MA
might represent a valuable strategy to counteract the development of cancer cachexia-induced
cardiomyopathy.
O107
CONTROLLED DELIVERY OF ENDOTHELIAL PROGENITOR CELL-CONDITIONED
MEDIUM BY POLYMER NANOPARTICLES IN ISCHEMIC TISSUE
ROSSELLA DI STEFANO (A), MARIA CHIARA BARSOTTI (A), LUCIA BOTTA (A),
TATIANA SANTONI (A), SILVIA BURCHIELLI (B), ANNA MARIA PIRAS (C),
FEDERICA CHIELLINI (C), ROBERTO SOLARO (C)
(A) DIPARTIMENTO DI PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E
DELL´AREA CRITICA - UNIVERSITÀ DI PISA - PISA; (B) FONDAZIONE TOSCANA
GABRIELE MONASTERIO - PISA; (C) DIPARTIMENTO DI CHIMICA E CHIMICA
INDUSTRIALE - UNIVERSITÀ DI PISA - PISA
Purpose: Endothelial progenitor cells (EPCs) contribute to ischemic tissue repair by secretion of
paracrine factors. Moreover, hypoxic stress, the patho-physiological status of ischemic tissue,
positively affects EPC paracrine secretion, as EPC-conditioned medium (CM) up-regulates factors
related to angiogenesis, cell recruitment and tissue repair. Polymer-based nanoparticles (NPs) could
be used as carriers for a controlled release in ischemia. Our aim was to characterize the in vivo effect
of EPC-CM-loaded NPs, comparing it to EPC-CM alone.
Methods: EPCs were obtained from peripheral blood of healthy donors. To obtain CM, EPCs were
cultured for 24 h in growth factor- and serum-free medium under hypoxia (1%O2). EPC-CM was
pooled from 6 different donors before storage at Ð80¡C. For the in vivo model, Sprague-Dawley rats
(n = 36) were used. The animals were divided into three experimental groups (12 animals for each
group): control (vehicle injection); EPC-CM injection; injection of EPC-CM-loaded NPs. Hind limb
ischemia was induced by ligation and resection of the arterial bed between the distal end of the
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external iliac artery and the femoral artery trifurcation. Contralateral limb was used as control. For
each animal, 500 μL serial intramuscular injections were performed at 3 sites into the ischemic
hindlimb, starting after ischemia induction. Injections were repeated after 1 week and 2 weeks. Rats
were monitored over a period of 3 weeks. The effect of ischemia was evaluated both using a Laser
Doppler Blood Flow imaging system (ratio between the ischemic and the contralateral limb), by
histology (hematoxylin/eosin, H/E, staining) to evaluate the inflammatory reaction and by
immunohistochemistry to evaluate capillary (CD31-positive) and artery (alpha-smooth muscle actin,
alpha-SMA-positive) number per mm2.
Results: A significant increase of blood perfusion was observed at 2 weeks in CM-NP group as
compared to both CM and control group (p<0.05). In control group animals, we did not observe any
ischemic-related change, either myocyte/fibers and interstitial tissue, presenting normal morphology
at 1, 2 and 3 weeks. Regarding histological analysis, in control animals the explanted tissues showed
a normal morphology, while in both CM and CM-NP groups, at 1 week, we observed myocyte
coagulative necrosis with enlarged interstitium mainly populated by inflammatory infiltrates and thinwalled new vessels; such changes appeared more extensive in CM-NP vs. CM. At 2 and 3 weeks,
fibrosis replacement of necrotic myocytes was found together with new vessels.
Immunohistochemistry evidenced a significant increase of capillary presence in the samples obtained
from rats treated with both CM and CM-NPs. Treatment with CM-NP significantly increased
capillary number at both 1 (p<0.05 vs. control) and 2 weeks (p<0.0005 vs. control and p<0.005 vs.
CM), while CM treatment had a significantly higher effect than control at 2 and 3 weeks (p<0.005)
(p<0.005). On the other hand, immunostaining for alpha-SMA failed to reveal any significant
difference in the numbers of arteries among different groups, suggesting a more pronounced effect
on angiogenesis rather than arteriogenesis.
Conclusions: Novel therapeutic strategies based on EPC paracrine factors may replace cell
transplantation, as "cell-free" therapy could overcome the risk of adverse immunological reactions
and the problem of heterologous rejection. Release of EPC-CM from loaded NPs was effective for
blood flow and capillary enhancement in an in vivo model of hindlimb ischemia, underlining the
advantages of using controlled release in regenerative medicine.
O108
THE ADULT MYOCARDIUM HAS A ROBUST ENDOGENOUS CARDIOMYOCYTE
TURNOVER POTENTIAL
FABIOLA MARINO (a), IOLANDA AQUILA (a), CARLA VICINANZA (a),
MARIANGELA SCALISE (a), CRISTINA CARRESI (c), CHRISTELLE CORREALE (a),
TERESA MANCUSO (a), VINCENZO MOLLACE (c), BERNARDO NADAL-GINARD (b),
DANIELE TORELLA (a), CIRO INDOLFI (a)
(a) MOLECULAR AND CELLULAR CARDIOLOGY, MAGNA GRAECIA UNIVERSITY,
CATANZARO, ITALY; (b) STEM CELL AND REGENERATIVE BIOLOGY INSTITUTE,
KING’S COLLEGE LONDON, LONDON, UK; (c) ENVIRONMENTAL, CELLULAR AND
MOLECULAR TOXICOLOGY LABORATORY, MAGNA GRAECIA UNIVERSITY,
CATANZARO, ITALY
The degree of cardiomyocyte (CM) turnover in the adult myocardium has been since decades a
matter of hot debate with many controversial and contradictory reports. The claimed range of CM
turnover in the adult heart spans from 0,5% up to 40% per year. Even taking into account the
potential dissimilarities in the methodological approaches used to calculate CM turnover rates, it is
evident that technical issues cannot explain the extrapolated ≈100-fold difference between
contrasting reports. Furthermore, the key aspect of the phenomenon at stake is not the mere best
approximation of normal CM turnover but rather the actual myocardial potential to replace lost CMs
by injury or aging. To clarify this significant issue we employed a genetic mouse model to determine
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an acute and selective loss of CMs in presence of a normal patent coronary circulation and we
analyzed the endogenous cardiac capacity to anatomically and functionally repair incremental
amounts of pure CM death. Transgenic mice mutated to express a Tamofixen (Tmx) inducible
membrane-estrogen-receptor linked Cre recombinase (mER-Cre-mER) under the alpha myosin
heavy chain (myh6) promoter were crossed with transgenic mice mutated in the Rosa 26(R26R) safe
gene arbor to express a floxed (‘cre erasable’) Stop sequence in front of the Diphteria toxin A gene
(R26R-stop-DTA). Thus, Tmx treatment in these double transgenic mice (myh6-mER-CremER/R26R-stop-DTA, hereafter named Tgmyo-Cre-mER2/DTA) activates the expression of DTA
selectively in CMs inducing their death. Using double transgenic myh6-mER-Cre-mER/R26R-stopYFP mice in which Tmx treatment recombines CMs to express a Yellow Fluorescent Protein (YFP),
we established that daily administration of Tmx progressively labels from ≈10% (at 1 day after only
1 injection) to ≈55% (at 5 days after 4 injections) and up to ≈90% (at 7 days after 6 injections) of
CMs. On this basis, Tgmyo-Cre-mER2/DTA mice were daily treated with Tmx for 2 days (n=4), for 3 days
(n=4), and for 4 days (n=4). All animals were implanted with osmotic mini-pumps to systemically
release BrdU over 28 days to track all newly generated cells. Echocardiography was performed every
day during Tmx injection and then at 7, 14, 21 and 28 days to assess cardiac function. All mice from
the group with 4 Tmx injections (corresponding to more than 50% acute Cm death) died by 7 days
showing significant overall cardiac dysfunction with autoptic histological analysis demonstrating
multiple areas of myocyte necrosis and extensive myocardial disarrangement. On the other hand, all
animals from the groups with 2 or 3 Tmx injections (corresponding to a total loss of 23 to 38% of
CMs, respectively) survived and showed a significant LV dysfunction with LV dilation and reduced
EF from 7 to 14 days. Cardiac performance started to improve at 21 days and was completely
normalized at 28 days. Importantly, immunohistochemistry analysis of cardiac cross sections
showed that in response to acute CM loss after Tmx injections the heart produces up to 25% of newly
formed BrdU positive mononucleated CMs. Taken together these data demonstrate for the first time
that the heart has a robust and functionally productive regenerative capacity to repopulate up to one
fourth of its CM content in just one month. The data strongly suggest that the heart has significant
endogenous potential to repopulate its CM content that needs to be better analyzed and understood
to design new effective protocols of myocardial regeneration for cardiovascular diseases.
O109
A SPECIFIC MICRORNA NETWORK REGULATES CARDIAC PROGENITOR CELL
TRANSFORMATION IN CARDIAC ATRIAL MYXOMA HISTOGENESIS
CARLA VICINANZA (E), GEORGINA M. ELLISON (A), MICHELE TORELLA (B),
FRANCESCA CRISTIANO (F), MARIANGELA SCALISE (E), IOLANDA AQUILA (E),
FABIOLA MARINO (E), CHRISTELLE CORREALE (E), VALTER AGOSTI (C),
PIERANGELO VELTRI (F), GIANANTONIO NAPPI (B), ALESSANDRO WEISZ (D),
BERNARDO NADAL-GINARD (A), DANIELE TORELLA (E), CIRO INDOLFI (E)
(A) STEM CELL AND REGENERATIVE BIOLOGY INSTITUTE, KING’S COLLEGE
LONDON, LONDON, UK; (B) DEPARTMENT OF CARDIO-THORACIC AND
RESPIRATORY SCIENCES, SECOND UNIVERSITY OF NAPLES, NAPLES, ITALY; (C)
MOLECULAR ONCOLOGY, MAGNA GRAECIA UNIVERSITY, CATANZARO, ITALY; (D)
DEPARTMENT OF GENERAL PATHOLOGY, UNIVERSITY OF SALERNO, SALERNO,
ITALY; (E) MOLECULAR AND CELLULAR CARDIOLOGY, MAGNA GRAECIA
UNIVERSITY, CATANZARO, ITALY; (F) BIOINFORMATICS LABORATORY,
DEPARTMENT OF MEDICAL AND SURGICAL SCIENCES, MAGNA GRAECIA
UNIVERSITY
Background: Cardiac myxoma is the most frequent primary cardiac tumor. The cellular origin of
myxomas remains uncertain. One of the most advocated but unproven explanations for the
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heterogeneous cell differentiation in cardiac myxomas postulates their origin from a mesenchymallike pluripotent stem cell. Recently, cardiac stem and progenitor cells (CSCs) have been described
both in fetal and adult life. These CSCs are distributed throughout the heart, with higher concentration
in the atrial tissue. Thus, the objective of this study was to assess whether CSCs contribute to cardiac
myxoma histogenesis.
Methods: We examined 4 left and 1 right atrial polypoid myxomas (47 to 65 years old) and the
myxoma isolated cell population by real time RT-PCR, western blot, FACS, immunohistochemistry
and confocal microscopy.
Results: Microscopically, all the tumors were characterized by the typical abundant myxoid matrix.
Also, myxoma cells were organized in single and complex structures as conventionally described.
Immunohistochemistry and confocal microscopy imaging detected abundant cells positive for the
cardiac lineage-specific transcription factors, MEF2C, Nkx2.5 and eHand, revealing cardiomyogenic
differentiation in cardiac myxomas. Interestingly, dispersed within the myxoid matrix, tumoral single
cells positive for c-kit, flk-1 and Isl-1 were also identified. Confocal microscopy revealed different
patterns of co-localization of these CSC markers. To analyze the properties of these putative CSCs,
we obtained primary cultures of cardiac myxoma cells from an additional 2 left atrial myxomas. When
analyzed by qRT-PCR, c-kit+ sorted cardiac myxoma cells expressed significant levels of transcripts
for multipotency and cardiac stem and progenitor genes, Oct-4, Nanog, Sox2, Tert, Isl-1, flk-1,
MEF2C and Nkx2.5. Furthermore, c-kit+ cardiac myxoma cells proved proliferative and clonogenic
in vitro exhibiting properties similar to those previously described for the adult human CSCs isolated
form normal atrial tissue of patients without myxoma.
However, microarray gene chip analysis revealed different pattern of expression of genes related to
stem cell function (self-renewal, clonogenesis), development/differentition and extracellular
matrix/proteoglycans in myxoma CSCs when compared to normal CSCs. Specific gene modifications
in myxoma CSCs mediated the cellular phenotype of myxoma cells, including the abortive cardiac
differentiation and the hyperproduction of proteoglycans forming the myxoma gelatinous matrix.
Concurrently we obtained the microRNA expression profile in myxoma CSCs identifying a specific
miRNA/mRNA network involved in gene expression dysregulation in myxoma CSCs compared to
normal c-kit+ CSCs.
Conclusions: c-kit+cardiac cells are present in atrial myxomas and seem to fulfill the function of
"cancer stem cells". These findings strongly support the hypothesis that cardiac myxomas are a
stem cell-derived tumor arising from multipotent resident cardiac stem and progenitor cells. Thus,
atrial myxoma seems to be the first CSC-derived cardiac disease.
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 3
O110
VALORE PROGNOSTICO DELLO STRAIN DELL'ATRIO SINISTRO NEI PAZIENTI
ASINTOMATICI CON INSUFFICIENZA MITRALICA DI GRADO MEDIO
MATTEO CAMELI (A), FRANCESCA MARIA RIGHINI (A), MATTEO LISI (A),
FLAVIO D´ASCENZI (A), MARTA FOCARDI (A), STEFANO LUNGHETTI (A),
STEFANIA SPARLA (A), VALERIA CURCI (A), CRISTINA DI TOMMASO (A),
MARIO STRICAGNOLI (A), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA
La funzione dell’atrio sinistro valutata con metodica 2D–Speckle Tracking Echocardiography (2D
STE) è stata dimostrata essere un marker del rischio cardiovascolare a breve termine, migliorando la
valutazione tradizionale dell’atrio sinistro, basata esclusivamente su parametri morfologici. In questo
studio è stata effettuata l’analisi funzionale dell’atrio sinistro nei pazienti asintomatici con
insufficienza mitralica di grado medio, e confrontata con i parametri morfologici convenzionali,
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valutandone la valenza prognostica riguardo all'insorgenza di eventi cardiovascolari. Questo studio
prospettico ha arruolato 276 pazienti con insufficienza mitralica di grado medio che erano stati
sottoposti ad esame ecocardiografico durante una visita cardiologica di controllo. La popolazione di
studio (età media 66 ± 8 anni) è stata seguita per un follow-up di 3,5 ± 1,6 anni; gli end-points primari
definiti nello studio erano l’insorgenza di fibrillazione atriale, ospedalizzazione per scompenso
cardiaco acuto, stroke e/o attacco ischemico transitorio e morte per cause cardiovascolari. La
valutazione morfologica dell’atrio sinistro è stata effettuata utilizzando parametri quali l’area, il
volume indicizzato e la frazione d’eiezione. L’analisi 2D-STE è stata utilizzata per la valutazione
funzionale dell’atrio sinistro, calcolando il Global peak atrial longitudinal strain (PALS) derivante
dalla media dello Strain longitudinale di tutti i segmenti atriali. Durante il periodo di follow-up, si
sono registrati 141 nuovi eventi cardiovascolari in 108 pazienti; tali pazienti presentavano tutti una
riduzione del global PALS, una ridotta frazione d’eiezione atriale sinistra e un incremento del volume
atriale indicizzato (p <0.0001). Inoltre tra tutti i parametri analizzati, il global PALS ha dimostrato la
maggiore accuratezza prognostica, utilizzando un valore di cut-off del 35 % (AUC global PALS:
0.87) . Questo studio prospettico ha dimostrato una forte associazione tra il Global PALS e la prognosi
nei pazienti asintomatici con insufficienza mitralica di grado medio, mettendo in evidenza come
questo nuovo indice di deformazione atriale abbia un più elevato potere predittivo rispetto ai
tradizionali parametri ecocardiografici e sottolineando una sua possibile potenzialità nella migliore
stratificazione del rischio in questo particolare gruppo di pazienti.
O111
IMPATTO PROGNOSTICO DELLA SINDROME METABOLICA NEI PAZIENTI CON
SCOMPENSO CARDIACO CRONICO: NUOVE EVIDENZE DAL TRIAL GISSI-HF
GIANLUIGI SAVARESE (A), PASQUALE PERRONE FILARDI (A), MARCO SCARANO (B),
RICCARDO CAVAZZINA (B), BRUNO TRIMARCO (A), SERGIO MINNECI (C), ALDO
PIETRO MAGGIONI (D), LUIGI TAVAZZI (B), GIANNI TOGNONI (B),
ROBERTO MARCHIOLI (B)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITÀ DEGLI STUDI
DI NAPOLI “FEDERICO II“; (B) CONSORZIO MARIO NEGRI SUD, SANTA MARIA
IMBARO; (C) OSPEDALE UNIVERSITARIO CAREGGI, FIRENZE; (D) FONDAZIONE
ANMCO PER IL TUO CUORE
Background. L’impatto prognostico negativo della sindrome metabolica (SM) è già stato
ampliamente indagato in popolazioni non selezionate ed in pazienti con cardiopatia ischemica.
L’obiettivo di questa analisi è stato quello di valutare l’impatto prognostico della SM nei pazienti con
scompenso cardiaco cronico (SC).
Metodi. Per la diagnosi di SM sono stati utilizzati i criteri dell’International Diabetes Federation.
Modelli di regressione di COX corretti per le variabili confondenti sono stati effettuati nei 6,648
pazienti arruolati nel trial GISSI-HF che non presentavano dati mancanti per le variabili di interesse,
utilizzando come outcomes la morte per tutte le cause e la morte per SC.
Risultati. Il rischio di morte per tutte le cause e morte per SC è risultato significativamente ridotto
nei pazienti con SM rispetto a quelli senza SM (HR=0.83, p=0.005; HR=0.76, p=0.031;
rispettivamente). Rispetto ai pazienti senza SM e senza diabete mellito di tipo 2 (DM), il rischio di
morte per tutte le cause e per SC era significativamente più basso nei pazienti con SM e senza DM
(HR=0.76, p=0.015; HR=0.65, p=0.046; rispettivamente), mentre si presentava significativamente
aumentato nei pazienti con DM e senza SM (HR=1.34, p<0.001; HR=1.44, p<0.001; rispettivamente).
I pazienti con SM e DM non mostravano alcuna differenza in termini di mortalità per tutte le cause e
per SC rispetto ai pazienti senza SM e senza DM (HR=1.03, p=0.762; HR=0.99; p=0.963;
rispettivamente). Il rischio di morte per tutte le cause e per SC è risultato essere più basso nei pazienti
con BMI>30 (HR=0.85. p=0.011; HR=0.82, p=0.071, rispettivamente) e nei pazienti con ipertensione
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(HR=0.80, p<0.001; HR=0.71, p<0.001), mentre si è presentato aumentato nei pazienti con glicemia
>100 mg/dl or DM (HR=1.08, p=0.136; HR=1.12, p=0.170, rispettivamente) o con bassi livelli di
colesterolo HDL (<40 mg/dl nei maschi e <50 mg/dl nelle femmine)(HR=1.08, p=0.097; HR=1.20,
p=0.027; rispettivamente). Nessuna associazione è stata individuata tra gli outcomes e
ipertrigliceridemia (>150 mg/dl).
Conclusioni. Nei pazienti con SC, la SM è associata ad una ridotta mortalità per tutte le cause e per
SC. Questi risultati sono verosimilmente attribuibili al fenomeno della “epidemiologia inversa”.
O112
LA QUANTIFICAZIONE DELL’INSUFFICIENZA MITRALICA FUNZIONALE COME
PREDITTORE INDIPENDENTE DI IPERTENSIONE POLMONARE IN PAZIENTI CON
STENOSI VALVOLARE AORTICA
GIOVANNI BENFARI (A), ANDREA ROSSI (A), POMPILIO FAGGIANO (B),
STEFANO NISTRI (C), GIOVANNI CIOFFI (D), CORRADO VASSANELLI (A)
(A) SEZIONE DI CARDIOLOGIA, DIPARTIMENTO DI MEDICINA, UNIVERSITÀ DEGLI
STUDI DI VERONA; (B) DIVISIONE DI CARDIOLOGIA, SPEDALI CIVILI DI BRESCIA; (C)
SERVIZIO DI CARDIOLOGIA, CMSR - VENETO MEDICA, ALTAVILLA VICENTINA; (D)
DIPARTIMENTO DI CARDIOLOGIA, OSPEDALE VILLA BIANCA, TRENTO
Background: L’ipertensione polmonare (IP) è un comune riscontro in pazienti con stenosi valvolare
aortica, essa predispone alla comparsa di sintomi e si associa ad una prognosi sfavorevole. Il ruolo
dell’insufficienza mitralica funzionale come determinante fisiopatologico dell’IP è ben consolidato
in alcuni modelli clinici, come nello scompenso cardiaco con frazione di eiezione ridotta. Nei pazienti
affetti da stenosi valvolare aortica permane invece qualche incertezza.
Obiettivo del presente lavoro è valutare le relazioni reciproche tra area dell’orifizio rigurgitante
effettivo mitralico (ERO) quantitativamente valutata e livello di pressione sistolica in arteria
polmonare (S-PAP) in pazienti consecutivi con stenosi valvolare aortica.
Metodi: Sono stati prospetticamente reclutati pazienti con velocità di flusso aortico > 2.5 m/s. I
pazienti con un rigurgito mitralico caratterizzato da ERO > 0.2 cm2 sono stati esclusi. I volumi
telediastolico (VTD) e telesistolico (VTS) del ventricolo sinistro, la frazione di eiezione (FE) e il
volume atriale sinistro (LA) sono stati misurati con il metodo di Simpson biplano. La velocità di
accorciamento longitudinale (S-DTI) e di allungamento precoce (E-DTI) sono state misurate con
Doppler tissutale. ERO, volume di rigurgito mitralico (RV) e frazione di rigurgito (RF) sono stati
ottenuti con il metodo PISA. L’indice di impedenza valvulo-arteriosa (Z) è stato calcolato.
L’area valvolare aortica (AVA) è stata quantificata con il metodo dell’equazione di continuità, ed
indicizzata per la superficie corporea. La S-PAP è stata calcolata sommando la pressione atriale
stimata al gradiente di pressione valutato a livello del rigurgito tricuspidale.
Risultati: 98 pazienti consecutivi sono stati inclusi; l'età media era di 77 ± 8 anni , FE media 55 ±
15%, classe NYHA 2.2 ± 0.9, l’AVA media era 0.56 ± 0.18 cm2/m2. 72 pazienti (73%) presentavano
insufficienza mitralica, e tra questi 48 (66 %) mostrano ERO < 0.10 cm2.
All’analisi della varianza (ANOVA) il valore di S-PAP risultava significativamente maggiore nel
sottogruppo di pazienti con ERO ≥ 0.10 cm2 rispetto al gruppo di pazienti con ERO 0-0.10 cm2 ed a
quello di pazienti con ERO = 0 cm2 (i valori medi di S-PAP erano rispettivamente 49 ±13 mmHg ,
42 ±9 mmHg e 37 ±6 mmHg; p = 0.001).
All'analisi univariata S-PAP correlava con VTD (R=0.37 , p<0.0001) , EF (R= -0.23 , p=0.01) , E
(R=0.43, p<0.0001) , E/E' (R=0.37 ; p<0.0001) ed in particolare con il valore di ERO (R=0.47,
p<0.0001). Non vi era alcuna associazione significativa tra S-PAP ed AVA o gradiente medio
transvalvolare aortico.
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In un modello di regressione multivariata solo ERO (p=0.004) e VTD (p = 0.03) rimanevano associati
con S-PAP, mentre E/E ' e FE perdevano di significatività. Lo stesso risultato si otteneva inserendo
RV o RF nel modello.
Conclusioni: L’area dell’orifizio rigurgitante effettivo mitralico, anche quando di modesta entità,
risulta un predittore indipendente del livello di pressione polmonare in una casistica di pazienti
consecutivi con diversi gradi di stenosi valvolare aortica. Questa relazione non è influenzata da altre
variabili comunemente associate al sovraccarico pressorio ventricolare, come il volume atriale
sinistro o il rapporto E/E'. La quantificazione dell’insufficienza mitralica risulta un elemento
importante per rivelare ulteriori relazioni fisiopatologiche con l’ipertensione polmonare in questo
contesto.
O113
HUMAN EPICARDIAL FAT TISSUE AND CALCIFIC AORTIC STENOSIS
VALENTINA PARISI (a), PIETRO FORMISANO (a), VITTORIA D´ESPOSITO (a),
FEDERICA PASSARETTI (a), MARIA ROSARIA AMBROSIO (a), DOMENICO LIGUORO (a),
AURELIO CARUSO (b), GABRIELLA GRIMALDI (b), FRANCESCO BALDASCINI (b),
AGNESE BEVILACQUA (a), GAETANA FERRO (a), GENNARO PAGANO (a),
GIUSEPPE RENGO (a), NICOLA FERRARA (a), DARIO LEOSCO (a)
(a) UNIVERSITA´ DI NAPOLI ´FEDERICO II´ DIPARTIMENTO DI SCIENZE MEDICHE
TRASLAZIONALI; (b) CASA DI CURA SAN MICHELE, MADDALONI (CE)
Background and aims. It is widely established that epicardial adipose tissue (EAT) influences key
pathogenic mechanisms of coronary atherogenesis through secretion of several inflammatory
mediators. Recent studies have demonstrated that the pathophysiology of aortic valve stenosis (AS)
is characterized by early atherosclerosis and inflammation. In the present study we aimed to evaluate
the
amount
of
EAT
and
its
secretory
profile
in
human
AS.
Methods. We measured EAT thickness by echocardiography in 70 pts with isolated, severe AS, 54
pts with isolated, severe coronary artery disease (CAD), 37 pts with both AS and CAD, and 23
controls matched for age, gender, BMI and cardiovascular risk factors. During cardiac surgery, EAT
and subcutaneous adipose tissue (SC) were collected from pts with isolated AS and CAD. The
secretome of EAT and SC was analyzed by human cytokine 27-plex immunoassay.
Results. Respect to controls, EAT thickness was significantly and similarly increased in pts with
isolated AS and isolated CAD (p<0.05). In pts with coexistent AS and CAD, EAT thickness was
significantly greater than the other 3 groups (p<0.05). Overall, EAT of AS and CAD pts showed a
more marked inflammatory profile than SC. In particular, in AS pts, of 27 measured factors (including
cytokines, chemokines, growth factors, and angiogenic mediators), 17 showed significant greater
levels in EAT with respect to SC (p<0,05) (Figure). In CAD pts, EAT secreted significant greater
levels of 7 inflammatory mediators with respect to SC (p<0,05). Of note, in AS pts, there was a close
relationship between EAT thickness and levels of secreted inflammatory mediators (p<0,05) (Figure).
Conclusions. This represents the first demonstration of increased EAT thickness in pts with severe
AS. In AS pts, EAT inflammatory secretory profile is exalted with respect to SC and shows a close
relationship with the amount of EAT. Overall, these preliminary data suggest a potential role for EAT
in the pathogenesis of AS.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 4
O114
CLINICAL AND INSTRUMENTAL CHARACTERIZATION AND THE LONG-TERM
PROGNOSIS OF MILDLY DILATED CARDIOMYOPATHY
MARTA GIGLI (A), MARCO MERLO (A), DAVIDE STOLFO (A), FRANCESCA ANTONINI
CANTERIN (A), ANITA SPEZZACATENE (A), MATILDA MUCA (A), GIANLUCA
ANTONIO D´ANGELO (A), SARA SCAPOL (A), MILENA DI NUCCI (A),
BRUNO PINAMONTI (A), GIANFRANCO SINAGRA (A)
(A) S.C. CARDIOLOGIA AZIENDA OSPEDALIERO-UNIVERSITARIA “OSPEDALI
RIUNITI“ DI TRIESTE
Objective: to define the clinical and instrumental characterization and the long-term prognosis of
Mildly Dilated Cardiomyopathy (MDCM).
Background: MDCM is a subgroup of idiopathic dilated cardiomyopathy (IDCM) characterized by
slightly dilated left ventricle and presenting systolic dysfunction. The long-term evolution and the
prognosis of the disease is unknown in the current treatment and clinical management era of IDCM.
Methods: From 1988 to 2008 we enrolled 659 patients with IDCM; MDCM was considered in
presence of LVEF <50% and LV end-diastolic volume index (LVEDVI) < 86 ml/m2 at
echocardiographic evaluation.
Results: 252 patients (38%) fulfill the pre-specified criteria for MDCM. At baseline evaluation
MDCM patients were less symptomatic than IDCM patients (NYHA III_IV 15% vs 30%
respectively, p< 0.001) and had a slightly higher LVEF (36±8 vs 30±12%, p <0.001). Interestingly
MDCM patients initially improved under optimal therapy, then were stable at mid-term, followed by
a progression in the long term approaching the condition of other IDCM patients. At 10 years follow
up mortality for all causes death was 21 % in MDCM and 39 % in IDCM (p < 0.001); heart failure
death/HTx and sudden death/malignant ventricular tachycardia rates were 10% vs 18% (p 0. 002) and
12vs 20% (p 0.005) in MDCM and IDCM patients respectively. MDCM with baseline LVEF ≤35%,
compared to the other MDCM patients, presented lower survival rates (p=0.001) but similar rates of
long-term sudden death and malignant ventricular arrhythmias (p 0.6).
Conclusions: MDCM identifies a consistent subgroup of IDCMs discovered in an early phase rather
than a specific disease and it presents benign long-term outcome. Initially it is characterized by a less
adverse evolution, however it presents a long time progression approaching the other IDCM. Baseline
LVEF cut-off of 35% is not helpful in predicting the risk of major arrhythmic events in MDCM.
O115
PROGNOSTIC VALUE OF LEFT VENTRICULAR RECOIL IN PRIMARY CHRONIC
MITRAL REGURGITATION
ROBERTA MANGANARO (A), SCIPIONE CARERJ (A), MAURIZIO CUSMÀ PICCIONE (A),
ALESSANDRA CAPRINO (A), ILARIA BORETTI (A), MARIA CHIARA TODARO (A),
GABRIELLA FALANGA (A), LILIA ORETO (A), MYRIAM D´ ANGELO (A),
CONCETTA ZITO (A)
(A) DIPARTIMENTO CLINICO SPERIMENTALE DI MEDICINA E FARMACOLOGIA.
UNIVERSITÀ DI MESSINA
Purpose. To evaluate the prognostic value of abnormalities of left atrial (LA) and/or ventricular (LV)
mechanics as predictors of cardiovascular events during follow-up in asymptomatic patients with
chronic primary mitral regurgitation (MR).
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Methods. 68 patients (mean age 57±17 years) with mitral valve prolapse, MR and normal LV ejection
fraction were prospectively enrolled. Patients were divided into three groups according to the severity
of MR: mild (n=24), moderate (n= 21) and severe (n= 23). Two- dimensional echocardiographic
images were acquired for speckle tracking analysis. At the end of follow- up, patients were subdivided
into two group according to the occurrence of events (death, dyspnea/palpitations and MV surgery).
Results. Compared to patients with mild MR, those with moderate MR showed increased LV mass
index (p< 0.001), E/E’ (p= 0.01), PAPs (p=0.007), basal rotation (p=0.04), twist (p=0.004), reduced
longitudinal LV strain (p= 0.04) and LA strain (p=0.005); furthermore LV mass index (p<0.001), LV
volumes (EDV p<0.001, ESV p=0.007), sphericity index (p=0.003), E/A (p=0.005), E/E’ (p=0.003),
LA volume (p=0.002) and PAPs (p=0.01) were higher in pts with severe than in those with moderate
MR, whereas LA strain (p<0.001)and LV recoil (p<0.001) were lower in pts with severe than in
those with moderate MR. After a mean follow-up of 23.8 months ± 17.5, 39 (57%) patients remained
asymptomatic whereas 29 (42%) developed events (17=MV surgery, 9=dyspnea/palpitations,
5=deaths). Compared to asymptomatic patients, those with events showed: higher LV sphericity
index (0.65±0.06 vs 0.60±0.08, p=0.028) and LV global circumferential strain (-23.2±4.8 vs 20.7±4.7, p=0.043) and decreased: LA strain (25.5±8.1% vs 31.9±7.9%, p=0.003), LV global
longitudinal strain (-19.1±4.7 vs -21.1±2.5, p=0.030), LV recoil (-69.7±34.6 vs -86.8±23.2, p=0.024).
On univariate Cox regression analysis, mitral E/A ratio (HR= 2.4, CI 1.2-4.8, p=0.010), LA volume
(HR= 1.02, CI 1.00-1.05, p=0.025), LA strain (HR= 0.92, CI 0.87-0.97, p=0.003) and LV recoil
(HR=1.02, C.I. 1.00-1.03, p=0.012) were associated with increased risk of events. On multivariate
regression analysis, only LV recoil was independent predictor of events (HR= 1.03, CI 1.00- 1.04,
p=0.024). The ROC analysis showed that a cut-off recoil= -77.5°/sec had the higher sensitivity and
specificity to identify patients at major risk (AUC=0.73; Sensitivity 73%, Specificity 72%).
Conclusions. Impaired LA and LV mechanics are associated with the occurrence of events in
asymptomatic patients with MR, however LV recoil is the only independent predictor of a worse
prognosis.
O116
IMPAIRED CORTICAL PAIN
MYOCARDIAL ISCHEMIA
PROCESSING
IN
PATIENTS
WITH
SILENT
ANTONINO DI FRANCO (A), GAETANO ANTONIO LANZA (A),
MASSIMILIANO VALERIANI (B, C), ANGELO VILLANO (A), GIULIO RUSSO (A),
ALFONSO SESTITO (A), DANIELA VIRDIS (D), COSTANZA PAZZAGLIA (E), FILIPPO
MARIA SARULLO (F), PAOLO MARIA ROSSINI (D), FILIPPO CREA (A),
CATELLO VOLLONO (D)
(A) DEPARTMENT OF CARDIOVASCULAR MEDICINE, UNIVERSITÀ CATTOLICA DEL
SACRO CUORE, ROME, ITALY; (B) NEUROLOGY DIVISION, PEDIATRIC HOSPITAL
“BAMBINO GESÙ” IRCCS, ROME, ITALY; (C) CENTER FOR SENSORY-MOTOR
INTERACTION, AALBORG UNIVERSITY, AALBORG, DENMARK; (D) DEPARTMENT OF
GERIATRICS, NEUROSCIENCE & ORTHOPEDICS, CATHOLIC UNIVERSITY, ROME,
ITALY; (E) DON CARLO GNOCCHI ONLUS FOUNDATION, MILAN, ITALY; (F)
CARDIOVASCULAR REHABILITATION UNIT, BUCCHERI LA FERLA
FATEBENEFRATELLI HOSPITAL, PALERMO, ITALY
Purpose. In the present study, we investigated whether the function of brain areas specifically
devoted to nociception presents any abnormalities in patients with silent myocardial ischemia (MI),
as compared to those with symptomatic MI.
Methods. We studied 3 groups of individuals: 1) 11 asymptomatic, non-diabetic patients with
documented obstructive coronary artery disease (CAD) (67±10 years, 6 men; group 1); 2) 10 patients
with obstructive CAD and a clinical pattern of chronic stable angina (66.5±10 years, 6 men; group
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Roma, 13 – 15 dicembre 2014
2); 3) 14 apparently healthy subjects matched for age and gender to patients (63.2±9 years, 8 men;
group 3). Patients with any chronic pain syndrome other than anginal chest pain were excluded.
Cortical nociception function was assessed by cortical laser evoked potentials (LEPs) recording in
response to chest skin stimulation by cutaneous CO2 laser pulses. Specifically, the N2/P2 wave of
LEPs, which reflects cortical pain processing, was measured. Three sequences of painful stimuli (at
the intensity of 2.5 times the individual sensory threshold) were applied, separated by 5-minute
intervals.
Results. N2/P2 amplitude during the first sequence of chest skin stimuli was 9.3±4.0, 14.0±7.3 and
15.5±6.4 µV in group 1, group 2 and group 3, respectively (p=0.03). N2/P2 amplitude decreased
across the three sequences of pain stimuli in group 2 (-37.5±14 %) and group 3 (-23.0±15 %), but not
in group 1 (-0.14±37 %) (comparison among groups, p=0.015).
Conclusion. CAD patients with silent MI show a reduced amplitude of N2/P2 LEP component
and inadequate habituation to painful stimuli, compared to symptomatic angina CAD patients and
healthy controls. This pattern is likely due to thalamic gate modulation of pain signals and can
contribute to the lack of pain perception during MI in these patients.
O117
UTILITY OF ULTRASOUND LUNG COMETS IN THE EARLY DIAGNOSIS OF ACUTE
HEART FAILURE IN POST–CARDIAC SURGERY - THE LUCE STUDY
F. RICCI (A), G. DI PACE (C), R. AQUILANI (B), F. RADICO (A), V. CICCHITTI (A),
F. BIANCO (A), A. GIORI (C), E. MINIERO (B), F. PETRINI (C), G. SCIPIONI (B), R. DE
CATERINA (A), S. GALLINA (A)
(A) CARDIOLOGIA UNIVERSITARIA - UNIVERSITA DEGLI STUDI “G.D´ANNUNZIO“ CHIETI; (B) ANESTESIA E TERAPIA INTENSIVA CARDIOCHIRURGICA - OSPEDALE
“SS.ANNUNZIATA“- CHIETI; (C) UNITÀ OPERATIVA DI ANESTIA E RIANIMAZIONE OSPEDALE “SS.ANNUNZIATA“ - UNIVERSITÀ DEGLI STUDI “G.D´ANNUNZIO“ - CHIETI
Purpose: Acute heart failure (AHF) after cardiac surgery is associated with a very poor prognosis.
Early diagnosis of AHF is key to ensure prompt and effective treatment. Lung ultrasonography (LUS)
have been proposed as a reliable diagnostic tool for the assessment and grading of pulmonary
congestion by means of ultrasound lung comets (ULCs) evaluation. The aim of this study is to assess
the diagnostic performance of ULCs, alone or in combination with echocardiographic evaluation of
left ventricular (LV) systolic and diastolic function, compared with chest-X-ray (CXR) and NTproBNP, for the early diagnosis of postoperative AHF in a cohort of patients admitted to the cardiac
surgery intensive care unit (CSICU) of our hospital.
Methods: We enrolled 42 consecutive patients (mean age: 71.1±8.8 years; mean EuroSCORE:
5.7±2.9 [±SD]), who were studied before and immediately after cardiac surgery with LUS,
transthoracic echocardiography (TTE), CXR and NT-proBNP. Final diagnosis of AHF, satisfying
ESC guidelines recommendations, was adjudicated by 2 independent investigators blinded to the
results of LUS. ROC-curve analyses were performed to compare diagnostic accuracy and predictive
values of LUS (±TTE-derived LV systolic and diastolic function), CXR and NT-proBNP with
reference to the adjudicated final diagnosis.
Preliminary results: The adjudicated final diagnosis of postoperative AHF was done in 18 patients
(42.9%). Mean postoperative ejection fraction was 49.3±12.37%. Decompensation was detected in
59.5% of patients when estimated by LUS (alone or in combination with TTE), 28.6% by CXR, and
26.2% by NTproBNP. At the time of admission in CSICU, a number of ULCs <5 safely ruled out
postoperative AHF with both excellent sensitivity and negative predictive value of 94%. In ROC
analyses, ULCs yielded a C-statistic of 0.81 (95% CI: 0.69-0.92) compared with 0.74 (95% CI: 0.610.87) for supine CXR, and 0.56 (95% CI: 0.42-0.70) for NT-proBNP (cut-off value >1000 pg/ml).
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LUS allowed significantly shorter average time to diagnosis (107 min) when compared with CXR
and NT-proBNP (261 and 165 min; p<0.0001).
Conclusions: In the postoperative period after cardiac surgery LUS allows rapid and reliable rulingout of AHF. LUS represents an attractive, radiation-free, bedside, non-invasive diagnostic tool for
early detection and monitoring of extravascular lung water.
STUDI OSSERVAZIONALI E TRIAL CLINICI - 1
O118
PROFILO CLINICO, STRATEGIE DIAGNOSTICHE, TERAPIA ED OUTCOME DI
PAZIENTI CON SINDROME AORTICA ACUTA: DATI DA UN AMPIO REGISTRO
MONOCENTRICO
ANNA CORSINI (A), GIULIA BUGANI (A), FABIO VAGNARELLI (A),
SIMONE LONGHI (A), MADDALENA GRAZIOSI (A), ELENA BIAGINI (A),
LAURA CINTI (A), GIULIA NORSCINI (A), GIOVANNI MELANDRI (A),
CLAUDIO RAPEZZI (A)
(A) ISTITUTO DI CARDIOLOGIA, POLICLINICO S.ORSOLA MALPIGHI, BOLOGNA
Obiettivo: valutare le caratteristiche epidemiologiche, la presentazione clinica, la cronobiologia, le
strategie diagnostiche, il trattamento e la prognosi dei pazienti affetti da sindrome aortica acuta (SAA)
che afferiscono ad un centro hub di terzo livello.
Metodi: abbiamo arruolato nel registro monocentrico “AESA – Archivio Elettronico delle Sindromi
Aortiche Acute” tutti i pazienti ricoverati presso il nostro Istituto con diagnosi di SAA (dissezione
aortica, ematoma intramurale, ulcera penetrante) dall’1 gennaio 2000 al 31 dicembre 2013. Sono stati
esclusi i pazienti con SAA cronicizzata (intervallo >14 giorni dall’insorgenza dei sintomi) o ad
eziologia traumatica.
Risultati: sono stati arruolati un totale di 398 pazienti, di cui 258 (65%) con SAA tipo A. L’età media
della popolazione è risultata di 66 ± 13 anni, con prevalenza di sesso maschile (67%). La diagnosi di
ematoma intramurale e di ulcera penetrante dell’aorta è quadruplicata negli anni 2007-2012 rispetto
agli anni 2000-2006 (22% vs. 2%, p=0,05), evento riconducibile ad un uso più sistematico della TAC
dopo l’implementazione nell’azienda ospedaliera di un percorso di cura dedicato. Una presentazione
clinica con sintomi non tipicamente correlati a SAA (assenza di dolore, dispnea isolata, sintomi
neurologici isolati, dolore agli arti inferiori, dolore toracico anteriore con ECG suggestivo di ischemia
acuta) si è verificata nel 38% dei casi. Un aspetto ECG compatibile con sindrome coronarica acuta
(SCA) è stato riscontrato nel 26% dei casi (29% dei pazienti con SAA tipo A vs. 19% dei pazienti
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
con SAA tipo B, p=0.044). Parallelamente la positività della troponina cardiaca si è osservata nel
18% dei pazienti (19% nelle SAA tipo A vs. 15% nelle SAA tipo B, p=0.341). Le alterazioni ECG
tipo SCA e la postitività della troponina sono risultate predittive di un ritardo diagnostico
(intraspedaliero) superiore al 75° percentile insieme alla presentazione con dispnea ed al versamento
pleurico/pericardico. L’esordio delle SAA si è rivelato più frequente nella fascia oraria 6-14 (44%),
rispetto alle fasce 14-22 (34%) e 22-6 (22%). Considerando il ritmo circannuale, il picco di incidenza
della patologia si è osservato nella stagione invernale (33%), dove si rileva peraltro un aumento di
mortalità (26%) rispetto agli altri periodi dell’anno. Il primo esame diagnostico è stato rappresentato
dall’angioTAC nel 73% dei pazienti, dall’ecocardiografia transtoracica nel 12%, dall’ecografia
addominale nel 9%, dall’angiografia nel 4%, dall’ecocardiografia transesofagea nel 2% (peraltro
eseguita, pre/intra-operatoria, in tutti i pazienti sottoposti a terapia chirurgica/endovascolare) e dalla
risonanza magnetica nello 0,2% dei casi. Ha beneficiato di un trattamento chirurgico l’86% dei
pazienti con SAA tipo A e il 47% di quelli con SAA tipo B. Il tasso di mortalità intraospedaliera è
stato del 22%: 26% nel tipo A e 14% nel tipo B.
Conclusioni: i dati di questo ampio registro ospedaliero mostrano un outcome delle SAA in linea con
i dati della letteratura internazionale. Una presentazione clinica atipica si verifica in più di un terzo
dei pazienti. Le alterazioni ECG suggestive di ischemia acuta e la positività della troponina cardiaca
si presentano in un quarto dei casi circa, anche quando non vi è coinvolgimento dell’aorta ascendente,
e rappresentano una causa importante di ritardo diagnostico. Infine la maggior parte delle SAA si
manifesta nel periodo invernale e con prognosi più severa.
O119
EVENTI CLINICI, OSPEDALIZZAZIONI, E PROCEDURE DI CARDIOVERSIONE ED
ABLAZIONE DURANTE IL FOLLOW-UP NEL REGISTRO PREFER IN AF:
CONFRONTO TRA DATI ITALIANI ED EUROPEI
BRUNO PEZZULICH (A), PIERPAOLO SORI (A), STEFANO MAGGIOLINI (B),
CLAUDIO CARBONE (B), LIVIO DI LECCE (C), FILIPPO FAVALLI (C),
GIULIA RENDA (D), RAFFAELE DE CATERINA (D)
(A) U.O. DI ELETTROFISIOLOGIA, VILLA MARIA PIA HOSPITAL GVM CARE&
RESEARCH, TORINO; (B) U.O. DI CARDIOLOGIA, OSPEDALE SAN LEOPOLDO MANDIC,
MERATE (LC) ; (C) DIREZIONE MEDICA, DAIICHI SANKYO ITALIA; (D) ISTITUTO DI
CARDIOLOGIA, UNIVERSITÀ “G. D’ANNUNZIO” C/O OSPEDALE SS. ANNUNZIATA,
CHIETI
Razionale: La fibrillazione atriale (FA) è la più comune aritmia riscontrata nella pratica clinica. La
sua incidenza aumenta con l’età e la presenza di patologie cardiache di fondo. Nonostante la
consapevolezza che gran parte dei pazienti possono andare incontro a molteplici eventi
cardiovascolari, ad oggi non ci sono studi che confrontino l’incidenza e la gestione di tali eventi in
Italia rispetto agli altri paesi europei.
Metodi: Nel registro PREFER in AF (The PREvention oF thromboembolic events – European
Registry in Atrial Fibrillation) sono stati arruolati, nel periodo compreso da Gennaio 2012 a Gennaio
2013, pazienti non selezionati affetti da FA nei seguenti paesi europei: Austria, Francia, Germania,
Italia (ITA), Spagna, Svizzera e Regno Unito. Il disegno dello studio prevedeva una visita basale e
una visita di follow-up dopo un anno. I dati di seguito riportati si riferiscono agli eventi clinici e
decessi osservati, ed alle procedure di cardioversione e ablazione effettuate nel periodo compreso fra
la visita basale e la visita di controllo.
Risultati: Nel Registro PREFER in AF sono stati arruolati 7243 pazienti in Europa (EU), di cui 1888
(26%) in ITA, coinvolgendo 98 centri. Alla visita di follow-up a 12 mesi dal basale, sono stati valutati
6412 pazienti tra tutti i paesi europei considerati; di questi 1655 erano italiani. Nei pazienti italiani,
gli eventi cardiovascolari più frequenti al follow-up sono stati insufficienza cardiaca cronica (12.1%
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vs media EU 7,6%), ridotta funzionalità di pompa del cuore sinistro (11.4% vs media EU 6,8%) e
TIA (media ITA 3,3% vs media EU 1,3%). Gli eventi osservati meno frequentemente sono stati:
infarto STEMI (0,1% sia in ITA che in EU), eventi tromboembolici polmonari (nessun evento in ITA
vs 0,1% in EU), intervento di bypass coronarico (media ITA 0,3% vs media EU 0,6%), embolia
arteriosa (nessun evento in ITA vs media EU 0,2%).
In Italia ci sono state 199 ospedalizzazioni (EU n= 628) e tra queste 67 per casi trattati in urgenza
(EU n= 178) e 137 per casi non urgenti (EU n=520). La durata media dei ricoveri ospedalieri è
stata complessivamente di 7.9 giorni (media EU: 8,6 giorni).
Il 7.7% dei pazienti italiani è stato sottoposto a cardioversione elettrica (media EU: 7,6%) ed il 3.8%
ad ablazione (media EU: 3,8%).
Conclusioni: Dai dati emersi risulta che in Italia non ci sono stati elevati tassi di eventi
cardiovascolari. Solo per eventi come l’insufficienza cardiaca cronica e una ridotta funzionalità di
pompa del cuore sinistro si ha una percentuale superiore alla media EU. Nonostante l’Italia abbia un
maggiore numero di ospedalizzazioni, tuttavia la durata media è in linea con quella degli altri paesi
europei. La percentuale di pazienti italiani trattati con procedure di cardioversione elettrica e
ablazione è paragonabile invece a quella dei paesi europei.
O120
IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE A MITRAL DOPPLER
VELOCIMETRIC PATTERN OF DIASTOLIC LEFT VENTRICULAR DYSFUNCTION
MAY ORIGINATE FROM A REDUCED LEFT VENTRICULAR PRELOAD: RESULTS OF
A CASE-CONTROL STUDY
RENATO DE VECCHIS (A), GIUSEPPINA DI BIASE (B), ARMANDO PUCCIARELLI (C),
CARMELINA ARIANO (A)
(A) CARDIOLOGY UNIT, PRESIDIO SANITARIO INTERMEDIO “ELENA D´AOSTA“,
NAPOLI, ITALY; (B) NEUROREHABILITATION UNIT,CASA DI CURA “S.MARIA DEL
POZZO“, SOMMA VESUVIANA, ITALY; (C) INVASIVE CARDIOLOGY LABORATORY,
CARDIOLOGY DIVISION, CLINICA MONTEVERGINE, MERCOGLIANO, ITALY
Background: According to some authors, changes in right ventricular afterload and left ventricular
preload would consistently be present in chronic obstructive pulmonary disease (COPD). Besides,
they per se would be able to generate the Doppler echocardiographic findings of diastolic
asymptomatic left ventricular dysfunction (ALVD) frequently seen in COPD.
Aims: Identifying the predictors of ALVD in COPD patients using a case control study.
Methods: Patients with COPD and ALVD were enrolled as cases, while patients affected by COPD
without ALVD were assumed as controls. The measurements of left ventricular function were
acquired using conventional Doppler echocardiography adequately complemented by Tissue
Doppler Imaging and speckle tracking. Left ventricular systolic dysfunction was defined by left
ventricular ejection fraction < 50 % . Diastolic left ventricular dysfunction was defined according to
guidelines of the European Association of Cardiovascular Imaging. A logistic regression model was
built taking left ventricular dysfunction as outcome variable. A number of anamnestic, clinical and
echocardiographical exposure variables were included in the model.
Results: 35 cases and 26 controls were recruited. Diastolic ALVD was found in all of 35 cases: 27
patients with grade I and 8 patients with grade II diastolic ALVD. Markers of increased risk of
ALVD were tricuspid annular plane systolic excursion(TAPSE) <17 mm (OR = 17.18; 95% CI: 1.89
- 155.62 p = 0.0114) and systolic pulmonary artery pressure(sPAP)> 40 mmHg (OR = 33.08; 95%
CI: 1.26 - 864.28 p = 0.0356). Furthermore, sPAP estimate was demonstrated to be related to ratio
of E flow velocity divided by early (e’) LV basal longitudinal myocardial lengthening velocity (E/e'
ratio) by a very significant negative correlation, while the left ventricular isovolumic relaxation
time (LV IVRT) was not affected by elevated pulmonary pressure.
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Conclusions: ALVD was predicted by a reduced TAPSE and an increased sPAP, i.e. an index of
RV function and a surrogate marker of ventilatory function, respectively. However, the inverse
linear correlation found between E/e’ ratio and sPAP, in the presence of a LV IVRT unaffected by
increased sPAP, would suggest that a LV reduced preload is present in COPD. Thus mitral Doppler
data may indicate that LV diastolic dysfunction in COPD patients is not related to increase in left
ventricular stiffness and/or intrinsic impairment in left ventricular relaxation/compliance but rather
it arises from a reduced left ventricular preload, pulmonary hypertension-related.
O121
APPLICATION OF PARTNERS HF AS A SCORE FOR REMOTE MANAGEMENT OF
PATIENTS WITH CARDIAC RESYNCHRONIZATION THERAPY
FRANCESCO MARIA ANGELO BRASCA (A), JESSICA FRANZETTI (A),
VALERIA RELLA (A), COSETTA CORAPI (A), ROBERTO BRAMBILLA (A),
MARIO FACCHINI (A), GIOVANNI BATTISTA PEREGO (A), GIANFRANCO PARATI (A)
(A) DEPT OF CARDIOVASCULAR, NEURAL AND METABOLIC SCIENCES, S. LUCA
HOSPITAL, IRCCS ISTITUTO AUXOLOGICO ITALIANO, MILANO, ITALY; CHAIR IN
CARDIOVASCULAR MEDICINE AND SCHOOL OF SPECIALIZATION IN
CARDIOVASCULAR MEDICINE; DEPT OF HEALTH SCIENCES, UNIVERSITY OF
MILANO-BICOCCA.
AIM: Early diagnosis of acute congestive events is a mainstay in heart failure (HF) treatment.
To this aim the PARTNERS HF trial elaborated a multiparametric model based on:
- new onset atrial fibrillation,
- ventricular rate during AF,
- decrease of thoracic impedance,
- reduction of physical activity,
- increase in nighttime heart rate,
- decrease of heart rate variability,
- decrease of biventricular pacing percentage,
- activation of device therapy for ventricular arrhythmia.
This approach allowed a significant improvement to be achieved in the early diagnosis of acute
decompensation in advanced HF patients treated with cardiac resynchronization therapy. Given
that most implantable devices now allow remote monitoring of relevant parameters used in
PARTNERS HF to be performed, aim of our study was to test the ability of PARTNERS HF
criteria to detect early acute cardiac decompensation in the frame of a remote HF patients’ control
setting in daily practice, including NYHA II HF patients.
MATERIALS AND METHODS: PARTNERS HF criteria were retrospectively applied to data
transmitted through remote monitoring by HF patients treated with cardiac resynchronization
therapy. We tested the value of a score based on these criteria for prediction of acute HF
decompensation events taking place within 15 days after the data transmission.
RESULTS: We analyzed 1398 data transmissions from 99 patients (age 68.9 ± 8.2 years; NYHA II
46.5%); median follow up was 35 months (range 1-36). In 360 cases, acute HF events were
observed after the index transmission. When 2 or more Partners HF criteria were satisfied,
the hazard ratio for events was 4.8 (CI 95% 3.5 – 5.9; p < 0.001). Optivol Index > 60, was associated
to a higher probability of events (Relative Risk 2.41 : IC 95% 1.35 – 4.29; p <0.001). No specific
associated condition modified the score best cut-off.
CONCLUSIONS: Our study shows that PARTNERS HF criteria can be used as a score for early
identification of acute decompensation events in HF patients followed by remote monitoring.
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A: alarm transmissions; NP: not programmed transmissions; OPT60: Optivol index > 60; P: programmed transmissions; PHF: score Partners HF
O122
ROLE OF BNP DECREASE AND BUN VALUE AT DISCHARGE IN PREDICTING
OUTCOME IN PATIENTS ADMITTED WITH ACUTE DECOMPENSATED HEART
FAILURE
GAETANO RUOCCO (A), MARCO PELLEGRINI (A), RICCARDO MARZOTTI (A),
CARMELO DE GORI (A), BARBARA LUCANI (B), BEATRICE FRANCI (B),
RANUCCIO NUTI (C), ALBERTO PALAZZUOLI (A)
(A) DEPARTMENT OF INTERNAL MEDICINE, CARDIOLOGY UNIT, LE SCOTTE
HOSPITAL UNIVERSITY OF SIENA, ITALY; (B) DEPARTMENT OF INTERNAL
MEDICINE, CHEMICAL LABORATORY, LE SCOTTE HOSPITAL UNIVERSITY OF SIENA,
ITALY; (C) DEPARTMENT OF INTERNAL MEDICINE, LE SCOTTE HOSPITAL
UNIVERSITY OF SIENA, ITALY
Background: B-type Natriuretic Peptide (BNP) is traditionally used for early assessment of Acute
Decompensated Heart Failure (ADHF); BNP decrease during hospitalization has been described to
be related to reduced risk of readmission and death. On the other hand Blood Urea Nitrogen (BUN)
increase is related with adverse events. Monitoring treatment efficacy and assessing outcome by serial
measurement of natriuretic peptides and BUN value in ADHF patients, may help to improve risk
stratification. In this study we would identify the power of BNP decrease in association with BUN
value in predicting outcome.
Methods: Seventy consecutive patients with diagnosis of ADHF [aged 79±7 years, New York heart
Association (NYHA) classes III-IV, left venricular ejection fraction < 45%] were admitted in our
hospital from April 2012 to May 2014. All patients underwent a clinical, echocardiographic and
laboratory (BNP, BUN and creatinine) assesment at admission and at discharge. All patients were
subsequently followed for six months for death or rehospitalization.
Results: Patients were studied according to: 1. the decrease of BNP levels at discharge more than
30% respect to basal values; 2. the persistence of congestion (congestion was defined as the presence
of 1 or more of the following symptoms and signs: pulmonary rales, jugular venous stasis,
hepatomegaly, and peripheral edema) at discharge; 3. the decrease of BNP levels at discharge more
than 30% respect to basal values, without congestion signs and symptoms at discharge; 4. BUN
increase at discharge more than 20% respect to baseline. Cox regression analysis demonstrated that
significant (more than 30% respect to baseline) BNP decrease, alone (univariate: HR 0.40 [0.17-0.95]
p=0.03; multivariable: HR 0.35 [0.14-0.84] p=0.02) and together with symtoms relief and congestion
signs reduction (univariate: HR 0.31 [0.13-0.80] p=0.01; multivariable: HR 0.25 [0.10-0.78]
p=0.004), was related to outcome improvement in these patients. On the opposite, BUN increase was
associated with poor outcome indipendently from BNP reduction (univariate: HR 1.92 [1.03-3.60]
p=0.04; multivariable HR 2.23 [1.13-4.39]p=0.02). Kaplan Meier survival plot showed this trend with
significant LogRank test (p=0.001).
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Conclusions: BNP reduction more than 30% respect to basal level is associated with outcome
improvement together with symptoms relief and congestion signs reduction during hospitalization.
When BNP reduction is associated to BUN increase more than 20 % at discharge respect to baseline
this trend is avoided. Therefore, inhospital BUN increase is the most powerfull parameter of poor
outcome
O123
TRATTAMENTO DELLA FIBRILLAZIONE ATRIALE IN RELAZIONE AL RISCHIO
TROMBOEMBOLICO FRA I PAZIENTI ARRUOLATI NEL REGISTRO EUROPEO
PREFER IN AF: CONFRONTO FOLLOW-UP VS BASALE E ITALIA VS EUROPA
GIULIO VLADIMIRO LETTICA (A), FRANCESCA INCAO (A), SALVATORE DI ROSA (B),
CALOGERO CATALANO (B), LIVIO DI LECCE (C), FABIO CONTARINO (C),
GIULIA RENDA (D), RAFFAELE DE CATERINA (D)
(A) UOC CARDIOLOGIA, OSPEDALE GUZZARDI, VITTORIA, RAGUSA; (B) UOC DI
CARDIOLOGIA, AO SAN GIOVANNI DI DIO, AGRIGENTO; (C) DIREZIONE MEDICA,
DAIICHI-SANKYO ITALIA; (D) ISTITUTO DI CARDIOLOGIA, UNIVERSITÀ “G.
D’ANNUNZIO” C/O OSPEDALE SS. ANNUNZIATA, CHIETI
Razionale: Le recenti linee guida europee per il trattamento della fibrillazione atriale (FA)
raccomandano la somministrazione della terapia anticoagulante per la prevenzione di eventi
tromboembolici in tutti i pazienti con FA, ad eccezione di quelli con un rischio tromboembolico molto
basso, valutato mediante il punteggio CHA2DS2-VASc. Tuttavia nel nostro paese poche informazioni
sono disponibili sull’utilizzo di questo punteggio e sull’impatto delle raccomandazioni delle linee
guida europee.
Metodi: Nel registro PREFER in AF (The PREvention oF thromboembolic events – European
Registry in Atrial Fibrillation) sono stati arruolati nel periodo Gennaio 2012-Gennaio 2013 pazienti
consecutivi affetti da FA nei seguenti paesi europei: Austria, Francia, Germania, Italia, Spagna,
Svizzera e Regno Unito. I dati raccolti hanno consentito una valutazione del punteggio CHA2DS2VASc e dell’uso di anticoagulanti orali in relazione ad esso.
Risultati: Nel registro PREFER in AF Sono stati reclutati 7243 pz in Europa (EU), di cui 1888 in
Italia (26% del totale), dove sono stati coinvolti 98 centri.
Secondo i dati alla visita basale, il 71.6% dei pz italiani era in trattamento con antagonisti della
vitamina K (VKA) (media EU 78.3%); il 29.6% era in trattamento con farmaci antipiastrinici (AP)
(media EU 24.3%); ridottissimo, infine, risultava l’uso dei nuovi anticoagulanti orali (NOAC) (0,3%
vs UE 6.1%),
Al follow-up (FU) di un anno, il 65.3% dei pz italiani è risultato in trattamento con VKA (media EU
72.1%), il 21.9% era in trattamento con AP (media EU 15.6%), il 3.2% utilizzava i NOAC (media
EU 12.8%).
Per quanto riguarda il rischio tromboembolico complessivo, fra i pz italiani è stato riscontrato al FU
un punteggio CHA2DS2-VASc medio di 3.3 (media EU 3.4), sovrapponibile al dato basale.
Il 73.9% dei pazienti italiani con punteggio ≥1 è stato trattato con anticoagulanti orali; in particolare,
il 58.2% dei pazienti con punteggio 1 (media EU 70%) e il 76.1% dei pazienti con valore ≥2 (media
EU 85.6%).
Il 49.3% dei pz con punteggio 0 ha assunto una terapia anticoagulante orale, associata o meno ad AP
(media EU 62.5%): in particolare il 45.7% antagonisti della vitamina K (VKA), il 3.7% VKA+AP, il
17.3% solo AP.
Conclusioni: Il registro PREFER in AF ha evidenziato, dopo un anno di FU, un aumento complessivo
dei pazienti trattati con i NOAC in Europa e anche in Italia, dove tuttavia si registra una percentuale
complessivamente più bassa, verosimilmente a causa della più tardiva disponibilità di questi nuovi
farmaci nel nostro paese. I dati hanno mostrato inoltre discrete discrepanze riguardo alle
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raccomandazioni circa il trattamento anticoagulante: infatti più di un pz su quattro con un punteggio
CHA2DS2-VASc ≥1, non riceve alcuna terapia anticoagulante orale; inoltre, esiste un diffuso utilizzo
inappropriato di anticoagulanti in categorie di pz a rischio basso o nullo.
IPERTENSIONE POLMONARE - 2
O124
PRE- VERSUS POST-CAPILLARY PULMONARY HYPERTENSION:
ECHOCARDIOGRAPHIC FEATURES FOR A DIFFERENTIAL DIAGNOSIS
EMANUELE ROMEO (A), MICHELE D´ALTO (A), PAOLA ARGIENTO (A), GIOVANNI
MARIA DI MARCO (A), ADRIANA PAVELESCU (B), ANTONELLO D´ANDREA (A),
ANNA CORRERA (A), BERARDO SARUBBI (A), CHRISTIAN MELOT (C),
ROBERT NAEIJE (B), MARIA GIOVANNA RUSSO (A)
(A) SECOND UNIVERSITY OF NAPLES - MONALDI HOSPITAL, DEPARTMENT OF
CARDIOLOGY, NAPLES, ITALY ; (B) DEPARTMENT OF PHYSIOLOGY, FACULTY OF
MEDICINE, ERASME ACADEMIC HOSPITAL, UNIVERSITÉ LIBRE DE BRUSSEL,
BRUSSELS, BELGIUM; (C) UNIVERSITÉ LIBRE DE BRUXELLES, EMERGENCY
DEPARTMENT, ERASME ACADEMIC HOSPITAL, BRUSSELS, BELGIUM
Background: The differential diagnosis between pre- and post-capillary pulmonary hypertension
(PH) is of major therapeutic relevance, and thus requires an optimal clinical probability assessment
with use of echocardiography.
Methods: We reviewed the medical records of 152 consecutive patients referred to a PH center over
a 1-year period of time and who underwent quasi simultaneous (within 1 hr) echocardiography and
right heart catheterization. Echocardiography was performed as usually recommended for the
assessment of PH and left heart conditions. PH was defined by a mean pulmonary artery pressure
(mPAP) ≥ 25 mmHg. Post-capillary PH was diagnosed on the basis of a wedged PAP (PAWP) > 15
mmHg.
Results: Ten/152 patients (7%) had no PH, 81/152 (53%) had pre-capillary PH and 61/152 (40%)
had post-capillary PH. The following echocardiographic variables predicted pre-capillary PH: right
greater then left heart chambers surface area at end-diastole (p = 0.0018), left ventricle eccentricity
index ≥1.1 (p = 0.0039), dilated inferior vena cava (IVC) with no inspiratory collapsibility (p =
0.0076), E/e’ ratio <10 (p = 0.00001), right ventricle forming the heart apex (p = 0.0144). β
coefficients from multiple logistic regression were significant for dilated IVC with no inspiratory
collapsibility (p = 0.0464) and E/e’ <10 (p = 0.0002). A score based on β coefficients, ranging from
3 to 34 points gave an optimal discrimination at > 5, with a positive predictive value of 68% and a
negative predictive value of 78% for pre-capillary PH.
Conclusion: Echocardiography allows for a clinically satisfactory differential diagnosis
between pre- and post-capillary PH.
O125
PROGNOSTIC VALUE OF RIGHT VENTRICULAR REMODELING MODELS BASED
ON ECHOCARDIOGRAPHIC PARAMETERS
CRISTINA BACHETTI (A), FABIO DARDI (A), ANDREA RINALDI (A), ENRICO GOTTI (A),
GAIA MAZZANTI (A), ALESSANDRA ALBINI (A), ENRICO MONTI (A),
CLAUDIA BERNABÈ (A), ELISA ZUFFA (A), CAROLINA BARBERI (A),
RACHELE BIONDI (A), MARGHERITA TIEZZI (A), MASSIMILIANO PALAZZINI (A),
ALESSANDRA MANES (A), NAZZARENO GALIÈ (A)
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Roma, 13 – 15 dicembre 2014
(A) DEPARTMENT OF SPECIALIZED, DIAGNOSTIC AND EXPERIMENTAL MEDICINE –
UNIVERSITY OF BOLOGNA - ITALY
Background: right ventricular (RV) failure is the leading cause of death in patients with pulmonary
arterial hypertension (PAH) and it depends on the ability of the RV to face the afterload increase.
Aim: to define the relationship between RV remodelling models, based on echocardiographic
parameters, and survival in 3 different subgroups of PAH: idiopathic+hereditable+drug and toxicinduced (PAH-IHD), associated with connective tissue disease (PAH-CTD) and associated with
congenital heart disease (PAH–CHD).
Materials and Methods: from September 2000 to December 2012, 530 PAH patients underwent
echocardiographic study. According to 2 variables (Right ventricular End Diastolic Area Index –
RVED Area I and severity of tricuspid regurgitation - TR) we defined three different models of RV
response: adaptative (A) [RVED Area I ≤18 cm2/m2 and no or mild TR], maladaptative (MA) [RVED
Area I 19-21 cm2/m2 and moderate TR], and severe dysfunction (SD) [RVED Area I >22 cm2/m2
and severe TR]. All patients were treated with PAH approved drugs according to current European
Guidelines (goal oriented treatment strategy). Kaplan-Meier curves were used to estimate the
survival.
Results: two hundred-ninety patients were included in the PAH-IHD subgroup, 135 in the PAH-CTD
subgroup and 105 in the PAH-CHD subgroup. As far as survival at 5 years is concerned, there were
no statistically significant differences among patients allocated in the A and MA models in all the
three clinical subgroups (PAH-IHD: 69% in A model and 76% in MA model; PAH-CHD: 81% in A
and 87% in MA; PAH-CTD: 33% in A and 34% in MA); nevertheless, in all the three clinical
subgroups, 5 years survival was significantly worse in patients allocated to SD model: 56% in PAHIHD (vs A: p=0.003; vs MA=0.008), 74% in PAH-CHD (vs A: p=0.093, vs M: 0.075) and 9% in
PAH-CTD (vs A: 0.007; vs MA: 0.021); within each model of RV dysfunction, survival was
significantly worse (p <0.001) in PAH-CTD subgroup versus both PAH-IHD and PAH-CHD
subgroups.
Conclusions: RV models based on RVED area I and on the severity of TR are able to differentiate
populations with different prognosis in PAH-IHD, PAH-CTD and PAH-CHD patients. Within each
model of RV dysfunction, survival is related to the PAH type and is significantly worse in PAH-CTD
patients.
O126
MODE OF DEATH IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION:
INSIGHT FROM AN ITALIAN MULTICENTER REGISTRY (IPHNET)
CARMINE DARIO VIZZA (A), BEATRICE PEZZUTO (A), ROBERTO BADAGLIACCA (A),
ROBERTO POSCIA (A), MARIO MEZZAPESA (A), MARTINA NOCIONI (A),
FRANCESCA PESCE (A), GIOVANNA MANZI (A), GABRIELE D´AMBROSIO (A),
MICHELE D´ALTO (B), STEFANO GHIO (C), PATRIZIO VITULO (D),
MASSIMILIANO MULÈ (E), CARLO ALBERA (F), FRANCESCO FEDELE (A)
(A) DEPT. OF CARDIOVASCULAR AND RESPIRATORY SCIENCE, POLICLINICO
UMBERTO I - SAPIENZA UNIVERSITY OF ROME, ITALY; (B) DEPT. OF CARDIOLOGY,
GUCH UNIT, MONALDI HOSPITAL - SECOND UNIVERSITY OF NAPLES, ITALY; (C)
DEPT. OF CARDIOLOGY, FONDAZIONE IRCCS POLICLINICO SAN MATTEO UNIVERSITY OF PAVIA, ITALY; (D) PULMONARY DIVISION, ISMETT
(MEDITERRANEAN INSTITUTE FOR TRANSPLANTATION AND ADVANCED
SPECIALIZED THERAPIES), PALERMO, ITALY; (E) FERRAROTTO HOSPITAL UNIVERSITY OF CATANIA, ITALY; (F) DEPT. OF CLINICAL AND BIOLOGICAL
SCIENCES, INTERSTITIAL AND RARE DISEASES UNIT - UNIVERSITY OF TURIN, ITALY
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Background. Right ventricular failure is currently considered the usual mode of death in patients
with pulmonary arterial hypertension (PAH), but it is a common clinical experience that PAH patients
often die suddenly or following an acute illness.
Methods and Materials. We conduced a retrospective analysis of 588 consecutive PAH patients
(idiopathic, 311; associated to connective tissue disease, 126; associated to congenital heart disease,
151), from 5 Italian PH Centers. According to the ACME classification, mode of death was classified
as due to congestive heart failure (CHF), sudden death (SD) and triggered by extra cardiac causes
(ExC).
Results. After a follow-up of 1200±961 days, we observed 150 deaths. The actuarial survival rate
was 94.6%, 86.2%, 79.8%, 75.6% at 1, 2, 3 and 5 years, respectively. In 26 patients it was not possible
to ascertain the cause of death, CHF was observed in 78 (62.9%), SD in 13 (10.5%) and ExC in 33
(26.6%) patients. We found no differences in clinical status and hemodynamics among the three
modes of death. Alive patients had a better clinical and hemodynamic condition compared to patients
who died (see table). Among the events that triggered the extra cardiac deaths, bleeding was the most
frequent one (21.2%).
Conclusions. Death in PAH is not exclusively due to refractory right ventricular failure, as SD and
ExC could account for about 37% of the deaths. Bleeding is a quite frequent event that might trigger
the death in PAH patients. This finding suggests careful bleeding risk assessment before starting
anticoagulants in these patients.
Comparison among the four groups: alive, dead for congestive heart failure (CHF), sudden death
(SD), ExC (extra cardiac cause)
Alive
CHF
SD
ExC
P
(anova)
n=438
n=78
n=13
n=33
NYHA
2.5±0.6
2.9±0.5
3.0±0.6
2.9±0.6
0.000000
6MWD, m
357.6±115.0 295.6±100.4 308.5±121.6 309.4±116.7 0.000012
RAP, mmHg
mPAP, mmHg
PCWP, mmHg
CI, L/min/m2
PVR, WU
9.1±4.8
50.7±17.4
11.1±4.1
2.5±0.8
10.5±6.5
9.9±6.6
51.5±12.6
11.2±4.5
2.1±0.7
12.7±6.0
10.2±4.2
52.0±15.3
11.4±4.2
2.1±0.6
12.8±8.1
10.0±4.8
54.6±17.6
10.4±3.2
2.1±0.7
13.7±5.7
Ns
Ns
Ns
0.000124
0.005449
NYHA: New York Heart Association; 6MWD: 6-minute walk distance; RAP: right atrial pressure; mPAP: mean
pulmonary artery pressure; PCWP: pulmonary capillary wedge pressure; CI: cardiac index; PVR: pulmonary vascular
resistance.
O127
CURRENT ERA SURVIVAL IN PATIENTS WITH PEDIATRIC PULMONARY
ARTERIAL HYPERTENSION
FABIO DARDI (A), CRISTINA BACHETTI (A), ANDREA RINALDI (A), ENRICO GOTTI (A),
GAIA MAZZANTI (A), ALESSANDRA ALBINI (A), ENRICO MONTI (A),
CLAUDIA BERNABÉ (A), ELISA ZUFFA (A), CAROLINA BARBERI (A),
RACHELE BIONDI (A), MARGHERITA TIEZZI (A), MASSIMILIANO PALAZZINI (A),
ALESSANDRA MANES (A), NAZZARENO GALIÉ (A)
(A) DEPARTMENT OF SPECIALIZED, DIAGNOSTIC AND EXPERIMENTAL MEDICINE –
UNIVERSITY OF BOLOGNA - ITALY
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Background: Pulmonary arterial hypertension (PAH) is a rare disease characterized by a progressive
increase of pulmonary vascular resistance leading to right ventricular failure and premature death.
Epidemiological data are scarce, particularly in the pediatric population.
Objectives: the aim of the present study was to assess prospectively the current era survival of
pediatric PAH patients (P-PAH) and to compare it with the survival of adult PAH (A-PAH) patients
with similar etiologies.
Methods: We included in the study consecutive PAH patients aged ≤ 18 years (Pediatric) and PAH
patients aged > 18 years (Adult) referred to a single center from February 1992 to October 2013. Due
to the epidemiology of pediatric PAH we included only idiopathic PAH (IPAH) and Hereditary PAH
(HPAH). Patients were treated with approved PAH drugs including combination therapy according
with recent guidelines and irrespective of the age. Survival data were assessed by Kaplan-Mayer
curves and compared by Log-rank test.
Results: 42 pediatric PAH patients (aged 9±5 years, 83% with IPAH, 17% with HPAH) and 364
adult PAH patients (mean age 51±6 y, 83% with IPAH, 17% with HPAH) were included. Forty-three
% of pediatric patients and 51 % of adult patients were treated with monotherapy and the remaining
with combination therapy with PAH approved drugs. Kaplan-Maier survival rate at 1, 3, 5 and 10
years after the diagnostic right heart catheterization was 93%, 79%, 76%, 64% and 92%, 79%, 68%,
52% for P-PAH and A-PAH, respectively (Log-rank test p-value at 10 years: 0.321). Hemodynamics
at time of referral to our centre was, in P-PAH and A-PAH, respectively: right atrial pressure 6 (3-8)
mmHg and 7 (4-11) mmHg [p-value: 0.011], mean pulmonary arterial pressure 64 (52-82) mmHg
and 52 (43-62) mmHg [p-value < 0.001], cardiac index 3.1 (2.3-3.7) l/min/m2 and 2.3 (1.9-2.9)
l/min/m2 [p-value < 0.001], pulmonary vascular resistance 16 (9-31) W.U. and 11 (7-15) W.U. [pvalue < 0.001], pulmonary vascular resistance index 18 (12-29) W.U.*m2 and 19 (14-25) W.U.*m2
[p-value: 0.972], mixed venous oxygen saturation 70 (60-74) % and 63 (56-70) % [p-value: 0.006].
Conclusions: in the current era of approved PAH medications the survival of IPAH and HPAH
patients is similar in the adult and in the pediatric population.
IMAGING CARDIOVASCOLARE: FUNZIONE ATRIALE - VENTRICOLARE
O128
INCREASED LEFT ATRIAL SIZE IS ASSOCIATED WITH LOW ATRIAL STIFFNESS IN
ATHLETE’S HEART: A SPECKLE-TRACKING STUDY
FLAVIO D´ASCENZI (A), EUFEMIA INCAMPO (A), VALENTINA ANDREI (A),
MATTEO CAMELI (A), MATTEO LISI (A), STEFANO LUNGHETTI (A),
MARTA FOCARDI (A), MARCO BONIFAZI (B), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA, SIENA,
ITALY; (B) DEPARTMENT OF MEDICINE, SURGERY, AND NEUROSCIENCE,
UNIVERSITY OF SIENA, SIENA, ITALY
Purpose. Atrial fibrosis and increased atrial stiffness as substrates for atrial arrhythmias have been
supposed in athletes. However, although supported by experimental data, this hypothesis has not been
confirmed in humans. Recently, a new non-invasive estimation of left atrial (LA) stiffness, using
tissue Doppler imaging and speckle tracking echocardiography (STE), has been validated. The aim
of this study was to determine LA stiffness in athletes and to compare it with controls. Methods. 150
top-level athletes and 90 age and sex-matched sedentary subjects were analyzed. STE was use to
obtain peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness
was determined using E/e’ ratio in conjunction with PALS. Left ventricular (LV) stiffness was also
calculated.
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Results. LA volume index was higher in athletes as compared with controls (24.6±7.3 vs. 18.4±7.8
mL/m2, p<.0001). Both global PALS and global PACS were lower (p<.05 and p≤.001,respectively)
and E/e’ ratio was lower in athletes in comparison with controls (4.9±1.2 vs. 6.1±1.4, p<.0001).
Although LA size was greater in athletes, they showed a lower LA stiffness as compared with
sedentary subjects (0.13±0.04 vs. 0.16±0.06, p≤.001). A lower LV stiffness was also found in athletes
(0.84±0.27 vs. 1.07±0.46, p≤.001). LV stiffness was the only independent predictor of LA stiffness
(β=0.46, p<.0001) while LV end-systolic volume index was the only independent predictor of LA
volume index (β=0.250, p=.002).
Conclusions. Competitive athletes had a lower LA stiffness as compared with controls, despite a
greater LA size. Thus, our data do not support the concept of an increased LA stiffness in athletes.
2D STE was a reliable and simple tool to non-invasively investigate left atrial stiffness in athletes.
O129
RUOLO DELL'ATRIO SINISTRO DURANTE LO SFORZO; UNO STUDIO SPECKLE
TRACKING ECHOCARDIOGRAPHY
AMATO SANTORO (A), FEDERICO ALVINO (A), GIOVANNI ANTONELLI (A),
ROBERTA MOLLE (A), SUSANNA BENINCASA (A), SERGIO MONDILLO (A)
(A) CARDIOLOGIA UNIVERSITARIA, UNIVERSITÀ DEGLI STUDI DI SIENA
L’atrio sinistro (ASn) svolge una funzione passiva di condotto ed una attiva di contrazione. Durante
l’esercizio la funzione di condotto si riduce. Scopo del nostro studio è analizzare il ruolo dell’ASn
nell’accoppiamento sisto–diastolico al termine di uno sforzo massimale (ME) utilizzando metodica
Speckle Tracking Echocardiography (STE).
METODI. 16 pallanuotisti agonisti hanno eseguito 6 ripetizioni di 100 metri in stile libero a
frequenza cardiaca massimale. Gli atleti sono stati sottoposti ad esame ecocardiografico a riposo (R)
ed immediatamente dopo ME.
RISULTATI. All’apice dello sforzo i valori di volume ASn non variano in maniera significativa; Le
onde E ed A aumentano dopo ME (E: R: 94 17 cm/s vs. ME: 120 20 cm/s; p<0.01. A: R: 47 11
cm/s vs. ME: 85 19 cm/s; p<0.01), E/A ratio si riduce dopo ME (E/A: R: 2.1 0.5 vs. ME: 1.4
0.3; p<0.01). I valori di peak atrial longitudinal strain (PALS) si riducono dopo ME (PALS: R:
39.4 10.1 % vs. ME: 32.6 8.4 %; p<0.05 ), mentre non vi sono variazioni significative del peak
atrial contraction strain (PACS); i tempi al picco di PALS e PACS sono più bassi dopo ME
(timePALS: R:343.1±41.3ms, ME:283.3 42.3; p<0.01; timePACS: R:727 161.7ms;
ME:404 65.1ms; p<0.01). PALS correla con E/A (r= 0.3; p<0.05 ), EF (r= -0.3, p<0.05), S’TDI (r=
-0.51, p<0.01).
CONCLUSIONI. La funzione “condotto” dell’ASn dopo ME si riduce ed è legata agli indici sistolici
del ventricolo sinistro. Il riempimento ASn è determinato dal rilassamento delle fibre ASn e tale
rilassamento dipende dall’allungamento delle fibre e dall’entità di accorciamento durante la
precedente contrazione ASn.
O130
ATRIAL MECHANICS AND STIFFNESS AS PREDICTORS OF PROGNOSIS IN
ASYMPTOMATIC SEVERE AORTIC STENOSIS.
CONCETTA ZITO (A), MARIA CHIARA TODARO (A), MAURIZIO CUSMÀ PICCIONE (A),
GABRIELLA FALANGA (A), MARTA ZUCCO (A), FAUSTO PIZZINO (A), GIANLUCA DI
BELLA (A), GIUSEPPE ORETO (A), SCIPIONE CARERJ (A)
(A) UNIVERSITY OF MESSINA, POLICLINIC G.MARTINO, CARDIOLOGY UNIT,
DEPARTMENT OF CLINICAL AND EXPERIMENTAL MEDICINE
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The purpose of the present study was to evaluate the prognostic value of left atrial (LA) mechanics
and stiffness in a prospective cohort of 82 asymptomatic patients (31 men, mean age 73±10 years)
with severe aortic stenosis (AS) (indexed aortic valve area, AVAi= 0.4±0.1cm2/m2) and normal left
ventricular (LV) ejection fraction (EF) compared to 40 age-gender matched controls. By the use of
2-dimensional speckle tracking echocardiography, LA reservoir, strain rate and strain derived
stiffness, LV strain (longitudinal, radial and circumferential), rotations, and twist were evaluated
during a standard echocardiographic examination. The predefined end points were the occurrence of
symptoms (dyspnea, angina, syncope), aortic valve replacement, and death. At study entry, all
patients had reduced LA reservoir (p<0.001) and LV global longitudinal strain (LVGLS) (p=0.001),
enhanced Zva (p<0.001) and LA stiffness (p<0.001) compared to controls. During follow-up
(17.2±15.3 months) 53 patients (64.6%) reached the predefined end-points. No difference was found
between symptomatic and asymptomatic patients as regards LV ejection fraction, LA volumes and
AS severity (p=ns for all). On the contrary, patients with events had lower: indexed stroke volume
(p=0.001), LVGLS (p<0.001), LA reservoir (p<0.001) and higher: LV mass (p=0.007), Zva
(p<0.001) and LA stiffness (p<0.001) than those asymptomatic. When the global patients’ population
was split in groups according to the median of LVGLS and Zva (GLS ≥ -15.2% and Zva ≤ 6.26
mmHg/ml/m2) we observed that whereas all patients with GLS < -15.2% and/or Zva >6.26
mmHg/ml/m2 developed events independent of LA functional status, in patients with GLS ≥15.2%
and/or Zva ≤6.26 mmHg/ml/m2, LA reservoir was lower (p=0.01 and p=0.02, respectively for GLS
and Zva subgroups) and LA stiffness higher (p=0.02 and p=0.02, respectively for GLS and Zva
subgroups) in the subset of patients who developed events than in those asymptomatic. In conclusion,
LA mechanics may be a relevant contributor to the prognostic stratification of patients with
asymptomatic severe AS, particularly at an early stage of the disease, when LV longitudinal
performance and global afterload are still not seriously damaged.
O131
THE LEFT VENTRICULAR GLOBAL FUNCTION INDEX BY CARDIAC MAGNETIC
RESONANCE IS MORE STRONGLY NEGATIVELY AFFECTED BY MYOCARDIAL
IRON OVERLOAD THAN THE GLOBAL SYSTOLIC FUNCTION
ANTONELLA MELONI (A), LINDA SANTOLERI (B), CHIARA LANZILLO (C),
AURELIO MAGGIO (D), CATERINA BORGNA-PIGNATTI (E), MARIA ELIANA LAI (F),
DANIELE DE MARCHI (A), MASSIMO MIDIRI (G), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) INSTITUTE OF CARDIOLOGY “G. D´ANNUNZIO“ UNIVERSITY - CHIETI-PESCARA,
OSPEDALE SS. ANNUNZIATA , CHIETI, ITALY; (C) DIPARTIMENTO DI CARDIOLOGIA,
POLICLINICO “CASILINO“, ROMA, ITALY; (D) EMATOLOGIA II CON TALASSEMIA,
OSPEDALE “V. CERVELLO“, PALERMO, ITALY; (E) CLINICA PEDIATRICA,
UNIVERSITÀ DI FERRARA, FERRARA, ITALY; (F) CENTRO TALASSEMICI ADULTI,
OSPEDALE MICROCITEMICO, CAGLIARI, ITALY; (G) ISTITUTO DI RADIOLOGIA,
POLICLINICO “PAOLO GIACCONE“, PALERMO, ITALY
Background: Cardiovascular Magnetic Resonance (CMR), by the multislice multiecho T2*
technique, allows detecting different patterns of myocardial iron overload (MIO). Moreover, the
analysis of cine images allows the quantification of the left ventricular global function index
(LVGFI), which combines information about the LV stroke volume, end-systolic and end-diastolic
volumes, as well as LV mass. An LVGFI <37% has been shown to be strongly predictive of
cardiovascular events. We aimed at verifying the association of different patterns of MIO with the
LVGFI compared with the LV ejection fraction (EF) in patients with thalassemia major (TM), in
whom transfusion-related MIO is known to occur and to impact prognosis.
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Methods: We included in this study 812 TM patients (391 M, 30.4±8.6 years), consecutively enrolled
in the Myocardial Iron Overload in Thalassemia (MIOT) network. In all, we evaluated the T2* value
in all the 16 cardiac segments. LVGFI and LVEF were quantitatively evaluated by steady-state free
precession (SSFP) cine images. Heart dysfunction was diagnosed in the presence of LVEF <2
standard deviations (SD) from the mean value, normalized for age and gender.
Results: We identified 4 groups of patients: 138 with a homogeneous MIO (all segments with T2*<20
ms); 97 with heterogeneous MIO (some segments with T2*<20 ms, others with T2*≥20 ms) and
significant global heart iron (global heart T2*<20 ms); 238 with heterogeneous MIO and no
significant global heart iron - global heart T2*≥20 ms; and 339 with no MIO (all segments with
T2*≥20 ms). The mean LVFGI was significantly different
across the 4 groups (Figure, upper panel).
Compared with the group with no MIO, all the other 3 groups
were significantly more likely to have a LVGFI <37%.
Conversely, only the groups with homogeneous MIO and
with heterogeneous MIO and significant global heart iron
showed a significantly higher risk of having LV dysfunction.
For all groups the association between different patterns of
MIO with a LVGFI <37% was stronger than the association
with the presence of a LV dysfunction (Figure, bottom panel).
Conclusions: LVGFI, a functional parameter integrating structural
as well as mechanical myocardial characteristics, is more strongly
associated with different patterns of MIO than the LVEF. Thus, a
LVGFI<37% can better identify patients with a significantly higher
risk of adverse cardiovascular events beyond heart failure in
conditions of iron-overload.
CARDIOPATIA ISCHEMICA - 1
O132
REGIONAL LONGITUDINAL STRAIN CORRELATES WITH TIMI FRAME COUNT
AND EXTENSION OF MYOCARDIAL DAMAGE IN PATIENTS WITH ACUTE
ANTERIOR STEMI
TULLIO NIGLIO (A), MAURIZIO GALDERISI (B), CIRO SANTORO (B),
MARIO SANTORO (A), GENNARO GALASSO (A), EUGENIO STABILE (A),
ANTONIO RAPACCIUOLO (A), LETIZIA SPINELLI (A), GIOVANNI DE SIMONE (B),
GIOVANNI ESPOSITO (A), BRUNO TRIMARCO (A)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO
II, NAPOLI; (B) CENTRO INTERDIPARTIMENTALE PER LA RICERCA
SULL´IPERTENSIONE ARTERIOSA E PATOLOGIE ASSOCIATE, UNIVERSITA´
FEDERICO II, NAPOLI
Purpose: Regional (RLS) and global longitudinal strain (GLS) by Speckle Tracking
Echocardiography (STE) has been successfully used after STEMI to assess left ventricular (LV)
function and recovery. We evaluated the relationship between RLS and GLS with currently available
coronary angiographic scores and myocardial markers after anterior STEMI .
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Methods: Nineteen patients with acute anterior STEMI underwent standard echocardiography and
STE-derived Automated Function Imaging early before coronary angiography. A group of 19 normal
subjects, matched for age and sex, were the control group for echocardiographic parameters. LV
ejection fraction (EF), the ratio of transmitral E velocity to annular tissue-Doppler e’ velocity (E/e’
ratio) and GLS (average of 18 RLS in the apical views) were calculated. Longitudinal strain of left
anterior descending territory (LSlad) was also generated as the average of 8 myocardial segments
(middle and apical posterior septum, basal, middle and apical anterior septum, basal, middle and
apical anterior wall). By coronary angiography TIMI flow grade and TIMI frame count (TFC) were
calculated. Laboratory biomarkers were also determined.
Results: The two study groups were comparable for blood pressure, heart rate and body mass index.
STEMI patients had lower EF and high E/e’ ratio (both p<0.0001) than controls. GLS was -10.9 ±
3.3% in STEMI and -19.9 ± 2.2% in controls (p<0.0001). LSlad was -7.1 ± 3.8% in STEMI and -21.0
± 2.6 in controls (p<0.0001). In STEMI patients, LSlas was negatively related with TFC (r =-0.58,
p<0.01) and troponin levels (r = -0.48, p<0.05) but not to TIMI grade. TFC was also marginally
related to E/e’ ratio (r = 0,40, p<0.05) but not to EF or GLS.
Conclusions: We demonstrate that STE-derived analysis can detect non invasively the ischemic
territory of the culprit lesion after acute STEMI. In particular, the determination of longitudinal strain
of the left anterior descending artery might be useful to identify the extent of myocardial damage and
the degree of myocardial perfusion before performing coronary angiography.
O133
ARITMIE VENTRICOLARI PRECOCI ED INFARTO MIOCARDICO ACUTO: RUOLO
DELLA RISONANZA MAGNETICA CARDIACA
ANGELA SUSANA (a), MANUEL DE LAZZARI (a), MARTINA DI PUMPO (a),
FILIPPO ZILIO (a), FEDERICO MIGLIORE (a), BENEDETTA GIORGI (b),
LUISA CACCIAVILLANI (a), GIUSEPPE TARANTINI (a), EMANUELE BERTAGLIA (a),
DOMENICO CORRADO (a), MARTINA PERAZZOLO MARRA (a), SABINO ILICETO (a)
(a) DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE E VASCOLARI.
UNIVERSITÀ DEGLI STUDI DI PADOVA; (b) ISTITUTO DI RADIOLOGIA. UNIVERSITÀ
DEGLI STUDI DI PADOVA
INTRODUZIONE: la caratterizzazione tissutale miocardica fornita dalla risonanza
magnetica cardiaca (RMC) è in grado di differenziare il danno miocardico reversibile (edema) da
quello non reversibile (“late enhancement”, LE, emorragia) e di conseguenza determinare l’area di
miocardio salvato. Le aritmie dell’IMA in fase precoce e subacuta possono avere diversa genesi,
inoltre la disomogeneità del tessuto miocardico dovuto all’edema in fase precoce, come causa di
insorgenza di eventi aritmici non è ancora chiara.
SCOPO: questo studio si propone di valutare il maggior determinante di danno miocardico
(necrosi/emorragia/miocardio salvato) nella genesi nelle aritmie precoci in corso di IMA.
METODI: sono stati arruolati consecutivamente 28 pazienti dal gennaio 2012 al giugno 2014. Sono
stati inclusi pazienti con primo evento di STEMI, sottoposti a PTCA primaria entro 12 ore
dall’insorgenza dei sintomi e che abbiano eseguito una RMC entro una settimana. La RMC è stata
eseguita con sequenze cine, TIRM per la valutazione dell’edema e danno emorragico, postcontrastografiche per necrosi, no reflow e miocardio salvato. Sono stati esclusi dallo studio pazienti
con IMA tardivo, con episodi di angina pre-infartuale, IRC severa (GFR<30 ml/min/mq),
fibrillazione atriale e claustrofobia. Sono stati raccolti i dati di monitoraggio ECG e definiti eventi
aritmici maggiori precoci (entro le 48h) la presenza di fibrillazione ventricolare (FV), tachicardia
ventricolare sostenuta (TVS) e non-sostenuta (TVNS).
RISULTATI: 28 pazienti (75% maschi), di cui 15/28 (54%) ipertesi, 19/28 (70%) fumatori, 10/28
(36%) dislipidemici, 18/28 (64%) con familiarità per CAD, 4/28 (14%) diabetici. In 7/50 (14%) si è
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verificato un episodio di FV prima della PTCA, il tempo medio “pain to balloon” è stato di 232±143
minuti, con un picco di TnI di 123±115 ug/L. La culprit lesion era il ramo discendente anteriore in
14/28 (50%) casi, circonflessa in 3/28 (11%), ramo destro in 11/28 (39%). In 7/28 casi (25%) si sono
verificati episodi aritmici maggiori. I pazienti con aritmie presentavano una maggior rapporto tra
miocardio salvato ed area a rischio (34±33 vs 15±17, p=0.05) ed una maggiore estensione di
miocardio salvato (14±15% vs 5±6%, p=0.02). Non vi erano invece differenze in termini di estensione
della necrosi o danno emorragico microvascolare.
CONCLUSIONI: sebbene le aritmie ventricolari maggiori precoci in era riperfusiva con PTCA
primaria risultino un evento raro rispetto al passato, spesso condizionano l’outcome intraospedaliero
di questi soggetti. Dai nostri dati preliminari emerge come la percentuale di miocardio salvato,
fondamentale per una ripresa a medio lungo termine della contrattilità, per la quota importante di
edema che tale parametro sottende, rappresenti anche un indicatore precoce di aritmie ventricolare in
soggetti con IMA.
O134
EPIDEMIOLOGIA ED OUTCOME DELL’ARRESTO CARDIACO
EXTRAOSPEDALIERO: I DATI DI UNA PROVINCIA ITALIANA.
SERENA RAKAR (A), SARA SCAPOL (A), RITA BELFIORE (A), LAURA MASSA (A),
VITTORIO ANTONAGLIA (B), VINCENZO CAMPANILE (C), C GANDOLFI (D),
FEDERICA PERISAN (E), ROSSANA BUSSANI (F), GIANFRANCO SINAGRA (A)
(A) AZIENDA OSPEDALIERO-UNIVERSITARIA“OSPEDALI-RIUNITI”, DIPARTIMENTO
CARDIOVASCOLARE, TRIESTE; (B) CENTRALE OPERATIVA 118, ASS 1 TRIESTINA,
TRIESTE; (C) ANESTESIA-RIANIMAZIONE E TERAPIA ANTALGICA, AZIENDA
OSPEDALIERO-UNIVERSITARIA“OSPEDALI-RIUNITI”, TRIESTE; (D) S.C.
PROGRAMMAZIONE E CONTROLLO, TRIESTE; (E) SERVIZIO DI MEDICINA LEGALE
ASS 1 TRIESTINA, TRIESTE; (F) ISTITUTO DI ANATOMIA PATOLOGICA, TRIESTE
BACKGROUND: L’incidenza dell’arresto cardiaco extraospedaliero (OHCA) nei paesi
industrializzati è stimata intorno ad 1 caso/1000 abitanti/anno. La sopravvivenza è ampiamente
variabile nelle diverse comunità, raggiungendo differenze del 500%, verosimilmente legate ad una
diversa tempestività d’intervento ed un diverso management dell’OHCA. Conoscere l’incidenza e la
percentuale di sopravvivenza dell’OHCA nella propria realtà è cruciale per valutare e potenziare la
risposta del sistema sanitario locale ai suoi vari livelli.
MATERIALI E METODI: Abbiamo analizzato retrospettivamente i dati relativi ai pazienti (pz)
colpiti da OHCA nella nostra provincia (212 km2, 207800 ab; 1 ospedale, 1 sistema d’emergenza
territoriale) nel biennio 2011-2013. Fonte dei dati sono stati le cartelle cliniche ed i diversi software
gestionali delle strutture coinvolte nel percorso di questi pz: 118, Pronto Soccorso, Anestesia e
Rianimazione, Cardiologia, Anatomia Patologica e Medicina Legale.
RISULTATI: Nel periodo considerato il 118 ha rilevato 485 OHCA (1.16/1000ab/a), 244 dei quali
(50.3%, 0.58/1000ab/a) rianimati e 198 di presunta eziologia cardiaca (40.8%, 0.48/1000ab/a; 58.6%
M, età media 70.9 ± 19.8 anni). Il 29.5% degli OHCA aveva la fibrillazione/tachicardia ventricolare
(FV/TV) come ritmo di presentazione, il 63.3% avveniva presso il domicilio e il 72.7% risultava
testimoniato, ma solo il 18.1% era stato rianimato dagli astanti. I pz che hanno presentato ROSC
erano 63 (31.8%), ma 55 (28%) sono stati ammessi vivi in ospedale (8 deceduti all’arrivo in PS). Il
63.6% (35) dei pz ricoverati è stato sottoposto a coronarografia (CGF) emergente e il 30.9% (17) ad
angioplastica coronarica. 35 pz (63.6%) sono stati trattati con ipotermia terapeutica entro 2 ore
dall’ammissione in terapia intensiva. L’11.6% (23) dei pz ricoverati è stato dimesso vivo, il 9.5% con
una buona funzione neurologica (CPC score ≤2) e 2.5% (5) trattati con ICD; 5 sono rimasti
lungodegenti per compromissione neurologica. Ad 1 anno erano vivi 26 (13.1%). I pz sopravvissuti
si distinguevano per la giovane età (61.4 vs 73.9 anni, p 0.002), la sede pubblica dell’evento (68.2 vs
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44.4%, p 0.097), l’FV/TV come ritmo di presentazione (90 vs 29.6%, p 0.0001), una rianimazione
cardiopolmonare (RCP) meno aggressiva (LUCAS 23.8 vs 53.6%, p 0.036; adrenalina 37.5 vs 89.7%,
p 0.0001), tempi di ROSC più brevi (ROSC<20 minuti 70 vs 50%) e più frequente CGF (78.3 vs
44.4%, p 0.015).
CONCLUSIONI: L’incidenza di OHCA nella nostra provincia conferma le stime di altre città
europee. La sopravvivenza pre, intra e post-ospedaliera è anch’essa in linea con i dati della letteratura,
ma inferiore a quella di città con programmi di training all’RCP nella popolazione generale ed una
più intensiva post-resuscitation care. Nel prossimo futuro a Trieste sarà pertanto importante investire
sull’espansione dell’RCP da parte degli astanti e su di una più attenta selezione dei pz da avviare a
CGF e HT.
O135
L'INTERVALLO QT PROLUNGATO NEI PAZIENTI CON INFARTO MIOCARDICO
ACUTO CON SOVRASLIVELLAMENTO DEL TRATTO ST: RUOLO PROGNOSTICO
NEL MEDIO TERMINE
ALESSANDRO GALLUZZO (A), CRISTINA GALLO (A), CRISTINA FORNENGO (A),
FEDERICO GIOVANNI CANAVOSIO (A), MICHELA BOTTA (A),
SERENA BERGERONE (A), FIORENZO GAITA (A)
(A) CITTÀ DELLA SALUTE E DELLA SCIENZA, UNIVERSITÀ DI TORINO,
DIPARTIMENTO DI MEDICINA INTERNA, DIVISIONE DI CARDIOLOGIA
Introduzione: L’intervallo QTc è la manifestazione elettrocardiografica della ripolarizzazione
miocardica ed è normalmente compreso tra i 360 e i 450-470 msec. Nella cardiopatia ischemica acuta
l’intervallo QTc si modifica con un allungamento, con raggiungimento del valore massimo tra la II e
III giornata, e un successivo ritorno ai valori simili al basale. Tale alterazione riflette il
rimodellamento elettrico dei miocardiociti. Un prolungamento dell’intervallo QTc correla con alcune
caratteristiche cliniche come la ridotta frazione di eiezione cardiaca e una malattia coronarica
multivasale. Non vi sono chiare evidenze sul ruolo prognostico dell'allungamento dell'intervallo QT
in fase acuta di ischemia.
Scopo del lavoro: studiare l’evoluzione in fase acuta dell’intervallo QTc in pazienti con STEMI e
correlarlo con caratteristiche cliniche degli stessi e con la prognosi a breve-medio termine.
Metodi: In questo studio prospettico sono stati arruolati i pazienti ricoverati per STEMI da gennaio
2011 a luglio 2013 c/o la nostra struttura. Per ogni paziente sono stati calcolati i QTc su 5 ECG: alla
presentazione in ospedale, dopo l’angioplastica, in I e II giornata e alle dimissioni dal reparto. Il
follow up è durato in media 18,6 mesi con visite ambulatoriali periodiche e telefonate a domicilio.
Risultati: Sono stati arruolati 185 pazienti consecutivi, di cui 128 uomini (69%) e 57 donne (31%)
con un’età media di 68±13.2 anni. È stata confermata una differenza significativa tra gli intervalli
QTc medi nel corso del tempo (p<0,001) e singolarmente tra i QTc pre PCI e quello successivo, e tra
quello in seconda giornata e quello in pre-dimissione (p<0,001). I fattori anamnestici che sono
risultati predittori di allungamento dell’intervallo QTc≥480 msec alla presentazione della
sintomatologia sono il diabete mellito di tipo 2, una pregressa CAD, la presenza di insufficienza
mitralica e una storia di neoplasia. Analogamente, gli elementi clinici e strumentali associati al
prolungamento del QT sono risultati il numero di coronarie coinvolte, la presenza di
ipo/iperpotassiemia, un maggior intervallo di tempo tra l’insorgenza dei sintomi e la coronarografia,
una FE ridotta, un incremento degli indici di infiammazione (globuli bianchi e PCR).
Quest’associazione dimostra che il parametro in esame riflette gli elementi di disfunzione
autonomica, elettrica e meccanica del cuore ischemico. Per quanto riguarda il valore prognostico, al
follow up il QTc pre-PCI≥480 msec all’analisi multivariata è risultato predittore indipendente di
mortalità non cardiovascolare, stratificato per confondenti significativi all’univariata quali la
presenza di emorragie cerebrali o stroke durante la degenza, una pregressa CAD e la presenza di
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neoplasie (p=0,037). Sempre all’analisi multivariata, valori di QTc pre PCI≥480 msec sono risultati
predittori indipendenti di morte cardiovascolare (p=0,014), dopo stratificazione per i confondenti
risultati significativi all’analisi univariata quali ipo/iperpotassiemia, emorragie o stroke in corso di
ricovero, neoplasie e pregressa CAD. Un Qtc pre PCI ≥480 msec si associa significativamente anche
alla presenza di IMA complicato con fibrillazione ventricolare in acuto (p=0,028). Le curve di
Kaplan-Meier confermano come un maggiore intervallo QTc pre-PCI rappresenti un predittore della
mortalità a breve e medio termine (p<0,001).
Conclusioni: Questo studio ha mostrato che i pazienti con valori di QTc≥480 msec durante STEMI
hanno una maggior probabilità di sviluppare aritmie ventricolari maggiori in fase acuta e una
maggior mortalità cardiovascolare e totale nel medio termine.
CONTROVERSIE SULL'USO DI TERAPIA ANTIAGGREGANTE E
ANTICOAGULANTE
O136
SHORT-TERM VERSUS STANDARD 12-MONTH DUAL ANTIPLATELET THERAPY
DURATION AFTER DRUG-ELUTING STENTS IMPLANTATION.
GIULIO STEFANINI (A), GEORGE SIONTIS (A), DAVIDE CAO (A), DIK HEG (A),
PETER JUNI (A), STEPHAN WINDECKER (A)
(A) BERN UNIVERSITY HOSPITAL, BERN, SWITZERLAND
Background: Current guidelines recommend up to 12 months dual antiplatelet therapy (DAPT) after
percutaneous coronary interventions (PCI) with drug-eluting stents (DES) implantation. However,
optimal DAPT duration is still a matter of debate. We aimed to evaluate clinical outcomes with shortterm (≤6 months) DAPT as compared to standard guideline-recommended12-month DAPT in
patients treated with DES.
Methods: In May 2014, we searched PubMed, Embase, and Cochrane Clinical Trials for randomized
trials directly comparing short-term (≤6 months) versus 12-month DAPT after PCI with DES
implantation. Risk ratios (RR) were used as a the metric of choice for treatment effects by using
random- and fixed-effects models. I-squared index was used to assess heterogeneity across trials. The
primary safety and efficacy outcomes were any bleeding and the composite of cardiac death and
myocardial infarction, respectively. The secondary efficacy outcome was definite or probable stent
thrombosis.
Results: We identified 3 trials: EXCELLENT (6-month vs. 12-month DAPT, N=1,443), RESET (3month vs. 12-month DAPT, N=2,117), and OPTIMIZE (3-month vs. 12-month DAPT, N=3,119) –
including a total of 6,679 patients with 12-month follow-up. At 12 months, short-term DAPT was
associated with a reduced risk of any bleeding as compared to 12-month DAPT (RR 0.67, 95% CI
0.46-0.99). Risks of cardiac death or myocardial infarction (RR 1.09, 95% CI 0.82-1.46) and stent
thrombosis (RR 1.31, 95% CI 0.68-2.50) did not differ between short-term DAPT compared with 12month DAPT. Noteworthy, landmark analyses at the time of DAPT interruption showed that risks of
cardiac death or myocardial infarction (RR 0.97, 95% CI 0.60-1.56) as well as stent thrombosis (RR
1.20, 95%CI 0.37-3.92) did not differ between the two groups after DAPT interruption up to 12
months follow-up. No evidence of heterogeneity was observed across trials.
Conclusions: This meta-analysis indicates that short-term DAPT is associated with a reduced risk of
bleeding but preserved antithrombotic efficacy compared with standard guideline-recommended 12month DAPT after DES implantation.
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O137
FREQUENT AND POSSIBLY INAPPROPRIATE USE OF COMBINATION THERAPY
WITH AN ORAL ANTICOAGULANT AND ANTIPLATELET AGENTS IN ATRIAL
FIBRILLATION – INSIGHTS FROM THE BASELINE DATA OF THE EUROPEAN
PREFER IN AF REGISTRY
GIULIA RENDA (A), HARALD DARIUS (B), JEAN-YVES LE HEUZEY (C), RICHARD
JOHN SCHILLING (D), TESSA SCHLIEPHACKE (E), JOSEF SCHMITT (E),
CHRISTINE SCHOBER (E), JOSÉ LUIS ZAMORANO (F), PAULUS KIRCHHOF (G),
RAFFAELE DE CATERINA (A)
(A) INSTITUTE OF CARDIOLOGY AND CENTER OF EXCELLENCE ON AGING, G.
D´ANNUNZIO UNIVERSITY, CHIETI, ITALY; (B) VIVANTES HOSPITAL NEUKÖLLN,
BERLIN, GERMANY; (C) CARDIOLOGY AND ARRHYTHMOLOGY, GEORGES
POMPIDOU HOSPITAL, RENÉ DESCARTES UNIVERSITY, PARIS, FRANCE; (D) BARTS
AND ST THOMAS HOSPITAL, LONDON, UK; (E) DAIICHI SANKYO EUROPE, MUNICH,
GERMANY; (F) DEPARTMENT OF CARDIOLOGY, UNIVERSITY HOSPITAL RAMÓN Y
CAJAL, MADRID, SPAIN; (G) UNIVERSITY OF BIRMINGHAM CENTRE FOR
CARDIOVASCULAR SCIENCES AND SWBH NHS TRUST, BIRMINGHAM, UK
Purpose: Combined oral anticoagulant (OAC) and antiplatelet (AP) therapy is generally discouraged
in atrial fibrillation (AF) outside of acute coronary syndromes or stenting because of increased
bleeding. We evaluated its frequency and possible reasons in an unselected contemporary European
AF population.
Methods: The PREvention oF thromboembolic events–European Registry in Atrial Fibrillation
(PREFER in AF) prospectively enrolled AF patients in France, Germany, Austria, Switzerland, Italy,
Spain and the United Kingdom from January 2012 to January 2013. We evaluated patterns of
combined VKA-AP therapy in this population.
Results: Out of 7243 patients enrolled, 5170 (71.4%) were treated with OAC alone, 808 (11.2%) with
AP alone and 791 (10.9%) with a combination of OAC and one (dual) or two AP (triple combination
therapy). Compared with patients only prescribed OAC, patients on combination treatment had
similar body mass index, but more frequently diabetes (p<0.05), dyslipidaemia (p<0.01), coronary
heart disease (CHD) (54.2 vs 18.6%; p<0.01) or peripheral arterial disease (PAD) (10.2 vs 3.7%;
p<0.01). Accordingly, they had a higher mean CHA2DS2VASc (3.7 vs 3.4), and HAS-BLED (2.7 vs
1.9) scores (for both, p<0.01). Of the 660 patients on dual AP + OAC combination therapy, 629
(95.3%) did not have an accepted indication. Out of the 105 patients receiving triple combination
therapy, 67 (63.8%) did not have an accepted indication (Figure).
Conclusions: The combined use of OAC and AP therapy is not uncommon in AF, largely
inappropriate, explained by the coexistence of coronary or peripheral vascular disease, and not
influenced by considerations on the risk of bleeding.
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Roma, 13 – 15 dicembre 2014
O138
CHARACTERIZATION OF DABIGATRAN EFFECTS ON PLATELET FUNCTION
VALENTINA BUCCIARELLI (A), GIULIA RENDA (A), GELSOMINA MALATESTA (A),
PAOLA LANUTI (B), TANYA SALVATORE (A), MARCO MARCHISIO (B),
SEBASTIANO MISCIA (B), JOANNE VAN RYN (C), RAFFAELE DE CATERINA (A)
(A) ISTITUTO DI CARDIOLOGIA E CENTRO STUDI
SULL’INVECCHIAMENTO,UNIVERSITÀ G. D’ANNUNZIO,CHIETI; (B) DIPARTIMENTO
DI MEDICINA E SCIENZE DELL’INVECCHIAMENTO E CENTRO STUDI
SULL’INVECCHIAMENTO,UNIVERSITÀ G. D’ANNUNZIO, CHIETI; (C) BOEHRINGER
INGELHEIM PHARMA, BIBERACH, GERMANY
Purpose: The impact of novel anticoagulants on platelet function is largely unknown and may have
clinical relevance. We characterized the effects of dabigatran (D) on platelet function.
Methods: With in vitro increasing concentrations of D (50, 150 and 250 ng/mL) added to platelet
rich plasma from 10 donors, we assessed light transmittance platelet aggregation by 2 and 5 μM ADP,
5 and 10 μM TRAP, 1.5, 3 and 6 ng/mL human γ-thrombin. With the same concentrations of D in
whole blood, we also quantified protease-activated receptors (PAR)-1 and P-selectin (CD62)
expression by flow-cytometry.
Results: We found a complete inhibition of γ-thrombin-induced aggregation with all plasma
concentrations of D compared with control without drug. ADP- and TRAP-induced aggregation was
not modified by the addition of D. PAR-1 expression (mean fluorescence intensity, MFI ratio) was
significantly higher as a function of increasing D blood concentration (Figure). Expressed as
mean±SE, MFI ratio was 33±8 for control, 53±6 for D 50 ng/mL (P<0.05 vs control), 82±15 for D
150 ng/mL (P<0.05 vs D 50 ng/mL), 94±20 for D 250 ng/mL (P<0.05 vs D 150 ng/mL). CD62
expression was not modified by the addition of D.
Conclusions: The complete inhibition of γ-thrombin-induced platelet aggregation by dabigatran was
also accompanied by a concentration-dependent increase of PAR-1 expression, in the absence of
platelet activation, as indicated by an unmodified CD62 expression. This may suggest an upregulation
of PAR-1 in a setting of reduced thrombin availability for PAR-1 occupancy. The increased
expression of these receptors may induce a recovery or an upregulation of platelet aggregation by
thrombin in the presence of inadequate dabigatran plasma concentrations. Further studies need to
confirm these findings in a clinical setting.
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O139
IL TRATTAMENTO ANTITROMBOTICO NELLA FIBRILLAZIONE ATRIALE DAL 1998
AD OGGI
GIANFRANCO PARISE (A)
(A) CARDIOLOGIA - CASA DI CURA SCARNATI – COSENZA
Scopi della ricerca: valutare in una popolazione ambulatoriale con fibrillazione atriale (FA)
l’utilizzo della terapia anticoagulante nel corso degli anni dal 1998 ad oggi.
Materiali e Metodi: sono stati selezionati 850 pazienti con FA venuti in modo consecutivo dal
1998. 314 presentavano una storia di FA parossistica (FA2), 536 una FA in atto al momento della
visita (FA1). 45% erano maschi e 72 anni era l’età media.
Sono stati individuati tre gruppi in base al trattamento per tutti i pazienti con FA (FA1 +FA2): 1)
389 pazienti sugli 850 trattati con antiaggreganti, pari al 45,65%; 2) 258 pazienti pari al 30,35% che
utilizzavano antagonisti della vitamina K (KVA); 3) 203 pazienti, il 24%, che non utilizzavano
nessuna terapia antitrombotica.
Prendendo in considerazione i soli pazienti con FA1, FA in atto al momento della visita, sui 536
complessivi: 1) 244 venivano trattati con antiaggreganti, pari al 45,52%; 2) 215 con anticoagulanti,
40,11%; 3) 77 con nessuna terapia antitrombotica, 14,37%.
Si è voluto quindi verificare nel gruppo dei pazienti che avevano FA in atto (FA1), così come nel
gruppo comprendente tutte le FA (FA1 + FA2), anno per anno, la percentuale di utilizzo degli
anticoagulanti, raggruppando i pazienti in periodi di 5 o 6 anni. Dal 1998 al 2002: 204 con FA1 e
274 pazienti con FA1+FA2; dal 2003 al 2008: 178 e 301; dal 2008 ad oggi: 154 FA1 e 275
(FA1+FA2).
Risultati: per tutti i pazienti (FA1+FA2) dal primo al terzo periodo si è verificato un progressivo
incremento nell’utilizzo degli anticoagulanti KVA passando dal 24 al 26% fino ad arrivare al 41%.
Nello stesso tempo si è verificata una graduale riduzione nell’utilizzo degli antiaggreganti dal 49 al
47% fino al 41%; i pazienti senza nessuna terapia antitrombotica sono passati dal 26 al 27% per
assestarsi al 18%. Se vengono presi in considerazione i soli pazienti con FA in atto (FA1) l’utilizzo
degli anticoagulanti passa dal 29% al 36% fino ad arrivare nel quinquennio più recente al 60%;
mentre gli antiaggreganti sono passati dal 52 al 48 fino al 33%; i pazienti senza terapia
antitrombotica dal 19 al 16 fino allo 6%.
Conclusioni: l’utilizzo della terapia anticoagulante nel corso degli anni dal 1998 ad oggi è andato
progressivamente aumentando, in particolare per i pazienti con FA in atto al momento della visita,
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presumibilmente persistente/permanente. Pertanto tra i vari elementi che condizionano l’utilizzo della
terapia anticoagulante bisogna tener conto degli anni in cui sono stati raccolti i dati e se si tratta di
FA parossistica o “cronica”.
O140
ANTIPLATELET THERAPY FOLLOWING MITRACLIP REPAIR: RESULTS FROM A
SINGLE CENTRE STUDY
ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A), VALERIA CAMMALLERI (A),
SAVERIO MUSCOLI (A), DOROTEA RUBINO (A), FRANCESCA DEPERSIS (A),
EUGENIA MAIO (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), GIANPAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Background: Optimal antiplatelet/anticoagulant therapy is crucial to prevent periprocedural
thrombotic complications after MitraClip repair. Intraprocedural anticoagulation with weightadjusted unfractionated heparin has been a well established standard of care. OAT is currently
recommended in patients with atrial fibrillation, mechanical valve prostheses or other. DAPT is
recommended in CAD patients treated with PCI
Aims: Aim of our study was to evaluate different antiplatelet/anticoagulation therapeutic options in
patients who underwent MitraClip procedure in our institute.
Methods: The study includes 71 consecutive patients (mean age 73±9 y.o.; males 72%) with mitral
regurgitation (MR) >3+ (80% functional; 20% degenerative), who underwent the procedure in
standard fashion. The MitraClip System was successfully implanted in all patients with a significant
reduction of MR (2+) maintained at discharge. One clip was implanted in 38%, two clips in 60% and
three clips in 2% of patients. After the intervention, patients were treated using only aspirin 100mg/die
(n=24, 34%); or double anticoagulation therapy (DAPT) with a daily dose of clopidogrel 75mg plus
aspirin 100mg, when they underwent prior percutaneous coronary intervention (n=20, 28%); or oral
anticoagulation therapy (OAT) plus aspirin 100 mg in patients with atrial fibrillation, heart
mechanical prostheses, or when the anticoagulation was indicated (n=18, 25%); aspirin was not added
in OAT patients with high bleeding risk (n=9, 13%).
Results: Follow-up data were obtained by outpatient visits and telephone interviews 30 days and 12
months after the procedure. We evaluated the composite of major adverse events, defined as death,
myocardial infarction, transfusion >2 blood units, ischemic and hemorrhagic stroke, urgent or
emergency conversion to surgery. Among patients who received aspirin alone, 2 patients (8%) died
during in-hospital stay and 2 patients died after 8 and 12 months, 1 patient (4%) received transfusions,
and 2 are currently in list for heart transplantation; among patients in DAPT, 2 patients (10%) received
transfusions during in-hospital stay, 1 patient (5%) who experience hemorrhagic stroke, died at 30
days, 2 patients died after 12 and 13 days respectively while 1 death (5%) was observed at 3 months;
in OAT plus aspirin group 3 transfusions occurred (17%), no patients died; in OAT alone one patient
died at 7 months. No cases of myocardial infarction, ischemic stroke, urgent or emergency conversion
to surgery have been reported in all groups.
Conclusion: Double antiaggregation therapy did not show clinical benefit when compared to the use
of aspirin alone. Therefore we suggest use of aspirin alone or OAT plus aspirin for 6 months, in
patients undergoing MitraClip procedure.
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O141
L’INTERRUZIONE
E
LE
CONTROINDICAZIONI
AL
TRATTAMENTO
ANTICOAGULANTE: DIFFERENZE E ANALOGIE NEL TRATTAMENTO TRA ITALIA
ED EUROPA DOPO UN ANNO DI FOLLOW-UP NEL REGISTRO PREFER IN AF
VITTORIO PENGO (A), SEENA PADAYATTIL (A), SALVATORE PIRELLI (B),
LUIGI MOSCHINI (B), ERIKA BENLODI (C), LIVIO DI LECCE (C), GIULIA RENDA (D),
RAFFAELE DE CATERINA (D)
(A) CARDIOLOGIA, AZIENDA OSPEDALIERA DI PADOVA, PADOVA; (B)
CARDIOLOGIA, ISTITUTI OSPITALIERI DI CREMONA, CREMONA; (C) DIREZIONE
MEDICA, DAIICHI SANKYO ITALIA; (D) ISTITUTO DI CARDIOLOGIA, UNIVERSITÀ “G.
D’ANNUNZIO” C/O OSPEDALE SS. ANNUNZIATA, CHIETI
Razionale: Le principali problematiche connesse con l’uso di farmaci antagonisti della vitamina K
derivano dalla complessa gestione del paziente in trattamento, con conseguenti difficoltà in termini
di aderenza e persistenza in terapia. Le controindicazioni della terapia con anticoagulanti orali
incidono ulteriormente sulla compliance del paziente al trattamento nel lungo termine.
Metodi: Nel registro PREFER in AF (The PREvention oF thromboembolic events – European
Registry in Atrial Fibrillation) sono stati arruolati, tra Gennaio 2012 e Gennaio 2013, pazienti non
selezionati affetti da FA nei seguenti paesi europei: Austria, Francia, Germania, Italia (ITA), Spagna,
Svizzera e Regno Unito. I dati qui riportati sono stati raccolti alla visita di follow-up, e si riferiscono
ad interruzione e controindicazioni al trattamento anticoagulante.
Risultati: Nel Registro PREFER in AF sono stati arruolati 7243 pazienti in Europa, di cui 1888 (26%)
in Italia, coinvolgendo 98 centri. In Italia 1655 pz (l’88%) hanno completato la visita di follow-up ad
un anno (vs 89% in Europa). Al follow-up il 65,3% dei pazienti trattati assumeva VKA (vs 72,1% in
Europa). Tra questi, il 56,1 % era in terapia con warfarin (vs 31.2% in Europa). Dei pazienti italiani
trattati con warfarin il 9,1% ha interrotto la terapia durante il follow-up (vs 10,3% in Europa): il 19%
per disagio e mancata aderenza (vs 15,2%), il 3,8% per interventi di chirurgia minore (vs 3%), l’8,9%
per eccessiva variabilità nella risposta (vs 9,1%) e il 63,3% per altri motivi (vs 64%).
In Italia solo il 3,2% (vs 12.8% in Europa) dei pazienti era trattato con nuovi anticoagulanti orali
(NOAC). Nessuno in Italia ha interrotto il trattamento. In Europa l’interruzione di rivaroxaban è
avvenuta nel 9,4% dei casi (29,4% dei casi per reazioni avverse al farmaco, 5,9% per interazioni
farmacologiche, 5,9% per vari disagi e mancata aderenza, 58,8% per altre ragioni). Per dabigatran
l’interruzione è avvenuta nel 10,3% dei casi (33,3% per reazioni avverse al farmaco, 2,4% per
interazioni farmacologiche, 2,4 % per disagi e mancata aderenza, e 61,9% per altre ragioni.
Relativamente alle controindicazioni al trattamento anticoagulante orale, l’1,2% dei pazienti aveva
un cancro in fase attiva (vs il 3% in Europa); il 2,4% aveva avuto emorragie nell’anno di osservazione,
esattamente come in Europa. Inoltre sanguinamenti maggiori gastrointestinali sono stati riportati
nell’1,6% dei casi (nella media europea), sanguinamenti cerebrovascolari nello 0,5% (vs 0,4% in
Europa), altre emorragie maggiori nello 0,9% (vs 1% in Europa) e una scarsa aderenza al trattamento
negli ultimi 12 mesi nel 5,9% (vs 2,2% in Europa);
Conclusioni: Nel registro PREFER in AF si sono evidenziate differenze relative ai motivi di
interruzione della terapia tra pazienti trattati con VKA e NOAC e numerose possibili
controindicazioni all’utilizzo della terapia anticoagulante. La conoscenza dei motivi di interruzione e
delle controindicazioni è molto importante alla luce della disponibilità ora anche in Italia dei NOAC,
in quanto permette di individuare la terapia più appropriata per ciascun paziente e ad aumentare la
percentuale di pazienti trattati.
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MIOCARDIOPATIA IPERTROFICA
O142
EARLY DETECTION OF ATRIAL FIBRILLATION IN PATIENTS WITH
HYPERTROPHIC CARDIOMYOPATHY AND ICD. THE IMPORTANCE OF HOME
MONITORING
RICCARDO MORGAGNI (A), EMANUELA RAFFONE (A), FRANCESCA MARCHETTI (A),
GIOVANNI BATTISTA FORLEO (A), FRANCESCO ROMEO (A)
(A) U.O.C. DI CARDIOLOGIA E CARDIOLOGIA INTERVENTISTICA, POLICLINICO TOR
VERGATA, ROMA
Introduction: Hypertrophic Cardiomyopathy (HCM) is an inherited myocardial disease
characterized by inappropriate ventricular hypertrophy and increased risk of sudden cardiac death.
Implantable cardioverter defibrillators (ICD) has changed the natural history of the disease, having a
significant mortality benefit. Atrial fibrillation (AF) is the most common supraventricular arrhythmia
in HCM, according to the literature may be found in one-fourth to one half of patients. Actually, in
addition to the scheduled check, ICDs have a remote home monitoring control allowing doctors to
detect cardiac tachyarrhythmias 24/7.
Aim of the study: Early detection and treatment of atrial fibrillation in older patients with HCM and
ICD.
Materials and Methods: We have studied 26 patients with familial HCM (echocardiographic
diagnosis confirmed by genetic study) and ICD implanted for primary prevention of SCD, aged ≥ 45.
The duration of follow up was 24 months. All ICDs had home monitoring. Only 3 of them had a
previous episode of parossistic AF, while none of them was on permanent AF. All subjects attended
2 scheduled FU with ICD check, echocardiogram and ECG.
Results: On 26 patients 11 (42,3%) had at least one episode of atrial fibrillation: 6 on 11 had one or
more episode of paroxysmal AF, 1 of them had an inappropriate shock due to ventricular rate
response. 5 patients on 11 (45,4%) had a persistent AF and were hospitalized in 48 hours for electric
cardioversion. 2 of them were completely asymptomatic. Only 1 patient had a pulmonary edema due
to AF and was hospitalized. After complete clinical evaluation decided to put them on oral
anticoagulation. No embolics events were documented. No patients had sustained ventricular
arrhythmias during FU.
Conclusions: AF seems to be very frequent in older HCM patients. ICDs with home monitoring can
identify clinically relevant atrial tachyarrhythmias in symptomatic or asymptomatic HCM patients
with no prior history allowing an earlier hospitalization as well as early optimization of
pharmacological therapy and ICD programming.
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O143
SEX-CORRELATED DIFFERENCES IN A POPULATION AFFECTED BY
HYPERTROPHIC CARDIOMYOPATHY REFERRED TO A SINGLE REGIONAL
CENTER
CATIA DE ROSA (A), SERGIO BONGIOANNI (A), TOMMASO FORNI (A),
BARBARA MABRITTO (A), ALFREDO PIZZUTI (A), STEFANIA LUCERI (A), MARIA
ROSA CONTE (A)
(A) MAURIZIANO HOSPITAL CARDIOVASCULAR DEPARTMENT
BACKGROUND: Hypertrophic Cardiomyopathy (HCM) is a disease with an autosomal dominant
pattern of inheritance. Gender-related differences have been described in a large multicenter
population of patients with HCM.
OBJECT: To examine which, if any, clinical or instrumental features in our outpatients HCM-clinic
appeared to be sex-related.
METHODS: We studied 526 consecutive patients followed-up in our centre from 1983 to 2013.
Mean follow-up duration was 15±11 years (yrs), no difference in length between male and female
was found.
RESULTS: Main characteristics in male (M) and female (F) patients, at first evaluation, are listed in
table below:
First
evaluation
OverallFemale
patients
Male
patients
p Value*
Number
526
Age (yrs)
52± 18 56± 19
50± 17
0.001
NYHA F.C.
1.5
1.6
1.3
< 0.0001
AF
88
42 (20%) 46 ( 15%) n.s.
LVOT
obstruction
209
94 (44%) 115 (35%)0.04
Mean
Gradient
78± 39 85± 39
209 (40%) 317 (60%)
77± 36
n.s.
Max LVWT19± 4 19± 4
(mean)
19± 5
n.s.
LA (M-mode)43± 9 44± 9
mm
33± 9
n.s.
Medical
Treatment
History
Syncope
FHSD
381
of44
96
Massive
17
Hypertrophy (3%)
169 (76%) 212 (66%)0.0001
19(9%)
25(8%)
n.s.
34 (16%) 62 (20%) n.s.
7 (3%)
10 (3%) n.s.
Legend: AF atrial fibrillation, LVOT= left ventricular outflow tract, LVWT= left ventricular wall
thickness, LA= left atrium, FHSD= familiar history of sudden death. * n.s. For p value >0.05 SIC | Indice Autori
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Twenty-three (11%) female and 24 (7%) male (p=0.2) were lost at follow-up.
After a mean f.u. of 15 ±11 yrs:
1) Mean age is still higher in women [62±18 and 56±16 yrs in F and M respectively (p= 0.0003)].
2) Women remain more symptomatic [mean NYHA FC: 1.5 M and 1.8 F (p <0.0001)].
3) Differences in medical treatment tend to disappear.[F=168 (90%) M=251 (86%) (p=0.15)].
4) Women are underinvestigated with treadmill test [F 100( 53%) M 213 (72%) (p<0.0001)] and
cardiac magnetic resonance [F=85(45%) M=177(60%) (p<0.001)].
Thirty-two (17%) women and and thirty-two (10%) men (p=0.05) died during f.u. Sudden death
occured in 14 (5%) men and in 4 (2%) women (p=0.04) while heart failure related death occurred
more frequently in women than in men [F=10 (3%) M=19 (10%) (p=0.001)]
CONCLUSIONS: As previously reported, also in our population women, either at first evaluation
and at f.u., are under-represented, older and more symptomatic. This could be, at least in part,
explained with an underdiagnosis, a higher prevalence of the obstructive form of the disease and
possibly a “gender bias”. We observed a trend toward higher mortality rates in women, in particularly
for heart failure related-death; if, to avoid delay in diagnosis in women translates in a better quality
of life or even in a mortality reduction, remains unresolved.
O144
SCREENING FOR SARCOMERE PROTEIN GENE MUTATIONS AND GENOTYPEPHENOTYPE
CORRELATIONS
IN
PATIENTS
WITH
HYPERTROPHIC
CARDIOMYOPATHY: EXPERIENCE OF A SINGLE CENTRE
ALESSANDRA SFRECOLA (A), CINZIA FORLEO (A), ROSANNA VALECCE (A),
SANDRO SORRENTINO (A), MASSIMO IACOVIELLO (A), FRANCESCA DE
PASCALIS (A), MARIA ISOLA PARODI (B), MASSIMILIANO CECCONI (B),
SABRINA DAVÌ (B), VITO MARANGELLI (A), PAOLO SPIRITO (C),
STEFANO FAVALE (A)
(A) CARDIOLOGY UNIT, DEPARTMENT OF EMERGENCY AND ORGAN
TRANSPLANTATION, UNIVERSITY OF BARI ALDO MORO, BARI, ITALY; (B)
LABORATORY OF GENETICS, GALLIERA HOSPITAL, GENOA, ITALY; (C) GALLIERA
HOSPITAL, GENOA, ITALY
Background. Hypertrophic cardiomyopathy (HCM) is a common inherited heart muscle disorder
affecting 1 in 500 people in the general population and it is associated with arrhythmias, sudden
cardiac death and heart failure. Genetic mutations can be identified in approximately 60% of patients
and the majority of these concern sarcomeric genes. The aim of our study was to evaluate the
prevalence of mutations in the MYH7, MYBPC3, TNNT2, TNNI3, TPM1 and ACTC1 genes and the
genotype-phenotype correlations in a group of patients with HCM.
Methods. We prospectively assessed consecutive unrelated patients with HCM, diagnosed on the
basis of two-dimensional echocardiography showing a hypertrophied left ventricle in the absence of
another cardiac or systemic disease that could account for the magnitude of hypertrophy, according
to the international guidelines. All patients underwent physical examination, 12-lead
electrocardiography, echocardiography, and 24 hour ECG Holter monitoring. For each patient, we
examined the following risk markers: family history of sudden cardiac death, unexplained syncope,
massive left ventricular hypertrophy (thickness > 30 mm), and nonsustained ventricular tachycardia
(NSVT) on serial Holter monitoring. Furthermore, we evaluated a positive family history for HCM.
All subjects underwent screening for mutations of the aforementioned six sarcomere genes by PCR
followed by direct Sanger sequencing. The study was approved by the Local Ethics Committee and
all participants provided written informed consent.
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Results. We evaluated 30 patients (mean ± SD age at diagnosis, 46.9±16 years, 19 males) with HCM,
15 (50%) of whom were found to have mutations: 3 in MYH7 (20%), 12 in MYBPC3 (80%), 1 in
TNNT2, 1 in ACTC1, and none in TNNI3 and TPM1 genes. Overall, 50% of mutations had not been
described before. Two patients harbored two mutations: double mutation in MYBPC3-TNNT2 genes
in a 49-year-old woman and in MYH7-MYBPC3 genes in a 35-year-old man. A significant difference
in the mean age at diagnosis was found between patients carrying sarcomeric protein gene mutations
(mean ± SD age, 40.3±13 years) and those with negative genetic test (mean ± SD age, 53.6±15 years).
Moreover, carriers more frequently had family history positive for HCM (53%) than non-carriers
(27%).
Conclusions. Overall, the prevalence of mutations in the six investigated genes was 50%. Half of the
identified mutations had not been described before. The MYBPC3 gene was the most frequently
mutated, followed by MYH7. Patients with sarcomere mutations were characterized by younger age
at diagnosis and higher likelihood of a positive family history for HCM in comparison with those
without sarcomere mutations. Genetic testing can be useful for clinicians in making an accurate
diagnosis and in identifying relatives at risk of developing HCM. To date, it is difficult to use genetic
information to stratify risk in these patients. Further efforts are needed to accumulate reliable evidence
on genotype-phenotype correlations.
O145
CORRELATION BETWEEN SERUM LEVELS OF GALECTIN-3 AND NT-PROBNP WITH
LATE GADOLINIUM ENHANCEMENT IN HYPERTROPHIC CARDIOMYOPATHY
CATIA DE ROSA (A), TOMMASO FORNI (A), SERGIO BONGIOANNI (A),
BARBARA MABRITTO (A), LAURA ERROI (B), DOMENICO COSSEDDU (B),
MARCO MIGLIARDI (B), MARIA ROSA CONTE (A)
(A) MAURIZIANO HOSPITAL CARDIOVASCULAR DEPARTMENT; (b) MAURIZIANO
HOSPITAL CLINICAL CHEMISTRY DEPARTMENT
Purpose: Galectin-3 (Gal-3) is a recently discovered marker of myocardial fibrosis and elevated
levels are associated with an impaired outcome after short-term and long-term follow up in heart
failure (HF) patients. Cardiac magnetic resonance (CMR) can identify the presence of fibrosis areas
in patients with Hypetrophic Cardiomyopathy (HCM) with late Gadolinium enhancement (LGE)
study. We assessed levels of Galectin-3 and NT-proBNP in a cohort of patients affected by HCM
who performed a complete cardiac magnetic resonance study with LGE valuation.
Methods: between January 2012 and December 2013 a total of thirty-eight patients (60,5% male,
median age 50,5 years) with HCM who performed a complete CMR with LGE were enrolled in the
study; circulating levels of Gal-3 and NT-proBNP were measured.
Results:Sixteen patients ( 42,1%) were asymptomatic (NYHA I FC); twenty (52,6%) were NYHA II
FC and two (5,3%) were NYHA III FC. In HF a value of Gal-3 lower than 17,9 ng/ml is supposed to
be a normal range; a value higher than 25,9 ng/ml is associated with higher mortality and morbidity
in short-term and long-term follow up.In our population the mean level of Gal-3 was 10,4 ng/ml and
all patients except one had a normal level of Gal-3. NYHA II patients didn’t showed significant
different levels of Gal-3 (p=0,2) than asymptomatic patients; there was a significant difference for
NT-proBNP levels between asymptomatic and NYHA II ( p=0,02). No correlation was found between
Gal-3 and LGE (p=0,5 r=0,14) and between NT-proBNP and LGE (p=0,3 r=0,21) (Fig.1 and 2).
Conclusion: in a population of HCM patients with NYHA I and II FC there is no correlation between
levels of Gal-3 and NT-proBNP with percentage of LGE in CMR.Of note patients enrolled were in
NYHA II FC and Gal-3 and NT-proBNP levels were low.Our proposal is to enroll also patients with
NYHA III-IV FC to investigate if eventual high level of Gal-3 and NT-proBNP correlate with LGE.
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Roma, 13 – 15 dicembre 2014
ADATTAMENTI CARDIORESPIRATORI NELLA INSUFFICIENZA CARDIACA
O146
POSSIBILE EZIOLOGIA EMODINAMICA DELL’ALTERATA VENTILAZIONE AL
TEST CARDIOPOLMONARE IN PAZIENTI ANZIANI CON SCOMPENSO CARDIACO
CRONICO
GABRIELLA MALFATTO (A), SERGIO CARAVITA (A, B), JESSICA ROSSI (A),
ALESSIA GIGLIO (A), ALESSANDRA VILLANI (A), MARIO FACCHINI (A),
GIANFRANCO PARATI (A, B)
(A) DIVISIONE DI CARDIOLOGIA, OSPEDALE SAN LUCA, ISTITUTO AUXOLOGICO
ITALIANO IRCCS, MILANO ; (B) DIPARTIMENTO DI MEDICINA CLINICA,
PREVENZIONE BIOTECNOLOGIE SANITARIE, UNIVERSITÀ DI MILANO-BICOCCA
Premesse: E’ ancora dibattuto se la disventilazione al test da sforzo cardiopolmonare (espressa a
riposo dalla P(ET)CO2 e durante sforzo dallo slope VEVCO2) in pazienti (pz) con insufficienza
cardiaca (IC) cronica derivi dalla congestione polmonare secondaria ad elevate pressioni di
riempimento ventricolari e associata a disfunzione diastolica. I valori di P(ET)CO2 e di slope VEVCO2
hanno una forte rilevanza prognostica, specie nei pz anziani. In questa popolazione, inoltre, anche
patologie pneumologiche possono alterare tali variabili. Abbiamo recentemente dimostrato che la
misura di conduttanza transtoracica (TFC) ottenuta con impedenziometria ha una buona correlazione
con la pressione di cuneo polmonare, un indice affidabile di elevate pressioni di riempimento.
Abbiamo quindi esaminato la relazione tra TFC e P(ET)CO2 immediatamente prima del test
cardiopolmonare,
e fra TFC e slope VEVCO2 durante test in pazienti anziani non
broncopneumopatici.
Metodi: In 76 pz con IC [75±4 anni, 55 M, 53% ischemici, FE 33±5%, 70% con ICD/CRT],
immediatamente prima di CPT abbiamo effettuato la valutazione emodinamica noninvasiva con
impedenziometria transtoracica (NiccomoLDT), il dosaggio di BNP (Triage, BioSite) e
l’ecocardiogramma colorDoppler per la valutazione della funzione diastolica (calcolo di E/E’). I
pazienti avevano effettuato una preliminare valutazione della funzione respiratoria, che risultava
normale. Abbiamo considerato la relazione fra TFC e VEVCO2 slope, e fra TFC e P(ET)CO2. Abbiamo
infine considerato il ruolo della disfunzione diastolica nel determinare alterazioni della conduttanza
TFC e nella ventilazione.
Risultati: Abbiamo osservato significative correlazioni (R > 0.55, p< 0.0001) tra TFC e P(ET)CO2 , e
tra TFC e VEVCO2 slope (Figura). Inoltre, la disfunzione diastolica a riposo (E/E’ > 15) era correlata
con più elevati valori di VEVCO2 slope (39.5±7.3 vs. 35.3±6.1, p< 0.01) e più bassi valori di
P(ET)CO2. (31.3±4.9 vs. 34.1 ± 4.8 , p< 0.02).
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Conclusioni: I nostri dati avvalorano l’ipotesi che nei pazienti anziani con insufficienza cardiaca le
alterazioni della ventilazione derivino in gran parte dalla congestione polmonare e dalla disfunzione
diastolica, rilevabili a riposo con la valutazione non invasiva.
O147
VENTILATORY
INEFFICIENCY,
DIASTOLIC
DYSFUNCTION,
MITRAL
REGURGITATION AND PULMONARY HYPERTENSION DURING EXERCISE: THE
CULPRIT INTERACTION IN HEART FAILURE REDUCED EJECTION FRACTION
GRETA GENERATI (A), FRANCESCO BANDERA (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background: Dyspnea and exercise intolerance are landmark manifestations of heart failure (HF).
An impaired efficiency in ventilation (VE) as indicated by a steep increase in VE vs CO2 output
during exercise provides remarkable prognostic indications. We aimed at defining the role of different
hemodynamic components that may determine the most unfavorable ventilatory phenotype and worse
clinical status.
Methods: 71 HF reduced ejection fraction patients (mean age 67±11; male 72%; ischemic etiology
61%; NYHA class I, II, III and IV 13%, 36%, 39% and 12%, mean ejection fraction 33±9%)
underwent cardiopulmonary exercise test evaluation on tiltable cycle-ergometer combined with
simultaneous echocardiographic assessment.
Results: Patients were divided in 4 ventilatory classes (VC) according to the VE/VCO2 slope
classification focusing on peak exercise variables. We observed a VC related increase in E/e’ ratio,
mitral regurgitation and pulmonary artery systolic pressure and a progressive reduction in TAPSE
and peak VO2. The best correlation with VC groups was found for E/e’ ratio and peak VO2.
Conclusions: A remarkable culprit interaction emerged between the degree of diastolic dysfunction,
mitral regurgitation, pulmonary hypertension and right heart dysfunction with inefficient VE during
exercise. A systematic analysis of these hemodynamic determinants by stress echo combined with
gas exchange analysis may become a valuable addition for appropriately refining therapeutic
interventions.
Peak exercise variables
Mitral Regurgitation ≥3/4+, %
Rest E/e’, ratio
Tricuspid annular systolic excursion (TAPSE),
mm
Pulmonary artery systolic pressure, mmHg
Cardiac Output, l/min
Cardiac Power Output, Watt
Oxygen consumption (VO2), ml/kg/min
VC I
(n=23)
30
18±9
22±4
VC II
(n=18)
44
28±13
20±4
VC III
(n=21)
62
30±15
18±6
VC IV
(n=9)
67
32±10
18±3
P coeff.
Anova
0.05
0.006
0.05
51±15
8.3±3
1.9±0.6
14.8±3.1
61±16
6.6±2
1.6±0.6
13±2.4
64±24
5.8±2
1.3±0.6
12.3±3.6
65±17
5.2±2
1.1±0.5
8.9±2
0.04
0.002
0.001
0.000
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O148
RISERVA CONTRATTILE E DENERVAZIONE CARDIACA IN PAZIENTI AFFETTI DA
CARDIOMIOPATIA DILATATIVA IDIOPATICA
PAOLA GARGIULO (A), LETIZIA SPINELLI (A), CARMEN D´AMORE (A),
TERESA PELLEGRINO (A), PELLEGRINO ANGELA (A), TIZIANA FORMISANO (A),
ANTONIO MARINIELLO (A), ALBERTO CUOCOLO (A), BRUNO TRIMARCO (A),
PASQUALE PERRONE-FILARDI (A)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITA´ DEGLI
STUDI DI NAPOLI FEDERICO II
Scopo: La riduzione della riserva contrattile nei pazienti affetti cardiomiopatia dilatativa idiopatica
(IDCM). è un potente predittore prognostico nei pazienti. Tuttavia, le basi fisiopatologiche di questa
associazione non sono ancora state chiaramente definite. Scopo di questo studio è quello di valutare
gli effetti dello stato di innervazione simpatica cardiaca sulla riserva contrattile nei pazienti affetti da
IDCM.
Metodi: Ventitre pazienti in condizioni cliniche stabili affetti da IDCM (21 maschi, 59 ± 11 anni)
con disfunzione sistolica del ventricolo sinistro (frazione di eiezione (FE) 33±3%) e arterie coronarie
esenti da lesioni angiograficamente significative sono stati sottoposti entro 1 settimana a valutazione
ecocardiografica della riserva contrattile mediante studio dello strain longitudinale globale speckle
tracking durante infusione di dobutamina alla dose di 10 ɣ/kg/min (10 ɣ GLS) e a studio
dell’innervazione simpatica cardiaca mediante scintigrafia con 123I-meta- iodobenzilguanidina con
stima
del
rapporto
tardivo
cuore/mediastino
(late
H/M
ratio).
Risultati: Nei pazienti affetti da IDCM, 10 ɣ GLS (12.08 % ± 4.15) è risultato significativamente
ridotto rispetto ai 10 soggetti sani di sesso ed età confrontabile arruolati come popolazione di controllo
(21,4 % ± 1.77, p<0.000). Quando i pazienti affetti da IDCM sono divisi utilizzando il valore mediano
del late H/M ratio, il 10 ɣ GLS è significativamente più basso nei pazienti con rapporto H/M < 1,6
(9,8 % ± 3,5 vs 14,5 ± 4,9 %, p<0.01). All’ analisi di Pearson, il 10 ɣ GLS è correlato
significativamente al late H/M ratio (r=0.62, p=0.002 ) e alla FE (r=0.54, p=0.008). All'analisi
multivariata, il late H/M si è dimostrato predittore indipendente di GLS compromesso (β=0.48,
p=0.011), insieme alla FE (β=0.36, p=0.04).
Conclusioni: Nei pazienti affetti da IDCM, la compromissione dell’innervazione simpatica cardiaca,
che riflette la down-regulation beta recettoriale, dovuta all’iperattività simpatica, è un determinante
della riduzione della riserva inotropa. Questi risultati forniscono spunti meccanicistici alla relazione
tra ridotta riserva contrattile e prognosi nei pazienti affetti da IDCM.
O149
EXERCISE ECHOCARDIOGRAPHIC ADAPTATIONS OF RIGHT VENTRICULAR
PERFORMANCE AND PULMONARY PRESSURES IN COMBINATION WITH GAS
EXCHANGE ANALYSIS IN HEART FAILURE
FRANCESCO BANDERA (A), GRETA GENERATI (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background: Echo tricuspid annular systolic plain excursion (TAPSE) is the most widely used noninvasive indicator of right ventricular (RV) systolic function. It has strong prognostic value in heart
failure (HF) patients. At rest TAPSE combined with pulmonary artery systolic pressure (PASP), as
TAPSE/PASP ratio, gives additional prognostic information in HF syndrome. Aim: We aimed at
describing the association between RV-pulmonary circulation (PC) behavior at rest and during
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Roma, 13 – 15 dicembre 2014
exercise, looking at simple functional and hemodynamic phenotypes in HF patients. Methods: 91
patients (mean age 65±11y, male 70%, ischemic etiology 69%, LVEF 33±10%, NYHA class I, II,
III, IV 22, 37, 31, 10%) underwent a maximal CPET on tiltable cycle-ergometer combined with
exercise-echocardiography, using an incremental personalized ramp protocol. Data were analyzed
focusing on TAPSE/PASP ratio at rest and during exercise.
Results: Study population was divided into three groups according to TAPSE/PASP ratio: Group A
had favorable RV-PC coupling both at rest and during exercise (TAPSE/PASP>0.35), B unfavorable
coupling only during exercise (rest TAPSE/PASP>0.35, peak TAPSE/PASP <0.35), C RV-PC
uncoupling already at rest (TAPSE/PASP<0.35). Group C patients showed more advanced cardiac
remodeling and steeper VE/VCO2 slope compared to the other two groups. Group B patients had
intermediate echo and CPET phenotype, characterized by more severe mitral regurgitation during
exercise and an impaired LV contractile response (lower peak cardiac output), corresponding to
impaired exercise tolerance (lower peak VO2, workload and O2 pulse) and an abnormal ventilatory
pattern during exercise (exercise oscillatory ventilation, EOV).
Conclusions: In a broad range HFrEF patients a low TAPSE/PASP ratio is associated with worse
cardiac remodeling and exercise ventilatory inefficiency. An impaired RV-PC response during
exercise is characterized by more severe dynamic MR and worse functional phenotype. These
findings suggest that non-invasive assessment of RV-PC exercise response is meaningful and better
help to categorize HF severity.
A
(n=45)
90±22
Rest LV end diastolic volume indexed,
ml/m
Rest LVEF, %
35±10
Peak LVEF, %
37±12
Rest MR ≥3/4+
3 (6.7)
Peak MR ≥3/4+
9 (20)
Rest left atrial volume indexed, ml/m2
50±24
Rest E/e’
19±10
Rest cardiac output, L/min
4±1
Peak cardiac output, L/min
7.5±2.6
Workload, Watt
73±21
-1
-1
Peak VO2, ml O2*Kg *min
14.3±3.5
VE/VCO2, slope
32±6.9
B
(n=22)
96±27
C
(n=24)
107±33
35±7
29±9
37±7
33±11
6 (27)
16 (67)
14 (64)
17 (71)
54±26
69±28
27±11
37±15
3.8±1.3 3.2±1.2
6.3±2.1 4.7±1.7
55±18
48±22
12.2±2.1 10.9±3.3
32±5.8 44±11.8
P (A vs
B)
ns
P (B vs
C)
ns
ns
ns
.01
.00
ns
.01
ns
.06
.00
.00
ns
.02
ns
.00
ns
.06
.02
ns
.01
ns
ns
.00
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Roma, 13 – 15 dicembre 2014
NEFROPATIA DA MEZZO DI CONTRASTO
O150
EFFETTI DELLA PROFILASSI SULL’INCIDENZA DI NEFROPATIA DA CONTRASTO
DOPO ANGIOPLASTICA PRIMARIA
LUCIANA PIERRO (a), SUSANNA POTO (a), MARCO DI MAIO (a), MARIA
VINCENZA POLITO (a), DARIO BOTTIGLIERO (a), RAFFAELE MENNELLA (a),
AMELIA RAVERA (b), ROSARIO FARINA (b), FEDERICO PISCIONE (a, b)
(a) CATTEDRA DI CARDIOLOGIA; DIPARTIMENTO DI MEDICINA E CHIRURGIA;
UNIVERSITÀ DEGLI STUDI DI SALERNO; SALERNO (ITALY); (b) “ DIPARTIMENTO
CUORE” AZIENDA OSPEDALIERA UNIVERSITARIA “SAN GIOVANNI DI DIO E RUGGI
D’ARAGONA”; SALERNO (ITALY)
BACKGROUND: La nefropatia da contrasto (contrast-induced nephropathy, CIN) rappresenta una
possibile complicanza delle procedure che richiedono la somministrazione di mezzo di contrasto. La
sua occorrenza è associata all’aumento della morbilità e mortalità intra-ospedaliere e nel lungo
termine ed a un ricovero ospedaliero di maggiore durata con conseguente aumento della spesa
sanitaria. I pazienti con infarto STEMI trattati con angioplastica primaria si presentano a più alto
rischio di CIN rispetto a quelli sottoposti ad una procedura coronarografica in elezione. In assenza di
una terapia, la profilassi della CIN risulta essere l’unico presidio a disposizione.
OBIETTIVI: Lo scopo dello studio è di valutare l’incidenza della CIN in pazienti con infarto
STEMI, sottoposti ad angioplastica primaria e pretrattati con infusione di N-acetilcisteina (NAC) e
di bicarbonato di sodio (BS). Tale studio, inoltre, si prefigge di ricercare parametri predittivi di CIN
confrontando le caratteristiche cliniche, laboratoristiche e procedurali del gruppo dei pazienti con
CIN con quelle dei pazienti senza CIN.
METODI: Sono stati esaminati 321 pazienti, con diagnosi di infarto STEMI, ricoverati presso
l’U.T.I.C. dell’A.O.U. “San Giovanni di Dio e Ruggi D’Aragona” di Salerno tra il 18/11/2011 e il
10/03/2013. Essi sono stati sottoposti a procedura coronarografica ed hanno ricevuto la profilassi con
infusione endovenosa di 2400 mg di NAC e 80 mEq di BS. Di ciascun paziente sono stati raccolti
dati clinici, i fattori di rischio per malattia cardiovascolare, dati di laboratorio e i dati procedurali.
Sono stati, inoltre, registrati gli eventi avversi a 30 giorni e a lungo termine. È stata considerata CIN
l’aumento della creatininemia ≥ 25% o ≥ 0,5 mg/dl del valore pre-procedurale entro i cinque giorni
successivi (120 ore) alla somministrazione di mezzo di contrasto.
RISULTATI: L’incidenza della nefropatia da contrasto è risultata del 23,99% (77 pazienti su 321).
All’analisi univariata, l’età > 75 anni (66,8 ± 13,99 aa vs 62,33 ± 11,56 aa, p= 0,005), il sesso
femminile (35,07% vs 19,67%, p=0,005), alti valori pre-procedurali di glicemia (187,57 ± 98,3 mg/dl
vs 162,75 ± 81,72 mg/dl, p=0,015) e bassi valori di emoglobina al ricovero (13,71 ± 2,18 g/dl vs
14,25 ± 1,84 g/dl, p=0,022), un valore pre-procedurale di creatininemia > 1,5 mg/dl (16,88 % vs
9,02% p=0,053) e l’accesso arterioso in sede femorale (62,67% vs 47,72% p=0,024) sono
significativamente associati allo sviluppo di CIN. All’analisi multivariata, l’età >75 anni (OR 3,179,
95% IC 1,346-7,510, p=0,008), il valore pre-procedurale di glicemia (OR 1,003, 95% IC 1,000-1,006,
p=0,043) e l’accesso arterioso in sede femorale (OR 1,718, 95% IC 0,966-3,056, p=0,048) sono
variabili indipendenti di sviluppo di CIN. È emerso, inoltre, che i pazienti con CIN presentano
mortalità più elevata sia al follow-up a breve termine (16,67% vs 2,99% p= <0,001) che a lungo
termine (9,72% vs 2,99% p= 0,006).
CONCLUSIONI: I pazienti con STEMI trattati con angioplastica primaria presentano alto rischio di
CIN. Da questo studio sono emersi come fattori di rischio per lo sviluppo di CIN: l’età > 75 anni, il
sesso femminile, alti valori di glicemia e bassi valori di emoglobina al ricovero, creatininemia al
ricovero > 1,5 mg/dl e l’accesso arterioso in sede femorale. L’ identificazione in fase pre-procedurale
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di tali fattori nei pazienti consentirebbe di applicare strategie profilattiche più aggressive e mirate,
come la preferenza dell’accesso arterioso in sede radiale.
O151
NEUTROPHIL GELATINASE ASSOCIATED LIPOCALIN (NGAL), MEASURED BY A
BEDSIDE ASSAY, IN THE EARLY DETECTION OF CONTRAST-INDUCED ACUTE
KIDNEY INJURY IN PATIENTS UNDERGOING
ANNUNZIATA NUSCA (A), FRANCESCA LASSANDRO PEPE (A),
MARCO MIGLIONICO (A), COSIMO MARCO CAMPANALE (A), CLAUDIO PROSCIA (A),
LUCIA AMMIRATI (A), EDOARDO BRESSI (A), ROSETTA MELFI (A), PAOLO GALLO (A),
GERMANO DI SCIASCIO (A)
(A) CAMPUS BIO-MEDICO UNIVERSITY OF ROME
Purpose. Contrast-induced Acute Kidney Injury (CI-AKI) is associated with high mortality and
morbidity. It implies a damage but not necessarily a reduction in the overall renal filtration rate
detected by serum creatinine (SCr); moreover SCr increases when the loss of greater than 50% of
kidney function occurs. Thus, there is the urgency of more sensitive biomarkers to identify kidney
damage. Neutrophil Gelatinase-Associated Lipocalin (NGAL) is the most promising biomarker,
because rapidly accumulated in urine and plasma after nephrotoxic and ischemic insults. The aim of
our study was to evaluate the diagnostic accuracy of a “bedside” NGAL assay, compared to the
standard SCr, in the early detection of CI-AKI in patients undergoing percutaneous coronary
intervention (PCI).
Methods. 97 consecutive patients undergoing PCI were enrolled. Exclusion criteria were: GFR < 60
ml/min, left ventricular dysfunction, ST-elevation myocardial infarction, thrombocytopenia (< 70 ×
109/L), sepsis, severe pulmonary disease, neoplasm. In all patients, blood samples were drawn before
and 6-hours after PCI in order to detect NGAL levels by a bedside test. SCr was measured before and
24-48 hours after procedure and its clearance (ClCr) estimated by Cockroft and Gault formula. CIAKI was defined as SCr increase ≥ 0.3 mg/dl within 48 hours from contrast administration. All
patients were treated with saline hydration at 1 ml/kg/min.
Results. We found a significant correlation between pre-PCI NGAL and SCr (r=0.446, p<0.001) and
ClCr (r=-0.405, p<0.001) at the baseline. A further correlation was found between 6-hours NGAL
and both post-PCI SCr (r=0.339, p=0.004) and ClCr (r=-0.303, p=0.010). In the overall population,
median post-PCI SCr increase (ΔSCr) was 0.24 mg/dL; thus, in patients with ΔSCr exceeding 0.24
mg/dl (47%), a significant NGAL elevation (ΔNGAL, 6.6 ± 34.7 vs -11.2 ± 40.5 ng/mL, p=0.049)
and higher 6-hours NGAL values (107.6 ± 49.1 vs 86.9 ± 41.2 ng/mL, p=0.056) were observed. The
ROC curve showed that 6-hours NGAL significantly discriminates between patients with and without
ΔSCr >0.24 mg/dl, with an area under the curve of 0.645 (p=0.034), identifying 96 ng/mL as the
optimal cut-off to predict renal injury, with a sensitivity of 53% and a specificity of 74%.
Conclusion. This study confirmed the effectiveness of NGAL, detected by a beside assay, in the early
diagnosis of CI-AKI. This marker may play a crucial role especially in the identification of such
patients who develop kidney injury regardless of significant increase in post-procedural SCr.
SIC | Indice Autori
134
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O152
THE INCREMENTAL VALUE OF RENAL FUNCTION-ADJUSTED CONTRAST
VOLUME OVER PRE-PROCEDURAL ESTIMATION OF RISK TO PREDICT CONTRAST
INDUCED-ACUTE KIDNEY INJURY AFTER PRIMARY PCI
GIUSEPPE ANDÒ (A), GAETANO MORABITO (A), CESARE DE GREGORIO (A),
OLIMPIA TRIO (A), GIUSEPPE NUCIFORA (A), ILARIA BORETTI (A),
ROBERTA TRIPODI (A), FRANCESCO SAPORITO (A), GIUSEPPE ORETO (A)
(A) DIPARTIMENTO DI MEDICINA CLINICA E SPERIMENTALE, SEZIONE DI
CARDIOLOGIA, UNIVERSITÀ DI MESSINA
Purpose: We have demonstrated that age, renal function and ejection fraction, summarized into the
AGEF Score, are pre-procedural predictors of Contrast-Induced Acute Kidney Injury (CI-AKI) after
primary PCI, whereas the impact of renal function-adjusted contrast volume (CV) remains not fully
explored. To date, Maximum Accepted Contrast Dose (MACD) from Cigarroa formula and CV to
eGFR ratio (CV/eGFR) have been proposed to calculate a maximum CV not to be overcome, although
a threshold for CV/eGFR has not been yet established. We investigated the association between
CV/eGFR and CI-AKI in a consecutive population of patients undergoing primary PCI.
Methods: CI-AKI was defined as an absolute increase in serum creatinine ≥0.5mg/dL or an increase
≥25% from baseline within 72 hours. Multivariate logistic regression and receiver-operating
characteristic (ROC) curve analyses were used to assess whether CV/eGFR was an independent
predictor of CI-AKI and the cutoff value was identified according to the Youden index. Finally, the
increased discriminative value of CV/eGFR over the pre-procedural model based on the AGEF score
was examined using the net reclassification improvement (NRI).
Results: 470 patients were consecutively enrolled and 25 (5.3%) cases of CI-AKI occurred. These
patients were older, had higher troponin, more severe impairment of hemodynamic status at
admission and worse basal renal function than patients without CI-AKI. Mean procedural CV was
164±63 ml; the incidence of CI-AKI was not higher across different quartiles of CV and no patient
exceeded the MACD. Despite patients developing CI-AKI had not received an absolutely higher total
CV (165±79 Vs 163±62 mL), they had received a much higher renal function-adjusted CV (CV/eGFR
3.62 Vs 1.96, p<0.001). Conversely, the difference in CV/MACD was not significant (0.52 Vs 0.40,
p=0.07). CI-AKI incidence was much higher (15%, p<0.001) in patients in the highest quartile of
CV/eGFR, corresponding to the cutoff indicated by the ROC curve (>2.5, AUC 0.77, 72% sensitivity
and 78% specificity). At multivariate analysis CV/eGFR above the cutoff or in the highest quartile
(OR 5.13, p=0.004) remained an independent predictor of CI-AKI. The model with CV/eGFR
demonstrated a statistically significantly NRI of 23% (p=0.021) over the baseline pre-procedural
model, largely driven by a significant improvement in classification of patients not experiencing CIAKI.
Conclusions: CV remains a key risk factor for CI-AKI in patients undergoing primary PCI and our
study supports the need for minimizing CV, independently from baseline pre-procedural risk
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135
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O153
REMOTE ISCHEMIC PRECONDITIONING AND RISK OF CONTRAST-INDUCED
NEPHROPATHY AFTER PERCUTANEOUS CORONARY INTERVENTION: THE EUROASIA CRIPS RANDOMIZED CONTROLLED TRIAL
CLAUDIO MORETTI (A), ERIKA CAVALLERO (F), ENRICO CERRATO (E),
FABRIZIO D´ASCENZO (A), S. LIN (H), PIERLUIGI OMEDÈ (A), MARCO
LUCIANO ROSSI (J), ANDREA PICCHI (B), FRANCESCA SANGUINETI (C),
FABRIZIO UGO (G), ALBERTO PALAZZUOLI (D), MAURIZIO BERTAINA (A),
PATRIZIA PRESBITERO (J), SL CHEN (H), ROBERTO POZZI (F), RICCARDO BELLI (E),
UGO LIMBRUNO (B), THIERRY LEFÈVRE (C), GIUSEPPE BIONDI ZOCCAI (I),
FIORENZO GAITA (A)
(A) DIVISION OF CARDIOLOGY, DEPARTMENT OF INTERNAL MEDICINE, CITTÀ
DELLA SALUTE E DELLA SCIENZA,TORINO ; (B) DIVISION OF CARDIOLOGY,
GROSSETO ; (C) DIVISION OF CARDIOLOGY, MASSY, PARIS ; (D) DIVISION OF
CARDIOLOGY, SIENA ; (E) DIVISION OF CARDIOLOGY, HOSPITAL MARIA VITTORIA,
TURIN ; (F) DIVISION OF CARDIOLOGY, HOSPITAL SAN LUIGI ; (G) DIVISION OF
CARDIOLOGY, HOSPITAL SAN GIOVANNI BOSCO ; (H) DEPARTMENT OF
CARDIOLOGY, NJANG CHINA; (I) DEPARTMENT OF MEDICO-SURGICAL SCIENCES
AND BIOTECHNOLOGIES, SAPIENZA UNIVERSITY OF ROME, LATINA, ITALY ; (J)
DIVISION OF CARDIOLOGY, HUMANITAS
Aims. The potential protective effect of remote ischemic preconditioning (RIPC) on contrast-induced
nephropathy (CIN) after Percutaneous Coronary Intervention (PCI) remains to be defined.
Methods. A double-blind, randomized, placebo controlled multicenter study was performed. Patients
were allocated 1:1 to RIPC or standard therapy if they are younger than 85 years old, with a renal
clearance in the interval 30–60 ml/min/1.73m2 and candidate to PCI for all clinical indications except
for primary PCI in ST segment elevation myocardial infarction (STEMI). Incidence of CIN was the
primary end point, whilst incidence of peri procedural myocardial infarction the secondary one.
Diabetes mellitus was the only pre-specified analysis.
Results. From February 2013 to April 2014 a total of 3108 patients scheduled for angiography were
screened. 442 fulfilled the inclusion criteria, 223 received PCI and were randomized to sham RIPC
(n=107) or treatment group (n=116). The only pre-specified subgroup of diabetic patients presented
88 (38%) cases. RIPC significantly reduced AKI incidence in the overall population (12.1% vs
26.1%, p=0.01, with a number needed to treat 9), in non diabetic patients (9.2% vs 25.0%, p=0.02)
whilst diabetic subgroup showed no benefitc (16.7% vs 28.2%, p=0.21). A trend, although not
significant, was reported for periprocedural myocardial infarction (8.4% vs. 16.4%, p 0.07)
Conclusions. Remote ischemic preconditioning significantly reduces the incidence of CIN in non
diabetic patients undergoing PCI. Larger studies are needed for patients with diabetes mellitus.
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136
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
GENETICA E BIOLOGIA MOLECOLARE - MICRO RNA
O154
INSUFFICIENTE CONSAPEVOLEZZA DEL PROPRIO PROFILO DI RISCHIO NELLA
POPOLAZIONE GENERALE: ANALISI PRELIMINARE NELL’AMBITO DELLA PRIMA
GIORNATA EUROPEA PER LO SCOMPENSO CARDIACO.
SIMONE MAURIZIO BINNO (A), ELENA CORBELLINI (B), ALESSIA ZANNI (B),
CONCETTA STICOZZI (B), ALESSIO ANTINARELLA (B), ALESSANDRO MALAGOLI (B),
ORNELLA BETTINARDI (C), ANTONIO MAZZA (D), SILVANA BORGHI (E), LETIZIA DA
VICO (F), ANTONIA PEROBON (G), MASSIMO PIEPOLI (B), GIOVANNI
QUINTO VILLANI (B)
(A) UNITÀ DI RICERCA CARDIORENALE, UNIVERSITÀ DEGLI STUDI DI PARMA; (B)
UNITÀ OPERATIVA CARDIOLOGIA, OSPEDALE “G. DA SALICETO“, PIACENZA; (C)
UOC EMERGENZA URGENZA DSMDP, AUSL DI PIACENZA; (D) UOC CARDIOLOGIA
IRCCS FONDAZIONE SALVATORE MAUGERI CARDIOLOGIA PAVIA (PV); (E)
MULTIMEDICA HOLDING (MI); (F) AZIENDA OSPEDALIERO UNIVERSITARIA
CAREGGI FIRENZE; (G) FONDAZIONE SALVATORE MAUGERI MONTESCANO (PV)
Introduzione: Per promuovere la conoscenza nella popolazione generale dello scompenso cardiaco,
prima causa cardiovascolare di ospedalizzazione e morte nei Paesi occidentali, la Heart Failure
Association della Società Europea di Cardiologia (ESC) propone da anni un evento dedicato intitolato
“Heart Failure Awareness Day”. Per la prima volta, nel 2014 l’Italia ha aderito a questa iniziativa.
Nell’ambito delle iniziative organizzate nella città di Piacenza è stato eseguita una indagine sulla
consapevolezza del profilo di rischio dei cittadini contattati negli spazi pubblici dedicati. Tale
indagine si è basata sulla compilazione di un questionario (6 items), indaganti dati clinici anamnestici,
livelli di attività fisica, controllo alimentare, compliance terapeutica, stato dell’umore, abitudine
tabagica.
Metodo: Coinvolti 155 soggetti (49% maschi), 41% ≤ 60 anni, 37% con ≤ 8 anni di scolarità . Ogni
soggetto ha compilato uno screening sui fattori di rischio, elaborato dalle Aree non Mediche del
GICR-IACPR, composto dalla Scala di Morisky per aderenza terapeutica, dalla scala Med Diet Score
per valutazione delle abitudini alimentari, dal questionario Fagerstrom inerente l’abitudine tabagica
ed infine da alcuni quesiti circa l’attività fisica e lo stato psicologico.
Risultati: Il 19% dei soggetti coinvolti riferisce anamnesi positiva per cardiopatia strutturale, il 23%
dei pazienti in trattamento farmacologico presenta un punteggio indicativo di scarsa aderenza alla
terapia prescritta, il 25% non svolge attività fisica e solo il 9% afferma abitudini alimentari che
rispecchiano il modello di dieta mediterranea. L’8% ha fornito risposte compatibili con profilo di
rischio per depressione; il 15% risulta fumatore attivo di cui il 32% con elevata dipendenza dal fumo.
Conclusioni: I risultati evidenziano la necessità di promuovere nella popolazione generale periodici
interventi informativi ed educazionali per favorire l’adozione di abitudini comportamentali sane atte
a prevenire l’insorgenza di patologie cardiovascolari ed un miglior controllo dell’aderenza alle
terapie.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O155
MIR-125A-5P REGULATES VASCULAR SMOOTH MUSCLE CELL PROLIFERATION
AND MIGRATION BY TARGETING ETS-1
ALESSANDRA CARVELLI (A), CLARICE GARERI (A), CLAUDIO IACONETTI (A),
SABATO SORRENTINO (A), JOLANDA SABATINO (A), ALBERTO POLIMENI (A),
FILOMENA CARIA (A), ANTONIO STRANGIO (A), ANNARITA CARINO (A),
CLAUDIA VENEZIANO (A), ANTONIO CURCIO (A), DANIELE TORELLA (A),
SALVATORE DE ROSA (A), CIRO INDOLFI (A)
(A) LABORATORIO DI CARDIOLOGIA MOLECOLARE E CELLULARE, UNIVERSITA´
MAGNA GRECIA, CATANZARO
Background: Proliferation and migration of vascular smooth muscle cells (VSMCs) are key steps
for atherosclerosis progression and vascular remodeling, including restenosis after vascular injury.
Several studies suggest that microRNAs (miRs) are implicated in the regulation of VSMCs’ biology,
hence influencing the development of vascular diseases. It is known that mir-125 is highly expressed
in VSMCs of normal vascular wall but no data are available on its involvement in vascular disease.
Thus, the aim of the present study was to evaluate the role of miR-125a-5p in the modulation of
smooth muscle phenotype.
Metodhs: In this study, we investigated the expression levels of miR-125a-5p in vessel wall on a rat
carotid balloon-injury model. Gain-of-function and loss-of-function approaches were used to evaluate
the effect of miR-125a-5p on VSMCs proliferation and migration in vitro. Proliferating VSMCs were
identified by using Click-it EdU Proliferation kit for the detection of 5-ethynyl-2'-deoxyuridine (EdU)
incorporation into cellular DNA. The migration of VSMCs was examined with the Boyden chamber
principle using inserts with a pore size of 8 μm. To investigate the predicted target genes, we used
dual-luciferase assay.
Results: Expression levels of miR-125a-5p are strongly decreased in injured carotid arteries
compared to control vessels and in cultured VSMCs in response to PDGF-BB and FBS. Importantly,
Gain of function studies showed that overexpression of miR-125a-5p inhibits VSMCs proliferation
and migration in response to PDGF-BB. The transcription factor ETS-1, known to be induced after
arterial injury or exposure to PDGF-BB, is a putative target of miR-125a-5p. A luciferase reporter
assay demonstrated that the seed region of miR-125a-5p directly interacts with ETS-1 3'-UTR.
Accordingly, our data show that ETS-1 mRNA and protein levels are modulated by miR-125a-5p
over-expression and upon stimulation with PDGF-BB or FBS.
Conclusions: Results of the present study show for the first time that miR-125a-5p plays a key role
in the regulation of VSMCs proliferation and migration, hence representing an interesting potential
therapeutic target for novel treatment approaches to vascular disease.
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138
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O156
IDENTIFICATION OF DIFFERENTIALLY EXPRESSED LONG NON-CODING RNAS IN
VSMC PHENOTYPIC SWITCH
CLARICE GARERI (A), CLAUDIO IACONETTI (A), JOLANDA SABATINO (A),
ALESSANDRA CARVELLI (A), ALBERTO POLIMENI (A), SABATO SORRENTINO (A),
ANNARITA CARINO (A), FILOMENA CARIA (A), GIANMARCO ARABIA (A),
ANTONIO CURCIO (A), DANIELE TORELLA (A), SALVATORE DE ROSA (A),
CIRO INDOLFI (A)
(A) LABORATORIO DI CARDIOLOGIA MOLECOLARE E CELLULARE, UNIVERSITÀ
MAGNA GRAECIA, CATANZARO
Background: Phenotypic switch of vascular smooth muscle cells (VSMCs) plays a key role in the
pathogenesis of different vascular disorders, such as atherosclerosis and restenosis after coronary
intervention. Long non-coding RNAs (LncRNAs) are emerging as new players in cardiovascular
biology. However, the expression and functions of the large majority of these lncRNAs in VSMCs are
currently unknown, yet. Thus, the aim of the present study was to evaluate the expression of selected
lncRNAs during VSMCs phenotypic switch.
Methods and Results: Human coronary artery smooth muscle cells (HCASMC) were modulated by
serum starvation or stimulation with platelet-derived growth factor (PDGF-BB). Total RNA was
isolated from HCASMC using Trizol reagent. LncRNA expression in HCASMC was measured using
quantitative RT-PCR (qRT-PCR) to evaluate the differential expression between the two treatment
conditions. Proliferating HCASMC showed altered expression of selected lncRNA compared
to
serum-starved
cells.
Particularly,
six
molecules
(TUG1,
lincRoR, LncRNA4, l ncRNA2,LncRNA30 and LncRNA30 ) were upregulated, while further two
LncRNAs (linc00657and LncRNA26) were downregulated in proliferating cells. Confirmingly,
similar results were obtained with PDGFBB used as a stimulus. Finally, we found for the first time
that selected members of the transcribed ultraconserved regions (T-UCRs), a well-connserved class
of LncRNAs are expressed in HCASMC and their levels are regulated upon phenotypic switch.
Conclusions: Our results identify selected LncRNAs that are specifically modulated during VSMC
phenotypic switch. These findings pave the way to further study aimed at evaluating the involvement
of these LncRNAs and their actual role in animal models of vascular diseases.
O157
MODULATION OF MATRIX GLA PROTEIN WITH MIR-125 PREVENT VASCULAR
CALCIFICATION.
ANNARITA CARINO (A), SALVATORE DE ROSA (A), CLARICE GARERI (A),
CLAUDIO IACONETTI (A), ANTONIO STRANGIO (A), CIRO INDOLFI (A)
(A) UNIVERSITA´ DEGLI STUDI MAGNA GRAECIA (CATANZARO)
Background: Vascular calcification are often associated to atherosclerosis and can impair the
vascular response to hemodynamic alterations. It is known that warfarin induces calcifications in
extra-hepatic tissues through Matrix Gla Protein (MGP). In particular, MGP effectively inhibits
vascular calcification by binding crystals and inhibiting bone morphogenic protein. In fact, MGP
deficient mice die prematurely as a result of extensive arterial calcification. In vitro, the presence of
beta-glycerolphosphate (bGP) in the culture medium can augment warfarin-induced calcification
process. Through a bioinformatic approach, we identified MGP as a putative target for miR-125a-5p.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Hence, we hypothesized that miR-125 can be a therapeutic target to interfere with vascular
calcification processed.
Methods and Results: A short-term treatment (3-7 days) with Warfarin (2mM) or Warfarin plus bGP
(10mM) increased the amount of Calcium in a VSMCs line (A10 cells), as evidenced with the Alizarin
red assay. Interestingly, treatment with Warfarin or with Warfarin/bGP induced a parallel increase in
the expression levels of MGP and Runx-2, as well as a decrease in the expression levels of
Osteopontin (OPN). A similar effect was achieved by treating A10 cells with the miR-125a-5p mimic.
Also very interestingly, treatment of A10 cells with the miR-125 antagonist had the opposite effect,
reducing the amount of calcium deposits.
Conclusion: Altogether, our data suggest for the first time an involvement of miR-125a-5p and the
MGP-associated calcification process. If confirmed in vivo experiments, treatment with the miR-125a
antagonist could be developed as an effective treatment strategy to prevent vascular calcifications
without interfering with the coagulation system.
O158
TRANSFERRIN RECEPTOR (TFR) 2 AND CARDIOPROTECTION
CLAUDIA PENNA (A), MARTINA BOERO (A), FRANCESCA TULLIO (A), ROSA
M PELLEGRINO (A), GIUSEPPE SAGLIO (A), PASQUALE PAGLIARO (A),
ANTONELLA ROETTO (A)
(A) DIPARTIMENTO SCIENZE CLINICHE BIOLOGICHE UNIVERSITÀ DI TORINO
Together with liver, duodenum and bone marrow, heart is an organ in which iron metabolism must
be tightly regulated. In fact iron overload associated diseases, like haemoglobinopathy and
haemochromatosis, can present signs of heart failure. Moreover, iron fluctuations during heart
ischemia have been associated with hypoxia injury damage. TFR2 is a gene involved in iron
metabolism transcribed in two main isoforms, the full length (Tfr2 alpha) and a shorter form (Tfr2
beta). The function of the latter form is correlated to iron efflux from splenic reticuloendothelial cells
via iron exporter Ferroportin 1. It was previously documented that Tfr2 beta is highly transcribed in
heart.
In order to understand whether Tfr2 beta has some role in cardiac iron metabolism we induced
ischemia reperfusion (IR) in hearts of WT and Tfr2 beta null mice (TFR2 KI and TFR2 LCKO-KI).
IR is an experimental technique consisting in rapid ischemia induction on isolated heart followed by
reperfusion with oxygenate solution, mimicking the clinical condition of an acute myocardial
infarction followed by reperfusion therapy, which is responsible of IR injury. During IR, cardiac iron
is subjected to rapid variations and the iron amount present during reperfusion could influence ROS
generation and modulate the reperfusion associated injury entity. Significant protection from
reperfusion damage has been experimentally obtained through the ischemic preconditioning phase
(IPC) before IR, consisting in very short cycles of ischemia/perfusion before the long infarcting
ischemia. A recent paper showed that a selective and significant L-ferritin (FtL) increase induced by
IPC phase could acts as scavenger of the mobilized iron during the ischemic phase. The authors
concluded that the small amount of iron released during IPC could be the signal for FtL increase.
Cardiac iron content was evaluated through standard methodology in hearts from WT and Tfr2 beta
null (KI and LCKO-KI) animals. No significant differences were found in Tfr2 mice hearts vs WT.
Subsequently, animals from the three groups underwent the following IR protocol: 30-min ischemia
and 60-min reperfusion. Myocardial infarct area was evaluated by nitroblue-tetrazolium staining.
Total infarct size, expressed as a percentage of left ventricle (LV) mass, was 58±3% in hearts of WT
group. A significant smaller infarct size was observed in hearts of Tfr2 KI and LCKO-KI (37±6%
and 36 ±6% of LV mass, respectively) (p<0.002 vs. WT).
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Roma, 13 – 15 dicembre 2014
Ferritin subunits protein analysis in Tfr2 beta null mice before IR revealed that, while FtH amount
remains constant, FtL was significantly increased compared to WT hearts, a scenario similar to that
seen in preconditioned WT animals.
In conclusion Tfr2 beta isoform seems to be involved in cardiac iron metabolism and Tfr2 silencing
results to have a protective effects on IR induced damages. It is likely that Tfr2 downregulation and
FtL upregulation positively affect iron-dependent signals that are involved in preconditioning
cardioprotection.
Transcriptional analysis of the main iron genes and proteins behavior in Tfr2 targeted hearts will help
clarifying the underlying molecular mechanisms.
O159
MICRORNAS LEVELS CORRELATE WITH PLATELET REACTIVITY AND
PERIPROCEDURAL MYOCARDIAL DAMAGE IN PATIENTS UNDERGOING
PERCUTANEOUS CORONARY INTERVENTION
ANNUNZIATA NUSCA (A), SILVIA CAROLI (A), GERMANO DI SCIASCIO (A)
(A) CAMPUS BIO-MEDICO UNIVERSITY OF ROME; (B) G. D´ANNUNZIO UNIVERSITY,
CHIETI
Purpose: High residual platelet reactivity (HRPR) is associated with an increased risk of procedural
myocardial infarction (PMI) in patients undergoing percutaneous coronary intervention (PCI).
MicroRNAs (miR), small non-coding RNA molecules, play a significant role in vascular,
inflammatory and platelet pathways by modulating several transcription factors. However, nowadays,
few clinical studies has been conducted to evaluate the prognostic role of microRNAs in patients
undergoing PCI. Thus, the aim of our study was to analyze possible role of these molecules on platelet
aggregation and PMI development in PCI-treated patients.
Methods: Up-to-date we enrolled 23 patients. Blood samples were collected before and after the
procedure for detection of cardiac markers (troponin I and creatine kinase-MB). PMI was defined as
an elevation of troponin >5 x 99th percentile upper reference limit occurring within 48 hours after
PCI. Moreover whole blood samples were drawn before PCI and used for circulating microRNAs
extraction. RT-quantitative PCR was performed and relative quantification of miR expression
calculated with the 2-ΔΔCt method. Platelet reactivity was measured by the VerifyNow P2Y12 assay
and HRPR was defined as PRU>240.
Results: Mir-495, mir-301a and mir-346 significantly correlated with platelet reactivity (r=0.758,
p<0.001; r=0.597, p=0.005; r=0.539, p=0.014, respectively). Patients with HRPR had higher levels
of mir-495 and mir-301a compared to those with pre-PCI PRU<240 (p=0.001 and p=0.036). The
ROC curve analysis confirmed high mir-495 levels as discriminating factor between patients with
and without HRPR (AUC 0.904, 95% CI 0.773-1.0, p=0.002). Mir-495 and mir-21 were also overexpressed in patients who developed PMI (p=0.032 and p=0.157). A significant correlation was found
between post-procedural troponin values and miR-495 (r=0.673, p<0.001) and miR-346 (r=0.582,
p=0.004). Logistic regression analysis identified high pre-PCI miR-495 levels as a positive predictor
for PMI (OR=2.719, 95% CI 1.016-7.278; p=0.046). ROC curve analysis confirmed the
discriminating power of mir-495 in detecting patients with PMI (AUC 0.767, 95% CI 0.559-0.973
p=0.039).
Conclusions. This study suggests that several microRNAs may influence molecular pathways leading
to increased inflammation and platelet reactivity related to PMI. These molecules may represent an
useful tool for the early identification of patients at higher risk for this complication. We need a larger
population to confirm these preliminary results.
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141
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
IMAGING CARDIOVASCOLARE - 1
O160
REGIONAL MYOCARDIAL CONTRACTILITY IN THALASSEMIA MAJOR BY
MAGNETIC RESONANCE TAGGING
CHIARA TUDISCA (A), ANTONELLA MELONI (B), EMANUELE GRASSEDONIO (A),
STEFANIA RENNE (C), VINCENZO POSITANO (B), ROBERTO MATTEI (D),
LORELLA PITROLO (E), CROCETTA ARGENTO (F), MASSIMO MIDIRI (A),
ALESSIA PEPE (B)
(A) ISTITUTO DI RADIOLOGIA, POLICLINICO “PAOLO GIACCONE“, PALERMO, ITALY;
(B) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(C) STRUTTURA COMPLESSA DI CARDIORADIOLOGIA, P.O. “GIOVANNI PAOLO II”,
LAMEZIA TERME, ITALY; (D) U.O. PEDIATRIA - U.L.S.S. 19, ADRIA (RO), ITALY; (E)
EMATOLOGIA II CON TALASSEMIA, OSPEDALE “V. CERVELLO“, PALERMO; (F)
CENTRO DI TALASSSEMIA, OSPEDALE “SAN GIOVANNI DI DIO“, AGRIGENTO, ITALY
Background: Magnetic resonance (MR) tagging analyzed by dedicated tracking algorithms allows
very precise measurements of myocardial motion and characterization of regional myocardial
function. No extensive data are available in literature. Our aim was to quantitatively assess for the
regional myocardial contractility in thalassemia major (TM) patients and to correlate it with heart
iron overload and global biventricular function.
Methods: Seventy-four TM patients (46 F; 31.8±8.5 yrs) enrolled in the MIOT (Myocardial Iron
Overload in Thalassemia) network underwent MR (1.5T). Three short-axis (basal, medial and apical)
tagged MR images were analyzed off-line using harmonic phase (HARP) methods (Diagnosoft
software) and the circumferential shortening (Ecc) was evaluated for all the 16 myocardial segments.
Four main circumferential regions (anterior, septal, inferior, and lateral) were defined. The same axes
were acquired by a T2* GRE multiecho technique to assess myocardial iron overload (MIO).
Biventricular function parameters were quantitatively evaluated by cine images.
Results: Segmental ECC values ranged from -9.66 ± 4.17 % (basal anteroseptal segment) to 13.36 ±
4.57 % (mid-anterior segment). No significant circumferential variability was detected.
Compared with previous studied healthy subjects, TM patients showed strain values significantly
lower in all the circumferential regions at each level (see Table).
Segmental Ecc values were not significantly correlated with the correspondent T2* values and no
correlation was detected considering the global values, averaged over all segmental values. Three
groups were identified on the basis of cardiac iron distribution: no MIO, heterogenous MIO and
homogeneous MIO. The global ECC was comparable among the three groups (-11.56 ± 1.60 % vs 11.70 ± 2.43 % vs -11.14 ± 1.95 %; P=0.602).
Global ECC values were not significantly correlated with age and were comparable between the
sexes. Circumferential shortening was not associated to left ventricular (LV) volumes and ejection
fraction (with a P>0.5 in all the comparisons).
Conclusions: TM patients showed a significantly lower cardiac contractility compared with healthy
subjects, but this altered contractility was not related to cardiac iron, volumes and function.
Basal
Healthy
Anterior
-0.20 ± 0.03
Septal
-0.17 ± 0.03
Inferior
-0.16 ± 0.03
Lateral
-0.21 ± 0.03
TM
-0.11 ± 0.04
-0.10 ± 0.03
-0.12 ± 0.04
-0.11 ± 0.03
Diff=0.09(P<0.001) Diff=0.07(P<0.001) Diff=0.04(P<0.001) Diff=0.10(P<0.001)
Medium
Healthy
TM
-0.23 ± 0.04
-0.16 ± 0.03
-0.16 ± 0.05
-0.22 ± 0.03
-0.14 ± 0.05
-0.12 ± 0.03
-0.11 ± 0.04
-0.12 ± 0.03
Diff=0.09(P<0.001) Diff=0.04(P<0.001) Diff=0.05(P<0.001) Diff=0.10(P<0.001)
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Apical
Healthy
TM
Roma, 13 – 15 dicembre 2014
-0.24 ± 0.06
-0.18 ± 0.03
-0.23 ± 0.04
-0.24 ± 0.04
-0.12 ± 0.04
-0.13 ± 0.04
-0.12 ± 0.05
-0.11 ± 0.04
Diff=0.12(P<0.001) Diff=0.05(P<0.001) Diff=0.11(P<0.001) Diff=0.13(P<0.001)
O161
3D AND 2D SPECKLE-TRACKING ECHOCARDIOGRAPHY IN EXERCISE-INDUCED
LEFT VENTRICULAR HYPERTRABECULATION: DIFFERENCES AND SIMILARITIES
WITH LEFT VENTRICULAR NON COMPACTION
FLAVIO D´ASCENZI (A), BENEDETTA MARIA NATALI (A), MARTA FOCARDI (A),
MATTEO CAMELI (A), MARCO SOLARI (A), MARCO BONIFAZI (B),
SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA, SIENA,
ITALY; (B) DEPARTMENT OF MEDICINE, SURGERY, AND NEUROSCIENCE,
UNIVERSITY OF SIENA, SIENA, ITALY
First descriptions of left ventricular non compaction (LVNC) were characterized by the identification
of the “spongy” appearance of the myocardium in a variety of congenital heart defects. Nowadays,
the “spongy myocardium” is contemplated as an isolated identity.
In the last years an increasing diagnosis of LVNC has been observed and it is not completely clear
whether it reflects the real incidence of this pathology or, in some cases, it represents an erroneous
interpretation of a physiologic aspect. Therefore, distinguishing better between pathologic spongy
myocardium (i.e. LVNC) and physiologic hypertrabeculation of the left ventricle is becoming
extremely important. Especially among athletes and particularly in black athletes, a high proportion
of subjects practicing sport fulfilled the conventional criteria for LVNC. Unfortunately, no
longitudinal data exploring the relationship between LV hypertrabeculation and high-volume training
are yet available .
Here we reported a case series of 4 high-level black athletes, competing in an international level,
observed before the beginning of the agonistic season and after 6 months of intensive, high-volume
training program. We observed for the first time a significant training-induced increase in LV
hypertrabeculation in our athletes, as assessed by 2D and 3D echocardiography. These changes were
accompanied by marked exercise-induced ECG changes, which are typical for black athetes and pone
a challenge for the differential diagnosis between athlete’s heart and cardiomyopathies. However, all
the indices of diastolic and systolic function were normal or even super-normal. We performed also
speckle-tracking echocardiographic analysis in all the athletes before and after training,
demonstrating no pathological findings. According to these preliminary data, we hypothesize that LV
hypertrabeculation could be interpreted as a further aspect of heart remodeling induced by training,
particularly in black athletes, supposing that exercise conditioning is able to stimulate a
hypertrabeculation of the heart and an electrical remodeling in suitable subjects. Moreover, in contrast
with the marked decrease of LV function observed in patients with LV non-compaction, neither LV
diastolic function nor LV myocardial deformation worsened in our athletes.
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Roma, 13 – 15 dicembre 2014
O162
CARDIAC MAGNETIC RESONANCE VERSUS ECHOCARDIOGRAPHY FOR THE
ASSESSMENT OF CARDIAC VOLUMES AND FUNCTION IN THALASSEMIA
INTERMEDIA PATIENTS
ANTONELLA MELONI (A), STEFANIA RENNE (B), FABRIZIA TERRAZZINO (C),
VINCENZO POSITANO (A), FRANCESCO MAMMI (D), ANGELA CIANCIO (E),
PETRA KEILBERG (A), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) STRUTTURA COMPLESSA DI CARDIORADIOLOGIA-UTIC, P.O. “GIOVANNI PAOLO
II”, LAMEZIA TERME (CZ), ITALY; (C) RADIODIAGNOSTICA - PADIGLIONE 17/C PIANO
SCANTINATO, ARNAS OSPEDALE CIVICO, PALERMO, ITALY; (D) CENTRO
MICROCITEMICO - U.O. DI PEDIATRIA E NEONATOLOGIA, PO LOCRI - A.S.L. N. 9,
LOCRI (RC), ITALY; (E) DAY HOSPITAL DI TALASSEMIA, OSPEDALE “MADONNA
DELLE GRAZIE”, MATERA, ITALY
Background: Cardiac Magnetic Resonance (CMR) and Echocardiography (US) are applied in
parallel to thalassemia intermedia (TI) patients for cardiac evaluation and ongoing monitoring. It is
important to know whether the results of each technique are interchangeable, and thereby how the
results obtained utilizing one technique can be applied using another. These aspects are unexplored
in TI. So, the aim of this study was to evaluate the agreement of left ventricular volumes and ejection
fraction (EF) by CMR and US.
Methods: 74 TI patients (36 F; 36.7±10.9 yrs) patients were studied with both echo and CMR (1.5T)
within 3 months of each other. All patients were enrolled within the MIOT (myocardial iron overload
in Thalassemia) network where CMR exams were performed in 8 sites using homogeneous and
validated procedures. Cine images were acquired in sequential 8-mm short-axis slices to assess
biventricular function parameters quantitatively in a standard way, using MASS® software.
Previously demonstrated inter-center variability for the quantification of cardiac function was 6.3%.
Echocardiographic studies were carried out in 9 echo labs linked to the thalassemia centers. LV
volumes were measured by two-dimensional echocardiography using the biplane Simpson's formula.
Paired-samples t-test or Wilcoxon test, correlation coefficient, intraclass correlation (ICC), and Bland
& Altman (BA) plot were used to compare CMR and US parameters.
Results: Table 1 shows the CMR and US parameters, quoted as mean ± SD with 95% CI in round
brackets. Table 2 shows the results of the comparison between the two techniques. All US volumes
were significantly underestimated, especially the end-diastolic volume index (EDVI), while the US
EF was significantly higher than the CMR EF. The correlation between US and CMR end-dyastolic
and stroke volume indexes was significant, but with a very low coefficient; while the correlation for
the ejection fraction was acceptable. The ICC was unsatisfactory for all volumes and good for the
ejection fraction. The widest Bland Altman plot range was found for the EDVI.
Conclusion: In a moderately large CMR versus echocardiographic comparative study in TI patients,
metrics of LV volume index and function showed significant systematic inter modality differences.
In particular, the US volumes were systematically underestimated. This suggests that serial
measurements of volumes and function in TI should be performed using the same method and if it is
available the more reproducible CMR technique.
Variable
LV EDVI
(ml/m2)
TABLE 1
CMR
US
96.3 ± 17.9
69.9 ± 18.1
(92.2 ÷ 100.4) (65.7 ÷ 74.1)
LV ESVI
(ml/m2)
36.6 ± 11.2
(34.0 ÷ 39.2)
26.2 ± 12.2
(23.4 ÷29.1)
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59.9 ± 11.8
(57.3 ÷ 62.7)
62.0 ± 7.4
(60.3 ÷ 63.7)
LV SVI
(ml/m2)
EF
(%)
CMR-US
Roma, 13 – 15 dicembre 2014
43.7 ± 12.9
(40.7 ÷ 46.7)
63.7 ± 6.6
(62.1 ÷ 65.2)
TABLE 2
LV EDVI LV ESVI LV ESVI
LV EF
(ml/m2)
(ml/m2)
(ml/m2)
(ml/m2)
26.4 ± 22.3 10.4 ± 13.5 16.3 ± 15.8 -1.65 ± 7.7
Difference,
mean ± SD
<0.0001
<0.0001
<0.0001
0.051
P
0.229
0.182
0.394
0.473
Correlation,
(P=0.050) (P=0.182) (P=0.001) (P<0.0001)
r (P-value)
0.200
0.392
0.177
0.631
ICC
-17.4 to 70.2 -16.0 to 36.8 -14.6 to 47.2 -15.7 to 12.4
BA limits
87.6
52.8
61.8
28.1
BA range
O163
IMPIANTO DI STENT VALVOLATO TRANSCATETERE: FOLLOW-UP A LUNGO
TERMINE CON RISONANZA MAGNETICA CARDIACA (RMC)
FRANCESCO SECCHI (A), ELDA CHIARA RESTA (A), PAOLA CANNAÒ (A),
FRANCESCA PLUCHINOTTA (A), MARIO CARMINATI (A),
FRANCESCO SARDANELLI (A), MASSIMO LOMBARDI (A)
(A) IRCCS POLICLINICO SAN DONATO
Scopo: valutare il valore diagnostico della RMC prima e dopo impianto di stent valvolato
transcatetere (Melody®, Medtronic).
Materiale e metodi: dopo IRB e consenso informato, i pazienti affetti da valvulopatia polmonare
sono stati prospettivamente sottoposti a RMC 1.5-T prima e dopo impianto di stent valvolato
polmonare rispettivamente a 36 e 48 mesi. Sono state eseguite sequenze cine true-FISP
(TR/TE=45/1.5 ms) per valutare volume tele-diastolico indicizzato (EDVI), volume tele-sistolico
indicizzato (ESVI), frazione di eiezione (FE) del ventricolo destro (VD) e del ventricolo sinistro (VS).
Wilcoxon test.
Risultati: 36 pazienti (21±8 anni) hanno eseguito RMC una settimana prima l’impianto; 10 pazienti
sono stati valutati 36 mesi dopo e 6 pazienti 48 mesi dopo. EDVI, ESVI, FE del VD prima l’impianto
sono: 83±38mL/m², 44±34mL/m² e 50±13%; i dati del follow-up a 36 mesi sono rispettivamente
72±19mL/m² (p=0.241), 33±15mL/m² (p=0.028) e 56±10% (p=0.047); i risultati del follow-up a 48
mesi sono 67±17mL/m² (p=0.916), 26±15mL/m² (p=0.042) e 62±12% (p=0.027), rispettivamente. I
dati del VS prima l’impianto sono 67±17mL/m², 30±13mL/m² e 56±9 %, rispettivamente; i dati a 36
mesi sono 78±19mL/m² (p=0.333), 34±11 mL/m² (p=0.475) e 57±7% (p=0.085); i dati a 48 mesi
sono 79±20mL/m² (p=0.345), 35±11mL/m² (p=0.599) e 58±7% (p=0.116).
Conclusioni: nel follow-up a 4 anni dopo impianto di stent valvolato polmonare abbiamo osservato
un significativo incremento della FE, una riduzione significativa dell’ESVI del VD ed un
miglioramento con significatività borderline per la funzione sistolica del VS. La RMC può essere
utilizzata per il follow-up a lungo termine non invasivo dopo impianto di stent valvolato polmonare
transcatetere.
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Roma, 13 – 15 dicembre 2014
O164
ACCURACY OF CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY COMPARED
TO TRANSCRANIAL DOPPLER ACCURACY IN DIAGNOSING PATENT FORAMEN
OVALE IN PATIENTS AFFECTED BY JUVENILE CEREBRAL EVENTS
PAOLA IERANÒ (A), ROBERTA ESPOSITO (A), CIRO SANTORO (A), FRANCESCO DE
STEFANO (A), RICCARDO MUSCARIELLO (A), AGOSTINO BUONAURO (A),
ANTONELLA TUFANO (A), MAURIZIO GALDERISI (A)
(A) CENTRO INTERDIPARTIMENTALE PER LA RICERCA SULL´IPERTENSIONE
ARTERIOSA E PATOLOGIE ASSOCIATE (CIRIAPA), DIPARTIMENTO DI SCIENZE
BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO II, NAPOLI
Purpose: Contrast transesophageal echocardiography (C-TEE) is the gold standard for diagnosing
patent foramen ovale (PFO). However, contrast transthoracic echocardiography (C-TTE) and contrast
transcranial Doppler (C-TCD) are other useful diagnostic tools for detecting PFO. Aim of our study
was to compare the diagnostic accuracy of these non invasive techniques using C-TEE as the
reference tool.
Methods: Eighty-nine subjects with previously diagnosed cerebral ischemic event underwent CTTE. Using a bolus of agitated saline injected into a vein of an arm, visualization of microbubbles (>
10) – before and/or after Valsalva maneuver - in the left cardiac chambers within 3-5 cardiac cycles
detected an abnormal right-to-left intracardiac shunt. C-TCD was performed identifying first segment
M1 of the middle cerebral artery: microbubbles reflecting the ultrasound waves produced typical
“high-intensity transient signals” (HITS). A number of HITS > 10 (before and/or after Valsalva
maneuver) within 40 seconds after bubble injection was deemed positive test. Finally, C-TEE was
performed to confirm presence of PFO.
Results: C-TTE detected PFO in 68 of 89 patients (76.4%). Only 3 patients with positive C-TTE did
not show PFO with C-TEE. This corresponds to a sensitivity of 100% and a specificity of 86%. The
negative predictive value (NPV) was 100% while its positive predictive value (PPV) was 96%. CTCD was positive in 29 patients (42.6%) with PFO and in only 1 patient (4.8%) without PFO. Twelve
patients (17.6%) with PFO and 13 (61.9%) without PFO had a completely negative C-TCD (HITS
absence). Twenty-seven subjects in PFO-group (39.7%) and 7 subjects in the group without PFO
(33.3%) presented a HITSs number ≥ 1. C-TCD detected PFO with a sensitivity of 43% that increased
up to 82% for a positive C-TCD with HITS ≥ 1. The specificity of C-TCD was 95% (62% in patients
with a number of HITS ≥ 1). C-TCD had an excellent PPV (97%) while NPV was 39%. These values
became 87% and 52% respectively if we considered a number of HITS ≥ 1 as a positive test .
Conclusions: Our findings demonstrate that both C-TTE and C-TCD have a good diagnostic
accuracy, but C-TTE is much more sensitive. Using 1 microbubble as cutoff for a positive C-TCD
study, sensitivity and VPN increase substantially (in comparison with at least 10 microbubbles as the
cut-off value) while reducing specificity and VPP with a lower extent. These techniques are non
invasive and therefore more suitable than C-TEE for routine preoperative screening of PFO in patients
with juvenile ischemic stroke.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O165
QUANTIFICAZIONE DEL VOLUME ATRIALE SINISTRO: ECOCARDIOGRAFIA E
MAPPAGGIO ELETTRO-ANATOMICO VS RISONANZA MAGNETICA IN PAZIENTI
CON FIBRILLAZIONE ATRIALE CANDIDATI AD ABLAZIONE TRANS-CATETERE
DANIELE ERRIGO (A), CRISTINA GALLO (A), MARINA ANTOLINI (A),
ALESSANDRO BRUSTIO (A), FEDERICA BONGIOVANNI (A), CRISTINA FORNENGO (A),
SIMONE FREA (A), WALTER GROSSO MARRA (A), MATTEO ANSELMINO (A),
RICCARDO FALETTI (B), MARA MORELLO (A), DORICO RIGHI (B),
FIORENZO GAITA (A)
(A) CITTÀ DELLA SALUTE E DELLA SCIENZA, UNIVERSITÀ DI TORINO,
DIPARTIMENTO DI MEDICINA INTERNA, DIVISIONE DI CARDIOLGIA; (B) CITTÀ
DELLA SALUTE E DELLA SCIENZA, UNIVERSITÀ DI TORINO, DIPARTIMENTO DI
DIAGNOSTICA PER IMMAGINI E RADIOTERAPIA
Introduzione. Il volume atriale sinistro è un parametro fondamentale nella gestione del paziente con
fibrillazione atriale (FA) ed è riconosciuto come marker di recidiva dopo cardioversione e di efficacia
di ablazione transcatetere.
Scopo del lavoro. Confrontare e validare i valori del volume massimo atriale sinistro (VmaxAS)
misurati con ecocardiografia 2D (Eco2D), 3D (Eco3D) e mappaggio elettroanatomico con sistema
CARTO (CARTO), versus i valori misurati in risonanza magnetica (RM), sia con tecnica Whole
Heart (WH) che con tecnica Angiografica (AngioRM).
Considerate WH e AngioRM come gold-standard nella misurazione delle dimensioni dell’atrio
sinistro, trovare dei fattori di correzione da applicare alle misure ecocardiografiche e al CARTO per
stimare il valore reale del VmaxAS.
Materiali e Metodi. 200 pazienti consecutivi afferenti alla nostra struttura da gennaio 2011 a gennaio
2014 sottoposti ad ablazione transcatetere di fibrillazione atriale (FA) (età 59,80 ± 11,20 anni, 75,5%
maschi, 32% FA persistente, VmaxAS 80,15 ± 30,99 ml).
Tutti i pazienti sono stati indagati con Eco2D, Eco3D e CARTO. 41 pazienti sono stati sottoposti a
RM con misurazione di WH e AngioRM, mentre 159 pazienti hanno eseguito solo AngioRM.
L’accordo fra il volume misurato con ogni tecnica e il corrispondete valore determinato dalla RM è
stato stimato in tre modalità diverse: coefficiente di correlazione lineare di Pearson, linea di
regressione e Bland-Altman plot, dal cui delta si sono ricavati i fattori di correzione.
Le variabili continue associate sono state analizzate con il test di Wilcoxon nel caso di due set di dati
o con il test di Friedman per un numero superiore di set di dati.
Risultati. Il confronto di Eco2D ed Eco3D versus WH mostra una buona correlazione
(rispettivamente Pearson’s r=0.74 e r=0.74). Il CARTO mostra invece una minore correlazione
(Pearson’s r=0,68). I fattori di correzione ricavati dal Bland-Altman plot (WH=Eco2D+31,
WH=Eco3D+36, WH=CARTO-15) permettono di ottenere un’ottima sovrapposizione dei dati
(Wilcoxon test p=0.94, p=0.73, p=0.42).
Il confronto di Eco2D ed Eco3D versus AngioRM mostra una buona correlazione (rispettivamente
Pearson’s r=0.69 e r=0.64). Il CARTO mostra invece una minore correlazione (Pearson’s r=0,62). I
fattori di correzione ricavati dal Bland-Altman plot (AngioRM=Eco2D+13, AngioRM=Eco3D+20,
AngioRM=CARTO-24) permettono di ottenere una migliore sovrapposizione dei dati (Friedman test
p=0.94).
Conclusioni. Eco2D ed Eco3D correlano bene con la RM, mentre i valori CARTO presentano una
maggiore dispersione. I fattori di correzione permettono una valida stima delle dimensioni atriali
sinistre, fondamentale per le decisioni cliniche.
Conclusion: A+C is still the most frequently prescribed acute AT for ACS, followed by the triple
antithrombotic drug regimen. Management pattern rank is the same for STEMI and UA/NSTEMI.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
IPERTENSIONE ARTERIOSA - DANNO D'ORGANO VASCOLARE
O166
PRECOCI ALTERAZIONI FUNZIONALI E STRUTTURALI VASCOLARI IN TOPI
TRATTATI CON L´INIBITORE DEL FATTORE DI CRESCITA DELL´ENDOTELIO
VASCOLARE VATALANIB
CARMINE SAVOIA (A), EMANUELE ARRABITO (A), AUGUSTO C MONTEZANO (B),
CARMINE NICOLETTI (C), HEATHER Y SMALL (B), LIDIA SADA (A),
FRANCISCO RIOS (B), RHIAN M TOUYZ (B), MASSIMO VOLPE (A)
(A) DIPARTIMENTO DI MEDICINA CLINICA E MOLECOLARE, SAPIENZA UNIVERSITA´
DI ROMA; (B) INSTITUTE OF CARDIOVASCULAR AND MEDICAL SCIENCES, BRITISH
HEART FOUNDATION GLASGOW CARDIOVASCULAR RESEARCH CENTRE,
UNIVERSITY OF GLASGOW, UK; (C) DAHFMO-UNITÀ DI ISTOLOGIA ED
EMBRIOLOGIA MEDICA, SAPIENZA UNIVERSITÀ DI ROMA
Background: L’inibizione dei recettori con attività tirosin-chinasica, come il recettore del fattore di
crescita dell'endotelio vascolare (VEGFR) e del fattore di crescita dell'epidermide (EGFR), è alla base
di alcune terapie antineoplastiche di provata efficacia. Tuttavia, solo gli inibitori del VEGFR, possono
indurre ipertensione arteriosa severa, i cui meccanismi non sono del tutto chiariti. Abbiamo ipotizzato
che l’inibizione del VEGFR induca precoci alterazioni funzionali e strutturali vascolari, che possono
precedere lo sviluppo di ipertensione arteriosa. Metodi e Risultati: Topi SV-129 normotesi (età 8 settimane, 5 per ogni gruppo) sono stati trattati
con l'inibitore del VEGFR Vatalanib (VAT, 100 mg/Kg/die) o l'inibitore dell’EGFR Gefitinib (GEF,
100 mg/Kg/die) e confrontati con topi di controllo trattati con veicolo. La pressione arteriosa (PA) è
stata misurata con metodo tail-cuff. La vasodilatazione endotelio-dipendente e -indipendente è stata
valutata con curve dose-risposta all'acetilcolina (1 nM - 100 µM) ± L-NAME (100 µM) e al
nitroprussiato di sodio (10 nM - 1 mM), rispettivamente, in arterie mesenteriche pre-contratte con
noradrenalina (10 µM). Il rapporto Media-Lume vascolare (M/L, un indice di precoce rimodellamento
vascolare), e l'area di sezione trasversa (CSA) sono stati valutati su preparati vascolari pressurizzati.
Dopo due settimane, la BP era similmente preservata in entrambi i gruppi trattati con VAT e GEF
rispetto ai topi di controllo (89,8±1,5 mmHg e 87,2±2,8 mmHg vs 92.2±2.2 mmHg, rispettivamente,
NS). La vasodilatazione endotelio-dipendente era similmente conservata nei topi trattati con veicolo
e GEF, mentre era ridotta nei topi trattati con VAT (-17% vs topi di controllo, P<0,05). L -NAME ha
ridotto la vasodilatazione in risposta all’acetilcolina in tutti i gruppi tranne che nei topi trattati con
VAT, suggerendo una riduzione della produzione di NO solo in questo gruppo. La vasodilatazione
endotelio- indipendente era simile in tutti i gruppi. Solo i topi trattati con VAT, hanno presentato un
aumento di M/L rispetto ai topi di controllo (6,3±0,1% vs 5,4±0,1%, P<0,05). M/L era simile nei topi
trattati con GEF rispetto ai topi di controllo. CSA era simile in tutti i gruppi.
Conclusioni: In topi normotesi, solo il VAT ha indotto alterazioni vascolari precoci come la
disfunzione endoteliale e il rimodellamento vascolare delle arterie di resistenza. Questi cambiamenti
nelle arterie di resistenza sono caratteristici della patologia ipertensiva e possono precedere e
sostenere lo sviluppo dell’ipertensione arteriosa.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O167
DIFFERENT RELATIONSHIP BETWEEN OBESITY INDEXES AND BLOOD PRESSURE
VALUES IN ITALIAN AND YEMENI POPULATIONS
PIETRO AMEDEO MODESTI (A), DOMENICO PALLI (B),
MOHAMED BAMOSHMOOSH (C), STEFANO RAPI (D), C SAIEVA (B),
BENEDETTA BENDINELLI (B), ELEONORA PERRUOLO (A)
(A) 1. DEPARTMENT OF CLINICAL AND EXPERIMENTAL MEDICINE, UNIVERSITY OF
FLORENCE, , FLORENCE, ITALY; (B) 2. MOLECULAR AND NUTRITIONAL
EPIDEMIOLOGY UNIT, CANCER RESEARCH AND PREVENTION INSTITUTE (ISPO),
FLORENCE, ITALY; (C) 3. UNIVERSITY OF SCIENCE AND TECHNOLOGY, SANA’A,
YEMEN; (D) LAB DEPARTMENT, CAREGGI HOSPITAL , FLORENCE, ITALY
Introduction: High blood pressure (BP) now ranks as a major contributing factor to the global burden
of non communicable diseases. Overweight and obesity have been widely recognized as risk factors
for elevated BP. Great attention is now focused on the control of overweight and obesity in high
income countries, whereas these factors are not yet fully addressed in low income countries to prevent
the burden of cardiovascular diseases in the near future. The aim of the present study was to
investigate the anthropometric differences and the associations between blood pressure values and
anthropometric parameters among the subjects of two large epidemiological studies performed in
Italy (Florence-EPIC, European Prospective Investigations into Cancer and Nutrition study) and in
Yemen (HYDY, HYpertension and Diabetes in Yemen study).
Materials and Methods: Subjects aged 30-70 years not receiving antihypertensive drugs were
considered: 10,260 subjects from Florence-EPIC and 6,343 subjects from the HYDY. In both studies
anthropometric measurements and BP values were collected following standardized procedures by
trained personnel. Differences in the mean values of the main anthropometric characteristics were
investigated between Florence-EPIC and HYDY cohorts. Multivariate regression analysis (adjusted
for sex, age, smoking habit and education level) was performed to investigate the associations
between BP, Body Mass Index (BMI) and weight to hip ratio (WHR) values in these two different
populations.
Results: Body mass index (BMI) and waist to hip ratio (WHR) were significantly lower in Yemeni
than in Italian males (Florence-EPIC= 26.03 vs HYDY=24.00 , p t test < 0.0001 for BMI; FlorenceEPIC= 0.92 vs HYDY=0.90, p t test < 0.0001 for WHR). Higher BMI and WHR were observed in
Yemeni women (Florence-EPIC= 24.90 vs HYDY=25.13 , p t test = 0.01 for BMI; FlorenceEPIC=0.78 vs HYDY=0.87, p t test < 0.0001 for WHR). Significant positive associations of BP with
BMI and WHR were observed in multivariate regression analyses in both populations. The slopes of
BMI and BP associations resulted significantly steeper in Italian than in Yemeni subjects for diastolic
and systolic values in the overall population (diastolic BP Beta = 0.63 and 0.30; systolic BP Beta =
0.83 and 0.47 in Florence-EPIC and HYDY, respectively, all p < 0.0001) and in each gender. For
WHR the differences tended to be in the opposite direction but did not reached significant level.
Conclusions: The different relationship between obesity and blood pressure values in Italy and
Yemeni subjects indicates that the effects of obesity on blood pressure values in European countries
is mediated by other undisclosed factors.
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Roma, 13 – 15 dicembre 2014
O168
RIGIDITA’
ARTERIOSA
E
PROGRESSIONE
DELLA
MALATTIA
ATEROSCLEROTICA: IL POSSIBILE RUOLO PROTETTIVO DELL’ANNESSINA A5
L. GIUPPONI (a), F. CESANA (a, b), R. FACCHETTI (a), M. MOLTENI (a), L. FRIGERIO (a),
F. PANZERI (a), P. MEANI (a), M. VARRENTI (a), G. COLOMBO (a), S. NAVA (a),
S. RAVASSA (c), A.M. DI BLASIO (d), C. GIANNATTASIO (a, b)
(a) UNIVERSITÀ MILANO-BICOCCA; (b) CARDIOLOGIA IV, DIPARTIMENTO A. DE
GASPERIS, H. NIGUARDA, MILANO, ITALIA; (c) CARDIOVASCULAR SCIENCES
DIVISION, CENTRA FOR APPLIED MEDICAL RESEARCH, UNIVERSITY OF NAVARRA,
PAMPLONA, SPAIN; (d) LABORATORIO DI BIOLOGIA MOLECOLARE, ISTITUTO
AUXOLOGICO ITALIANO, MILANO, ITALIA
Obiettivo: L’annessina A5 (AnxA5) è strettamente implicata nella fisiopatogenesi della malattia
aterosclerotica e della disfunzione endoteliale. Sembra possa modulare l’infiammazione vascolare ed
avere un ruolo protettivo sulla parete dei vasi, migliorando quindi la stabilità di placca. Scopo del
nostro studio è valutare la possibile associazione tra l’annessina A5 e la stiffness vascolare, indice di
danno d’organo vascolare, valutata mediante Pulse Wave Velocità carotido-femorale (cf-PWV).
Materiali e Metodi: Abbiamo reclutato 175 pazienti consecutivi con ipertensione arteriosa di grado
1 (HT), in buon controllo dei valori pressori, e 175 controlli (C). Abbiamo prima valutato la possibile
relazione tra annessina A5 e diverse variabili cliniche (età; frequenza cardiaca, HR; pressione sistolica
e diastolica, SBP e DBP; BMI e PWV) misurate nella nostra coorte di pazienti (Correlazione di
Pearson, R). Quindi, abbiamo analizzato i livelli di AnxA5 nei pazienti che presentavano (OD, n 193)
e che non presentavano (NOD, n 155) danno d’organo vascolare (i.e. PWV >= 10 m/sec) (Student T
test). Infine, sempre sulla base della presenza di danno d’organo vascolare, abbiamo ripetuto la
divisione nel gruppo HT e C ottenendo 4 gruppi (HTOD, n 110; HTNOD, n 35; COD, n 57; CNOD,
n 114;) e confrontando anche in questi l’espressione di AnxA5 (ANOVA test).
Risultati: Nell’intera popolazione (n= 350, 55±15 anni), abbiamo individuato una correlazione
positiva tra AnxA5 e PWV (p 0.04, r 0.10), SBP (p 0.03, r 0.11), HR (p 0.01, r 0.13) ed età (p 0.01, r
0.13), mentre nessuna correlazione è stata individuata con DBP e BMI. L’espressione di AnxA5 era
più elevata nei pazienti con danno d’organo vascolare rispetto (12.5±9.7 vs 10.1±7.46 ng/mL, p-value
0.005). In più, i livelli plasmatici di AnxA5 erano più alti in entrambi i gruppi HTNOD e HTOD
rispetto al gruppo CNOD (14.2±10.9 and 13.2±10.2 vs 8.8±7.31, p<0.05), anche dopo aggiustamento
per l’età.
Conclusioni: Dai primi dati disponibili, sembra che AnxA5 abbia un’effettiva relazione con la
rigidità arteriosa sia nei pazienti con ipertensione arteriosa che nei pazienti normotesi. Possiamo
quindi ipotizzare che AnxA5 potrebbe essere maggiormente espressa nei pazienti ipertesi al fine di
controbilanciare lo sviluppo e la progressione della rigidità vascolare, marker indicativo di iniziale
malattia aterosclerotica.
Questo lavoro ha ricevuto fondi dal Seventh Framework Programme (FP7/2007-2013) della comunità
europea grazie al Grant Agreement n° 278249.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O169
RIGIDITÀ AORTICA E RIGIDITÀ LOCALE CAROTIDEA: CORRELAZIONE CON IL
DANNO D’ORGANO VASCOLARE E CARDIACO IN UNA POPOLAZIONE GENERALE
DEL NORD ITALIA
ANNA PAINI (A), MASSIMO SALVETTI (A), FABIO BERTACCHINI (A),
CLAUDIA AGABITI ROSEI (A), GIULIA MARUELLI (A), GIULIA RUBAGOTTI (A),
EFREM COLONETTI (A), CARLOTTA DONINI (A), ELISA CASELLA (A),
ENRICO AGABITI ROSEI (A), MARIA LORENZA MUIESAN (A)
(A) CLINICA MEDICA - UNIVERSITÀ DEGLI STUDI DI BRESCIA
Introduzione: la velocità dell’onda di polso carotido-femorale è risultata associata a diverse forme
di danno d’organo cardiaco e vascolare.Al contrario,poche informazioni sono attualmente disponibili
circa le correlazioni tra la rigidità locale,valutata a livello carotideo,e diverse forme di danno d’organo
preclinico.
L’obiettivo di questo studio è stato quello di analizzare le correlazioni tra la rigidità aortica (aoPWV)
e quella carotidea (CS) e il danno d’organo preclinico cardiaco e vascolare in una popolazione
generale del nord d’Italia (Studio Vobarno).
Metodi: 245 soggetti (57%femmine,età 56±4anni) sono stati sottoposti ad esami ematochimici,
misurazione della PA clinica e delle 24 ore,ultrasonografia cardiaca e carotidea ed a misurazione della
aoPWV(Complior). La CS è stata derivata dalle modificazioni sisto-diastoliche del diametro
carotideo misurate mediante tecnologia di echotracking ad alta risoluzione e dalla pressione stimata
a livello carotideo con tonometria; è stata espressa con la stessa unità di misura della aoPWV(m/s).
Risultati: sia la aoPWV che la CS sono risultate correlate con l’età (rispettivamente: r=0.29, p<0.001
e r=0.23, p<0.001). Una correlazione statisticamente significativa è stata osservata tra la aoPWV e
CS e la PA sia clinica che delle 24 ore. L’aoPWV è risultata significativamente correlata con l’indice
di massa ventricolare sinistro (iMVS, r=0.20, p<0.05), ed era significativamente maggiore nei
soggetti con ipertrofia VS (iMVS>115g/m2 negli uomini, >95g/m2 nelle donne) rispetto ai soggetti
senza ipertrofia (9.1±1.5 vs 8.5±1.4m/s, p<0.05). La CS non è risultata correlata con l’iMVS e non
sono state osservate differenze tra soggetti con o senza ipertrofia(6.5±1.5 vs 6.3±1.2,p=ns).
L’aoPWV, ma non la CS,è risultata correlata con il danno d’organo vascolare (IMT carotideo:
Meanmax: r=0.16,p<0.05; CBMmax:r=0.16, p<0.05; Tmax:r=0.19, p<0.005).
Conclusioni: sebbene la velocità di polso carotido-femorale e la rigidità carotidea forniscono simili
informazioni circa l’impatto dell’età e della pressione arteriosa sulla rigidità dei grossi vasi, solo
l’AoPWV,e non la CS,è risultata correlata con il danno d’organo cardiaco (MVS) e vascolare (IMT)
in una popolazione generale.
O170
IL 18 PREDICE LO SVILUPPO DI DANNO D’ORGANO CARDIACO IN UNA
POPOLAZIONE DI IPERTESI ESSENZIALI
P. MEANI (a), F. CESANA (a, b), M. MASCOLO (a), M. MOLTENI (a), F. PANZERI (a),
L. GIUPPONI (a), S. MAURI (a), P. SORMANI (a), M. BARONI (a), P. VALLERIO (a),
S. SIGNORINI (c), P. BRAMBILLA (c), C. GIANNATTASIO (a, b)
(a) UNIVERSITÀ MILANO-BICOCCA; (b) CARDIOLOGIA IV, DIPARTIMENTO A. DE
GASPERIS, H. NIGUARDA, MILANO, ITALIA; (c) LABORATORIO DI MEDICINA, H.
DESIO, DESIO, ITALIA
Obiettivi: i pazienti ipertesi (HTS) sviluppano danno d’organo (TOD) arterioso e
cardiaco, marker di morbilità per malattie cardiovascolari. È noto come l'attivazione infiammatoria
sia un importante determinante delle patologie cardiovascolari.
L'interleuchina-18 (ILSIC | Indice Autori
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Roma, 13 – 15 dicembre 2014
18), predittore di malattia cardiovascolare e morte , è risultato associato alla vulnerabilità e
progressione della placca aterosclerotica. Obiettivo dello studio è stato studiare il ruolo dell’IL- 18
nello sviluppo di TOD in una popolazione di ipertesi essenziali.
Metodi: 568 HT in soddisfacente controllato (55,1 ± 13,0 anni , BP = 138/84 ± 22/13 mmHg, media
± DS), senza manifestazioni di malattia cardiovascolare sono stati sottoposti a screening per danno
d’organo arterioso e cardiaco (carotid-femoral Pulse Wave Velocity (PWV)), Intima-media thickness
of common carotid artery (IMT) ed ecocardiografia transtoracica standard) e per ciascuno sono stati
prelevati marcatori infiammatori sistemici (IL - 18 , interleuchina 6, IL- 6, proteina sierica amiloide
A, SAA, la proteina C -reattiva, PCR).
Risultati: IL-18 risultava superiore nei HTS con ipertrofia ventricolare sinistra (LVMI > 115 per i
maaschi /95 per le femmine, g/m2) (236.7vs268 , 3 pg/mL , p = 0,0012) e nei soggetti con
incrementata rigidità vascolare (PWV >12m/s) (245.7 vs 267pg/mL , p=0,0473). Alcuna differenza
è stata riscontrata negli altri marker infiammatori. IL-18 era correlato con i valori di LVMI e PWV
(LVMI: r = 0.185, p < 0.0001; PWV: r = 0.124, p = 0,003). Tuttavia, l’analisi multivariata ha mostrato
un’associazione indipendente tra IL -18 ed la sola LVMI (regressione lineare: beta = 0,0658, p <
0.0001), anche dopo aggiustamento per età , pressione arteriosa sistolica, pressione arteriosa
diastolica (SBP, DBP) e BMI. Contrariamente, l'età e la SBP sono risultati predittori di valori di PWV
incrementati (Età: beta = 0,09, p < .0001; SBP: beta = 0,05, p < 0.0001). Nessuna relazione è stata
trovata tra IL-18 e IMT.
Conclusione: L'IL- 18 è over-espressa nei HTS con danno d’organo arterioso e cardiaco. Risulta
associata in modo indipendente con la sola LVMI, noto surrogato di danno d’organo cardiaco.
L'invecchiamento e lo stress meccanico rivestono notoriamente un ruolo cruciale nella fisiopatologia
del danno arterioso. Questo dato sottolinea l'importante azione dell’infiammazione (IL-18) nello
sviluppo di danno cardiaco e conferma il predominante contributo delle sollecitazioni meccaniche
nella malattia arteriosa.
O171
PREVALENZA DI IPERTENSIONE IN AMBIENTE CLINICO E NELLE 24 ORE IN
SOGGETTI RESIDENTI AD ALTA QUOTA. DATI DELLO HIGHCARE-ANDES
HIGHLANDERS STUDY
GRZEGORZ BILO (A), FRANCISCO VILLAFUERTE (B), CECILIA ANZA RAMIREZ (B),
JOSE LUIS MACARLUPU (B), GUSTAVO ANDRÉS VIZCARDO GALINDO (B),
MIRIAM REVERA (A), ANDREA GIULIANO (A), ANDREA FAINI (A),
SERGIO CARAVITA (A), FRANCESCA GREGORINI (A), GIANFRANCO PARATI (A)
(A) DIP. DI CARDIOLOGIA, ISTITUTO AUXOLOGICO ITALIANO, MILANO; (B)
UNIVERSIDAD PERUANA CAYETANO HEREDIA, LIMA, PERU; (C) DIP. DI SCIENZE
DELLA SALUTE, UNIVERSITA´ DI MILANO-BICOCCA, MILANO
Razionale. Poco si sa sulla prevalenza dell’ipertensione arteriosa (IA) in residenti ad alta quota.
Inoltre i dati disponibili si basano su misurazioni convenzionali della pressione arteriosa (PA) nello
studio medico, mentre mancano dati ottenuti mediante monitoraggio dinamico nelle 24h (ABPM).
Obiettivo di HIGHCARE-ANDES Highlanders Study è stato esplorare la prevalenza e i determinanti
dell’IA in ambiente clinico e nelle 24h in una popolazione delle Ande Peruviane.
Metodi. Abbiamo eseguito ABPM 24h (AND, TM2430, Japan) e raccolto PA convenzionale e dati
clinici in soggetti residenti permanentemente (età 18-65aa) a Cerro de Pasco, Perù (alt. 4300 m). E’
stata valutata la prevalenza di PA elevata e la relazione tra presenza di IA e variabili cliniche.
Risultati. Abbiamo studiato 286 soggetti (età 38.2±13.1aa, 143M/143F, BMI 25.3±3.4 kg/m2, SpO2
86.4±4.4%, emoglobina [Hb] 17.8±2.8 g/L). IA in clinica (PA sistolica(S) >=140 e/o diastolica(D)
>=90 mmHg) era presente nel 6,6% dei soggetti, mentre IA ambulatoria nel 11.2% (PA
24h>=130/80mmHg), 10.8% (PA diurna>=135/85 mmHg), 13.4% (PA notturna>=120/70 mmHg).
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IA diastolica era più frequente della sistolica (10.1 vs. 6.3% per PA 24h, 12.9 vs. 6.3% per PA
notturna). Soggetti con IA ambulatoria differivano significativamente (p<0.05) dai normotesi per
l’età (48.3±12.7 vs. 37.0±12.6aa), BMI (27.2±2.9 vs. 25.1±3.5 kg/m2), SpO2 (84.8±4.8 vs.
86.6±4.3%), Hb (20.1±3.3 vs. 17.5±2.6 g/L). In regressione logistica, IA era associata
indipendentemente con: età, SpO2, Hb per IA diurna; età, frequenza cardiaca 24h, sesso per IA
notturna.
Conclusioni: La prevalenza di IA è bassa ma non trascurabile in residenti ad alta quota, soprattutto
se si considera la PA ambulatoria piuttosto che clinica. Esistono differenze rilevanti tra i fattori
associati con IA diurna rispetto a notturna e con IA diastolica rispetto a sistolica. Ipossia e
aumentata viscosità del sangue da policitemia potrebbero svolgere ruolo rilevante nella patogenesi
dell’IA in residenti ad alta quota.
STUDI OSSERVAZIONALI E TRIAL CLINICI - 2
O172
VARIABILITA' DELLA PRESSIONE ARTERIOSA, PROFILO METABOLICO E
RISCHIO CARDIOVASCOLARE NELL'EUROPA ORIENTALE: STUDIO BP-CARE
GINO SERAVALLE (A), GIANMARIA BRAMBILLA (B), RITA FACCHETTI (B),
SILVIA BUZZI (B), STEPHANE LAURENT (C), JOSEPH REDON (D),
GIUSEPPE MANCIA (E), GUIDO GRASSI (B)
(A) ISTITUTO AUXOLOGICO ITALIANO OSPEDALE SAN LUCA, MILANO, ITALY; (B)
CLINICA MEDICA, UNIVERSITÀ MILANO-BICOCCA, OSPEDALE SAN GERARDO,
MONZA, ITALIA; (C) PHARMACOLOGY DEPARTMENT AND INSERM U970 HOSPITAL
EUROPEEN GEORGES POMPIDOU, PARIS, FRANCE; (D) INTERNAL MEDICINE,
HOSPITAL CLINICO, UNIVERSIDAD DE VALENCIA, SPAIN; (E) DIPARTIMENTO DI
SCIENZE DELLA SALUTE, UNIVERSITÀ MILANO-BICOCCA, MILANO, ITALY
INTRODUZIONE: Vari studi indicano che la variabilità della pressione arteriosa (PA) ha un ruolo
predittivo nel determinare il rischio cardiovascolare. Scopo di questa analisi dei dati dello studio BPCARE è quella di valutare la relazione tra variabilità della PA e fattori di rischio cardiovascolare nella
popolazione ipertesa di 9 paesi dell’Europa orientale.
METODI: In ciascun soggetto dello studio BP-CARE veniva calcolato il coefficiente di variazione
(CV) della PA sistolica ambulatoriale. La popolazione veniva quindi divisa in quartili di CV e questi
confrontati con i profili di glucosio e lipidi, prevalenza di precedenti eventi cardiovascolari, presenza
di danno d’organo e valori di PA.
RISULTATI: L’età media dei 6425 pazienti ipertesi era 59.2±11.4 anni (maschi 49.4%). I soggetti
nel quartile di CV più alto erano più anziani (Q1:58.5±11.4 aa vs Q4:60.3±11.3 aa, P<0.001), con
una predominanza di maschi rispetto al quartile più basso. I valori di indice di massa corporea,
circonferenza addominale, prevalenza di sindrome metabolica, obesità e dislipidemia non differivano
tra quartili mentre vi era una maggior prevalenza di diabete, pregressi eventi cardiovascolari e
ipertensione resistente nei soggetti nel primo rispetto al quarto quartile (Q1:24.4% vs Q4:27.6%,
Q1:57.4% vs Q4:63.9% and Q1:30.1% vs Q4:32.7% rispettivamente, P<0.05). La PA delle 24-h
risultava meno controllata negli ipertesi con maggior variabilità (Q1:31.9% vs Q4:15.8%, P<0.01). I
soggetti con il quartile CV maggiore presentavano anche valori di colesterolemia e glicemia più
elevati rispetto rispetto a quelli nel quartile inferiore (Q1:213.0±45.9 mg/dl vs Q4:216.4±50.7 mg/dl
e Q1:106.2±35.5 mg/dl vs Q4:109.8±39.1 mg/dl rispettivamente, P<0.05). La filtrazione glomerulare
era maggiore nei pazienti con quartile CV inferiore (Q1:75.9±24.4mL/min/1.73m2 vs
Q4:71.9±22.0mL/min/1.73m2, P<0.01). La prevalenza di danno d’organo era simile tra quartili CV
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mentre il rischio cardiovascolare aumentava progressivamente dal quartile CV inferiore a quello
superiore (Q1:66.8% vs Q4:71.8).
CONCLUSIONI: Nella popolazione ipertesa dello studio BP-CARE l’incremento di variabilità della
PA si associa ad un incremento del rischio cardiovascolare, ad uno sfavorevole profilo glucidico e
lipidico e ad un ridotto controllo della PA delle 24-h.
O173
LA RETE OSPEDALE-TERRITORIO PER LO SCOMPENSO CARDIACO: CRITICITÀ E
PROSPETTIVE
MARCO RUSSO (A), SARA DOIMO (A), STEFANO POLI (A), DONATELLA RADINI (A),
KIRA STELLATO (A), FRANCO HUMAR (A), ANTONELLA CHERUBINI (A),
GIULIA RUSSO (A), CRISTINA MONTESI (A), CARMINE MAZZONE (A),
GIULIA BARBATI (A), GIANFRANCO SINAGRA (B), ANDREA DI LENARDA (A)
(A) CENTRO CARDIOVASCOLARE, AZIENDA PER I SERVIZI SANITARI E UNIVERSITÀ
DI TRIESTE; (B) DIPARTIMENTO CARDIOVASCOLARE, AZIENDA OSPEDALIEROUNIVERSITARIA “OSPEDALI RIUNITI“, TRIESTE
In ambito cardiovascolare (CV) la cronicità è lo scenario con cui il sistema sanitario deve confrontarsi
per sviluppare risposte assistenziali efficaci e sostenibili. L’esigenza di offrire ai pazienti complessi
e cronici con scompenso cardiaco (SC) punti di riferimento lungo tutto il percorso di cura, in contrasto
con la usuale discontinuità e frammentarietà assistenziale, può trovare soluzione solo nell’ambito di
una efficiente rete assistenziale integrata tra ospedale e territorio.
Metodi e Risultati: Dal 2009 è stata implementata la rete integrata ospedale-territorio per il paziente
con SC nella Provincia di Trieste (250.000 abitanti circa). I dati clinici e strumentali sono stati estratti
dalla cartella elettronica per pazienti ambulatoriali Cardionet® del Centro Cardiovascolare di Trieste.
Dal 11/2009 al 10/2013 sono stati arruolati nell’Osservatorio Cardiovascolare della Provincia di
Trieste 2217 con SC (10.4% dei pazienti totali; età 75.5 anni, maschi 56%, NYHA 3-4 25%,
cardiopatia ipertensiva 49%, ischemica 47% e valvolare 45%). Nel 93% dei pazienti all’arruolamento
è stato eseguito un ecocardiogramma. Nel 27% dei pazienti la FEVS era ≤40%, nel 14% la FEVS era
tra 41 e 49% e nel 59% la FEVS≥50%. L’età e l’indice di Charlson >5 nei 3 gruppi era rispettivamente
73, 74 e 76 anni (p<0.001) e 38%, 33% e 26% (p<0.001). I 3 gruppi di pazienti erano trattati con ACE
inibitori/sartani e beta bloccanti rispettivamente nel 78%, 73% e 72% e nel 54%, 62% e 48%. Un
intervento infermieristico di continuità assistenziale è stato attivato nel 24% e 36% dei pazienti in
NYHA 1-2 e 3-4 rispettivamente. Le prestazioni cardiologiche eseguite a domicilio od in una struttura
intermedia (indicazioni preventivamente condivise tra MMG e cardiologo) sono rimaste stabili negli
anni (8-10% del totale).
Il numero di Ricoveri per SC (DRG 127) nella Provincia di Trieste ha continuato a ridursi dai 1225
del 2010 ai 1095 del 2013 (-10.6%), a fronte di un aumento dei ricoveri in Cardiologia (da 12.9% a
18.8% del totale). Tutti i pazienti dimessi dalla Cardiologia e sopravvissuti sono stati presi in carico
ambulatorialmente entro 3 mesi dalla dimissione dalla Cardiologia Ospedaliera o Territoriale. Dei
pazienti dimessi dai reparti internistici l’attivazione del PDTA ospedale-territorio per i pazienti con
SC si è associato ad un progressivo aumento dei pazienti presi in carico (da 6% e 17% a 14% e 29%
rispettivamente entro 30 o 90 gg dalla dimissione).
Fino al 2012 tutti i pazienti sono stati presi in carico nell’Ambulatorio del Cardiopatico Cronico. Dal
gennaio 2013, 173 pazienti (7.8%; 479 visite, 2.8/pz) con SC avanzato, fragilità e/o multiple
comorbidità (68% maschi; età media 76±9; 68% NYHA 3-4; 59% LVEF<40%; 53% in fibrillazione
atriale; 92% in terapia con almeno 5 farmaci; 45% con Indice di Charlson >5; 36% con almeno una
BADL mancante, 77% con almeno una IADL) sono stati presi in carico dal team multidisciplinare e
multiprofessionale dell’Ambulatorio dello SC avanzato e cure palliative in stretta collaborazione con
i Distretti socio-sanitari. Nel 39.3% dei pazienti è stata eseguito almeno un accesso domiciliare o in
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struttura intermedia, nel 69.3% almeno un intervento di continuità assistenziale infermieristica, nel
27% almeno una valutazione psico-assistenziale da parte di una psicologa.
Conclusioni: La presenza di una rete integrata Ospedale-Territorio per lo SC, composta da PDTA
condivisi tra Ospedale, Strutture Intermedie, Distretti socio-sanitari ed Ambulatori cardiologici
ospedalieri e territoriali dedicati al Cardiopatico Cronico ed ai pazienti con SC avanzato con necessità
di cure supportive/palliative permette di ridurre i ricoveri ospedalieri e di gestire in continuità
assistenziale anche una consistente quota di pazienti anziani e fragili dimessi dai reparti
internistici/geriatrici caratterizzati da SC avanzato, multiple comorbidità, e politerapia.
O174
APNEASCAN: ALGORITMO INTEGRATO PER LA DIAGNOSI DI OSAS NEI PAZIENTI
PORTATORI DI PMK/ICD
LUCIA CICCHINI (A), GIOVANNI BATTISTA FORLEO (A), DOMENICO
GIOVANNI DELLA ROCCA (A), MARIA ALBANESE (B), PELAGIE ZOUNDI (A),
LAURA GUDDELMONI (A), ALESSANDRA NITTI (B), DOMENICO SERGI (A),
LUCA SANTINI (A), ANDREA ROMIGI (B), NICOLA BIAGIO MERCURI (B),
FRANCESCO ROMEO (A)
(A) DIPARTIMENTO DI CARDIOLOGIA-UNIVERSITÀ DI TOR VERGATA; (B)
DIPARTIMENTO DI NEUROFISIOPATOLOGIA - UNIVERSITÀ DI TOR VERGATA
Introduzione: l’alta prevalenza di OSAS nei pazienti portatori di PMK/ICD e le possibili
implicazioni cliniche in termini peggiorativi che essa determina, comportano la necessità di una
specifica strategia diagnostica per individuare precocemente il disturbo respiratorio in tali pazienti e
consentirne così lo specifico trattamento.
L’ApneaScan è un avanzato algoritmo di alcuni ICD e PMK in grado di avvertire l’OSA grazie ad un
sensore di impedenza transtoracica, dalle cui variazioni l’algoritmo ricava un valore medio di disturbi
respiratori (apnee e/o ipopnee) per ora di sonno, l’RDI.
Lo scopo di tale studio è quello di validare l’ApneaScan per lo screening/diagnosi di OSAS.
Materiali e metodi: arruolati i pazienti portatori di PMK/ICD con ApneaScan, sono stati sottoposti
a studio polisonnografico, PSG. L’indice di apnea/iponea (PSG-AHI) di ciascun paziente è stato
comparato con l’RDI, in modo puntuale per la stessa notte. La concordanza fra i metodi è stata
analizzata statisticamente.
Risultati: 19 pazienti (5 portatori di PMK e 14 con ICD; 82% uomini; età media 67.2 ± 9.2 anni;
BMI 27 ± 4.2 Kg/m2) sono stati sottoposti a controllo incrociato. Il valore dell’indice di disturbi
respiratori (apnee e/o ipopnee) RDI ≥ 32 eventi/h è stato scelto come cut-off per la diagnosi di OSAS
di grado severo. Stessa diagnosi corrisponde ad un PSG-AHI ≥30 eventi/h.
La PSG ha riscontrato OSAS di grado severo nel 32% dei pazienti (6 pazienti). L’RDI mostra una
sensibilità del 67% ed una specificità del 79% (vedi figura in allegato), nell’individuare i pazienti con
OSAS di grado severo.
Conclusioni: i risultati suggeriscono che l’ApneaScan rappresenti uno strumento valido e prezioso
per lo screening/diagnosi e follow-up di OSAS nei pazienti portatori di PMK/ICD.
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O175
PROGNOSTIC ROLE OF PERCENT-PREDICTED PEAK VO2 AND VE/VCO2 SLOPE IN
IDIOPATHIC DILATED CARDIOMYOPATHY: REVISITED CUT-POINTS.
GIANFRANCO SINAGRA (A), ANNAMARIA IORIO (A), ELENA ZAMBON (A),
STEFANIA PAOLILLO (B), GIULIA BARBATI (A), MARCO MERLO (A),
MARCO BOBBO (A), COSIMO CARRIERE (A), CONCETTA DI NORA (A),
DAMIANO MAGRÌ (C), GAIA CATTADORI (D), MARCO CONFALONIERI (E), ANDREA DI
LENARDA (F), PIERGIUSEPPE AGOSTONI (D)
(A) CARDIOVASCULAR DEPARTMENT AOU OSPEDALI RIUNITI, TRIESTE, ITALY; (B)
DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY,
NAPLES, ITALY; (C) DEPARTMENT OF CLINICAL AND MOLECULAR MEDICINE,
SAPIENZA UNIVERSITY, ROME, ITALY; (D) CARDIOLOGIC CENTER MONZINO, IRCCS,
MILANO, ITALY; (E) DEPARTMENT OF PNEUMOLOGY & RESPIRATORY INTENSIVE
CARE UNIT, UNIVERSITY HOSPITAL OF CATTINARA, TRIESTE, ITALY; (F)
CARDIOVASCULAR CENTRE, AZIENDA PER I SERVIZI SANITARI N°1, TRIESTE, ITALY
Background: The role of cardiopulmonary exercise performance (CPET) in Idiopathic Dilated
Cardiomyopathy (IDCM) is not completely defined. The aim of the study was to assess the prognostic
value of CPET in a large cohort of patients with IDCM.
Methods and Results: We analysed 381 patients (75% males, mean age 50±11 years, NYHA III-IV
46%, left ventricular [LV] ejection fraction 32±9%, LV end-diastolic volume 192±69 ml) with
IDCM that underwent CPET consecutively from May 1998 to October 2012. The composite study
end-point was cardiovascular death/urgent heart transplantation (D/HTx). At enrollment, peak
oxygen consumption (peak VO2/kg), percent-predicted peak VO2 (peak VO2%) and VE/VCO2 slope
were 17.1±5.1 ml/kg/min, 59±15% and 29.8±6.1, respectively. ROC AUC for peak VO2% (0.74) and
for VE/VCO2 slope (0.78) were significantly greater than that for peak VO2/kg (0.60) (p<0.001).
The optimal cut points for peak VO2% and VE/VCO2 slope were 60% (sensitivity 0.60; specificity
0.79) and 29 (sensitivity 0.86; specificity of 0.60), respectively. Notably, in multivariable analysis for
D/HTx, peak VO2/kg did not emerge as a predictor parameter, neither as continuous nor as dichotomy
variable (with cut-point 14-12 ml/kg/min), while peak VO2% and VE/VCO2 slope were confirmed
as the most significant independent predictors in either way. Moreover, the prognostic power of
VE/VCO2 slope > 29 and peak VO2% < 60% was highly strengthened considering the combination
of both cut-points in another multivariate model.
Conclusions: Peak VO2% (cut off 60%) and VE/VCO2 slope (cut off 29) provide the best predictive
resolution for risk stratification in IDCM patients. Therefore, considerations should be given to revise
the current CPET prognostic variables and their cut off according to the etiology of HF.
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O176
CARDIOPULMONARY EXERCISE PERFORMANCE IN IDIOPATHIC DILATED
CARDIOMYOPATHY: ROLE OF TISSUE DOPPLER IMAGING
ANNAMARIA IORIO (A), ELENA ZAMBON (A), ELENA ABATE (A), CONCETTA DI
NORA (A), MARCO MERLO (A), GIULIA BARBATI (A), FRANCESCO LO GIUDICE (A),
ANDREA DI LENARDA (B), PIERGIUSEPPE AGOSTONI (C), GIANFRANCO SINAGRA (A)
(A) CARDIOVASCULAR DEPARTMENT AOU OSPEDALI RIUNITI, TRIESTE, ITALY; (B)
CARDIOVASCULAR CENTRE, AZIENDA PER I SERVIZI SANITARI N°1, TRIESTE, ITALY;
(C) CARDIOLOGIC CENTER MONZINO, IRCCS, MILANO, ITALY
Background: To examine the relation between left ventricular (LV) function and exercise
performance in Idiopathic Dilated Cardiomyopathy (IDCM) patients.
Methods and Results: 76 consecutive IDCM patients in sinus rhythm (49 ± 13 years; left ventricular
ejection fraction (EF) 31 ± 7%, indexed left ventricular end diastolic volume 96 ± 31 ml/m2; peak
oxygen consumption (peak VO2) 18 ± 5.6 ml/kg/min), undergoing cardiopulmonary exercise testing
(CPET) and echocardiography from January 2005 to April 2012, were studied. Linear regression
analysis revealed that peak systolic velocity (S’) for LV systolic function (r= 0.46; p= 0.001) and
E/E’ for LV diastolic function (r= -0.43; p <0.001), two Tissue Doppler Imaging (TDI) derived
parameters, were related to peak VO2. In addition to this, E/E’ showed the most significant
correlation with VE/VCO2 slope (r= 0.64; p <0.001), among CPET parameters. Considering ROC
analysis, E/E’emerged as a strong predictor of peak VO2 (AUC 0.79), and even more of VE/VCO2
slope (AUC 0.84). Multivariate regression analysis showed that age, E/E’ and S' were the only
independent predictors of peak VO2, whereas VE/VCO2 slope confirmed age and E/E’ as
independent predictors.
Conclusions: In IDCM patients, cardiopulmonary exercise performance variables were
strongly related to E/E’ and S', both TDI derived measures of LV function.
O177
A RARE CASE OF CONSTRICTIVE PERICARDITIS IN A YOUNG PATIENT WITH
DERMATOMYOSITIS
VITO MAURIZIO PARATO (A), DOMENICO DELFINO (B), MANRICO PARTEMI (B),
ANIELLO ASCIONE (C)
(A) UOC CARDIOLOGIA, OSPEDALE MADONNA DEL SOCCORSO, SAN BENEDETTO
DEL TRONTO; (B) UOC CARDIOLOGIA, OSPEDALE MAZZONI, ASCOLI PICENO; (C)
UOC CARDIOLOGIA, OSPEDALE BUON CONSIGLIO FATEBENEFRATELLI - NAPOLI
The case. The patient was male, 16 y-old, and for three months he presented: muscle weakness, skin
rash, arthralgia , subcutaneous indurations, intermittent fever. He was referred to our Institution
because of progressive weakness, chest pain, weigth loss, peripheral oedema.
Phisycal findings: temperature=38°C; liver edge was palpable 4 cm below the costal margin; oedema
of the legs, ascitis, ANASARCA, congested jugular veins, absence of cardiac murmurs, BP 100/60,
HR 62/min, no pulmonary congestion.
Laboratory tests: high bilirubine and transaminase, high Ck, immunoglobulin G,A, normochromic
and normocytic anaemia, positive Rose-Waaler test.
Chest X-ray: diffuse calcification of soft tissues over the chest, neck, shoulders, arms, pelvis and
thighs.
The patient was diagnosed as having dermatomyositis.
The trans-thoracic and trans-esophageal echocardiogram showed a pericardial calcification with a
pericardium markedly thickened. There was a clear interventricular septum bulging. The tricuspid
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flow velocity increased during breathe-in and decreased during breathe-out. A constrictive
pericarditis was diagnosed.
Discussion. Dermatomyositis has an incidence of 4 : 1.000.000. It is an inflamatory disease of the
muscle and skin. The cause may result from either a viral infection or an autoimmune reaction.
Cardiac involvement in dermatomyositis and polymyositis consists of myocardial disease, heart
block and acute pericarditis. Chronic and constrictive pericarditis is very rare. The only case we found
was published in 1988 [1].
Figure 1. TEE image showing a calcified pericardium and a clear interventricular septum bulging.
CARDIOPATIA ISCHEMICA - 2
O178
DIFETTO INTERVENTRICOLARE DOPO STEMI INFERIORE
MARCO FABIO COSTANTINO (A), VINCENZO DOMENICO MARTONE (A),
ANTONELLA MATERA (A), ERNESTA DORES (A), COSTANZA MOREA (A),
GIANCARLO CALCULLI (A)
(A) OSPEDALE SAN CARLO, POTENZA
Uomo di 62 anni, ex fumatore, iperteso di lunga data in trattamento con beta-bloccanti, ACE-inibitori,
Ca-antagonisti, con storia di rettocolite ulcerosa, si presenta al P.S. per dolore all’arto superiore
sinistro insorto da oltre un’ora. Analoghi episodi di dolore negli ultimi 10 giorni.
Alla visita il paziente appare lievemente dispnoico. All’esame obiettivo si apprezza soffio olosistolico
4/6 L maggiormente udibile al centrum cordis. Al torace: rantoli crepitanti alle basi polmonari. La
PA è 140/80 mmHg e la saturazione di O2 94%. All’ECG è presente ritmo sinusale con FC di 88
bpm. BBS. Sopraslivellamento dell’ST in DIII e AVF con sottoslivellamento speculare in V4-V6 e
in DI e AVL. Gli enzimi di miocardionecrosi risultano elevati (Troponina I 3,02 ng/ml; Troponina I
max 16,84 ng/ml). Viene posta diagnosi di STEMI inferiore. All’Ecocardiogramma riscontro di
ventricolo sn di normali dimensioni endocavitarie, con conservata funzione sistolica globale e
aneurisma della parete inferiore medio-basale e del SIV inferiore medio-basale con DIV restrittivo
inferiore di circa 1 cm, shunt sn>dx e Vmax >4 m/sec. QP/QS 1,3. Insufficienza mitralica moderata.
Le sezioni dx appaiono nei limiti e la PAPs stimata è di 35 mmHg. E’ presente, inoltre, versamento
pericardico circonferenziale non emodinamicamente significativo. Viene eseguito studio
coronarografico che mostra occlusione della coronaria dx. L’ecocardiogramma transesofageo
conferma la presenza dell’aneurisma della parete inferiore medio-basale e del SIV inferiore mediobasale e del DIV restrittivo inferiore di circa 1 cm di diametro con shunt sn>dx, l’insufficienza
mitralica moderata e il versamento pericardico non tamponante. Si esegue RM del cuore che mostra
esiti di infarto delle pareti infero-settale ed inferiore del ventricolo sinistro medio-basale e della parete
inferiore medio-basale del ventricolo dx, con parziale coinvolgimento del muscolo papillare posteromediale. Ampio aneurisma della parete inferiore basale e del SIV inferiore basale legato a
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slaminamento miocardico e breccia di circa 1 cm del SIV inferiore con shunt sn>dx. Marcato
assottigliamento della parete ventricolare sn a tale livello (2 mm di spessore in sistole). Edema e
impregnazione tardiva a tutto spessore dopo contrasto come per esiti necrotici in fase subacuta. Le
dimensioni del ventricolo sinistro appaiono lievemente aumentate e la FE lievemente ridotta, circa
50%. Ventricolo dx di normali dimensioni con acinesia della parete inferiore basale e FE 50%.
Modesto versamento pericardico. Insufficienza mitralica moderata. Versamento pleurico moderato
bilaterale con congestione polmonare in particolare a livello dei segmenti inferiori.
Il paziente viene sottoposto ad intervento cardochirurgico di chiusura del DIV posteriore che presenta
circa 2 cm di diametro + plastica del VS (plicatura del ventricolo sinistro in duplice sutura dall’anello
mitralico fino alla base del papillare ad escludere il setto dilatato dove è presente in DIV).
L’ecocardiogramma post-operatorio mostra un ventricolo sinistro di dimensioni lievemente
aumentate (EDV 140 ml) con lieve riduzione della funzione sistolica globale (EF 47%); esiti di
chiusura del DIV post-infartuale senza evidenza di shunt sn>dx residuo, acinesia inferiore basale.
Disfunzione diastolica del VS di I grado. Lieve rigurgito mitralico. Funzione sistolica del VD
conservata. PAPs stimata nei limiti. Non versamento pericardico. La ventricolografia post-operatoria
conferma buon esito della plastica del ventricolo sinistro e della correzione del DIV e circoscritta
acinesia della parete inferiore basale.
O179
EXERCISE GAS EXCHANGE PHENOTYPES IN DIABETIC SUBJECTS: FINDINGS
FROM THE EURO(PEAN) EX(ERCISE) POPULATION-BASED STUDY
MARTA PELLEGRINO (A), GRETA GENERATI (A), FRANCESCO BANDERA (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) IRCCS POLICLINICO SAN DONATO
Background: Diabetes mellitus (DM) is a risk condition that may determine exercise limitation and
reduced oxygen consumption (VO2). No study in literature has addressed the cardiopulmonary
exercise testing (CPET) phenotype in diabetic subjects with normal left ventricular function. Their
functional characterization by expired gas analysis may help to better define cardiovascular (CV) risk
and to improve the timing of therapeutic interventions.
Methods: 442 asymptomatic subjects enrolled in the EURO EX trial, (mean age 60±14 years; male
49.3%; BMI 28±5.5 kg/m2) with different CV risk factors (hypertension 66%, dyslipidemia 50.2%,
smoking habit 19.2%, diabetes 15.4%) underwent a maximal CPET with personalized ramp protocol.
Results: The population was divided into two groups according to the presence of diabetes. Diabetic
subjects (n=68) were significantly older than non-DM subjects and showed a significant lower VO2
at peak exercise (16.3±4.1 vs 19.9±7.4 ml/kg/min), a steeper VE/VCO2 slope (27±3.7 vs 25.7±4) and
an impaired heart rarte reserve (peak HR 123±27 vs 135±22 bpm) and recovery (HRR 12±6 vs 17±11
beats) and higher systolic blood pressure (SBP) at rest (142±22 vs 132±15 mmHg) and peak exercise
(193±20 vs 184±22 mmHg). A significant difference in the VE/VCO2 slope, peak O2 pulse, SBP at
rest and ΔVO2/ΔWR slope was maintained when a correction for confounding factors (BMI, age,
gender, prevalence of dyslipidemia and hypertension) was applied.
Conclusions: Asymptomatic DM subjects with normal left ventricular function compared to nondiabetics show a reduced HRR and peak O2 pulse, an increased VE/VCO2 slope and higher SBP as a
typical phenotype. These findings suggest that an impaired sympathovagal control may play a key
role. Whether assessment of these variables may improve the risk-related definition and a timely
metabolic control in this patients seems to be worth of further investigation.
No DM
DM
Variables
(n=374)
(n=68)
P value
Age, y
59±14
68±10
.0000
BMI, kg/m2
28±5.5
30±5.3
.001
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Peak VO2, ml/kg/min
% predicted VO2, %
VO2 @ AT, ml/kg/min
Peak O2 pulse, ml/beat
VE/VCO2 slope
Peak HR, bpm
HRR, beats
ΔVO2/ΔWR, slope
Rest SBP, mmHg
Peak SBP, mmHg
19.9±7.4
73±21
15±5.4
11.2±3.9
25.7±4
135±22
17±11
9.4±1.5
132±15
184±22
16.3±4.1
71±20
13.1±2.9
10.5±3.1
27±3.7
123±27
12±6
9.4±2.1
142±22
193±20
Roma, 13 – 15 dicembre 2014
.0000
ns
.0001
.09
.01
.002
.0000
ns
.0007
.0007
O180
INSULIN RESISTANCE IS ASSOCIATED WITH IMPAIRED CARDIAC SYMPATHETIC
INNERVATION IN PATIENTS WITH HEART FAILURE
STEFANIA PAOLILLO (a), GIUSEPPE RENGO (b), TERESA PELLEGRINO (a),
ROBERTO FORMISANO (b), GENNARO PAGANO (b), PAOLA GARGIULO (a),
SOLARIA PISCITELLI (b), DARIO LEOSCO (b), BRUNO TRIMARCO (a),
ALBERTO CUOCOLO (a), PASQUALE PERRONE FILARDI (a)
(a) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO II,
NAPOLI; (b) DIPARTIMENTO DI SCIENZE MEDICHE TRASLAZIONALI, UNIVERSITA´
FEDERICO II, NAPOLI
Purpose: Insulin resistance (IR) represents cause and consequence of heart failure (HF) and affects
prognosis in HF patients, but pathophysiological mechanisms remain unclear. Hyperinsulinemia, that
characterizes IR, enhances sympathetic drive and it can be hypothesized that IR is associated with
impaired cardiac sympathetic innervation in HF. Yet, this hypothesis has never been investigated.
Aim of the present study was to assess the relationship between insulin resistance and cardiac
sympathetic innervation in non diabetic HF patients.
Methods: Ninety-five patients (88% males; 64.8±11.1 years) with severe-to-moderate HF (ejection
fraction 32.4 9.6%), underwent iodine-123 meta-iodobenzylguanidine (123I-MIBG) myocardial
scintigraphy to assess sympathetic innervation and Homeostasis Model Assessment Insulin
Resistance (HOMA-IR) evaluation to determine the presence of IR. From 123I-MIBG imaging early
and late heart to mediastinum (H/M) ratios were calculated.
Results: Fifty-eight (61%) patients showed IR and 37 (39%) were non-IR. No significant differences
between IR and non-IR patients were found for age, ejection fraction, NYHA class, HF etiology and
NT-proBNP levels. As expected, IR patients showed significantly higher fasting insulinemia
compared to non-IR patients (16.0±9.6 vs 5.2±5.6 mUI/l; p<0.001). Both early (1.68±0.25 vs
1.82±0.20; p=0.007) and late H/M ratio (1.50±0.28 vs 1.65±0.60; p=0.029) were significantly
reduced in IR compared to non-IR patients, whereas washout rate did not differ between the two
groups (10.7±8.2 vs 9.6±10.0, respectively; p=0.560). In addition, early and late H/M ratio showed
significant inverse correlation with fasting insulinemia (r=-0.30, p=0.003; r=-0.21, p=0.04,
respectively) and HOMA-IR (r=-0.34, p=0.001; r=-0.21, p=0.03, respectively).
Conclusion: Cardiac sympathetic innervation is more impaired in patients with IR and HF compared
to matched non-IR patients. These findings contribute to explain the unfavorable prognostic impact
of IR in patients with HF.
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O181
IMPATTO PROGNOSTICO DELLA RIVASCOLARIZZAZIONE CHIRURGICA VS
IBRIDA IN PAZIENTI CON MALATTIA ATEROSCLEROTICA CAROTIDEA CRITICA
CANDIDATI A BYPASS CORONARICO: RISULTATI DI UNO STUDIO
MULTICENTRICO
ANNA PICCOLI (a), FABRIZIO TOMAI (b), RAOUL BORIONI (b), GIOVANNI DE
PERSIO (b), FAUSTO CASTRIOTA (c), ALBERTO CREMONESI (c),
ANDREA PACCHIONI (d), BERNHARD REIMERS (d), CORRADO VASSANELLI (a),
FLAVIO RIBICHINI (a)
(a) DIPARTIMENTO DI MEDICINA, UNIVERSITÀ DEGLI STUDI DI VERONA, VERONA,
ITALIA; (b) DIPARTIMENTO DI SCIENZE CARDIOVASCOLARI, EUROPEAN HOSPITAL,
ROMA, ITALIA; (c) UNITÀ CARDIOVASCOLARE, GVM CARE AND RESEARCH, VILLA
MARIA CECILIA HOSPITAL, COTIGNOLA, ITALIA; (d) DIVISIONE DI CARDIOLOGIA,
OSPEDALE CIVILE DI MIRANO, MIRANO, ITALIA
BACKGROUND: L’aterosclerosi multidistrettuale è un’entità clinica in continuo aumento in
parallelo con l’aspettativa di vita. Nonostante la sua elevata prevalenza, la gestione ottimale di
pazienti con malattia coronarica e carotidea combinate rimane controversa. In presenza di una
indicazione alla rivascolarizzazione carotidea in candidati ad intervento di bypass coronarico (BC)
non sono disponibili chiare evidenze di quale strategia invasiva sia superiore. Storicamente la
tromboendoarterectomia chirurgica (TEA) è stata il trattamento di riferimento, ma attualmente
l’angioplastica con stent (CAS) è un’opzione alternativa specialmente nei pazienti ad alto rischio
chirurgico.
FINALITA’ DELLO STUDIO: Valutare l’outcome clinico a 30 giorni e ad 1 anno in pazienti con
aterosclerosi coronarica e carotidea critiche sottoposti a rivascolarizzazione completamente
chirurgica (BC+TEA) vs trattamento ibrido (BC+CAS).
METODI: Nel contesto di una cooperazione multicentrica (FRIENDS, Finalized Research in
ENDovascular Strategies) svoltasi in 4 centri ad alto volume dedicati al trattamento della malattia
vascolare multidistrettuale, tra il 2006 e il 2012 sono stati arruolati 1043 pazienti con malattia
coronarica e carotidea critica. Per questa analisi è stato selezionato un sottogruppo di 258 pazienti
sottoposti ad intervento di BC in associazione ad un intervento di rivascolarizzazione carotidea:
chirurgico (TEA) per 199 pazienti ed endovascolare (CAS) per 59 pazienti. I due distretti arteriosi
sono stati sottoposti a trattamento simultaneo oppure differito con una distanza temporale massima
di 60 giorni. L’obiettivo di questo studio è quello di valutare l’incidenza a 30 giorni di MACCES
(morte, infarto miocardico acuto, ictus cerebri) ed emorragie maggiori (BARC >2) e ad 1 anno di
MACCES nei due gruppi sottoposti a differente trattamento.
RISULTATI: L’età media dei pazienti era di 70±9 anni, 63 (24%) pazienti erano di genere
femminile, 121 (47%) diabetici e 229 (89%) ipertesi; tali caratteristiche non differivano
significativamente tra i gruppi sottoposti a differente strategia di trattamento (p>0,1 per tutti).
226 (88%) pazienti sono stati ricoverati per una causa cardiologica di cui 37 (14% del totale) per
sindrome coronarica acuta, mentre 23 (9%) per un evento neurologico acuto (ictus cerebri o attacco
ischemico transitorio). Al momento del ricovero 28 (11%) pazienti presentavano sintomi neurologici.
A 30 giorni di follow-up 13 (5%) pazienti hanno presentato MACCES e 23 (9%) emorragie maggiori.
L’incidenza di MACCES non differiva nei due gruppi sottoposti a CAS o TEA risultando
rispettivamente 1 (2%) e 12 (6%); p=0,3. Considerando all'interno dei MACCES anche le emorragie
emergeva una differenza significativa nella numerosità degli eventi tra i due gruppi: 17 (29%) nel
gruppo BC+CAS vs 19 (10%) nel gruppo BC+TEA; p<0,0001.
Ad 1 anno di follow-up 42 (16%) pazienti hanno presentato MACCES e l’incidenza non differiva tra
i due gruppi sottoposti a CAS o TEA risultando rispettivamente 8 (14%) e 34 (17%); p=0,5.
SIC | Indice Autori
161
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
CONCLUSIONI: Nella presente esperienza l’incidenza cumulativa di eventi maggiori (morte,
infarto miocardico acuto, ictus cerebri) a 30 giorni e ad 1 anno non differiva tra i due gruppi. Tuttavia
i pazienti sottoposti ad approccio terapeutico ibrido presentavano un rischio emorragico elevato.
O182
ECHOCARDIOGRAPHIC EVALUATION OF RIGHT VENTRICULAR FUNCTION
AFTER MITRACLIP IMPLANTATION IN FUNCTIONAL MITRAL REGURGITATION.
FRANCESCA FIORELLI (A), CRISTINA GIANNINI (A), MARCO DE CARLO (A),
LORENZO CONTE (A), IACOPO FABIANI (A), ANNA SONIA PETRONIO (A),
VITANTONIO DI BELLO (A), FABIO GUARRACINO (A)
(A) CARDIOTHORACIC AND VASCULAR DEPARTMENT, AZIENDA OSPEDALIEROUNIVERSITARIA PISANA, PISA, ITALY
Aims: Percutaneous mitral valve repair (PMVR) for mitral regurgitation (MR) can be performed with
the MitraClip System. Our aim was to assess the changes of right ventricular (RV) after Mitraclip in
patients with functional MR.
Methods and Results: Between November 2009 and December 2013, 52 patients affected by severe
functional MR underwent PMVR with the MitraClip. Patients who didn’t undergo successful
Mitraclip implantation were excluded from the analysis. Therefore, the study population included 47
patients. Median age was 74 years (63-81), 82,9% (n=39) were male with a median logistic
EuroSCORE of 25%. Patients with MR grade ≥3+ were 9.6% and 11.4% at discharge and 6 months,
respectively (p<0.0001) versus 100% at baseline, with a clinical benefit in NYHA class (p<0.0001).
BNP plasma levels revealed a significant overall decrease at follow-up(from 61.1±16.5 to 32.9±18.4;
P<0.0001). Improvements in left ventricular (LV) size and function were observed. At baseline,
before discharge and 6-months, respectively, the LV end-diastolic diameter was 67.3±9.9mm,
65.6±9.8mm and 62.7±10.3mm (p<0.0001), the LV end-diastolic volume 198.9±69.1ml,
186.4±70.6ml and 178.6±78.6ml (p=0.001), the LV ejection fraction 34.3±10.6%, 36.3±9.0% and
40.0±11.7% (p=0.001). During follow-up, an improvement in the RV function was also observed. At
baseline, before discharge and 6-months, respectively, the tricuspid annulus plane systolic excursion
(TAPSE) was 16.7±3.8mm, 18.2±3.44mm and 19.3±4.1mm (p=0.02), the systolic pulmonary artery
pressure (SPAP): 50.6±8.4mmHg, 40.9±8.2 mmHg and 39.1±10.4 mmHg (p<0.0001), the systolic
velocity at the tricuspid annular (RV-Sm): 9.2±3.8 cm, 10.1±3.3 cm and 11.8±3.1 cm (p=0.003).
Moreover, we observed right atrial (RA) reverse remodeling with significant decrease in RA area
(p<0.0001).
Conclusion: MitraClip implantation has induced a significant reduction of LV volume overload. The
concomitant reduction of LV filling pressure, after Mitraclip implantation, reflected nearly
immediately on clinical profile and hemodynamics of the right sections. Since discharge, we
observed both a significant reduction of SPAP and a significant increase of longitudinal RV systolic
function as shown by the increase of TAPSE and RV-Sm.
SIC | Indice Autori
162
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O183
CLINICAL OUTCOME IN ACUTE CORONARY SYNDROME PATIENTS TREATED
WITH A 2ND GENERATION DRUG-ELUTING STENT: THE ROLE OF DIABETES
MELLITUS IN TERMS OF LESION- AND PATIENT-RELATED OUTCOME
ALESSANDRO LUNARDON (A), GIANPIERO D´AMICO (A), TOMMASO FABRIS (A),
CLAUDIA ZANETTI (A), NATASCIA BETTELLA (A), ALBERTO BARIOLI (A),
MARCO MOJOLI (A), MICHELA FACCHIN (A), PAOLA ANGELA MARIA PURITA (A),
ELISA COVOLO (A), FILIPPO ZILIO (A), GIULIA MASIERO (A), GILBERTO DARIOL (A),
AHMED AL MAMARY (A), BLERI CELMETA (A), MASSIMO NAPODANO (A),
SABINO ILICETO (A), GIAMBATTISTA ISABELLA (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA
Background. Drug-eluting stent (DES) have shown promising clinical results in the treatment of
acute coronary syndrome (ACS) patients. However diabetes mellitus (DM) is a predictor of poor
outcome after percutaneous coronary intervention. There are limited data on ACS patients treated
with 2nd generation DES according to diabetic status.
Methods. This prospective study included 452 ACS patients (78% male, age 65.6 ±11.6) treated
with a 2nd generation DES. We evaluate the clinical outcomes in terms of lesion-related events
(including target lesion revascularization, cardiac death and target vessel myocardial infarction) and
patient-related events (including all-cause death, any myocardial infarction and any
revascularization)
Results. Since January 2009 to March 2013, 210 DM patients and 242 non DM patients with ACS
were enrolled. DM patients were older, more frequently of male sex and suffering more often of
hypertension, hypercholesterolemia and chronic renal failure. DM was statistically associated with
multi-vessel CAD and incomplete revascularization. Lesion-related outcomes were comparable
between the two groups (10.4% for DM vs 8.8% for non DM, p=0.61) while patient-related outcome
show a statistical trend against DM population (21.4% for DM vs 14.6% for non DM,
P=0.08). Kaplan Meier survival curves show a statistical significance for patient-related outcome
(Figure).
Conclusion. There is a significant gap in patient-related outcome compared to lesion-related
outcome among DM patients in ACS population, mainly driven by the rate of repeated
revascularization of the non-culprit lesions due to the chronic background of diabetic coronary artery
disease.
SIC | Indice Autori
163
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
CARDIOPATIA ISCHEMICA - 3
O184
PASTA ENRICHED WITH BARLEY(1-3)BETA-D-GLUCAN INCREASES MYOCARDIAL
PARKIN EXPRESSION AND PREVENTS CARDIAC ISCHEMIA/REPERFUSION INJURY
IN MICE
VALENTINA CASIERI (A), MARCO MATTEUCCI (A), GAIA PAPINI (A),
SILVERIO SBRANA (C), MICHELE TORELLI (D), VINCENZO LIONETTI (A, B)
(A) LABORATORY OF MEDICAL SCIENCE, INSTITUTE OF LIFE SCIENCES, SCUOLA
SUPERIORE SANT´ANNA, PISA, ITALY; (B) FONDAZIONE TOSCANA “GABRIELE
MONASTERIO“, PISA, ITALY; (C) INSTITUTE OF CLINCIAL PHYSIOLOGY, NATIONAL
COUNCIL OF RESEARCH, PISA, ITALY; (D) PASTIFICIO ATTILIO MATROMAURO
GRANORO S.R.L., CORATO, ITALY
Introduction: Parkin, an E3 ubiquitin ligase, is required for cardioprotective effects of ischemic
preconditioning by triggering mitophagy. However, the noninvasive induction of myocardial parkin
level is a desirable achievement. (1-3) β-D-glucan, a water-soluble polysaccharide, protects against
cardiac ischemia/reperfusion (I/R) injury, yet mechanisms are still unknown.
Hypothesis: Dietary intake of pasta enriched with 3% w/v barley (1-3) β-D-glucans upregulates the
expression of parkin in cardiomyocytes and increases cell resistance to I/R microenvironment.
Methods: Adult male C57BL/6 mice were fed for 5 weeks with a low-fat diet supplemented with
pasta enriched with barley (1-3) β-D-glucan (3g/100mg) (β-D-glucan, n=15) or regular pasta (control,
n=15). Food and caloric intake, glucose tolerance test and cardiac function were weekly assessed. At
fifth week of diet, each group underwent to 30 min of cardiac ischemia and 60 min of reperfusion.
Infarct size/area at risk was assessed at the end of cardiac reperfusion. Myocardial expression of
parkin and p53, a parkin inhibitor, were measured by western blot. Cardiac anion superoxide (O2-)
load was detected by dihydroethidium staining. To evaluate the impact of β-D-glucan on mitophagy,
we further examined the parkin level and mitochondria JC1 staining green in β-D-glucan-treated HL1
cardiomyocytes exposed to acute oxidative stress (100uM H2O2).
Results: Food and caloric intake, plasma glucose level and cardiac function were similar in both
groups. Dietary supplementation with functional pasta increased myocardial parkin level by 85±2%
(P<0.00001) without altering p53 protein expression. At the end of cardiac I/R, survival of β-Dglucan mice was significantly increased by 50±2% compared to control. Infarct size/area at risk was
reduced by 62±5% (P<0.001) in β-D-glucan mice in the presence of reduced myocardial O2- load
(P<0.0001). In vitro, JC1 staining green was increased in β-D-glucan-treated HL1(P<0.001), which
have shown higher parkin level and resistance to oxidative burst.
Conclusions: Long-term dietary intake of pasta enriched with 3% w/v barley β-D-glucan increased
cell survival to I/R microenvironment and reduced infarct size through increasing parkin-dependent
mitophagy in cardiomyocytes.
SIC | Indice Autori
164
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O185
CARDIOPROTECTIVE ROLE OF CALCITONIN GENE-RELATED PEPTIDE (CGRP)
RELEASE INDUCED BY ANGELI’S SALT
CLAUDIA PENNA (B), KARINE CABIALE (A), MARIA-GIULIA PERRELLI (B),
SAVERIA FEMMINÒ (B), FRANCESCA TULLIO (B), MARCO R. GALLONI (A),
PASQUALE PAGLIARO (B)
(A) DIPARTIMENTO DI SCIENZE VETERINARIE; (B) DIPARTIMENTO SCIENZE
CLINICHE E BIOLOGICHE UNIVERSITA TORINO
Reperfusion therapy is mandatory in acute myocardial infarction (AMI). However restoration of
blood flow on ischemic heart produces a further damage of myocardium, namely
ischemia/reperfusion (I/R) injury. Preconditioning and postconditioning have been shown to
protect the heart against I/R injury. Studies have shown that one electron reduction product of NO
nitroxyl (HNO/NO-) donated by Angeli’s salt (AS) induces myocardial protection against I/R
injury like preconditioning effect. HNO/NO- signaling appears to be coupled to calcitonin generelated peptide (CGRP) release that activates KATP channels.
The aim of this study was to determine the AS cardioprotection and its link with CGRP in ex vivo
model, and to determine whether CGRP is involved in vitro cardiac protection.
In isolated heart we studied the effect of infusion of AS and its relation with CGRP system. Each
animal was anesthetized, the heart was rapidly excised and retrogradely perfused with oxigenated
Krebs-Henseleit buffer and electrically paced at 280 bpm at temperature controlled. Each heart
was allowed to stabilize for 30 min. After the stabilization period, hearts were subjected to a
specific protocol, which included in all groups a 30 min of global no-flow ischemia (I) followed a
period of 120-min reperfusion (R). Pacing was discontinued on initiation of ischemia and restarted
after the third minute of reperfusion in all groups. After stabilization in Group 1 the hearts were
subjected to I/R only; Group 2 before ischemia the hearts were perfused with AS (1M) for 19
min then I-30 min and R-120min; in Group 3 the role of CGRP in AS induced protection was
examined in hearts where AS (1 μM) effects were evaluated during co-infusion with the CGRP
receptor antagonist CGRP8-37. At the end of reperfusion we evaluated myocardial injury (infarct
size (IS) and LDH release, by nitro-bluetetrazolium and spectrophotometric assay, respectively)
and mechanical performance (left ventricular pressure). In H9C2 cells we studied the action of
CGRP in Hypoxia/Reoxygenation (H/R) protocol and its molecular pathway (inhibitor of PKC,
mitochondrial potassium channels and ROS scavenger) and modulation of oxidative stress
(hydrogen peroxide test). H9C2 cells were grown in α-MEM, fetal bovine serum and
streptomycin/penicillin, thereafter submitted to a pretreatment with CGRP and/or blocking factors
and then to H/R protocol.
We observed in isolated hearts that AS reduces significantly the IS (38±3.5 and 67±6% in AS and
I/R group, respectively, p<0.05 respect to I/R), this result was corroborated by reduction of LDH
and myocardial dysfunction. AS was unable to reduce IS in the presence of CGRP receptor
blocker. In in vitro CGRP abolishes the cellular death induced by H/R protocol and all inhibitors
abolish this protective effects. The oxidative stress reduced significantly the cells viability and this
effect is reverted by CGRP treatment.
In conclusion these results demonstrate that in the isolated heart the preconditioning-like protective
effect of AS is dependent by CGRP, this protection is reproducible in cellular model and it is
dependent by PKC and mitochondrial potassium channel.
SIC | Indice Autori
165
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O186
DIABETES MELLITUS AND ISCHEMIC HEART DISEASE SUSCEPTIBILITY: WHICH
IS THE INFLUENCE OF GENETIC POLYMORPHISMS FOR KATP CHANNELS?
PAOLO SEVERINO (A), ALESSANDRA CINQUE (A), NICOLÒ SALVI (A),
ANTONIO FUSTO (A), GIORGIO CALABRESE (A), ALESSANDRA ARMATO (A), MARIA
LAURA DE MARCHIS (B), RAFFAELE PALMIROTTA (B), MASSIMO MANCONE (B),
FRANCESCO FEDELE (B)
(A) DEPARTMENT OF CARDIOVASCULAR, RESPIRATORY, NEPHROLOGY,
ANESTHESIOLOGY AND GERIATRIC SCIENCES, SAPIENZA UNIVERSITY OF ROME,
UMBERTO I POLICLINIC, VIALE DEL POLICLINICO 155, 00161 ROME, ITALY; (B)
DEPARTMENT OF ADVANCED BIOTECHNOLOGIES AND BIOIMAGING, IRCCS SAN
RAFFAELE PISANA, ROME, ITALY
Background: Several evidences show that patients with diabetes mellitus (DM) are at high risk for
ischemic heart disease (IHD). In patients with DM, the public health impact of IHD is vast and is
growing. Recently, we proposed that genetic polymorphisms (SNP) of coronary ion channels may be
involved in IHD pathophysiology. We showed that the genotype distribution of SNP rs5215 for
Kir6.2 subunit of ATP-dependent potassium (KATP) channels moderately deviated from the HW
equilibrium and that rs5215_GG is linked to IHD susceptibility. Especially, we found that rs5215_GG
genotype of Kir6.2 might have a ‘‘protective’’ role in IHD genesis. Moreover, previous studies
described that SNP rs5215_GG is strongly correlated with DM and hyperinsulinism in human.
Aim and Methods: In the present study, we hypothesized that SNP rs5215_GG for Kir6.2 subunit
for KATP channels had some influences in the susceptibility of DM to IHD. We performed a
subgroup analysis about the influence of rs5215_GG in diabetic patients on our previous population,
i.e. 242 patients candidates to elective or emergency coronary angiography for acute coronary
syndrome or chronic angina, of which 155 with CAD, 46 with microvascular dysfunction and 41 with
anatomically and functionally normal coronary arteries (control group).
Results: Among 242 patients, comparing subjects with DM to those without, there was not any
significant difference in the prevalence of rs5215_GG. However, among 33 subjects without DM
with normal coronary arteries, SNP rs5215_GG had a higher prevalence compared to those in the
CAD group (10/33; 30.3%; p= 0.0277) as well as non-diabetic patients in the microvascular
dysfunction group (9/33; 27.2%; p= 0.0295).
Conclusions: The variant rs5215_GG is a missense SNP (ATC-GTC) that results in the substitution
of isoleucine (I) residue with valine (V) in the Kir6.2 subunit of KATP channels. Our results confirm
that rs5215_GG might decrease susceptibility to IHD in patients without DM. In fact, rs5215_GG
was confirmed to be present more frequently in patients without DM presenting anatomically and
functionally normal coronary arteries. We might assume that the well-known protective status of
absence of DM against IHD genesis may be improved by coronary KATP channels expressing
rs5215_GG. Taken together, our data ratify the possibility of associations between SNP for coronary
ion channels and IHD, endorsing the idea that ion channels play a key role in coronary homeostasis
and that genetic polymorphism encoding for ion channels are involved in IHD pathophysiology.
SIC | Indice Autori
166
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O187
CARDIAC MAGNETIC RESONANCE IMPROVES NO REFLOW DIAGNOSTIC
ACCURACY AND PROGNOSTIC STRATIFICATION COMPARED TO CORONARY
ANGIOGRAPHY IN PATIENTS WITH ST-SEGMENT ELEVATION ACUTE
MYOCARDIAL INFARCTION
ALESSANDRO DURANTE (A, B), FRANCESCO DE COBELLI (B, C),
PIETRO LAFORGIA (B), ANTONIO ESPOSITO (B, C), GIUSEPPE PIZZETTI (C),
GIULIA BENEDETTI (B, C), ANNA DAMASCELLI (B, C), MARIANGELA CAVA (B, C),
CLAUDIA BORGHI (A), GIOVANNI CORRADO (A), ANTONIO COLOMBO (C),
ALBERTO MARGONATO (B, C), ORNELLA E. RIMOLDI (D), PAOLO G. CAMICI (B, C)
(A) OSPEDALE VALDUCE, COMO; (B) UNIVERSITÀ VITA-SALUTE SAN RAFFAELE,
MILANO; (C) OSPEDALE SAN RAFFAELE, MILANO; (D) IBFM CNR, MILANO
Objectives: To assess the no reflow (NR) diagnostic accuracy and prognostic stratification ability of
coronary angiography versus cardiac magnetic resonance (CMR) in patients with acute ST-elevation
myocardial infarction (STEMI).
Methods: We enrolled 70 consecutive STEMI patients within 12 hours of symptoms onset who
underwent primary percutaneous coronary intervention (PCI). Angiographic NR (ANR) was defined
as TIMI flow grade <3 and/or blush grade <2 post PCI. CMR NR (Philips Achieva 1.5 T) was defined
as microvascular obstruction (MVO) on early and late T1w IR images (LGE) aquired after injection
of 0.15 mmol/kg of Gadobutrol. The area at risk was delineated on T2W STIR images. Left ventricle
(LV) volumes were indexed for BSA.Patients underwent CMR between 2 and 5 days after STEMI
and at 6 months follow-up.
Results: Twenty-two patients (31%) had ANR and 46 (66%) showed MVO at CMR. Among patients
with ANR, only 2 did not have MVO. Among patients with MVO, 24 had ANR and 22 did not.
Patients with MVO had larger infarct size as assessed by biochemistry and CMR parameters. In fact,
they had both higher troponin T (TnT) peak (8.24±5.31 vs 2.62±2.28 µg/l, p<0.0001) and larger LGE
area (31.5±10.6 vs 19.6±10.3% LV , p<0.0001) compared to patients without MVO. Patients with
MVO had significantly lower LV ejection fraction (LVEF) (47.1±9.3 vs 56.3±8.3%, p<0.001) and
increased LV end systolic volume (LVESVi) (40.8±12.0 vs 33.2±10.0 ml/sqm, p=0.02). In contrast,
patients with ANR showed a non-significant trend towards larger infarct size compared to those
without ANR (TnT peak 7.72 ± 4.40 vs 5.56 ± 5.56 µg/l, p=0.12; LGE area 28.5±10.8 vs
26.9±12.6%LV, p=0.64).
At univariate analysis, a pre-PCI TIMI flow of 0-1 predicted MVO (OR 0.26 ,p=0.05), but not ANR
(OR 0.52, p=0.38). The occurrence of ANR predicted the presence of MVO at CMR (OR 7.56,
p=0.01), but not LGE extension (OR 1.01, p=0.64). Conversely, MVO occurrence was related to
larger LGE (OR 1.12, p=0.002). TnT peak predicted MVO at univariate analysis (OR 1.742,p<0.001).
After multivariate analysis, only TnT peak was an independent predictor of MVO (OR 2.10,
p<0.001).
Mean clinical follow-up (FU) was 390 ± 243 days. FU CMR showed that patients with acute phase
MVO + had lower LVEF (51.7±9.3 vs 61.5±5.6%, p<0.05) and higher LVEDVi (90.6±18.3 vs
69.6±14.3 ml/sqm, p<0.05) and LVESVi (46.1±15.8 vs 27.3±9.6 ml/sqm, p<0.01). Patients with and
without ANR did not have significant differences in LVEF, iEDV, iESV and LGE area at FU CMR.
MACE-free survival was significantly worse in patients with MVO (34% vs 11% without MVO,
p=0.05), while it was similar in patients with and without ANR (32% vs 28%, p=0.53).
Conclusion: Our data suggest a higher diagnostic efficiency, accuracy and prognostic stratification
of CMR vs angiography in STEMI patients.
SIC | Indice Autori
167
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O188
TRANSITORIA ATTENUAZIONE DELL'AMPIEZZA DEL QRS NEI PAZIENTI CON
SINDROME DI TAKOTSUBO: UNO STUDIO CASO-CONTROLLO
FEDERICO GUERRA (A), EDLIRA RRAPAJ (A), IRENE GIANNINI (A),
AZZURRA FABBRIZIOLI (A), GIULIA PONGETTI (A), LORENZO FAETANI (A),
VALENTINA PELIZZONI (B), DANIELA ASCHIERI (B), ALESSANDRO CAPUCCI (A)
(A) CLINICA DI CARDIOLOGIA ED ARITMOLOGIA, OSPEDALI RIUNITI DI ANCONA,
UNIVERSITÀ POLITECNICA DELLE MARCHE; (B) DIVISIONE DI CARDIOLOGIA,
OSPEDALE “GUGLIELMO DA SALICETO“, PIACENZA
Background: La sindrome Takotsubo (ST) è una cardiomiopatia reversibile stress-correlata che
mima clinicamente la sindrome coronarica acuta (SCA), in assenza di una coronaropatia significativa.
In questo studio è stata valutata l’ampiezza del QRS durante la fase acuta rispetto ad ECG antecedenti
e successivi, nei pazienti con SCA e ST.
Metodi: 58 pazienti affetti da ST ospedalizzati tra Agosto 2010 e Aprile 2014 sono stati confrontati
con 58 pazienti con diagnosi di SCA e caratteristiche simili quali il sesso, l’età e le caratteristiche del
tratto ST all’esordio. I pazienti che si presentavano in ospedale oltre le 12 ore dall’esordio dei sintomi
sono stati esclusi. Gli ECG sono stati registrati all’ingresso, il giorno dopo la coronarografia e prima
della dimissione in tutti i 116 pazienti. 29 pazienti hanno fornito ECG precedenti l’evento acuto che
sono stati inclusi nell’analisi. 26 pazienti hanno accettato di ripetere un ECG dopo la dimissione, che
è stato incluso nell’analisi. Una bassa ampiezza del QRS (LQRSV) è stata definita come un QRS di
ampiezza totale ≤ 5 mm nelle derivazioni periferiche e ≤10 mm nelle derivazioni precordiali.
L’ampiezza di ogni singolo QRS è stata divisa per il valore di ampiezza registrato all’ECG precedente
la coronarografia in modo da ottenere un valore utilizzabile per il confronto statistico. Le ampiezza
dei QRS sono state valutate nei seguenti gruppi di derivazioni: anteriori (V1- V3), laterali (V4 - V5),
laterali alte (I e aVL), inferiori (II, III, aVF) e aVR, quest’ultima come rappresentativa di tutte le
derivazioni degli arti.
Risultati: entrambi i gruppi hanno mostrato un analogo
numero di derivazioni con LQRSV dall’esordio fino
all’ECG eseguito dopo la coronarografia. Tuttavia alla
dimissione e durante il follow-up successivo, i pazienti
con ST avevano un minor numero di derivazioni con
LQRSV (p=0.030 e p=0.003, rispettivamente).
L’ampiezza del QRS segue un determinato trend di
variazione nel tempo (Figura 1), in cui si identifica una
prima fase, dopo l’evento acuto, caratterizzata
dall’attenuazione dell’ampiezza del QRS in entrambi i gruppi (within subjects effect p=0.002). Dopo
la coronarografia, i pattern cominciano a divergere (between subjects effect p=0.019). I pazienti con
ST mostrano nella seconda fase un progressivo incremento dell’ampiezza del QRS che torna al valore
pre-evento, prendendo la forma di una curva quadratica (between-subjects quadratic contrast for ST
p=0.004). Nei pazienti con SCA non si osserva questo trend e l’ampiezza del QRS non mostra
modificazioni significative dopo l’ingresso. Questo trend è particolarmente evidente in aVR e nelle
derivazioni laterali alte. Un aspetto simile si può osservare nelle derivazioni inferiori e laterali
nonostante il between-subject contrast non mostri significatività statistica. D’altro canto le
derivazioni anteriori non mostrano un trend significativo nel tempo, né differenze tra i due gruppi.
Conclusioni: Pazienti con ST e SCA mostrano pattern di attenuazione del QRS differenti: nei primi si osserva una transitoria attenuazione dell’ampiezza del QRS che inizia a risolversi dopo alcuni giorni dall’evento acuto. Nonostante l’edema miocardico possa esserne una spiegazione plausibile, il reale meccanismo dietro tali modificazioni non è ancora del tutto chiaro.
SIC | Indice Autori
168
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O189
GENETIC VARIANTS FOR KATP CHANNELS AS PROTECTIVE FACTORS IN
ISCHEMIC HEART DISEASE SUSCEPTIBILITY: GENDER DIFFERENCES.
PAOLO SEVERINO (A), ALESSANDRA CINQUE (A), GIORGIO CALABRESE (A),
PASQUALINA BRUNO (A), MARIATERESA PUCCI (A), ALESSANDRA ARMATO (A),
MARIA LAURA DE MARCHIS (B), RAFFAELE PALMIROTTA (B),
MASSIMO MANCONE (A), FRANCESCO FEDELE (A)
(A) DEPARTMENT OF CARDIOVASCULAR, RESPIRATORY, NEPHROLOGY,
ANESTHESIOLOGY AND GERIATRIC SCIENCES, SAPIENZA UNIVERSITY OF ROME,
UMBERTO I POLICLINIC, VIALE DEL POLICLINICO 155, 00161 ROME, ITALY; (B)
DEPARTMENT OF ADVANCED BIOTECHNOLOGIES AND BIOIMAGING, IRCCS SAN
RAFFAELE PISANA, ROME, ITALY
Background: Coronary artery disease has been widely considered a “man's disease” and not a major
concern for women. However, in last few years scientists have been trying to unlock the female
physiology of ischemic heart disease (IHD). In fact, women are more prone than men to
microvascular coronary dysfunction. Recently, we proposed that genetic polymorphisms (SNP) of
coronary ion channels may be involved in IHD susceptibility. Our published data showed that the
genotype distribution of SNP rs5215 for Kir6.2 subunit of ATP-dependent potassium (KATP)
channels moderately deviated from the HW equilibrium and that rs5215_GG is correlated with IHD
susceptibility. In particular, we described that rs5215_GG genotype of Kir6.2 might have a
‘‘protective’’ role in IHD genesis.
Aim and Methods: In order to better describe the role of SNP rs5215_GG on IHD susceptibility in
woman, we conducted a gender difference in term of prevalence of rs5215_GG on our previous
population, i.e. 242 patients with acute coronary syndrome or stable angina, of which 155 with CAD,
46 with microvascular dysfunction and 41 with anatomically and functionally normal coronary
arteries.
Results: Among 242 patients, rs5215_GG was found to be more frequent in women (16/82; 19.51%;
p=0.0450) compared to men. In particular, rs5215_GG was more frequent in female patients with
anatomically and functionally normal coronary arteries (8/24; 33.3%; p=0.0428) compared with
women with CAD, whereas there was no difference between men in normal and CAD groups.
Conclusions: The polymorphism rs5215_GG is a missense SNP (ATC-GTC) that results in the
substitution of isoleucine (I) residue with valine (V) in the Kir6.2 subunit of KATP channels. Our
data validate the hypothesis that rs5215_GG could reduce susceptibility to IHD. In fact, rs5215_GG
was confirmed to be present more frequently in woman presenting anatomically and functionally
normal coronary arteries. Results of the present study suggest that coronary KATP channels
expressing rs5215_GG play a key role in the protective status of women against IHD. Our data
endorse the prospect of associations between SNP encoding coronary ion channels and IHD,
validating the idea that ion channels act in coronary homeostasis and that polymorphisms for ion
channels might be included in IHD genesis.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
CARDIOLOGIA INTERVENTISTICA STRUTTURALE
O190
IMPACT OF CAROTID ARTERY DISEASE AND CAROTID REVASCULARIZATION IN
PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION
PAOLA ANGELA MARIA PURITA (A), MARCO MOJOLI (A), GIULIA MASIERO (A),
MICHELA FACCHIN (A), MASSIMO NAPODANO (A), AUGUSTO D´ONOFRIO (A),
ANDREA COLLI (A), DEMETRIO PITTARELLO (A), ELISA COVOLO (A),
GIANPIERO D´AMICO (A), ALBERTO BARIOLI (A), MARTA MARTIN (A),
CLAUDIA ZANETTI (A), CHIARA FRACCARO (A), VALERIA GASPARETTO (A),
BLERI CELMETA (A), FILIPPO ZILIO (A), AHMED AL-MAMARY (A),
GILBERTO DARIOL (A), MARCO BASILE (B), GIAMBATTISTA ISABELLA (A),
GINO GEROSA (A), SABINO ILICETO (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) MALATTIE DELL’APPARATO CARDIOVASCOLARE, D.E.T.O.,
UNIVERSITÀ DEGLI STUDI DI BARI “ALDO MORO”
Background: No data are available on the impact of carotid artery disease (CD) on outcomes of
patients undergoing TAVI. In particular, it is uncertain whether the presence of CD at the time of
TAVI may influence outcomes and if carotid revascularization before TAVI might affect the
incidence of cerebral vascular accidents or other major adverse events.
Methods: Consecutive patients undergoing TAVI in Padova between june 2007 and may 2014 were
enrolled in a prospective registry. TAVI was performed by percutaneous trans-femoral, transsubclavian or trans-apical approach, using either the self-expandable 3rd generation CoreValve
(Medtronic, Minneapolis, Minnesota USA) or the Edwards SAPIEN, SAPIEN XT or SAPIEN 3
balloon-expandable prostheses (Edwards Lifesciences Irvine, CA). Clinical and echocardiographic
follow-up was collected at 30-days, 3, 6, 12, 24 months and yearly thereafter. We assessed the impact
of CD versus absence of CD and, among patients with CD, the impact of treated versus non-treated
carotid artery disease at the time of TAVI in terms of major adverse events.
Results: Out of 305 patients who underwent TAVI, 125 (40.9%) had CD, defined as at least one
carotid artery with stenosis ≥50% and/or previous carotid revascularization. Mean age was 80.5 ± 6.5
years (52.4% female), mean logistic EuroSCORE was 20.7% ± 12.2. Previous (≥90 days before
TAVI) percutaneous or surgical revascularization had been performed respectively in 10 (3.3%) and
35 (11.5%) patients. Ad hoc pre-procedural carotid revascularization (<90 days before TAVI) was
performed in 8 (2.6%) patients. 14 patients underwent TAVI with untreated CD. At 30-day follow up
after TAVI, overall mortality was 5%, while overall stroke incidence was 2.7%. No difference was
detected in mortality or stroke incidence by logistic regression analysis in the comparisons between
patients with or without CD and, among patients with CD, between patients with CD left untreated at
the time of TAVI vs patients treated at any time-point before TAVI. At late follow-up (median 23.9
months), overall mortality was 27% and stroke incidence was 4.4%, without difference between
patients with or without CD. However, among patients with CD, late stroke incidence was found to
be significantly higher in patients with carotid disease left untreated at the time of TAVI (p=0,047),
while there were no difference in mortality. All other major adverse events were comparable among
groups both at early and late follow up.
Conclusion: In this study, the prevalence of carotid artery disease was high in patients referred for
TAVI. The presence of untreated carotid artery disease was associated to significantly higher stroke
rates at late follow up. This observation provides the proof of concept for further prospective studies
on ad hoc pre-TAVI carotid revascularization in patients with carotid artery stenosis >50%.
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Roma, 13 – 15 dicembre 2014
O191
ANALYSIS OF RENAL FUNCTION IN PATIENTS UNDERGOING TAVI
FRANCESCA DE PERSIS (A), DOROTEA RUBINO (A), SAVERIO MUSCOLI (A),
VALERIA CAMMALLERI (A), ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A),
EUGENIA MAIO (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), FABIANA COZZA (A), GIANPAOLO USSIA (A),
FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Background: Transcatheter aortic valve implantation (TAVI) is an emerging procedure for high-risk
and inoperable patients with severe aortic stenosis. Renal impairment occurs in more patients
undergoing cardiac surgery and it is associated with substantial morbidity and mortality, independent
of all other factors. The correlation between TAVI and renal function has not been completely
elucidated. The aim of this study was to determine the influence of baseline and post procedural renal
function on prognosis after TAVI.
Methods: From November 2011 to June 2014, we performed TAVI in 114 consecutive patients (60%
male; mean age 80±8,3 y.o.) with severe, symptomatic aortic stenosis and high surgical risk (mean
Logistic EuroSCORE 29,8 ± 15,6%, median STS score 8,21%): 107 patients were treated with
CoreValve Revalving System (CRS) and 7 with Direct Flow Medical System (DFM). All the
procedures were performed under fluoroscopy in deep sedation and local anesthesia, except for two
cases that required general anesthesia and orotracheal intubation. CRS was implanted via
transfemoral (95%) or transaxillary access (5%). Serum levels of creatinine were measured the day
before and the days after TAVI during hospital stay. Estimated glomerular filtration rate (eGFR) was
calculated by Cockfault and Gault Formula and acute kidney injury (AKI), defined as an increase in
serum creatinine of 50% and a reduction in urine output of <0,5 ml/Kg/hr for more than 6 hours was
evaluated. Institutional protocol was to hydrate the patient with eGFR <60 infusing 80 ml/hour of
saline solution in the first 24 hours based on the central venous pressure (range 5-10 mmHg) and
monitoring the urine output. Four patients on dialysis treatments were excluded from this study
Kidney complications and all causes of mortality were determined after 30 days and 6 months.
Results: At baseline serum creatinin levels was 1.47 ± 0,5 mg/dl and eGFR 41,7 ± 17 mg/min, 83%
of patients had eGFR <60. The procedural success rate was 91%. The mean device time 4,9±2,3
minutes. The volume of contrast medium was 164 ± 20,5 ml. Post procedural data shows no
significant differences in serum creatinine levels (from 1.47 ± 0,5 mg/dl to 1.5±0,38 mg/dl, P=0,623)
and eGFR (from 41,7±17 mg/min to 42,6±20 mg/min, P=0,719). According to definition, no patients
developed AKI after the procedure and at 6 months follow-up. At 30 days the mortality was 2,6 and
at 6 months 3%.
Conclusions: Guided hydration in patients undergoing TAVI may reduce incidence of post
procedural AKI. The procedure, has no adverse effects on renal function, therefore the TAVI may
improve renal perfusion.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O192
EARLY AND MID-TERM OUTCOMES OF 1904 PATIENTS UNDERGOING
TRANSCATHETER BALLOON-EXPANDABLE VALVE IMPLANTATION: RESULTS
FROM THE ITER REGISTRY
STEFANO SALIZZONI (A), AUGUSTO D´ONOFRIO (G), MARCO AGRIFOGLIO (H),
OTTAVIO ALFIERI (I), GENNARO GIUSTINO (I), TOMMASO REGESTA (J),
GIUSEPPE TARANTINI (G), VALERIA GASPARETTO (G), CHIARA TESSARI (F),
DAVIDE GABBIERI (K), FRANCESCO SAIA (C), CARLO SAVINI (C),
CORRADO TAMBURINO (M), SEBASTIANO IMMÈ (M), FLAVIO RIBICHINI (N),
DIEGO CUGOLA (F), MARCO AIELLO (P), FRANCESCO SANNA (E),
ALESSANDRO IADANZA (R), ESMERALDA POMPEI (S), MIROSLAVA STOLCOVA (T),
ANTIOCO CAPPAI (U), ALESSANDRO MINATI (V), MAURO CASSESE (W),
GIANLUCA MARTINELLI (W), ANDREA AGOSTINELLI (X), ANDREA AUDO (B),
CARLA BOSCHETTI (Y), FRANCESCO CASILLI (Z), ABDEL GHANI BARDIS (AA),
SONIA PETRONIO (AB), ROSALBA MOZZILLO (AC), MICHELE DALLAGO (AD),
CARLO BRIGUORI (AE), ARMANDO LISO (AF), ANTONIO COLOMBO (I, AG),
FABIO MIRALDI (AH), GIUSEPPE BRUSCHI (AI), CLAUDIA FIORINA (AJ),
CLAUDIO MORETTI (A), MAURIZIO D´AMICO (A), GINO GEROSA (G),
MAURO RINALDI (A)
(A) CITTA´ DELLA SALUTE E DELLA SCIENZA - MOLINETTE, TORINO; (B) A.O.
CESARE BIAGIO E ARRIGO, ALESSANDRIA; (C) AOU S. ORSOLA, BOLOGNA; (D)
SPEDALE CIVILI, BRESCIA; (E) AO BROTZU, CAGLIARI; (F) AZIENDA OSPEDALIERA
PAPA GIOVANNI XXIII, BERGAMO; (G) DEPARTMENT OF CARDIAC, THORACIC AND
VASCULAR SCIENCES, UNIVERSITY OF PADOVA; (H) CENTRO CARDIOLOGICO
MONZINO, MILANO; (I) OSPEALE SAN RAFFAELE, MILANO; (J) DIVISIONE DI
CARDIOCHIRURGIA, IRCCS SAN MARTINO-IST, GENOVA; (K) HESPERIA HOSPITAL,
MODENA; (L) AOU S. ORSOLA, BOLOGNA; (M) OSP FERRAROTTO , CATANIA; (N)
AZIENDA OSPEDALIERA UNIVERSITARIA INTEGRATA VERONA; (O) AZIENDA
OSPEDALIERA PAPA GIOVANNI XXIII, BERGAMO; (P) IRCCS POLICLINICO S.
MATTEO, PAVIA; (Q) AO BROTZU, CAGLIARI; (R) AZIENDA OSPEDALIERA
UNIVERSITARIA - POLICLINICO LE SCOTTE, SIENA ; (S) AOU S. MARIA
MISERICORDIA, UDINE; (T) AZIENDA OSPEDALIERO-UNIVERSITARIA CAREGGI,
FIRENZE; (U) HUMANITAS RESEARCH HOSPITAL, ROZZANO; (V) OSPEDALE
CATTINARA, TRIESTE; (W) CLINICA S. MARIA, BARI; (X) OSPEDALE MAGGIORE,
PARMA; (Y) AZIENDA OSPEDALIERA SAN CAMILLO-FORLANINI, ROMA; (Z) I.R.C.C.S..
POLICLINICO SAN DONATO, MILANO; (AA) ISTITUTO CLINICO SANT´AMBROGIO,
MILANO; (AB) AOU PISANA, PISA; (AC) AOUP FEDERICO II, NAPOLI; (AD) S.C. DI
CARDIOLOGIA – OSPEDALE S. CHIARA, TRENTO; (AE) CLINICA MEDITERRANEA,
NAPOLI; (AF) CITTÀ DI LECCE HOSPITAL - GVM CARE & RESEARCH, LECCE; (AG)
CASA DI CURA COLUMBUS, MILANO; (AH) POLICLINICO UMBERTO I, ROMA; (AI)
OSPEDALE NIGUARDA, MILANO; (AJ) SPEDALI CIVILI, BRESCIA
Background:Transcatheter Aortic Valve Implantation (TAVI) has been proposed as a therapeutic
option for high risk or inoperable patients with severe symptomatic aortic valve stenosis. Aim of this
retrospective multicenter study is to report early and mid-term clinical and echocardiographic
outcomes of patients undergoing TAVI with a balloon-expandable device in Italy.
Methods:From 2007 through 2012, 1904 patients were enrolled at 33 centers in the Italian
Transcatheter balloon-Expandable valve Registry (ITER). The study device is the SAPIEN/SAPIEN
XT (Edwards Lifesciences, Irvine, USA). A minimum follow-up of one-year was required to be part
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Roma, 13 – 15 dicembre 2014
of the Registry. Outcomes were assigned according to the updated Valve Academic Research
Consortium (VARC-2) definitions.
Results: Mean age was 81.6±6.2 and 1147 (60.2%) patients were female. Out of 352 (18.5%) patients
who had at least one previous cardiac intervention, 49 (2.6%) underwent Valve-in-Valve TAVI. Mean
Logistic EuroSCORE, EuroSCORE II and STS Score were 22.4±14.6%, 7.3±6.7% and 9.2±7.6%,
respectively. The procedural accesses were: transfemoral, 1252; transapical, 629; transaortic, 19;
transaxillary, 4. The reported 30-day mortality was 7.2% (137 patients). The most significant VARC2 outcomes are summarized in the following table.
At discharge mean transprosthetic gradient was 10.7±4.5 mmHg. Incidence of post-operative mild,
moderate or severe paravalvular leaks were respectively: 32.1%, 5.0% and 0.4%. Overall 1, 2 and 3
years survival were 84.5%, 76.4 % and 68.2%.
Conclusions: According to our data, patients undergoing TAVI with a balloon expandable device
show good early and mid-term clinical and hemodynamic results. In particular the incidence of postoperative pace-maker implantation as well as moderate/severe regurgitations seems reasonable. The
incidence of mild regurgitation is still a matter of concern.
Device insuccess
>1 valve implanted
Aortic valve replacement
Operative mortality (within 24h)
Aortic regurgitation ≥ moderate
Mean aortic gradient ≥ 20 mmHg
Acute Myocardial Infarction ( ≤72 h)
Stroke (non disabling)
Stroke (disabling)
Life threatening bleeding
Major bleeding
Major vascular complication
Acute Kidney Injury (AKIN) grade 2-3
PM implantation (before discharge)
n/1904 (%)
221 (11.6)
14 (0.7)
9 (0.5)
47 (2.5)
100 (5.2)
64 (3.4)
26 (1.4)
36 (1.9)
18 (1.0)
186 (9.9)
200 (10.6)
177 (9.3)
155 (8.1)
116 (6.1)
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Roma, 13 – 15 dicembre 2014
O193
CHANGES IN MITRAL REGURGITATION SEVERITY AFTER TAVI
ELISA COVOLO (A), PAOLA ANGELA MARIA PURITA (A), MICHELA FACCHIN (A),
BLERI CELMETA (A), ERMELA YZERAJ (A), MARCO MOJOLI (A),
GIANPIERO D´AMICO (A), ALBERTO BARIOLI (A), VALERIA GASPARETTO (A),
CHIARA FRACCARO (A), GIULIA MASIERO (A), ROBERTO BIANCO (A),
AUGUSTO D´ONOFRIO (A), DEMETRIO PITTARELLO (B), GINO GEROSA (A),
MASSIMO NAPODANO (A), GIAMBATTISTA ISABELLA (A), SABINO ILICETO (A),
GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) ANESTHESIOLOGY DEPARTMENT, UNIVERSITY OF PADUA
Backgrounds. Mitral regurgitation (MR) severity improvement following transcatheter aortic valve
implantation (TAVI) has been described using both self- and balloon-expandable transcatheter heart
valves. However, a lesser degree of MR improvement with Corevalve system compared to Edwards
valve has been suggested. Moreover, in some patients, MR severity was observed unchanged or even
worsened after TAVI. The aim of our study was to evaluate the impact of TAVI on MR at early
assessment and late follow-up, both in self- and balloon-expandable valves.
Methods. Monocentric study enrolling 324 consecutive patients treated by TAVI between Jun 2007
and December 2013. Baseline echocardiographic severity of MR was classified in 4 grades (0 none
or trivial, 1 mild, 2 moderate, 3 relevant, 4 severe). MR changes were echocardiographic evaluated
48 hours after TAVI and over mean follow-up time of 23 ± 18 months.
Results. Study population presented mean age of 80±6 years, female gender in 53% of patients, mean
logistic Euroscore of 20.4±12.1. Eighty-eight patients were treated by CoreValve (27%), 236 patients
(73%) were treated by Edwards TAVI. Baseline MR was defined absent or trivial in 15 patients (17%)
in CoreValve group and 45 (19%) in Edwards group, mild in 53 (60%) and 131 (55%), moderate in
18 (20%) and 52 (22%), relevant in 2 (2%) and 8 (3%) in CoreValve and in Edwards groups,
respectively, p=0.86. None patient presented severe MR. Acute improvement in MR after TAVI was
observed in 20 (23%) of patient treated by CoreValve and 64 (27%) of patients treated by Edwards,
p=0.42. However, implantation of Edwards valve was associated with lower prevalence of moderate
or relevant MR at 48-hours after TAVI (p=0.001, OR 0.30, 95%CI 0.15-0.59). Last 2D TTE
evaluation revealed prevalence of none MR in 11 (13%) patients in CoreValve group and 49 (21%)
in Edwards group, mild MR in 48 (54%) and 141 (60%), moderate MR in 24 (27%) and 37 (16%),
relevant in 5 (6%) and 9 (3%) in CoreValve group and Edwards group respectively, p=0.01. Grade
of MR worsened in 26 (30%) patient in CoreValve and 41 (17%) patients in Edwards groups (p=0.02).
Implantation of Edwards valve was associated with lower prevalence of moderate or relevant MR at
late follow-up (p=0.015, OR 0.49, 95%CI 0.28-0.87).
Conclusions. In one fourth of patients with severe aortic stenosis and concomitant MR, TAVI may
contribute to reduce MR severity. Moreover, Edwards valve is associated with lower prevalence of
moderate or relevant MR both at 48-hours after TAVI and at late follow-up.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O194
EFFECTS OF TRANSCATHETER AORTIC VALVE IMPLANTATION ON LEFT
VENTRICULAR SYSTOLIC LONGITUDINAL STRAIN
ROBERTO PADALINO (A), ANTONELLO D´ANDREA (A), MAURIZIO CAPPELLI
BIGAZZI (A), RENATOMARIA BIANCHI (A), ROSANGELA COCCHIA (A),
GIOVANNI ROSSI (B), PAOLO CALABRÒ (B), BIAGIO LICCARDO (A), PIETRO MUTO (B),
MARIA GIOVANNA RUSSO (A), RAFFAELE CALABRÒ (A)
(A) CHAIR OF CARDIOLOGY – SECOND UNIVERSITY OF NAPLES, ITALY; (B)
DEPARTMENT OF RADIOLOGY-AORN DEI COLLI-MONALDI HOSPITAL-NAPLES
Aims: transcatheter aortic valve implantation (TAVI) is an alternative treatment in surgically highrisk or inoperable patients with severe aortic stenosis. The objective of this study was to analyze
effects of TAVI on left ventricular (LV) function assessed by longitudinal systolic strain, which focus
on the longitudinal myocardial fibers and may add more information than the conventional ejection
fraction (EF) that reflects primarily load-dependent radial function.
Methods: in our prospectively-conducted study, a total of 18 symptomatic (NYHA class II or higher)
patients with severe aortic stenosis, considered to be at increased risk for undergoing surgical aortic
valve replacement (Euroscore > 15), were recruited. Patients were submitted to a complete clinical
and laboratory evaluation, ECG, standard and two-dimensional Speckle Tracking Echocardiography
(2DSTE) (Vivid E9 – GE Ultrasound System). A multi-detector cardiac tomography was also
performed to obtain information about valve sizing and arterial accesses. Echocardiographic analysis
was assessed before and 6 months after TAVI. 2DSTE was obtained in all the 17 segments in the
three standard apical views, in order to obtain segmental and global longitudinal strain (GLS)
information.
Results: all the patients received the CoreValve self-expanding prosthesis. Six months after TAVI
patients showed a significant reduction in mean transaortic gradient (52,1 ± 15,8 vs 8,2 ± 3,3 mmHg,
p<0,0001) and LV mass (240,79 ± 65,37 vs 204,15 ± 57,63 g, p<0,0001 ), and an improvement of
EF (48,84 ±11,80 vs 53,30 ± 12,84 %, p<0,0001). In addition, GLS increased significantly
after TAVI (-11,78 ± 3,24 vs. -16,27 ± 4,13%; p <0,0001). Such improvement of LV myocardial
deformation was evidenced in all LV basal, mid an apical segments. In a stepwise forward multiple
logistic regression analysis, after adjusting for potential determinants, LV mass pre TAVI (beta
coefficient: - 0.45; p< 0.001) and peak CK MB mass post TAVI (beta: - 0.66; p< 0.0001) were
powerful independent predictors of lower improvement of GLS.
Conclusions: TAVI in patients with AS and high surgical risk resulted in geometric changes known
as “reverse remodelling” and improved LV function assessed by longitudinal systolic strain. Higher
myocardial injury after the procedure and higher LV mass at baseline were powerful independent
predictors of lower improvement of strain parameters after TAVI.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O195
6-YEARS CLINICAL AND HEMODYNAMIC OUTCOMES FOLLOWING TRANSCATHETER AORTIC “BALLOON-EXPANDABLE” VALVE IMPLANTATION.
MICHELA FACCHIN (A), PAOLA ANGELA MARIA PURITA (A), ELISA COVOLO (A),
MARTA MARTIN (A), ERMELA YZEIRAY (A), MARCO MOJOLI (A),
GIANPIERO D´AMICO (A), ALBERTO BARIOLI (A), VALERIA GASPARETTO (A),
CHIARA FRACCARO (A), MASSIMO NAPODANO (A), BLERI CELMETA (A),
FILIPPO ZILIO (A), AHMED AL MAMARY (A), MARCO BASILE (B),
AUGUSTO D´ONOFRIO (A), ANDREA COLLI (A), ROBERTO BIANCO (A),
DEMETRIO PITTARELLO (A), GINO GEROSA (A), GIAMBATTISTA ISABELLA (A),
SABINO ILICETO (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) MALATTIE DELL’APPARATO CARDIOVASCOLARE, D.E.T.O.,
UNIVERSITÀ DEGLI STUDI DI BARI “ALDO MORO”
Background. Transcatheter aortic valve implantation (TAVI) is a therapeutic option in high-risk or
inoperable patients suffering from severe symptomatic aortic valve stenosis (SSAVS). Concerns still
exist regarding long-term results and freedom from adverse events.
Aim. Our single-center prospective study assessed long-term clinical and hemodynamic outcomes in
patients undergoing TAVI with “ballon-expandable” prosthesis.
Methods. Since 2007 through 2014, 361 consecutive patients underwent TAVI at our institution.
Data were prospectively collected in our TAVI database and retrospectively analyzed selecting
patients treated with “balloon-expandable” device. Variables were defined according to the Euroscore
definitions and outcomes were reported according to the VARC and VARC-2 definitions. Patients
underwent clinical and echocardiographic follow-up at our “TAVI-dedicated” out-patient clinic.
Multivariate logistic regression analysis was performed in order to identify independent predictors of
mortality at follow-up.
Results. We included 254 patients treated with balloon-expandable device (23.8% with Edwards
Sapien, 72.5% with Edwards Sapien XT and 3.7% with Edwards SAPIEN 3; Edwards Lifesciences
Irvine, CA). The mean age was 80±7 years, 47% was male and trans-femoral (TF), trans-aortic (TAo)
and trans-apical (TA) TAVI were performed in 144 (56.7%), 6 (2.4%) and 104 (4.08) patients,
respectively. Mean follow-up was 22.0±14.3 months (Range:0.1-56). At 30-day total mortality was
4.6%, cardiovascular death 3.8%, stroke 2.5% and myocardial infarction 2.1%. Moreover, 1-year and
long term total mortality were 15.2% and 19.3%, cardiovascular death 7.8% and 9.7 %, stroke 2.9%
and 3.3 and myocardial infarction 2.9% and 3.5%, respectively. The rate of pace maker implantation
was 10.5%. Independent predictors of all-cause mortality at follow-up were previous myocardial
infarction (OR 2.1, p=0.04), any grade pre-procedural aortic regurgitation (OR 2.2, p=0.05) and AKI
(OR 2.9, p=0.04). Mean gradient and effective orifice area at follow-up were: 10.5±5.9 and 1.9±0.6
cm2/m2, respectively.
Conclusions. Our data show that TAVI has good early and long-term clinical and hemodynamic
outcomes in high risk or inoperable patients with SSAVS.
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O196
FATTORI PREDITTIVI DI MORTALITÀ PRECOCE NEI PAZIENTI SOTTOPOSTI A
TAVI
MARTINA MORETTI (B), FRANCESCA CAVALLA (B), VALENTINA BOASI (C),
FILIPPO RAPETTO (A), MASSIMO VISCHI (B), CLAUDIO BRUNELLI (B),
MANRICO BALBI (B)
(A) U.O. CARDIOCHIRURGIA IRCCS AOU SAN MARTINO IST, GENOVA; (B) U.O.
CLINICA DELLE MALATTIE DELL´APPARATO CARDIOVASCOLARE IRCCS AOU SAN
MARTINO IST, GENOVA; (C) U.O. CARDIOLOGIA OSPEDALE G. BOREA, SANREMO
BACKGROUND: I documenti di consenso VARC e VARC-2 hanno stabilito gli endpoint, per
valutare con uniformità la sicurezza e l’efficacia clinica della TAVI. Obiettivo del nostro studio è
stato valutare le caratteristiche e le complicanze periprocedurali dei pazienti deceduti sottoposti a
TAVI presso il nostro centro, per cercare elementi predittivi di mortalità intra-ricovero, a 1 mese e a
1 anno dall’intervento. Ulteriore analisi ha riguardato la qualità di vita dei pazienti deceduti, per
valutarne un eventuale cambiamento prima del decesso.
METODI: Dei 206 pazienti sottoposti a TAVI da novembre 2009 ad aprile 2014 sono stati selezionati
i 63 pazienti deceduti. La mortalità è stata valutata in acuto (intra-procedurale e a 1 mese) e entro 1
anno dall’intervento (mortalità precoce) utilizzando la curva di Kaplan-Meier. Le complicanze
intraoperatorie e peri-procedurali prese in considerazione sono quelle stabilite dai criteri VARC. La
qualità di vita è stata valutata mediante questionario KCCQ prima e, quando possibile a 1 e 12 mesi
dalla
TAVI.
RISULTATI: Sono state utilizzate 160 protesi Edwards SAPIEN e 46 CoreValve tramite approccio
trans-femorale (88.8%), trans-apicale (6.8%) e trans-succlavio (4.4%). I 63 pazienti deceduti (30,6%
di cui 59% donne) avevano un STS SCORE di 8.4 ± 3.7. Le comorbidità più rappresentate erano:
BPCO (27.0%), diabete (25.4%), coronaropatia (41.3%), fibrillazione atriale (39.7%), insufficienza
renale (30.2%). L’85.7% era in classe NYHA≥ III. La mortalità acuta è stata 8.7% e la mortalità
precoce 21.7%. Tra i pazienti deceduti, 20 erano andati incontro a complicanze: 55% intraprocedurali
e 45% entro 1 mese dalla TAVI. Le principali complicanze sono state: vascolari (maggiori e
minori,35%), tamponamento cardiaco (25%), impianto di PM (5%), stroke (5%) e altre (scompenso
cardiaco, aritmie e disturbi della conduzione, arresto cardiaco,30%). All’analisi multivariata la
mortalità intraricovero è risultata maggiormente correlata (p<0,05) con BPCO, incremento di
troponine post TAVI, il verificarsi di complicanze procedurali e l’insufficienza aortica (IAo) residua;
la mortalità a 30 giorni con IAo e insufficienza mitralica pre-intervento; la mortalità a 1 anno con IAo
residua e anemizzazione post TAVI. Le cause di mortalità sono state suddivise in cardiovascolari
(CV) e non CV: a 1 mese e a 1 anno dalla TAVI non si sono riscontrate differenze significative in
termini di mortalità tra i due gruppi. L’85% dei decessi per cause non CV si è verificato nei primi 2
anni della nostra esperienza. Nonostante il decesso si è evidenziato un miglioramento della qualità di
vita, oggettivato mediante i punteggi ottenuti al KCCQ, a 1 mese e, seppur in modo meno
significativo, a 1 anno dalla TAVI.
CONCLUSIONI: Dall’analisi del nostro studio si evince che alcune caratteristiche cliniche e
complicanze procedurali possono essere predittive di mortalità in acuto e precoce. A 1 anno dalla
TAVI non abbiamo riscontrato differenze tra mortalità CV e non CV. Un beneficio in termini di
qualità di vita è possibile anche nei pazienti deceduti precocemente. Nella nostra casistica una
migliore selezione dei pazienti, possibile mediante curva di apprendimento, ha consentito la riduzione
delle morti non CV precoci, in accordo con le linee guida ESC 2012 che raccomandano l’esecuzione
della TAVI in pazienti con aspettativa di vita superiore ad un anno.
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O197
EFFECTS OF TRANSCATHETER AORTIC VALVE IMPLANTATION ON LEFT ATRIAL
MORPHOLOGICAL AND FUNCTIONAL MEASUREMENTS
ROBERTO PADALINO (A), ANTONELLO D´ANDREA (A), MAURIZIO CAPPELLI
BIGAZZI (A), RENATOMARIA BIANCHI (A), PASQUALE COPPOLINO (A),
LUCIA RIEGLER (A), PAOLO CALABRÒ (A), DONATO TARTAGLIONE (A),
GIOVANNI ROSSI (B), MARIA GIOVANNA RUSSO (A), RAFFAELE CALABRÒ (A)
(A) CHAIR OF CARDIOLOGY – SECOND UNIVERSITY OF NAPLES, ITALY; (B)
DEPARTMENT OF RADIOLOGY, AORN DEI COLLI, MONALDI HOSPITAL, NAPLES
Aims: transcatheter aortic valve implantation (TAVI) is an alternative treatment in surgically highrisk or inoperable patients with severe aortic stenosis. We know the improvement of left ventricular
(LV) function after this procedure. The objective of this study was to analyze effects of TAVI on left
atrial (LA) function evaluated by Speckle Tracking Echocardiography which may add more
information than 2D standard echocardiography and Doppler assessment
Methods: in our prospectively-conducted study, a total of 18 symptomatic (NYHA class II or higher)
patients with severe aortic stenosis, considered to be at increased risk for undergoing surgical aortic
valve replacement (Euroscore > 15), were recruited. Patients were submitted to a complete clinical
and laboratory evaluation, ECG, standard and two-dimensional Speckle Tracking Echocardiography
(2DSTE) (Vivid E9 – GE Ultrasound System). A multi-detector cardiac tomography was also
performed to obtain information about valve sizing and arterial accesses. Echocardiographic analysis
was assessed before and 6 months after TAVI. We used a 12-segment model and QRS onset as the
reference point (corresponding to atrial reservoir) in order to quantify positive peak atrial longitudinal
strain of lateral wall. We measured also LV global longitudinal strain (GLS)
Results: all the patients received the CoreValve self-expanding prosthesis. Six months after TAVI
patients showed a significant reduction in mean transaortic gradient, LV mass, LV mass index
(LVMI), and LA volume index (LAVI) (41,56 ± 15,53 vs 36,56 ± 13,84 ml/m2) and improvement
of EF There were no alterations in LV end diastolic diameter,
LA diameter or PAPs.
LA longitudinal strain improved after TAVI (14,21 ± 5,36 vs 26,56 ± 10,07 %, p<0,0001) Morever
in a stepwise forward multiple logistic regression analysis, after adjusting for potential determinants,
LVMI (beta 0.45 p < 0.001) and LV GLS strain (beta 0.54; p<0.001) pre TAVI were powerful
independent predictor of LA longitudinal strain post TAVI
Conclusions: TAVI in patients with AS and high surgical risk resulted in morfhological changes
and improvement of LA function evaluated by 2DSTE. LVMI and LV GLS strain (beta 0.54;
p<0.001) pre TAVI were powerful independent predictor of LA longitudinal strain post TAVI
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FIBRILLAZIONE ATRIALE – PFO
O198
LONG TERM OUTCOMES FOLLOWING TRANSCATHETER PFO CLOSURE: IMPACT
ON THROMBOEMBOLISM AND ON CHRONIC CEPHALALGIA
MARCO MOJOLI (A), GIANPIERO D´AMICO (A), NATASCIA BETTELLA (A),
CLAUDIA ZANETTI (A), MICHELA FACCHIN (A), ELISA COVOLO (A),
FILIPPO ZILIO (A), ALBERTO BARIOLI (A), GIULIA MASIERO (A), PAOLA ANGELA
MARIA PURITA (A), ALESSANDRO LUNARDON (A), TOMMASO FABRIS (A),
MARCO BASILE (B), GILBERTO DARIOL (A), AHMED AL-MAMARY (A),
MASSIMO NAPODANO (A), PAOLO BUJA (A), DEMETRIO PITTARELLO (A),
GIAMBATTISTA ISABELLA (A), SABINO ILICETO (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) MALATTIE DELL’APPARATO CARDIOVASCOLARE, D.E.T.O.,
UNIVERSITÀ DEGLI STUDI DI BARI “ALDO MORO”
BACKGROUND: The clinical significance of patent foramen ovale (PFO) is not well defined. Even
though transcatheter closure of PFO has been available for over 2 decades, it has remained
controversial due to a paucity of evidence to guide patient and device selection.
AIM: To assess safety and efficacy of percutaneous PFO closure in a prospective single center
registry.
METHODS: Between July 2001 and March 2014, all consecutive patients undergoing transcatheter
PFO closure in our institution using the Amplatzer PFO Occluder or the Amplatzer Cribiform Septal
Occluder (St Jude Medical, St Paul, MN) were included. Clinical follow-up was collected at 30-days,
6, 12, 24 months and yearly thereafter.
RESULTS: 150 patients were included in the study (60% female, mean age 48.9±12.9). Indications
for closure were cryptogenic stroke (43.3%), TIA (46%), migraine with ischemic lesions at cerebral
CT/MR (4%), decompression syndrome in scuba divers (1.3%), peripheral embolism (0.6%), primary
prevention in patients with anatomical or clinical risk factors for thromboembolism (4.8%). 56
patients (37.3%) had a clinical history of recurrent cerebral ischemia, 58 patients (38.6%) had
multiple ischemic lesions at cerebral CT/MR, 17 patients (11.3%) had a documented thrombophylia.
PFO closure was successfully performed in 149 (99.3%) patients, with a mean procedural time of 33
minutes. Intraprocedural complications were 1 major air embolism, 1 isolated transient ST elevation,
1 pericardial effusion requiring pericardiocentesis, 2 new onset atrial fibrillations. There were no
major in-hospital complications, and mean length of stay was 4.2 days. At median 50.5 months follow
up (range 1-155 months), 4 TIA and 1 stroke were observed. New onset of atrial arrhythmias occurred
in 5 patients. Among 50 patients (33.3%) who had previous history of chronic headache or migraine
requiring medications, the majority (30 patients, 60%) referred substantial relief or total regression
of symptoms after PFO closure.
CONCLUSIONS: In our experience, transcatheter PFO closure is a safe procedure, which may
effectively prevent ischemic events in patients with history of TIA/stroke or other conditions at risk
for paradoxical embolism. Among patients with previous history of migraine/headache, symptoms
were substantially reduced or abolished in the majority of patients.
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O199
ABLATION OF ATRIAL FIBRILLATION AND ESOPHAGEAL INJURY: THE ROLE OF
BIPOLAR AND UNIPOLAR ENERGY USING A NOVEL MULTIPOLAR IRRIGATED
ABLATION CATHETER (NMARQ).
ANTONIO DI MONACO (A), FEDERICO QUADRINI (A), GRIGORIOS KATSOURAS (A),
GIACOMO CECERE (A), TOMMASO LANGIALONGA (A), MASSIMO GRIMALDI (A)
(A) OSPEDALE GENERALE REGIONALE “F. MIULLI”- ACQUAVIVA DELLE FONTIBARI-ITALY
Background. Previous studies reported the usefulness of a novel irrigated decapolar radiofrequency
energy circular ablation catheter (nMARQ™, Biosense Webster, Diamond Bar, USA) for pulmonary
vein isolation (PVI). Furthermore, some authors reported a high incidence of thermal esophageal
lesions using this new ablation catheter. In this study we reported our experience evaluating the role
of bipolar and unipolar energy on the esophageal injury.
Methods. 80 patients (mean age 55 ± 12 years; 48 male) were enrolled to perform PVI due to
symptomatic atrial fibrillation (63 paroxysmal). All patients underwent PVI using the nMARQ
catheter and CARTO3 system (Biosense Webster, Diamond Bar, USA). All patients received oral
barium sulfate to visualize the esophageal dimension and location, moreover they received an
esophageal temperature probe. This probe was visualized by CARTO3 system in order to position it
as close as possible to ablation catheter. We obtained detailed data regarding the esophageal
temperature increase using bipolar and unipolar energy on the posterior wall. In particular, on the
posterior wall we delivered 15-18W unipolar energy and 15W bipolar energy. Ablations were stopped
if esophageal temperature increased above 39°C or after electrograms elimination. 20 patients
performed esophagoscopy 24 hours after procedure.
Results. PVI was successfully obtained in all patients without procedural complications. No patients
had dysphagia or esophageal injury evaluated by esophagoscopy. Bipolar energy was associated to a
significant lower mean temperature increase than unipolar energy: 0,5°C (range 0,1 to 1,8) vs. 2°C
(range 0,7 to 2,9), respectively, p=0.003. The temperature increased above 39°C in 9 patients (12,5%)
during bipolar energy and in 66 patients (92%) during unipolar energy. Finally, a significant
difference of radiofrequency time was found during unipolar energy compared to bipolar energy
(13±2 sec vs 16±6 sec, respectively, p=0.003).
Conclusion. The use of a novel irrigated multielectrode ablation system for PVI is feasible and safe,
resulting in acute isolation of all targeted PVs with no complications. The use, for a short time, of
bipolar energy (max 15W) or unipolar energy (15-18W) on the posterior wall is an optimal strategy
to reduce the esophageal injury using this new ablation catheter. Larger studies are needed to better
assess the long-term efficacy and safety.
O200
TRANSCATHETER LEFT ATRIAL APPENDAGE CLOSURE WITH THE AMPLATZER
CARDIAC PLUG DEVICE FOR ISCHEMIC STROKE PREVENTION IN PATIENTS WITH
ATRIAL FIBRILLATION: A SINGLE CENTER EXPERIENCE
CLAUDIA ZANETTI (A), GIANPIERO D´AMICO (A), MARCO MOJOLI (A),
TOMMASO FABRIS (A), ALESSANDRO LUNARDON (A), NATASCIA BETTELLA (A),
PAOLA ANGELA MARIA PURITA (A), ELISA COVOLO (A), ALBERTO BARIOLI (A),
MICHELA FACCHIN (A), GIULIA MASIERO (A), FILIPPO ZILIO (A),
GILBERTO DARIOL (A), AHMED AL MAMARY (A), MASSIMO NAPODANO (A),
PAOLO BUJA (A), DEMETRIO PITTARELLO (B), GIAMBATTISTA ISABELLA (A),
SABINO ILICETO (A), GIUSEPPE TARANTINI (A)
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(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) ANESTHESIOLOGY DEPARTMENT, UNIVERSITY OF PADUA
Background: Stroke prevention in patients with atrial fibrillation (AF) is largely based on the use of
oral anticoagulants. A significant proportion of patients with atrial fibrillation do not receive
anticoagulation due to relative or absolute contraindications, oral anticoagulants failure in stroke
prevention or patients reluctance. The left atrial appendage (LAA) percutaneous closure has been
demonstrated to be a safe and feasible approach for those patients. The aim of our study is to evaluate
the clinical and procedural outcomes in patients undergoing percutaneous LAA closure with the
Amplatzer Cardiac Plug (ACP) device.
Methods: This was a prospective single-center study of consecutive patients undergoing
percutaneous LAA closure with the ACP device. All patients had a high risk for stroke and bleedings.
Stroke risk assessment was performed with the CHA2DS2VASC score and the bleeding risk was
estimated with the HAS-BLED score. The procedure was performed through a transseptal access
under fluoroscopic and trans-esophageal echocardiography guidance. Clinical and imaging
(transthoracic or transesophageal echocardiography, or CT scan) follow-up was performed at 1, 6 and
12 months.
Results: Between May 2011 and May 2014, LAA occlusion was attempted in 22 patients (13 males,
median age 75 [range 71-79]) with AF. All patients were at high risk for cardioembolic stroke (median
CHA2DS2Vasc score 5 [range 3-6]) and for bleeding (median HAS-BLED 4, corresponding to 9.5%
annual risk of major bleeding in anticoagulated AF patients). The APC was successfully implanted
in all patients. The anatomical features of the LAA included a LAA median diameter of 21 mm [range
18.5-23] and a median landing zone length of 21 mm [range 19-24]. The most frequently used ACP
size was 24 mm. The median procedural duration was 75 minutes [range 60-91] with a median
fluoroscopic time of 15 min [range 13-19]. The median length of stay after the procedure was 2 days
[range 2-3]. There were two in-hospital events: a cardiac tamponade successfully treated with
pericardiocentesis the day after the procedure and a peri-procedural ischemic stroke (the second
patient undergoing LAA percutaneous closure in our experience). The median follow-up was of 252
days [range 60-465]. Two patients died for heart failure not related to device implantation. Even if
estimated annual stroke risk based on the CHA2DS2Vasc score was 6.7%, the observed rate of outof-hospital ischemic stroke was 4.5% at follow-up. The predicted risk of major bleeding based on
HAS-BLED score was 9.5%, while in our population no major bleedings occurred at follow up, even
though two patients with chronic GI bleeding underwent transfusions also after LAA occlusion for
hemoglobin drop without overt bleeding (BARC 2 bleedings).
Conclusions: Percutaneous closure of LAA with ACP seems to be safe and effective to prevent
stroke in patients with AF at high risk for stroke and bleeding, who do not receive oral anticoagulant
therapy. The observed stroke rate after percutaneous LAA closure in this series seems to be lower
than predicted by baseline CHA2DS2VASC.
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Roma, 13 – 15 dicembre 2014
O201
GHOSTS AFTER LEAD REMOVAL: WHERE DO THEY COME FROM? A
PRELIMINARY REPORT OF AN INTRACARDICAC AND TRANSESOPHAGEAL
ECHOCARDIOGRAPHIC STUDY.
ISABELLA LACITIGNOLA (A), CARLO CAIATI (A), MARIO ERMINIO LEPERA (A),
ALESSANDRO DE SANTIS (A), ALESSANDRO SANTO BORTONE (B),
TOMMASO ACQUAVIVA (B), GIOVANNI LUZZI (A), STEFANO FAVALE (A)
(A) UNITÀ OPERATIVA DI CARDIOLOGIA UNIVERSITARIA, POLICLINICO DI BARI,
PIAZZA G. CESARE, 70123 BARI, ITALY; (B) UNITÀ OPERATIVA DI
CARDIOCHIRURGIA, POLICLINICO DI BARI, PIAZZA G. CESARE, 70123 BARI, ITALY
OBJECTIVES: We are going to evaluate the presence of new post-removal mobile masses, known
as “ghosts” in right cardiac chamber, by ICE immediately after lead extraction and by TEE
immediately before reimplantation or weeks later based on clinical conditions of patients. We believe
that “ghosts” are residuals of fibrotic sheath covering the leads that are cut during lead extraction with
manual dilatation; as consequence, they could appear immediately after lead extraction, and
considered benign masses, essentially aseptic.
BACKGROUND: Use of intracardiac devices has rapidly increased during the past decade with an
increasing number of infections and of lead removal procedures. It remains unknown if these ghosts
are actually the result of the persistence of fibrous sheath covering the leads and so they should appear
immediately after lead extraction and should be substantially aseptic, or they represent a relapse of
infection, so associated with the diagnosis of cardiac device-related infective endocarditis (CDRIE)
and consequently they should appear days or weeks later after extraction. The fact that we do not
really know the actual origin of ghosts causes prolonged hospitalization and antibiotic therapy.
METHODS: Five patients scheduled for lead removal underwent ICE immediately before and after
lead extraction. TEE was also performed within one month from the extraction procedure. Ghosts
were defined as new, post-removal, tubular, mobile masses visualized by ultrasound (ICE and/or
TEE). Fibrosis encapsulating the leads were defined as dense echoes inglobing leads and extended
to the surrounding structure (tricuspid valve, atrial and ventricular wall).
RESULTS: Two out of 5 patients showed ghosts (40%): one immediately after the extraction by
ICE and the other by TEE a few weeks later after the extraction (see table). The patients with ghosts
showed also areas of fibrosis surrounding the leads and creating adherence to the cardiac wall and/or
the tricuspid valve. It was found a correspondence between distribution of areas of fibrous adherences
and locations of ghosts. No ghosts or fibrosis were detected in the remaining 3 patients. A Chi-square
test for independence (Yates correction) showed an initial statistical trend for a significant association
between fibrosis and ghosts (χ2= 1.7, p=0.19, phi= 1). Lead culture performed after lead removal were
not associated with ghosts (χ2= 0.05, p=0.82).
CONCLUSION: We believe that the real incidence of “ghosts” is certainly higher than it was
reported in literature. Ghosts are probably related to the debris of fibrous sheath covering the leads
that remains after lead extraction in the right cardiac chambers. No evident correlation exists between
ghosts and infected leads. Consequentially in pts with ghost neither prolonged antibiotic therapy nor
further hospitalization are peremptorily required.
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CARATTERIZZAZIONE TISSUTALE MIOCARDICA
O202
MYOCARDIAL TISSUE CHARACTERIZATION BY CARDIAC MR IMAGING IN
MYELODYSPLASTIC SYNDROMES
ALESSIA PEPE (A), ANTONELLA MELONI (A), GIANCARLO CARULLI (B), ESTHER
N. OLIVA (C), FRANCESCO ARCIONI (D), VINCENZO FRATICELLI (E),
EMANUELE GRASSEDONIO (F), STEFANIA RENNE (G), MASSIMILIANO MISSERE (H),
MICHELE RIZZO (I)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) DIPARTIMENTO DI ONCOLOGIA, DEI TRAPIANTI E DELLE NUOVE TECNOLOGIE
IN MEDICINA – DIVISIONE DI EMATOLOGIA, FACOLTÀ DI MEDICINA E CHIRURGIA,
UNIVERSITÀ DEGLI STUDI DI PISA, PISA, ITALY; (C) HEMATOLOGY UNIT, AZIENDA
OSPEDALIERA BIANCHI MELACRINO MORELLI, REGGIO CALABRIA, ITALY; (D)
DIPARTIMENTO DI MEDICINA CLINICA E SPERIMENTALE, UNIVERSITÀ DEGLI STUDI
DI PERUGIA, SEZ. EMATOLOGIA ED IMMUNOLOGIA CLINICA, OSPEDALE “SANTA
MARIA DELLA MISERICORDIA, PERUGIA, ITALY; (E) UOC DI ONCO-EMATOLOGIA,
UNIVERSITÀ CATTOLICA DEL SACRO CUORE - CENTRO DI RICERCA E FORMAZIONE
AD ALTA TECNOLOGIA NELLE SCIENZE BIOMEDICHE, CAMPOBASSO, ITALY; (F)
ISTITUTO DI RADIOLOGIA , POLICLINICO “PAOLO GIACCONE“, PALERMO, ITALY; (G)
STRUTTURA COMPLESSA DI CARDIORADIOLOGIA, P.O. “GIOVANNI PAOLO II”,
LAMEZIA TERME, ITALY; (H) DIPARTIMENTO DI RADIOLOGIA, UNIVERSITÀ
CATTOLICA DEL SACRO CUORE - CENTRO DI RICERCA E FORMAZIONE AD ALTA
TECNOLOGIA NELLE SCIENZE BIOMEDICHE, CAMPOBASSO, ITALY; (I) REPARTO DI
EMATOLOGIA, AZIENDA SANITARIA PROVINCIALE CALTANISSETTA - OSPEDALE
“SANT´ELIA”, CALTANISETTA, ITALY
Introduction: Magnetic Resonance Imaging (MRI) provides unique insight regarding tissue
characterization in the heart. We reported the baseline MRI findings at the end of the recruitment in
the MIOMED (Myocardial Iron Overload in MyElodysplastic Diseases) study. In particular, we
evaluated the distribution of iron overload in the whole left ventricle (LV) and he presence of
myocardial fibrosis in patients with myelodysplastic syndromes (MDS); the association with LV
function was also investigated. No data are available in the literature about this issue.
Methods: MIOMED is an observational, MRI multicentre study in low and intermediate-1 risk MDS
patients who have not received regular iron chelation therapy. Out of the 51 MDS patients enrolled,
48 underwent the baseline MRI exam. Mean age was 71.7±8.5 years and 17 patients were females.
MIO was assessed using a multislice multiecho T2* approach. Biventricular function parameters were
quantified by cine sequences. Myocardial fibrosis was evaluated by late gadolinium enhancement
acquisitions.
Results: We found 27 (56.3%) patients with no MIO (all 16 segmental T2* values >20 ms). The
remaining patients showed an heterogeneous MIO (some segments with T2* values >20 ms and other
segments with T2* values <20 ms) and of them 2 (9.5%) showed a global T2* value <20 ms,
indicating significant MIO.
A reduced LV ejection fraction (EF) was found in the 29.5% of cases and a reduced RV EF in the
23.3%. There was not a significant association between heart T2* values and LV EF.
Myocardial fibrosis was detected in the 35.9% of the patients. Three patients showed an ischemic
pattern and one of them had a transmural fibrosis in the LV apical region. Out of the 3 patients with
an ischemic pattern, only one patient had a positive history for a previous myocardial infarction. The
majority of the patients had two or more foci of myocardial fibrosis, involving more frequently the
septal segments. Patients with myocardial fibrosis were significantly older (75.4±7.9 vs 68.9±7.6 yrs;
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P=0.019). Global heart T2* and LV volumes were not significantly different between patients with
and without fibrosis. The LV EF was lower in fibrotic patients but the statistical significance was not
reached (58.4±11.7 vs 64.8±8.9 %; P=0.067).
Conclusions: Although a significant heart iron was found only in two cases, nearly half the patients
had abnormal T2* values in at least one myocardial segment. This finding underlines the importance
to use a multislice approach in order to perform an early diagnosis and prevent a more diffuse iron
distribution by chelation therapy. This goal could be critical in patients with myocardial fibrosis that
seems to be a relative common findings in the old MDS patients. In fact, an underlying heart damage
as represented by fibrosis could make the hearts of the old MDS patients more sensitive to lower
levels of accumulated iron.
O203
MYOCARDIAL
SCAR
ECHOCARDIOGRAPHY
EVALUATION
BY
CONTRAST
ENHANCED
2D
FRANCESCO FULVIO FALETRA (A), ROMINA MURZILLI (A, C), LAURA ANNA LEO (A,
B), MARIO MARZILLI (B), MARIA PENCO (C)
(A) CARDIOCENTRO TICINO; (B) UNIVERSITÀ DEGLI STUDI DI PISA; (C) UNIVERSITÀ
DEGLI STUDI DELL´AQUILA
Background: To date Delayed-Enhanced Cardiac Magnetic Resonance (DE-cMR) is the gold
standard thecnique for identification of myocardial scar and evaluation of its transmurality. The aim
of our study was to evaluate the diagnostic accuracy of Contrast Enhanced 2 D-echocardiography
(CE 2D-Echo) to identify ischemic myocardial scar using DE-cMR as reference method.
Materials and Methods: Between December 2012 and December 2013, we enrolled 38 subjects (31
men and 7 women; age 62+12 years) in sinus rhythm who underwent DE-cMR and CE 2D-Echo
for clinical indications.
29 patients (76%) were affected by ischemic cardiomyopathy and 19 (50%) had prior myocardial
infarction (mean infarct age 8+7 years). Mean LV ejection fraction was 41 +15 % by 2D-Echo and
40+ 16 % by cMR.
2D Echo acquisition was performed using a mechanical index (MI) of 0.1 at a pulse emission
frequencies of 1,5-3.0 MHz. At such low MI level, the intensity of the echo signals reflected by
normal myocardium is very low while myocardial scar appears bright. We used ultrasound contrast
agent SonoVue (Bracco Diagnostics, Inc, Geneva, Switzerland) to appropriately delineate
endocardial and epicardial contours and appreciate the transmural extent of infarction.
Results: In this analysis a total of 608 segments were evaluated; 149 were infarcted segments of
which 71 (47%) with subendocardial and 78 (53%) with transmural scar, 22 segments (15%) were
located in anterior wall, 17 segments (11%) in antero-lateral, 47 segments (31%) in inferior , 25
segments (17%) in infero-lateral wall, 27 segments (18%) in anterior septum and 11 segments (7%)
in inferior septum.
A good correlation between 2D CE-echo and DE-cMR for identification of scar was founded,
expecially in inferior, inferolateral and septum wall, while in anterior and anterolateral segments the
agreement was poor . On a per-segment analysis, CE-2D Echo allowed the identification of DE-cMR
scars with a sensitivity of 60% (95% CI, 51% to 68%), a specificity of 99% (95% CI, 97% to 99%),
and a PPV of 94% (95% CI, 86% to 98%), NPV of 88% ( 95% CI, 85% to 91%).
The assessment of myocardial scar in per-level analysis showed that the agreement between CE 2DEcho and DE-cMR was better for basal and medium level than apical level, yelding a sensitivity and
specificity respectively of 84 % (95% CI, 70%-93%) and 98% (95% CI, 95%-100%) in basal
segments; 62% (95% CI, 49%-73%) and 99% (95% CI, 97%-100%) in medium segments; 30% (95%
CI, 17%-47%) and 98% (95% CI, 94%-100%) in apical segments. Also we have investigated if
myocardial thickness could be predictor of false negative in CE 2D -Echo. The end-diastolic
SIC | Indice Autori
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Roma, 13 – 15 dicembre 2014
myocardial thickness was graded in 3 categories: 1) < 4 mm, 2) 5-6 mm, 3) >7 mm. At a univariable
analysis, the agreement was better for segments with myocardial thickness of 5-6 mm (OR 0.10, 95%CI, 0.05-0.22; p<0.001) and > 7 mm (OR 0.03, 95%-CI, 0.11-0.08; p<0.001) compared with
myocardial thickness of 4 mm.
Conclusions: This study shows that CE 2D-Echo could give additional diagnostic information for
detection of myocardial scar in patients with chronic ischemic cardiomyopathy known or suspected,
expecially when cardiac magnetic resonance is controindicated or not immediately available.
O204
ECHOCARDIOGRAPHIC ASSESSMENT IN TYPE I GAUCHER DISEASE
FRANCESCO LO IUDICE (A), MAURIZIO GALDERISI (A), ANTONIO BARBATO (B),
RICCARDO MUSCARIELLO (B), CARLO DI NARDO (A), FRANCESCO DE STEFANO (A),
PASQUALE STRAZZULLO (B), GIOVANNI DE SIMONE (A)
(A) CENTRO INTERDIPARTIMENTALE PER LA RICERCA SULL´IPERTENSIONE
ARTERIOSA E PATOLOGIE ASSOCIATE (CIRIAPA), DIPARTIMENTO DI SCIENZE
BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO II, NAPOLI ; (B) DIPARTIMENTO
DI CLINICA MEDICA E CHIRURGIA,UNIVERSITÀ FEDERICO II DI NAPOLI
Purpose: Type I Gaucher Disease (GD1) is an autosomal recessive lysosomal storage disease
characterized by multi-organ damage. Right ventricular overload due to pulmonary hypertension is
the most frequent manifestation, whereas left ventricular (LV) involvement has been rarely reported.
Accordingly, aim of the study was to evaluate LV geometry and function in a series of patients with
GD1.
Methods: Eighteen patients with GD1, 18 age and sex-matched normal controls and 18 age and sex
matched hypertensive patients (HTN) were compared by standard echo-Doppler examination. LV
mass index, relative diastolic wall thickness and 2D (modified Simpson method) ejection fraction,
transmitral E/A ratio, deceleration time (DT) of E velocity, atrial filling fraction (AFF = time-velocity
integral of A velocity (time-velocity integral of total diastole x 100), the ratio between transmitral E
velocity and pulsed Tissue Doppler derived early diastolic velocity of mitral annulus (E/e’ ratio) and
left atrial volume index were determined.
Results: Nine GD1 patients also exhibited arterial hypertension. The intergroup difference of LV
mass index and relative wall thickness was not significant. Transmitral E/A ratio was lower in HTN
(1.10 ± 0.30) than in normal controls (1.37 ± 0.34) and GD1 (1.14 ± 0.39) (p<0.05). GD1 exhibited
longer DT (221.2 ± 42.9 msec) than NC (186.0 ± 34.4 msec) and HTN (189.9 ± 30.1 msec) (p=0.009).
AFF was higher in GD1 (37.0 ±11.5%) and HTN (35.5 ±6.9%) compared to NC (29.3 ± 4.7%)
(p=0.034). After adjustment for heart rate, GD1 was associated with longer DT (p<0.001) and greater
AFF (p=0.036) while HTN was associated only with AFF (p=0.013). No interaction was found
between GD1 and HTN for both DT (p=0.104) and AFF (p=0.77).
Conclusion: The present study is the first to pint out the existence of a subclinical LV damage GD1
in GD1 corresponding to a mild degree (stage I) of LV diastolic dysfunction. . This subclinical LV
diastolic dysfunction is independent of the coexistence of arterial hypertension. Subclinical LV
impaired relaxation in the context of myocardial infiltrative damage could be the mechanism
underlying these alterations. This information should foster echo-Doppler follow-up of GD1 patients.
Further studies are needed to analyze the possible progression of LV damage over time and whether
there is a possible role of enzyme replacement therapy.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O205
CARDIAC IRON OVERLOAD AND FUNCTION BY CMR IN DIFFERENT PHENOTYPIC
GROUPS OF THALASSEMIA INTERMEDIA PATIENTS
ANTONELLA MELONI (A), CHIARA LANZILLO (B), MONIA MINATI (B),
VINCENZO POSITANO (A), VALENTINA VINCI (C), SILVIA MACCHI (D),
ALESSANDRA QUOTA (E), PETRA KEILBERG (A), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) DIPARTIMENTO DI CARDIOLOGIA, POLICLINICO “CASILINO“, ROMA, ITALY; (C)
ISTITUTO DI RADIOLOGIA, AZ. OSP. “GARIBALDI“ PRESIDIO OSPEDALIERO NESIMA,
CATANIA, ITALY ; (D) SERVIZIO TRASFUSIONALE, OSPEDALE SANTA MARIA DELLE
CROCI, RAVENNA, ITALY; (E) SERV. TALASSEMIA, OSP. “V. EMANUELE III“, GELA
(CL), ITALY
Introduction: Thalassemia intermedia (TI) indicates a clinical condition of intermediate gravity
between thalassaemia minor, the asymptomatic carrier, and thalassaemia major, the transfusiondependent, severe form. The clinical manifestations can be very variable, and span from a later
clinical onset with a milder anemia, better prognosis, and patients requiring therapeutic intervention
later in life. Cardiac involvement in TI patients seems to be more related to an high cardiac output
state than to myocardial iron burden. The relationship between the presence of a precise phenotype
and the cardiac impairment in TI has not been investigated. The aim of our study was to detect if
different phenotypes could be related to different levels end kind of cardiac involvement, evaluated
by cardiovascular magnetic resonance (CMR).
Methods: We performed a retrospective review of the CMR results and of clinical data about 52 TI
patients (age 38 ±10 years, 54% females) enrolled in the Myocardial Iron Overload in Thalassemia
(MIOT) project. In the MIOT network all CMR and thalassemia centers are linked by a web-based
network, configured to collect patients’ anamnestic, clinical, and diagnostic data. Myocardial iron
overload was assessed using a multislice multiecho T2* approach. Cine sequences were obtained to
quantify biventricular morphological and functional parameters.
Results: Three groups of patients were identified: heterozygote (N=18), homozygote β+ (N=19),
homozygote β° (N=15). No significant differences for sex and age were found among the groups. The
global heart T2* value was significantly higher in the homozygote β° group compared to the
homozygote β+ group (42 ± 5.6 ms vs 34 ± 8 ms, P=0.006). The homozygote β° group showed
significantly higher Left Atrial Area values than the heterozygote group (28 ± 4 cm2 vs 22 ± 5 cm2,
P = 0.014). The homozygote β° group showed significantly higher LV EDV indexes than the
heterozygote and homozygote β+ group (116 ± 19 ml/m2 vs 94.7 ± 21.7 ml/m2 vs 96 ± 23 ml/m2, P
= 0.019) and significantly higher LV mass indexes than the heterozygote group (70 ± 15 g/m2 vs 57
± 14 g/m2, P=0.032). The homozygote β° group showed significantly higher RV EDV and ESV
indexes than the heterozygote group (113 ± 24 ml/m2 vs 90 ± 24 ml/m2, P=0.031; 43 ± 17 ml/m2 vs
29 ± 10 ml/m2, P=0.01).
Conclusions: Heart remodelling related to a high cardiac output state cardiomyopathy was more
pronounced in the homozygote β° TI patients. These data support the knowledge of the different
phenotypes in the clinical and instrumental management of the TI patients.
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Roma, 13 – 15 dicembre 2014
FIBRILLAZIONE ATRIALE
O206
CARATTERISTICHE DEI PAZIENTI AFFETTI DA FIBRILLAZIONE ATRIALE:
DIFFERENZE E ANALOGIE NEL TRATTAMENTO TRA L’ITALIA E L’EUROPA DOPO
UN ANNO DI FOLLOW-UP NEL REGISTRO PREFER IN AF
GUIDO MELILLO (A), FABIO VALENTINI (A), ANDREA CAMERA (A), MARIA
PAOLA GEMMITI (B), ALICE FISCHETTI (C), LIVIO DI LECCE (C), GIULIA RENDA (D),
RAFFAELE DE CATERINA (D)
(A) UNITÀ OPERATIVA COMPLESSA DI CARDIOLOGIA OSPEDALE I.D.I. - I.R.C.C.S.
ROMA; (B) U.O. CARDIOLOGIA E UTIC, OSPEDALE SS TRINITÀ, SORA (FR); (C)
DIREZIONE MEDICA, DAIICHI SANKYO ITALIA; (D) ISTITUTO DI CARDIOLOGIA,
UNIVERSITÀ “G. D’ANNUNZIO” C/O OSPEDALE SS. ANNUNZIATA, CHIETI
Razionale: La Fibrillazione Atriale (FA) è uno dei più comuni disturbi del ritmo cardiaco, con una
prevalenza stimata nei paesi sviluppati del 1,5-2% nella popolazione generale e un aumento legato
all’età. Il profilo dei pazienti affetti da FA in Europa e in Italia è ben delineato; poche sono invece le
informazioni disponibili riguardanti il trattamento dei pazienti italiani ed europei che mettano
particolarmente in evidenza modalità di cura simili o discordanti.
Metodi: Nel registro PREFER in AF (The PREvention oF thromboembolic events – European
Registry in Atrial Fibrillation) sono stati arruolati, nel periodo compreso da Gennaio 2012 a Gennaio
2013, pazienti non selezionati affetti da FA nei seguenti paesi europei: Austria, Francia, Germania,
Italia (ITA), Spagna, Svizzera e Regno Unito. Ad un anno dall’arruolamento è stata effettuata una
visita di follow-up. I dati di seguito riportati mostrano le differenze al follow-up rispetto alla visita
basale nel tipo di trattamento, ed evidenziano differenze nella gestione della terapia farmacologica
dei pazienti con FA in Italia rispetto al resto dei paesi europei investigati.
Risultati:Nel Registro PREFER in AF sono stati arruolati 7243 pazienti in Europa, di cui 1888 (26%)
in Italia, coinvolgendo 98 centri. In Europa l’89% (n=6412), e in Italia l’88% (n=1655) dei pazienti
inizialmente arruolati ha effettuato ad un anno la visita di follow-up. La percentuale dei pazienti
italiani in trattamento con solo VKA osservata alla visita di FU era del 58%, inferiore rispetto al dato
al basale (62,4%); l’utilizzo della terapia combinata VKA+farmaci antipiastrinici (AP) si è ridotta
dall’ 8,8% al 5%, così come l’utilizzo di uno o più AP (18,1% vs 15%). In generale l’utilizzo degli
AP, in cui l’ASA rimaneva il farmaco più prescritto, è diminuito dal 29,6% della visita al basale al
21,9% nella visita al follow-up. La prescrizione dei Nuovi Anticoagulanti Orali (NAO) è aumentata
invece dallo 0,3 al 3.2%, come anche la percentuale dei pazienti che non ricevono alcuna terapia
(10,4% vs 19%).
La percentuale in Europa dei pazienti in trattamento con solo VKA si è ridotta dal 66,3% al 62%;
analogamente è diminuita la prescrizione della terapia con AP (24,3% vs 15,6%). Si è ridotta inoltre
la percentuale della terapia combinata VKA+AP e l’utilizzo di uno o più AP (rispettivamente 9,9%
vs 6% e 11,2% vs 8%). Si evidenzia viceversa un aumento nella prescrizione dei NAO dal 6,1% al
12,5%. Anche in Europa si osserva un aumento della percentuale dei pazienti non trattati (6,5% vs
11,9%).
Conclusioni: I dati dopo un anno di follow-up del registro PREFER in AF confermano il minor
utilizzo di AVK in Italia rispetto alla media europea , e un incremento di pazienti non trattati (dato
questo in linea con il risultato Europeo). Si osserva inoltre una riduzione dell’utilizzo della terapia
antipiastrinica, somministrata da sola o in associazione al VKA. L’utilizzo dei NAO, seppur in
aumento rispetto al basale, è ancora limitato in Europa, e in modo particolare in Italia.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O207
PROGNOSTIC IMPACT OF CHA2DS2VASC AND RENAL DYSFUNCTION IN NON
VALVULAR ATRIAL FIBRILLATION PATIENTS: WHICH IS THE BEST EQUATION TO
STRATIFY THE RISK OF FUTURE EVENTS?
CARMINE MAZZONE (A), GIULIA BARBATI (A), COSIMO CARRIERE (A),
GIANNI CIOFFI (B), LUIGI TARANTINI (C), ANTONELLA CHERUBINI (A),
ELIANA GRANDE (A), GIULIA RUSSO (A), SILVIA MAGNANI (A), STEFANO POLI (A),
SARA DOIMO (A), MARCO RUSSO (A), ANDREA DI LENARDA (A)
(A) CARDIOVASCULAR CENTER, HEALTH AUTHORITY N°1 AND UNIVERSITY OF
TRIESTE, ITALY; (B) DEPARTMENT OF CARDIOLOGY, VILLABIANCA HOSPITAL,
TRENTO, ITALY; (C) DEPARTMENT OF CARDIOLOGY, S.MARTINO HOSPITAL,
BELLUNO, ITALY
Purpose: Renal dysfunction (RD) is associated with an increased risk of thromboembolic (TE) and
hemorrhagic events (HE) in non valvular atrial fibrillation (NVAF). Which method of RD evaluation
can better stratify the risk of cardiovascular (CV) events in NVAF is still unknown. We evaluated the
additive prognostic role of RD in a wide “real world” population of NVAF outpatients.
Methods: Between November 2009 and October 2013, we enrolled 3398 consecutive NVAF patients
(pts). Clinical data were derived from the E-data chart for outpatient clinic (Cardionet®) of
Cardiovascular Center of Trieste, Italy. In 1509 pts glomerular filtration rate (GFR) was estimated at
first clinic evaluation with Cochkroft-Gault (CG), Modification of Diet in Renal Disease (MDRD)
and Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) equations. RD was defined as
GFR <60ml/min. We recalculated CHA2DS2VASc score, adding 1 point for RD, using the three
equations. The median follow-up was 27 months (Interquartile Range-IR- 15 to 40). We evaluated
incidence of death, CV hospitalization (CVH), HE (fatal bleeding or leading to transfusion, a decrease
in hemoglobin level of ≥2g/dL or hospitalization) and thromboembolism.
Results: The median age was 75 years (IR 68-81), 39.7% were male; 38% of pts had paroxysmal,
31.9% persistent and 30.1% permanent NVAF. 1217 (80.1%) pts had hypertension, 466 (30.8%)
diabetes mellitus, 295 (19.5%) heart failure, 196 (13%) prior stroke or transient ischemic attack and
23 (1.5%) previous bleedings. Median GFR was 61.8mL/min (IR 47-77) with CG, 72.4 (IR 59-87)
with MDRD and 69.1 (IR 55-84) with CKD-EPI. Median HAS-BLED score was 3 (IR 2-4) and ≥3
in 70% of the pts; median CHA2DS2VASc score was 4 (IR 3-5) and ≥2 points in 91.1% pts. 771
(51%) pts were on anticoagulant therapy (OAT). During follow-up we recorded 531 (35%) deaths or
CVH, 113 (7.5%) TE and 24 (1.6%) HE. A significant percentage (47% with CG, 34% with CKDEPI and 27% with MDRD; p<0,001) of these pts were correctly reclassified in a worse class of risk
by adding 1 point for RD to CHA2DS2VASc score. Pts with TE during follow-up were reclassified
by the presence of RD in a worst class of risk in 64% with CG, 47% with CKD-EPI and 35% with
MDRD (p=0.009); patients with HE were reclassified by the presence of RD in a worst class of risk
in 58% with CG, 50% with CKD-EPI and 42% with MDRD (p=NS). Stratifying these pts by
antithrombotic therapy, the presence of RD, estimated by CG, was associated to a significant higher
risk of TE during follow-up in pts not treated or treated with anticoagulant (probably because of a
higher burden of previous events in the medical history); conversely using CKD-EPI or MDRD there
was a significant higher risk only in non-treated patients (p=0,005 and p=0,035 respectively).
Adding RD (1 point) to CHA2DS2VASc score considering pts that experienced death/CVH, 58.5%,
44.7% and 36.4% of pts with RD were reclassified in a worst class of risk with CG, CKD-EPI and
MDRD respectively (p<0.001), independently from OAT.
Conclusions: In NVAF pts the risk reclassification by CHA2DS2VASc and moderate RD seems to
have an additive prognostic impact, considering death, CVH and TE. CG was the best formula for
global performance to reclassify pts for risk of events during follow-up.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O208
FIBRILLAZIONE ATRIALE INCIDENTE NELL’IPERTENSIONE
TRATTATA: IL CAMPANIA-SALUTE NETWORK
ARTERIOSA
MARIA-ANGELA LOSI (A, D), RAFFAELE IZZO (B, D), MARINA DE MARCO (A, D),
GRAZIA CANCIELLO (A, D), RAFFAELLA AMERICA (A, D), VALENTINA TRIMARCO (C,
D), GIOVANNI ESPOSITO (A, D), NICOLA DE LUCA (B, D), GIOVANNI DE SIMONE (B,
D), BRUNO TRIMARCO (A, D)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITÀ FEDERICO II
- NAPOLI; (B) DIPARTIMENTO DI SCIENZE MEDICHE TRASLAZIONALI, UNIVERSITÀ
FEDERICO II -NAPOLI; (C) DIPARTIMENTO DI NEUROSCIENZE, UNIVERSITÀ
FEDERICO II - NAPOLI; (D) CENTRO INTERDIPARTIMENTALE DI RICERCA PER
L’IPERTENSIONE ARTERIOSA E PATOLOGIE ASSOCIATE, UNIVERSITÀ FEDERICO II NAPOLI
Nonostante lo sviluppo di nuove strategie terapeutiche, la fibrillazione atriale (FA) continua
ad accompagnarsi ad una prognosi cardiovascolare (CV) sfavorevole; d’altra parte, la conoscenza
dei fattori che ne influenzano lo sviluppo è incompleta. Di conseguenza, abbiamo analizzato le
caratteristiche ed il profilo di rischio di FA in pazienti del registro del Campania Salute Network
(CSN), per studiare la frequenza ed i determinanti dello sviluppo di FA.
Metodi e Risultati: Dal CSN, abbiamo selezionato 7062 pazienti ipertesi (52+12 anni), senza storia
di FA, malattie CV prevalenti, frazione di eiezione ventricolare sinistra (VS) <50%, e con funzione
renale normale o lievemente ridotta (I-III stadio).
Durante il follow-up (mediana
36 mesi), 117 pazienti
sviluppavano
un
primo
episodio
di
FA,
con
un’incidenza di 6.6/1000
pazienti/anno. Questi pazienti
erano più anziani, avevano
indice di massa corporea,
frequenza
cardiaca
ed
pressione arteriosa sistolica
maggiori dei pazienti che non
sviluppavano FA, sia di base
che al follow-up (tutte le
p<0.0001). I pazienti con FA
presentavano
più
bassa
frazione di eiezione, più alti
valori di massa VS e di diametro atriale sinistro (AS) (tutte le p<0.0001). Di base, i pazienti che
sviluppavano FA assumevano un numero maggiore di farmaci, (p<0.0001) dovuto ad una maggiore
prescrizione di diuretici (p=0.002), ACE inibitori e/o sartani (p=0.013), -bloccanti (p=0.012) e
Ca++- antagonisti (p=0.001). In un modello di regressione di Cox, sviluppato considerando gli eventi
CV maggiori precedenti lo sviluppo di FA come eventi competitivi, si confermava che una terapia
aggressiva iniziale si associava ad un alto rischio di sviluppare FA, così come valori elevati di
dimensione AS, di massa VS e di rapporto tra pressione differenziale ed indice sistolico (tutte le
p<0.001) (Figura). In questo modello, l’uso di diuretici riduceva il rischio di sviluppo di FA di circa
il 50% (p<0.03) (Figura).
Conclusioni: Età avanzata, la necessità di assumere più farmaci già alla prima visita in un
ambulatorio per pazienti ipertesi, aumentate massa VS, dimensioni AS e rigidità arteriosa
identificano un fenotipo di paziente iperteso ad alto rischio di sviluppare FA. L’uso di diuretici,
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Roma, 13 – 15 dicembre 2014
controllando sia la pressione arteriosa che lo strech atriale, potrebbe avere un ruolo importante nella
prevenzione della FA in pazienti ipertesi ad alto rischio.
O209
IL MONITORAGGIO DELLA TERAPIA ANTICOAGULANTE ORALE NEI PAZIENTI
CON FIBRILLAZIONE ATRIALE IN ITALIA: CONFRONTO FRA I DATI AL BASALE E
AL FOLLOW-UP DEI PAESI PARTECIPANTI AL REGISTRO EUROPEO PREFER IN AF.
MARCELLO PIACENTI (A), ANDREA ROSSI (A), DOMENICO PRISCO (B),
ELENA SILVESTRI (B), LIVIO DI LECCE (C), GIORGIO FERRARI (C), GIULIA RENDA (D),
RAFFAELE DE CATERINA (D)
(A) U.O.S. V.D. ELETTROFISIOLOGIA INTERVENTISTICA, FONDAZIONE TOSCANA
“G.MONASTERIO”, PISA; (B) DIPARTIMENTO DI MEDICINA SPERIMENTALE E
CLINICA, S.O.D. PATOLOGIA MEDICA, A.O.U. CAREGGI, FIRENZE ; (C) DIREZIONE
MEDICA, DAIICHI SANKYO ITALIA; (D) ISTITUTO DI CARDIOLOGIA, UNIVERSITÀ “G.
D’ANNUNZIO” C/O OSPEDALE SS. ANNUNZIATA, CHIETI
Razionale: Nei pazienti con diagnosi di Fibrillazione Atriale (FA), la prevenzione degli eventi
tromboembolici si fonda ancora in prevalenza sugli antagonisti della vitamina K (VKA). Tale terapia
richiede un periodico monitoraggio dei parametri coagulativi, per garantirne l’efficacia minimizzando
l’incidenza di effetti avversi. Mancano studi sull’impatto delle diverse strategie di monitoraggio dei
paesi europei sul mantenimento dei valori desiderabili di International Normalized Ratio (INR).
Metodi: Nel registro PREFER in AF (The PREvention oF thromboembolic events – European
Registry in Atrial Fibrillation) sono stati arruolati, fra Gennaio 2012 a Gennaio 2013, pazienti non
selezionati affetti da FA nei seguenti paesi europei: Austria, Francia, Germania, Italia (ITA), Spagna,
Svizzera e Regno Unito. I dati descritti sono stati raccolti in occasione della visita basale e della visita
di follow-up (ad 1 anno) dello studio e fanno riferimento alla sottoanalisi dei pazienti italiani ed al
relativo confronto rispetto agli altri paesi europei, con riferimento all’adeguatezza del controllo degli
anticoagulanti anti-vitamina K.
Risultati: Nel Registro PREFER in AF sono stati arruolati 7243 pazienti in Europa, di cui 1888 (26%)
in Italia. Fra i pazienti italiani, il 64.7% è stato sottoposto ad almeno una misurazione di INR nel
mese precedente l’arruolamento nel registro rispetto ad una media europea del 67.6%. Il numero
medio dei monitoraggi dell’ INR nel mese precedente l’arruolamento è risultato essere in Italia pari
a 2.8, valore più alto fra tutti i paesi partecipanti allo studio (media europea: 2.1), proporzione
mantenuta anche per il numero medio di misurazioni INR nell’ultimo anno (Italia 16.1, media
europea: 14.6). Alla visita di follow-up dopo 1 anno l’Italia si conferma il paese con il maggior
numero di misurazioni INR nell’anno di osservazione (Italia: 21.4, media Europea: 16.7). In Italia il
monitoraggio INR era effettuato presso i centri di anticoagulazione nel 47.5% dei casi (media europea
del 19.4%). Il tempo nel range terapeutico (Time in Therapeutic Range, TTR) dei pazienti italiani,
calcolato sulle ultime 3 misurazioni INR, è risultato maggiore al follow-up (86.2%; media europea:
84.7%) rispetto al basale (72.2%; media europea: 75.9%), I livelli di controllo INR al follow-up erano
correttamente stimati dai medici, in Italia così come negli altri paesi, a differenza delle stime al basale
dove il TTR reale era sovrastimato.
Conclusioni: I dati del registro PREFER in AF hanno mostrato come in Italia la gestione
dell’anticoagulazione nei pazienti affetti da FA sia per lo più demandata ai centri di terapia
anticoagulante orale (TAO), a differenza di altri paesi europei. Sia al basale che al follow-up l’Italia
è il paese con il numero più elevato di misurazioni dell’INR, ottenendo al follow-up risultati superiori
alla media dei paesi europei in termini di qualità del trattamento (valutata con il TTR), inferiori solo
alla Germania. Si apprezza al follow-up una migliore percezione soggettiva della qualità
dell’anticoagulazione dei pazienti da parte dei medici di tutti i paesi, probabilmente anche in relazione
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
ad una maggiore attenzione terapeutica nei confronti dei pazienti partecipanti al registro rispetto alle
valutazioni prima dell’inserimento dei pazienti nel registro stesso.
ABLAZIONE FIBRILLAZIONE ATRIALE
O210
LEFT ATRIAL FUNCTION AFTER RADIOFREQUENCY CATHETER ABLATION OF
ATRIAL FIBRILLATION: CAN PRE-ABLATION FUNCTION PREDICT CONTRACTILE
RECOVERY DURING FOLLOW UP?
ALESSANDRO BRUSTIO (A), MARINA ANTOLINI (A), FEDERICA BONGIOVANNI (A),
DANIELE ERRIGO (A), CRISTINA FORNENGO (A), CRISTINA GALLO (A),
SIMONE FREA (A), WALTER GROSSO MARRA (A), LAURA BERGAMASCO (A),
MARA MORELLO (A), FIORENZO GAITA (A)
(A) DIVISION OF CARDIOLOGY, CARDIOVASCULAR AND THORACIC DEPARTMENT,
”CITTÀ DELLA SALUTE E DELLA SCIENZA” HOSPITAL AND DEPARTMENT OF
MEDICAL SCIENCES, UNIVERSITY OF TURIN, TURIN, ITALY
Aims: To find a cut off for the pre-ablation left atrial (LA) function able to predict atrial functional
recovery after radiofrequency catheter ablation (RFCA).
Methods and Results: 64 consecutive AF patients who underwent RFCA were enrolled (age 59.05
± 12.09 years, 75% males, 36% persistent atrial fibrillation, left atrial volume 76.1±28.8 ml).
Transthoracic echocardiographic was performed before and 48 hours, 15 days, 1, 2, 3 and 9 months
after ablation in order to assess LA function fate. Maximum, minimum and pre-systolic volumes were
used to calculate LA emptying fraction (LAEF), LA active emptying fraction (LAAEF), LA passive
emptying fraction (LAPEF) and LA expansion index (LAEI).
At univariate analysis only baseline atrial function proved to be an independent predictor of LA
function improvement after ablation (p=0.002), OR=0.001, 95%CI 0.000-0.099) The Receiving
Operator Curve (ROC) results (AUC=0,70) determined 0.40 as cutoff for the baseline LAEF. At 9
months, patients with LAEF<0.40 showed a significant improvement in atrial performance (LAEF
p=0.01, LA AEF p=0.036, LA EI p=0.004); a significant negative correlation between baseline LAEF
and its improvement was observed (r= -0.62 (IC 95% -0.83;-0.26), p (r=0) < 0,002). For every 1% in
baseline LAEF reduction, there was an average 8% improvement in LAEF.
Conclusion: Baseline LAEF function confirmed to be an independent predictor of LA function
recovery after RFCA. The beneficial effect of AF ablation is most evident in patients with LAEF
<0.40.
O211
FEASIBILITY AND SAFETY OF UNINTERRUPTED RIVAROXABAN IN PATIENTS
UNDERGOING RADIOFREQUENCY ABLATION FOR LONG STANDING PERSISTENT
ATRIAL FIBRILLATION.
LUIGI DI BIASE (A, C), FRANCESCO SANTORO (C), PASQUALE SANTANGELI (C),
RONG BAI (B), JAVIER SANCHEZ (B), STEPHEN HAO (D), RICHARD HONGO (D),
DHANUJAYA R. LAKKIREDDY (E), MADHU REDDY (E), JUAN F. VILES-GONZALEZ (F),
J. DAVID BURKHARDT (B), ANDREA NATALE (B)
(A) ALBERT EINSTEIN COLLEGE OF MEDICINE AT MONTEFIORE HOSPITAL, NEW
YORK, USA ; (B) TEXAS CARDIAC ARRHYTHMIA INSTITUTE, ST DAVID´S MEDICAL
CENTER, AUSTIN, TX, USA; (C) DEPARTMENT OF CARDIOLOGY,UNIVERSITY OF
FOGGIA, ITALY; (D) CALIFORNIA PACIFIC MEDICAL CENTER, SAN FRANCISCO,
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CALIFORNIA, USA; (E) UNIVERSITY OF KANSAS MEDICAL CENTER, KANSAS CITY,
KANSAS,USA; (F) UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI,
FLORIDA,USA
Introduction: Periprocedural anticoagulation management is key to minimize bleeding and
thromboembolic complications during and after radiofrequency catheter ablation. Uninterrupted
strategies with warfarin in high risk patients have shown superiority over interrupted strategies.
We sought to assess the safety and feasibility uninterrupted rivaroxaban during atrial fibrillation (AF)
ablation in patients with long standing persistent atrial fibrillation.
Methods: One hundred and ninety six (196) consecutive patients undergoing AF ablation with
uninterrupted rivaroxaban (last dose taken with food the night before the procedure and the following
dose taken the night of the procedure) were matched by age and sex with an equal number of patients
undergoing AF ablation with uninterrupted warfarin on a “therapeutic range”. All patients underwent
pulmonary vein antrum isolation and ablation of non pulmonary vein triggers as disclosed by
isoproterenol challenge test.
Results: Baseline characteristics and procedural variables were similar between groups. Mean INR
in warfarin group was 2.2 ± 0.5. CHADS2 Score was ≥ 2 in 141 (72%) in the rivaroxaban group and
130 (66%) in the warfarin patients (p=0.20). One pericardial tamponade and one groin hematoma
occurred in rivaroxaban group while 2 patients in warfarin group developed groin hematoma. One
TIA with positive MRI was present in the rivaroxaban group.
Conclusions: Uninterrupted rivaroxaban therapy appears to be as safe and efficacious as
uninterrupted warfarin strategy in preventing bleeding and thromboembolic events in patients
undergoing long standing persistent AF ablation.
O212
IS IT TIME TO CALCULATE RENAL FUNCTION IN NON VALVULAR ATRIAL
FIBRILLATION PATIENTS TO STRATIFY THE RISK OF FUTURE EVENTS?
CARMINE MAZZONE (A), GIULIA BARBATI (A), COSIMO CARRIERE (A),
GIANNI CIOFFI (B), LUIGI TARANTINI (C), ANTONELLA CHERUBINI (A),
ELIANA GRANDE (A), SILVIA MAGNANI (A), STEFANO POLI (A), SARA DOIMO (A),
MARCO RUSSO (A), ANDREA DI LENARDA (A)
(A) CARDIOVASCULAR CENTER, HEALTH AUTHORITY N°1 AND UNIVERSITY OF
TRIESTE, ITALY; (B) VILLA BIANCA HOSPITAL, CARDIOLOGY, TRENTO, ITALY ; (C)
SAN MARTINO HOSPITAL, CARDIOLOGY, BELLUNO, ITALY
Purpose: Chronic kidney disease with Renal Disfunction (RD) is associated with an increased risk
of thromboembolic and hemorrhagic events in non valvular atrial fibrillation (NVAF). Although
current European Guidelines on NVAF suggest that an accurately evaluation of renal function is
useful in hemorrhagic risk stratification, it is not yet considered in thromboembolic risk score
CHA2DS2VASc. The aim of our study was to evaluate the prognostic role of RD in a wide “real
world” population of NVAF outpatients.
Methods: Between November 1, 2009 and October 31, 2013, we enrolled 3398 consecutive NVAF
patients. Clinical data were derived from the E-data chart for outpatient clinic (Cardionet®) of
Cardiovascular Center of Trieste, Italy, and collected in a regional Data Warehouse. In 1509 patients,
glomerular filtration rate (GFR) was available at first visit. Renal disfunction (RD) was defined as
GFR <60ml/min estimated using MDRD equation. The events recorded during follow-up were death,
cardiovascular hospitalization (CVH), major bleeding (namely fatal bleeding, transfusion or
hospitalization requiring bleeding or associated to a decrease in hemoglobin level ≥2g/dL) and
thromboembolism.
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Results: The median patient age was 75 years (range 68-81), 39.7% were male, 38% had paroxysmal,
31.9% persistent and 30.1% permanent NVAF; 1217 (80.1%) had hypertension, 466 (30.8%) diabetes
mellitus, 295 (19.5%) heart failure, 491 (32%) coronary artery disease, 196 (13%) prior stroke or
transient ischemic attack, 23 (1.5%) previous bleeding episode, 31.9% and 13.2% had Charlson
Comorbid Index in the range 3-5 and >5, respectively. 1014 patients (67.2%) were treated with more
than 5 drugs. Median HAS-BLED score was 3 (range 2-4) and ≥3 in 70% of patients; median
CHA2DS2VASc score was 4 (range 3-5) and ≥2 points in 91.1% of patients. During a median followup of 27 months were recorded 531 (35%) deaths or CVH, 113 (7.5%) thromboembolic events and
24 (1.6%) major bleedings.
The presence of RD identified a group of older patients with more cardiovascular (CV) risk factors,
more severe heart disease, higher Charlson Index, more concomitant medical therapies. During
follow-up we recorded 48% vs 30% of deaths or CVH (p<0.001), 10% vs 7% of thromboembolic
events (p=0.02) and 2.5% vs 1% of hemorrhagic events in those with and without RD (p=0.09).
Patients with RD showed a global worse prognosis for CVH/death-free survival independently from
the prescription of anticoagulant/antiplatelet therapy (p<0.001). Instead, considering
thromboembolism free survival, patients with RD had a worse prognosis only if not taking oral
anticoagulant nor antiplatelet therapy (p =0,035). Conversely considering hemorrhagic events the
presence of RD did not identify patients with a significant worse prognosis, independently from the
therapy.
Conclusions: In the “real world” of NVAF outpatients, RD identified a subgroup of older patients,
with more complex CV and non CV disease at higher risk of CV events. RD was associated to a
higher rate of thromboembolism in patients not taking antithrombotic therapy.
O213
IMPACT OF LEFT ATRIAL SIZE ON CLINICAL OUTCOME AFTER PULMONARY
VEIN ISOLATION
ANIELLO VIGGIANO (A), KEITH MORRICE (A), PETER GEELEN (A), TOM DE
POTTER (A), GAZMEND BARDHAJ (A)
(A) OLV CLINIC CARDIOVASCULAR CENTER, AALST
Purpose: The success rate of catheter ablation of atrial fibrillation (AF) is superior to the efficacy of
anti-arrhythmic drugs but it remains difficult to predict. A large left atrial (LA) diameter is associated
with an increased risk of recurrent AF after cardioversion or ablation in several echocardiographic
studies. Neverthless the measurement of a single diameter may underestimate LA size so we
evaluated the relationship between high accuracy LA volume and the clinical outcome after ablation
performing a 3D rotational angiography (3DRA) of the left atrium.
Methods and Results: This is a single center retrospective study, enrolling patients that underwent
a pulmonary vein isolation (PVI) procedure for treatment of AF in our institution using a
nonfluoroscopic navigation system (CARTO®, Biosense-Webster) with an open irrigated tip
radiofrequency ablation catheter. In all cases 3DRA was used to obtain a 3D model of the LA (using
Innova EP Vision® General Electric) reconstructed from 2D angiographic data acquired during a
high-speed 200-degree spin using fast ventricular pacing or intracardiac high dose administration of
adenosine.
All patients had a follow up of six months including a 3 months blanking period. All available data
(ECG, Holter, pacemaker recordings, outpatient visits) within this period were evaluated. AF, atrial
flutter and atrial tachycardia lasting >30 sec were considered as relapses of arrhythmia. The total
number of patients included in the study was 85 (61.3±12.7 years): 56(65.8%) males and 29 (34.2%)
females. AF was Paroxismal in 76.2% of all cases versus Persistent in 23.8%.
Clinical characteristics included: arterial hypertension in 33 (38.8%), previous stroke/TIA in 7 (8.2
%), congestive heart failure in 14 (16.4 %) and COPD in 4 (4.7%). The mean 3DRA LA volume
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measured was 171.4±45.6 ml and mean volume indexed for body surface area was 87.4±23.5 ml/m².
After a six month follow up, 24 (28.3%) patients had a relapse of arrhythmia and 61 (71.7%) of them
were free of arrhythmias. All anti-arrhythmic drugs were withdrawn immediately after the procedure
or at least by the end of the blanking period. Binary logistic regression analysis showed no
relationship between LA size expressed as 3DRA indexed volume and clinical outcome (p=0.45).
Conclusion: Using a highly accurate LA volume estimation, we found that LA size is not an
independent predictor for the clinical success after PVI at short to mid term. As suggested in previous
studies only a combination of data regarding LA size/function plus clinical data can predict success
rate after a first ablation procedure for AF. Therefore an approach using an LA volume cut-off for
patient selection prior to PVI cannot be supported at this state.
O214
PREDITTORI ECOCARDIOGRAFICI E CLINICI DI RECIDIVA DI FIBRILLAZIONE
ATRIALE DOPO ABLAZIONE TRANSCATETERE
FEDERICA BONGIOVANNI (A), MARINA ANTOLINI (A), ALESSANDRO BRUSTIO (A),
DANIELE ERRIGO (A), CRISTINA FORNENGO (A), CRISTINA GALLO (A),
SIMONE FREA (A), WALTER GROSSO MARRA (A), FEDERICO FERRARIS (A),
LAURA BERGAMASCO (A), MARCO SCAGLIONE (B), MARA MORELLO (A),
FIORENZO GAITA (A)
(A) DIVISIONE DI CARDIOLOGIA, DIPARTIMENTO DI MALATTIE CARDIOVASCOLARI,
“CITTÀ DELLA SALUTE E DELLA SCIENZA”, UNIVERSITÀ DI TORINO, TORINO,
ITALIA ; (B) DIVISIONE DI CARDIOLOGIA, OSPEDALE CARDINAL MASSAIA, ASTI,
ITALIA
Introduzione L’ablazione transcatetere rappresenta una comprovata strategia di controllo del ritmo
nei pazienti affetti da Fibrillazione Atriale (FA). Nonostante le tecniche di ablazione siano state
implementate negli anni, il 30% dei pazienti va ancora incontro a recidiva post-procedura. Questo
studio prospettico è volto ad individuare quali fattori clinici ed ecocardiografici pre-procedurali
possano predire il rischio di recidiva di FA dopo ablazione transcatetere.
Metodi e Risultati Nel biennio 2011-2013 sono stati valutati 215 pazienti sottoposti ad ablazione
trans-catetere di FA presso il Laboratorio di Elettrofisiologia della Cardiologia Universitaria
dell’Ospedale ‘Città della Salute e della Scienza’ di Torino. 202 pazienti sono stati arruolati e
suddivisi in due gruppi: Gruppo 1, pazienti in Ritmo Sinusale pre-ablazione (N 145), Gruppo 2,
pazienti in FA pre-ablazione (N 57). Pre-procedura tutti i pazienti sono stati sottoposti ad accurata
anamnesi ed a valutazione ecocardiografica transtoracica e transesofagea. In tutti i casi è stato
eseguito l’isolamento delle Vene Polmonari, nel 4.95% la procedura è stata completata dal
confezionamento di Lesioni Lineari e/o dall’ablazione di Potenziali Frammentati (7.42%). Postprocedura tutti i pazienti sono stati sottoposti a visita cardiologica ogni 3-6-9 mesi, per un totale di
12 ± 8 mesi di followup. Nel Gruppo 1 (età 58.12 ± 11.91 anni, maschi 73%, ipertesi 60.7%, FA
persistente 31%, LAV 40.74 ± 15.19 mL/m2, Velocità in auricola 66.04 ± 21.82 cm/s, onda A’settale
8.29 ± 2.46 cm/s) solo la valutazione ecocardiografica della contrazione atriale mediante Doppler
Tissutale (onda A’ settale ridotta) risultava predittore di recidiva post-procedura (7.47 ± 2.36 vs. 8.59
± 2.43, P 0,016). Nel Gruppo 2 (età 59.4 ± 9.5 anni, maschi 86%, ipertesi 65%, FA persistente 58%,
LAV 45.68 ± 16.53 mL/m2, Velocità in auricola 46.76 ± 20.42 cm/s) i seguenti parametri risultavano
significativamente associati a maggior probabilità di recidiva di FA post-ablazione: LAV ≥ 50 mL/m2
(P 0,003), velocità di flusso in LAA (Left Atrial Appendage) ≤ 45 cm/s (P 0,025), FA di tipo
persistente o long-standing (Non-Paroxysmal AF) (P 0,007, RR= 2.9, 95% CI 1.3 - 6.7). La
distribuzione del rischio di recidiva dopo ablazione ha mostrato un incremento di rischio correlato
all’aumentare del numero di fattori di rischio (LAV, Velocità di flusso in LAA, FA persistente,
ipertensione) (AUC 0,73, 95% CI 0,59 – 0,87); la presenza di almeno 3 fattori di rischio aumenta il
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rischio di recidiva di 3 volte (P 0,003, RR 2.6, 95% CI 1.4 – 4.9). Ogni fattore di rischio aggiuntivo
incrementa la probabilità di recidiva del 20%.
Conclusioni L’identificazione di predittori di recidiva post-ablazione (LAV ≥ 50 mL/m2, Velocità
in LAA ≤ 45 cm/s e NPAF) nei pazienti che affrontano la procedura ablativa in FA e la scelta di un
cut-off permettono l’applicazione di un modello di rischio incrementale nella pratica clinica,
favorendo migliore selezione dei candidati e adeguata gestione terapeutica post-procedura.
O215
INTRACARDIAC ECHO FINDINGS POST ATRIAL FIBRILLATION ABLATION ARE AN
IMPORTANT PREDICTOR OF LATE PERICARDIAL EFFUSION
LUIGI DI BIASE (A, B, C), FRANCESCO SANTORO (C), J. DAVID BURKHARDT (B),
PASQUALE SANTANGELLI (B, C), RODNEY HORTON (B), PATRICK HRANITZKY (B),
JOSEPH GALLINGHOUSE (B), SAKIS THEMISTOCLAKIS (D), RONG BAI (B),
DHANUJAYA R. LAKKIREDDY (E), MADHU REDDY (E), RICHARD HONGO (F), MARIA
LUCIA NARDUCCI (G), GEMMA PELARGONIO (G), CLAUDE S. ELAYI (H),
GIOVANNI FORLEO (I), ANTONIO DELLO RUSSO (J), MICHELA CASELLA (J),
CLAUDIO TONDO (J), ROBERT SCHWEIKERT (K), ANDREA NATALE (B)
(A) ALBERT EINSTEIN COLLEGE OF MEDICINE, MONTEFIORE HOSPITAL, NEW
YORK,USA; (B) TEXAS CARDIAC ARRHYTHMIA INSTITUTE, AUSTIN, TEXAS, USA ; (C)
DEPARTMENT OF CARDIOLOGY, UNIVERSITY OF FOGGIA, ITALY; (D) DELL´ANGELO
HOSPITAL, MESTRE-VENICE, ITALY; (E) UNIV OF KANSAS MEDICAL CENTER,
KANSAS CITY, USA; (F) CALIFORNIA PACIFIC MEDICAL CENTER, SAN FRANCISCO,
CALIFORNIA, USA; (G) CATHOLIC UNIV OF THE SACRED HEART - INSITUTE OF
CARDIOLOGY, ROME, ITALY; (H) UNIV OF KENTUCKY, GILL HEART INST,
CARDIOLOGY, LEXINGTON, KY,USA; (I) UNIV OF TOR VERGATA, ROME, ITALY; (J)
CARDIAC ARRHYTHMIA RES CTR, CTR CARDIOLOGICO MONZINO, IRCCS, MILAN,
ITALY; (K) AKRON GENERAL MEDICAL CTR, AKRON, OH,USA
Introduction: Major bleeding are serious complications of catheter ablation for atrial fibrillation
(AF). Late effusions following AF ablation procedures have been recently reported.
We sought to determine whether the presence of a trivial effusion detected by intracardiac echo at the
end of AF ablation procedures performed without warfarin discontinuation predicts the development
of late pericardial effusion.
Methods: A total of 2618 consecutive patients undergoing catheter ablation for AF with continuous
warfarin have been enrolled in this prospective registry. All ablation procedures were performed
under intracardiac echocardiography (ICE) guidance. At the end of each procedure ICE was utilized
to detect any degree of effusions.
Results: In 510 out of 2618 (19%) patients, trivial pericardial effusion was detected by ICE at the
end of the procedure. All 2108 patients with negative ICE did not show any late pericardial effusions.
On the other hand, 8 of the 510 (1.5%) patients with trivial effusion developed late significant
pericardial effusion requiring pericardial drainage. The incidence of delayed effusion was 0.31% in
this series. In none of the patients requiring epicardial drainage, warfarin was discontinued. A
negative ICE finding for trivial pericardial effusion had a negative predictive value (NPV) of 99.6%.
Conclusion: This study shows that the presence of trivial pericardial effusion detected at the end of
the ablation procedure by ICE warrant further follow-up by echocardiogram to exclude late
tamponade. On the other hand, the absence of any effusion by ICE has a very high negative predictive
value for late effusion.
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SCIENZE DI BASE - MISCELLANEA
O216
LA REGOLAZIONE GENICA ALLA BASE DELL’ESAGERATA RISPOSTA
VASCULOPROLIFERATIVA DOPO ANGIOPLASTICA SPERIMENTALE NEL DIABETE
DIPENDE DA UNO SPECIFICO NETWORK DI MICRORNA
CHRISTELLE CORREALE (a), CARLA VICINANZA (a), ROBERTA TARALLO (b),
GIORGIO GIURATO (b), IOLANDA AQUILA (a), MARIANGELA SCALISE (a),
FABIOLA MARINO (a), CRISTINA CARRESI (c), ANTONIO CURCIO (a),
VINCENZO MOLLACE (c), GIANLUIGI CONDORELLI (d), ALESSANDRO WEISZ (b),
DANIELE TORELLA (a), CIRO INDOLFI (a)
(a) CARDIOLOGIA MOLECOLARE E CELLULARE, UNIVERSITA´ MAGNA GRAECIA DI
CATANZARO; (b) LABORATORIO DI MEDICINA MOLECOLARE E GENOMICA,
UNIVERSITA´ DI SALERNO; (c) LABORATORIO DI TOSSICOLOGIA MOLECOLARE E
CELLULARE,UNIVERSITA´ MAGNA GRAECIA DI CATANZARO; (d) CENTRO DI
RICERCA CARDIOVASCOLARE, HUMANITAS, ROZZANO, MILANO
La prevalenza nel mondo del Diabete Mellito (DM) raggiungerà circa 300 milioni di persone entro il
2025, e più di tre quarti della mortalità nei pazienti con DM sarà causata dalle malattie
cardiovascolari. In particolare, è noto che i pazienti diabetici hanno un’eccessiva morbilità e mortalità
per malattia coronarica e in seguito ad interventi di rivascolarizzazione coronarica percutanea (PCI).
I meccanismi che portano al rimodellamento vascolare dopo danno vasale, significativamente
peggiore nei pazienti diabetici, sono molteplici e non completamente compresi. I microRNA (miR)
sono una classe di piccoli RNA regolatori, noti per regolare più della metà dei trascritti genomici.
Recentemente un gruppo di miRNA è stato riconosciuto come modulatore di programmi genetici
chiave nella biologia, fisiologia e patologia vascolare. Tuttavia, poco si sa sulla regolazione dei
microRNA sul rimodellamento vascolare nel DM. Pertanto abbiamo valutato il profilo dei miRNA
vascolari in animali di controllo non diabetici e negli animali con diabete di tipo 1 e di tipo 2. In Ratti
Wistar maschi è stata somministrata Streptozotocina (100 mg/kg i.p.) per indurre diabete di tipo 1.
L’iperglicemia è stato trattata mediante somministrazione sottocutanea di Insulina (3 UI/2 die). Gli
animali con livelli di glucosio nel sangue costantemente superiori a 300 mg/dl (prima della
somministrazione di Insulina) per quattro settimane consecutive sono stati arruolati nello studio, come
gruppo diabete di tipo 1 (DM-1). Ratti Zucker sono stati utilizzati come modello animale di diabete
di tipo 2 (DM-2). Infine, ratti non diabetici, di uguale razza età e peso sono stati utilizzati come
controllo (CTRL). Alcuni animali sono stati sacrificati al tempo 0 (baseline) e altri sottoposti ad
angioplastica carotidea con palloncino 2F Fogarty e sacrificati dopo 2 o 14 giorni. Al momento del
sacrificio, sono state asportate le carotidi destre sane o danneggiate e congelate per l'estrazione di
mRNA e di proteine o fissate in formalina per l'istologia e l'analisi immunoistochimica. Il Profilo dei
miRNA e degli mRNA vascolari è stato ottenuto mediante RNA-Seq (whole Transcriptome Shotgun
Sequencing). 2 giorni dopo danno l’angioplastica sperimentale, la proliferazione delle cellule
muscolari lisce (SMC) e l'apoptosi è stata significativamente (p <0.05) aumentata nelle arterie
carotidee del DM-1 e DM-2 rispetto a CTRL. 14 giorni dopo danno, si è osservata un’esagerata
iperplasia della neointima e una alterata rigenerazione endoteliale negli animali diabetici vs ctrl
euglicemici. 2 giorni dopo danno, quando le SMC raggiungono il loro picco di attivazione, un insieme
di miR sono specificamente down-regolati (4 miR) o up-regolati (2 miR) sia nel DM-1 e DM-2 (DiabmiRNA) rispetto al CTRL. Questi miR sono specificamente coinvolti nell'espressione e traduzione
di mRNAs noti per essere regolatori chiave nello switch fenotipico delle SMC nelle malattie
vasculoproliferative. Infatti, l’analisi del trascrittoma ha identificato specifici mRNA targets
dell’attività di silenziamento genico dei miRNA disregolati nel Diabete. Tali targets sono stati validati
mediante saggio di Luciferasi come direttamente modulati dai Diab-miRNA. In particolare,
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esperimenti di gain e loss of function degli identificati Diab-miRNA hanno dimostrato che questi
miRNA regolano l’esagerata risposta neointimale nell’animale diabetico e la specifica modulazione
di questi miRNA è in grado di prevenirla. Pertanto i miRNA vascolari sono differentemente regolati
nel diabete mellito rispetto agli animali euglicemici di controllo. Il network di miRNA vascolari
identificati nel fenotipo diabetico regola la trascrizione genica alla base dell’esagerata risposta
iperplastica vascolare nel DM.
O217
THE INOTROPIC EFFECT OF MILD HYPOTHERMIA EXCEEDS THE FORCEFREQUENCY RELATIONSHIP IN HEALTHY PIGS.
ALESSIO ALOGNA (A), MICHAEL SCHWARZL (A), BIRGIT ZIRNGAST (B),
PAUL STEENDIJK (C), HEINRICH MAECHLER (B), BURKERT PIESKE (A),
HEINER POST (A)
(A) DEPT. OF CARDIOLOGY, MEDICAL UNIVERSITY OF GRAZ, AUSTRIA; (B) DEPT. OF
CARDIAC SURGERY, MEDICAL UNIVERSITY OF GRAZ, AUSTRIA; (C) DEPT. OF
CARDIOLOGY, LEIDEN UNIVERSITY MEDICAL CENTER, THE NETHERLANDS
Introduction: The induction of mild hypothermia (MH, 33°C) is guideline therapy to attenuate
hypoxic brain injury after cardiac arrest. In patients with concomitant cardiac failure, MH also lowers
the need for catecholamines. In experimental settings, MH increases myocardial contractility,
indicating that lowering temperature can recruit an endogenous inotropic reserve. To better evaluate
the relevance of this effect, we compared MH to the inotropic effect of the force-frequency
relationship.
Methods: Ten anaesthetized pigs were acutely instrumented (closed chest) with a left ventricular
(LV) pressure-volume catheter, a Swan-Ganz catheter and a right atrial pacing probe. After baseline
measurements, heart rate (HR) was increased to 100, 120, 140, 160 and 180 bpm, if possible. At each
HR, steady state haemodynamics were measured and the end-systolic pressure-volume relationship
(ESPVR) was assessed by inflation of an intraaortic balloon catheter. Measurements were repeated
at normal body temperature (NT, 38 °C) and during MH (33 °C, intravascular cooling catheter).
Results: During MH, spontaneous HR decreased from 85±4 to 68±3 bpm (p<0.05), cardiac output
decreased from 6.6±0.3 to 4.6±0.3 l/min (p<0.05), mean aortic pressure remained unchanged (81±2
to 75±3 mmHg, p=0.10) and systemic vascular resistance increased from 11.6±0.5 to 16.0±1.5
mmHg/l/min (p<0.05). LV dP/dtmax did not change significantly (NT: 1791±82 vs MH: 1846±27
mmHg/s, p=0.41). The LV end-systolic volume at an end-systolic pressure of 100 mmHg (LVVPes100) decreased during pacing in NT, reflecting the force-frequency effect in vivo (see graph).
In MH compared to NT, LV-VPes100 decreased to a larger extent already at spontaneous heart rate,
and decreased further with increasing heart rate. However, maximum heart rate was lower during
MH.
Conclusion: In normal porcine hearts, the positive inotropic effect recruited by MH clearly exceeded
the force-frequency effect. This finding indicates that direct cardiac effects of MH may be relevant
in resuscitated patients with acute cardiac failure.
SIC | Indice Autori
197
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O218
IL PARTICOLATO AMBIENTALE PROMUOVE IL RILASCIO DI MICROPARTICELLE
PROCOAGULANTI IN CELLULE MONONUCLEATE UMANE
TOMMASO NERI (A), FEDERICA ROTA (B), SILVIA PETRINI (A), CRISTINA BALIA (A),
VALENTINA SCALISE (A), YURI CARMAZZI (A), ROBERTO PEDRINELLI (A),
PIERLUIGI PAGGIARO (A), VALENTINA BOLLATI (B), ALESSANDRO CELI (A)
(A) DIPARTIMENTO DI PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E DELL´
AREA CRITICA, UNIVERSITÁ DI PISA, PISA, ITALIA; (B) DIPARTIMENTO DI SCIENZE
CLINICHE E DI COMUNITÀ “CLINICA DEL LAVORO LUIGI DEVOTO“, UNIVERSITÁ DI
MILANO, MILANO, ITALIA
Background: Le microparticelle (MP) sono vescicole di diametro compreso tra 0.05 e 1μm, rilasciate
da molteplici tipologie cellulari. Descritte fino a 30 anni fa come “polvere cellulare” inerte, le MP
sono state di recente coinvolte nei processi di coagulazione e d’infiammazione. Sia l'attivazione
mediante processi chimici/fisici che l'apoptosi possono indurre la formazione di MP; tuttavia i
meccanismi di formazione non sono ancora chiariti. Il particolato atmosferico (PM) è una miscela di
particelle solide e liquide di diversa origine, sospese in aria. La loro composizione chimico-fisica
dipende dalle sorgenti di emissione, e anche dalle condizioni atmosferiche. Dati epidemiologici
suggeriscono che l’esposizione a PM potrebbe essere correlata all'aumento di morbidità e mortalità
cardiovascolare. L'osservazione che il PM possa indurre sia la mobilizzazione del calcio citosolico
sia l’apoptosi cellulare, meccanismi noti nella formazione delle MP, è in linea con l'ipotesi che il PM
induca la generazione di MP.
Scopo: Lo scopo di questa progetto è di valutare la possibilità che il PM possa essere in grado di far
generare MP procoagulanti da parte di cellule mononucleate umane (PBMC).
Metodi: Le PBMC sono state incubate con il PM (SRM1648a) ottenuto dal National Institute of
Standards and Technology (US Department of Commerce, USA). La generazione delle MP è stata
valutata tramite il test della protrombinasi il quale misura la concentrazione di fosfatidilserina (PS)
basandosi sulla quantità di trombina generata a partire dalla protrombina, in una reazione PSdipendente; l’attività del fattore tissutale (TF) associata alle MP (PCA) è stata valutata sul pellet
delle MP ottenuto dopo centrifugazione ad alta velocità (100000xg per 75 min) mediante il “one
stage clotting assay”. La concentrazione del calcio intracellulare è stata misurata attraverso il Fluo-4
NW kit (Molecular Probes) ed espressa come unità di fluorescenza relativa (RFU).
Risultati: Il trattamento con PM induce un aumento dose-dipendente della generazione di MP da
parte delle PBMC (fig A) e un aumento dell’attività del TF ad esse associata (fig B). La generazione
di MP indotta dal PM avviene attraverso la mobilizzazione del calcio intracellulare (fig C).
Conclusioni: La generazione di MP pro-coagulanti PM-mediata potrebbe contribuire a spiegare la
correlazione tra esposizione a particolato ambientale e malattie cardiopolmonari.
SIC | Indice Autori
198
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O219
EFFECTS OF ACUTE PDE-5A INHIBITION ON CARDIAC FUNCTION IN A PORCINE
MODEL OF HYPERTENSIVE HEART DISEASE.
ALESSIO ALOGNA (A), MICHAEL SCHWARZL (A), BIRGIT ZIRNGAST (B),
MARTIN MANNINGER-WUENSCHER (A), JOCHEN VERDERBER (A),
DAVID ZWEIKER (A), PAUL STEENDIJK (C), HEINRICH MAECHLER (B),
BURKERT PIESKE (A), HEINER POST (A)
(a) MEDICAL UNIVERSITY OF GRAZ, DEPT. OF CARDIOLOGY, GRAZ, AUSTRIA; (b)
MEDICAL UNIVERSITY OF GRAZ, DEPT. OF CARDIAC SURGERY, GRAZ, AUSTRIA; (c)
LEIDEN UNIVERSITY MEDICAL CENTER, DEPT. OF CARDIOLOGY, LEIDEN, THE
NETHERLANDS
Background: Experimental data indicate that stimulation of the NO – soluble guanylate cyclase
(sGC) – cGMP – protein kinase G (PKG) pathway can increase left ventricular (LV) end-diastolic
distensibility (LVed-Dist) via phosphorylation of the myofilamental protein titin. We tested the
hypothesis that acute pharmacological inhibition of cGMP breakdown by the phosphodiesterase-5A
(PDE-5A) inhibitor sildenafil would improve LVed-Dist in a porcine model of hypertensive heart
disease in which total LV titin phosphorylation was reported to be decreased.
Methods: 8 female piglets underwent subcutaneous implantation of DOCA releasing pellets (an
aldosterone-analogon) together with a high-salt diet over 12 weeks. After 12 weeks, pigs (58±2 kg)
were anaesthetized and instrumented with a Swan-Ganz-catheter, a LV pressure-volume catheter, and
an intraaortic ballon catheter in a closed chest setting. Pressure-volume relationships were derived
from short aortic occlusions. Following baseline measurements, the PDE-5A inhibitor sildenafil was
given as a 0.25mg/kg intravenous bolus. In a subgroup of n=4, sildenafil was followed by the sGC
stimulator BAY 41-8543 (1 and 3 μg/kg/min over 20 min, intravenously).*: p<0.05 vs baseline.
Results: Compared to weight-matched historic controls, echocardiography confirmed LV concentric
hypertrophy (relative wall thickness 0.81±0.02 vs 0.51±0.04*), while ejection fraction was not
different. After sildenafil, heart rate (85±2 vs 91±4 bpm) and cardiac output (5.3±0.1 vs 5.7±0.2
l/min) did not change, while mean aortic pressure (90±5 vs 71±4* mmHg) and systemic vascular
resistance (16.5±1.2 vs 11.9±0.6* mmHg/l/min) decreased. LV ejection fraction (59±1 vs 61±2%)
and the isovolumic relaxation constant tau (40±1 vs 40±1 ms) did not change. Both the end-systolic
(ESPVR) and the end-diastolic (EDPVR) pressure-volume relationships were slightly shifted
rightwards after sildenafil, indicating some trendwise improvement of LVed-Dist along with a
negative inotropic effect. Addition of the sGC stimulator BAY 41-8543 (n=4) further decreased
systemic vascular resistance, but had no further effect on the EDPVR.
Conclusion: In spite of a pronounced effect on vascular tone, acute inhibition of PDE-5A only had a
minor effect on LVed-Diast that was not potentiated by stimulation of sGC. These data argue against
the concept that acute potentiation of cGMP-dependent signaling can recruit a preload reserve in
hypertrophied LV myocardium. It remains to be determined how long-term potentiation of the
pathway would impact on LV function and remodeling.
SIC | Indice Autori
199
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
MIOCARDITI
O220
PREDICTORS OF DEATH, HEART TRANSPLANTATION AND RELAPSE IN BIOPSYPROVEN AND CLINICALLY SUSPECTED MYOCARDITIS: A PROSPECTIVE STUDY
ALESSANDRO SCHIAVO (A), MARTINA TESTOLINA (A), MARTINA PERAZZOLO
MARRA (A), LOIRA LEONI (A), CLAUDIA RADU (A), RENZO MARCOLONGO (B),
ANNALISA ANGELINI (A), CRISTINA BASSO (A), MARCO PANFILI (A),
GIAMBATTISTA ISABELLA (A), MASSIMO NAPODANO (A), GIUSEPPE TARANTINI (A),
PAOLO SIMIONI (A), GAETANO THIENE (A), GINO GEROSA (A), SABINO ILICETO (A),
ALIDA L.P. CAFORIO (A)
(A) DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE E VASCOLARI
UNIVERSITÀ DI PADOVA; (B) EMATOLOGIA ED IMMUNOLOGIA CLINICA
UNIVERSITÀ DI PADOVA
Myocarditis may resolve, relapse or lead to dilated cardiomyopathy, death or transplantation. A
positive result for serum autoantibodies, anti-heart (AHA), anti-intercalated disk (AIDA), and antinucleus (ANA), identifies autoimmune forms. Predictors of poor prognosis in biopsy-proven
myocarditis (BPM) and in clinically suspected myocarditis (CSM) are not well defined.
Purpose: To identify predictors of death, cardiac transplantation and relapse in BPM and in CSM,
defined on the basis of a plausible clinical scenario, normal coronary arteries, and Cardiac Magnetic
Resonance (CMR) findings.
Methods: We studied 466 patients (317 male, mean age 37 ± 17 years, median follow-up 50
months), of whom 250 BPM and 216 CSM. All patients underwent selective coronary angiography.
Serum AHA, AIDA, and ANA were measured by indirect immunofluorescence. Univariate and
multivariable Cox regression analysis was used.
Results: At the last follow-up, 366 were alive (89.7%), 42 were dead or transplanted (10.3%) and 58
patients were lost. Survival free from death or transplantation at 10 years was 83% in the whole group
and was lower in BPM compared to CSM (76% vs 94% respectively, p<0.001). Univariate predictors
of negative prognosis were: female gender, history of myocarditis, heart failure presentation,
advanced NYHA class, giant-cell myocarditis, AHA and ANA. Independent predictors of death or
heart transplantation were: female gender, a lower left ventricular echocardiographic ejection
fraction, high titre organ-specific AHA and ANA. Univariate predictors of relapse were: young age,
history of myocarditis, presence of symptoms before diagnosis, a diffuse CMR pattern of late
gadolinium enhancement, and positivity for AIDA. Multivariate analysis identified young age and
history of myocarditis as independent predictors of relapse. Conclusions: Independent predictors of
death and cardiac transplantation in myocarditis included ventricular dysfunction at presentation,
female gender and autoimmune markers, in particular high titre AHA and ANA. Independent
predictors of relapse were young age and history of myocarditis. Prognostic predictors did not differ
between BPM and CSM, suggesting that the latter is part of the myocarditis spectrum.
SIC | Indice Autori
200
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O221
BIOPSY-PROVEN MYOCARDITIS: GENDER DIFFERENCES
AUTOANTIBODY MARKERS OF DISMAL PROGNOSIS
AND
SERUM
MARTINA TESTOLINA (A), ALESSANDRO SCHIAVO (A), MARTINA PERAZZOLO
MARRA (A), LOIRA LEONI (A), CLAUDIA RADU (D), RENZO MARCOLONGO (E),
ANNALISA ANGELINI (B), CRISTINA BASSO (B), MARCO PANFILI (A),
GIAMBATTISTA ISABELLA (A), GIUSEPPE TARANTINI (A), MASSIMO NAPODANO (A),
PAOLO SIMIONI (F), GAETANO THIENE (B), GINO GEROSA (C), SABINO ILICETO (A),
ALIDA L.P. CAFORIO (A)
(A) CARDIOLOGY, DEPT OF CARDIOLOGICAL, VASCULAR AND THORACIC SCIENCES,
UNIVERSITY OF PADUA, PADUA, ITALY; (B) PATHOLOGY, DEPT OF CARDIOLOGICAL,
VASCULAR AND THORACIC SCIENCES, UNIVERSITY OF PADUA, PADUA, ITALY; (C)
CARDIAC SURGERY, DEPT OF CARDIOLOGICAL, VASCULAR AND THORACIC
SCIENCES, UNIVERSITY OF PADUA, PADUA, ITALY; (D) CLINICAL PHARMACOLOGY,
DEPT OF EXPERIMENTAL AND CLINICAL SCIENCE, UNIVERSITY OF PADUA, PADUA,
ITALY; (E) HEMATOLOGY AND CLINICAL IMMUNOLOGY, DEPT OF EXPERIMENTAL
AND CLINICAL SCIENCE, UNIVERSITY OF PADUA, PADUA, ITALY; (F) MEDICINE,
DEPT OF EXPERIMENTAL AND CLINICAL SCIENCE, UNIVERSITY OF PADUA, PADUA,
ITALY
Myocarditis is an inflammatory heart muscle disease, which can be associated with right and/or left
ventricular dysfunction and mainly affects young male. It has different etiology (infectious, toxic or
autoimmune) and heterogeneous clinical presentation. It may heal or progress to dilated
cardiomyopathy (DCM) with a need for heart transplantation, or cause sudden or heart-failure-related
cardiac death. The diagnosis of certainty is based on Dallas criteria applied on endomyocardial biopsy
(EMB). Prognostic features in endomyocardial biopsy (EMB)-proven myocarditis remain poorly
defined, in particular, the role of gender and of serological markers of autoimmunity as predictors of
dismal prognosis.
Purpose: We assessed role of gender and of serum anti-heart (AHA), anti-intercalated disk (AIDA),
anti-endothelial (AECA) and anti-nuclear autoantibodies (ANA) at diagnosis as possible predictors
of death or heart transplantation (HTx).
Methods: Our prospective cohort studied 250 consecutive myocarditis patients (117 with active, 102
borderline lymphocytic, 10 giant cell, 21 other histology types), 87 female, aged 37 ± 24 years,
follow-up 57 ± 49 months. Polymerase chain reaction (PCR) was used to detect viral genomes on
EMB. AHA (organ-specific, partially organ-specific or cross-reactive types) and AECA, AIDA,
ANA were detected by indirect immunofluorescence on human heart and skeletal muscle. Univariate
and multivariable Cox regression analyses for death or HTx status were used.
Results: At last follow-up in May 2012, 179 patients were alive, 38 were dead or transplanted, 33
were lost to follow-up. In 20% of patients viral PCR was positive. Frequencies of positive antibody
tests were as follows: AHA 55%, AIDA 17%, ANA 17%, AECA 10%. Acturial survival at 6 years
was lower in females (72% vs 87%, P=0.02). Females compared to males had higher frequency of
family history of heart disease (45% vs 26%, p=0.003), extra-cardiac autoimmune disease (p=0.008),
presentation with heart failure (p=0.01), higher NYHA class (p=0.03), higher frequency (p=0.009)
and higher titer ANA (p=0.03). Univariate predictors of death/HTx in the whole cohort were: longer
symptom duration, giant cell myocarditis, NYHA II-IV, presentation with ventricular
dysfunction/symptomatic heart failure, echocardiographic and hemodynamic indexes of biventricular
dysfunction, positivity for AECA and ANA. Independent predictors were female gender (p=0.01),
young age (p=0.04), high titre ANA (p=0.001), high titre organ-specific AHA (p=0.02), lower
echocardiographic LV ejection fraction at diagnosis (p=0.000).
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Conclusions: In EMB-proven myocarditis, an autoimmune pathogenesis, identified by high titer
organ-specific AHA and ANA, is associated with a dismal prognosis, particularly in young females.
This may reflect the well-known predilection of autoimmune disease for the female gender.
O222
CARDIAC MAGNETIC RESONANCE IMAGING IN ACTIVE AND BORDERLINE
BIOPSY-PROVEN MYOCARDITIS: RESULTS FROM A PROSPECTIVE SERIES
ALESSANDRO SCHIAVO (A), MARTINA TESTOLINA (A), MARTINA PERAZZOLO
MARRA (A), ANNALISA ANGELINI (A), CRISTINA BASSO (A), LOIRA LEONI (A),
RENZO MARCOLONGO (B), MARCO PANFILI (A), GIAMBATTISTA ISABELLA (A),
MASSIMO NAPODANO (A), GIUSEPPE TARANTINI (A), GAETANO THIENE (A),
GINO GEROSA (A), SABINO ILICETO (A), ALIDA L.P. CAFORIO (A)
(A) DIPARTIMENTO DI SCIENZE CARDIOLOGICHE, TORACICHE E VASCOLARI
UNIVERSITÀ DI PADOVA; (B) EMATOLOGIA ED IMMUNOLOGIA CLINICA
UNIVERSITÀ DI PADOVA
Cardiac magnetic resonance (CMR) with T2-weighted STIR (T2W) and T1-weighted late gadolinium
enhancement (LGE) sequences is widely used in the non-invasive diagnosis of myocarditis, but its
role in differentiating biopsy-proven active versus borderline myocarditis, based on the histological
Dallas Criteria, is not well defined.
Purpose: We used T2-weighted STIR (T2W) and T1-weighted late gadolinium enhancement (LGE)
CMR imaging in 65 consecutive patients with biopsy-proven myocarditis (BPM) to assess CMR
accuracy in differentiating active vs. borderline myocarditis.
Methods: We studied 65 patients with BPM, 35 of whom with active myocarditis, defined as
inflammation with evidence of non-ischemic myocyte necrosis, and 30 with borderline myocarditis,
characterized by the presence of myocardial inflammation without myocyte necrosis, in keeping with
the Dallas Criteria. CMR was performed, according to the Lake Louis Criteria, using T2W imaging
for myocardial edema and T1-weighted sequence for LGE detection.
Results: Myocardial edema was present in 20 patients with active myocarditis and in 11 with
borderline myocarditis. LGE was found in 25 patients with active versus 20 with borderline
myocarditis. Detection of LGE alone was quite sensitive (71.4%) but had a very low specificity
(33.3%) in the diagnosis of active myocarditis, whereas presence of edema was less sensitive than
LGE (64%) but more specific (62%). Detection of both myocardial edema and LGE in the same
patient was highly sensitive (78.9%) but had low specificity (50%) for the diagnosis of histologically
proven active myocarditis.
Conclusions: CMR is a well-established method for the non-invasive diagnosis of myocarditis but
its accuracy in differentiating between acute and borderline myocarditis, defined on the basis of
histological criteria, is not satisfactory, because of a high number of false positives. It remains to be
seen whether using T1-weighted sequences for detection of early enhancement in addition to T2W
and LGE, will increase diagnostic CMR accuracy in the diagnosis of active biopsy-proven
myocarditis.
SIC | Indice Autori
202
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O223
EFFETTI DELLA CONTROPULSAZIONE AORTICA IN SEI CASI DI MIOCARDITE
FULMINANTE
MARIA VINCENZA POLITO (a), AMELIA RAVERA (b), RAFFAELE MENNELLA (a),
MARCO DI MAIO (a), DONATELLA FERRAIOLI (a), RODOLFO CITRO (b),
SAVERIO FERRARA (b), ROSARIO FARINA (b), FEDERICO PISCIONE (a, b)
(a) CATTEDRA DI CARDIOLOGIA; DIPARTIMENTO DI MEDICINA E CHIRURGIA;
UNIVERSITÀ DEGLI STUDI DI SALERNO; SALERNO (ITALY); (b) “ DIPARTIMENTO
CUORE” AZIENDA OSPEDALIERA UNIVERSITARIA “SAN GIOVANNI DI DIO E RUGGI
D’ARAGONA”; SALERNO (ITALY)
Background e Obiettivi: Per miocardite si intende un disordine infiammatorio che interessa il
miocardio, a eziologia prevalentemente virale, il cui quadro clinico può variare da forme
asintomatiche e paucisintomatiche a forme caratterizzate da grave compromissione emodinamica,
fino allo shock cardiogeno. E’noto che le miocarditi a esordio più drammatico (definite miocarditi
fulminanti) una volta superata la fase acuta hanno la prognosi migliore. In letteratura vi sono pochi
studi, e con pochi pazienti, sulle miocarditi fulminanti, ma tutti sottolineano l’importanza dell’uso,
durante la fase acuta, di sistemi di assistenza ventricolare in associazione ai farmaci inotropi di
vecchia e di nuova generazione.
Lo scopo del nostro studio è quello di rendere nota la nostra esperienza su alcuni casi di miocardite
fulminante e sugli effetti dell’IABP sul loro outcome clinico.
Metodi: Attraverso un’analisi retrospettiva del database dell’unità di terapia intensiva cardiologica
dell’azienda ospedaliera universitaria ‘’San Giovanni di Dio e Ruggi d’Aragona’’dal 2010 al 2013
abbiamo selezionato, tra i 30 pazienti con diagnosi di miocardite, 6 pazienti affetti da miocardite
fulminante ovvero con esordio clinico caratterizzato da grave depressione della contrattilità
ventricolare con shock cardiogeno. Tutti i pazienti erano precedentemente sani e riferivano sintomi
simil influenzali nelle settimane precedenti l’ospedalizzazione. Sono stati riportati nel database le
caratteristiche demografiche, cliniche, laboratoristiche, strumentali (ECG, ecocardiografia, RMN
cardiaca) dei pazienti, il tipo di management in UTIC, i suoi effetti e le eventuali complicanze. I
pazienti sono stati poi sottoposti ad un follow up ecocardiografico ad una media di 30,3 ± 15,6 mesi.
Risultati: L’età media dei pazienti era 34,3 ± 12,4 anni (range 24-51)e quattro erano maschi .
L’anamnesi fisiologica e patologica remota erano negative. I sintomi d’esordio erano: febbre, vomito
e dispnea documentati in 4 pazienti, diarrea in 3 pazienti, astenia in 5 pazienti, palpitazioni in 1
paziente. In 5 pazienti tali sintomi si erano manifestati nelle precedenti due settimane, mentre in uno
erano iniziati due mesi prima. Al momento del ricovero, tutti i pazienti presentavano un quadro
conclamato di shock cardiogeno (classe Forrester 4). La frazione di eiezione media calcolata
all’ecocardiografia trans toracica, all’ingresso in UTIC, era 24,6 ± 6 %. Tre pazienti venivano
sottoposti ad esame coronarografico che mostrava l’assenza di lesioni coronariche significative e
quattro a RMN cardiaca che risultava suggestiva per miocardite. Tutti i pazienti erano trattati,
immediatamente dopo il ricovero, con terapia inotropa e sottoposti ad impianto di contropulsatore
aortico, per un periodo medio di 53,3±20,2 ore. A partire dalla prima ora successiva all’impianto del
contropulsatore, in 4 pazienti si osservava un miglioramento dei parametri emodinamici che si
stabilizzavano nelle prime 6 ore. A conferma di ciò, si osservava la ripresa della diuresi, spontanea o
stimolata da diuretici, e la normalizzazione dell’equilibrio acido base. Questi pazienti venivano
successivamente dimessi con un valore medio di FE di 42,33±13,65% e nel controllo a un mese
presentavano una normalizzazione della FE che persisteva fino alla fine del follow-up . Negli altri 2
pazienti dopo l’impianto del contropulsatore non si osservava alcun miglioramento dei parametri
emodinamici, nella prima ora come nelle ore successive. Questi pazienti sono deceduti in 5±2,8
giorni.
SIC | Indice Autori
203
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Conclusioni:Il contropulsatore aortico è, tra i sistemi di assistenza ventricolare sinistra, quello di più
facile impianto e di più facile gestione. Nei nostri pazienti il precoce miglioramento delle condizioni
emodinamiche, in seguito alla contropulsazione aortica, è predittivo di outcome favorevole; invece la
non risposta sin dalle primissime ore individua una categoria di pazienti con prognosi peggiore.
PROGNOSI INSUFFICIENZA CARDIACA – 1
O224
ROLE OF 123-IODINE METAIODOBENZYLGUANIDINE IMAGING IN PREDICTION
OF ARRHYTHMIC EVENTS IN HEART FAILURE PATIENTS CANDIDATE TO ICD
NICOLÒ SALVI (A), NOEMI BRUNO (A), PAOLA SCARPARO (A),
CAMILLA CALVIERI (A), ALESSANDRA ARMATO (A), ALESSANDRA CINQUE (A),
PASQUALINA BRUNO (A), MASSIMO MANCONE (A), GIUSEPPE DE VINCENTIS (A),
FRANCESCO FEDELE (A)
(A) “SAPIENZA“ UNIVERSITÀ DI ROMA
Background: according to guidelines, implantable cardioverter defibrillator (ICD) is recommended
in prevention of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Guidelines have
several limitations because ICD indication is based mainly on left ventricular ejection fraction (EF).
Recent data showed that, independently from EF, 123-iodine metaiodobenzylguanidine
imaging (123-I MIBG) could help to identify HF pts at high risk of SCD [heart/ mediastinum (H/M)
ratio ≤1.6 and a summed score (SS) > 26], who may benefit of ICD.
Aims: our aim is to assess, in a real world registry, the role of 123-I MIBG for the prediction of
ventricular tachyarrhythmia (VT) causing appropriate ICD therapy in HF pts.
Methods: we consecutively enrolled 97 patients admitted to our hospital with diagnosis of HF, left
ventricular ejection fraction (LVEF) ≤35% and indication to ICD. All patients underwent MIBG
imaging. The patients were classified into two groups: Group 1 with H/M≤1.6 , SS> 26; Group2 with
H/M>1.6, SS <26. All patients underwent 1 year follow-up.
Results: 65 pts were included in group 1 and 32 pts in group 2. All baseline characteristics were
similar in 2 groups apart from the aetiology (Table 1). In group 1, H/M ratio was 1.37±0.3 vs 1.8 ±
0.2 in group 2 (p=0.0002); SS was 37.5± 9.7 vs 16 ±6 in group 2 (p = 0.0001). At 1 year follow-up
VTs causing appropriate ICD therapy in group 1 were 13.4% vs 1.28% in group 2(p=0.02); overall
cardiac events were in group 1 16.4 % vs 1.92% in group 2 (p=0.02).
Conclusion: our results suggest that 123 I-MIBG can identify patients at increased risk for arrhythmic
death and can be useful in the decision-making of ICD implantation independently from ejection
fraction.
Group 1
Group 2
P value
H/M > 1.6
H/M ≤ 1.6
(n=32)
(n= 65)
H/M
1.37±0.3
1.8±0.2
0.0002
SS
37.5±9.7
16±6
0.0001
Hypertension (%)
73.9
83.3
0.16
Diabetes(%)
47.8
41.6
0.4
Ischaemic CM (%)
76
37
0.02
Idiopatic DCM (%)
34
76
0.02
EF %
28.3±6.16
30.3±5.4
0.06
ICD implantation
100%
100%
Malignant ventricular
13 (13.4%)
2 (1.28%)
0.02
arrhythmias
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Cardiac events
16 (16,4%)
Roma, 13 – 15 dicembre 2014
3 (1,92%)
0.02
O225
BLOOD UREA NITROGEN PREDICT OUTCOME IN PATIENTS WITH CHRONIC
STABLE HEART FAILURE
CARLO LOMBARDI (A), VALENTINA CARUBELLI (A), ISOTTA CASRINI (A),
GUIDO LEVI (A), SARA PELLIZZARI (A), ANDREA VIGNONI (A),
FEDERICA ZILIANI (A), SAVINA NODARI (A), MARCO METRA (A)
(A) CATTEDRA DI CARDIOLOGIA UNIVERISTA´ DEGLI STUDI E SPEDALI CIVILI DI
BRESCIA
BACKGROUND: Laboratory exams are periodically assessed in patients (pts) suffering from
chronic heart failure (HF) usually to detect any undesired effects of the therapy but not as potential
variables of prognostic value
AIM: Elevated blood urea nitrogen (BUN) may represent increased neurohormonal activation in HF.
The purpose of this study is to evaluate the prognostic value of BUN and its variation in stable chronic
HF outpatients
METHODS: 241 outpatients affected by mild to moderate CHF (NYHA class II-III) underwent a
complete physical examinations, blood sample collection and a echocardiography in two periodic
controls. The population was divided in four groups according to the median value of BUN at visit
1 and according to its variation at the visit 2
group 1 BUN <54 mg/dl and variation <3.4%
group 2 BUN <54 mg/dL and ≥3.4 %
group 3 BUN ≥54 mg/dL and <3.4%
group 4 BUN ≥54 mg/dL and ≥3.4%
RESULTS: During a median follow up of one year, 3 (1.2%) patients died and 49 (20%) were
hospitalized due to worsening HF. The Kaplan-Meier curve showed that group 3 and group 4 had
worse prognosis compared with group 1 and 2 and that a greater change in BUN, respect the median,
was associated with a further worsening of the prognosis (group 4). Multivariable model confirmed
that cardiovascular death and HF hospitalizations were more frequent in patients with a variation of
BUN major the median value between the two measurements (HR 1.011 [IC 95% 1.002-1.021],
p=0.015).
CONCLUSIONS: Serial measurements of Blood Urea Nitrogen and its variation have a significant
prognostic value with HF.
Figure 1 Kaplan-Maier survival curves and
hospitalization)
BUN Variation (Composite endpoint death/ HF
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O226
INSUFFICIENTE CONSAPEVOLEZZA DEL PROPRIO PROFILO DI RISCHIO NELLA
POPOLAZIONE GENERALE: ANALISI PRELIMINARE NELL’AMBITO DELLA PRIMA
GIORNATA EUROPEA PER LO SCOMPENSO CARDIACO
SIMONE MAURIZIO BINNO (A), ELENA CORBELLINI (B), ALESSIA ZANNI (B),
CONCETTA STICOZZI (B), ALESSIO ANTINARELLA (B), ALESSANDRO MALAGOLI (B),
ORNELLA BETTINARDI (C), ANTONIO MAZZA (D), SILVANA BORGHI (E), LETIZIA DA
VICO (F), ANTONIA PEROBON (G), MASSIMO PIEPOLI (B), GIOVANNI
QUINTO VILLANI (B)
(a) UNITÀ DI RICERCA CARDIORENALE, UNIVERSITÀ DEGLI STUDI DI PARMA; (b)
UNITÀ OPERATIVA CARDIOLOGIA, OSPEDALE “G. DA SALICETO“, PIACENZA; (c)
UOC EMERGENZA URGENZA DSMDP, AUSL DI PIACENZA; (d) UOC CARDIOLOGIA
IRCCS FONDAZIONE SALVATORE MAUGERI CARDIOLOGIA PAVIA (PV); (e)
MULTIMEDICA HOLDING (MI); (f) AZIENDA OSPEDALIERO UNIVERSITARIA CAREGGI
FIRENZE; (g) FONDAZIONE SALVATORE MAUGERI MONTESCANO (PV)
Introduzione Per promuovere la conoscenza nella popolazione generale dello scompenso cardiaco,
prima causa cardiovascolare di ospedalizzazione e morte nei Paesi occidentali, la Heart Failure
Association della Società Europea di Cardiologia (ESC) propone da anni un evento dedicato intitolato
“Heart Failure Awareness Day”. Per la prima volta, nel 2014 l’Italia ha aderito a questa iniziativa.
Nell’ambito delle iniziative organizzate nella città di Piacenza è stato eseguita una indagine sulla
consapevolezza del profilo di rischio dei cittadini contattati negli spazi pubblici dedicati. Tale
indagine si è basata sulla compilazione di un questionario (6 items), indaganti dati clinici anamnestici,
livelli di attività fisica, controllo alimentare, compliance terapeutica, stato dell’umore, abitudine
tabagica.
Metodo Coinvolti 155 soggetti (49% maschi), 41% ≤ 60 anni, 37% con ≤ 8 anni di scolarità . Ogni
soggetto ha compilato uno screening sui fattori di rischio, elaborato dalle Aree non Mediche del
GICR-IACPR, composto dalla Scala di Morisky per aderenza terapeutica, dalla scala Med Diet Score
per valutazione delle abitudini alimentari, dal questionario Fagerstrom inerente l’abitudine tabagica
ed infine da alcuni quesiti circa l’attività fisica e lo stato psicologico.
Risultati Il 19% dei soggetti coinvolti riferisce anamnesi positiva per cardiopatia strutturale, il 23%
dei pazienti in trattamento farmacologico presenta un punteggio indicativo di scarsa aderenza alla
terapia prescritta, il 25% non svolge attività fisica e solo il 9% afferma abitudini alimentari che
rispecchiano il modello di dieta mediterranea. L’8% ha fornito risposte compatibili con profilo di
rischio per depressione; il 15% risulta fumatore attivo di cui il 32% con elevata dipendenza dal fumo.
Conclusioni I risultati evidenziano la necessità di promuovere nella popolazione generale periodici
interventi informativi ed educazionali per favorire l’adozione di abitudini comportamentali sane atte
a prevenire l’insorgenza di patologie cardiovascolari ed un miglior controllo dell’aderenza alle
terapie.
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O227
CARDIOVASCULAR MEDICINE HEART FAILURE (CVM-HF) INDEX AS
PROGNOSTIC MODEL IN PATIENTS TREATED WITH TRANSCATHETER MITRAL
VALVE REPAIR
ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A), VALERIA CAMMALLERI (A),
SAVERIO MUSCOLI (A), DOROTEA RUBINO (A), FRANCESCA DEPERSIS (A),
EUGENIA MAIO (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), GIANPAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Background: The CardioVascular Medicine Heart Failure (CVM-HF) index is a prognostic model
useful predict outcomes and one-year mortality in HF patients at all stages of disease. It is a simple
score based on routinely available clinical information, including cardiac parameters and noncardiac
co-morbidities.
Aim: Aim of our study was to validate the usefulness of the CVM-HF index as predictor of one-year
outcomes, in HF patients with severe functional MR, undergoing MitraClip procedure.
Methods: Our study population consists of 30 patients, who underwent MitraClip repair in our
institute and completed one-year of follow-up. All patients had a logistic EuroSCORE >20% or other
adjunctive risk criteria. The CVM-HF index was calculated for all patients, basing on the sum of 13
points derived from non-invasive parameters : 7 non-cardiac (age, anaemia, hypertension, COPD,
complicated diabetes mellitus, moderate to severe kidney dysfunction and, metastasis of cancer) and
6 cardiac (no β blockers, no angiotensin-converting enzyme inhibitors/angiotensin receptor blockers,
NYHA III-IV, left ventricular ejection fraction [LVEF] ≤20%, severe valvular heart disease and atrial
fibrillation).
Results: In accordance with CVM-HF index, one patient (3%) was included in the low-risk category
(group A, score <6); 15 patients (50%) were included in the medium-risk (group B, score 6-11) and
14 patients (47%) in high-risk category (group C, score 12-16); no patients had very-high-risk score
(group D, score ≥17). Basing on patients distribution a statistical analysis was performed between
group B and C. As expected, patients belonging to the group C were more compromising in their
clinical status, with more advanced left ventricle systolic dysfunction with lower LVEF (23.2±6.4%
vs. 30.7±6.44; p=0.004) and higher logistic EuroSCORE (39,79±24,7% vs. 17,48±12,64; p=0.005).
Acute procedural success was obtained in all patients. The Kaplan-Meier analysis showed that
patients of group C had significantly poorer outcomes regarding the primary endpoint with a 12months survival freedom from events of 66.7% and 28.6%, respectively; (log-rank test, p=0.033);
also survival freedom from cardiac mortality was 100% and 78.6% in group B and C, respectively
(log-rank test, p=0.05). One-year survival free from re-hospitalization was 80% and 50% in group B
and C, respectively (log-rank test; p=0.042). Survival free from all-cause of mortality was 93.3% and
71.4%, respectively (log-rank test; p=0.107).
Conclusion: The CVM-HF score can be an additional useful tool in the screening process of patients
candidate to MitraClip repair. It can easily predict the outcome and the prognosis after the procedure
in clinical and research activity.
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PROGNOSI INSUFFICIENZA CARDIACA - 1
O228
INCREMENTAL VALUE OF NORMAL ADENOSINE
MAGNETIC RESONANCE: LONG-TERM OUTCOME
PERFUSION
CARDIAC
FABIOLA SOZZI (A), LAURA IACUZIO (B), CIRO CANETTA (A), FILIPPO CIVAIA (B),
STEPHANE RUSEK (B), FREDERIC BERTHIER (B), FEDERICO LOMBARDI (A),
PHILIPPE ROSSI (B), GILLES DREYFUS (B), VINCENT DOR (B)
(A) FONDAZIONE POLICLINICO IRCCS CA´ GRANDA, MILANO, IT; (B)
CARDIOTHORACIC CENTRE, MONACO, MC
Objectives: To determine the long-term prognostic value of normal adenosine stress cardiac
magnetic resonance imaging (CMR) in patients referred for evaluation of myocardial ischemia.
Methods: We retrospectively reviewed 300 consecutive patients (age 65 ± 11 years, 74% male) with
suspected or known coronary disease and normal wall motion, who had undergone adenosine stress
CMR, negative for ischemia and scar. End-points, during a mean follow-up of 5.5 years (5.4 ± 1.1),
were all causes of mortality and major adverse cardiac events including cardiac death, myocardial
infarction, revascularization, hospitalization for unstable angina.
Results: During follow-up, 16 patients died due to various causes (cardiac death in 5 patients). Three
patients had nonfatal myocardial infarction. Seven patients were hospitalized for revascularization
and 11 for unstable angina medically treated. The annual cardiac event rate was 1.3% (0.78% in the
first 3 years and 1.9% between the fourth and sixth year). The predictors of major adverse cardiac
events in a multivariate analysis model were advanced age [hazard ratio (HR) 1.15; 95% confidence
interval (95% CI) 1,02-1,30], diabetes (HR 17.5, 95% CI 2.2-140) and smoking habit (HR 5.9, 95%
CI 1.0-35.5). For all causes of mortality the only predictor was diabetes (HR 11.4, 95% CI 1.76-74.2).
Patients with normal stress CMR had excellent outcome during the 3 years after the study. The cardiac
event rate was higher between the fourth and sixth year. Therefore, it may be useful to repeat a new
study to reassess the risk status of ischemia after 3 years.
Conclusion: A low event-rate and excellent prognosis occurred in patients with normal adenosine
stress CMR.
O229
LONG-TERM
PROGNOSTIC
VALUE
OF
DIPYRIDAMOLE
STRESS
CARDIOVASCULAR MAGNETIC RESONANCE IN PATIENTS WITH KNOWN OR
SUSPECTED CORONARY ARTERY DISEASE
ERIKA BERTELLA (C), MONICA LOGUERCIO (C), ANDREA BAGGIANO (C),
SAIMA MUSHTAQ (C), GIOVANNI DONATO AQUARO (B), SARA SALERNI (A),
CARMEN ROSSI (A), DANIELE ANDREINI (C), PIERGIORGIO MASCI (B),
GIANLUCA PONTONE (C)
(A) INSTITUTE OF CARDIOLOGY, “G.D´ANNUNZIO“ UNIVERSITY - CHIETI PESCARA,
ITALY; (B) FONDAZIONE CNR/REGIONE TOSCANA ‘G. MONASTERIO’, PISA-ITALY; (C)
CENTRO CARDIOLOGICO MONZINO, IRCCS, MILAN-ITALY
Background: Adenosine stress perfusion cardiac magnetic resonance (CMR) and dobutamine CMR
are useful technique for the diagnostic and prognostic stratification based on perfusion defect and
wall motion abnormalities (WMA), respectively. However, a few data are available regarding the
additional prognostic value of perfusion and WMA in the same subset of patients. Dipyridamole stress
CMR is potentially able to provide information on both phases (perfusion and WMA) of ischemic
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cascade. The aim of this study is to determine the prognostic value of dipyridamole stress CMR in
patients with known or suspected coronary artery disease.
Methods: seven hundred ninety-three patients (63.9±10.9 yo, 657 men) with known or suspected
coronary artery diseae (CAD) performed dipyridamole stress CMR and were followed-up for a mean
follow-up of 810±665 days. Based on stress CMR findings, the study population was classified in
group 1 (no reversible ischemia), group 2 (stress perfusion defect alone) and group 3 (stress perfusion
defect and WMA). The endpoints were "all cardiac events", defined as unstable angina, myocardial
infarction, cardiac death and revascularization, and "hard cardiac events" defined as all cardiac events
excluding revascularization.
Results: During a median follow-up of 622 days (range 425 to 963 days), 162 all cardiac events and
56 hard cardiac events were observed, respectively, including 26 unstable angina, 22 nonfatal
myocardial infarction and 5 cardiac death. The incidence of all cardiac events in group 1, 2 and 3 was
9.9%, 33.3% and 69%, respectively with a significant higher rate in group 2 vs. group 1 (p<0.0001)
and group 3 vs. both group 1 and 2 (p<0.0001). The hard cardiac events were observed in 4.9%, 8.5%
and 17.8% of patients of group 1, 2 and 3, respectively, with a significant higher rate in group 3 vs.
group 1 (p<0.0001) and vs. group 2 (p<0.05) while no differences were found between group 2 and
1 (p: 0.10). Multivariate analysis showed both stress perfusion defect alone [HR: 1.05 (1.0-1.1),
p<0.05] or with WMA [HR: 2.9 (2.3-3.6), p<0.0001] as independent predictors of all cardiac events
while only stress perfusion defect plus WMA was predictor of hard cardiac events [HR: 1.6 (1.0-2.5),
p<0.05].
Conclusions: Dypiridamole stress CMR seems to have an added value for predicting cardiac events
improving the prognostic stratification by the differentiation between the stress perfusion defect alone
and the combined perfusion defect and WMA.
O230
CARDIAC DETERMINANTS OF MEAN PULMONARY PRESSURE-TO-CARDIAC
OUTPUT RESPONSE DURING EXERCISE IN HEART FAILURE WITH REDUCED
EJECTION FRACTION PATIENTS
FRANCESCO BANDERA (A), GRETA GENERATI (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), SIMONA VILLANI (B),
MADDALENA GAETA (B), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE; (B) UNIT OF BIOSTATISTICS AND CLINICAL EPIDEMIOLOGY,
DEPARTMENT OF PUPLIC HEALTH, EXPERIMENTAL AND FORENSIC MEDICINE,
UNIVERISTY OF PAVIA
Background: Heart failure patients with reduced ejection fraction (HFrEF) are prone to develop type
2 pulmonary hypertension (PH) due to retrograde transmission of increased left ventricle pressures,
particularly during exercise, affecting the functional capacity and long-term prognosis. Non-invasive
haemodynamic evaluation during effort by exercise-echocardiography has been proposed to early
identify high-risk patients. We aimed to evaluate the cardiac determinants of the impaired pulmonary
pressure response during exercise and to define the related functional phenotype in HFrEF patients.
Methods and Results: We studied 68 HFrEF by cardiopulmonary exercise test (CPET) combined
with simultaneous exercise-echocardiography using a symptom-limited maximal incremental ramp.
Mean pulmonary pressure to cardiac output (mPAP/CO) slope was determined considering rest and
peak value of mPAP and CO (defining the normal response when slope was ≤3.5). Patients whit
pathological response (Group A, n=44, 65% of population, with slope >3.5) presented a globally
worse functional profile (reduced maximal work 75±21 vs 57±20 Watt, peak VO2 14.9±2.6 vs
12.4±3.5 mL/Kg/min, anaerobic threshold 11.3±2 vs 10±3 mL/Kg/min, O2 pulse 10±2.1 vs 8.4±2.8
mL/beat, impaired VE/VCO2 30.4±5.3 vs 36.5±8.5 and higher prevalence of exercise oscillatory
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ventilation 29 vs 57%). At univariate analysis, rest and peak LV end-diastolic volume indexed
(LVEDVi, rest 89±30 vs 104±26, peak 85±20 vs 102±28 mL/m2), LV indexed mass (122±37 vs
142±33 g/m2), prevalence of rest and peak mitral regurgitation ≥3/4 degrees (rest 12.5 vs 45.5, peak
29.2 vs 63.6%), rest E/A (1.1±0.7 vs 2±1.4) and E/e’ (rest 19±12 vs 30±12), peak indexed stroke
volume (38±11 vs 30±9 mL/m2) and cardiac output (CO, 8.6±2.7 vs 5.6±1.8 L/min), peak heart rate
(121±18 vs 106±19 bpm) and mean blood pressure (89±10 vs 101±13 mmHg) were all significantly
(p <0.05) worse in Group A. The best logistic regression model (R2 0.78) identified the peak CO (OR
0.23; CI 0.08 – 0.63; p= 0.004), peak TAPSE (OR 1.5; CI 1.09 – 2.06; p= 0.013) and LVEDVi (OR
1.07; CI 1.00 – 1.13; p= 0.034) as main cardiac determinants of abnormal mPAP/CO slope.
Conclusion: In HFrEF patients, the abnormal pulmonary pressure response during exercise, as
identified by a steeper mPAP/CO slope, is associated with significantly impaired functional
phenotype whose main cardiac determinants are the impaired contractile reserve, of both left and right
ventricles, and an advanced eccentric LV remodeling.
O231
CIRCULATORY POWER AND EXERCISE PHENOTYPES: INSIGHTS ON DISEASE
SEVERITY IN HEART FAILURE REDUCED EJECTION FRACTION
GRETA GENERATI (A), FRANCESCO BANDERA (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MRACO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background: Cardiopulmonary exercise testing (CPET) provides several indexes of functional
capacity. Circulatory power (CP= peak systolic BP X peak VO2) shows additional prognostic value
to peak VO2 in heart failure reduced ejection fraction (HFrEF) patients. Ventilatory power (VP= peak
systolic BP/VE/VCO2, cutoff value 3 ) combined with CPET derived CP (cutoff value 1750 mmHg*
ml2*kg−1*min−1) allows to better stratify this population.Aim: We aimed at describing the
relationship between peak exercise CP and VP functional and echo phenotypes in HFrEF patients
Methods: 94 HFrEF patients (mean age 64±12; male 70%; ischemic etiology 56%; NYHA class I,
II, III, IV 28, 32, 31, 9; mean EF 39±9%) underwent maximal symptoms limited CPET on tiltable
cycle-ergometer using a personalized incremental ramp protocol. CPET was combined with exercise
echocardiography.
Results: Data were analyzed dividing patients into three groups according to peak VP and CP using
cutoff value of 3 W and 1750 mmHg* ml2*kg−1*min−1 respectively: Group A=preserved VP and CP,
B=impaired CP, C=impaired both VP and CP. Group C had worse cardiac remodeling and biventricular function already at rest. Group B showed lower right ventricular systolic function (peak
TAPSE) and dynamic pulmonary hypertension (higher peak PASP) compared to group A patients,
associated with more severe degree of dynamic mitral regurgitation (MR). These echo-data
corresponded to impaired exercise tolerance (lower peak VO2, workload and O2 pulse) and ventilatory
efficiency.
Conclusions: Assessment of CP and VP, seems very useful to unmask different degree of impaired
functional phenotypes. Patients exhibiting a combined CP and VP impairment are those with the
worse phenotype of RV-pulmonary circulation uncoupling.
Rest LV end diastolic
volume indexed, ml/m2
Rest LVEF, %
Peak LVEF, %
Rest MR ≥3/4+, n (%)
A (n=62)
87±25
B (n=14)
94±17
C (n=16)
130±39
P (A vs B)
ns
P (B vs C)
0.003
36±9
39±11
8 (13)
30±8
36±8
4 (29)
27±8
31±12
10 (63)
0.02
ns
ns
ns
ns
0.05
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Peak MR ≥3/4+, n (%)
Rest TAPSE, mm
Peak TAPSE, mm
Rest systolic PAP, mmHg
Peak systolic PAP, mmHg
Peak circulatory power,
mmHg* ml2*kg−1*min−1
Peak ventilatory power,
mmHg
Workload, Watt
Peak VO2, ml O2*Kg-1*min-1
VE/VCO2, slope
Roma, 13 – 15 dicembre 2014
18 (29)
8 (57)
12 (75)
19±4
17±4
15±3
22±4
19±5
15±5
31±9
40±19
52±18
53±13
69±25
65±18
2426±454 1421±195 1081±187
0.05
ns
0.06
ns
0.04
0.000
ns
ns
ns
ns
ns
0.000
5.5±1.3
4.4±0.9
2.8±1
0.001
0.000
76±21
15±2.6
31±6
55±20
9.7±2.2
35±6
39±13
9.1±1.6
46±12
0.001
0.000
0.03
0.04
ns
0.003
O232
A RARE CASE OF A CORONARY ARTERY
MULTIDETECTOR COMPUTED TOMOGRAPHY
ANOMALY
DETECTED
ON
VITO BONOMO (A), MARIACONCETTA DI PIAZZA (A), SALVATORE EVOLA (A),
DAVIDE PIRAINO (A), LUDOVICO LA GRUTTA (B), MASSIMO MIDIRI (B),
SALVATORE NOVO (A)
(A) U.O.C. DI CARDIOLOGIA, CATTEDRA MALATTIE DELL’ APPARATO
CARDIOVASCOLARE, A.O.U.P. “P. GIACCONE”, UNIVERSITÀ DEGLI STUDI DI
PALERMO, ITALY; (B) DEPARTMENT OF RADIOLOGY, A.O.U.P. “P. GIACCONE”,
UNIVERSITÀ DEGLI STUDI DI PALERMO, ITALY
A treadmill exercise test was interrupted due to chest pain, and an electrocardiogram showed exerciseinduced ST-segment depressions of up to 3 mm. After the stress test, the patient underwent coronary
angiography, which revealed the absence of stenosis or thrombi, although it aroused suspicion of a
congenital coronary origin anomaly (Fig. A).
MDCT-CA volume-rendering reconstruction showed the right coronary artery (RCA), left anterior
descending artery (LAD) and retroaortic coronary artery (RAA) arising separately from the right
Valsalva sinus (Fig. E-F). Multiplanar reconstruction revealed that the LAD had an acute take-off
angle with a proximal epicardial segment and an intramyocardial course through the interventricular
septum beneath the right ventricular infundibulum, which then coursed in the distal anterior
interventricular sulcus (Fig. G).
The retroaortic coronary artery arising with an acute take-off angle gave off two branches. One branch
coursed in the proximal anterior interventricular sulcus, while the other coursed-in the atrioventricular
sulcus as a normal circumflex coronary artery (Fig. H).
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O233
EXERCISE ECHO-DERIVED CARDIAC POWER OUTPUT IDENTIFIES AN
UNFAVORABLE RIGHT VENTRICULAR TO PULMONARY CIRCULATION
COUPLING IN HEART FAILURE AND CORRELATES WITH CARDIOPULMONARY
EXERCISE TESTING VARIABLES
GRETA GENERATI (A), FRANCESCO BANDERA (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background: Cardiac power output (CPO= mean BP x (SV/60) x HR) is an echo-derived parameter
of cardiac work and assessed during exercise reflect myocardial contractile reserve. Peak exercise
CPO (CPO= CO x MAP X 2·22 X 10-3), measured non-invasively with cardiopulmonary exercise
testing (CPET), is an independent predictor of mortality in HF patients (cutoff 1.96 W). CPET
provides other indices of functional capacity with additional prognostic value, such as circulatory
power (peak systolic BP X peak VO2) and ventilatory power ( peak systolic BP/VE/VCO2).
Aim: Our aim was to explore the relationship between echo-derived peak CPO and echo and CPET
variables. We also aimed to identify which CPET functional parameters best correlates with CPO in
HF population.
Methods: 94 HFrEF patients (mean age 64±12; male 70%; ischemic etiology 56%; NYHA class I,
II , III, IV 28, 32, 31, 9; mean EF 39±9%) underwent maximal symptoms limited CPET (tiltable
cycle-ergometer, personalized incremental ramp protocol) combined with exercise echocardiography.
Results: Population was divided into two groups according to peak CPO ≥/< 1.96: Group A (CPO
2.49±0.53) and Group B (CPO 1.26±0.43) with preserved and impaired myocardial contractile
reserve respectively. Group B showed worse diastolic (E/e’) and right ventricular systolic function
(lower TAPSE) and higher pulmonary artery systolic pressure (PASP) both at rest and during
exercise. An impaired myocardial contractile reserve was also associated with more severe mitral
regurgitation (MR) particularly during exercise, impaired exercise tolerance and ventilatory
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efficiency. A good correlation was found between CPO, circulatory power and ventilatory power (rho
0.63 and 0.60, p <0,0001).
Conclusions: An impaired myocardial contractile reserve, as expressed by low CPO at peak exercise,
reflects an impaired RV and pulmonary response to exercise and more severe MR. Worse CPO
corresponds to lower functional CPET phenotype, which shows a good correlation with CPET
parameters of functional capacity
LV end diastolic volume indexed, ml/m2
LV ejection fraction, %
E/e’, ratio
MR ≥3/4+,n ( %)
TAPSE, mm
PASP, mmHg
Workload, Watt
Peak VO2, ml O2*Kg‐1*min‐1
% of predicted peak VO2
VE/VCO2, slope
Circulatory Power, mmHg* ml2*kg−1*min−1
Ventilatory Power, mmHg
Group A (n=23)
Rest
Peak
91±24
88±24
Group B (n=71)
Rest
Peak
98±32
98±33
36±7
39±11
20±10
2(9)
6(26)
20±4
22±4
32±9
52±16
85±24
15.6±2.3
64±16
29±5
2611±437
33±10
36±11
ns
ns
27±14
.0013
22(31)
34 (48)
.007 .003
17±4
19±5
.005 .002
38±17
60±18
.036 .080
60±22
.000
12.4±3.6
.000
52±15
.003
36±10
.000
1853±6.41
.000
5.86±1.16
4.5±1.52
P
Rest
ns
Peak
ns
.000
IMAGING CARDIOVASCOLARE - 2
O234
LOW-DOSE CT CORONARY ANGIOGRAPHY WITH A NOVEL INTRACYCLE
MOTION-CORRECTION ALGORITHM IN PATIENTS WITH HIGH HEART RATE OR
HEART RATE VARIABILITY: CT-CA WITH INTRACYCLE MOTION-CORRECTION
CHIARA SEGURINI (A), EDOARDO CONTE (A), SAIMA MUSHTAQ (A),
ERIKA BERTELLA (A), ANDREA BAGGIANO (A), ANTONIO L. BARTORELLI (A, B),
ANDREA ANNONI (A), ALBERTO FORMENTI (A), MARIA PETULLA´ (A),
VIRGINIA BELTRAMA (A), MAURO PEPI (A), GIANLUCA PONTONE (A),
DANIELE ANDREINI (A, B), CESARE FIORENTINI (A, B)
(A) CENTRO CARDIOLOGICO MONZINO, IRCCS, MILAN, ITALY; (B) DEPARTMENT OF
CLINICAL SCIENCES AND COMMUNITY HEALTH, CARDIOVASCULAR SECTION,
UNIVERSITY OF MILAN, MILAN, ITALY
Objectives: To evaluate the impact of a new MC algorithm used in conjunction with low-dose
prospective ECG-triggering coronary computed tomography angiography (CCTA) on motion
artifacts, image quality and coronary assessability.
Background: CCTA has high diagnostic performance. However, motion artifacts due to high or
irregular heart rate (HR) are common limitations. Recently, a motion-correction (MC) algorithm has
been developed.
Materials and Methods: Among 380 patients undergoing CCTA for suspected CAD, we selected
120 patients with pre-scanning HR >70 bpm or HR variability (HRv) >10 bpm during scanning
irrespective of pre-scanning HR or both conditions. In patients with pre-scanning HR <65 bpm or
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
≥65 bpm, prospective ECG triggering with padding of 80 msec (58 cases) or padding of 200 msec
(62 cases) was used, respectively.
Results: Mean pre-scanning HR and HRv were 70±7 bpm and 10.9±4 bpm, respectively. Overall,
mean effective dose was 3.4±1.3 mSv, while a lower dose (2.4±0.9 mSv) was measured for padding
of 80 msec. In a segment-based analysis, coronary assessability was significantly higher with MC
(97%) as compared to standard (STD) reconstruction (81%) due to a significant reduction of severe
artifacts (54 vs. 356 cases, respectively). An artifact sub-analysis showed significantly lower number
of motion artifacts and artifacts related to chest movement with MC (16 and 4 cases) than with STD
reconstruction (286 and 24 cases). The number of coronary segments ranked among those of excellent
image quality was significantly higher with MC.
Conclusions: The MC algorithm improves CCTA image quality and coronary assessability in
patients with high HR and HRv, despite low radiation dose.
O235
ANALISI DELLE SEZIONI DESTRE CON METODICA ECOCARDIOGRAFICA
STANDARD E SPECKLE TRACKING AL TERMINE DI UNO SFORZO MASSIMALE.
AMATO SANTORO (A), FEDERICO ALVINO (A), GIOVANNI ANTONELLI (A),
ROBERTA MOLLE (A), SUSANNA BENINCASA (A), SERGIO MONDILLO (A)
(A) CARDIOLOGIA UNIVERSITARIA, UNIVERSITÀ DEGLI STUDI DI SIENA
BACKGROUND. L’aumento della performace cardiaca sotto sforzo è legato al riempimento
diastolico e all’aumento della frequenza cardiaca (HR) e della contrattilità. Scopo del nostro studio
è analizzare il ruolo delle sezioni cardiache destre durante sforzo massimale (ME) utilizzando Speckle
Tracking Echocardiography (STE).
METODI. 16 pallanuotisti agonisti hanno eseguito 6 ripetizioni di 100 metri stile libero a HR
massimale. Sono stati poi sottoposti ad ecocardiografia a riposo (R) ed immediatamente dopo (ME).
RISULTATI. Gli atleti mostravano un aumento degli indici di funzione longitudinale del ventricolo
destro (VDx) misurati con TAPSE m-mode, onda S’ tissue Doppler (TDI) e peak ventricular
longitudinal strain (PVLS) STE. Durante ME vi era una riduzione dell’onda di riempimento
protodiastolico misurata con TDI (E’) e di peak atrial longutidinal strain (PALS) STE (PALS; R:
43.77 15.28 % vs ME: 29.67 11.42%, p<0.01). Il PALS correlava con il TAPSE (r= -0.25,
p<0.05), con S’(r= -0.5, p<0.01) con E’(r= -0.33, p< 0.05). Il PVLS correlava con il TAPSE (r= 0.38;
p<0.05), con S’ (r1=0.7; p<0.01), con E’ (r:0.5; p<0.01) e con E/A ratio (r:-0.4; p<0.01).
CONCLUSIONI. La funzione di reservoir dell’atrio destro si riduce durante lo sforzo mentre la sua
funzione contrattile diviene necessaria al riempimento ventricolare. Parallelamente si verifica un
fisiologico aumento di contrattilità del VDx durante lo sforzo. L’aumentato postcarico durante ME
determina un aumento degli indici sistolici ecocardiografici del VDx. Lo strain longitudinale del
VDx, i tempi di attivazione e la frequenza di strain sono indici di funzione sistolica Vdx, che non
risentono dell’angolo dipendenza.
O236
DOPPLER END-DIASTOLIC PULMONARY REGURGITANT PRESSURE GRADIENT
OUTPERFORMS EAE GUIDELINES-SUGGESTED INDICES OF PULMONARY WEDGE
PRESSURE. HEMODYNAMIC VALIDATION STUDY.
PAOLO BARBIER (C), MC SCALI (D), A SIMIONIUC (D), M GUGLIELMO (F),
G SAVIOLI (H), C CEFALÙ (C), O MIREA (A), L FUSINI (C), F DINI (D)
(A) EMERGENCY COUNTY HOSPITAL, DEPARTMENT OF CARDIOLOGY, CRAIOVA,
ROMANIA; (B) CENTRO CARDIOLOGICO MONZINO, IRCCS, MILANO, ITALY; (C)
CENTRO CARDIOLOGICO MONZINO, IRCCS, MILANO, ITALY; (D) UNIVERSITY
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
HOSPITAL OF PISA, CARDIAC AND THORACIC DEPARTMENT, PISA, ITALY; (E)
DIVISION OF CARDIOLOGY, BIOMEDICAL DEPARTMENT OF INTERNAL MEDICINE
AND MEDICAL SPECIALTIES (DIBIMIS), UNIVERSITY HOSPITAL PAOLO GIACCONE,
PALERMO, ITALY; (F) DIVISION OF CARDIOLOGY, BIOMEDICAL DEPARTMENT OF
INTERNAL MEDICINE AND MEDICAL SPECIALTIES (DIBIMIS), UNIVERSITY HOSPITAL
PAOLO GIACCONE, PALERMO, ITALY; (G) EMERGENCY COUNTY HOSPITAL,
DEPARTMENT OF CARDIOLOGY, CRAIOVA, ROMANIA ; (H) FOUNDATION IRCCS
POLYCLINIC SAN MATTEO, MEDICAL CLINIC II - UNIVERSITY OF PAVIA, PAVIA,
ITALY
Purpose. The continuous-wave Doppler end-diastolic pulmonary regurgitant pressure gradient
(PRG) has long been validated to estimate pulmonary artery diastolic pressure, and the latter
correlates closely with pulmonary wedge pressure (PWP). We sought to re-validate and compare the
use of PRG and EAE guidelines-recommended indices for the noninvasive estimation of PWP in
patients undergoing diagnostic catheterization.
Methods. In 183 patients (age 68±11 y.; heart rate: 40-186 bpm; NYHA: 2.4±.6) evaluated for
coronary artery disease (n= 63), dilated cardiomyopathy (n= 52) or aortic stenosis (n= 68), we
measured PWP and right atrial (RAP), pulmonary artery diastolic (PDP), and left ventricular (LV)
end-diastolic (LVEDP) pressures and pulmonary vascular resistances (PVR), together with contrast
(saline)-enhanced PRG and conventional 2D systolic and pulsed Doppler flow and tissue annular
indices of LV systolic and diastolic function. We calculated: non-invasive PDP (PDPecho)= RAP +
PRG; pulsed Doppler mitral E/E’; AArdur= pulmonary venous (PV) - mitral A wave duration; SF=
systolic fraction of PV velocity-time integrals.
Results. After exclusion of 5 patients with elevated pre-capillary PVR (>250 103 dynes·cm-5) PDP
and PWP correlated highly (r=.92, p<.001). Only PDPecho correlated closely with PWP
(independently of LV EF%); of note, AARdur showed no specific relation to LVEDP (Table). At
ROC analysis, PDPecho predicted accurately PWP (AUC: .86, CI: .79-.92) with excellent positive
(PPV 91%) and low negative predictive values (NPV 55%). Mitral E/E’ (single cutoff= 8.5 set
at AUC: .85, CI: .77-.92) showed similar excellent PPV (93%), but lower NPV (47%) and only in
patients with EF <50%. When a second cutoff=13 was tested, it excluded the majority of patients
with increased PWP (68% false negative rate).
Conclusions. Estimation of PWP with PDPecho is more accurate than with guideline-suggested
pulsed Doppler indices, and is independent of LV EF. In contrast, LVEDP estimation appears not
feasible with current indices.
Table. *<.01; † <.001.
PDPecho
EF < 50% PWP
.71†
LVEDP
.32*
.75†
EF  50% PWP
LVEDP
.36*
E/E’
.58†
.24*
.36*
.16
SF
‐.73†
‐.34†
‐.27
.047
AArdur
.57†
.33†
.45†
.2
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215
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O237
DIAGNOSTIC ACCURACY OF RAPID KILOVOLT PEAK-SWITCHING DUAL-ENERGY
CT CORONARY ANGIOGRAPHY IN PATIENTS WITH HIGH CALCIUM SCORE:
ACCURACY OF DUAL-ENERGY CT CORONARY ANGIOGRAPHY
EDOARDO CONTE (a), SAIMA MUSHTAQ (a), ERIKA BERTELLA (a),
CHIARA SEGURINI (a), MARTA GIOVANNARDI (a), ANDREA BAGGIANO (a),
ANDREA ANNONI (a), ALBERTO FORMENTI (a), MARIA PETULLA´ (a),
VIRGINIA BELTRAMA (a), VALENTINA VOLPATO (a), ANTONIO L. BARTORELLI (a, b),
DANIELA TRABATTONI (a), MAURO PEPI (a), GIANLUCA PONTONE (a),
DANIELE ANDREINI (a, b), CESARE FIORENTINI (a, b)
(a) CENTRO CARDIOLOGICO MONZINO IRCCS, MILAN, ITALY; (b) DEPARTMENT OF
CLINICAL SCIENCES AND COMMUNITY HEALTH, CARDIOVASCULAR SECTION,
UNIVERSITY OF MILAN, MILAN, ITALY
Background: Although good diagnostic performance of computed tomography coronary
angiography (CT-CA) has been widely demonstrated, beam-hardening artifacts resulting from
heavily calcified plaques may preclude high-quality images and diagnostic accuracy. Recently, a new
CT technology that combines dual-energy CT (DECT) with the latest gemstone detectors for spectral
imaging (GSI) and allows to reconstruct material decomposition images was introduced in clinical
practice.
Objectives: To evaluate the diagnostic accuracy of CT-CA using DECT with monochromatic images
and calcium removal by material decomposition images (MDI) vs. conventional polychromatic
images evaluation as standard of reference (STD).
Methods: We enrolled 75 patients referred for clinically indicated invasive coronary
angiography who had a coronary calcium score (CCS) >400 and underwent CT-CA with prospective
ECG-triggering without padding. In all patients, conventional poly-chromatic images (STD) and MDI
(Iodine minus calcium) derived from mono-chromatic images at 77 KeV were reconstructed.
Results: The mean CCS was 606±253. Coronary evaluability was significantly higher with MDI vs.
STD (98% vs.95%). A significantly lower number (6 vs. 46) of beam-hardening artifacts was
observed with MDI vs. STD. In a segment-based analysis, specificity, negative predictive value and
accuracy for >50% coronary stenosis identification were significantly higher with MDI vs. STD
(99%, 94% and 99% vs. 96%, 66% and 96%, respectively). Similarly, in a patient-based analysis,
specificity, negative predictive value, positive predictive value and accuracy were significantly higher
with MDI vs. STD (89%, 100%, 94% and 96% vs. 11%, 50%, 65% and 64%, respectively).
Conclusions: DECT with MDI improves CT-CA evaluability and diagnostic accuracy in patients
with suspected CAD and high CCS.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O238
PHYSIOLOGICAL ADAPTATION OF THE RIGHT VENTRICULAR MORPHOLOGY
AND FUNCTION IN TOP-LEVEL ATHLETES DURING THE SEASON
FLAVIO D´ASCENZI (A), ANTONIO PELLICCIA (B), DOMENICO CORRADO (C),
STEFANO CASELLI (B), MATTEO CAMELI (A), VALERIA CURCI (A),
FEDERICO ALVINO (A), BENEDETTA MARIA NATALI (A), MARTA FOCARDI (A),
MARCO BONIFAZI (D), SERGIO MONDILLO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASES, UNIVERSITY OF SIENA, SIENA,
ITALY; (B) INSTITUTE OF SPORTS MEDICINE AND SCIENCE, ROME, ITALY; (C)
DIVISION OF CARDIOLOGY, DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR
SCIENCES, UNIVERSITY OF PADOVA, PADOVA, ITALY; (D) DEPARTMENT OF
MEDICINE, SURGERY, AND NEUROSCIENCE, UNIVERSITY OF SIENA, SIENA, ITALY
Purpose. Conflicting evidence exists concerning right ventricular (RV) morphology and function in
top-level athletes. Although cross-sectional studies have been performed in athletes, longitudinal data
investigating the in-seasonal changes in RV are not yet available. The aim of this study was to
investigate whether morphological and functional RV changes can be observed in athletes during the
season.
Methods. Thirty top-level players were enrolled in this study. Echocardiographic measurements were
performed at the beginning of the study, after 3, and after 6 months of training, corresponding to preseason, mid-, and pre-end-season periods.
Results. At mid-season time point RV end-diastolic basal diameter (p<.05), RV end-diastolic area
(p=0.001), and RV end-systolic area (p<0.001) increased in comparison with pre-season data, with a
slight reduction at pre-end-season time point. RV fractional area change did increase at mid-season
time point (p≤.005 vs. pre-season data). Conversely, E/A ratio and E/e’ ratio did not significantly
vary. Both RV sphericity index and ratio between RV and left ventricular end-diastolic volume did
not significantly change (overall p=.073 and =.176, respectively), suggesting a global and
physiological remodeling of the heart. Free wall global strain and strain rate remained stable during
the season (overall p= .522 and =.227, respectively). However, when differences in regional
myocardial deformation were analyzed, while basal and middle free wall strains did not change, an
increase of apical free wall strain was observed (p≤.005 vs. pre-season time point). None of the
participants experienced a pathological reduction of RV strain values.
Conclusions. This study demonstrated that changes in RV myocardial morphology and deformation
occur in top-level athletes during the season. However, in this study none of the athletes experienced
a marked asymmetric dilatation of the right ventricle or a pathological reduction of RV strain values,
suggesting that the observed training-related changes can be interpreted as a physiological response
to training load and considered as complementary features of athlete’s heart.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O239
CORRELATIONS BETWEEN PANCREATIC IRON BURDEN AND HEART IRON
OVERLOAD AND FUNCTION BY MRI IN A LARGE COHORT OF THALASSEMIA
MAJOR PATIENTS.
ANTONELLA MELONI (A), GENNARO RESTAINO (B), MASSIMILIANO MISSERE (B),
STEFANIA RENNE (C), VINCENZO POSITANO (A), GIUSEPPINA SECCHI (D),
NICOLA ROMANO (E), DANIELE DE MARCHI (A), GIUSEPPINA SALLUSTIO (B),
ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) DIPARTIMENTO DI RADIOLOGIA, UNIVERSITÀ CATTOLICA DEL SACRO CUORE CENTRO DI RICERCA E FORMAZIONE AD ALTA TECNOLOGIA NELLE SCIENZE
BIOMEDICHE, CAMPOBASSO, ITALY; (C) STRUTTURA COMPLESSA DI
CARDIORADIOLOGIA-UTIC, P.O. “GIOVANNI PAOLO II”, LAMEZIA TERME (CZ),
ITALY; (D) SERVIZIO TRASFUSIONALE, AZIENDA USL N° 1, SASSARI, ITALY; (E) S.C.
MEDICINA TRASFUSIONALE, ARCISPEDALE “S. MARIA NUOVA“, REGGIO EMILIA,
ITALY
Background. The leading cause of death in thalassemia major patients remains the heart failure, but
impairment of the endocrine and exocrine function of the pancreas is a common complication.
Multiecho T2* Magnetic Resonance Imaging (MRI) is a well established technique for heart and liver
iron overload assessment. Little is known about the relationship between myocardial iron burden and
cardiac function with pancreatic siderosis. Aim of our study was to investigate using quantitative
MRI the correlation between heart iron overload and function with pancreatic siderosis in thalassemia
major (TM) patients.
Methods. We studied 147 TM (233 males, mean age
31±9 years) consecutively enrolled in the Myocardial
Iron Overload in Thalassemia network where MRI (1.5
T) was performed using standardized and validated
procedures. Myocardial iron overload was measured by
T2* multislice multiecho technique. Biventricular
function parameters were quantitatively evaluated by
cine images. Pancreatic iron burden was measured using
a T2* gradient-echo multiecho sequence. The images
were analyzed using a previously validated, customwritten software (HIPPO-MIOT®).
Results. Significant positive correlations of the global
pancreas T2* values were demonstrated for global heart
T2* values (r=0.355, P<0.0001; see Figure), number of
segments with normal T2* (r=0.389, P<0.0001) and T2* values in the mid-ventricular septum
(r=0.323, P<0.0001). Of the 136 patients with pancreatic iron overload (T2*<26 ms), 45 (33.1%) had
a pathological global heart T2* value (<20 ms). No patients without pancreatic iron overload had
cardiac iron overload. A normal global pancreas T2* value showed a negative predictive value of
100% for cardiac iron.
Pancreatic T2* values were positively related with left ventricular (r=0.21, P=0.028) and right
ventricular (r=0.23, P=0.015) ejection fractions. No significant correlation was found between
pancreatic T2* values and biventricular volumes.
Conclusions. Pancreatic iron overload is positively correlated to myocardial iron overload and
negatively correlated to bi-ventricular systolic function.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
RESINCRONIZZAZIONE CARDIACA - ICD
O240
THE EFFECTS OF SHOCKS AND ANTI-TACHYCARDIA PACING ON ANXIETY AND
QUALITY OF LIFE: A MADIT-RIT SUB-STUDY
ALESSANDRO PAOLETTI PERINI (A), VALENTINA KUTYIFA (B),
WOJCIECH ZAREBA (B), SCOTT MCNITT (B), ARTHUR J MOSS (B),
LUIGI PADELETTI (A)
(A) UNIVERSITA` DEGLI STUDI DI FIRENZE, DIPARTIMENTO CUORE E VASI; (B)
UNIVERSITY OF ROCHESTER (NY, USA) MEDICAL CENTER
Introduction: Data on the effects of shocks and ATPs on anxiety and quality of life (QoL) in ICD
patients are limited and contradictory. Recently, the MADIT-RIT trial showed that innovative ICD
programming is significantly reducing inappropriate therapies.
Methods: We evaluated QoL using EQ-5D questionnaire at baseline and at 9 months in 1268 ICD
patients enrolled in the MADIT-RIT trial. We also assessed the Florida shock anxiety scale (1-10
score) (n=1273) to investigate the effect on anxiety of appropriate or inappropriate shocks, and
appropriate or inappropriate ATPs, delivered during the first 9 months of the trial. Analysis was
stratified by the number of shocks or ATPs (0-1 vs. ≥2) delivered, and adjusted for age, gender,
NYHA class, implanted device (ICD only versus CRT-D) and randomized programming arm.
Results: In MADIT-RIT, 15 patients (1%) had ≥2 appropriate shocks, and 38 (3%) had ≥2
appropriate ATPs. Two or more inappropriate shocks were delivered in 16 patients (1%), ≥2
inappropriate ATPs in 70 (5.5%). In multivariate analysis, patients with ≥2 appropriate shocks had a
significantly higher level of shock-related anxiety than those with ≤1 therapy given (p<0.01).
Furthermore, ≥2 inappropriate shocks were more anxiety producing than ≤1 therapy given (p=0.005).
Consistently, ≥2 appropriate ATPs resulted in more anxiety than ≤ 1 (p=0.028), while there was no
evidence that inappropriate ATPs had association with anxiety (p=0.997). Older age, female gender,
and better functional status were also independently associated with lower anxiety at 9-month (p <
0.05 for all). However, associations between QoL and appropriate or inappropriate shocks and
appropriate or inappropriate ATPs were not significant (all p-values >0.05).
Conclusion: In ICD patients enrolled in MADIT-RIT, two or more appropriate or inappropriate
shocks and appropriate ATPs were associated with increased anxiety at 9-month follow-up, although
there was no evidence that this was translated to an impaired quality of life. Novel strategies aiming
at reducing the arrhythmic burden and the number of delivered therapies would be desirable to reduce
anxiety in ICD patients.
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O241
MULTI POINT PACING NELLA TERAPIA
CARDIACA:UN'ESPERIENZA MULTICENTRICA
DI
RESINCRONIZZAZIONE
LUCA SANTINI (b), GIOVANNI FORLEO (b), FRANCESCO ZANON (v),
MASSIMO GIAMMARIA (a), ANTONELLO VADO (c), ANNA MARIA MARTINO (d),
EMANUELE BERTAGLIA (e), GIOVANNI MORANI (f), VITO CALABRESE (g),
GERARDO ANSALONE (h), CARLO PIGNALBERI (i), CARLO D´AGOSTINO (j),
ANTONIO CICCAGLIONI (k), GAETANO SENATORE (l), MAURIZIO DEL GRECO (m),
ENNIO CARMINE LUIGI PISANò (n), DOMENICO SPAZIANI (o),
MATTEO SANTAMARIA (p), ALESSANDRO PROCLEMER (q), PIETRO DELISE (r),
VITTORIO CALZOLARI (s), ALESSANDRO LOCATELLI (t), MASSIMILIANO MARINI (u),
LUIGI MANCINI (w), GIANNI PASTORE (v), ENDRJ MENARDI (c), MARIA
TERESA LUCCIOLA (a), FRANCESCO ROMEO (b)
(a) OSPEDALE MARIA VITTORIA-TORINO; (b) POLICLINICO TOR VERGATA-ROMA; (c)
OSPEDALE S.CROCE E CARLE-CUNEO; (d) POLICLINICO CASILINO-ROMA; (e)
OSPEDALE UNIVERSITARIO-PADOVA; (f) OSPEDALE UNIVERSITARIO-VERONA; (g)
OSPEDALE CAMPUS BIOMEDICO-ROMA; (h) OSPEDALE VANNINI-ROMA; (i)
OSPEDALE SAN FILIPPO NERI-ROMA; (j) OSPEDALE DI VENERE-BARI; (k)
POLICLINICO UMBERTO PRIMO-ROMA; (l) OSPEDALE DI CIRIÈ; (m) OSPEDALE MARIA
DEL CARMINE - ROVERETO; (n) OSPEDALE VITO FAZZI-LECCE; (o) OSPEDALE
FORNAROLI-MAGENTA; (p) FONDAZIONE GIOVANNI PAOLO SECONDOCAMPOBASSO; (q) OSPEDALE UNIVERSITARIO-UDINE; (r) OSPEDALE CIVILECONEGLIANO; (s) OSPEDALE CÀ FONCELLO-TREVISO; (t) AZIENDA OSPEDALIERA
BOLOGNINI-SERIATE; (u) OSPEDALE DI TRENTO; (v) OSPEDALE S.MARIA DELLA
MISERICORDIA-ROVIGO; (w) OSPEDALE SAN PAOLO-BARI
Introduzione: La nuova modalità di stimolazione MultiPoint™ (MPP) per la terapia di
resincronizzazione cardiaca (CRT) permette di stimolare il ventricolo sinistro (VS) con due impulsi
sequenziali da differenti catodi di un catetere quadripolare posizionato in un ramo del seno
coronarico. In associazione con la stimolazione destra potrebbe migliorare la funzione contrattile del
ventricolo sinistro catturandone un’area maggiore e migliorando quindi la risposta alla CRT. Lo
scopo di questa raccolta dati multicentrica è verificare la fattibilità e la performance della
stimolazione MPP in termini di soglie di cattura (SC) e presenza di stimolazione del nervo frenico
(PNS).
Metodi: Sono stati raccolti i dati di 175 pazienti in 30 centri (80% uomini, 69±10 anni, LVEF 27±5%,
QRS 163±18 ms, 89 con cardiomiopatia non ischemica). Durante l’impianto sono state misurate le
SC ed è stata valutata la presenza di PNS in diverse configurazioni di stimolazione. La
programmazione del dispositivo è stata ottimizzata secondo pratica del centro e sono stati misurati i
ritardi elettrici tra catetere ventricolare destro (VD) e ciascun polo del catetere in VS (D1, distale;
M2-M3, mediali; P4, prossimale).
Risultati: Il tempo medio della procedura di impianto è stato di 110 min±57min. Il catetere sinistro
è stato posizionato nel 43% dei casi in una vena laterale, nel 31% in una postero-laterale, nel 19% in
una antero-laterale, nel 5% in una posteriore e solo nel 2% dei casi in una vena anteriore. In 156
pazienti (90%) la SC del catetere VS è stata misurata in almeno 2 delle 10 configurazioni disponibili.
In tutti i pazienti la media delle SC (a 0.5 ms) è risultata <3V in 9/10 configurazioni e <2,5V in
8/10(vd.Tab). La nuova funzione MPP è risultata attivabile nel 99% dei pazienti e nel 93% c’era
almeno un vettore con SC inferiore a 2V. Nel 87% dei casi c’erano almeno 2 vettori con soglia minore
di 3V*0,5ms. In 36 casi (23%) è stata riportata PNS, ma la modalità MPP era comunque
programmabile per la disponibilità di altre configurazioni. I ritardi elettrici VD-VS sono stati misurati
in 98 pazienti in modalità VD-sentito: l’elettrodo più ritardato nel 22% dei casi è stato D1, nel 18%
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M2, nel 24% M3 e nel 36% P4. Nel 47% dei casi uno dei poli più ritardati è stato scelto come catodo
per uno dei due vettori MPP o per il vettore biventricolare convenzionale (BIV). Non sono state
osservate complicanze procedurali o effetti pro-aritmici. In 27 patienti è stata valutata la durata del
QRS nelle configurazioni BIV e MPP. Il QRS durante stimolazione BIV ottimale si è ridotto
significativamente rispetto al basale (159±22 vs 177±26 p=0,0002). La migliore stimolazione MPP
ha ulteriormente e significativamente ridotto il QRS rispetto alla stimolazione BIV (152±23 p=0,002).
Conclusione: Nella nostra esperienza preliminare, la funzione Multi Point è fattibile e programmabile
nella maggior parte dei casi senza problemi di soglia o stimolazione del nervo frenico. Inoltre riduce
significativamente la durata del QRS se confrontata con la stimolazione biventricolare tradizionale.
Vettori
di
Stimolazione
Media [V]
Dev. St.[V]
D1-M2
D1-P4
D1-RV
M2-P4
M2-RV
M3-M2
M3-P4
M3-RV
P4-M2
P4-RV
1,58
1,35
1,93
1,50
1,40
1,24
2,28
1,72
1,67
1,33
2,27
1,69
1,97
1,62
2,05
1,63
3,05
2,03
2,76
1,97
O242
PREVALENZA E PREDITTORI DI ESTERNALIZZAZIONE DEGLI CATETERI DA
DEFIBRILLAZIONE RIATA
GRAZIELLA MALERBA (a), MADDALENA ZINGARO (a), MARIA
CARMELA MASCOLO (a), MARIANGELA PINTO (a), FRIDA NACCI (a),
MATTEO ANACLERIO (a), STEFANO FAVALE (a), MATTEO MARCO CICCONE (a)
(a) CARDIOLOGIA UNIVERSITARIA POLICLINICO DI BARI
Background. Nel 2011 la Food and Drugs administration (FDA) ha “richiamato” gli elettrocateteri
endocardici in Silicone Riata® e Riata ST prodotti dalla St. Jude Medical per l’alto tasso di failure
prematura connesso ad abrasione dell’isolante in silicone ed esternalizzazione dei conduttori.
Obiettivi dello studio. Gli obiettivi del nostro studio sono: determinare la prevalenza
dell’esternalizzazione dei conduttori, identificare i fattori predittori di esternalizzazione e determinare
la storia naturale degli elettrocateteri con questa anomalia strutturale.
Materiali e Metodi. Stati arruolati 46 pazienti portatori di elettrocateteri endocardardici in Silicone
Riata® e Riata ST, impiantati tra giugno 2002 e marzo 2010. Tutti i 46 pazienti previo consenso
informato hanno aderito al programma di screening che comprendeva: controllo elettronico del
device, riprogrammazione specifica del device, esame fluroscopico dell’elettrocatetere. A ciascun
paziente è stato assegnato un sistema di monitoraggio remoto. Il programma di follow up di ciascun
paziente è stato definito secondo la presenza o meno dell’esternalizzazione dei conduttori e secondo
la classe di rischio del paziente cosi come descritto nel documento AIAC. l pazienti ad alto rischio
e/o con esame fluoroscopico positivo per esternalizzazione dei conduttori sono stati sottoposti a
controllo elettronico del device ogni 3 mesi ed esame fluoroscopico ogni 6 mesi; gli altri pazienti
sono stati sottoposti a controllo del device e ad esame fluoroscopio rispettivamente ogni 6 e 12 mesi.
Risultati. In 7 dei 46 (15.22%) pazienti l’esame fluoroscopio, eseguito al momento
dell’arruolamento, è risultato positivo per esternalizzazione dei conduttori. L’età media
dell’elettrocatetere al momento del riscontro dell’ esternalizzazione era di 86 ±17 mesi. Tutti gli
elettrocateteri esternalizzati presentavano diametro di 8Fr. In tutti gli elettrocateteri con anomalia
strutturale la sede di esternalizzazione è risultata prossimale ai coil ventricolare in prossimità del
piano valvolare della tricuspide Nella popolazione esternalizzati 2 dei 7 pazienti (28.6% vs 2.56 del
gruppo non esternalizzati P=0.05) hanno presentato, contestualmente al riscontro di
esternalizzazione, anomalie elettriche al controllo elettronico del device. L’analisi univariata ha
mostrato, nel confonto tra il gruppo esternalizzati e quello non esternalizzati, differenze
significativamente statistiche in relazione al parametro rigurgito tricuspidalico lieve (P=0.04);
modello di elettrocatetere 1580 (P= 0.05); soglia di pacing ventricolare destro (P= 0.02) risultata più
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alta nel primo gruppo e anomalie elettriche risultate più frequenti nel primo gruppo (P= 0.05).
L’analisi multivariata relativa ai predittori di esternalizzazione ha mostrato che il modello RiataTM
differente dal 1580 è fattore protettivo statisticamente significativo di esternalizzazione (P=0.05);
mentre l’impedenza di pacing maggiore è fattore predittore statisticamente significativo di
esternalizzazione (P=0.05). Nessun elettrocatetere esternalizzato ha sviluppato anomalie elettriche
durante il follow up. Nel nostro studio un elettrocatetere esternalizzato e mal funzionate è stato
estratto e sostituito mentre l’altro è stato isolato elettricamente, lasciato in situ e sostituito.
Conclusioni. L’esternalizzazione dei conduttori rappresenta un importante problema di non semplice
gestione. La scelta di nuovi materiali isolanti come l’Optim ® ha consentito di limitare la failure
strutturale degli elettrocateteri endocardici da defibrillazione.
O243
ICD SOTTOCUTANEO ED ICD TRADIZIONALE NEI PAZIENTI
CONFRONTO TRA COMPLICANZE PERI- E POST-IMPIANTO
GIOVANI:
Laura Cipolletta (a), Federico Guerra (a), Piangerelli Luca (a), Mario Luzi (a),
Alessandro Capucci (a)
(a) CLINICA DI CARDIOLOGIA ED ARITMOLOGIA, OSPEDALI RIUNITI DI ANCONA,
UNIVERSITÀ POLITECNICA DELLE MARCHE
Background: Attualmente gli ICDs trans-venosi (TV-ICD) hanno raggiunto un cospicuo numero di
indicazioni in diverse situazioni cliniche, ma sfortunatamente il loro utilizzo è correlato al rischio di
complicanze maggiori, quali le endocarditi, i malfunzionamenti dei cateteri ed il tromboembolismo
venoso. Per ovviare a tali complicazioni, l’ICD sottocutaneo (S-ICD) sta emergendo come una valida
alternativa, soprattutto nei giovani pazienti. In questo studio si riporta l’esperienza di un singolo
centro, riguardo alle performances dell’S-ICD in un gruppo di pazienti sotto i 65 anni.
Metodi: Studio osservazionale tra 13 pazienti portatori di S-ICD e 13 pazienti portatori di TV-ICD,
comparabili per età, sesso e tipo di cardiopatia. L’età media all’impianto era di 43.1±10.5 anni. Tutti
gli impianti erano stati effettuati in un singolo centro dallo stesso operatore. Si sono registrate le
eventuali complicanze, come gli interventi inappropriati dell’ICD, le endocarditi, i malfunzionamenti
dei cateteri, il tromboembolismo venoso e le revisioni programmate del device. Il follow-up medio è
stato di 18 mesi.
Risultati: La popolazione di pazienti portatori di S-ICD era composta da: 7 pazienti affetti da
sindrome di Brugada (6 di tipo 1 spontaneo e 1 indotto da flecainide), 2 pazienti con cardiomiopatia
ipertrofica, 1 paziente con cardiomiopatia dilatativa, 1 paziente con sindrome del QT lungo, 1
paziente con fibrillazione ventricolare idiopatica e 1 paziente con cardiopatia congenita complessa. I
pazienti del gruppo di controllo erano affetti dalle stesse cardiopatie, erano dello stesso sesso ed erano
di età compresa nella stessa decade dei pazienti con S-ICD che costituivano il rispettivo match. In 2
pazienti del gruppo S-ICD si sono verificati ematomi nel post-impianto, uno dei quali ha richiesto
una revisione, mentre un altro paziente del gruppo dei TV-ICD ha sviluppato un enfisema
sottocutaneo dopo il tradizionale impianto di ICD. Durante il follow-up, un paziente ha subito
un’estrazione del TV-ICD per infezione della tasca con erosione cutanea, mentre non si è verificata
nessuna infezione nel gruppo dei pazienti con S-ICD. Un paziente portatore di S-ICD ha ricevuto 2
shock appropriati con termine immediato dell’aritmia in entrambi gli episodi. Si è verificato un caso
di oversensing dell’onda T con shock inappropriato nel gruppo degli S-ICD, risolto al follow-up
invertendo il vettore di sensing. Nel gruppo del TV-ICD sono stati documentati 2 casi di rumore nel
canale di shock, senza nessun intervento inappropriato da parte del device.
Conclusioni: In base all’esperienza del nostro centro, l’S-ICD è sicuro e tollerato, rispetto al
tradizionale TV-ICD nei pazienti giovani, mantenendo la stessa efficacia terapeutica. L’S-ICD
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potrebbe essere considerato una valida alternativa nei giovani pazienti per ridurre il tasso di
complicanze a lungo termine.
O244
RISPOSTA ECOCARDIOGRAFICA E OUTCOMES A LUNGO TERMINE DOPO
RESINCRONIZZAZIONE CARDIACA: VALUTAZIONE MULTIPARAMETRICA DEI
FATTORI PREDITTIVI
ELISA FILIPPINI (A), IGOR DIEMBERGER (A), MATTEO ZIACCHI (A),
CRISTIAN MARTIGNANI (A), MAURO BIFFI (A), GIUSEPPE BORIANI (A)
(A) ISTITUTO DI CARDIOLOGIA POLICLINICO UNIVERSITARIO S.ORSOLA-MALPIGHI,
BOLOGNA.
Introduzione: la terapia di resincronizzazione cardiaca (CRT) è una valida opzione nel trattamento
dello scompenso cardiaco ma solo il 60-70%% circa dei candidati alla CRT risponde in termini di
rimodellamento ventricolare inverso che appare essere il predittore più forte di riduzione delle
ospedalizzazioni e della mortalità.
Materiali e Metodi: abbiamo preso in considerazione 107 pz. sottoposti a CRT; principalmente in
classe NYHA II e III, 72 % maschi e 28% femmine, 77% affetti da CMPD e 23% da cardiopatia
ischemica (CAD); sottoposti ad ecocardiogramma e test cardiopolmonare (CPET) prima e dopo
l'impianto, con follow-up variabile da 24 a 140 mesi (media 68 mesi). Nel corso del follow-up 10
pazienti sono morti e 5 sottoposti a trapianto ortotopico di cuore. Si è cercato quindi di valutare se il
test da sforzo cardiopolmonare potesse essere utile nel predire la risposta alla CRT e di ricercare tra
le altre variabili analizzate predittori di outcome e risposta alla CRT. I pz. responder sono stati definiti,
in accordo alla letteratura, sulla base di una riduzione del volume telediastolico (VTD) di almeno il
15% a 6 mesi post CRT.
Risultati: dopo CRT si è documentato un miglioramento dei parametri ecocardiografici rispetto al
basale (riduzione del VTD p<0,0001, del VTS p<0,0001, aumento della FE p<0,0001) e dei parametri
del CPET (aumento del p-VO2 p=0,004, riduzione del VE/VCO2 slope p=0,018, aumento del
cardiaco di lavoro p=0,007). Nessuna delle variabili relative al CPET basale o alle modificazioni nel
successivo follow-up si è dimostrata un valido predittore della risposta ecocardiografica e/o di
outcome. La presenza di insufficienza mitralica emodinamicamente significativa (moderato-severa o
severa) nella valutazione pre-impianto è risultata essere l’unico fattore indipendente predittivo di
outcome in termini di mortalità/trapianto cardiaco (p<0,001). Se congiuntamente alle variabili preimpianto si considerano le modificazioni a 6 mesi dalla CRT, il rimodellamento inverso valutato
all’eco si evidenzia come predittore di outcome (morte/trapianto) insieme all’eziologia e alla
presenza di IM emodinamicamente significativa (HR 7,03, CI 2,2-22,2; eziologia non ischemica HR
0,32 CI 0,11-0,92; rimodellamento inverso HR 0,16; IC95% 0,05-0,59). Gli unici predittori dell’endpoint combinato, risposta strutturale e sopravvivenza, all'analisi multivariata sono stati la durata del
QRS (HR 0,98; IC95% 0,97-0,99), l’età (HR 0,97; IC95% 0,94-0,99) e l'insufficienza mitralica
emodinamicamente signifitiva (HR 6,8; IC95% 2,9-16,1).
Conclusione: il CPET migliora dopo impianto di pacing biventricolare ma non si è evidenziato un
ruolo nel predire la risposta alla CRT. L'eziologia non ischemica e la maggior durata del QRS sono
fattori associati a una migliore risposta alla CRT. L’insufficienza mitralica emodinamicamente
significativa è al contempo un predittore indipendente di morte a medio-lungo termine e di risposta
alla CRT in pazienti con scompenso cardiaco moderato.
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O245
OTTIMIZZAZIONE DI DISPOSITIVI MULTI POINT PACING NELLA TERAPIA DI
RESINCRONIZZAZIONE CARDIACA: FOCUS SULLA PRATICA CLINICA
MASSIMO GIAMMARIA (A), GIOVANNI FORLEO (B), LUCA SANTINI (B),
ANTONELLO VADO (C), ANNA MARIA MARTINO (D), EMANUELE BERTAGLIA (E),
GIOVANNI MORANI (F), DANILO RICCIARDI (G), GERARDO ANSALONE (H),
CARLO PIGNALBERI (I), CARLO D´AGOSTINO (J), ANTONIO CICCAGLIONI (K),
MARCO GIUGGIA (L), MAURIZIO DEL GRECO (M), GIOVANNI MILANESE (N),
DOMENICO SPAZIANI (O), QUINTINO PARISI (P), ALESSANDRO PROCLEMER (Q),
GIUSEPPE ALLOCCA (R), VITTORIO CALZOLARI (S), BRUNO CASIRAGHI (T),
MASSIMILIANO MARINI (U), LUIGI MANCINI (W), ENRICO BARACCA (V), MARIA
TERESA LUCCIOLA (A), ENDRJ MENARDI (C), FRANCESCO ZANON (V)
(A) OSPEDALE MARIA VITTORIA-TORINO; (B) POLICLINICO TOR VERGATA-ROMA;
(C) OSPEDALE S.CROCE E CARLE-CUNEO; (D) POLICLINICO CASILINO-ROMA; (E)
OSPEDALE UNIVERSITARIO-PADOVA; (F) OSPEDALE UNIVERSITARIO-VERONA; (G)
OSPEDALE CAMBUS BIO-MEDICO-ROMA; (H) OSPEDALE VANNINI-ROMA; (I)
OSPEDALE SAN FILIPPO NERI-ROMA; (J) OSPEDALE BARI DI VENERE; (K)
POLICLINICO UMBERTO PRIMO-ROMA; (L) OSPEDALE DI CIRIÈ; (M) OSPEDALE
MARIA DEL CARMINE-ROVERETO; (N) OSPEDALE VITO FAZZI-LECCE; (O) OSPEDALE
FORNAROLI-MAGENTA; (P) FONDAZIONE GIOVANNI PAOLO SECONDOCAMPOBASSO; (Q) OSPEDALE UNIVERSITARIO-UDINE; (R) OSPEDALE CIVILECONEGLIANO; (S) OSPEDALE CÀ FONCELLO-TREVISO; (T) AZIENDA OSPEDALIERA
BOLOGNINI-SERIATE; (U) OSPEDALE DI TRENTO; (V) OSPEDALE S.MARIA DELLA
MISERICORDIA-ROVIGO; (W) OSPEDALE SAN PAOLO-BARI
Introduzione: I dispositivi impiantabili per la resincronizzazione cardiaca (CRT) non sempre
vengono ottimizzati all’impianto, preferendo le impostazioni di default o l’ottimizzazione sui soli
pazienti non-responder al follow-up. In questa raccolta dati multicentrica si vuole valutare la pratica
clinica di ottimizzazione di dispositivi CRT di recente introduzione, dotati di stimolazione sinistra
biventricolare multisito (MPP).
Metodi: 131 pazienti sono stati impiantati con dispositivo CRT-MPP (età 68±9 anni, FE 27±6%,
durata del QRS 160±18 ms). In 30 centri italiani è stata compilata una survey sulle modalità di
programmazione dei dispositivi e sulle modalità di ottimizzazione all’impianto.
Risultati: In 97 (69,5%) pazienti è stata effettuata un’ottimizzazione del dispositivo all’impianto con
diverse metodiche, a seconda del centro. In 46 (47%) pazienti è stata effettuata un’ottimizzazione
della programmazione MPP confrontandola con stimolazione Biventricolare convenzionale (BIV), in
25 (26%) casi è stata ottimizzata soltanto la
stimolazione BIV e in 26 (27%) soltanto quella
MPP.
In 35 (36%) pazienti è stata fatta una valutazione
della durata del QRS con ECG a 12 derivazioni
(considerando la derivazione con QRS più largo);
in 14 pazienti (14%) è stata utilizzata una guida di
pressione invasiva per valutare il dP/dT e misurato
il QRS; in 36 pazienti (37%) sono stati valutati i
ritardi elettrici tra gli elettrodi e usati algoritmi
automatici per la determinazione dei ritardi
ottimali tra gli stimoli; in soli 4 pazienti (4%) sono
state utilizzate metodiche ecocardiografiche
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(valutazione VTI , FE o Volumi) per l’ottimizzazione; nei restanti casi (9%), sono stati usati dei criteri
combinati.
Conclusioni: Nella reale pratica clinica il 69,5% dei dispositivi CRT-MPP impiantati viene
ottimizzato già all’impianto e non soltanto dopo aver verificato la risposta clinica. Per la scelta della
migliore modalità di stimolazione, all’impianto si predilige una metodica più veloce quale la
valutazione del restringimento del QRS o la minimizzazione dei ritardi elettrici tra i poli di
stimolazione, mediante algoritmi automatici.
MECCANISMI DI RIPARAZIONE MIOCARDICA - 3
O246
TRANSPLANTATION OF MESENCHYMAL STROMAL CELLS OVEREXPRESSING
TELOMERASE AND MYOCARDIN GENES PROMOTES REVASCULARIZATION AND
TISSUE REPAIR IN A MURINE MODEL OF ACUTE MYOCARDIAL INFARCTION
ROSALINDA MADONNA (B), FRANCESCA RENNA (B), MARIA ANNA TEBERINO (B),
LYUBOMIR PETROV (A), SEPPO YLA-HERTUALA (A), RAFFAELE DE CATERINA (B)
(A) BIOCENTER KUOPIO, A. I. VIRTANEN INSTITUTE FOR MOLECULAR SCIENCES,
KUOPIO, FINLAND ; (B) INSTITUTE OF CARDIOLOGY, “G. D’ANNUNZIO” UNIVERSITY
– CHIETI, ITALY
Background and Objective: The number and function of stem cells decline with aging, reducing
their ability to contribute to endogenous repair processes. The repair capacity of stem cells in older
individuals may be improved by genetically reprogramming stem cells to enhance their regenerative
properties. We analyzed the impact of enhanced expression of myocardin (MyC) and telomerase
(TeM) on the therapeutic efficacy of transplantation of adipose tissue-derived mesenchymal stromal
cells (AT-MSCs) in murine hearts with ischemic injury.
Methods: AT-MSCs isolated from 12 month-old male C57BL/6 mice were efficiently co-transduced
with 3rd generation lentiviral vectors carrying the cDNAs coding for TeM-YFP (yellow fluorescence
protein) or MyC-V5 epitope fusion proteins. Mice underwent coronary artery ligation (Lig), followed
by randomization into 5 groups (n=6/group): I. Sham operation; II. AMI control (phosphate-buffered
saline (PBS) 20 µL); III. AMI followed by intramyocardial injection with AT-MSCs only (2.5x105
cells/20 µL); IV. AT-MSCs transduced with empty vectors (mock, 2.5x105 cells/20 µL); or V. ATMSCs (2.5x105 cells/20 µL) transduced with TeM and MyC genes (TeM+/MyC+).
Results: TeM+/MyC+ AT-MSCs, but not AT-MSCs or mock AT-MSCs decreased the area of
fibrosis (Figure A) and increased myogenesis, arteriogenesis (Figure B), number of cardiac-resident
c-Kit positive cells (p<0.05 vs PBS+lig) and myocardial fractional shortening (FS) when transplanted
into the infarcted hearts [ΔFS as difference between baseline (pre-lig) and 2 weeks after lig: II. 27 10**; III. -22 4**; IV. -12 14*; V. +2 8] (**p<0.01 and *p<0.05 vs baseline, by ANOVA).
Figure legend: A: Structural analysis by hematoxylin/eosin staining; B: Immunofluorescence staining
with Cy3-conjugated anti-alpha smooth muscle actin.
Conclusions: The simultaneous delivery of the TeM and MyC genes confers AT-MSCs
the potential of improving revascularization and repairing ischemic tissues when transplanted into
infarcted hearts.
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Roma, 13 – 15 dicembre 2014
O247
SILENCING OF VON WILLEBRAND FACTOR REDUCES ENDOTHELIN-1
EXPRESSION INDEPENDENTLY OF ENOS ACTIVATION IN PORCINE ENDOTHELIAL
CELLS EXPOSED TO ANGIOTENSIN II
ANAR DUSHPANOVA (A, B), SILVIA AGOSTINI (A), MARCO MATTEUCCI (A),
VALENTINA CASIERI (A), MANUELA CABIATI (C), SILVIA DEL RY (C),
SERGIO BERTI (B), ALDO CLERICO (A, B), VINCENZO LIONETTI (A,B,C)
(A) LABORATORIO DI SCIENZE MEDICHE, ISTITUTO DI SCIENZE DELLA VITA,
SCUOLA SUPERIORE SANT´ANNA, PISA, ITALIA; (B) FONDAZIONE TOSCANA “G.
MONASTERIO“, PISA, ITALIA; (C) ISTITUTO DI FISIOLOGIA CLINICA, CNR, PISA,
ITALIA
Introduction: Angiotensin II (AngII) generated under conditions of myocardial ischemia and
reperfusion increases endothelial levels of endothelin (ET)-1, von Willebrand factor (vWF) and anion
superoxide (O2-), which lead to progressive coronary endothelial dysfunction. Recent
study described that vWF blockade improves endothelial function in coronary patients, but
the mechanisms are still unknown.
Hypothesis: The downregulation of vWF modulates the ET-1 level, eNOS activity and O2generation in porcine aortic endothelial cells (PAOECs) chronically exposed to AngII.
Methods: The silencing of vWF in PAOECs was induced with selective short interference RNA.
Protein expression of endothelial vWF, ET-1, eNOS and phospho-Ser1177eNOS (p-eNOS) was
measured by western blotting in wild type and vWF-knockdown cells exposed to vehicle or AngII
(100nM for 24h). O2- formation was measured by dihydroethidium staining. In additional
experiments, wild type and vWF-knockdown cells were treated with phorbol 12-myristate 13-acetate
(PMA, 5nM for 48h), a nonsubtype selective agonist of protein kinase type C and inhibitor of eNOS
activity.
Results: Nearly 65% silencing of vWF cell viability and growth were not impaired. Levels of ET-1,
phospho-Ser1177eNOS (peNOS)/eNOS ratio and O2- were unchanged in vWF-knockdown
compared to wild type cells under normal conditions. Conversely, ET-1expression was reduced by
93.7±4 % (P<0.0001) in the presence of normal p-eNOS/eNOS ratio in vWF-knockdown cells under
oxidative microenvironment; although, the intracellular load of O2- was reduced by 33.3±2% in
vWF-knockdown cells with lower level of Mn superoxide dismutase. In additional experiments, the
inhibition of eNOS activity by PMA did not reverse the downregulation of ET-1.
Conclusions: We demonstrated that vWF-knockdown modulates the response of PAOECs to chronic
exposure to AngII by preventing cell death, reducing ET-1 and O2- production without affecting
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endothelial function. Our findings support the usefulness of vWF as upstream modulator of ET-1
expression under oxidative stress.
O248
RUOLO CARDIOPROTETTIVO DI ZOFENOPRIL IN PAZIENTI DIABETICI CON
INFARTO MIOCARDICO ACUTO: ANALISI DEGLI STUDI PROSPETTICI SMILE
Claudio Borghi (a), Stefano Omboni (b), Giorgio Reggiardo (c), Stefano Bacchelli (a),
Daniela Degli Esposti (a), Ettore Ambrosioni (a)
(a) UNITÀ DI MEDICINA INTERNA, POLICLINICO S.ORSOLA, UNIVERSITÀ DI
BOLOGNA, BOLOGNA; (b) UNITÀ DI RICERCA CLINICA, ISTITUTO ITALIANO DI
TELEMEDICINA, SOLBIATE ARNO, VARESE; (c) MEDISERVICE, AGRATE BRIANZA,
MILANO
Introduzione: gli studi SMILE hanno dimostrato come la somministrazione precoce di zofenopril
comporti un beneficio nella prognosi dei pazienti con infarto miocardico acuto (IMA) rispetto al
placebo o ad altri inibitori dell’enzima di conversione dell’angiotensina (ACEI). Nella seguente metaanalisi di dati individuali sono stati riesaminati i risultati dei quattro studi del progetto SMILE, nel
sottogruppo di pazienti affetti da diabete mellito.
Metodi: 1216 dei 3630 pazienti arruolati durante i 15 anni del progetto SMILE avevano un’anamnesi
positiva per diabete mellito e sono stati selezionati per l’analisi. 311 pazienti (26%) sono stati trattati
con placebo (SMILE 1 e 3), 605 (50%) con zofenopril 30-60 mg/die (tutti e quattro gli studi), 63 (5%)
con lisinopril 5-10 mg/die (SMILE 2) e 237 (20%) con ramipril 10 mg/die (SMILE 4), per un periodo
compreso tra 6 e 48 settimane. L’obiettivo dell’analisi è stato di valutare l’impatto di zofenopril e
degli altri ACEI rispetto al placebo sulla morbilità e sulla mortalità cardiovascolare (CV) ad un anno.
Risultati: il rischio di eventi CV era significativamente ridotto del 39% con zofenopril rispetto al
placebo [OR e IC 95%: 0.61 (0.43, 0.87); p=0.007]. Anche gli altri ACEI riducevano la morbilità e
mortalità CV, ma in maniera non statisticamente significativa [-33%; OR: 0.67 (0.41, 1.12); p=0.127].
Il trattamento con zofenopril si associava nei pazienti diabetici ad un rischio di eventi CV del 9%
inferiore rispetto al trattamento con gli altri ACEI [OR: 0.91 (0.61, 1.35)], con una differenza tra i
due gruppi tuttavia non statisticamente significativa (p=0.631).
Conclusioni: i risultati dell’analisi degli studi SMILE confermano gli effetti favorevoli del
trattamento con zofenopril in pazienti affetti da cardiopatia coronarica, anche in concomitanza con il
diabete. In questo sottogruppo di pazienti cardiopatici ad alto rischio CV, zofenopril comporta una
riduzione clinicamente significativa della morbilità e mortalità CV a lungo termine rispetto al placebo
e un trend favorevole, anche se non statisticamente significativo, rispetto agli altri ACEI.
O249
TRANSPLANTATION OF ADIPOSE TISSUE MESENCHYMAL CELLS CONJUGATED
WITH PLGA MICROSPHERES FOSTER C-KIT+ PROGENITOR CELLS AND
PROMOTES REVASCULARIZATION AND TISSUE REPAIR THROUGH PARACRINE
SIGNALING IN A MURINE MODEL OF ACUTE MYOCARDIAL INFARCTION
MARIA ANNA TEBERINO (A), ROSALINDA MADONNA (A), FRANCESCA
VERA RENNA (A), LYUBOMIR PETROV (B), JEAN-PIERRE KARAM (C),
CLAUDIA MONTERO-MENEI (C), SEPPO YLA-HERTUALA (B), RAFFAELE DE
CATERINA (A)
(A) INSTITUTE OF CARDIOLOGY, “G. D’ANNUNZIO” UNIVERSITY – CHIETI, ITALY; (B)
BIOCENTER KUOPIO, A. I. VIRTANEN INSTITUTE FOR MOLECULAR SCIENCES,
KUOPIO, FINLAND; (C) INSERM U 1066, LABORATOIRE D´INGÉNIERIE DE LA
VECTORISATION PARTICULAIRE, UNIVERSITÉ D´ANGERS, ANGERS, FRANCE
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Rationale: The engraftment and survival of transplanted stem cells may be improved by combining
such cells with scaffolds to delay apoptosis and enhance their regenerative properties.
Objectives: We examined whether poly (lactide-co-glycolide) (PLGA) microspheres (PAM)
functionalized with VEGF enhance survival of Adipose tissue-derived mesenchymal stromal cells
(AT-MSCs). We compared the therapeutic efficacy of transplanted AT-MSCs conjugated with
VEGF-PAM with injection of conditioned medium from AT-MSCs in a murine model of acute
myocardial infarction (AMI).
Methods: Twelve month-old male C57BL/6 mice underwent coronary artery ligation (Lig), followed
by randomization into 6 groups (n=5/group): I. Sham operation, II. AMI control (saline PBS 20 µL),
III. AMI followed by intramyocardial injection with AT-MSCs only (2.5x105 cells/20 µL), or IV.
concentrated medium from AT-MSCs (CM, 20 µL), or AT-MSCs (2.5x105 cells/20 µL) conjugated
with empty microspheres (V) or VEGF-PAM (VI).
Results: AT-MSCs conjugated with VEGF-PAM inhibited H2O2-induced apoptosis , decreased the
area of fibrosis (Figure A and C) and increased myogenesis, arteriogenesis (Figure B), number of
cardiac-resident c-Kit positive cells (Figure A and D, p<0.05 vs PBS+lig) and myocardial fractional
shortening (FS) when transplanted into the infarcted hearts of C57 mice (%FS: I. 40 11, II. 15 3**,
III. 29 7°, IV. 33 7°°, V. 20 1, VI. 34 7°°) (**p<0.01 vs sham; °p<0.05 and °°p<0.01 vs
Lig+PBS; anova test). All such effects, however, were fully paralleled by the injection of CM (p<0.01
vs PBS+lig).
Conclusions: AT-MSCs conjugated with VEGF-PAM exert a paracrine effect, that may have
therapeutic applications to enhance survival of AT-MSCs and regenerative capacity of the heart.
O250
EFFETTO DEL FUMO SULLA PRECOCITÀ DI INSORGENZA DI INFARTO
MIOCARDICO ACUTO CON ELEVAZIONE DEL TRATTO ST IN PAZIENTI
SOTTOPOSTI AD ANGIOPLASTICA PRIMARIA: DATI DI UNA CASISTICA DI 6 ANNI
CONSECUTIVI
RENATO ROSIELLO (B), ANTONIO IZZO (B), LUCA TOMASI (B),
NICOLA CICORELLA (B), PAOLA MANTOVANI (B), VALENTINA CHIARINI (B),
MARCO AROLDI (B), MICHELE ROMANO (B), CORRADO LETTIERI (B),
BEATRICE IZZO (B), ROBERTO ZANINI (B)
(A) AZIENDA OSPEDALIERA “C. POMA“ MANTOVA; (B) STRUTTURA COMPLESSA DI
CARDIOLOGIA
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Background: Il fumo è tra le principali cause di infarto in uomini e donne, si associa al 30% delle
morti causate da malattie coronariche e ad un aumentato rischio di morte improvvisa. I fumatori
corrono un rischio di ammalarsi che è più del doppio di quello dei non fumatori. Si stima che il 2025% degli incidenti cardiovascolari siano legati al consumo di sigarette.
Materiali e Metodi: Sono stati analizzati 973 pazienti consecutivi giunti alla nostra osservazione per
la comparsa di STEMI (infarto miocardico acuto con elevazione del tratto ST) nel periodo di
osservazione 2/2001 – 2/2007. Tutti i pazienti sono stati inseriti in un data-base per le analisi
successive. Le caratteristiche demografiche, i fattori di rischio e le comorbilità sono espresse in Tab.I
Risultati: La distribuzione tra pazienti fumatori/non fumatori in relazione al sesso è indicata in Tab.
II. La popolazione generale mostra una sensibile differenza di età tra i generi (p = 0,000) che resta
evidente anche nel confronto tra i non fumatori maschi e le non fumatrici (p = 0,000).Pertanto le
donne sviluppano STEMI in età più avanzata. La differenza di età tra fumatori e fumatrici risulta
invece non significativa (p =0,065) Tab.III
Conclusioni: Il fumo, nella nostra casistica annulla il vantaggio di genere delle femmine
relativamente all'età d'insorgenza dell'infarto miocardico acuto. Inoltre all'interno della popolazione
femminile il fumo risulta meno frequente che all'interno della popolazione maschile (p = 0,000)..
Tab I
Tab II
Tab III
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O251
ANTIPLATELET THERAPY AND RISK OF HAEMORRHAGIC EVENTS IN PATIENTS
UNDERGOING CORONARY ARTERY BYPASS: COMPARISON BETWEEN
INDOBUFEN AND ASPIRIN
MARIA GRAZIA DONATIELLO (A), SONIA SERGI (A), TANIA DOMINICI (A),
MARCO TOTARO (A), FRANCESCO MACRINA (A), GENNARO PETRIELLO (A),
GIUSEPPE PANNARALE (A), CONCETTA TORROMEO (A), VINCENZO PARAVATI (A),
FRANCESCO BARILLÀ (A)
(A) DIPARTIMENTO CUORE E GROSSI VASI “ATTILIO REALE“ , UNIVERSITÀ DEGLI
STUDI DI ROMA “LA SAPIENZA“
Background: Bleeding and ischemic complications in patients undergoing coronary artery bypass
graft (CABG) are strongly influenced by the management of antithrombotic therapy before and after
surgery. Pre-treatment with acetylsalicylic acid (ASA) in monotherapy or in association with an
P2Y12 inhibitor in patients previously undergoing percutaneous coronary intervention (PCI) improve
venous grafts patency and reduces ischemic complication. However this treatment is associated with
an increase of major bleeding and of blood products requirements, that increase the risk of death and
compromise the long-term benefits of CABG. Indobufene is a platelet cyclooxygenase-1 reversible
inhibitor with a half-life of 8 hours. For its pharmacodynamics characteristics, Indobufen can be
suspended 12 hours before surgery so that reduce the bleeding risk with beneficial antiplatelet effect.
Objectives: The purpose of this study is to evaluate the safety of Indobufen pre-treatment in patients
with coronary artery disease (CAD) revascularized with CABG.
Materials and Methods: 62 patients with CAD undergoing CABG were enrolled between January
2011 and March 2014. Patients were divided into two groups: group A of 34 patients treated with
ASA (100 mg daily) and group B of 28 patients treated with Indobufen (200 mg x 2 daily). Aspirin
was suspended 24 hours before surgery; Indobufen was discontinued 12 hours before. Primary
endpoint was rate of major bleeding post-CABG defined by the need for reoperation for bleeding,
chest tube output >1.5 L within a 24-h period, and transfusion of ≥4 U packed red blood cells
(PRBCs). Secondary endpoint was rate of ischemic complication ( IM and stroke) peri and postoperation.
Results: Our data shows that major bleeding was 26.4% in group A and 3.5% in group B (p=0.019).
In fact, 4 patients (11.74%) in the aspirin-treated group required reoperation for the purpose of
controlling bleeding, no one of the patients assigned Indobufen group required haemostatic surgical
control (p= 0,07 ). Request for postoperative packed red blood cells (PRBCs) was significantly
increased in Aspirin users than in patients treated with Indobufene (Group A 70.6%, Group B 32.1%,
p < 0.01 ). In addition, 20.6% of patients in group A were transfused with ≥4 U PRBCs against 3.5%
of patients treated with Indobufene. Chest tube output within a 24-hours period was similar (Group
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A : 671.6 ± 414 ml and Group B : 477.8 ± 275.3 ml ). Moreover, in 8,8% patients treated with
Aspirin, chest-tube blood loss 24 hours after operation was > 1,5 L. No one of the patients treated
with Indobufene presented chest output more than 1,5 L. No patients of both groups showed coronary
ischemic events in the follow-up post-CABG.
Conclusion: Present data suggest that pre-treatment of patients undergoing CABG with Indobufene
as effective as Aspirin in the prevention of ischemic coronary events in the follow-up postintervention, but significantly reduces postoperative bleedings complication.
MITRACLIP E TAVI
O252
ANAESTHESIOLOGICAL MANAGEMENT USING DEEP
SPONTANEOUS BREATHING DURING MITRACLIP REPAIR
SEDATION
AND
ERSILIA MAZZOTTA (A), GIUSEPPINA PASCUZZO (A), VALERIA CAMMALLERI (A),
SAVERIO MUSCOLI (A), DOROTEA RUBINO (A), FRANCESCA DEPERSIS (A),
EUGENIA MAIO (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), PASQUALE DE VICO (A), VALENTINA MESSINO (A),
GIULIA LICIANI (A), GIANPAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Background: As general anaesthesia can be associated with potential hemodynamic and respiratory
complications, we have developed an approach where MitraClip procedures are performed under
deep sedation and spontaneous breathing.
Aim: We evaluated the difference between deep sedation and general anesthesia in patients who
underwent MitraClip procedure in our institute.
Methods: The study population includes 60 consecutive patients treated with MitraClip for mitral
regurgitation (MR) ≥3+. Twenty-four patients received general anaesthesia and orotracheal
intubation (GA group); 36 patients underwent deep sedation management, consisting of
administration of midazolam and fentanyl citrate as anaesthesia inductors, followed by continuous
infusion of remifentanil hydrochloride (DS group).
Results: No statistical differences in demographic data and surgical risk profile were observed. Most
of patients were in NYHA functional class III/IV with secondary MR. GA patients had a more
compromising of left ventricular function compared to DS group, especially in case of secondary MR
(mean left ventricle ejection fraction 27±7 vs 32±7; p=0.008). Anaesthesia and procedural time were
significantly shorter in DS group (p<0.0001 for both); similarly device time was shorter in DS patients
(p=0.03). No differences in the number of clips implanted were present. All procedures were carried
out successfully resulting in final MR <2+, without major intraprocedural complications. In-hospital
and 30-days outcomes were similar in both groups. At 30-day a persistent MR reduction and
improvement in NYHA functional class were observed uniformly.
Conclusions: MitraClip repair under deep sedation with spontaneous breathing may be a viable
alternative, with particular advantages in patients at high risk for general anaesthesia, with ideal mitral
valve anatomy and in heart failure setting.
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O253
MITRACLIP IMPLANTATION IN PATIENTS WITH END-STAGE SYSTOLIC HEART
FAILURE
FRANCESCA FIORELLI (A), CRISTINA GIANNINI (A), MARCO DE CARLO (A), ANNA
SONIA PETRONIO (A), CORRADO TAMBURINO (B), FEDERICA ETTORI (C),
FRANCESCO BEDOGNI (D)
(A) CARDIAC CATHETERIZATION LABORATORY, CARDIOTHORACIC DEPARTMENT,
AZIENDA OSPEDALIERO-UNIVERSITARIA PISANA, PISA, ITALY; (B) DIVISION OF
CARDIOLOGY, FERRAROTTO HOSPITAL, UNIVERSITY OF CATANIA, CATANIA,
ITALY; (C) CARDIAC CATHETERIZATION LABORATORY, CARDIOTHORACIC
DEPARTMENT, SPEDALI CIVILI, BRESCIA, ITALY; (D) ISTITUTO CLINICO
SANT´AMBROGIO, MILANO, ITALY.
Purpose: The aim of the present study was to investigate the predictors of mortality of percutaneous
mitral valve repair (PMVR) using the MitraClip System in patients affected by severe MR (mitral
regurgitation) with end-stage heart failure and severely reduced left ventricular ejection fraction (LVEF).
Methods: Between October 2008 and October 2013, 304 consecutive patients undergoing PMVR at
4 Italian centers were prospectively enrolled in a registry. To the purpose of our study, we analyzed
the 88 patients with functional MR and LV-EF<30% who reached 1 year follow-up. Results: Mean
age was 70±10 years, 71.6% were male, with a mean EuroSCORE II of 9.8±4.5%. Patients with MR
grade ≥3+ were 5.7% and 11.4% at discharge and 1 year, respectively, versus 100% at baseline
(p<0.0001), with a marked clinical benefit (NYHA class ≥3 at 1 year 9.0%, vs. 86.3% at baseline;
p<0.0001). One year all-cause mortality was 21.6%. Baseline factors associated with 1 year mortality
at univariate analysis were lower haemoglobin values (12.2±1.6 vs 11.4±1.6 g/dl; p=0.04), higher
creatinine values (1.35±0.95 vs 1.67±0.67 mg/dl; p=0.01), lower glomerular filtration rate values
(65.1±29.2 vs 54.3±33.1 ml/min/1.73m2; p=0.03), presence of chronic renal failure (8.9 vs 36.6%;
p=0.002), higher EuroSCORE II and STS score values (8.0±6.3 vs 12.9±10.2%; p=0.02 and 6.2±5.8
vs 9.9±8.4%; p=0.05; respectively), lack of implantable cardiac defibrillator with resichronization
therapy (ICD-CRT) (27.6 vs 10%; p=0.05) and NYHA class 4 (41.2 vs 16.9%; p=0.03). At Cox
proportional hazards analysis, chronic renal failure (p=0.029; OR 4.0; 95%CI 1.2-14.2), lack of CRTICD (p=0.021; OR 0.22; 95%CI 0.06-0.80), and NYHA class 4 (p=0.047; OR 9.3; 95%CI 1.03-83.4)
were independent predictors of 1 year mortality. Lower haemoglobin values almost reached statistical
significance (p=0.06; OR 0.72; 95%CI 0.51-1.01).
Conclusion: MitraClip procedure reduces functional MR and improves NYHA class even in endstage heart failure patients. However, among these critically ill patients, the 1-year mortality is still
prohibitive in case of renal failure, NYHA class IV, or anaemia, while the presence of ICD-CRT
appears protective.
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O254
IS GLOBAL LONGITUDINAL STRAIN AN INDEPENDENT PREDICTOR OF REVERSE
LEFT VENTRICULAR REMODELING AFTER MITRACLIP IMPLANTATION?
CESARE BALDI (a), RODOLFO CITRO (a), MARCO DI MAIO (a), ANGELO SILVERIO (a),
ELISABETTA MARIA BELLINO (a), GENEROSO MASTROGIOVANNI (a),
MASSIMO SIMEONE (a), MICHELE ROBERTO DI MURO (a), GIUSEPPE GIGANTINO (a),
EDUARDO BOSSONE (b), PIETRO GIUDICE (a), GIUSEPPE DI BENEDETTO (a),
FEDERICO PISCIONE (a)
(a) UNIVERSITY HOSPITAL SAN GIOVANNI DI DIO E RUGGI D´ARAGONA,
DEPARTMENT OF CARDIOLOGY, SALERNO, ITALY; (b) CAVA DE´TIRRENI-AMALFI
COAST HOSPITAL, DIVISION OF CARDIOLOGY, CAVA DE´ TIRRENI, SALERNO, ITALY
BACKGROUND: Reverse left ventricular (LV) remodeling, along with a more favorable
outcome, have been recently reported in high-risk surgical patients with moderate to severe mitral
regurgitation (MR), who underwent percutaneous mitral valve repair with the MitraClip® system
(Abbott Vascular, Redwood City, CA, USA). The aim of this study is to assess the determinant of
reverse LV remodeling after MitraClip Implantation (MCI).
METHODS: A total of 33 consecutive patients (21 male, mean age: 73.51 ± 9.88; ) with severe
mitral regurgitation (MR; functional and degenerative in 27 and 6 patients, respectively), severe LV
systolic dysfunction and advanced NYHA class, treated with MCI, were included in the study. MR
grade, left ventricular end diastolic (EDV) and systolic (ESV) volumes, ejection fraction (EF) and
systolic pulmonary artery pressure (SPAP), before implantation and at short term follow-up, were
evaluated by transthoracic echocardiography. Furthermore, Global Longitudinal Strain (GLS) at
baseline was evaluated. A reduction of ESV > 10% after MCI was considered as index of reverse left
ventricular remodeling.
RESULTS: In the overall population, at short term follow up, a significant reduction of MR (from
3.8 ± 0.3 to 2 ± 0.8 ; p < 0.001) was obtained. A contemporary reduction of EDV (from 164 ± 73.3
to 150,6 ± 67 ml p < ; 0.001) and ESV (from 108,9 ± 55.7 to 95.5 ± 51.6 ml; p < 0.001), with an
increase of LVEF (from 34,6 ± 5.1 to 38.4 ± 7.8%; p < 0.001) were detected. Furthermore, NYHA
class reduced from 3 ± 0.43 to 2.18 ± 0.68. Patients with (n = 20) and without (n = 13) reverse LV
remodeling were compared. A reverse remodeling was more frequent in patients with functional
compared with degenerative MR (75 vs 15 %, respectively) and was associated with reduced NYHA
class (1,85 ± 0,48 vs 2.69 ± 0,63; p = 0,000), lower MR grade (1,65 ± 0,74 vs 2,54 ± 0,77; p = 0,002),
higher EF (41,74 ± 7,78 vs 32,98 ± 3,86; p = 0,000) and lower pre implantation GLS (11,74 ± 3,43
vs 7,12 ± 1,93; p = 0,001). At multivariate regression analysis, only GLS was an independent
predictor of reverse remodeling (p = 0.044; HR 4.055, CI 1.022-4.957).
CONCLUSIONS: Despite a preexisting LV dysfunction, GLS is an independent predictor of
significant reverse LV remodeling which occurs early in the majority of patients after MCI
particularly in those with functional MR.
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O255
IMPACT OF MITRAL REGURGITATION ON SURVIVAL AFTER TRANSCATHETER
AORTIC VALVE IMPLANTATION
ELISA COVOLO (A), MICHELA FACCHIN (A), PAOLA ANGELA MARIA PURITA (A),
ERMELA YZERAJ (A), BLERI CELMETA (A), GIANPIERO D´AMICO (A),
ALBERTO BARIOLI (A), MARCO MOJOLI (A), CLAUDIA ZANETTI (A),
TOMMASO FABRIS (A), GILBERTO DARIOL (A), AHMED AL MAMARY (A),
GIULIA MASIERO (A), VALERIA GASPARETTO (A), MARTA MARTIN (A),
CHIARA FRACCARO (A), MASSIMO NAPODANO (A), AUGUSTO D´ONOFRIO (A),
ROBERTO BIANCO (A), DEMETRIO PITTARELLO (B), GIAMBATTISTA ISABELLA (A),
SABINO ILICETO (A), GINO GEROSA (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA; (B) ANESTHESIOLOGY DEPARTMENT, UNIVERSITY OF PADUA
Backgrounds. Transcatheter aortic valve implantation (TAVI) has recently been consolidated as an
alternative for patients at high or prohibitive surgical risk. However, concomitant significant mitral
regurgitation (MR) in this setting is frequent. Some studies have identified the presence of
concomitant moderate-to-severe MR as a predictor of early and late mortality after TAVI,
nevertheless impact of MR on late survival remains challenging. The aim of our study was to evaluate
the presence of MR as a prognostic marker after TAVI.
Methods. Monocentric study enrolling 333 consecutive patients treated by TAVI between Jun 2007
and December 2013. Baseline echocardiographic severity of MR was classified in 4 grades (0 none
or trivial, 1 mild, 2 moderate, 3 relevant, 4 severe). Kaplan-Meier survival analysis evaluated impact
of MR on survival after TAVI. Mean follow-up duration was of 23 ± 18 months.
Results. Study population presented mean age of 80 ± 6, 176 patients were females (53%), mean
logistic Euroscore was of 20.4 ± 12.2. Eighty-eight patients were treated by CoreValve (26%), 245
patients (74%) were treated by Edwards TAVI. Among study population, baseline MR was defined
absent or trivial in 61 patients (18%), mild in 192 patients (58%), moderate in 70 patients (21%),
relevant in 10 patients (3%). None patient presented severe MR. Baseline moderate or relevant MR
(2-3+/4) was a predictor of 30-days mortality (p =0.048, OR 2.88, 95%CI 1.01-8.23). TAVI patients
with moderate or relevant MR (2-3+/4) had similar late mortality compared to patients with mild or
less MR (0-1+/4) (Log Rank p=0.27, see Figure A). However, specific degrees of baseline MR
severity presented different survival curves (Log Rank p=0.015, see Figure B). In fact, relevant MR
(3+/4) was associated to increase in overall mortality at long-term follow-up (p<0.001, OR 4.75,
95%CI 2.18-10.36).
Conclusions: Baseline moderate or relevant MR was associated to an increase in early mortality; late
mortality after TAVI was related to relevant MR.
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O256
THE NEOCHORD PROCEDURE FOR SEVERE
REGURGITATION: SAFETY AND EFFICACY
DEGENERATIVE
MITRAL
ANDREA COLLI (A), ERICA MANZAN (A), FABIO ZUCCHETTA (A),
DEMETRIO PITTARELLO (A), CRISTIANO SARAIS (A), GINO GEROSA (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA
Introduction: Transapical off-pump mitral valve repair using the Neochord device has evolved as a
new tool in the treatment of degenerative mitral valve regurgitation (MR).
Hypothesis: This prospective study sought to assess the safety and effectiveness of the Neochord
procedure in patients with significant MR.
Methods: symptomatic patients with 3-4+ MR were selected if presented a favorable anatomy
(presence of flail/prolapse with consistent overlap of tissue of one or both mitral leaflets).
Acute device success was defined as residual MR ≤2+ after procedure. The primary safety and
efficacy end-point were evaluated at 30 days.
Results: A total of 32 patients were treated, median age 73 years (range 31-90), median Euroscore-I
6% (range 0.9-38.9), Euroscore II 1.9% (range 0.5-24.9) and STS score 1.7% (range 0.2-14.6).
Twenty-eight patients (87.5%) presented a posterior leaflet disease, 3 (9.3%) an anterior leaflet
disease and 1 (3.1%) a combined disease. Acute procedure success was achieved in all patients. Three
neochords were implanted in 10 patients (31.2%), 4 in 14 (43.7%), 5 in 6 (18.7%), 6 in 1 (3.1%). No
death, stroke, AMI, bleeding events occurred within 30-days. MR at 30-days was absent in 16 patients
(50%), grade 1+ in 11 patients (34.3%), grade 2+ in 5 patients (15.6%).
Two patients presented a recurrence of MR>2+ after 30 days due to leaflet rupture and successfully
underwent reintervention with conventional surgery.
Conclusions: Our initial results with the Neochord procedure in a small number of patients indicate
that transapical off-pump mitral valve repair is feasible and may be accomplished with favourable
short-term safety, efficacy results and clinical benefit.
O257
PATIENT PROSTHESIS MISMATCH INDUCES INCREASE IN LEFT VENTRICULAR
FILLING PRESSURE TWO MONTHS AFTER TRANSCATHETER AORTIC VALVE
IMPLANTATION
CIRO SANTORO (B), MAURIZIO GALDERISI (B), MARCO FABIO COSTANTINO (C),
GIANDOMENICO TARSIA (C), PASQUALE INNELLI (C), ERNESTA DORES (C),
ANTONELLA MATERA (C), GIOVANNI ESPOSITO (A), GIOVANNI DE SIMONE (B),
BRUNO TRIMARCO (A)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO
II, NAPOLI; (B) CENTRO INTERDIPARTIMENTALE PER LA RICERCA
SULL´IPERTENSIONE ARTERIOSA E PATOLOGIE ASSOCIATE, UNIVERSITA´
FEDERICO II, NAPOLI; (C) DIVISIONE DI CARDIOLOGIA, AO SAN CARLO, POTENZA
Purpose: Transcatheter aortic valve implantation (TAVI), the treatment of choice in high-risk
patients with severe, symptomatic aortic stenosis, can be complicated by “patient prosthesis
mismatch” (PPM) more frequently than expected after conventional aortic valve replacement.
However, the hemodynamic profile of PPM in TAVI patients has not been investigated. Accordingly,
we evaluated echo-Doppler features of patients with or without PPM, 2 months after TAVI.
Methods: One-hundred-one patients (M/F = 52/49, age = 80.4± 5.2 years) underwent standard echoDoppler exam 2 months after TAVI. Doppler indices of left ventricular (LV) filling were measured
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and the ratio of transmitral E velocity to early diastolic velocity (e’) of the mitral annulus was
calculated as an estimate of LV filling pressure (LVFP). Left atrial volume index (LAVi) was
determined as a marker of left atrial hemodynamic load. Post-TAVI effective orifice area index
(EOAi) was calculated according to standardized procedures. Valvulo-arterial impedance (Zva,
mmHg /mL× m-2) was estimated by the formula: (mean pressure gradient + systolic blood pressure)
/ stroke volume index. Based on established EOAi values, patients were divided in 2 groups: 69
without PPM (EOAi ≥ 0.85 cm2/m2) and 32 with PPM (EOAi< 0.85cm2/m2).
Results: The two groups were comparable for age, body mass index, blood pressure and heart rate.
There was no between-group difference in relative diastolic wall thickness, LV mass index and
ejection fraction. Also transmitral E/A ratio and E velocity deceleration time were similar between
the two groups, but e’ velocity was lower in PPM group (9.6 ± 2.4 cm/s) than in patients without PPM
(11.1 ± 1.5 cm/s) (p<0.0001). Thus, E/e’ ratio was higher in PPM patients (10.7 ± 2.4 versus 9.2 ±
1.4, p<0.0001), without significant difference of left atrial volume index (33.5 ± 4.9 vs. 33.9 ± 6.0
ml/m2). In the pooled population sample, low EOAi was significantly associated with high E/e’ ratio
(r = -0.29, p=0.003). This association remained significant (standardized β coefficient = -0.25), even
after adjusting for age, heart rate, LV mass index and Zva (cumulative R2 = 0.15, p<0.01) by a
multiple linear regression analysis.
Conclusions: Patient prosthesis mismatch exhibits significant hemodynamic impact as early as 2
months after TAVI. PPM is associated with increased LVFP, that appears to be independently
associated with the low EOAi. In relation with the recognized prognostic value of LVFP, these
findings could have important reflections on the outcome after TAVI implantation.
O258
IMPACT OF FUNCTIONAL MITRAL REGURGITATION ON THE QUALITY OF LIFE
OF PATIENTS WITH SYSTOLIC CHRONIC HEART FAILURE
DANIELA CLEMENTE (A), MICHELE DI MAURO (A), ALBERTO MARRANGONI (A),
BIANCA IADANZA LANZARO (A), GABRIELE D´AMBROSIO (A), RENATA PETRONI (A),
ALFREDO CARDINALI (A), SILVIO ROMANO (A), MARIA PENCO (A)
(A) DEPARTMENT OF CARDIOVASCULAR DISEASE, UNIVERSITY OF L’AQUILA,
L’AQUILA, ITALY
Purpose. Functional mitral regurgitation (FMR) impairs significantly either survival or transplantfree survival of patients with systolic chronic heart failure (CHF). However, whether FMR can affect
the quality of life (QoL) of this subset patients was little investigated. Hence, the purpose of this
retrospective study was to evaluate this particular cause-effect relationship.
Methods. From 2005 to 2012, 507 patients with left ventricular ejection fraction (LVEF) lower than
50% were discharged from a peripheral hospital with the diagnosis of CHF; 148 were initially
excluded because of: significant aortic valvulopathy, mitral stenosis, organic mitral regurgitation,
congenital mitral regurgitation, mitral or aortic prosthesis, acute coronary syndrome, missing data.
Then 84 out of 359 remaining patients died during follow up and were excluded from the final
analysis. Thus, 273 patients were finally enrolled in the study. The QoL was assessed by means of
Minnesota Living With Heart Failure Questionnaire (MLHFQ) with following cutoffs of score: <24
(good), 24-45 (moderately-impaired), >45 (severely-impaired). Mitral regurgitation was graded as
mild, moderate and severe. The entire population was divided in two groups: no-mild MR (Group A,
164) versus moderate-severe MR (Group B, 109).
Results. MLHFQ score was significantly higher in group B (49±29 vs 29±20, p <0.001); rates of
good, moderately-impaired and impaired QoL were 53%, 27% and 20% in Group A and 28%, 13%
and 59% in group B, respectively. Four-year possibility to be either in good QoL (48±5 vs 40±5,
p=0.035) or good/moderately-impaired QoL (81±4 vs 47±6, p<0.001) were significantly higher in
Group A; A propensity score was built (AUC 0.87) and forced into the multivariate analysis to adjust
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the results for differences between groups. The proportional-Cox analysis confirmed that moderate
or more FMR impair significantly the QoL either moderately (HR=2.0, 95CL=1.3-3.3) or severely
(HR=4.6, 95CL=2.4-8.8).
Conclusions. The presence of functional mitral regurgitation impairs significantly the QoL of patients
with systolic CHF.
O259
IMPACT OF DYNAMIC MITRAL REGURGITATION ON FUNCTIONAL CAPACITY IN
HEART FAILURE PATIENTS
FRANCESCO BANDERA (A), GRETA GENERATI (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
BACKGROUND: In heart failure reduced ejection fraction (HFrEF) patients the severity of mitral
regurgitation (MR) at rest has a well-established prognostic value. MR increase during exercise
further adds to an increased risk. MR plays a central role in determining pulmonary flow overload
and pulmonary hypertension (PH), which is associated with poor prognosis.
AIM: Our aim was to define the relationship between dynamic MR, echocardiographic phenotypes
and functional capacity in a cohort of HFrEF patients. METHODS: 102 HFrEF patients (age 65±11;
male 71%; ischemic etiology 60%; EF 33±9%; NYHA class I, II, III and IV 21, 34, 36, 9%)
underwent cardiopulmonary exercise test (CPET) on tiltable cycle-ergometer (standard incremental
ramp protocol) combined with exercise-echocardiography. The population was studied according to
the degree of functional MR and data were analyzed looking at CPET- and echo-derived phenotypes.
RESULTS: Study population was divided into three groups according to the degree of functional
MR: rest and peak exercise ERO<20 mm2 (Group A); rest ERO<20 mm2 and peak ERO≥20 mm2
(dynamic MR, Group B); rest ERO≥20 mm2 (Group C). The latter group had higher resting and peak
exercise pulmonary pressure (PAP), an impaired RV systolic function and ventilatory efficiency.
Group B patients exhibited a worse exercise response (lower peak VO2 and workload), more
advanced cardiac remodeling and higher pulmonary artery systolic pressure (SPAP) compared to
Group A, despite similar LVEF.
CONCLUSIONS: Dynamic MR is an intermediate condition of the functional MR in HFrEF
patients. Exercise-induced MR is associated with a worse CPET phenotype, more unfavorable cardiac
chambers remodeling, severe diastolic dysfunction, dynamic PH and RV dysfunction . A combined
approach with CPET and echocardiographic assessment can help to early unmask and treat functional
dynamic MR and its unfavorable phenotypes.
Rest LV end diastolic
volume indexed, ml/m2
Rest LVEF, %
Peak LVEF, %
Rest E/e’
Rest TAPSE, mm
Peak TAPSE, mm
Rest systolic PAP, mmHg
Peak systolic PAP, mmHg
Workload
A
(n=60)
84±24
B
(n=17)
107±34
C
(n=25)
115±30
P (A vs
B)
0.008
P (A vs
C)
0.000
P (B vs
C)
ns
35±10
37±12
20±12
18±4
21±5
33±14
54±19
70±24
31±8
34±8
25±11
19±4
21±3
35±5
63±16
56±21
32±9
35±9
36±12
15±4
15±5
51±17
68±14
50±17
ns
ns
0.037
ns
ns
0.049
0.015
0.0049
ns
ns
0.000
0.000
0.000
0.000
0.000
0.000
ns
ns
0.008
0.001
0.001
0.002
ns
ns
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Peak VO2, ml O2*Kg1
*min-1
VE/VCO2, slope
Roma, 13 – 15 dicembre 2014
13.7±3.6
11.8±3.2 11.5±3.0
32.4±8.2
31.6±7.7
41.2±11
0.084
0.011
ns
ns
0.000
0.002
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 5
O260
PROLONGED QT-SEGMENT IS ASSOCIATED WITH VENTRICULAR FIBRILLATION
AND EXTRACELLULAR SIGNAL-REGULATED KINASE 1/2 ACTIVATION IN
LYMPHOCYTES FROM PATIENTS WITH CARDIAC RESYNCHRONIZATION
THERAPY
ANGELA BOCHICCHIO (A), ANTONIO CURCIO (A), CLAUDIA VENEZIANO (A),
MILENA SACCOMANNO (B), GIUSEPPE SANTARPIA (A), GIANMARCO ARABIA (A),
VALTER AGOSTI (B), GIOVANNI CUDA (B), DANIELE TORELLA (A), CIRO INDOLFI (A)
(A) DIVISION OF CARDIOLOGY, LABORATORY OF MOLECULAR AND CELLULAR
CARDIOLOGY, DEPARTMENT OF MEDICAL AND SURGICAL SCIENCES, UNIVERSITY
OF MAGNA GRAECIA, CATANZARO, ITALY; (B) DEPARTMENT OF EXPERIMENTAL
AND CLINICAL MEDICINE, UNIVERSITY OF MAGNA GRAECIA, CATANZARO, ITALY
BACKGROUND: The combined effect of pharmacologic medications and cardiac
resynchronization therapy (CRT) in preventing ventricular tachyarrhythmias (VT) has not been fully
elucidated yet. Left ventricular dysfunction due to coronary artery disease or to idiopathic dilative
cardiomyopathy is associated with increased dispersion of repolarization and sudden cardiac death.
AIMS: We therefore wanted to address three specific aims: i) to assess whether changings in the
electrocardiogram could be directly associated with VT; ii) to evaluate the prognostic value of
repolarization determinants from the 12-lead ECG in patients affected by heart failure and treated
with CRT; iii) to investigate the usefulness of new biomarkers, such as stress-activated kinases in
lymphocytes for predicting response to therapy.
METHODS: A case-control study with 1:2 matching was realized enrolling twenty patients (age
64±11 years, 13 males) who underwent baseline noradrenaline levels evaluation and CRT
implantation, then followed for 11±9 months. In outpatient clinics, subjects were checked for medical
device functioning; for ECG assessment with and without biventricular pacing; for blood samples
withdrawal to extract lymphocytes and to measure noradrenaline concentration upon written
informed consent. All of them fulfilled current guidelines for CRT indication; exclusion criteria were:
use of noncardiac drugs associated with QT prolongation; predisposition to life-threatening VT;
pacemaker-dependent clinical status. According to major arrhythmic events at follow-up, patients
were divided in cases (N=6) and controls (n=14).
RESULTS: No significant differences in durations of paced QRS segments were observed (116±18
vs. 101±16ms), nor in QTc (469±32 vs. 452±35ms), whereas percentage of biventricular pacing was
96% in cases vs. 99% in controls (p<0.05). However, ΔQTc from CRT-off ECGs was significantly
higher in VF group compared to controls (five-fold increase, p<0.05), and this finding was reinforced
by augmented circulating noradrenaline levels in the cases. Finally, phosphoERK1/2 levels were
investigated in lymphocytes in basal conditions and after isoproterenol (10μM) and isoproterenol plus
Nadolol (20μM) stimulation, demonstrating robust phosphoERK1/2 up-regulation in arrhythmic
patients, and restoration after β-blocker administration.
CONCLUSIONS: We demonstrated for the first time that patients suffering major arrhythmic
events present with repolarization abnormalities and increased ERK1/2 activation; the dynamic
changes in the QT segment correlate with lymphocytes acute response. Our findings strengthen the
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importance of ECG assessment and medical therapy optimization in CRT patients follow-up.
Further studies are required to establish the usefulness of temporarily switching off the CRT device
in heart failure patients.
O261
DOWNGRADE FROM CRT-D TO CRT-P AT THE MOMENT OF DEVICE
REPLACEMENT IN PATIENTS WITH NO PREVIOUS ANTIARRHYTHMIC
INTERVENTION DELIVERED: IS IT POSSIBLE?
MARTINA NESTI (A), GIUSEPPE RICCIARDI (A), PAOLO PIERAGNOLI (A),
ALESSANDRO PAOLETTI PERINI (A), PAOLA ATTANÀ (A),
ANTONIO MICHELUCCI (A), LUIGI PADELETTI (A)
(A) UNIVERSITÀ DEGLI STUDI DI FIRENZE
Aims: Cardiac resynchronization therapy (CRT) reduces mortality and hospitalizations; it is debated
whether CRT alone (CRT-P) or CRT plus defibrillator (CRT-D) is preferable, and still guidelines are
not exhaustive. The aim of the study was to investigate whether to implant CRT-P or CRT-D in CRTD patients who did not experience malignant arrhythmias at time of battery depletion.
Methods: Out of 451 heart failure patients undergoing CRT-D according to guidelines, 103 (67±10
years, 80% men) underwent device replacement with CRT-D. Every 6 months clinical evaluation,
echocardiography and device interrogation were performed and episodes of ventricular arrhythmias
(VA) stored. Patients were defined responders if, at 6-month evaluation, left ventricular (LV)
endsystolic volume decreased ≥15% and super-responders if LV ejection fraction increased ≥40% or
≥50%.
Results: Mean follow-up was 63±23 months after implantation and 18±12 months after replacement.
First VAs incidence per year did not decrease over time (p=0.619). Before replacement, 27 patients
(26.2%, 15 responders/12 non-responders) experienced VA. After replacement, 8 patients (7.7%, 4
responders/4 non-responders) experienced VA for the first time. Super-responder condition was not
associated with lower VA incidence before (=0.499) and after (p=0.339) replacement. At multivariate
analysis, age was the only independent predictor of electrical appropriate therapy after substitution
(ORper year =1.17; CI 95%= 1.03-1.34; p=0.003).
Conclusions: Freedom from VA before device replacement does not correlate with freedom from
VA after replacement, so downgrade from CRT-D to CRT-P is not feasible at the time of battery
depletion, in particular in the elderlies, independently of responder and super-responder condition.
O262
LUCIA PRATI (A), FRANCESCO FEDELE (A), VALERIO PECCHIOLI (B),
GIUSEPPE GERMANO´ (A)
(A) UNIVERSITA´ LA SAPIENZA DI ROMA POLICLINICO UMBERTO I; (B) SSD
PREVENZIONE CARDIOVASCOLARE OSPEDALE F SPAZIANI ASL FROSINONE
Background: La fibrillazione atriale (FA), la più comune aritmia sopraventricolare nei soggetti
affetti da ipertensione arteriosa sistemica. Il rischio cardioembolico nonché il rischio di morbidità e
mortalità cardiovascolare di tale aritmia è noto ed è tanto maggiore quanto più l’aritmia si verifica in
maniera asintomatica ritardando il contatto con il medico e l’inizio di una accurata terapia. Le LG
Europee sulla gestione della FA raccomandano di eseguire, dai 65 anni in poi, lo (SO), attenta
palpazione del polso radiale, solo in caso di riscontro di polso aritmico l’esecuzione di un ECG. La
sensibilità della rilevazione palpatoria del polso radiale per la diagnosi di FA è del 90% con una
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
specificità tra 85% e 90%. Un ausilio alla rilevazione opportunistica della FA può venire dagli
apparecchi per l’automisurazione domiciliare della pressione arteriosa ( HBPM).
Obiettivo del nostro studio: valutare sensibilità e specificità nel rilevare la presenza di fibrillazione
atriale attraverso l’utilizzo di un nuovo misuratore di pressione oscillometrico automatico, che
possiede un algoritmo specifico per il rilievo della stabilità emodinamica ( HSD) analizzando
l’andamento del periodo delle onde di polso allo sgonfiaggio del manicotto.
Materiali e Metodi: Abbiamo arruolato da settembre 2013 fino ad ora un totale 76 pazienti ipertesi
afferenti al nostro centro (37 maschi, 39 femmine). Di questi 45 risultavano affetti da fibrillazione
atriale e 31 erano in ritmo sinusale stabile.
I pazienti arruolati sono stati sottoposti a misurazione clinica della pressione arteriosa sistemica con
apparecchio Help Check mediante tre misurazioni consecutive come da linee guida per la misurazione
della pressione arteriosa ESC/ESH e contemporaneamente a ecg di superficie a 12 derivazioni
continuo per il riscontro del ritmo del paziente. Veniva considerato significativo per la possibile
presenza di fibrillazione atriale la comparsa dell’indicatore di instabilità emodinamica sul display del
device durante ciascuna delle tre misurazioni cliniche di PA.
Risultati: L’apparecchio utilizzato ha mostrato, nel rilevare la presenza di fibrillazione atriale, una
sensibilità pari al 100% in tutte e tre le misurazioni consecutive cliniche, una specificità media fra le
tre misurazioni pari al 85% con una accuratezza del 94%.
In conclusione si può asserire che nella popolazione degli ipertesi l’uso dell’HELP CHECK aumenta
la sensibilità della rilevazione precoce della FA rispetto al solo screening opportunistico.
L’arruolamento sta proseguendo.
O263
INCREASED DURATION AND REDUCED SLOPE OF THE J WAVE AS POSSIBLE NEW
ECG TOOLS ABLE TO DISTINGUISH BETWEEN MALIGNANT AND BENIGN ER.
LUIGI BIASCO (A), YVONNE CRISTOFORETTI (A), DAVIDE CASTAGNO (A),
CARLA GIUSTETTO (A), GIANPASQUALE GANZIT (B), PIERO ASTEGIANO (B), CARLO
GABRIELE GRIBAUDO (B), FIORENZO GAITA (A)
(A) DIPARTIMENTO DI SCIENZE MEDICHE, DIVISIONE DI CARDIOLOGIA,
UNIVERSITA DEGLI STUDI DI TORINO; (B) INSTITUTE OF SPORTS MEDICINE, TURIN,
ITALY
Background: ECG features capable to distinguish between malignant and benign forms of early
repolarization are needed. Until now the entity of J point elevation, its localization, the morphology
of the J wave, transient spontaneous or extrasystolic related augmentation of the J wave, and the
presence of short coupled ventricular extrasystolic beats have been postulated as possible
electrocardiographic markers of increased arrhythmic risk in the contest of ER. Data about the role
of slope and duration of J waves as possible discriminating ECG characteristics are still missing.
Aim: To compare slope and duration of the J waves between patients with early repolarization (ER)
syndrome and athletes with ECG evidence of J point elevation associated with J wave.
Methods: We selected from the available literature the ECGs of 26 patients with ER syndrome.
Twenty four control athletes with evidence of J point elevation >2 mm and J wave either with a
notched or a slurred appearance, whatever the morphology of the ST segment (horizontal/descending
or ascending), were selected by our population of 333 healthy professional football players followed
up for a median of 13.3 years. All ECG were digitally acquired; the angle between the descending
limb of the J wave and an orthogonal line to the isoelectric was measured at a 400% magnification
with an electronic caliper. The duration for the J wave was classified as <40 ms, >40 ms but < 80 ms
and >80 ms by two independent reviewers blinded to subjects’ characteristics.
Results: The mean slope of the J waves resulted to be 33,0°±9,33° (95% C.I.: 29,7°-36,3°) in cases
and 22,0°±6,8° (95% C.I: 17,3-24,7) in athletes, p<0,001. A slope greater than 30° was common
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among cases (77%) but not among controls (8%). A significant difference was also observed among
duration of the J wave duration between cases and athletes. J waves were < 40 ms in 1/26 cases and
in 16/24 athletes, >40 ms but < 80 ms in 19/26 cases and in 8/24 athletes and > 80 ms in 5/26 cases.
Athletes never showed a J wave duration > 80 ms (p>0,001).
Conclusion: An increased duration of the J wave as well as a reduced slope of the J wave could be
new tools able to distinguish between malignant and benign ER.
HIGHLIGHTS GIOVANI RICERCATORI LAVORI INEDITI - 6
O264
ROLE OF ACUTE HEMODYNAMIC IMPROVEMENT ON FUNCTIONAL MITRAL
REGURGITATION REDUCTION AFTER CARDIAC RESYNCHRONIZATION
THERAPY IN IDIOPATHIC DILATED CARDIOMYOPATHY.
DAVIDE STOLFO (A), ELISABETTA TONET (A), GIULIA BARBATI (A),
MARTA GIGLI (A), MASSIMO ZECCHIN (A), BRUNO PINAMONTI (A),
FEDERICA RAMANI (A), MARCO MERLO (A), GIANFRANCO SINAGRA (A)
(A) CARDIOVASCULAR DEPARTMENT, “OSPEDALI RIUNITI” AND UNIVERSITY OF
TRIESTE, TRIESTE, ITALY
Background. Functional mitral regurgitation (FMR) is associated with reduced survival in idiopathic
dilated cardiomyopathy (IDCM). It is known that cardiac resynchronization therapy (CRT) can
improve FMR. We sought to identify predictors of FMR improvement after CRT, then evaluating its
impact on long-term outcome.
Methods. This was a retrospective case-control study. A total of 44 patients with IDCM and moderate
to severe FMR undergoing CRT have been matched with 30 patients not treated with CRT (control
group) despite conventional indications (left bundle-branch block and left ventricular ejection
fraction<35%). Improvement in FMR (grade 0-1) was evaluated after 6-12 months and we further
divided CRT group according to FMR evolution.
Results. No differences were observed between CRT and control groups except for aldosteroneantagonists administration (57 Vs 21%, respectively; p=0.002). At short-term 48% of CRT patients
Vs 13% of controls improved FMR (p=0.002). CRT was the only independent predictor of FMR
decrease (OR 0.191, 95%CI 0.054-0.684, p=0.011). Limited to CRT group, no pre-implantation
variables predicted FMR evolution. However FMR improvement at 6-12 months was significantly
associated to reduced FMR severity with a favorable hemodynamic response
(persistence/developement of normal right ventricular function and decrease of 10 mmHg or
normalization of systolic pulmonary artery pressure) immediately after implantation (2.5 days; IQR
1.2-15), further showing a better long-term survival-free from heart transplantation (90 Vs 74%;
p=0.033 during a mean follow-up of 59±36). Acute hemodynamic response was the best predictor of
stable FMR improvement (OR 20.4; 95%CI 2.17-192.6; p=0.002).
Conclusions. Stable FMR improvement is frequently determined by CRT-implantation in IDCM and
is associated with a better survival in the long-term. Acute evaluation of hemodynamic response to
CRT is helpful to identify favourable FMR evolution.
SIC | Indice Autori
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Roma, 13 – 15 dicembre 2014
O265
AUTOMATED FUNCTION IMAGING-DERIVED STRAIN RATE EVALUATION OF
LEFT VENTRICULAR SYSTOLIC FUNCTION
G SAVIOLI (A), M GUGLIELMO (A), O MIREA (C), C CEFALÙ (B), P BARBIER (B)
(A) FOUNDATION IRCCS POLYCLINIC SAN MATTEO, MEDICAL CLINIC II UNIVERSITY OF PAVIA, PAVIA, ITALY ; (B) CENTRO CARDIOLOGICO MONZINO,
IRCCS, MILANO, ITALY ; (C) EMERGENCY COUNTY HOSPITAL, DEPARTMENT OF
CARDIOLOGY, CRAIOVA, ROMANIA
Purpose. Speckle-tracking Automated Function Imaging (AFI) offers a fast “on board”
echocardiographic method to calculate left ventricular (LV) global peak longitudinal systolic strain,
proposed as an index of global systolic function with the advantage to detect “subclinical” (normal
ejection fraction) LV systolic dysfunction. In contrast, the utility of AFI-derived LV global peak
systolic strain rate (SRs) has not been assessed.
Methods. We studied 427 consecutive patients with (339) and without (88) heart diseases undergoing
echocardiography (ranges, age: 14-93 y., HR: 40-130 bpm, systolic arterial pressure: 90-180 mmHg,
EFb: 15-78 %), using GE Vivid 7/9 systems (offline analysis on Echopac v12). AFI-derived peak
maximum SRs and time to peak SRs (SRstp) were obtained offline by averaging the first derivatives
of
the
systolic
strain
curve
measured
in
the
3
apical
views.
Results. Both peak SRs and SRstp showed a normal distribution and were respectively -1.39 .37s1(95% CI= -1.31, -1.47) and 159 31ms(95% CI= 153, 166) in normals and -1 .47 and 186 62 in
patients (both, p <.001). Compared to normals, SRs and SRstp were unchanged in athletes (n= 12; 1.73 .77, 159 31), and decreased in dilated cardiomyopathy (n= 35; -.65 .28, 252 89; p<.001),
CAD with normal preload (n= 30; -.77 .33, 207 69; p .001), and aortic stenosis (n= 23; -.97 .31
p<.001, 178 31; p=ns). At multiple regression analysis, adjusted for LV preload, filling pressures,
stroke volume, LV mass index and left atrial volume, SRs was positively determined by LV ejection
fraction and tricuspid annular excursion, and negatively by wall motion score index and pulmonary
systolic hypertension (r= .72, p<.001), whereas SRstp was positively determined by LV end-systolic
volume index and myocardial performance index, and negatively by heart rate (r= .58, p<.001).
Conclusions. Whereas AFI-derived peak maximum longitudinal systolic strain rate is related to both
LV and right ventricular (mediated by the interventricular septum) mechanical systolic functions, our
analysis suggests that time to peak strain rate may approximate LV contractility. These findings, if
confirmed by experimental data, may expand the clinical utility of AFI in the evaluation of LV
systolic function.
O266
VALENTINA CARUBELLI (a), ANDREA ZANOLETTI (a), CARLO LOMBARDI (a),
VALENTINA LAZZARINI (a), ANNA ISOTTA CASTRINI (a), FILIPPO QUINZANI (a),
IVANO BONADEI (a), ENRICO VIZZARDI (a), GAD COTTER (b), MARCO METRA (a)
(a) CATTEDRA DI CARDIOLOGIA UNIVERSITA E SPEDALI CIVILI BRESCIA ; (b)
MOMENTUM RESEARCH DURHAM NC (USA)
Purpose: Acute heart failure (AHF) is associated with poor prognosis. High plasma levels of Nterminal B-type natriuretic peptide (NT-proBNP) at discharge identify patients at higher risk. We
hypothesized that NT-proBNP levels guided herapy may improve prognosis.
Methods: 325 consecutive patients admitted for AHF were prospectively randomized to NT-proBNP
guided therapy (intervention group) or standard care (control). Blood samples were colected at 4872 hours before planned discharge and at discharge. NT-pro-BNP levels were known to the physician
only in the intervention group who improved medical treatment when NT-proBNP was >3000 pg/mL.
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Results: mean age was 69±11 years and mean left ventricle ejection fraction (LVEF) was 30.8 ±
11.9%. 57% (n=155) of patients received angiotensin-converting-enzyme inhibitors, 22% (n=56)
angiotensin receptor blockers, 69% (n=186) beta-blockers and 62% (n=167) aldosterone antagonists.
99% ( n=269) received a loop diuretic (furosemide) at a mean dose of 354 ± 261 mg. At discharge
there were no significant differences in type and dosage of medication in both groups The primary
end-points CV death/CV rehospitalisation to day 180 and day 1000 occurred with similar in both
groups (NT-proBNP guided treatment Vs usual care); respectively HR 1.22 (0.84,1.76) p=0.31; HR
1.13 (0.84,1.53) p=0.42).
In a multivariable model the NT-proBNP variation (p=0.0019), previous hospitalization for HF
(p=0.0005), SBP at admission (p=0.042), and haemoglobin at discharge (p=0.0066), were
independent predictors of the primary endpoint CV death and CV rehospitalisation at day 180
Conclusion: NT-proBNP guided therapy did not reduced the primary endpoint death/hospitalization
rate compared to standard care in AHF patients. The change in plasma values of NT-proBNP is an
independent predictor of prognosis after an hospitalization for AHF.
Figure 1. Kaplan Meier curves CV death/CV rehospitalization to day 180 (combinations of treatment group and NT‐proBNP level) O267
TESTOSTERONE ANTAGONIZES
CARDIOMYOCYTES
DOXORUBICIN-INDUCED
SENESCENCE
OF
Pietro Ameri (a), Paola Altieri (a), Sveva Bollini (b), Chiara Barisione (a), Marco Canepa (a), Carlo
Gabriele Tocchetti (c), Gian Paolo Bezante (a), Paolo Spallarossa (a), Claudio Brunelli (a)
(a) CARDIOLOGY UNIT, DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF
GENOVA; (b) CELL THERAPY LABORATORY, DEPARTMENT OF EXPERIMENTAL
MEDICINE, UNIVERSITY OF GENOVA; (c) CLINICA MONTEVERGINE, MERCOGLIANO
(AV), ITALY
Chronic anthracycline cardiotoxicity is less common in males than in females. Here, we hypothesized
that this gender difference might be at least in part secondary to an inhibitory effect of androgens on
cardiomyocyte senescence, which is thought to be central to the development of long-term
anthracycline cardiomyopathy. Neonatal murine cardiomyocytes and H9c2 cardiomyoblasts were
treated with doxorubicin alone or in combination with testosterone. As previously reported, a single
3-h pulsed exposure to doxorubicin resulted in accumulation of p53, down-regulation of telomere
binding factor 2 (TRF2) and, ultimately, extensive senescence of cardiomyocytes (Figure, panels A
and B). Of note, senescence remained significantly more frequent in treated than untreated cells up
to 21 days after incubation with doxorubicin. Testosterone counteracted both immediate (panel A)
and delayed senescence elicited by doxorubicin. At the molecular level, testosterone induced the
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phosphorylation of AKT and prevented the changes in p53 and TRF2 triggered by doxorubicin (panel
B). Pre-treatment with the androgen receptor (AR) antagonist, flutamide, and the phosphatidylinositol
3 (PI3) kinase inhibitor, LY294002, abrogated the reduction in senescence (panel A), as well as AKT
activation and normalization of p53 and TRF2 levels (panel B), attained by testosterone. We conclude
that testosterone protects against cardiomyocyte senescence caused by doxorubicin by modulating
p53 and TRF2 via the AR-PI3K-AKT pathway. This is a potential mechanism by which males are
less prone to chronic anthracycline cardiotoxicity than females.
Panel A: representative images of the staining for senescence-associated β-galactosidase.
Panel B: representative western blots for phosphorylated (phospho) AKT, TRF2, and p53. Total AKT
and GAPDH were used as loading controls.
CTR: control; Dox: doxorubicin; T: testosterone; Flut: flutamide; LY: LY294002.
O268
DETERMINANTS OF FUNCTIONAL CAPACITY IN
CARDIOMYOPATHY: PROPOSAL FOR A NOMOGRAM
IDIOPATHIC
DILATED
ANNAMARIA IORIO (A), ELENA ZAMBON (A), CONCETTA DI NORA (A),
ELENA ABATE (A), ELISABETTA SALVIONI (C), FRANCESCO LO GIUDICE (A),
ANDREA DI LENARDA (B), PIERGIUSEPPE AGOSTONI (C), GIANFRANCO SINAGRA (A)
(A) CARDIOVASCULAR DEPARTMENT, “OSPEDALI RIUNITI“ AND UNIVERSITY,
TRIESTE, ITALY; (B) CARDIOVASCULAR CENTER, ASS 1, TRIESTE, ITALY; (C)
CENTRO CARDIOLOGICO MONZINO, IRCCS, MILANO, ITALY
Objective: Investigate predictors of exercise capacity, considering cardiopulmonary exercise testing
(CPET) variables, in a well-selected idiopathic dilated cardiomyopathy (IDCM) population.
Methods and Results: We analysed 146 patients with IDCM (76% males, mean age 51±12 years,
NYHA III-IV 68%, left ventricular ejection fraction [EF] 32±8%, left ventricular end-diastolic
volumes 97±28 ml/m2) that underwent a complete clinical and instrumental evaluation consecutively
from January 2005 to June 2013. Univariable linear regression analysis revealed that peak VO2/kg
was significantly related to demographic parameters (age, gender, body mass index [BMI]),
laboratoristic data (BNP), clinical variables (diuretics) and echocardiograpic indices (EF, E/E’,
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tricuspid annular plane systolic excursion (TAPSE), mitral regurgitation and pulmonary artery
systolic pressure). In multivariable analysis with peak VO2/kg as dependent variable, E/E' and
TAPSE were the only echo significant predictors, followed by BMI, age, gender and diuretics. From
this multivariate model, a nomogram for estimating individual prediction of peak VO2 was made.
Multivariable analysis were also performed for other CPET variables. Notably, E/E’ and TAPSE were
confirmed as independent predictors of VE/VCO2 slope, along with NYHA classification. Moreover,
E/E’ and TAPSE independently predict oxygen pulse at peak and VO2 at anaerobic threshold,
respectively.
Conclusions: In IDCM patients, the nomogram offers a good ability to predict individual exercise
capacity, highlighting the role of RV function (assessed by TAPSE) and diastolic properties (assessed
by E/E’). These two factors are also related to other prognostic variables of cardiopulmonary
performance.
O269
LIMITS OF CURRENT EAE GUIDELINES ALGORITHM FOR THE NONINVASIVE
ESTIMATION OF PULMONARY WEDGE PRESSURE. EVALUATION IN A LARGE
UNSELECTED POPULATION
M GUGLIELMO (A), C CEFALÙ (A), G SAVIOLI (B), O MIREA (C), L FUSINI (A),
MC SCALI (D), A SIMIONIUC (D), F DINI (D), P BARBIER (A)
(A) CARDIOLOGY CENTER MONZINO IRCCS, MILAN, ITALY ; (B) FOUNDATION IRCCS
POLYCLINIC SAN MATTEO, MEDICAL CLINIC II - UNIVERSITY OF PAVIA, PAVIA,
ITALY; (C) EMERGENCY COUNTY HOSPITAL, DEPARTMENT OF CARDIOLOGY,
CRAIOVA, ROMANIA; (D) UNIVERSITY HOSPITAL OF PISA, CARDIAC AND THORACIC
DEPARTMENT, PISA, ITALY
Purpose. We previously re-validated noninvasive estimation of pulmonary wedge pressure (PWP)
measuring the CW pulmonary valve regurgitation end-diastolic pressure gradient (PWPecho). Using
the latter as surrogate of PWP, we sought to test accuracy of left ventricular (LV) filling pressures
estimation by the EAE guidelines algorithm (EAEalg) in a large non-selected population.
Methods. We studied 1019 patients in sinus rhythm with GE Vivid7/9 systems (age: 10-93 y.; EF%:
13-83%, normal, n= 827 and reduced <50%, n= 192), in whom PWPecho could be measured
(feasibility 75%), with normal pulmonary vascular resistances (WU< 2). The EAEalg combined E/e’
(average), left atrial volume (LAV), E/A, Edec, pulmonary venous systolic fraction (SF), and echoderived pulmonary systolic pressure (PSPe) to obtain 3 groups: normal, high PWP and not
classifiable. These were compared to the PWPecho estimate.
Results. Feasibility was high for all variables (E/E’ 90%, LAV 93%, E/A 95%, Edec 90%, SF 91%,
PSPe 92%), and for the EAEAlg (94%). Using the EAEAlg, 17% (n=137) of patients with normal in
contrast to 10% (n=19) of patients with EF<50% were not classifiable, in the former secondary to the
combination of a E/E’= 9-13 range, and LAV≥ 34ml/m2. In the remaining (classified, 84%) patients,
utility of EAEalg even when limited to patients with EF<50% was still hampered by a low positive
predictive value (PPV) (Table). Further, when only E/e’ was tested in the same patients at ROC
analysis (cutoff= 15; AUC=0.72, CI:0.6-0.8), accuracy was still impaired by a low PPV (53%), albeit
a fair negative predictive value (NPV) (79%). Correlation between PWPecho and E/e’ was modest
even in patients with EF<50% (r=0.4, p<0.001), and at multiple regression analysis, E/e’ was
independently determined by age and mitral regurgitation in all patients, and by LV end-diastolic
volume in EF<50% (r= 0.7, p<0.001) and by LV mass index in EF>50% (r= 0.64, p<.001).
Conclusions. Noninvasive estimation of PWP by EAE guidelines is limited by a low PPV in both
patients with and without reduced LV EF. In this setting, utility of the E/e’ is limited, it being
influenced by patient age, preload and LV mass.
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Table, all patients
Sensitivity
EF≥ 50%
72
EF < 50%
71
Specificity
78
80
PPV
18
65
Roma, 13 – 15 dicembre 2014
NPV
98
84
CARDIOPATIE CONGENITE, CIRCOLAZIONE POLMONARE,
VALVULOPATIE
O270
DIAGNOSI ED ASPETTI MORFO-FUNZIONALI DELL’AORTA BICUSPIDE DALL’ETA'
PEDIATRICA ALL’ETA' ADULTA: CASISTICA DEL NOSTRO CENTRO
GIULIA DOLCI (A), MARIA ANTONIA PRIOLI (A), VALENTINA BENETTI (A), ELENA
GIULIA MILANO (A), MICOL REBONATO (A), LUCIA ROSSETTI (A),
GIORGIO GOLIA (A), CORRADO VASSANELLI (A)
(A) AZIENDA OSPEDALIERA UNIVERSITARIA INTEGRATA DI VERONA
BACKGROUND: La valvola aortica bicuspide (AoB) è la più frequente cardiopatia congenita con
un incidenza dell’1-2% nella popolazione generale ed un rapporto M/F=3/1. Può presentarsi isolata
od associata ad altre anomalie cardiache congenite. La storia naturale dei pz con AoB è rappresentata
da uno spettro che va da una precoce disfunzione valvolare in epoca neonatale fino a valvole normofunzionanti in età adulta avanzata. In passato il vizio dominante dell’AoB è stato considerato la
stenosi aortica.
MATERIALI E METODI: 806 pz (età media 29,8aa, range 0-88aa) con diagnosi di AoB
ecocardiografica certa sono stati selezionati dal nostro database. I pz sono stati suddivisi in decadi
d’età e sulla base dell’analisi ecocardiografica del flusso Doppler le valvole sono state suddivise in
normo-funzionanti (N), insufficienti (IAO) o stenotiche (SAO). Al fine di evitare la sovrastima della
disfunzione valvolare considerando che il nostro è un centro di terzo livello abbiamo selezionato un
sottogruppo di 404 pz con prima diagnosi.
RISULTATI: Le anomalie cardiache congenite associate più frequenti sono la Coartazione aortica
(12%) e il Prolasso valvolare mitralico (5%). Nel 25% dei pz la diagnosi avviene già in età pediatrica.
Nelle decadi successive la percentuale dei diagnosticati rimane stabile al 20% con un ulteriore
incremento dopo i 50 anni. Il numero di valvole normo-funzionanti riscontrate alla diagnosi mostra
un cospicuo calo tra la prima e la seconda decade d’età (dal 56% al 29%), nelle successive decadi di
vita la percentuale di valvole normo funzionanti riscontrate si assesta al 20%. Il vizio valvolare
dominante tra i 20 e i 50 aa d’età è rappresentato dall’insufficienza aortica mentre la stenosi è tipica
dell’epoca neonatale e ricompare dopo i 50 aa per processi sclero-calcifici (Fig.1). Questi dati sono
riconfermati anche nel sottogruppo di pz (404) con prima diagnosi (Fig.2).
CONCLUSIONI: L’AoB oggi è il vizio valvolare congenito più frequente, spesso misconosciuto
fino all’età adulta. Il rigurgito valvolare aortico e non la stenosi rappresenta il vizio dominante in
questi pz, verosimilmente rispetto al passato per una pressocchè totale scomparsa della cardiopatia
reumatica. La precoce diagnosi fin dall’età pediatrica consente un follow-up con adeguato
monitoraggio della funzione valvolare e della dilatazione aortica, con eventuali interventi
farmacologici se necessario in modo da evitare eventi improvvisi e drammatici quali la dissecazione
aortica.
Fig. 1: Funzione valvolare nei pz tot(806).Fig. 2: Funzione valvolare nei pz con 1° diagnosi (404).
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O271
BIVENTRICULAR FUNCTION IN SYSTEMIC SCLEROSIS: A 3-YEAR LONGITUDINAL
STUDY
EMANUELE ROMEO (A), MICHELE D´ALTO (A), GIOVANNA CUOMO (B),
PAOLA ARGIENTO (A), MICHELE IUDICI (B), SERENA VETTORI (B), GIOVANNI
MARIA DI MARCO (A), GABRIELE VALENTINI (B), MARIA GIOVANNA RUSSO (A)
(A) SECOND UNIVERSITY OF NAPLES - MONALDI HOSPITAL, DEPARTMENT OF
CARDIOLOGY, NAPLES, ITALY ; (B) SECOND UNIVERSITY OF NAPLES,
RHEUMATOLOGY UNIT, NAPLES, ITALY
Objectives. To investigate by standard echocardiography (SE) and pulsed tissue Doppler imaging
(TDI) the course of systemic sclerosis (SSc) - heart disease (HD) and its correlation with
epidemiological, clinical and serological features of the disease and drug treatment.
Methods. Seventy-four consecutive patients with SSc (69 female, aged 19-71 years, disease duration
1-43 years) and 71 age- and sex-matched controls underwent cardiac assessment at baseline and at 3year follow-up.
Results. At baseline, SSc patients showed an impaired left (LV) and right ventricular (RV) diastolic
function compared to controls (Em/Am 0.85±0.4 vs 1.5±0.7, p=0.000001; Et/At 0.9±0.3 vs 1.3±0.4,
p=0.000001) and subtle LV and RV systolic dysfunction (Sm 13.7±2.7 vs 15.4±3.2 cm/sec, p=0.001;
St 14.4±3.5 vs 15.7±4.7 cm/sec, p=0.03). Pulmonary artery systolic pressure (sPAP) was significantly
higher in SSc patients than in controls (26.1±6.0 vs 24.1±5.1; p=0.0013). At 3-year follow-up, SSc
patients showed a further deterioration of biventricular diastolic and systolic function and a further
increase in sPAP. At multiple regression analysis of baseline data, Em/Am <1, detected in 55/74 SSc
patients vs 25/71 controls (p<0.0001), was associated with age >40 years (p=0.0001), and Et/At <1,
detected in 16/74 patients vs 7/71 controls (p<0.0001), was associated with NYHA class ≥II
(p=0.018), late capillaroscopic pattern (p=0.022) and a Medsger severity score ≥1 (p=0.0459). TDI
evidence of new abnormalities in RV and/or LV diastolic function was associated with a Medsger
severity score ≥1 (p=0.01). No correlation was observed between diastolic or systolic abnormalities
or sPAP changes and drug treatment.
Conclusions. Our study confirms that SSc patients exhibit biventricular systolic and diastolic
dysfunction and increased sPAP, with a further deterioration at 3-year follow-up, and suggests that
currently available drugs have no protective effect on the course of SSc-HD.
O272
PATHOPHYSIOLOGY OF EXERCISE IN AORTIC STENOSIS: THE RIGHT VENTRICLE
STAGE
GRETA GENERATI (A), FRANCESCO BANDERA (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
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(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background. Cardiac output (CO) increase is the mainstay of exercise (Ex) physiology. A
prerequisite for adequate increase is that flow through the cardiac valves is unimpeded. Aortic
stenosis (AS) allows to investigate how Ex physiology changes when left ventricular (LV) output is
impeded.
Methods and Results. Twentyseven moderate – severe AS subjects performed semisupine bicycle
ergometry (ramp protocol) with baseline and peak Ex respiratory gases and echo-Doppler
measurements. They were divided according to linear VO2/WR (O2 uptake/work rate) relationship
(ΔVo2/ΔWR=10.7, which is normal) throughout the test (63% Group A), or decline in the latter part
(25% Group B). At peak Ex, Group B, compared to A, despite similar transaortic gradient increase
and Ex gas exchange respiratory ratio, developed functional mitral regurgitation, lower peak VO2
(63.2% vs 82.3% predicted) and VO2/heart rate, steeper ventilation to CO2 production slope and,
consistently, decline in stroke volume (-36% vs +21%) and inadequate increase of CO (+ 44% vs +
90%). Global LV afterload (Zva) rose similarly and LV ejection fraction (EF) remained constant in
both groups. Oppositely, changes in pulmonary pressure (PASP + 65% vs + 33%), effective
pulmonary artery elastance (PEAE +79% vs +19%) and tricuspid annular plane systolic excursion
(TAPSE)/PASP (-51% vs -43%) were definitely greater in group B; right ventricular (RV) area also
slightly augmented in this group.
Conclusions. Some AS subjects showed nearly normal aerobic capacity. Some did not, due to
defective CO. In them, the raised Zva did not depress LVEF, whereas the excessive hemodynamic
load markedly reduced RV contractile performance. All the LV-pulmonary circulatory- RV apparatus
is involved in AS patients with altered Ex physiology and the RV is predominant in disrupting CO.
O273
A RANDOMIZED OPEN LABEL STUDY COMPARING FIRST-LINE TREATMENT
WITH BOSENTAN OR SILDENAFIL IN CHRONIC THROMBOEMBOLIC PULMONARY
HYPERTENSION (CTEPH)
ENRICO GOTTI (A), ANDREA RINALDI (A), CRISTINA BACHETTI (A), FABIO DARDI (A),
GAIA MAZZANTI (A), ALESSANDRA ALBINI (A), ENRICO MONTI (A),
CLAUDIA BERNABÉ (A), ELISA ZUFFA (A), CAROLINA BARBERI (A),
RACHELE BIONDI (A), MARGHERITA TIEZZI (A), MASSIMILIANO PALAZZINI (A),
ALESSANDRA MANES (A), NAZZARENO GALIÉ (A)
(A) DEPARTMENT OF SPECIALIZED, DIAGNOSTIC AND EXPERIMENTAL MEDICINE –
UNIVERSITY OF BOLOGNA - ITALY
Background: phosphodiesterase type-5 inhibitors (PDE-5 I) and endothelin receptor antagonists
(ERA) are oral drugs effective in patients with idiopathic pulmonary arterial hypertension (PAH) and
PAH associated with connective tissue diseases. We assessed the effects of these two classes of drugs
in patients with CTEPH.
Objectives: to compare first-line sildenafil (S) treatment (20 mg tid) with first-line bosentan (B)
treatment (125 mg bid) in patients with operable and not operable CTEPH.
Methods: consecutive naïve patients with CTEPH were randomized to receive B or S. Evaluation
was performed by clinical assessment, 6-minute walk test [6MWT] and right-heart catheterization
[RHC] at baseline and after 3-4 months of therapy. Statistical analysis: T-test and Wilcoxon-MannWhitney test.
Results: 114 CTEPH patients were randomized: 58 to the B group (mean age 64±16; Female/Male:
37/21) and 56 to the S group (mean age 61±17; Female/Male: 26/30). Four patients (6.9 %) in the B
group and 3 (5.4%) in the S group did not complete the short term evaluation because of death,
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pulmonary endoarterectomy (PEA) before the re-evaluation, adverse events. 54 patients in the B
group and 53 in the S group completed the study (mean treatment period: 4.0 ± 1.5 months). Twentythree patients in B group and 33 patients in S group underwent PEA after the treatment period.
Effects of therapies are shown in the Table. No differences in the effects were observed between S
and B and between operable and not operable patients
Conclusions: Treatment with S or B are associated with similar improvements in exercise capacity
and hemodynamics in patients with operable and not operable CTEPH.
Baseline
Bosentan
p
6mwt
(m)
372±141
418±139
<0.001
RAP
(mmHg)
8±4
7±4
0.79
Baseline 406±134 8±5
Sildenafil 461±144 7±3
p
<0.001
0.007
mPAP
(mmHg)
44±10
40±9
<0.001
CI
(mmHg)
2.6±0.7
2.9±0.8
<0.001
49±11
42±8
<0.001
2.6±0.8
2.8±0.6
<0.001
PVR
(mmHg)
8.3±3.9
6.3±3.0
<0.001
8.6±3.8
6.5±2.4
<0.001
MVO2
(mmHg)
63±8
65±7
0.04
64±9
67±7
<0.001
Legend: RAP: right atrial pressure; mPAP: mean pulmonary arterial pressure; CI: cardiac index;
PVR: pulmonary vascular resistance, MVO2 mixed venous oxygen.
O274
PERCUTANEOUS CLOSURE OF RESIDUAL INTERATRIAL COMMUNICATION
AFTER TRANSCATHETER EDGE-TO-EDGE PROCEDURE IN HEART FAILURE
PATIENTS
GIUSEPPINA PASCUZZO (A), ERSILIA MAZZOTTA (A), VALERIA CAMMALLERI (A),
SAVERIO MUSCOLI (A), DOROTEA RUBINO (A), FRANCESCA DEPERSIS (A),
EUGENIA MAIO (A), MASSIMILIANO MACRINI (A), MASSIMO MARCHEI (A),
ANDREA ANCESCHI (A), GIANPAOLO USSIA (A), FRANCESCO ROMEO (A)
(A) TOR VERGATA DIPARTIMENTO DI CARDIOLOGIA
Background: MitraClip procedure requires transeptal access from right to left atrium with a 22F
guiding catheter. Although the residual interatrial communication (IAC) diameter is not predictable,
the left to right shunt is usually trivial. We assess the hemodynamic impact of the intracardiac shunt
due to the residual interatrial communication (IAC) after transcatheter edge-to-edge repair.
Aims: Aim of our study was to assess differences in clinical presentation and outcomes between
patients who needed percutaneous closure of the residual interatrial communication (IAC) after edgeto-edge mitral valve procedure (group closure) and patients for whom it was not necessary (group
not-closure).
Methods: From January 2012 to May 2014, 71 consecutive patients (72% males; mean age 73±9
y.o.; mean logistic EuroSCORE 23±20%), have been treated with MitraClip device (Abbott Vascular,
Santa Clara, CA, USA). Fifty-seven patients (80%) had secondary mitral regurgitation with a mean
left ventricle ejection fraction (LVEF) of 29±11%; 14 patients suffered from primary MR with a
LVEF of 55±10% (p<0,00001). The residual IAC was immediately evaluated with transesophageal
echo after the guiding-catheter was withdrawn; additionally the right cardiac catheterization was
performed before and after the procedure. Intraprocedurally deep-sedation with spontaneous
breathing was used in 47 patients (66%), whereas 24 (34%) were intubated under general anesthesia,
without significant differences between group closure and group not-closure. One, two and three clips
were implanted in 27 (38%), 43 (60%), 1 (2%) patients, respectively. The mean IAC, after that the
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delivery system was withdrawn, measured 0,6±0,4 cm and Qp/Qs was estimated 1,4±0,2 in the overall
population.
Results: Twelve patients (17%) needed percutaneous closure of the residual defect, using occluder
devices for patent foramen ovale, because the shunt was judged to have significant hemodynamic
impact: in 8 patients the closure was performed acutely during the same MitraClip session; 4 patients
underwent closure of the defect later, in a elective procedure, for development of signs of right heart
failure.
Patients who needed IAC closure were significantly at higher risk, with most compromising clinical
status and more left ventricular dysfunction: STS score mortality plus morbidity was higher in group
closure when compared to group not-closure (57±28% vs 52±20%; p=0.049); NT-pro-BNP plasma
level was 23180±4910 pg/ml in group closure and 13015±4945 pg/ml in group not-closure
(p<0.00001); left ventricle end-diastolic and end-systolic diameters were 58±10 mm and 40±20 mm
in group closure vs 42±29 mm (p=0.001) and 29±25 mm (p=0.012) in group not-closure; similarly
left atrium was larger in group closure (44±18 mm vs. 32±20 mm; p=0.001). Even if not statistically
significant patients who needed IAC closure had very low LVEF and right ventricle dysfunction at
baseline echocardiogram. Additionally not significant differences were observed in procedural data
and in-hospital and 30-days clinical outcomes.
Conclusion: The residual IAC after MitraClip procedure can create a hemodynamic acute
decompensation during the procedure and late right ventricle dysfunction, which, in our experience,
have led to a transcatheter closure of the defect. Patients who need IAC closure have often advanced
heart failure with more compromising clinical status at moment of hospitalization.
O275
ANALISI DELLE PROPRIETÀ VISCOELASTICHE DELLE GRANDI ARTERIE PER LA
STRATIFICAZIONE DEL RISCHIO AORTICO NELLA SINDROME DI MARFAN
ALESSANDRO PINI (B), ANDREA GRILLO (A, C), SUSAN MARELLI (B), LAN GAO (D, E),
ANDREA GIULIANO (A), GIULIANA TRIFIRO´ (F), FRANCESCA SANTINI (A),
LUCIA SALVI (A, B), PAOLO SALVI (A), MAURIZIO VIECCA (B), RENZO CARRETTA (C),
GIANFRANCO PARATI (A, E)
(A) DIP. SCIENZE CARDIOVASCOLARI, NEUROLOGICHE E METABOLICHE. ISTITUTO
AUXOLOGICO ITALIANO, MILANO; (B) CENTRO MALATTIE RARE CARDIOLOGICHE,
MARFAN CLINIC, U.O. DI CARDIOLOGIA, AZIENDA OSPEDALIERA L. SACCO,
MILANO; (C) DIP. DI SCIENZE MEDICHE CHIRURGICHE E DELLA SALUTE,
UNIVERSITÀ DI TRIESTE; (D) DPT. OF CARDIOLOGY, PEKING UNIVERSITY FIRST
HOSPITAL, BEIJING, CHINA; (E) DIP. SCIENZE DELLA SALUTE, UNIVERSITÀ DI
MILANO-BICOCCA, MILANO ; (F) U.O.C. PEDIATRIA, AZIENDA OSPEDALIERA
SALVINI, RHO
La sindrome di Marfan è una patologia genetica autosomica dominante con sintesi di una fibrillina-1
anomala, una proteina strutturale del connettivo. Tra le manifestazioni cardiovascolari, la dilatazione
della radice aortica e la dissecazione sono tra i principali problemi quoad vitam. La profilassi
farmacologica con losartan in monoterapia o con betabloccante controlla l’accrescimento della radice
dell’aorta, ma è necessario un monitoraggio per valutare la risposta terapeutica e identificare i soggetti
non responder. Gli studi genotipo-fenotipo non consentono di delineare l’esatto profilo di rischio e
mancano analisi di sicuro significato predittivo. Scopo del presente studio è di individuare marker
non invasivi per identificare i pazienti Marfan a maggiore rischio di complicanze aortiche. Sono stati
studiati 71 pazienti Marfan (criteri di Gent 2010 e analisi genetica positiva), età 38±13aa (media±ds).
28 pazienti (39.4%) erano stati sottoposti a sostituzione dell’aorta ascendente (sec. David I o Bentall).
Mediante tonometro PulsePen® é stata registrata la curva pressoria centrale e sono state studiate le
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proprietà viscoelastiche dell’aorta mediante determinazione della velocità dell’onda di polso (VOP)
carotido-femorale.
Rispetto ai valori di normalità secondo l’Arterial-Stiffness-Collaboration, la media della VOP
correlata con l’età risultava pari al 60° percentile nei Pz non operati e al 75° percentile in quelli
operati. I pazienti Marfan presentano una pressione arteriosa tendenzialmente bassa, a causa della
profilassi farmacologica, e sono stati confrontati con una popolazione sana di 329 soggetti (127
maschi), omogenea per età (36±16aa.), frequenza cardiaca (67±11/min vs 65±11/min) e valori
pressori (PAM=80±5 mmHg vs PAM=79±10 mmHg).
Nei pazienti Marfan la VOP media globale è risultata più elevata rispetto ai controlli sani
(VOP=6.91±1.66), un risultato confermato anche nei pazienti Marfan non operati (VOP=7.64±1.58;
p=0.006) e in quelli operati (VOP=9.97±3.74; p<0.0001).
Un’alterazione significativa della distensibilità dell’aorta è stata riscontrata nella sindrome di
Marfan; ulteriori analisi sono necessarie per confermare il significato prognostico della VOP.
O276
ASSESSING RIGHT VENTRICULAR-PULMONARY CIRCULATION RESERVE
DURING EXERCISE CHALLENGE IN PATIENTS WITH HEART FAILURE AND
SEVERELY DEPRESSED RIGHT HEART FUNCTION AT REST
GRETA GENERATI (A), FRANCESCO BANDERA (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), MARCO GUAZZI (A)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE
Background: Right ventricular (RV) dysfunction at rest has a significant prognostic role in heart
failure (HF) syndrome and its combination with pulmonary artery systolic pressure (PASP) is useful
for risk stratification. Different response to exercise of echo-derived tricuspid annular systolic
excursion (TAPSE), as RV function indicator, and PASP may provide further clinical stratification
in a population of HF patients with advanced bi-ventricular disease and depressed RV function.
Aim: We aimed to assessed RV-pulmonary circulation functional response to maximal exercise in a
population of HF patients with severe RV systolic impairment (TAPSE<16 mm) and to explore the
association between right heart functional capacity and exercise capacity as evaluated by
cardiopulmonary exercise testing (CPET) parameters combined with echo.
Methods: 39 HFrEF patients (mean age 64 y, male 82%, ischemic etiology 64%, LVEF 33±10%,
NYHA class I, II, III, IV 20, 21, 42,17 %, mean TAPSE 13±2 mm, PASP 43±19 mmHg) underwent
a maximal symptoms-limited CPET on a tiltable cycle ergometer using an incremental personalized
ramp protocol and stress echo.
Results: Study population was divided in two groups according to the presence RV functional reserve
(increase of TAPSE at peak exercise >20%). Despite similar left ventricular (LV) function and RV
systolic impairment at rest, patients with impaired RV reserve (Group B) showed lower exercise
capacity (peak VO2, peak O2 pulse), associated with more advanced cardiac remodeling and more
severe degree of mitral regurgitation (MR) both at rest and during exercise.
Conclusions: In HF patients an impaired RV function at rest may not invariably lead to an
unfavorable RV adaptive response to exercise. Testing the degree of RV functional reserve and RVpulmonary circulation coupling during exercise can be useful even in the most advanced stages of
disease to unmask different clinical phenotypes and, very likely, different levels of risk.
Variables
2
LV mass indexed, g/m
LV ejection fraction, %
Group A (n=17)
Rest
Peak
127±29
33±10
39±13
Group B (n=22)
Rest
Peak
148±35
32±10
33±10
P
Rest
0.05
ns
Peak
ns
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Left atrial volume indexed,
52±23
74±35
0.025
2
ml/m
E/A, ratio
1.6±1.4
2.8±1.5
0.05
E/e’, ratio
25±17
34±14
ns
MR ≥3/4+,n ( %)
4 (24)
5 (21)
13 (59)
14 (64) 0.015 0.007
TAPSE, mm
13±2
18±3
14±2
14±3
ns
0.000
PASP, mmHg
36±19
59±25
47±17
64±17
0.08
ns
TAPSE/PASP, mm/mmHg
0.43±0.20 0.34±0.13 0.33±0.13 0.23±0.08 0.09 0.008
Workload, Watt
67±27
50±17
0.03
Peak VO2, ml O2/Kg/min
13.4±4.5
11.3±3.3
ns
Peak O2 pulse, ml/beat
10±3
7.6±2
0.01
Exercise oscillatory ventilation,
6 (35)
14 (64)
0.08
n (%)
O277
RIGHT VENTRICULAR STRUCTURE AND FUNCTION IN IDIOPATHIC PULMONARY
FIBROSIS WITH OR WITHOUT PULMONARY HYPERTENSION
ENZA DI PALMA (A), ANTONELLO D´ANDREA (A, B), ANNA STANZIOLA (D),
MARIA MARTINO (D), MEREDYTH VANESSA BETANCOURT (A),
RANIERI FORMICA (A), MARCO MAGLIONE (A), MARIA GIOVANNA RUSSO (A, B),
EDUARDO BOSSONE (C)
(A) DEPARTMENT OF CARDIOLOGY, SECOND UNIVERSITY OF NAPLES, MONALDI
HOSPITAL, NAPLES, ITALY; (B) CHAIR OF CARDIOLOGY, SECOND UNIVERSITY OF
NAPLES; ITALY; (C) DEPARTMENT OF MEDICINE, DIVISION OF CARDIOLOGY,
UNIVERSITY OF SALERNO, SALERNO, ITALY; (D) DEPARTMENT OF RESPIRATORY
DISEASES, FEDERICO II UNIVERSITY - MONALDI HOSPITAL, NAPLES, ITALY.
Background: idiopathic pulmonary fibrosis (IPF) can lead to the development of pulmonary
hypertension (PH), which is associated with an increased risk of death. In PH, survival is directly
related to the capacity of the right ventricle to adapt to elevated pulmonary vascular load.
Objectives: the aims of the present study were to elucidate right ventricular (RV) function and
structure in patients with IPF with or without PH, and their relation to other instrumental features of
the disease.
Methods: clinical evaluation, standard Doppler echo, Doppler Myocardial Imaging (DMI) and 2D
X-strain echocardiography (2DSE) of RV longitudinal deformation in RV septal and lateral walls
were performed in 52 IPF patients (mean age: 66.5± 8.5 years; range 42 – 80; 27 males) and in 45
age- and sex-comparable controls using a commercial US system (MyLab Alpha, Esaote Florence,
Italy). Pulmonary artery systolic and mean pressure (mPAP) were estimated by standard echoDoppler formulas. RV global longitudinal strain (RVGLS) was calculated by averaging local strains
along the entire right ventricle. The IPF patients were divided into 2 groups by non-invasive
assessment of PH: no PH (mPAP <25 mm Hg; 36 pts) and PH (mPAP ≥25 mmHg; 16 pts).
Results: left ventricular diameters, ejection fraction and TAPSE were comparable between the two
groups, while RV end-diastolic diameter was mildly increased in IPF (p<0.01). Tricuspid inflow E/A
ratio was decreased in IPF (p<0.01), while mPAP was increased (p<0.001). Pulsed DMI detected in
IPF impaired myocardial RV early-diastolic (Em) peak velocity (p<0.0001), and comparable systolic
velocity at tricuspid annulus level. In IPF, peak systolic RV 2DSE was reduced in basal, middle and
apical RV lateral free walls, and also RVGLS was impaired (14.3±5.3 vs 22.4±6.1 %; p<0.001). The
impairment in RV wall strain was more evident when comparing controls with the no PH group than
comparing the no PH group with the PH group.
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By multivariate analysis, independent association of RV lateral wall 2DSE with both 6-minute
walking test distance (p<0.001), mPAP (p<0.01), as well as with FVC% pulmonary (<0.005) in IPF
patients were observed. A RV GLS cut-off value of 0.16% differentiated controls and IFP with an
85% sensitivity and a 90 % specificity.
Conclusions: the present study showed that impaired RV diastolic and systolic myocardial function
were present even in IFP patients without PH, which indicates an early impact on RV function and
structure in patients with IF. RV xstrain is a valuable non-invasive and easy-repeatable tool for
detecting early RV myocardial involvement caused by IPF.
IMAGING CARDIOVASCOLARE - 3
O278
FAST GENERATION OF T2* MAPS IN THE WHOLE RANGE OF CLINICAL INTEREST:
APPLICATION TO THALASSEMIA MAJOR PATIENTS
VINCENZO POSITANO (A), ANTONELLA MELONI (A), PIETRO GIULIANO (B),
NICOLA GIUNTA (B), FILOMENA SANTARELLI (C), GIUSEPPE SERRA (D),
STEFANO PULINI (E), PAOLO PREZIOSI (F), LUIGI LANDINI (A), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) U.O. DI CARDIOLOGIA, OSPEDALE CIVICO E BENFRATELLI, PALERMO, ITALY; (C)
INSTITUTE OF CLINICAL PHYSIOLOGY, CNR, PISA, ITALY; (D) PRESIDIO OSP. N.2 “S.
GIUSEPPE DA COPERTINO“, COPERTINO (LE), ITALY; (E) U.O. EMATOLOGIA CLINICA,
OSPEDALE CIVILE “SPIRITO SANTO”, PESCARA, ITALY; (F) U.O.C. DIAGNOSTICA PER
IMMAGINI E INTERVENTISTICA, POLICLINICO “CASILINO“, ROMA, ITALY
T2* maps obtained by processing of multiecho Magnetic Resonance (MR) sequences could be useful
in several clinical applications. Fast T2* map generation usually involves the modelling of the signal
decay curves as a pure exponential decay, to quickly estimate the T2* value by the linear fitting of
the logarithm of the signal. In patients with severe iron overload, where the signal nulls at later echoes
diverging from the pure exponential model, this approach may fail leading to incorrect T2* values
estimation in the map. We propose a method for T2* map generation, including automatic
background pixels detection and automatic truncation of decay curve to be fitted to compensate for
signal collapse at low T2* values. The proposed method (see Figure) was validated on synthetic
images and on 60 thalassemia major patients with different levels of myocardial iron overload. As
the true value of T2* in patients is unknown, the validation on patients data was conducted by
comparing the measurement done with the proposed methodology with the ones performed by a
validated software (HIPPO MIOT) that uses a region of interest (ROI)- based approach. The
developed procedure was effective in generating correct T2* maps in the whole T2* range of clinical
interest (error below 10%) in a time compatible with on-line image analysis. A good agreement was
found between T2* map measurement and ROI-based measurement performed by experts in
myocardial iron overload assessment (CoV=1.84% in global heart T2*, CoV=5.8% in segmental
analysis). In conclusion, this approach could be easily incorporated into T2* analysis software to
spread in the clinical arena the development of a fully automated myocardial iron quantification.
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O279
SPECKLE TRACKING ASSESSMENT FOR DETECTING EARLY CARDIOVASCULAR
BURDEN IN SJOGREN SYNDROME
STEFANO GALAVERNA (B), CHIARA COLOMBO (B), DANIELE STELLA (B),
LUIGI GIANTURCO (B), FABIOLA ATZENI (A), PIERCARLO SARZI-PUTTINI (A),
MAURIZIO TURIEL (B)
(A) DIVISIONE REUMATOLOGIA-OSP. LUIGI SACCO, MILANO; (B) SERVIZIO
CARDIOLOGIA-IRCCS IST. ORTOPEDICO GALEAZZI, MILANO
Background: Sjögren’s syndrome (SS) is a common chronic autoimmune disease with a prevalence
of 0.5–1% that is characterized by lymphocytic infiltration and progressive injury to the exocrine
glands.
We have previously shown that plasma asymmetric dimethylarginine (ADMA) levels and coronary
flow reserve (CFR) are impaired in patients (pts) with SS; speckle tracking echocardiography (STE)
moreover has been used to identify subclinical cardiac involvement. Our aim was to underline the
role of impaired speckle tracking, as marker of subclinical left ventricular dysfunction, in pts affected
by SS with normal ejection fraction in predicting congestive heart failure at follow-up.
Methods: The study group consisted of 49 outpatients (14 males and 35 females; mean age 57±6,9
years), who fulfilled the American College of Rheumatology (ACR) criteria for SS. The control group
consisted of 22 healthy volunteers matched for age, gender and other anthropometric characteristics.
In all of subjects were performed a cardiovascular (CV) risk profile by means of: CFR evaluation,
carotid ultrasonography and stiffness measurements, ADMA dosages and finally STE exams.
Continuous variables are expressed as mean values and standard deviations or as median values and
interquartile ranges (IQR) according to variable skewness. Non-continuous variables were described
as percentages. All of the tests were two-tailed, and probability (p) values of <0.05 were considered
statistically significant.
Results: Although within the normal range, CFR was lower than that of the controls (median 2.64,
IQR 2.40–2.90 vs. 3.20, IQR 3.06–3.33; p<0.0001), PWV values were significantly higher in the SS
group, as well as cIMT values, but these differences were not statistically significant. And finally,
speckle tracking analysis has shown that global longitudinal strain deformation in the apical four
chambers view, being significantly less in the SS pts.
Conclusions: We have already demonstrated that ADMA was a useful markers for detecting
endothelial dysfunction in SS. Nowadays, we have found myocardial longitudinal strain
measurements impaired in SS pts in absence of any other clinical evidence of CV disease and when
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traditional echocardiographic evaluations were still negative, thus suggesting an early myocardial
alteration and becoming a pivotal marker for cardiologists in order to identify subclinical CV
involvement in SS.
O280
EVALUATION OF CARDIAC MAGNETIC RESONANCE TECHNIQUES FOR THE
QUANTIFICATION OF LATE GADOLINIUM ENHANCEMENT IN HYPERTROPHIC
CARDIOMYOPATHY
CARLA CONTALDI (A, B), DANIEL C. LEE (B, C), BRANDON BENEFIELD (C),
BRADLEY ALLEN (C), JAMES CARR (C), MICHAEL MARKL (C),
LUBNA CHOUDHURY (B), ROBERT O. BONOW (B)
(a) DEPARTMENT OF ADVANCED BIOMEDICAL SCIENCES, FEDERICO II UNIVERSITY
SCHOOL OF MEDICINE OF NAPLES-ITALY; (b) DEPARTMENT OF MEDICINE –
CARDIOLOGY, NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF MEDICINE,
CHICAGO, IL, USA; (c) DEPARTMENT OF RADIOLOGY, NORTHWESTERN UNIVERSITY
FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Background: Late gadolinium enhancement (LGE) using cardiac magnetic resonance (CMR) has
been linked to outcome in hypertrophic cardiomyopathy (HCM). In contrast to ischemic
cardiomyopathy, HCM is characterized by histopathologic abnormalities of the entire LV
myocardium, including scar, interstitial fibrosis and/or myocyte disarray. Various techniques have
been used to quantify LGE in HCM, but the optimal approach for this quantification in HCM is still
not well defined.
Objectives: The aim of this study was to compare different techniques for the quantification of LGE
in HCM patients.
Methods: LGE CMR imaging was performed in 32 HCM patients (mean age 54.4 ± 13.1 years).
LGE images were acquired 10 min after administration of gadopentetate dimeglumine, 0.2 mmol/Kg.
LGE mass was evaluated and quantified slice by slice, using software Q-MassMR, first with manual
assessment; then with gray-scale thresholds of 2 and 6 standard deviations (SD) above the mean of
normal null myocardium; and then with full width at half maximum (FWHM). Bland-Altman analysis
and correlation coefficients were used to compare the manual with thresholding and FWHM methods.
Results: Focal and diffuse LGE was observed in 12 patients (37.5%) while only diffuse LGE was
seen in 20 (62.5%) patients. The mean magnitude of LGE by manual analysis was 14.4 ± 8.2 g
compared with 12.4 ± 7.5 g at 6SD, 53.8 ± 19.5 g at 2 SD and 24.4 ± 7.6 g at FWHM. The figure
shows Bland-Altman analysis. All techniques were significantly correlated with manual assessment.
The 6SD threshold had the strongest correlation (r = 0.95) compared with 2 SD threshold (r = 0.85)
and FWHM (r = 0.23) and was the most reproducible compared with manual assessment. p<0.001
for all comparisons.
Conclusions: The 6SD threshold is the most reproducible technique and the method that most
closely correlates with manual analysis of LGE; it is superior to FWHM. This objective method
should be considered for quantifying LGE in HCM patients.
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O281
CARDIAC MAGNETIC RESONANCE VERSUS ECHOCARDIOGRAPHY FOR THE
ASSESSMENT OF CARDIAC VOLUMES AND FUNCTION IN THALASSEMIA MAJOR
PATIENTS
ANTONELLA MELONI (A), STEFANIA RENNE (B), GIANLUCA VALERI (C),
VINCENZO POSITANO (A), SABRINA ARMARI (D), ELENA FACCHINI (E), DANIELE DE
MARCHI (A), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G.MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) STRUTTURA COMPLESSA DI CARDIORADIOLOGIA, P.O. “GIOVANNI PAOLO II”,
LAMEZIA TERME, ITALY; (C) DIPARTIMENTO DI RADIOLOGIA, AZIENDA
OSPEDALIERO-UNIVERSITARIA OSPEDALI RIUNITI “UMBERTO I-LANCISI-SALESI“,
ANCONA, ITALY; (D) REPARTO DI PEDIATRIA, AZIENDA OSPEDALIERA DI LEGNAGO,
LEGNAGO (VR), ITALY; (E) U.O. PEDIATRIA - PESSION, M.O. ONCOLOGIA ED
EMATOLOGIA PEDIATRICA “LALLA SERÀGNOLI“, POLICLINICO UNIVERSITARIO S.
ORSOLA, BOLOGNA, ITALY-MALPIGHI
Background: Cardiac Magnetic Resonance (CMR) and Echocardiography (US) are applied in
parallel to thalassemia major (TM) patients for cardiac evaluation and ongoing monitoring. The aim
of this study was to compare the agreement of left ventricular (LV) volumes and ejection fraction
(EF) by CMR and US in a larger cohort of TM patients .
Methods: 307 TM patients (162 F; 31.8±8.5 yrs) enrolled in the MIOT (Myocardial Iron Overload
in Thalassemia) Network were studied by both US and CMR (1.5T) within 3 months of each other.
Cine images were acquired to quantify biventricular function parameters in a standard way using
MASS® software. Inter-center variability for the quantification of cardiac function was 6.3%.
Echocardiographic studies were carried out in 10 echo labs linked to the thalassemia centers. LV
volumes were measured by two-dimensional echocardiography using the biplane Simpson's formula.
Paired-samples t-test or Wilcoxon test, correlation coefficient, intraclass correlation (ICC), and Bland
& Altman plot were used to compare CMR and US parameters. The Cohen’s kappa coefficient (k)
was used to evaluate the agreement between CMR and echo in identifying borderline EF, mild EF
reduction and abnormal EF.
Results: Table 1 shows the CMR and US parameters, quoted as mean ± SD with 95% CI in round
brackets. Table 2 shows the results of the comparison between the two techniques. All US volumes
were significantly underestimated, especially the EDVI, while the US EF was significantly higher
than the CMR EF. The correlation between US and CMR volume indexes and EF was significant,
but with a low coefficient; especially for the EF. The ICC was good for all the parameters, but never
excellent. The Bland Altman plot ranges were wide, with the widest value found for the EDVI. In all
EF categorizations, k was <0.2, indicating slight agreement.
Conclusion: In a large CMR versus echocardiographic comparative study in TM patients, metrics of
LV volume index and function showed significant systematic inter modality differences. Conversely
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to the previous findings, CMR and US resulted not interchangeable for LV EF assessment. Of clinical
relevance, this study suggests that serial measurements of volumes and function in TM should be
performed using the same method and if it is available the more reproducible CMR technique.
TABLE 1.
Measurement
CMR
TABLE 2.
US
LV EDVI
(ml/m2)
86.5 ± 19.9 69.5 ± 17.4
(84.2 ÷ 88.7) (67.5 ÷ 71.5)
LV ESVI
(ml/m2)
LV SVI
(ml/m2)
EF (%)
34.3 ± 11.5
(33.0 ÷ 35.6)
52.2 ± 10.8
(50.9 ÷ 53.4)
60.8 ± 6.7
(60.0 ÷ 61.5)
25.3 ± 9.6
(24.3 ÷ 26.4)
44.2 ± 12.0
(42.8 ÷ 45.5)
64.1 ± 6.6
(63.3 ÷ 64.8)
CMR-US
LV EDVI
(ml/m2)
LV ESVI
(ml/m2)
LV ESVI
(ml/m2)
LV EF
(%)
Difference,
mean ± SD
16.9 ± 18.4
8.9 ± 10.9
8.0 ± 12.6
-3.3 ± 7.6
<0.0001
<0.0001
<0.0001
<0.0001
P
0.536
0.498
0.381
0.279
Correlation,
(P<0.0001) (P<0.0001) (P<0.0001) (P<0.0001)
r (P-value)
ICC
BA limits
BA range
0.537
0.519
0.483
0.473
-19.1 to 53.1 -12.3 to 30.2 -16.6 to 32.7 -18.2 to 11.6
72.2
42.5
49.3
29.8
PROGNOSI INSUFFICIENZA CARDIACA - 2
O282
ULTRASOUND ASSESSMENT OF JUGULAR VEIN DISTENSIBILITY IN PATIENTS
WITH HEART FAILURE AND ITS PROGNOSTIC SIGNIFICANCE. A REPORT FROM
THE SICA- HF STUDY (FP7/2007-2013/ 241558)
PIERPAOLO PELLICORI (A), ANNA BENNETT (A), JUFEN ZHANG (A),
VENNELA BOYALLA (A), PAOLA PUTZU (A), RIET DIERCKX (A), BEN DICKEN (A),
ANDREW CLARK (A), JOHN CLELAND (A)
(A) ACADEMIC CARDIOLOGY - CASTLE HILL HOSPITAL - HULL - UK
Aims: Jugular venous distension reflects increased right atrial pressure and is a classical sign of heart
failure (HF). However, its clinical assessment may be difficult.
Methods: Ambulatory patients with HF and control subjects enrolled in the SICA-HF study were
assessed. Internal jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound
probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was
calculated as the diameter during Valsalva to that at rest.
Results: 311 patients (mean age 71 years; mean left ventricular ejection fraction 42%, median (interquartile [IQR] range) NT-proBNP 979 (441-2007) ng/l) and 66 controls were included. JVD (median
and IQR range) at rest was smaller in controls (0.16 (0.14-0.20) cm) than in patients with HF (0.23
(0.17-0.33) cm; p<0.001) but similar during Valsalva (1.03 (0.90-1.16) cm vs 1.08 (0.90-1.25) cm;
p=0.28). Consequently, JVD ratio was greater in controls (6.3 (4.9-7.6)) than in patients (4.5 (2.96.1); p<0.001).
During a median FU of 516 (IQR: 335-622) days, 48 patients with HF died or were hospitalized for
heart failure. Different multivariable models were tested. Amongst clinical, echocardiographic or
biochemical variables, only NTproBNP and ultrasound assessment of internal jugular vein (either at
rest, JVD ratio or deep inspiration, but not JVD during Valsalva) provided independent prognostic
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information. Compared to those in lowest tercile, HF patients in the highest tercile of JVD ratio had
10-fold greater risk of an adverse event (HR: 10.05, 95% CI: 3.07-32.93).
Conclusions: Echocardiographic assessment of internal jugular vein identifies ambulatory patients
with heart failure who have a high risk of an adverse outcome. Greater JVD diameter at rest or during
deep inspiration or smaller JVD ratio provide similar prognostic information.
O283
PROGNOSTIC ROLE OF CLINICAL AND LABORATORISTIC ASSESSMENT IN ACUTE
HEART FAILURE
STEFANO PIDELLO (A), SIMONE FREA (A), FEDERICO GIOVANNI CANAVOSIO (A),
MICHELA BOTTA (A), VIRGINIA BOVOLO (A), SERENA BERGERONE (A),
FIORENZO GAITA (A)
(A) CITTÀ DELLA SALUTE E DELLA SCIENZA DI TORINO
Background: Clinical evaluation is pivotal for management of patients with acute heart failure
(AHF). "Cold profile", assessed by physical examination, is associated with worse prognosis (Nohria,
2003). Moreover impaired end organ function is a strong predictor of death. Aim of the study was to
evaluate the incremental prognostic role of a new definition of cold presentation, adding worsening
renal function and serum bilirubin to clinical evaluation ("Cold Modified 2014").
Methods and Results: We prospectively enrolled 223 consecutive patients (EF 25.6 ±8.2, SBP 104.3
± 26.1 mmHg) admitted for AHF. Among them 38 were defined as "cold" according to "Nohria 2003"
(at least one of the following signs of hypoperfusion: proportional pulse pressure <25%, pulsus
alternans, symptomatic hypotension, cold extremities or impaired mental status) while 64 patients
were defined as cold according to "Cold Modified 2014" (with at least two of the following: 1.
"Nohria 2003" or ACE-inhibitors intolerance or sodium <130 mmol/L; 2. worsening renal function;
3. serum bilirubin ≥ 1.2 mg/dl). At 6 months 77 patients (34.5%) met the primary composite endpoint
(cardiac death, urgent heart transplantation or urgent L-VAD implantation). At univariate analysis
"Cold Modified 2014" performed better (HR 4.27, CI 95% 2.71-6.72) than cold profile by "Nohria
2003" (HR 2.00, CI 95% 1.20-3.33). Moreover at ROC analysis "Cold Modified 2014" showed a
better diagnostic accuracy than "Nohria 2003" (AUC 0.73 vs 0.57, p=0.007). Besides "Cold Modified
2014" but not "Nohria 2003" significantly predicted all cause mortality at 6 months (HR 3.21, CI
95% 1.73-5.95) and worsening heart failure (HR 3.13, CI 95% 1.70-5.80).
Conclusions: "Cold Modified 2014", an association of clinical evaluation and end-organ damage
assessed by laboratoristic data, improved risk stratification when compared to clinical evaluation.
This easy tool resulted a good predictor of short term outcome since it identified patient who
expererienced worsening heart failure during the index hospitalization and those with a poor outcome
at 6 months.
O284
ANALYSIS OF THE VARIABLES ASSOCIATED WITH INCREASED RISK OF ANEMIA
IN PATIENTS WITH CHRONIC HEART FAILURE: A CASE-CONTROL STUDY.
RENATO DE VECCHIS (A), GIUSEPPINA DI BIASE (B), ARMANDO PUCCIARELLI (C),
CARMELINA ARIANO (A)
(A) CARDIOLOGY UNIT, PRESIDIO SANITARIO INTERMEDIO“ ELENA D’AOSTA“,
NAPOLI, ITALY; (B) NEUROREHABILITATION UNIT, CLINICA “S. MARIA DEL POZZO”,
SOMMA VESUVIANA, ITALY; (C) INVASIVE CARDIOLOGY LABORATORY,
CARDIOLOGY DIVISION, CLINICA “MONTEVERGINE”, MERCOGLIANO, ITALY
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Background: The role of anemia as a determinant of increased mortality and worsening of functional
capacity and life quality in chronic congestive heart failure (CHF) has long been neglected. However,
in the last few years, several studies have at long last demonstrated the anemia to be a frequent
contributing cause of hospitalization in CHF patients and to have an unfavourable prognostic
meaning, so as to allow it to become a primary target of therapy.
Aim: To detect the possible predictors associated with occurrence of significant drop in serum
hemoglobin (Hb) and red cell count in CHF patients undergoing periodical hematochemical checkup.
Methods: A retrospective, case-control study was designed, by enrolling as cases the CHF patients
who had shown, at the end of 2 year follow-up, a drop in serum Hb of 10% at least (with or without
fulfillment of the adopted cut-off for diagnosis of anemia , i.e. a Hb concentration of ≤11 g/dl),
compared to concentration found at the starting measurement. For each patient assumed as a case, 3
patients at least, without evidence of the required falling- off in Hb, had to be recruited as controls,
matched with the corresponding case for age, sex and duration of CHF symptoms. The exclusion
from the study was stated if any patient had shown serum Hb values of ≤10.5 g/dl at the initial
measurement or had undergone an anti-anemic treatment before the end of the prescribed 2 years
of follow up.
Results: 15 CHF patients with a fall in Hb of 10% at least compared to initial concentration were
included in the study together with 45 controls. At univariable logistic analysis, patient location in
NYHA class ≥ III, serum creatinine values >1.5 mg/dl, clinical history of digestive tract bleeding,
an enalapril mean dose higher than 10 mg/day and a furosemide oral mean dose of ≥ 125
mg/day were shown to be associated with increased risk of significant fall in Hb values. At
multivariate analysis, the role of predictor of Hb decrease was retained by serum creatinine values
>1.5 mg/dl (OR: 15.2, 95% CI: 4.05-55.1, p<0.0001) and by a dose of enalapril >10 mg/day (OR:
12.33, 95%CI: 3.7-62.25, p<0.0002).
Conclusions: The fall in Hb level, as typically found in advanced stages of CHF, should be labeled
as an anemia of chronic disorder, mainly caused by renal dysfunction; furthermore, it could be
propitiated or aggravated by inappropriately high doses of ACE-inhibitors, known to be capable of
counteracting or blocking the synthesis of endogenous erythropoietin, especially in the presence of
impaired renal function
O285
VALORE PROGNOSTICO DI MARKERS DI FUNZIONE EPATICA IN PAZIENTI
SOTTOPOSTI A RESINCRONIZZAZIONE CARDIACA
CHIARA ANDREOLI (a), ERBERTO CARLUCCIO (a), PAOLO BIAGIOLI (a),
GIANFRANCO ALUNNI (a), GIANLUCA ZINGARINI (b), SANDRA D´ADDARIO (a),
ANNA MENGONI (a), CLAUDIO CAVALLINI (b), GIUSEPPE AMBROSIO (a)
(a) CARDIOLOGIA E FISIOPATOLOGIA CARDIOVASCOLARE, UNIVERSITÀ DEGLI
STUDI DI PERUGIA; (b) SC DI CARDIOLOGIA, AZIENDA OSPEDALIERA DI PERUGIA
Obiettivi: Valutare il ruolo prognostico di markers di funzionalità epatica in pazienti con scompenso
cardiaco sottoposti a terapia di resincronizzazione cardiaca.
Background: In pazienti con scompenso cardiaco possono coesistere ipoperfusione d’organo e
congestione venosa; entrambe possono avere impatto sulla funzionalità epatica con conseguenze
negative sulla prognosi dei pazienti.
Metodi: In 214 pazienti (83 % maschi, età media 69.9 ± 8.4 anni; QRS medio 147.2±25 ms) con
scompenso cardiaco (classe funzionale NYHA 2.7 ± 0.6) sottoposti ad impianto di pacemaker
biventricolare sono state dosate, prima dell'impianto del device, le concentrazioni ematiche di
glutamico-ossalacetico transaminasi (GOT), glutamico-piruvico transaminasi (GPT), gammaglutamil transferasi (GGT), fosfatasi alcalina (ALP), bilirubina, emoglobina (Hb), peptide
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della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
natriuretico (BNP) e creatinina. I pazienti sono stati successivamente seguiti per 29.5±21 mesi; l’endpoint primario considerato è stata la mortalità totale. E’ stata utilizzata la regressione multivariata di
Cox al fine di identificare le variabili predittive di mortalità per tutte le cause.
Risultati: Nell’intera popolazione i valori medi di GGT sono stati 54.8±54.2 UI/L; 69 pazienti ( 32.2
%) hanno mostrato valori di GGT > 50 UI/L. Durante il follow-up si sono verificati 39 decessi
(18.2%). All'analisi multivariata di Cox, dopo correzione per vari fattori confondenti (durata e
morfologia del QRS, frazione di eiezione, età..) i livelli ematici di GGT (HR 2.05, I.C.95% 1.0823.874, p: 0.028), BNP (HR 1.56, I.C.95% 1.065-2.309, p: 0.022), ALP (HR 1.004, I.C.95% 1.0011.007, p: 0.006), Hb (HR 2.41, I.C.95% 1.214-4.811, p: 0.012), creatinina (HR 2.09, I.C.95% 1.0594.145, p: 0.034), e la terapia con beta bloccanti (HR 0.39, I.C.95% 0.203-0.771, p: 0.007), sono
risultati predittori indipendenti di mortalità per tutte le cause. Le curve di Kaplan-Meyer hanno
mostrato una differenza statisticamente significativa nella sopravvivenza tra pazienti con valori di
GGT nella norma o elevati.
Conclusioni: La prevalenza di elevati valori ematici di GGT in pazienti con SC sottoposti a CRT
appare elevata. I livelli di GGT risultano uno dei predittori indipendenti di mortalità per tutte le cause.
La valutazione degli indici di funzionalità epatica può contribuire ad un più accurata selezione dei
pazienti candidati a CRT.
O286
INFLUENZA DEL GENOTIPO ACE SULL'EFFICACIA DELLA TERAPIA CON ACE
INIBITORI NELLO SCOMPENSO CARDIACO CRONICO
ELISA MARIA NERINA COMPAGNINO (A), MAURO CONTINI (A), DAMIANO MAGRÌ (A),
GAIA CATTADORI (A), PIERGIUSEPPE AGOSTONI (A)
(a) CENTRO CARDIOLOGICO MONZINO, IRCCS
Premesse: La concentrazione plasmatica di enzima ACE è regolata da un polimorfismo genico
inserzione/delezione che genera tre possibili genotipi: DD, ID, II. I soggetti DD mostrano più elevate
concentrazioni plasmatiche dell’enzima e, nello scompenso cardiaco cronico (SCC), una maggiore
severità della malattia. Nei pazienti con SCC la terapia con ACE inibitori migliora la diffusione
polmonare e l’efficienza ventilatoria, ma non è noto se tale beneficio possa essere influenzato dal
polimorfismo ACE. Scopo del nostro studio è stato confrontare l’effetto protettivo degli ACE inibitori
nei tre diversi genotipi in un modello di sovraccarico idrico acuto.
Popolazione e Metodi: Nello studio, condotto in cieco, sono stati inclusi pazienti affetti da SCC con
frazione di eiezione ≤ 40%, in stabili condizioni cliniche, terapia medica ottimizzata comprensiva di
enalapril al massimo dosaggio tollerato e senza aspirina, classe NYHA I-III. Al giorno 1 ciascun
paziente ha eseguito un test cardiopolmonare massimale a rampa (CPET). Al giorno 2 sono state
eseguite prove di funzionalità respiratoria con misurazione della DLCO e delle sue sottocomponenti
(diffusione di membrana, Dm e volume capillare, Vc) prima e dopo infusione di 500 cc di soluzione
fisiologica in un’ora. Dopo l’infusione è stato quindi ripetuto il CPET.
Risultati: Abbiamo arruolato 100 pazienti (75 maschi e 25 femmine) di età media 61 ± 11 anni,
suddivisi in tre gruppi in base al genotipo (28 DD, 55 ID e 17 II). Non sono state osservate differenze
significative tra i tre gruppi in termini di caratteristiche cliniche o ecocardiografiche, parametri del
CPET, meccanica respiratoria o diffusione polmonare. La dose di enalapril è risultata statisticamente
omogenea tra i tre gruppi (DD 15,2 ± 9,1 mg/die; ID 19,3 ± 10,7 mg/die; II 18,8 ± 12,2 mg/die,
p=0,23). Gli effetti del carico idrico acuto sono riassunti nella tabella. Il carico idrico ha determinato
un peggioramento significativo della diffusione e dell’efficienza ventilatoria (slope VE/VCO2)
nell’intera popolazione. Tale peggioramento è apparso tuttavia significativamente maggiore nel
genotipo DD rispetto agli altri due genotipi.
∆ DLCO
∆ DLCO% ∆ DLCO/VA ∆ Dm
∆ Dm/VA
∆VE/VCO2
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della Società Italiana di Cardiologia
mL/mmHg/min
Tutti -1.19 ± 1,72
DD
- 2.3 ± 1.33 β
ID
- 0.82 ± 1.84
mL/mmHg/
min/L
- 4.82 ± - 0.15 ± 0.37
7.22
- 9.6 ± 6.24 - 0.3 ± 0.35 θ
μ
Roma, 13 – 15 dicembre 2014
mL/mmHg/min mL/mmHg/
min/L
- 3.83 ± 6.5
- 0.7 ± 1.51
- 6.9 ± 4.7 τ
0.68 ± 3
- 1.35 ± 1.4 φ 1.85 ± 1.88 α
- 3.16 ± - 0.08 ± 0.38 - 3.10 ± 7.2
- 0.54 ± 1.56 0.55 ± 3.41
7.34
II
- 0.57 ± 0.96
- 2.28 ± - 0.04 ± 0.22 - 1.22 ± 4.8
- 0.16 ± 1.17 - 0.83 ± 2.31
4.27
β
p < 0,0001 vs ID, p = 0,002 vs II; μ p < 0,0001 vs ID, p = 0,001 vs II; θ p = 0,009 vs ID,
p = 0,02 vs II; τ p = 0,03 vs ID, p = 0,01 vs II; φ p = 0,05 vs ID, p = 0,02 vs II; α p = 0,01 vs II.
VA= volume alveolare; ∆= differenza pre-post carico idrico acuto; %= percentuale del predetto.
Conclusioni: Il polimorfismo presente a livello del gene che codifica per l’enzima ACE modula la
protezione della terapia con ACE inibitori nei confronti del sovraccarico idrico acuto, con un minore
grado di protezione nel genotipo DD. È pertanto verosimile che tali soggetti possano essere
maggiormente vulnerabili all’edema polmonare acuto.
O287
CLINICAL AND PROGNOSTIC ROLE OF AMMONIA IN ADVANCED
DECOMPENSATED HEART FAILURE. THE CARDIO-ABDOMINAL SYNDROME?
STEFANO PIDELLO (A), SIMONE FREA (A), FEDERICO GIOVANNI CANAVOSIO (A),
VIRGINIA BOVOLO (A), MICHELA BOTTA (A), SERENA BERGERONE (A),
FIORENZO GAITA (A)
(A) CITTÀ DELLA SALUTE E DELLA SCIENZA DI TORINO
Background: Advanced heart failure is associated to end-organ damage. Recent literature suggested
an intriguing crosstalk between failing heart, abdomen and kidneys. Venous ammonia, as a byproduct
of the gut, could be a marker of abdominal injury in heart failure patients.
Aim of the study was to investigate the clinical and prognostic role of ammonia in patients with
advanced decompensated heart failure (ADHF).
Methods & Results: A total of 90 consecutive patients admitted with ADHF treated with intensive
medical therapy were studied. The prognostic role of ammonia at admission was evaluated. Primary
end-points were: need for renal replacement treatment (RRT) and a composite of cardiac death, urgent
heart transplantation and mechanical circulatory support at 3 months.
In the study cohort (age 58.98 ± 12.01 years, FE 21.61 ± 9.02%, INTERMACS profile 3.66 ± 0.86,
creatinine 1.71 ± 0.95 mg/dl) 9 patients (10%) needed RRT, while 27 patients (30%) underwent the
cardiac composite endpoint.
At ROC curve analysis ammonia ≥130 μg/dl the best diagnostic accuracy (sensitivity 55.6%;
specificity 81.5%, AUC 0.683). At logistic regression analysis ammonia predicted the need for RRT
(OR 11.4, CI 1.2-111.1; p=0.031) and the cardiac composite endpoint (OR 6.9 CI, 1.1-43.4; p=0.041)
[Figure 1]. Other common predefined risk factors did not predict events. Ammonia correlated with
cardiac index (r=-0.390; p=0.036) and mean right atrial pressure (r=0.386; p=0.039) [Figure 2].
Conclusion: In a selected population admitted for ADHF ammonia, as a marker of abdominal
derangement, seemed to be a new promising predictor of diuretic refractoriness and adverse cardiac
events.
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della Società Italiana di Cardiologia
Figure 1
Roma, 13 – 15 dicembre 2014
Figure 2
PREVENZIONE E RIABILITAZIONE
O288
EFFETTI DI UN PROGRAMMA RIABILITATIVO OLISTICO IN DAY-HOSPITAL SU
PARAMETRI FUNZIONALI E PSICOLOGICI IN PAZIENTI AFFETTI DA
IPERTENSIONE ARTERIOSA POLMONARE
MAURIZIO BUSSOTTI (A), MARINELLA SOMMARUGA (C),
PATRYCJA KRANSINSKA (A), SILVIA DI MARCO (A), PAOLA CORBO (A),
GIOVANNI MARCHESE (A), PAOLA GREMIGNI (B), ROBERTO FE PEDRETTI (A)
(A) U.O. CARDIOLOGIA RIABILITATIVA -ISTITUTO SCIENTIFICO DI RIABILITAZIONE IRCCS - FONDAZIONE SALVATORE MAUGERI - MILANO; (B) DIPARTIMENTO DI
PSICOLOGIA - UNIVERSITA´ DI BOLOGNA - BOLOGNA; (C) U.O. PSICOLOGIA ISTITUTO SCIENTIFICO DI RIABILITAZIONE - IRCCS - FONDAZIONE SALVATORE
MAUGERI - MILANO
L’ipertensione arteriosa polmonare (IAP) è una malattia rara caratterizzata da una severa
compromissione della capacità funzionale e della qualità di vita. Quindici pazienti affetti da IAP in
classe funzionale WHO II e III ed in stabili condizioni cliniche, sono stati arruolati in un programma
riabilitativo cardiorespiratorio della durata di 4 settimane condotto in regime di day-hospital,
comprendente sessioni di esercizi aerobici e di resistenza, rinforzo dei muscoli respiratori, sessioni di
respiro lento e di rilassamento. I pazienti vanivano valutati durante una prima visita di controllo (T0),
un mese più tardi all’inizio del periodo riabilitativo (T1), ed al termine di tale periodo (T2). Ogni volta
venivano sottoposti a spirometria e valutazione della diffusione alveolo-capillare, a dosaggio del
BNP, ad ecocardiografia, a test del cammino dei 6 minuti (6-MWT) e ad un test da sforzo
cardiorespiratorio massimale (CPET). La qualità di vita era valutata con l’ Hospital Anxiety and
Depression Scale (HADS) e con l’ EuroQUOL-5D. Obiettivo primario dello studio era valutare gli
effetti della riabilitazione sul consumo di O2 al picco dell’esercizio (VO2 di picco). Al termine delle
4 settimane, i pazienti hanno mostrato un miglioramento significativo degli indici di qualità di vita,
ansia e depressione (p<0.01), e della capacità funzionale (+5.2% al 6-MWT, p<0.05; +22% di carico
di lavoro al CPET, p<0.01), con un incremento significativo del VO2 di picco e del polso dell’ O2.
Nessuna modifica è stata osservata a carico dei parametri respiratori ed ecocardiografici. Durante le
sessioni riabilitative non sono stati osservati eventi avversi. In conclusione, lo studio dimostra come
un programma riabilitativo condotto in day-hospital su pazienti affetti da IAP ed in classe funzionale
II e III possa essere non solo fattibile ma apportare in sole 4 settimane significativi miglioramenti
della capacità d’esercizio e della qualità di vita.
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262
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
6MWT
T0
122 ± 127
454 ± 114
T1
114 ± 122
456 ± 115
T2
137 ± 164
487 ± 120
p
NS
<0.05
75 ± 14
75 ± 13
80 ± 10
<0.05
72 ± 23
17.3 ± 4.2
53 ± 9
7.8 ± 1.9
73 ± 22
16.9 ± 3.4
52 ± 8
8.1 ± 2.4
87 ± 21
20.0 ± 4.5
61 ± 11
8.7 ± 2.3
<0.01
<0.01
<0.01
<0.01
92 ± 5
42.4 ± 10.3
9.6 ± 1.8
-
93 ± 5
42.5 ± 9.8
9.9 ± 1.8
9.7 ± 5.3
5.7 ± 3.5
92 ± 6
40.6 ± 9.3
10.5 ± 1.7
6.1 ± 3.6
4.1 ± 2.6
NS
NS
<0.05
<0.01
<0.01
EQ-5D
-
0.6 ± 0.3
0.9 ± 0.1
<0.01
EQVAS
-
61.4 ± 19.2
81.8 ± 14.3
<0.01
BNP
Distanza (mt)
Distanza % predetto
CPET
Test
psicologic
i
Roma, 13 – 15 dicembre 2014
Carico lavoro (watt)
VO2/kg picco(ml/min/kg)
VO2 % predetto
Polso O2 picco
(ml/min/bpm)
SpO2 picco (%)
VE/VCO2 slope
ΔVO2/ΔWR (ml/min/watt)
HADS-Ansia
HADS-Depressione
O289
ADDITIONAL DIAGNOSTIC VALUE OF POCKET SIZE IMAGING DEVICE FOR
IDENTIFICATION OF RIGHT HEART INVOLVEMENT IN ASYMPTOMATIC
REGULAR SMOKERS.
ROBERTA ESPOSITO (A), VINCENZO SCHIANO LOMORIELLO (A), CIRO SANTORO (A),
AGOSTINO BUONAURO (A), FRANCESCO LO IUDICE (A), GIOVANNI DE SIMONE (A),
MAURIZIO GALDERISI (A)
(A) CENTRO INTERDIPARTIMENTALE PER LA RICERCA SULL´IPERTENSIONE
ARTERIOSA E PATOLOGIE ASSOCIATE, UNIVERSITA´ FEDERICO II, NAPOLI
Purpose: Aim of the study was the assessment of the additional diagnostic power of Pocket Size
Imaging Device (PSID) in comparison with simple physical exam (PE) in detecting early signs of
right heart deterioration in asymptomatic regular smokers (RS) free of overt cardiac involvement.
Methods: PE, PSID (Vscan, GE) exam and standard echocardiographic assessment was performed
in 151 RS with or without chronic obstructive pulmonary disease and 51 healthy controls, comparable
for age and sex. Based on a simplified Boston score, values ≥1 of clinical signs as jugular venous
pressure elevation, hepatomegaly, peripheral pitting oedema and abnormal pulmonary sounds were
considered indicative of right heart involvement. By PSID, 4 quantitative parameters (maximal
diameter of inferior vena cava [IVC], abnormal cut-point >2.0 cm), percent respiratory variation of
IVC (cut-point <50%), maximal right atrial (RA) minor dimension (cut-point > 4.5 cm), maximal
minor-axis middle right ventricular (RV) dimension (cut-point >4.2 cm) were analyzed and a
composite score (1 to 4) was generated by summing the points (0=normal value, 1=abnormal value)
of single parameters. The ultrasound imaging deriving from both PSID and standard
echocardiography was performed by blinded operators experienced with ultrasound techniques.
SIC | Indice Autori
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Results: Simplified Boston score was 0.06 ± 0.02 in healthy controls and 0.10 ± 0.3 in RS (p=0.33,
NS). By PSID, IVC (1.3 ± 0.3 in controls and 1.6 ± 0.4 cm in RS, p<0.0001), RA diameter (3.1 ± 0.5
in controls and 3.4 ± 0.5 cm in RS, p<0.002), RV diameter (3.4 ± 0.5 in controls and 3.5 ± 0.5 cm in
RS, p<0.05) and PSID score (0.27 ± 0.5 vs 0.64 ± 0.7, p<0.0001) were greater in RS. Positive
correlations of the number of cigarettes per day with IVC (r=0.26, p<0.0001) and RA dimension
(r=0.15, p=0.03) were found in RS group. Differences and correlations were confirmed by statistical
analyses also using standard echocardiography. The 95% confidence interval for IVC agreement
between PSID and standard echocardiography was from -0,49 to 0.51. Intra-class correlation was
ρ=0.87 (0.80-0.92), p<0.0001. The additional diagnostic power of PSID (score ≥1 = 56.2%) in
comparison with PE (at least 1 clinical sign, 11.3%) in RS was of 44.9%.
Conclusion: The present study indicates good feasibility and additional diagnostic power in
comparison with physical exam for early ultrasound detection of right heart involvement in regular
otherwise healthy smokers, by using the prompt technology of PSID. The agreement between PSID
and echocardiographic measurements appears to be very good and highlights the accuracy of PSID
exam in this clinical setting.
O290
RISULTATI PRELIMINARI DEL PROGETTO ‘FOOTBALL MANAGER YOUNG’:
SCREENING
ELETTROCARDIOGRAFICO
MEDIANTE
SUPPORTO
TELECARDIOLOGICO IN GIOVANI ATLETI DILETTANTI
NATALE DANIELE BRUNETTI (A), GIULIA DELLEGROTTAGLIE (C), GIUSEPPE DI
GIUSEPPE (C), CLAUDIO LOPRIORE (C), LUISA DE GENNARO (D),
GIOVANNI GARDINI (E), SILVIA PATRUNO (F), SAVERIO LANZONE (B),
TERESA LOIACONO (C), MATTEO DI BIASE (A)
(A) CARDIOLOGIA UNIVERSITARIA OSPEDALI RIUNITI FOGGIA; (B) OSPEDALE DI
VENERE BARI; (C) CARDIO-ON-LINE EUROPE S.R.L. BARI; (D) OSPEDALE SAN PAOLO
BARI; (E) HELLAS VERONA F.C.; (F) FOOTBALL MANAGER YOUNG
Background: La prevenzione della morte improvvisa nei giovani atleti prevede lo screening
mediante elettrocardiogramma. Le metodiche di tele-medicina possono essere utili
nell’implementazione di tali strategie di screening e nella riduzione dei costi di gestione. Riportiamo
i risultati preliminari del progetto ‘Football Manager Young’, un progetto di tutoraggio che la società
calcio Hellas Verona, in collaborazione con la sezione pugliese della Federazione Italiana Gioco
Calcio, ha avviato per promuovere la formazione di giovani atleti di 20 scuole calcio della regione
Puglia. Il progetto prevede attività di tutoraggio tecnico-formativo e la possibilità di accesso ad uno
screening elettrocardiografico mediante supporto telecardiologico.
Metodi: Da gennaio del 2014, i primi 515 dei 2000 allievi di 20 scuole calcio della regione Puglia
sono stati sottoposti a screening elettrocardiografico mediante supporto tele-cardiologico. Gli
elettrocardiogrammi sono stati effettuati da personale delle scuole calcio, istruito appositamente con
un breve training, e registrati mediante apparecchi Cardiovox. Gli elettrocardiogrammi sono stati
inviati ad una centrale di telecardiologia situata a Bari e refertati online. I reperti elettrocardiografici
sono stati pertanto analizzati.
Risultati: L’età media dei soggetti screenati è stata di 13±10 anni, il 98,5% dei soggetti screenati era
di genere maschile. Il reperto elettrocardiografico è stato ritmo sinusale nel 95,5% dei soggetti, 6
soggetti mostravano extrasistolia sopraventricolare, 7 ventricolare, 6 T negative, 1 elevati voltaggi
del QRS, 75 blocco di branca destra incompleto, 3 blocco di branca destra completo. In 7 soggetti è
stata consigliata visita cardiologica, in 2 Holter, in 3 ecocardiogramma: in tali soggetti non sono state
tuttavia rilevate patologie di rilievo.
Conclusioni: Lo screening elettrocardiografico della morte improvvisa può essere realizzato
mediante supporto tele-cardiologico remoto in una popolazione di giovani allievi di scuole calcio.
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Roma, 13 – 15 dicembre 2014
O291
REGULAR PHYSICAL EXERCISE WITH NORDIC WALKING IMPROVES CARDIAC
PERFORMANCE AND VASCULAR ENDOTHELIAL FUNCTION IN POSTMENOPAUSAL WOMEN
SARA SALERNI (A), FRANCESCO RADICO (A), ROBERTO TOMMASI (A),
PASCAL IZZICUPO (B), EMANUELE D´ANGELO (B), ANDREA DI BLASIO (B),
ANGELA DI BALDASSARRE (B), RAFFAELE DE CATERINA (B), SABINA GALLINA (A)
(A) DEPARTMENT OF NEUROSCIENCES, IMAGING AND CLINICAL SCIENCES,
UNIVERSITY OF CHIETI, ITALY; (B) DEPARTMENT OF INTERNAL MEDICINE AND
AGING, UNIVERSITY OF CHIETI, ITALY
Background: It is well known that women experience cardiovascular events mainly after menopause,
while during the reproductive period estrogens exert protective effects on cardiovascular system. The
post-menopausal hormones withdrawal is associated with the development of cardiac risk factors
such as dyslipidemia, hypertension, glucose intolerance, diabetes and obesity with a typical android
pattern of fat distribution. A sedentary lifestyle can also increase exponentially the risk of adverse
cardiovascular events, so a regular moderate-intensity physical activity is strongly recommended.
Nordic Walking is a simple and feasible form of aerobic exercise which differs from the classical
brisk walking for the additional use of specially designed poles, which provides the advantage to
actively involve a higher amount of muscle mass including also the upper body and arms leading to
superior cardiorespiratory fıtness.
Aims: To assess cardiovascular effects of a regular moderate-intensity physical training program with
Nordic Walking in post-menopausal women.
Methods: Thirty-two voluntary healthy postmenopausal women (mean age 59±4), underwent a 15
weeks Nordic Walking training program at moderate intensity (Borg Scale 11-13). Treadmill exercise
test, color-Doppler echocardiography, flow-mediated dilation (FMD) of the brachial artery, intimamedia thickness (IMT) of common carotid artery, anthropometric measurements, bioelectrical
impedance analysis, and blood test including complete blood count, lipid profile, glycemia, glycated
hemoglobin, were performed at baseline and after the training period.
Results: We found an improvement in both systolic and diastolic cardiac performance as documented
by an increase of left ventricle ejection fraction (67.7 vs 70.8%; p=0.002) and a reduction of
isovolumetric relaxation time (83.8 vs 80.3 ms; p=0.003) from baseline to the end of training program.
An improvement of vascular endothelial function was also documented by a significant increase of
FMD (12.1 vs 19.0%; p=0.004). There were no significant modifications of body composition and
anthropometric measurements. Accordingly it can be postulated that the improvement of vascular
endothelial function is independent from metabolic and body composition modifications, and it is
maybe related to a direct effect of exercise.
Conclusions: The study emphasizes the benefits of a regular physical activity on cardiovascular
system in postmenopausal women, and proposes the Nordic Walking as an effective and welltolerated method of aerobic exercise.
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Roma, 13 – 15 dicembre 2014
O292
ECHOCARDIOGRAPHIC EVALUATION OF EARLY CHANGES IN THE AORTIC WALL
OF YOUNG PATIENTS WITH BICUSPIDIC AORTIC VALVE
LUCA LONGOBARDO (A), MYRIAM D´ANGELO (A), MARTA ZUCCO (A),
FRANCESCO COSTA (A), MARIA CHIARA TODARO (A), LILIA ORETO (A),
MAURIZIO CUSMÀ-PICCIONE (A), SCIPIONE CARERJ (A), GIUSEPPE ORETO (A),
MARIA PIA CALABRÒ (A), CONCETTA ZITO (A)
(A) SCUOLA DI SPECIALIZZAZIONE IN MALATTIE DELL´APPARATO
CARDIOVASCOLARE - UNIVERSITA´ DEGLI STUDI DI MESSINA
BACKGROUND: Bicuspid aortic valve (BAV) is one of the most common congenital heart diseases,
commonly associated to a diffuse aortopathy. Aortic stiffness increase is one of early manifestation
of this disease. However, changes in aortic strain are not well established, to date. Aim of our study
was to identify early pathophysiological changes in aortic wall of patients with BAV.
METHODS: 13 patients (9 males; age:19 ±1.5 years) with BAV and 10 control subjects (4 males;
age 20 ±2 years ) comparable for gender and body surface area (BSA) were enrolled. Overall aortic
dimensions were obtained (annulus, Valsalva sinuses, sinotubular junction and ascending aorta) by
two-dimensional echocardiographic parasternal long axis view, and indexed by BSA. Aortic stiffness
index (SI) was evaluated according to the formula: ln(SBP/DBP)/[(AoS -AoD)/AoD] where SBP and
DBP refer to brachial systolic and diastolic blood pressures, respectively, measured in mmHg; pulse
pressure (PP) was calculated as SBP - DBP, and ln(SBP/DBP) refers to the natural logarithm of the
relative pressure. Longitudinal strain (LS) of ascending aorta and circumferential strain (CS) of
abdominal aorta were evaluated offline by a customized commercial speckle-tracking software
(Echopac, GE Horten, Norway)
RESULTS: BAV patients had increased aortic stiffness (5.8±4.3 vs. 1.93±1,42; p < 0.049) and
reduced longitudinal strain (30.8±19 vs. 48±12, p< 0.036) of the ascending aorta. Circumferential
strain (CS) of abdominal aorta was not significantly different between BAV patients and normal
subjects. Indexed diameters of both ascending aorta and abdominal aorta were within the normal
range in patients and controls (p=ns). A significant correlation was found between the ascending
aortic LS and the ascending aortic systolic diameter (R -0,69, p<0.03) after adjusting for the body
size.
CONCLUSIONS: The presence of BAVs is associated with a lower longitudinal strain and a higher
stiffness of the ascending aorta, compared with normal subjects, in patients with normal ascending
aortic diameters. Aortic wall changes could be well detected by 2D speckle tracking
echocardiography, that could be considered a useful tool for an early diagnosis of aortic alterations
in these subjects.
O293
IL TESSUTO ADIPOSO EPICARDICO: POSSIBILE MARKER PRECOCE DI MALATTIA
CARDIOVASCOLARE?
SABRINA BENCIVENGA (A), RENATA PETRONI (B), MICHELE DI MAURO (A),
ANGELO ACITELLI (A), MARCO CICCONETTI (A), ROBERTA MAGNANO (A),
ANTONIO STORNELLI (B), ANGELO PETRONI (B), SILVIO ROMANO (A),
MARIA PENCO (A)
(A) CARDIOLOGIA-UNIVERSITA´ DELL´AQUILA; (B) CASA DI CURA DI LORENZOAVEZZANO
Background: Il tessuto adiposo epicardico rappresenta il tessuto adiposo viscerale del cuore. È
correlato con l’adiposità viscerale addominale e, come questo, assolve ad una funzione endocrina, e
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potrebbe causare un aumento del rischio cardiovascolare. Esiste una vasta letteratura che mette in
relazione lo spessore del tessuto adiposo pericardico con i fattori di rischio e le malattie
cardiovascolari, specialmente tramite TC e RM, ma c’è una scarsa letteratura sul tessuto adiposo
epicardio.
Obbiettivo: L’obbiettivo di questo studio è quello di dimostrare se vi sia una relazione tra lo spessore
del grasso epicardico, i fattori di rischio cardiovascolari e gli eventi cardiovascolari, usando una
tecnica non invasiva e facilmente accessibile come l’ecocardiografia.
Metodi: Da ottobre 2013 a dicembre 2013, 140 pazienti consecutivi (m = 68, f = 72), con età media
di 53±8 anni, sono stati arruolati nel nostro studio clinico. Tutti i soggetti sono stati sottoposti a un
ecocardiogramma transtoracico. Una finestra parasternale asse lungo è stata eseguita per misurare lo
spessore epicardico (spazio tra la parete libera del ventricolo destro e il foglietto viscerale del
pericardio) alla fine della sistole in 3 cicli cardiaci, perpendicolarmente all’anulus aortico. I fattori di
rischio per l’aterosclerosi considerati sono stati: ipertensione, ipercolesterolemia e diabete. L’endpoint primario è stato valutare se pazienti con fattori di rischio mostravano uno spessore del grasso
epicardico maggiore. L’end-point secondario è stato valutare se lo spessore del grasso epicardico era
correlato con eventi cardiovascolari (cardiopatia ischemica e ictus cerebri).
Risultati: La popolazione è stata divisa in due gruppi. Gruppo A: 105 soggetti con epicardio normale
(< 7mm) e Gruppo B: 35 soggetti con epicardio ispessito (≥ 7 mm). I due gruppi erano simili per età
e genere.Lo spessore del grasso epicardico si è dimostrato essere correlato in maniera significativa
con l’età (p < 0,001, R = 0.39) e con l’indice di massa corporea ( p < 0.001, R = 0.31), mentre non ci
sono state differenze statisticamente significative tra i due sessi. Il Gruppo B ha mostrato una più alta
percentuale di ipertesi (Gruppo B: 65%, Gruppo A: 40%, p=0,006), ipercolesterolemici (Gruppo B:
54%, Gruppo A: 27%, p=0,004) e diabetici (Gruppo B: 68%, Gruppo A 33%, p=0,003).Il numero di
fattori di rischio è direttamente correlato con l’incremento medio dello spessore epicardico (da 4,8
mm per zero fattori di rischio a 7,8 mm per 3 fattori di rischio p<0,001).La presenza di almeno un
fattore di rischio è stata 42% nel Gruppo B vs 28% nel Gruppo A, p=0.01; per due fattori di rischio
questa percentuale è stata 40% nel Gruppo B vs 21% nel Gruppo A (p<0,01) e per tre fattori di rischio
36% nel Gruppo B e 21% nel Gruppo A (p=0,03).Inoltre, il Gruppo B ha mostrato una più alta
incidenza di eventi cardiovascolari (cardiopatia ischemica, stroke, arteriopatia periferica) rispetto al
Gruppo A (31% vs 19% p =0.04), con un valoremedio di spessore epicardico maggiore nei soggetti
con eventi cardiovascolari (7.4 mm) se paragonati alla popolazione senza eventi (5.8 mm).
Conclusioni: Lo spessore del tessuto adiposo epicardico si correla bene con i fattori di rischio
cardiovascolare (diabete, dislipidemia, ipertensione). Inoltre, all'incremento dello spessore del tessuto
adiposo aumenta anche il numero di eventi cardiovascolari anamnestici. Queste osservazioni possono
essere lo spunto per successivi lavori prospettici al fine di valutare il ruolo dello spessore epicardico
come predittore di eventi cardiovascolari.
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Roma, 13 – 15 dicembre 2014
O294
CMR SURVEY IN A LARGE COHORT OF TI PATIENTS
ANTONELLA MELONI (A), STEFANIA VACQUER (B), MARIA PAOLA CARTA (B),
STEFANIA RENNE (C), ANNA PIETRAPERTOSA (D), CHIARA TUDISCA (E),
VINCENZO POSITANO (A), MARIA ELIANA LAI (B), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G.MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) OSPEDALE MICROCITEMICO, CENTRO TALASSEMICI ADULTI, CAGLIARI, ITALY;
(C) STRUTTURA COMPLESSA DI CARDIORADIOLOGIA-UTIC, P.O. “GIOVANNI PAOLO
II”, LAMEZIA TERME (CZ), ITALY; (D) SERVIZIO REGIONALE TALASSEMIE,
POLICLINICO DI BARI, BARI, ITALY; (E) ISTITUTO DI RADIOLOGIA, POLICLINICO
“PAOLO GIACCONE“, PALERMO, ITALY
Introduction: Little is known about cardiac involvement in thalassemia intermedia (TI) using
cardiovascular magnetic resonance (CMR). We investigated myocardial iron overload (MIO),
biventricular parameters, and myocardial fibrosis in a large cohort of TI patients, underlying the
differences between transfusion-dependent and non-transfusion-dependent patients.
Methods: We studied 252 adult TI patients (119 females, 39.5±10.4 years) enrolled in the MIOT
Network. MIO was assessed using a multislice multiecho T2* approach. Biventricular function
parameters were quantified by cine sequences. Myocardial fibrosis was evaluated by late gadolinium
enhancement acquisitions.
Results: One-hundred and eighty-eight (74.6%) patients showed no MIO in any segment, 56 (22%)
had an heterogeneous distribution (52 with global heart T2*≥20 ms), and 8 (0.3%) showed an
homogeneous MIO. Left ventricular (LV) and right ventricular (RV) dilatations were present in 113
(45%) and in 49 (19%) patients, respectively. LV dysfunction was present in the 18.0% of the cases
while RV dysfunction in the 3.63%. High LV mass indexes were present in 22 (8.7%) patients. Fiftytwo/227 (22.9%) patients showed myocardial fibrosis. Myocardial fibrosis was associated to LV
dysfunction (P=0.001) and high mass indexes (P=0.038).
One-hundred and fourteen patients were non-transfusion dependent (transfusion requirements absent
or sporadic) while 138 patients were transfusion-dependent (regular transfusions). The Table shows
the comparison between the two groups. Non-transfusion-dependent patients showed significantly
higher global heart T2* values and MIO with a global heart T2* < 20 ms was detected in two of them
(one requiring occasional blood transfusions and one non transfused). Biventricular end-diastolic
volume index, stroke volume index, left ventricular (LV) mass index, and LV cardiac index were
significantly higher in the non-transfusion dependent group.
Conclusions: CMR plays a key role in the management of TI patients. Heart iron (global heart
T2*<20 ms) was not common, but a quarter of the patients had some pathological segments. A
consistent number of patients had the stigmata of the high cardiac output state cardiomyopathy.
Myocardial fibrosis was related to the high cardiac output state. The signs of the high output state
were controlled in transfusion-dependent patients.
Age
Sex (M/F)
Global heart T2* (ms)
NonTransfusion- P
transfusion- dependent
dependent
39.9 ± 11.5 39.2 ± 9.4 0.922
67/47
38.8 ± 6.7
66/72
0.083
35.5 ± 9.2 0.014
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MIO pattern, N (%):
No MIO
Het. MIO with global T2*≥20 ms
Het. MIO with global T2*<20 ms
Homogeneous MIO
Roma, 13 – 15 dicembre 2014
0.103
92 (80.7)
96 (69.6)
20 (17.5)
32 (23.2)
1 (0.9)
3 (2.2)
1 (0.9)
7 (5.1)
LV EDVI (ml/m2)
99.4 ± 19.6 92.9 ± 19.1 0.009
LV SVI (ml/m2)
62.9 ± 12.4 58.6 ± 13.1 0.007
LV mass index (g/m2)
69.9 ± 13.9 63.9 ± 12.9 0.004
LV ejection fraction (%)
63.7 ± 6.8
62.5 ± 6.6 0.163
LV cardiac index (L/min/m2)
7.6 ± 2.3
6.5 ± 2.2
0.002
LGE, N (%)
20/105(19) 32/122(26.2) 0.199
RV EDVI (ml/m2)
92.0 ± 23.3 86.5 ± 20.8 0.048
RV SVI (ml/m2)
58.5 ± 14.9 54.5 ± 14.3 0.017
RV ejection fraction (%)
64.7 ± 8.3
63.3 ± 7.5 0.168
O295
UTILITÀ
DELLA
MISURAZIONE
DEL
GRASSO
STRATIFICAZIONE DEL RISCHIO DI PAZIENTI OBESI
EPICARDICO
NELLA
GIUSEPPINA NOVO (a), ILENIA MARTURANA (a), VITO BONOMO (a),
LUISA ARVIGO (a), VINCENZO EVOLA (a), GIORGIO KARFAKIS (a), MIRIAM LO
PRESTI (a), SALVATORE VERGA (b), SALVATORE NOVO (a)
(a) CATTEDRA E DIVISIONE DI CARDIOLOGIA, UNIVERSITA´ DI PALERMO; (b)
CATTEDRA E DIVISIONE DI MEDICINA INTERNA MALATTIE CARDIOVASCOLARI E
NEFROUROLOGICHE, UNIVERSITA´ DI PALERMO
Obbiettivo del nostro studio è stato valutare l’utilità della misurazione del grasso epicardico,
all’ecocardiografia transtoracica, nella valutazione del rischio cardiovascolare in pazienti obesi.
Metodi: abbiamo arruolato pazienti obesi ( BMI ≥ 30 kg/m2) senza valvulopatie significative,
con frazione di eiezione normale (FE >55%) e finestra acustica idonea alla valutazione del grasso
epicardico. Tutti i pazienti sono stati sottoposti ad anamnesi con rilevazione dei fattori di rischio
tradizionali e dei precedenti eventi cardiovascolari, visita cardiologica, elettrocardiogramma, esame
ecocardiografico transtoracico ed eco-color Doppler TSA.
Il grasso epicardico è stato valutato in telediastole in proiezione parasternale asse lungo.
Risultati: I pazienti studiati sono stati 113 pazienti (52,7 % di sesso maschile, età media 49,43 ±
11,63 anni), con BMI medio di 41,22 ± 7,82 Kg/m2 .
Presentavano un precedente evento cardiovascolare il 16,96% dei pazienti.
Della popolazione studiata il 7% ha avuto un infarto del miocardio, il 6,4% ha avuto almeno un
episodio di angina instabile e il 2.6% l’embolia polmonare.
Il valore medio del grasso epicardico della nostra popolazione era di 6,43± 2,50 mm.
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Il 41.6% dei pazienti presentava normale funzione diastolica mentre il 58.4% dei pazienti presentava
disfunzione diastolica (31 pazienti con disfunzione di I grado, 35 pazienti con disfunzione di II grado
e nessun paziente presentava disfunzione di III grado).
Presentavano placca o ispessimento medio intimale (IMT >0.9) il 47,32% dei pazienti.
Abbiamo osservato una relazione significativa tra lo spessore del grasso epicardico e la disfunzione
diastolica (valutata come E’ < 8), (p=0.001; F-ratio 11,769), con la presenza di aterosclerosi carotidea
(IMT >0.9mm o presenza di placca) (p<0,001; F-ratio 25,302) e precedenti eventi avversi
cardiovascolari (p=0.002; F-ratio 10,029).
Conclusioni: il nostro studio conferma che il grasso epicardico, parametro semplice da misurare
durante un esame ecocardiografico standard, aggiunge informazioni circa il rischio cardiovascolare
in pazienti obesi.
FUNZIONE VENTRICOLARE
O296
LAYER-SPECIFIC ANALYSIS OF MYOCARDIAL DEFORMATION BY 2D SPECKLE
TRACKING AND 3D STUDY FOR ASSESSMENT VENTRICULAR FUNCTION IN
PATIENTS WITH ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
(ARVC) AND IN THEIR RELATIVES
ROBERTA ANCONA (A), SALVATORE COMENALE PINTO (A), PIO CASO (A), MARIA
GABRIELLA COPPOLA (A), FORTUNATO ARENGA (A), ORNELLA RAPISARDA (A),
ANTONIO D´ONOFRIO (A), VINCENZO SELLITTO (A), RAFFELE CALABRÒ (A)
(a) NON INVASIVE CARDIOLOGY, CHAIR OF CARDIOLOGY, DEPARTMENT OF
CARDIOLOGY, SECOND UNIVERSITY OF NAPLES, MONALDI HOSPITAL, NAPLES,
ITALY.
Purpose: We evaluated 2DStrain (S)-Strain rate (SR), 3DE, 3DS, to quantitatively assess RV (right
ventricle), LV (left ventricle) function in ARVC patients (pts), with apparently normal LV and in
their relatives with apparently normal RV.
Methods: We studied 115 subjects: 35 with ARVC (GroupA), 40 relatives (GroupB) and 40controls
(GroupC). By E9GE we measured LV ejection fraction (EF%), RV dimension, fractional area change
(FAC%), RVOT fractional shortening (RVOTfs%); by DTI annulus velocities; by 2D Speckle
tracking longitudinal systolic S-SR in apical 4 and 2-chambers views, at level of LV segments (4
basal,4 mid,4 apical), RV segments (1 basal,1 mid,1apical) and circumferential (with endocardial an
epicardial layer analysis) and radial peak systolic LV 2D S-SR in short axis views; by 3DE RV
volumes and RVEF; by 3DS peak of global longitudinal, circumferential, radial and area S in apical
4-chambers.
Results: No significant differences were found between relatives and controls for RVdimensions,
RVFAC
(50±12vs51±11%),
RVOTfs
(64,8±13vs65,3±14%),
3DRVend-diastolic
(31±10,5vs33±11ml/mq) and end-systolic volume (15±4vs16±6ml/mq). Differences were present
between Group A and C for RV dimensions, 3DRV end-diastolic (52,8±9ml/mq) and end-systolic
volume (27±6,8ml/mq), FAC(27,8±12,1%), RVOTfs (27,2±16%), 3D RVEF(49±7,4%. Tricuspidal
E’/A’ ratio was inverted in pts and in 32/40 ARVC relatives. RV 2DSR-S were lower in pts (SR=1,37±0,37S-1;S=-12,45±4,4%, p<0.001) and in 28/40 (70%) subjects of GroupB (S=-18,5±4,8%;
SR=-1,54±0,4S-1, p<0.002) compared with controls (S=-26,6±8,1%,SR=-2,37±0,51 S-1). LV SR-S
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were significantly lower in GroupA compared to controls (longitudinal: 2DSR=-1,01±0,21vs1,53±0,49S-1;2DS=-15,2±4,3%vs-20,59±4,47%,3DS-12,3±2,3%vs-19±3,1%;
circumferential:2DSR=-1,18±0,33vs1,62±0,4S-1; 2DS=-15,12±3,9vs-21±5,1%; 3DS -13,8±3,1% vs15,3±2,6%;
radial:
2DSR=1,19±0,26vs1,58±0,3S-1,
2DS=16,25±8,9vs46,3±9,2%;
3DS
34,5±6,1%vs48±9%; 3DareaS -23,3±2,9%vs-30,1±3,6%; p<0.007) without differences for GroupB
(longitudinal: 2DSR=1,49±0,45S-1, 2DS=19,59±4,1%, 3DS -17,7 ±3,2%; circumferential: 2DSR=1,59±0,4S-1; 2DS=-20,8±5%; 3DS -18,8±1,9%; radial:2DSR=1,56±0,29S-1; 2DS=45,9±9%; 3DS 49
±8,1%;3DareaS -31±3,1%). The difference in peak systolic circumferential LV 2DS between
endocardial and epicardial layer amounted to 34% for group C and to 50% for group A (P>0,01).
Conclusions: 2DS-SR shows early RV dysfunction in asymptomatic ARVC relatives and LV
dysfunction in ARVC, when standard echo appears normal and a more marked difference in
circumferential S between endocardial and epicardial layer
O297
RIGHT VENTRICULAR STRAIN AND DYSSYNCHRONY ASSESSMENT IN
ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY: A CARDIAC
MAGNETIC RESONANCE FEATURE TRACKING STUDY
GIULIO PRATI (B), GIANCARLO VITRELLA (C), GIUSEPPE ALLOCCA (D),
SONIA CUKON BUTTIGNONI (D), GIORGIO MOROCUTTI (A), DANIELE MUSER (B),
GIANLUCA PICCOLI (E), PIETRO DELISE (D), ALESSANDRO PROCLEMER (A),
GIANFRANCO SINAGRA (C), GAETANO NUCIFORA (A)
(A) CARDIOTHORACIC DEPARTMENT, UNIVERSITY HOSPITAL “SANTA MARIA
DELLA MISERICORDIA”, UDINE, ITALY; (B) POSTGRADUATE SCHOOL OF
CARDIOVASCULAR SCIENCES, UNIVERSITY OF TRIESTE, TRIESTE, ITALY; (C)
CARDIOVASCULAR DEPARTMENT, UNIVERSITY HOSPITAL “OSPEDALI RIUNITI”,
TRIESTE, ITALY; (D) DIVISION OF CARDIOLOGY, “SANTA MARIA DEI BATTUTI”
HOSPITAL, CONEGLIANO, ITALY; (E) DEPARTMENT OF DIAGNOSTIC IMAGING,
UNIVERSITY HOSPITAL “SANTA MARIA DELLA MISERICORDIA”, UDINE, ITALY
Purpose: Cardiac magnetic resonance (CMR) imaging represents the gold-standard non-invasive
imaging technique for the assessment of right ventricular (RV) function; however, analysis of
regional dysfunction in arrhythmogenic right ventricular cardiomyopathy (ARVC) may be inadequate
due to the complex contraction pattern of the RV. Aim of the present study was to determine the
utility of RV strain and dyssynchrony assessment using a novel feature-tracking CMR software
system in ARVC patients and its incremental value over conventional CMR imaging.
Methods: 32 consecutive patients with ARVC diagnosed according to the 2010 Task force criteria
(45±13 years, 69% males) referred to CMR imaging were included. 32 patients with idiopathic right
ventricular outflow tract (RVOT) arrhythmias and 32 control subjects, matched for age and gender to
the ARVC group, were included for comparison purpose. CMR imaging using a 1.5 Tesla scanner
was performed to assess biventricular function; moreover, feature-tracking analysis (2D Cardiac
Performance Analysis MR©, TomTec, Munich, Germany) was applied to assess regional and global
RV strain and RV dyssynchrony from the 4-chamber cine CMR images. Peak systolic longitudinal
strain from basal, mid and apical RV free wall segments was measured and averaged as a measure of
global RV function (global longitudinal strain, GLS). In addition, standard deviation (SD) of timeto-peak strain (TPS) was calculated as a parameter of mechanical dispersion, using a 6 RV segment
model (three RV free wall and three septal segments)
Results: Systolic strain at RV basal (-22±11% vs. -35±14% vs.-35±15%; p <0.001), mid (-15±8%
vs. -22±12% vs.-26±11%; p<0.001) and apical level (-14±8% vs. -22±12% vs.-25±11%; p < 0.001)
and RV GLS (-17±5% vs. -26±6% vs.-29±6%; p<0.001) were significantly lower and RV SD-TPS
(145±90ms vs. 68±47ms vs. 50±23ms; p<0.001) was significantly higher among ARVC patients
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compared to RVOT patients and controls. Except for RV basal free wall systolic strain, differences
remained significant even when considering only ARVC patients with RV ejection fraction ≥50% or
RV segments without wall motion abnormalities. At ROC curve analysis, RV GLS >-23.19% and
RV SD-TPS >113.13ms had the highest sensitivity and specificity for identification of patients with
ARVC (91% and 75% and 59% and 95%, respectively). According to these cut-off values, RV GLS
and RV SD-TPS allowed correct identification of 14 out of 17 (82%) and 11 out of 17 (65%) ARVC
patients with RV ejection fraction ≥50%, respectively.
Conclusion: Strain analysis by feature-tracking CMR helps to objectively quantify global and
regional RV dysfunction and RV dyssynchrony in ARVC patients; in addition it provides incremental
value over conventional CMR imaging, allowing the identification of abnormalities even when RV
ejection fraction is preserved or regional wall motion is normal.
O298
MOVEMENT ABNORMALITIES IN THE LEFT VENTRICLE OF THALASSEMIA
MAJOR PATIENTS
ANTONELLA MELONI (A), CHIARA LANZILLO (B), MONIA MINATI (B), DANIELE DE
MARCHI (A), MARIA CHIARA RESTA (C), PIER PAOLO BITTI (D), BASILIA PIRAINO (E),
VINCENZO POSITANO (A), ALESSIA PEPE (A)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) DIPARTIMENTO DI CARDIOLOGIA, POLICLINICO “CASILINO“, ROMA, ITALY; (C)
STRUTTURA COMPLESSA DI RADIOLOGIA, OSP. SS. ANNUNZIATA ASL TARANTO,
TARANTO, ITALY; (D) SERVIZIO IMMUNOEMATOLOGIA E MEDICINA
TRASFUSIONALE - DIPARTIMENTO DEI SERVIZI, P. O. SAN FRANCESCO, NUORO,
ITALY; (E) U.O. GENETICA E IMMUNOLOGIA PEDIATRICA, POLICLINICO “G.
MARTINO“, MESSINA, ITALY
Introduction. Movement abnormalities of the left ventricle (LV) have been reported in thalassemia
major (TM) patients. We investigated the relationships between movement abnormalities and
myocardial iron overload (MIO) and fibrosis, detected by cardiovascular magnetic resonance (CMR).
Methods. 1092 patients (537 male; 30.6±8.5 years) were considered. Cine images were acquired in
short, vertical and horizontal long-axis plans. MIO was measured by multislice multi-echo
T2*technique. To detect myocardial fibrosis, late gadolinium enhanced (LGE) images were acquired.
For image analysis the 17-segment LV model of the AHA/ACC was taken into account. Segmental
wall motion was visually assessed and scored as 1=normal, 2=hypokinesia, 3=akinesia and
4=dyskinesia. The T2* value in all segments as well as the global value were calculated. Presence of
LGE was assessed for each segment.
Results. Abnormal LV motion was found in 66 (6%) patients (60 hypokinetic and 6 dyskinetic) with
a predominant involvement of medium anterior, anterolateral and septal segments.
Patients with abnormal motion had significantly lower global T2* value (22.5±14.7 ms versus
28.9±11.9 ms; P=0.001) and significantly higher number of segments with T2*<20 ms (8.6±7.5
versus 4.6±6.1; P<0.0001).
LGE areas were detected in 196 patients (18%) and were predominantly located in the mid-ventricular
septum. There was a significant correlation between LGE and abnormal motion: 34 (17.4%) patients
with LGE had abnormal motion while among the 896 patients without LGE 32 (3.6%) had abnormal
motion (P<0.0001).
Conclusions. Movement abnormalities in the left ventricle were not really frequent in thalassemia
major patients but were associated with MIO and myocardial fibrosis.
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O299
ROLE OF RIGHT VENTRICLE AND PULMONARY HYPERTENSION ON
DETERMINING DELTA VO2/DELTA WORK RATE FLATTENING: INSIGHTS FROM
CARDIOPULMONARY
EXERCISE
TEST
COMBINED
WITH
EXERCISE
ECHOCARDIOGRAPHY
FRANCESCO BANDERA (A), GRETA GENERATI (A), MARTA PELLEGRINO (A),
VALENTINA LABATE (A), ELEONORA ALFONZETTI (A), SIMONA VILLANI (B),
MADDALENA GAETA (B), MARCO GUAZZI (B)
(A) HEART FAILURE UNIT, IRCCS POLICLINICO SAN DONATO, SAN DONATO
MILANESE; (B) UNIT OF BIOSTATISTICS AND CLINICAL EPIDEMIOLOGY,
DEPARTMENT OF PUBLIC HEALTH, EXPERIMENTAL AND FORENSIC MEDECINE,
UNIVERSITY OF PAVIA
Background: several cardiovascular diseases are characterized by an impaired O2 kinetic during
exercise. The lack of a linear increase of ΔVO2/ΔWork Rate (WR) relation, as assessed by expired
gas analysis, is considered an indicator of abnormal cardiovascular efficiency. We aimed at describing
the frequency of ΔVO2/ΔWR flattening in a symptomatic population of cardiac patients,
characterizing its functional profile and testing the hypothesis that dynamic pulmonary hypertension
and right ventricular contractile reserve play a major role.
Methods and Results: We studied 136 patients, with different cardiovascular diseases, referred for
dyspnoea during effort. Cardiopulmonary exercise test (CPET) combined with simultaneous
exercise-echocardiography were performed using a symptom-limited protocol. ΔVO2/ΔWR
flattening was observed in 36 patients (Group A, 26.5% of population) and was associated with a
globally worse functional profile (reduced peak VO2, anaerobic threshold 11.4±3.3 vs 13.8±4.4
mL/kg/min, O2 pulse 8.2±2.3 vs 10.9±3.1 mL/beat, impaired VE/VCO2). At univariate analysis,
exercise EF, exercise mitral regurgitation, rest and exercise TAPSE, exercise systolic pulmonary
artery pressure (SPAP) and exercise cardiac output (7.7±2 vs 9.0±2.8 L/min) were all significantly (p
<0.05) impaired in Group A. The multivariate analysis identified exercise SPAP (OR 1.06; CI 1.01 1.11; p= 0.011) and exercise TAPSE (OR 0.88; CI 0.8 -0.97; p= 0.013) as main cardiac determinants
of ΔVO2/ΔWR flattening.
Conclusion: In patients symptomatic for dyspnea, the occurrence of ΔVO2/ΔWR flattening reflects
a significantly impaired functional phenotype whose main cardiac determinants are the impaired
SPAP response and the reduced peak RV longitudinal systolic function.
Flattening
No flattening
Univariate P
value
Rest Peak
Rest Peak
Reast Peak
Peak VO2, mL/Kg/min
-13.4±3.9 -18±6.6 -<.0001
VE/VCO2
-33.2±8 -29.8±6.8 -.02
LV EF, %
47±14 47±17 52±16 55±17 .12
.03
Mitral regurgitation ≥3/4+, 14
39
14
20
.9
.025
%
TAPSE, mm
20±5 22±5
22±5 25±6
.05
.0029
SPAP, mmHg
37±17 61±19 33±14 51±18 .22
.0009
Multivariate P
value
Peak
--NS
.013
.011
.013
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VASCULOPATIE PERIFERICHE E ICTUS
O300
X-RAY ASSESSMENT OF SUBLUXATION OF C1-C2 IN PATIENTS WITH CHRONIC
CEREBRO-SPINAL VENOUS INSUFFICIENCY AND MULTIPLE SCLEROSIS
SANDRO MANDOLESI (a)
(a) DEPARTMENT OF CARDIO-VASCULAR AND RESPIRATORY SCIENCES – SAPIENZA
UNIVERSITY ROMA, ITALY
Purpose: The complete compression of the internal jugular veins, in front position, shows a
prevalence of 48% and it is equally distributed in the various segments of these veins in patients with
Chronic Cerebro-Spinal Venous Insufficiency (CCSVI) and Multiple Sclerosis (MS) . The passage
from the supine to the upright position causes an increased incidence of compressions. Such a high
incidence of Venous Compression Syndrome of the internal jugular veins prompts us to seek specific
postural alterations in these patients. The aim of this manuscript is to identify radiological dislocation
of C1-C2 as specific markers in patients with CCSVI and Multiple Sclerosis (MS).
Methods: We investigated 386 patients suffering from CCSVI and Multiple Sclerosis and a control
group of 156 patients without MS. We assessed all these patients by X-rays upright examination. The
sample with CCSVI and MS also by cerebral venous ultrasound EchoColorDoppler, EDSS severity
scale and clinical types Relapsing-remitting MS –RR, Secondary Progressive MS –SP, Primary
progressive MS -PP. The types of misalignment of C1-C2 assessed by X-ray were: left laterality,
right laterality, left anterior rotation, right anterior rotation, left post rotation, right post rotation, tilt
superior, tilt inferior, anterior intrusion(antero-listesis).
Results: The assessment of Anterior Intrusion shows the following average values: in the group with
CCSVI and MS: 4.29 ±1.48 mm while in the control group: 3.78 ±1.45 mm (p = 0.0008).The
evaluation of the Right Laterality has the following average values: in group with CCSVI and MS:
2.31±1.41 mm, in control group: 1.97 ±1.28 mm (p = 0.0426). We found also that a longer duration
of the disease corresponds to a higher severity of the pathological condition (p <0.0001).
Conclusion: Data analysis of the X-Ray parameters shows a particular profile of people with
CCSVI and MS, severe anterior intrusion and right laterality misalignment that are two to three
times more frequent as compared to controls. Considering the novelty of this work and the total
absence of scientific similar works able to confirm this data, it is necessary to continue these studies
in order to improve the clinical management of these patients and to perform a therapeutic strategy
based on venous decompressive treatments both surgical that manipulatives.
O301
DIAGNOSTIC DELAY IN ACUTE AORTIC SYNDROMES: ROLE OF CARDIAC
TROPONIN T ELEVATION
Background: Acute aortic syndrome (AAS) is a life-threatening cardiovascular emergency, often
presenting with chest pain and ECG findings mimicking acute coronary syndrome. However little is
known about troponin elevation and its clinical significance in AAS. Therefore, the aims of this study
were to describe the frequency of troponin positivity in AAS, its clinical implications and its impact
on diagnostic delay and in-hospital mortality.
Methods: We enrolled all patients referred to our institution from 2000 to 2013 who received a final
diagnosis of spontaneous AAS and whose routinely performed troponin test results were available.
Cardiac troponin was measured with standard assay (cTnT) until 2010, while then it was replaced by
high sensitivity (Hs) troponin T assay; blood samples were collected at presentation and after 3-6
hours or as long as clinically indicated. For the standard cTnT test the analytical limit of detection
(LoD) and the URL are both 10 ng/L, and the 10% CV cut-off value is 30 ng/L. The diagnosis of
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troponin positivity using standard cTnT testing was made in the presence of at least one value of
cTnT > 30 ng/L (10% CV cut-off). The hs-cTnT assay has an analytical LoD of 3 ng/L, the URL is
14 ng/L and the 10% CV cut-off is 13 ng/L. When hs-cTnT was used, the diagnosis of troponin
positivity was made in the presence of at least one value of hs-cTnT > 14 ng/L (URL).
Results: we considered 248 patients, 67% presenting with Stanford A. Troponin positivity occurred
in 28% of patients, without difference between Stanford subtypes (type A 29% vs. type B 25%,
p=0.47) and this proportion was higher among those tested by hs assay (42 of 77, 54% vs. 28 of 171,
16%, p=0.001). Patients with positive troponin showed more often ACS-like ECG findings both in
overall population (41% vs. 22%, p=0.003) and Stanford subtypes (type A 46% vs. 25%, p=0.01;
type B, 40% vs. 13%, p=0.02). Troponin positivity implied a longer median in-hospital diagnostic
times (210 minutes vs. 177 minutes, p=0.04) and was associated with approximately twofold
increased risk of long (> 75th percentile) in-hospital delay (OR 2.02, 95% CI 1.1-3.8, p =
.03). Troponin positivity was not associated with increased risk of death (unadjusted OR 1.63, 95%
CI 0.86-3.10, p=0.13), while independent predictors of in-hospital mortality were pleural effusion,
age and shock on presentation.
Conclusion: About one third of patients with AAS had positive troponin T, both in Stanford A and
B. Even if troponin elevation was not associated with significantly increased mortality, its positivity
represented a strong clinical confounder, being associated with approximately twofold increased risk
of late in-hospital diagnosis.
O302
INDOXYL SULFATE PROMOTES MONOCYTE DIFFERENTIATION INTO PROFIBROTIC M2 MACROPHAGES. CLINICAL IMPLICATIONS IN ABDOMINAL AORTIC
ANEURYSM
CHIARA BARISIONE (A), SILVANO GARIBALDI (A), DANIELA PALMIERI (D),
DOMENICO PALOMBO (D), ANNALISA FURFARO (B), MARIA PAOLA NITTI (B),
SEBASTIANO LA MAESTRA (C), PATRIZIA FABBI (A), PAOLA ALTIERI (A),
CLAUDIO BRUNELLI (A), PIETRO AMERI (A), GIORGIO GHIGLIOTTI (A)
(A) LAB. BIOLOGIA CARDIACA E VASCOLARE, DIP. MEDICINA INTERNA,
UNIVERSITA´ DI GENOVA; (B) DIP. MEDICINA SPERIMENTALE, UNIVERSITA´ DI
GENOVA; (C) DIP. SCIENZE DELLA SALUTE, UNIVERSITA´ DI GENOVA; (D) LAB.
BIOLOGIA VASCOLARE CLINICA E SPERIMENTALE, DIP. SCIENZE CHIRURGICHE,
UNIVERSITA´ DI GENOVA
The cardiorenal syndromes (CRS) are defined by heart and kidney dysfunction, with mutual
detrimental feedback; the association of even mild chronic kidney disease (CKD) with cardiovascular
(CV) events is still underestimated.
In patients with abdominal aortic aneurysm (AAA), we previously found a frequent history of mild
CKD and a higher frequency of CD16+ monocytes, a subset known to be increased in patients with
renal damage.
Increased Uremic toxins (UT) plasma levels are CV risk factors in CRS patients. The UT Indoxyl3-sulphate (IS), a ligand of Aryl hydrocarbon Receptor (AhR), accumulates early during CKD and is
associated to overall mortality and CV diseases.
In this study we found that IS plasma levels are higher in AAA patients than in age-matched
controls (p = 0.0017) and correlate with CD14+CD16+ monocytes (p = 0.0028; r = 0.3454).
We therefore investigated the effect of IS at the concentrations found in AAA patients (1, 10, 20
microM) on monocyte-macrophage differentiation.
Using a monocyte cell line (THP-1 ) we demonstrated that IS slowers cell cycle progression, increases
migration rate and CD163 surface expression. These effects are mediated by the AhR-Nrf2/HO-1
cross-talk pathways, through upregulation of AhR Repressor (AhRR) and HO-1, and are effectively
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counteracted by the AhR antagonist CH-223191. Moreover, IS down-regulates the CCR2 and
upregulates the MCP-1 gene expression; CD163 overexpression together with CCR2 downregulation
and MCP-1 upregulation are phenomena associated to monocyte-to-macrophage transition and
hallmarks of CD14+CD16+ monocytes.
Macrophages derived from IS-primed monocytes overexpress components of the AhR/AhRR and
Nrf2/HO1 axes and features of both classical (MCP-1, COX2) and alternative immunity (MMP-9
downregulation; PPARg, TIMP-1 and TGF-b overexpression).
Thus, a moderate increase of IS can promote monocyte differentiation towards macrophages with
low-inflammatory, profibrotic potential.
In conclusion our results suggest that the uremic toxin IS may be involved in the pathogenesis of
AAA and provide a mechanistic link between this condition and the CRS.
O303
NILOTINIB ASSOCIATED CARDIOVASCULAR EFFECTS: A CASE REPORT
ANTONINO MIGNANO (A), IDA MURATORI (B), CORRADO AMATO (B),
EGLE CORRADO (A), GIUSEPPE COPPOLA (A), FILIPPO FERRARA (B),
SALVATORE NOVO (A)
(A) AOUP PAOLO GIACCONE UNIT OF CARDIOLOGY; (B) AOUP PAOLO GIACCONE
UNIT OF ANGIOLOGY
Introduction: The second generation BCR/ABL kinase inhibitor nilotinib is increasingly used for
the treatment of imatinib-resistant chronic myeloid leukemia (CML).
Cardiotoxicity and cardiovascular complications have only recently been reported for drugs that
target tyrosine kinases but the exact incidence of these adverse effects is unclear.
Case report: A 75-year-old male patient without cardiovascular risk factors and with CML
(diagnosed 2008; in remission/chronic phase), treated with imatinib for 6 months, was switched to
nilotinib 400 mg twice daily due to imatinib suspected resistance. One year later, the patient was
hospitalised due to acute inferior myocardial infarction and underwent primary coronary angioplasty
with bare metal stent implantation for the right coronary artery and, after a week, a second coronary
angioplasty was performed with bare metal stent implantation for interventricular coronary artery.
After this event, patient stopped nilotinib for three years, during which no cardiovascular events
occurred. In 2014 patient restarted nilotinib therapy and after two months was hospitalized in our unit
of angiology for acute ischemia of left foot. Infusion therapy with synthetic prostacicline (iloprost)
was started but no benefit was observed and patient developed ischemic ulceration of the first toe.
Vascular surgeon was contacted for femoral-tibial bypass grafting and, after a pre-operative
cardiological evaluation, patient underwent coronary catheterization that showed severe restenosis of
right coronary artery stent. A medicated balloon angioplasty was performed and patient was
discharged with indication of femoral-tibial bypass after a month. When he was readmitted in vascular
surgery unit, he arrived to medical observation with neurological symptoms (Right-sided
hemiparesis, aphasia) and head CT showed acute ischemic stroke. After stabilization of clinical
picture patient underwent femoral-tibial bypass with good result at 3 month. He stopped nilotinib
when acute ischemia of the first toe occurred and after 6 month he doesn't show any progression of
CML.
Discussion: In summary, nilotinib is very rarely associated with clinically relevant vascular events.
However this possibility should be considered when selecting nilotinib for the treatment of patients
with CML, particularly those with known risk factors for vascular disease. Few data on nilotinib
associated cardiovascular events are available in literature and, usually, only one vascular district is
involved in reported clinical cases. Other clinical studies are necessary to evaluate the real impact of
second generation BCR/ABL kinase inhibitors adverse effects and to undestand the mechanism of
drug associated vascular damage. Considering that both microvascular and macrovascular alterations
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are reported, a vascular inflammation based mechanism can be proposed to explain all of these
cardiovascular adverse effects (stroke, myocardial infarction, acute peripheral arterial ischemia and
Raynaud syndrome).
O304
LA DISSEZIONE AORTICA NEI PAZIENTI CON MALATTIA POLICISTICA RENALE
AUTOSOMICA DOMINANTE
COSTANTINA PROTA (a), ANGELO SILVERIO (a), MARCO DI MAIO (a), MARIA
VINCENZA POLITO (a), FRANCESCO MARIA COGLIANI (a), RODOLFO CITRO (b),
ALBERTO GIGANTINO (b), SEVERINO IESU (b), FEDERICO PISCIONE (a, b)
(a) CATTEDRA DI CARDIOLOGIA; DIPARTIMENTO DI MEDICINA E CHIRURGIA;
UNIVERSITÀ DEGLI STUDI DI SALERNO; SALERNO (ITALY); (b) “ DIPARTIMENTO
CUORE” AZIENDA OSPEDALIERA UNIVERSITARIA “SAN GIOVANNI DI DIO E RUGGI
D’ARAGONA”; SALERNO (ITALY)
Background: La dissezione aortica (AD) rappresenta, nell’ambito delle sindromi aortiche acute, la
più comune condizione gravata da altissima mortalità. Solitamente tale patologia si manifesta in modo
isolato, non associata cioè a condizioni patologiche sistemiche; raramente risulta associata alla
Malattia Policistica Renale Autosomica Dominante (ADPKD), una sindrome genetica dovuta a
mutazioni dei geni PKD1 o PKD2 caratterizzata dalla degenerazione cistica del rene con o senza cisti
in altri organi e altre possibili manifestazioni, in particolare a carico dell’apparato cardiovascolare.
Abbiamo deciso quindi di analizzare i casi di AD in ADPKD presenti in letteratura, riportando inoltre
due casi derivanti dalla nostra personale esperienza clinica.
Metodi: Abbiamo effettuato una ricerca sistematica in letteratura con l’ausilio del database Medline,
utilizzando come parole-chiave “Dissezione Aortica” e “Malattia Policistica Renale Autosomica
Dominante”. Sono stati così selezionati tutti gli studi in lingua inglese completi di testo integrale che
riportavano casi di dissezione aortica in pazienti con malattia policistica, ottenendo una serie di 24
casi. Aggiungendo i 2 casi provenienti dalla nostra esperienza clinica, abbiamo ottenuto un totale di
26 casi, dai quali abbiamo estrapolato e analizzato i dati quali sesso, età, storia familiare di ADPKD
e/o AD, habitus, ipertensione, funzione renale, presenza di cisti epatiche/pancreatiche/spleniche,
presentazione clinica della AD, tipo di AD (A o B secondo Stanford), trattamento e outcome a breve
e lungo termine.
Risultati: L’ipertensione arteriosa rappresenta il fattore di rischio più importante per la AD; da notare
una frequenza notevolmente più elevata di tale fattore di rischio nella popolazione con ADPKD
esaminata (90%) rispetto alla frequenza riscontrata nella popolazione generale affetta da AD (75%).
Un altro importante riscontro è quello riguardante l’età media di presentazione dell’evento AD nei
pazienti con ADPKD, che è risultata marcatamente ridotta rispetto al valore medio riscontrato nella
popolazione generale con AD (48 ± 11 vs 62 ± 14 years, p < 0,001). Come atteso, la più comune
presentazione clinica di AD è rappresentata dal dolore toracico e/o interscapolare (79%) anche nei
pazienti con ADPKD, sebbene in 3 casi (16%) la diagnosi sia stata incidentale in occasione di esami
effettuati per altre ragioni. AD tipo Stanford A è stata documentata nel 61% dei pazienti analizzati,
mentre meno frequente è apparso il tipo B (39%). Sono state documentate infine sette morti (27%),
una percentuale molto simile alla mortalità generale dei pazienti con AD.
Conclusioni: AD nei pazienti con ADPKD rappresenta un evento tutt’altro che infrequente,
probabilmente correlato non solo alle possibili anomalie strutturali vascolari geneticamente
determinate ma anche alla più alta prevalenza di ipertensione arteriosa. Poiché la AD può essere
rapidamente fatale senza una diagnosi precoce ed un trattamento adeguato, dovrebbe sempre essere
presa in considerazione tra le diagnosi differenziali in pazienti con ADPKD e sintomi suggestivi,
nonostante la giovane età o l’assenza di familiarità. Un attento monitoraggio preventivo attraverso
periodici controlli clinici e con metodiche non invasive, quali gli ultrasuoni, associato ad un controllo
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ottimale della pressione arteriosa potrebbe ridurre il rischio di AD e migliorane l’outcome in questa
categoria di pazienti.
O305
PREVALENT CARDIAC, RENAL AND CARDIORENAL DAMAGE IN PATIENTS WITH
ADVANCED ABDOMINAL AORTIC ANEURYSMS
CHIARA BARISIONE (A), SILVANO GARIBALDI (A), ALESSANDRA LORENZONI (A),
RICCARDO BALDASSINI (A), MARCO CANEPA (A), PIETRO AMERI (A),
PAOLO SPALLAROSSA (A), CLAUDIO BRUNELLI (A), BIANCA PANE (B),
GIOVANNI SPINELLA (B), DOMENICO PALOMBO (B), GIORGIO GHIGLIOTTI (A)
(A) DIVISION OF CARDIOLOGY, IRCCS UNIVERSITY HOSPITAL SAN MARTINO,
RESEARCH CENTRE OF CARDIOVASCULAR BIOLOGY, UNIVERSITY OF GENOA,
ITALY; (B) VASCULAR AND ENDOVASCULAR SURGERY UNIT, UNIVERSITY OF
GENOA, ITALY
Background: Cardiac and renal damage often go undetected and thus untreated in patients with
abdominal aortic aneurysms (AAA). Pts with advanced AAA undergo either endovascular
procedures (EVAR) that require repeated use of contrast medium or high-risk open surgery
(OS). Life style and pharmaceutical interventions aimed to provide cardiac and renal protection
before EVAR/OS may reduce immediate and delayed events in these patients.
Aim: This study is aimed to assess the prevalence of cardiac (CD), renal (CKD), cardiorenal (CRS)
damage and of anemia in a cohort of 512 AAA patients who underwent cardiac screen to assess
cardiac risk associated to a procedure of EVAR/OS in Northern Italy.
Methods: CD was defined by at least stage B of the ACC/AHA classification of CHF; CKD was
defined by an estimated GFR < 60 mL/min/1.73 m2 (CKD-EPI). Anemia (WHO guidelines) and
iron deficiency (criteria used in CHF patients) were also reported. AAA patients were separated in
four groups, according to presence of CD, CKD, CD+CKD (CRS) or none of these conditions (no
RF). Values for age, NTproBNP, eGFR and Haemoglobin are shown as mean±SD.
Results: Attributable CKD stage (I-II-IIIa-IIIb-IV-V) in AAA pts is
respectively:
10.8%, 55%, 19.4% , 10.2%, 2.9% and 1.2%. Anemia mostly unrecognized increases in frequency
in CKD/CD/CRS vs No RF up to 40% in CRS.
Conclusions: This large-scale observational study: 1) provides clues for the increased CD and
CKD risk profile of this unselected cohort of Italian AAA patients, and 2) underlines the need
for better identification of anemia and for appropriate treatment of CKD and CD before these pts
proceed to EVAR/OS.
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ARITMOLOGIA - 3
O306
ARITMIE IN CORSO DI INFARTO MIOCARDICO ACUTO IN PAZIENTI CHE
AFFERISCONO IN UNITÀ CORONARICA: STUDIO OSSERVAZIONALE
RENATO ROSIELLO (B), ANTONIO IZZO (B), LUCA TOMASI (B),
PAOLA MANTOVANI (B), VALENTINA CHIARINI (B), NICOLA CICORELLA (B),
MICHELE ROMANO (B), CORRADO LETTIERI (B), BEATRICE IZZO (B),
ROBERTO ZANINI (B)
(A) AZIENDA OSPEDALIERA “C.POMA“ MANTOVA; (B) STRUTTURA COMPLESSA DI
CARDIOLOGIA
Introduzione: Le aritmie cardiache rappresentano una delle principali complicanze dell’infarto
miocardico acuto (IMA). Scopo del nostro studio è l’osservazione dell’impatto clinico dei fenomeni
aritmici in pazienti affetti da IMA in un periodo di 6 anni.
Metodi:I dati derivano da un data-base dei pazienti consecutivi e affetti da IMA e ricoverati in Unità
Coronarica (UTIC). La differenza delle frequenze tra variabili è stata analizzata con il test esatto di
Fisher e la differenza tra variabili continue con test t di Student. Tutti i test sono stati considerati a
due code.
Risultati: Sono stati analizzati 1.963 pazienti consecutivi con IMA dal febbraio 2001 al febbraio
2007. Le aritmie sono state (Tab.I): aritmie ventricolari totali (AV) (7.0%), fibrillazione/flutter atriale
(FA) (8,0%), fibrillazione ventricolare (FV) (4,8%), blocco atrioventricolare III grado (BAVT)
(3,6%), tachicardia ventricolare non sostenuta (TVNS) (2,3%). I pazienti che hanno presentato FV
sono più giovani della media (-4 anni di età mediana), mentre quelli con FA o BAVT sono nettamente
più anziani (+8 anni di età mediana). La mortalità totale è risultata del 5,23% con la differenza relativa
al tipo di infarto a aritmia con mostrato in TabII.
Discussione: Sono state evidenziate differenze significative di mortalità in relazione a sesso, età,
BAVT, FA mentre la FV non pare correlata con l’evento morte (Tab III e tab.IV). Il confronto
relativamente alla mortalità dei pazienti con i vari tipi di aritmia tra odds ratio “crudo”, corretto età e
corretto per età e sesso ha mostrato come i due “fattori confondenti” non modifichino il valore
predittivo di BAVT relativamente all’evento morte (+ 20%) a differenza della FA il cui potere
predittivo si riduce nettamente.
Per contro la FV che è più frequente nei pazienti più giovani assume un netto significato prognostico
sfavorevole solo quando l’odds ratio viene corretto per età e per età e sesso.
Conclusioni: È quindi possibile concludere che nonostante le cure tempestive dell’infarto miocardico
la FV conserva il significato prognostico sfavorevole soprattutto nei pazienti più giovani mentre nei
pazienti anziani si verificano più frequentemente FA e BAVT.
Tab.I Numero soggetti per aritmia, media delle età, p-value e relativi intervalli di confidenza
Tab. II Aritmie e patologia cardiaca sottesa
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Tab. III Descrizione della popolazione
Tab. IV Numero soggetti deceduti e proporzioni secondo i
parametri considerati, odds ratio (OR) e relativi
intervalli di confidenza
O307
LA SINCOPE IN ETÀ PEDIATRICA: RISULTATI PRELIMINARI DALLA PRIMA
SINCOPE UNIT PEDIATRICA IN ITALIA
SILVIA PLACIDI (A), CORRADO DI MAMBRO (A), DANIELA RIGHI (A),
ROSALINDA PALMIERI (A), MARIO SALVATORE RUSSO (A), ROBERTA VALLONE (B),
FABRIZIO GIMIGLIANO (A), FABRIZIO DRAGO (A)
(A) UNITÀ COMPLESSA DI ARITMOLOGIA E SINCOPE UNIT, OSPEDALE PEDIATRICO
BAMBINO GESÙ, PALIDORO (RM); (B) UNITÀ SEMPLICE DI PSICOLOGIA CLINICA,
OSPEDALE PEDIATRICO BAMBINO GESÙ, PALIDORO (RM)
Introduzione: La sincope è una condizione frequente in età pediatrica: circa il 15% dei bambini
sperimentano almeno un episodio prima della fine dell’adolescenza. Sebbene si tratti nella
maggioranza dei casi di una patologia benigna, in alcuni casi può essere il primo sintomo di una
patologia cardiaca sottostante o espressione di altre malattie (pseudo-sincope). La diagnosi è spesso
complessa, deve essere finalizzata all’esclusione d’importanti patologie e richiede un approccio
multidisciplinare. Pertanto la sincope in età pediatrica rappresenta una sfida per il cardiologo pediatra
e si pone come una problematica di rilievo sia da un punto di vista gestionale che socio-economico.
La Sincope Unit è un’unità funzionale multidisciplinare che, partendo da risorse già disponibili,
riunisce e coordina in modo rapido le competenze di diversi specialisti allo scopo di 1) ottimizzare la
gestione clinica 2) aumentare l’accuratezza diagnostica e terapeutica 3) ridurre la spesa. Nel 2013 il
Gruppo Italiano per lo Studio Multidisciplinare della Sincope ha rilasciato la prima certificazione
ufficiale di Sincope Unit Pediatrica alla UOC di Aritmologia Pediatrica dell’Ospedale Bambino Gesù.
Scopo del nostro studio è stato quello di analizzare tutti i dati riguardanti i pazienti afferenti alla nostra
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Sincope Unit al fine di 1) fornire dati epidemiologici e clinici sulla sincope in età pediatrica, 2)
valutare il funzionamento e l’efficacia del modello della Sincope Unit.
Metodi: Dal 1 ottobre 2011 al 31 marzo 2014 sono stati studiati un totale di 1011 pazienti con sincope
o presincope (50% maschi, età media 13 anni, età media alla prima sincope 10 anni). Tutti i pazienti
sono stati valutati seguendo un protocollo diagnostico-terapeutico che prevede una valutazione
clinica e diagnostica a vari livelli di complessità. Tale protocollo era finalizzato alla stratificazione
del rischio e all’individuazione di tre principali sottogruppi di pazienti: 1) sospetta sincope cardiaca
2) sospetta sincope neuromediata e 3) sospetta pseudo-sincope ed aveva lo scopo di indirizzarli ad un
percorso terapeutico specifico. Il primo gruppo di pazienti viene valutato in tempi rapidissimi con
esami strumentali anche complessi e invasivi (studio elettrofisiologico endocavitario o transesofageo,
impianto di loop recorder interno), i pazienti con sospetta sincope neuromediata vengono invece
seguiti in ambulatorio o Day Hospital dove è possibile effettuare esami diagnostici di secondo livello
(tilt test, Holter ECG, Holter PA, test da sforzo, ecocardiogramma, loop recorder esterno, potenziali
tardivi). I casi di sospetta pseudo-sincope vengono infine inviati all’attenzione dello specialista di
competenza (neurologo, endocrinologo, psicologo ecc).
Risultati: La sincope neuromediata è stata la più frequente (71%), la sincope aritmica è stata
diagnosticata nel 3,7% (e nel 50% dei casi si è posta indicazione ad impianto di pacemaker e/o
defibrillatore), la pseudosincope è stata riscontrata nel 3,2% e nel 21,5% l’eziologia è rimasta
indeterminata. La sincope era ricorrente nel 58% e nel 25% dei casi l’anamnesi familiare era positiva
per sincope e morte improvvisa. Nel corso del follow-up il 54% dei pazienti ha riferito un completo
controllo dei sintomi. La maggioranza dei pazienti è stata gestita in regime ambulatoriale e di DH
(96%) e solo una minoranza di casi ha richiesto il ricovero (4%).
Conclusioni: Quella presentata è la prima serie di pazienti pediatrici studiati nell’ambito di una
Sincope Unit. Questo modello organizzativo si dimostra efficace sia in termini di gestione clinica e
accuratezza del percorso diagnostico e terapeutico del paziente, sia termini di gestione delle risorse
economiche.
O308
DIFFERENCE IN TRENDS OF RS AND T AMPLITUDE DURING STRESS TEST IN
NORMAL AND IN ISCHEMIC PATIENTS
MARISA VARRENTI (A), ANDREA QUARESIMA (A), CAMILLO CAMMAROTA (A),
SILVIA DA ROS (A), SERGIO MATTEOLI (A), MARIO CURIONE (A)
(a) UNIVERSITA DI ROMA LA SAPIENZA
Background: RS and T wave amplitude is often observed in ECG stress test. Trends in RS and T
wave amplitude during stress test in normal subjects seem to show telediastolic and telesistolic
volume changes respectively, as they present a specular behaviour according to the Frank –
Starling law.
Aim: to find differences in RS and T amplitude trends in ischemic patients during stress test respect
to normal subjects.
Method: 22 ischemic patients (20 males, 2 females, mean age 48 years) and 20 healthy subjects (15
males, 5 females, mean age 38 years) underwent to ECG stress test performed according to Bruce
protocol. Standard 12-leads ECG was recorded using PC-ECG 1200 (Norav Medical Ltd.) device.V5
lead was used as less influenced by motion artifacts R peak detection was performed using a
derivative-threshold algorithm. T apex was detected as the height of the T wave with respect to the
baseline subsequent to each R peak. A wavelet multiscale analysis was used to decompose the signal
into trend and noise components. The wavelet filter (acting as a low frequency pass filter) filters
out also respiratory modulations. In comparations between two groups the standard t-test is used;
confidence intervals are computed with 95% significance.
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Results: RS amplitude trend were similar in two groups of patients showing no significant difference
in left ventricle diastolic compliance. The most important differences were observed in T wave
amplitude trend shape between two groups of patients demonstrating that the systolic performance in
this kind of patients is principally affected.
Conclusion: the most important difference was found in T wave trend shape between ischemic
patients and normal subjects. These findings suggest, as expected, that the systolic performance is
affected primarily in ischemic patients. It could represent a useful tool in classifying ischemic patients
with silent ischemia and negative stress.
O309
PREVALENCE OF TYPE 1 BRUGADA ELECTROCARDIOGRAPHIC PATTERN
EVALUATED ON 12-LEAD 24-HOUR HOLTER MONITORING
NATASCIA CERRATO (A), CARLA GIUSTETTO (A), ELENA GRIBAUDO (A),
CHIARA SCROCCO (A), ELENA RICHIARDI (B), LORELLA BARBONAGLIA (C),
DOMENICA ZEMA (A), ELISABETTA TOSO (D), GIORGIO MILLESIMO (A),
FIORENZO GAITA (A)
(A) UNIVERSITY OF TORINO, DEPARTMENT OF MEDICAL SCIENCES, “CITTÀ DELLA
SALUTE E DELLA SCIENZA“ HOSPITAL, DIVISION OF CARDIOLOGY, TORINO, ITALY ;
(B) GRADENIGO HOSPITAL, DIVISION OF CARDIOLOGY, TORINO, ITALY; (C)
DIVISION OF CARDIOLOGY, SANT’ANDREA HOSPITAL, VERCELLI, ITALY ; (D)
CARDINAL MASSAIA HOSPITAL, DIVISION OF CARDIOLOGY, ASTI, ITALY
Purpose. Spontaneous type 1 ECG pattern (BrECG) is a risk factor in Brugada syndrome, however
it is probably underestimated because of the well-known BrECG fluctuations. Aim of the study was
to analyze in a large population of Brugada patients the prevalence of type 1 BrECG using 12-lead
24-hour Holter monitoring (12L-Holter), its correlation with the time of the day and reproducibility.
Methods. We collected 303 12L-Holter recorded in 251 patients. Thirty-eight patients (15%) had
from 2 to 4 12L-Holter. Seventy-six (30%) exhibited spontaneous type 1 BrECG at basal ECG (group
1), 175 (70%) had only drug-induced type 1 BrECG (group 2). Thirty-two (13%) had syncope, one
aborted sudden death and 218 (86%) were asymptomatic. 12L-Holter was recorded in the right
precordial leads both at the 4th and 2rd intercostal space and all 12L-Holter recordings were analyzed
independently by two cardiologists. To evaluate the circadian fluctuations of the BrECG, 4 periods
were considered: 12 midnight-6 am, 6 am–12 noon, 12 noon-6 pm and 6 pm-12 midnight. Type 1
BrECG was defined as “permanent” (>85% of the 12L-Holter recording), “intermittent” (<85%) or
“absent”.
Results. Fifty-two (68%) out of 76 group 1 patients showed type 1 in at least one 12L-Holter, in 9
(12%) of them type 1 BrECG was persistent at all the 12L-Holter; 24 (32%) never had spontaneous
type 1 at 12L-Holter: in 6 of them the type 1 BrECG had been documented only during fever. Thirtyfive (20%) out of 175 group 2 patients developed intermittent type 1 BrECG at 12L-Holter recording;
in the remaining 80% type 1 BrECG was never recorded. Spontaneous type 1 BrECG on 12L-Holter
was present in 33% of symptomatic and 34% of asymptomatic patients (p=NS). Spontaneous type 1
BrECG was more frequently recorded between 12-noon and 6 pm (52%) than in the other three
periods (p< 0.001). Eleven out of the 38 patients (29%) with more than one 12L-Holter showed
discordant results concerning the presence of spontaneous type 1 BrECG between one Holter and the
other.
Conclusions. 12L-Holter recording significantly increases the chances to identify spontaneous type
1 BrECG. At the opposite, some patients with BrECG recorded during fever may never show type 1
ECG at 12L-Holter. Considering the higher sensitivity of 12L-Holter recording as compared to
periodic 12 lead ECGs in documenting the diagnostic BrECG, in selected cases, such as children or
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in presence of borderline diagnostic basal ECG, it might be a good alternative to document the
diagnostic pattern, before using sodium channel blockers.
In serial 12L-Holter recordings significant fluctuations of BrECG pattern are seen. Type 1 BrECG
was mainly documented between 12-noon and 6 pm. Further studies with more patients with repeated
12L-Holter recordings and longer follow-up are needed to better understand the role of type 1 ECG
burden in the risk stratification of patients with Brugada syndrome.
O310
RS AND T WAVES AMPLITUDE AS MARKERS OF INTRAVENTRICULAR VOLUME
CHANGES DURING STRESS TEST IN NORMAL SUBJECTS
SILVIA DA ROS (A), ANDREA QUARESIMA (A), MARISA VARRENTI (A),
CAMILLO CAMMAROTA (A), SERGIO MATTEOLI (A), MARIO CURIONE (A)
(A) UNIVERSITA DI ROMA LA SAPIENZA
Background: increasing or decreasing in “telediastolic volume” leads to a decrease or increase in
QRS wave amplitude respectively. An inverse correlation between electrocardiographic and
hemodynamic variables has been observed in some clinical experimental conditions in which
endoventricular volume progressively changes, such as during stress test (see Fig.1), during
haemodialysis or during cardiac arrhythmias. The mechanism underlying to this phenomenon is
complex and still debated, but the role played by changes in intraventricular volume seems to be the
most reliable. Increasing telediastolic volume leads to an increase in electrical resistivity due to
higher number of red cells in the left ventricular chamber. In our opinion the same mechanism could
play a role in T waves amplitude changes observed in some clinical conditions, which in this case
represent, “telesistolic volume” changes.
Aim: to obtain information about left ventricular compliance by continuous RS and T wave
amplitude monitoring during stress test in normal subjects.
Methods: 20 healthy subjects (15 males, 5 females, mean age 38 years) underwent to ECG stress test
performed according to Bruce protocol. Standard 12-leads ECG was recorded using PC-ECG Norav
Medical Ltd.) device. V5 lead was used as less influenced by motion artifacts. A wavelet
multiscale analysis was used to decompose the signal into trend and noise components. The wavelet
filter acting as a low frequency pass filter, filters out also eventual respiratory modulations.
Results: the RS amplitude trend appears stable until the late effort stage in which there is a decrease
as consequence of an abrupt increase in “ telediastolic volume due to a drop in heart rate(see Fig 2
central panel). At the same time T wave amplitude starts to grow as a result of a progressive decrease
in “ telesistolic volume” meaning there is normal systolic response to diastolic overload (see Fig.2
right panel). RS and T amplitude trends show mirror appearance and seem to conform to the Frank Starling law.( see Fig. 3)
Conclusions: RS and T wave amplitude trends seem to be an expression of telediastolic and
telesistolic volume changes during stress test in normal subjects, as they show a secular behaviour
according to the Frank – Starling law. Finding differences in RS and T amplitude trends in ischemic
patients with no depressed ST segment could represent a useful tool in the setting of these patients.
More studies are needed in order to confirm the mechanism which links these ECG features with
hemodynamic changes. In our opinion using echocardiographic or non invasive haemodinamic
monitoring with ECG monitoring, represents an important way to solve this problem. Regarding
speculative viewpoint we hope the outcomes of this study will be usefully employed in
clinical practice.
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Fig. 1. RS and T waves amplitude
modifications at rest (left panel)
and during (right panel)
in normal subject.
O311
RIPOLARIZZAZIONE PRECOCE NEI SOGGETTI PSORIASICI
MARIO MASTROLONARDO (B), NATALE DANIELE BRUNETTI (A),
MASSIMO GRIMALDI (A, D), MARICA CAIVANO (A), DOMENICO BONAMONTE (C),
MATTEO DI BIASE (A)
(A) CARDIOLOGIA UNIVERSITARIA OSPEDALI RIUNITI FOGGIA; (B) DERMATOLOGIA
UNIVERSITARIA OSPEDALI RIUNITI FOGGIA; (C) DERMATOLOGIA UNIVERSITARIA
POLICLINICO BARI; (D) OSPEDALE MIULLI ACQUAVIVA BARI
Background: La psoriasi è una malattia cutanea cronica caratterizzata da un substrato infiammatorio
e proliferativo. Secondo alcuni autori il tono neurovegetativo è implicato nel determinismo della
malattia. Il nostro studio si è pertanto proposto di valutare la prevalenza di uno dei possibili marker
elettrocardiografici di attivazione del sistema neurovegetativo, la ripolarizzazione precoce (RP), in
una popolazione di soggetti psoriasici.
Metodi: Lo studio ha arruolato 100 soggetti affetti da psoriasi e 100 controlli con fattori di rischio
cardiovascolare comparabili: tutti i soggetti sono stati sottoposti ad elettrocardiogramma a riposo.
Sono state considerate la presenza di RP in almeno 2 derivazioni contigue, le derivazioni in cui era
presente l’aspetto RP, l’attività fisica abituale, i farmaci assunti, la frequenza cardiaca di base.
Risultati: L’aspetto RP in almeno due derivazioni contigue era presente nel 40% dei soggetti
psoriasici vs 14% dei controlli (p <0.001), (36% vs 10% nelle derivazioni anteriori, p <0.001; 6% vs
3% nelle inferiori, p n.s.; 10% vs 2% nelle laterali p <0.05).
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Dopo correzione per genere, età, frequenza cardiaca ed attività fisica abituale, la presenza di RP era
associata alla presenza di malattia psoriasica con un odds ratio pari a 8.6 (95% CI, 2.1-35.2, p<0.01),
7.1 (95% CI, 1.6-31.8, p <0.05) nelle derivazioni anteriori.
Conclusioni: In un piccolo studio caso/controllo la prevalenza all’elettrocardiogramma a riposo di
un aspetto RP era più elevata nei soggetti affetti da malattia psoriatica rispetto ad una popolazione di
controlli. Il significato clinico di tale associazione rimane da approfondire in studi futuri.
STUDI OSSERVAZIONALI E TRIAL CLINICI - 3
O312
STUDIO DELLA MECCANICA VENTRICOLARE SINISTRA IN PAZIENTI AFFETTI DA
CARDIOMIOPATIA
CIRROTICA
MEDIANTE
3D-SPECKLE
TRACKING
ECHOCARDIOGRAPHY
FRANCESCA CUCCHI (A), GIANNA IACOVONE (B), GELTRUDE GIURA (A),
TANIA DOMINICI (A), DARIO DEL PRETE (A), LORELLA BATTISTA (A),
PIERPAOLO PELLICORI (C), OLIVIERO RIGGIO (B), PAOLO EMILIO PUDDU (A),
MANUELA MERLI (B), CONCETTA TORROMEO (A)
(A) DIPARTIMENTO DI SCIENZE CARDIOVASCOLARI, RESPIRATORIE,
NEFROLOGICHE, ANESTESIOLOGICHE E GERIATRICHE, UNIVERSITÀ SAPIENZA,
ROMA ; (B) GASTROENTEROLOGIA, DIPARTIMENTO DI MEDICINA CLINICA,
UNIVERSITÀ SAPIENZA, ROMA.; (C) CASTLE HILL HOSPITAL, DEPARTMENT OF
ACADEMIC CARDIOLOGY, HULL, UNITED KINGDOM
Scopo: La cardiomiopatia cirrotica (CCM) implica la presenza di una disfunzione diastolica
ventricolare sinistra di lieve entità , di anomalie elettro-fisiologiche e / o di cambiamenti strutturali
del miocardio in pazienti affetti cirrosi epatica. Tuttavia, i criteri diagnostici sono ancora vaghi , in
quanto non esistono parametri certi per individuare la disfunzione cardiaca. Lo scopo dello studio è
stato quello di valutare la meccanica del ventricolo sinistro (LV) con la tecnica del 3D Speckle
Tracking Echocardiography (3D-STE ) nei pazienti affetti da CCM.
Metodi: 10 pazienti con cirrosi epatica (7 in Child - Pugh A e 3 in B; MELD score di 11.2 ± 3.26 , 5
con varici esofagee e 2 con ascite ) e 32 controlli sani sono stati studiati sia con l’ecocardiografia
convenzionale 2D, sia con 3D-STE (3D Wall Motion Tracking). I risultati sono stati analizzati
secondo le Linee Guida della Società Americana di Ecocardiografia.
Risultati: Secondo i risultati ottenuti con l’ecografia convenzionale, i pazienti con cirrosi avevano
un aumento dell’indice di massa ventricolare sinistra e della frazione di eiezione ( 105 ± 21 vs 70 ±
14 g / m ^ 2 , p ≤ 0,001 e 62 ± 7 vs 57 ± 5 % , p = 0.009 ) rispetto ai controlli. La 3D-STE ha mostrato
che il global peak circumferential LV strain era significativamente ridotto nei pazienti con cirrosi
(24,6 ± 4,5 vs 27,3 ± 3,4 % , p = 0,045 ). Il global peak LV twist ed il global peak LV torsion erano
simili ( 5,2 ± 1,3 vs 2,8 ± 4 , p = 0,20 e 1,1 ± 0,4 vs 0,9 ± 1,1 , p = 0.60).
Conclusioni: Nei pazienti affetti da cirrosi epatica, la 3D-STE è in grado di identificare una riduzione
del LV peak circumferential strain seppur in presenza di una frazione di eiezione del LV aumentata.
Ulteriori studi sono necessari per caratterizzare in maniera più precisa le alterazioni meccaniche del
LV in pazienti con CCM.
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O313
VALUTAZIONE GLOBALE DELLA CARDIOTOSSICITÀ DA CHEMIOTERAPICI IN
PAZIENTI AFFETTE DA CARCINOMA DELLA MAMMELLA MEDIANTE SCREENING
PRECOCE
FEDERICO GUERRA (A), IACOPO CICCARELLI (A), MARCO MARCHESINI (A),
DANIELE CONTADINI (A), ALESSIO MENDITTO (A), MARIA AGNESE LATINI (A),
ELISA PICCOLO (A), ROSSANA BERARDI (B), NICOLA BATTELLI (B),
STEFANO CASCINU (B), ALESSANDRO CAPUCCI (A)
(A) CLINICA DI CARDIOLOGIA ED ARITMOLOGIA, OSPEDALI RIUNITI DI ANCONA,
UNIVERSITÀ POLITECNICA DELLE MARCHE ; (B) CLINICA DI ONCOLOGIA, OSPEDALI
RIUNITI DI ANCONA, UNIVERSITÀ POLITECNICA DELLE MARCHE
Background: la cardiotossicità è una comune complicanza di diversi farmaci antitumorali e resta una
importante limitazione al loro utilizzo. Con l’aumento dei pazienti trattati con chemioterapia e con
farmaci biologici (o dalla loro combinazione), l’incidenza della tossicità cardiaca è aumentata. Lo
scopo di questo studio è il riscontro precoce di cardiotossicità e la valutazione di eventuali fattori
predittivi clinico-strumentali.
Metodi: studio osservazionale prospettico monocentrico su 35 pazienti donne (età media 53±15 anni)
affette da carcinoma duttale o lobulare della mammella e destinate a ricevere trattamento
chemioterapico presso l’Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona. Le pazienti
sono stati valutati clinicamente, laboratoristicamente (dosaggio di BNP, Hs-TnI e CK-MB), con ECG
a 12 derivazioni, con ecocardiografia trastoracica (ETT) tradizionale e con metodica 2D-strain, prima
di iniziare il trattamento chemioterapico e a distanza di 3 mesi dall’inizio della terapia.
Risultati: La terapia chemioadiuvante somministrata era costituita da: ciclofosfamide (100%),
adriamicina (31%), epirubicina (34%), 5-fluorouracile (31%), doxorubicina (26%), taxotere (23%),
docetaxel (6%), metotrexate (3%) e transtuzumab (3%). Nei tre mesi di osservazione si è assistito ad
un signifcativo peggioramento delle condizioni cliniche, con un peggioramente della classe
funzionale NYHA di almeno un punto nel 37% dei casi (p<0.001), e ad un significativo innalzamento
dei livelli di Hs-TnI (+0.3 ng/ml; p=0.001) e BNP (+27 ng/ml; p=0.011), assieme ad una parallela
riduzione del livelli di Hb (-1.8 g/dl; p<0.001).
Riguardo ai parametri ecocardiografici, si è assistito ad una sostanziale riduzione della frazione
d’eiezione (-3%; p<0.001), dovuta sostanzialmente ad un aumento dei volumi ventricolari (+10 cm3
e +6 cm3 per il diastolico ed il sistolico rispettivamente; p<0.001). Le dimensioni delle camere atriali
non hanno subito modificazioni significative. Lo strain rate globale non ha subito modificazioni
significative nei 3 mesi di follow-up.
4 pazienti hanno subito una ri-ospedalizzazione mentre altre 3 hanno manifestato episodi di
tachicardia sopraventicolare. Non sono state riportati episodi di crisi ipertensiva, scompenso cardiaco
acuto, infarto miocardico o morte per tutte le cause.
Conclusioni: la terapia chemioadiuvante nel carcinoma della mammella è in grado di incidere in
maniera precoce sui marker clinici, laboratoristici ed ecocardiografici di funzione cardiaca e danno
d’organo. Uno screening completo di elettrocardiogramma, laboratorio ed ecocardiografia permette
di monitorizzare la tossicità al trattamento in modo da prevenire eventuali complicanze anche gravi.
L’utilizzo della metodica 2D-strain non sembra aumentare la sensibilità dell’ecocardiografia
durante monitoraggio precoce a 3 mesi rispetto ad un esame standard.
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O314
DIASTOLIC
DYSFUNCTION
IN
ASYMPTOMATIC
ALCOHOL-DEPENDENT
PATIENTS: ECHOCARDIOGRAPHIC EVALUATION AND CORRELATION WITH
ALCOHOL ABUSE PARAMETERS
ALFONSO SESTITO (A), CHRISTIAN LAURIA (A), ANTONIO MIRIJELLO (B),
CLAUDIA TARLI (B), GABRIELE ANGELO VASSALLO (B),
MARIANGELA ANTONELLI (B), ANNA FERRULLI (B), FILIPPO BERNARDINI (B),
RAFFAELE LANDOLFI (B), GIOVANNI ADDOLORATO (B)
(A) UNIVERSITÀ CATTOLICA DEL SACRO CUORE DIPARTIMENTO DI MEDICINA
CARDIOVASCOLARE; (B) UNIVERSITÀ CATTOLICA DEL SACRO CUORE
DIPARTIMENTO DI MEDICINA INTERNA
Chronic alcohol consumption represents the leading cause of a non-ischemic dilated cardiomyopathy
called alcoholic cardiomyopathy. It has been showed that alcohol induces several changes in the
myocardial structure by inducing myocyte loss, intracellular organelle dysfunction, contractile
protein alterations, and influencing calcium homeostasis. Literature data show the presence of
diastolic dysfunction, evaluated by E/A, as early sign of alcoholic cardiomyopathy. Aim of the present
study was to evaluate the echocardiographic characteristics of a population of alcohol-dependent
patients, asymptomatic for heart disease, assessing left ventricular diastolic function by E/A and E/E’
parameters. Moreover, the relationship with the duration of alcohol abuse and with the mean daily
alcohol consumption have been evaluated. A total of 14 patients affected by Alcohol Use Disorder
(AUD, American Psychiatric Association’s criteria), referring to the Alcohol Addiction Unit (AAU)
of the Institute of Internal Medicine, Catholic University of Rome, without clinical signs and
symptoms of cardiomyopathy were evaluated. Echocardiographic examination was performed in
collaboration with the Institute of Cardiology by a dedicated sonographer and a dedicated
cardiologist. Echocardiographyc evaluation was specifically oriented toward diastolic function (E/A,
E/E '), early markers of myocardial injury. The mean E/A was 1.58 (SD 0.44), E/E’ 9.92 (SD 2.24),
mean ejection fraction (EF) 62.29% (SD 7,21), 4C diastolic volume 96.80 ml (SD 19,02), 4C systolic
volume 36.83 ml (SD 13.05). The mean duration of alcohol abuse was 22.86 years (SD 9.08). The
mean daily alcohol consumption was 190 grams (SD131.86). A significant positive linear correlation
between E/A value and the duration of alcohol abuse (0,52, p-value 0,05) was found. A trend of
positive linear correlation between E/E’ value and the duration of alcohol abuse (0,44, p-value 0,06)
was found, although without reaching the statistical significance. No significant relation between the
mean daily alcohol consumption and E/A was found (0,12, p-value 0,68). Conclusions: These
preliminary data show an impairment of diastolic function in alcohol-dependent patients
asymptomatic for heart disease. A time-dependent effect of ethanol toxicity on diastolic heart function
seems to be present. Future studies on a larger sample are needed.
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O315
EXTRAMEDULLARY HEMATOPOIESIS (EMH) IS ASSOCIATED WITH LOWER
CARDIAC IRON LOADING IN REGULARLY POLYTRANSFUSED THALASSAEMIA
PATIENTS
ALESSIA PEPE (A), ANTONELLA MELONI (A), ANNA SPASIANO (B),
STEFANIA RENNE (C), PETRA KEILBERG (A), ROBERTA RENNI (D),
ELISABETTA CHIODI (E), VINCENZO POSITANO (A), PAOLO RICCHI (B)
(A) CMR UNIT, FONDAZIONE G. MONASTERIO CNR-REGIONE TOSCANA, PISA, ITALY;
(B) AORN CARDARELLI, UOSD CENTRO PER LE MICROCITEMIE, NAPOLI, ITALY; (C)
STRUTTURA COMPLESSA DI CARDIORADIOLOGIA-UTIC, P.O. “GIOVANNI PAOLO II”,
LAMEZIA TERME (CZ), ITALY; (D) DAY HOSPITAL, OSPEDALE CIVILE “F. FERRARI”,
CASARANO (LE), ITALY; (E) SERVIZIO RADIOLOGIA OSPEDALIERA-UNIVERSITARIA,
ARCISPEDALE “S. ANNA”, FERRARA, ITALY
Introduction. Extramedullary hematopoiesis (EMH) is an incidental finding in regularly and
historically polytransfused thalassaemia patients but no study has evaluated if it is a marker of a
peculiar pattern cardiac of iron loading
Methods. 1266 thalassemia patients (pts) regularly transfused consecutively enrolled in the
Myocardial Iron in Thalassemia (MIOT) Network were considered. Magnetic Resonance Imaging
(MRI) was used to assess the presence of EMH by SPGR sequences, to quantify cardiac and hepatic
iron overload by a multiecho T2* approach, and to assess cardiac function, volumes, atrial areas and
pulmonary diameter by SSFP sequences. Myocardial fibrosis was evaluated by LGE technique.
Results. EMH was detected in 167 pts (13.2%). The Table shows demographic and haematological
comparisons between EMH- and EMH+ pts. No significant differences were found in the chelation
regimens between the two groups.
EMH+ pts had significant less cardiac iron overload than EMH- pts (13.2 vs 28.3% of pts with global
heart T2* < 20 ms; P=0.003). Biventricular volumes, cardiac indexes, ejection fractions, atrial areas
and presence of myocardial fibrosis were comparable between the two groups. EMH+ patients had a
significantly higher LV mass index (62.3 ± 13.2 vs 58.63 ± 13.19 g/m2; P=0.001) and a significantly
higher pulmonary artery diameter (24.7 ± 4.2 vs 23.6 ± 3.8 mm; P=0.002).
Considering the 482 (38.1%) patients with MRI LIC≥7 mg/g dw, the EMH+ group had a significant
lower frequency of global heart T2*<20 ms (18.4% vs 40.8% p=0.007).
Conclusions: In this large cohort of regularly transfused thalassemia patients, EMH was not rarely
observed and was associated to a heart thalassemia intermedia like pattern (reduced cardiac iron
loading and stigmata of high cardiac output state) despite the transfusional regimen.
Age (yrs)
EMH(N=1099)
30.08  8.63
EMH+
(N=167)
38.93  6.10
<0.0001
Sex (M/F)
520/579
91/76
0.084
Pre-transfusion Hb (g/dl)
9.61  0.72
9.63  0.91
0.900
Age at first transfusion (yrs)
1.52  1.69
2.03  2.05
<0.0001
Regular transfusions starting age (yrs)
1.89  2.52
3.56  6.24
<0.0001
51.4
73.1
<0.0001
Splenectomy (%)
Mean Serum Ferritin (ng/ml)
1562.0 ±1475.9
993.9  1065.7
P
<0.0001
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Chelation starting age (yrs)
4.64  3.95
Roma, 13 – 15 dicembre 2014
7.71  6.05
<0.0001
O316
ENDOTHELIAL FUNCTION, PULSE PRESSURE AND CARDIOVASCULAR RISK
ANDREA CARDONA (A), GIUSEPPE AMBROSIO (A), ANNA MENGONI (A),
ANTONELLA D´ANTONIO (A), MAURIZIO BENTIVOGLIO (A), FABIO ANGELI (A)
(A) OSPEDALE S. MARIA DELLA MISERICORDIA FISIOPATOLOGIA
CARDIOVASCOLARE PERUGIA
Purpose: Pulse pressure (PP) is an established surrogate marker of atherosclerosis. Although flowmediated-dilatation (FMD) seems to be associated with arterial stiffness, it is not clear if its predictive
value for the identification of patients at high cardiovascular (CV) risk is superior to clinic PP.
Methods: We investigated 149 patients without previous CV events (age 45±15; 55% males; mean
PP 50 mmHg). Ultrasonographic FMD was calculated and the 10-year risk of CV events was
estimated based on the Framingham risk score (FRS). Accuracy of FMD for the recognition of
patients at high CV risk (FRS>20%) was estimated by ROC curve analysis. ROC curves were
compared by means of two-tailed univariate z-test of the difference between the areas under 2 curves.
Results: A significant correlation between FMD and FRS was found (R=0.11,p<0.001). However,
such association was weaker in patients with increased PP: the significant inverse relation between
FMD and FRS in patients with PP<46 mmHg (slope:-0.95;p=0.029), and PP ranging from 46-53
mmHg (slope:-1.97; p=0.008) was lost in patients with PP>53 mmHg (slope:-1.17;p=0.170).
Comparison of ROC curves showed that performance of FMD for the identification of patients at
high CV risk (FRS>20%) was not different from that of PP (difference between
areas:0.002,p=0.079).
Conclusions: Lack of significant association between FMD and CV risk among patients with
increased PP indicates little additive prognostic value of endothelial function, suggesting that FMD
assessment might be hampered in patients with increased arterial stiffness.
O317
CONTROLLO DI QUALITA’ DELLA RIANIMAZIONE CARDIO POLMONARE
MAURIZIO SANTOMAURO (a), ALESSANDRO SACCENTI (a), LOREDANA GRANDE (a),
GIUSEPPINA LANGELLA (a), GIANLUCA VOSA (a), LUIGI MATARAZZO (a),
CARLO VOSA (a)
(a) UOC DI CARDIOCHIRURGIA ADULTI E PEDIATRICA, UNIVERSITA´ FEDERICO II
NAPOLI
Bachground: La RCP (Rianimazione cardio polmonare) deve rispondere alle specifiche esigenze del
paziente. Tomlinson et al hanno messo in evidenza che i pazienti presentano rapporti di profonditàforza molto diversi. I tassi di sopravvivenza agli arresti cardiaci improvvisi sono rimasti invariati
negli ultimi 25 anni. Tuttavia rapporti recenti del sistema EMS nel Wiscosin ( 48%) a Seattle (46%)
e Kansas City (44%) in Arizona riportano un aumento significativo del tasso di sopravvivenza. Il
fattore che piu' probabilmente ha contribuito a questo incoraggiante progresso è la maggiore
attenzione alla somministrazione di una RCP di qualità secondo le piu' recenti linee guida.
Recentemente per garantire che la manovra del massaggio cardiaco sia effettuata in modo corretto
durante la RCP si è reso disponibile un nuovo sistema: il QCPR Meter (Laerdal). Esso è in grado di
guidare il soccorritore nella somministrazione di compressioni toraciche corrette ed efficaci, adeguate
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
ai bisogni specifici del paziente in conformità alle linee guida AHA e ERC 2005 attraverso un
feedback grafico dinamico in tempo reale che fornisce un mini-debriefing.
Materiale e metodi: Nello svolgimento di 20 corsi di addestramento indirizzati a laici volontari è
stato utilizzato il QCPR Meter (Laerdal). Il misuratore è stato posto nella zona dove si è eseguito il
massaggio cardiaco e si sono memorizzati i valori di profondità, di rilasciamento, periodi di assenza
di compressione e frequenza. L’acquisizione dei dati è avvenuta sia nella prima fase di addestramento
che nella fase finale dopo il retraining. In totale il QCPR Meter è stato utilizzato da 555 volontari
(300 maschi e 155 femmine) appartenenti alla Protezione Civile, Guardia di Finanza, Carabinieri,
Polizia di Stato, Polizia Penitenziaria.
Risultati: Durante la prima fase di addestramento i valori di profondità, rilascio e di frequenza hanno
raggiunto la soglia di sufficienza nel 15% dei volontari (compressioni corrette 15%, rilascio completo
13%, assenza di compressione 85%, frequenza corretta 13%). Dopo il retraining gli stessi parametri
hanno raggiunto il livello di esecuzione ottimale nel 96% dei volontari (compressioni corrette 96%,
rilascio corretto 96%, assenza di compressione 4%, frequenza corretta 96%) (p 0.001).
Conclusioni: Il misuratore per RCP si è rivelato un utile strumento per il soccorritore laico non
professionista per garantire il massimo livello di qualità durante l’esecuzione del massaggio cardiaco.
Questa manovra in accordo alle linee guida deve essere interrotta il meno possibile durante il
soccorso. Tuttavia non viene eseguita correttamente da parte del soccorritore non professionista. I
dati raccolti suggeriscono che questo strumento andrebbe utilizzato sia durante la fase di
addestramento sia nelle situazioni reali di soccorso.
DIABETE E MALATTIE CARDIOVASCOLARI
O318
IMPACT OF DRUG-ELUTING STENT GENERATION ON PATIENT- AND STENTRELATED ADVERSE EVENTS OF DIABETIC PATIENTS TREATED BY
PERCUTANEOUS CORONARY INTERVENTION
GIANPIERO D´AMICO (A), TOMMASO FABRIS (A), MARCO MOJOLI (A),
ALESSANDRO LUNARDON (A), NATASCIA BETTELLA (A), PAOLA ANGELA
MARIA PURITA (A), MICHELA FACCHIN (A), GIULIA MASIERO (A), ELISA COVOLO (A),
CLAUDIA ZANETTI (A), FILIPPO ZILIO (A), ALBERTO BARIOLI (A),
GILBERTO DARIOL (A), AHMED AL MAMARY (A), MASSIMO NAPODANO (A),
SABINO ILICETO (A), GIAMBATTISTA ISABELLA (A), GIUSEPPE TARANTINI (A)
(A) DEPARTMENT OF CARDIAC, THORACIC AND VASCULAR SCIENCES, UNIVERSITY
OF PADUA
Background. Diabetes mellitus (DM) patients are at high risk of patient- and stent-related adverse
events following percutaneous coronary intervention (PCI) even in drug-eluting stent (DES) era.
Compared to first-generation, the second-generation DES improved safety and efficacy in overall
population. However, in DM population results from previous studies comparing the two DES
generations are controversial. We aimed to assess the potential interaction of stent generation type
with both stent- and patient-related outcomes in a real-world DM population treated by DES PCI.
Methods. Data were obtained from a prospective, single-center registry of 816 consecutive patients
with diabetes mellitus (23% insulin-requiring) who underwent percutaneous coronary intervention
between April 2003 and May 2012 with first- (n=534) or second-generation DES (n=282) at our
Institution, with at least 12 months of follow-up. We assessed the occurrence of stent-related outcome,
including cardiac death, target vessel-related myocardial infarction and target lesion
revascularization, versus patient-related outcome, including any cause death, any myocardial
infarction and any coronary revascularization.
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Roma, 13 – 15 dicembre 2014
Results. Patients treated with second-generation DES were older and had more complex lesions than
patients treated with first-generation DES. Both among patients treated with first-generation DES and
those treated with second generation DES, patient-related events were almost double than stentrelated events. No interactions were observed between the DES generation type and insulin
requirement status.
Conclusions. In this observational study, first- and second-generation DES were equally safe and
efficacious in diabetic patients undergoing PCI, regardless of insulin requirements. The greater
number of patient-related than stent-related events in patients with complex clinical and lesion
characteristics emphasizes that during long-term follow-up, the optimization of secondary prevention
is at least as important as the selection of which new generation DES to implant in a specific lesion.
O319
THE ROLE OF CORONARY MICROVASCULAR DYSFUNCTION IN TYPE II DIABETIC
PATIENTS WITH NORMAL CORONARY ANGIOGRAPHY: ASSOCIATION BETWEEN
CORONARY FLOW RESERVE AND CONTRACTILE RESERVE
FRANCESCO LO IUDICE (A), MAURIZIO GALDERISI (A), CIRO SANTORO (A),
PAOLA GARGIULO (A), CARMEN D´AMORE (A), IANA SIMOVA (A),
ROBERTA ESPOSITO (A), CARLO DI NARDO (A), PASQUALE PERRONE FILARDI (A)
(A) CENTRO INTERDIPARTIMENTALE PER LA RICERCA SULL´IPERTENSIONE
ARTERIOSA E PATOLOGIE ASSOCIATE (CIRIAPA), DIPARTIMENTO DI SCIENZE
BIOMEDICHE AVANZATE, UNIVERSITA´ FEDERICO II, NAPOLI
Purpose: Diabetes Mellitus (DM) has detrimental effects on the heart even in the absence of
epicardial coronary artery stenosis. Aim of our study was to investigate the relationship between
coronary flow reserve (CFR), a marker microvascular function in absence of coronary artery stenosis
(CAS), and inotropic response after high-dose dipyridamole (Dip) infusion.
Methods: 37 affected by Diabetes Mellitus Type II (mean age 61± 10; 22 males) and 39 control
subjects (mean age 57±11; 26 males) all free from significant CAS, within one month from enrolment,
underwent stress echocardiography by Dip (0.84 mg/kg i.v. in 6 min) to evaluate CFR (ratio of high
Dip to rest peak diastolic coronary flow velocity at left anterior descending coronary). Contractile
reserve was assessed as percent increment (between baseline and Dip) of global longitudinal strain
(Δ% GLS, average of 18 myocardial segments in the 3 apical views) assessed by speckle tracking
echocardiography.
Results: DM patients had both reduced CFR (2.49±0.90 versus 2.92±0.76; p=0.03) and Δ% GLS
(14.44±13.05 vs 20.80±15.25 ; p=0.05) compared with normal controls. GLS at rest did not differ
between DM patients and controls, while Dip-derived GLS was significantly lower in DM patients (22.59±3.56 vs -24.24±3.48; p=0.04). In the pooled population CFR was positively associated with Δ
GLS (r=0.25 ; p=0.03).
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
Conclusion: In our study, CFR is significantly associated with contractile reserve, suggesting
microvascular dysfunction as one of the pathophysiological mechanisms underlying the reduced
increase of longitudinal systolic function during stress in DM patients. The reduction of Dip-stress
derived longitudinal function when it is still normal at rest could represent an early marker of
myocardial dysfunction in DM.
O320
C21, UN AGONISTA DEL RECETTORE DELL’ANGIOTENSINAII, IN PRESENZA DI
ALTE CONCENTRAZIONI DI GLUCOSIO INIBISCE IN CELLULE MONONUCLEATE
UMANE L’ATTIVITÀ PROCOAGULANTE DEL FATTORE TISSUTALE LPSSTIMOLATA
CRISTINA BALIA (A), VALENTINA SCALISE (A), SILVIA PETRINI (A),
SILVANA CIANCHETTI (A), TOMMASO NERI (A), ALESSANDRO CELI (A),
ROBERTO PEDRINELLI (A, B)
(a) DIPARTIMENTO DI PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E
DELL´AREA CRITICA, UNIVERSITÀ DEGLI STUDI DI PISA; (b) ISTITUTO NAZIONALE
DI RICERCHE CARDIOVASCOLARI, INRC, BOLOGNA
Background: Il Fattore Tissutale (Tissue Factor,TF), l’iniziatore della via estrinseca della
coagulazione ed il principale regolatore dell’emostasi e della coagulazione, è fortemente sensibile
all’effetto di stimoli proinfiammatori, una relazione cui l’Angiotensina(AT)II generata localmente
partecipa amplificando l’effetto di svariati stimoli infiammatori. All’azione procoagulante
dell’ATII, mediata dal suo legame con il recettore di tipo 1 (AT1R), appare opporsi la stimolazione
del recettore di tipo 2 (AT2R) tramite C21, un agonista AT2R-selettivo, un dato recente ottenuto in
cellule mononucleate isolate da sangue periferico (Peripheral Blood Mononuclear Cell, PBMCs)
attivate da un tipico agente pro infiammatorio quale il lipopolisaccaride (LPS, endotossina). E’
tuttavia ignoto se la modulazione AT2 recettoriale si manifesti anche in presenza di alte
concentrazioni di glucosio, uno stimolo che attiva la trascrizione genica NFkB-mediata di svariate
citochine proinfiammatorie ed aumenta la concentrazione cellulare e l’attività dei componenti del
sistema renina-angiotensina tissutale.
Scopo: Valutare l’effetto del C21, un AT2R-agonista altamente selettivo, in PBMCs esposte ad
elevate concentrazioni di glucosio (High Glucose, HG).
Materiali e metodi: Le PBMCs, ottenute dal sangue di donatori sani usando il gradiente di densità
discontinuo Ficoll/Hystopaque, sono state attivate con LPS (0,1 μg/mL) e trattate con C21 (Vicore
Pharma AB, Mintage Scientific AB, Göteborg, Svezia), Olmesartan (OLM), un AT1R antagonista
(10-8-10-5 M per entrambi), PD123,319, un AT2R antagonista (10-6 M) e BAY-11-7082 (10-5 M), un
inibitore selettivo di NF-kB, il fattore cruciale per la trascrizione del gene del TF. Gli studi sono stati
condotti in PBMCs esposte a HG (50 mM) e glucosio normale (NG, 5mM). L’attività procoagulante
(ProCoagulant Activity, PCA) del TF è stata determinata tramite “one-stage clotting assay” ed i
risultati espressi in unità arbitrarie (AU) tramite il confronto con una curva di calibrazione ottenuta
con concentrazioni note di TF.
Risultati: L’incubazione di PBMCs in HG amplificava l’effetto procoagulante indotto da LPS
(0,85±0,39 vs 2,8±0,98 AU, n=51, p<0.001) che il BAY-11-7082, un inibitore selettivo di NFkB,
aboliva (-95±0.4%, n=8, p<0.001). Il C21 inibiva in modo concentrazione-dipendente la PCA LPSindotta (10-8 M:−32±21%, 10-7 M:−38±21%, 10-6 M:−40±20%, 10-5 M:−45±24%, n=12, p<0.001) ed
il PD 123,319 (10-6M), un AT2R antagonista, ne annullava l'effetto (10-8 M:−10±17%, 107
M:−7±25%, 10-6M:−3±26%, 10-5M:−7±41%, n=7, NS). L’AT1R antagonista OLM antagonizzava
la PCA LPS-indotta in modo quantitativamente analogo a quello del C21 (10-8 M:−35±18%, 10-7
M:−36±17%, 10-6 M:−43±24%, 10-5 M:−56±14%, n=12, p<0.001).
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Roma, 13 – 15 dicembre 2014
Conclusioni: Elevate concentrazioni di glucosio amplificano l’effetto procoagulante di LPS
inducendo la trascrizione NFkB-mediata di TF che il C21 modula negativamente attraverso la
stimolazione dei recettori AT2 il cui effetto inibitorio bilancia quello opposto esercitato dagli AT1R.
I dati confermano la complessità dei meccanismi che collegano infiammazione e coagulazione e
dimostrano il ruolo rilevante che il sistema renina-angiotensina gioca anche in presenza di elevate
concentrazioni di glucosio, una condizione sperimentale che simula quella che si verifica in presenza
di diabete.
O321
LA MALATTIA CARDIOVASCOLARE PRECLINICA NEL DIABETE: DIFFERENZE DI
GENERE
FRANCESCA SIDA (A), PIER SERGIO SABA (A), GIUSEPPE DAMIANO SANNA (A),
GIUSEPPINA CASALNUOVO (A), PAOLO PISCHEDDA (A), GIOVANNI LORENZONI (A),
LEONARDO PUDDU (A), FABIO SECHI (A), ANTONELLO GANAU (A)
(A) CARDIOLOGIA, AZIENDA OSPEDALIERO-UNIVERSITARIA DI SASSARI
Background e Obiettivi dello studio: Il diabete mellito di tipo 2 (DM2) è uno dei maggiori fattori
di rischio cardiovascolare (CV). Il suo impatto prognostico è differente negli uomini e nelle donne,
poiché il rischio relativo di eventi CV nelle donne diabetiche è 3-4 volte maggiore rispetto alle donne
non diabetiche, mentre negli uomini diabetici il rischio aumenta 2-3 volte. L’obiettivo del nostro
studio è quello di verificare se il maggior rischio di eventi CV nelle donne diabetiche possa dipendere
da una maggiore prevalenza di fattori di rischio CV e/o di danno d’organo subclinico rispetto agli
uomini diabetici. Metodi: In 135 uomini e 107 donne affetti da DM2 senza precedenti eventi CV, di età compresa tra
34 e 87 anni, sono stati raccolti i dati antropometrici e di laboratorio (profilo glicemico, HbA1c,
funzionalità renale, profilo lipidico) per valutare il profilo di rischio. In tutti i pazienti sono stati
valutati massa e geometria ventricolare sinistra mediante ecocardiografia e spessore medio-intimale
e delle placche mediante ultrasonografia carotidea. In un sottogruppo di 156 soggetti (62 femmine e
94 maschi) è stata inoltre eseguita la tonometria carotidea per valutare i parametri di riflessione
dell’onda pressoria (augmentation pressure, AP, e tempo di transito, TT) e misurare la rigidità
arteriosa (pulse wave velocity, PWV). Risultati: Le donne avevano una età lievemente ma significativamente maggiore degli uomini (66±8
vs 64±9 anni; p<0,05). La PA era 141±20/83±9 mmHg nelle donne e 138±18/83±9 mmHg negli
uomini (p>0,05 sia per la sistolica che per la diastolica) e anche la prevalenza di ipertensione non era
dissimile (72% vs 79%, rispettivamente; p>0,05). La prevalenza di obesità era significativamente
maggiore nelle donne rispetto agli uomini (81% vs 44%; p<0,001), come anche la prevalenza di
sindrome metabolica (78% vs 43%, p<000,1). La percentuale di soggetti fumatori/ex fumatori era
significativamente minore nelle donne che negli uomini (29% vs 71%; p<0,001). Bassi valori di HDL
erano più frequenti nelle donne rispetto agli uomini (52% vs 36%; p<0,001). Uomini e donne non
differivano significativamente (p>0,05) per valori di spessore medio-intimale carotideo (0,8±0,14
mm vs 0,8±0,15 mm), prevalenza di ispessimento medio-intimale (46% vs 37%) o prevalenza di
placche (82% vs 75%). La prevalenza di ipertrofia ventricolare sinistra era più elevata nelle donne
rispetto agli uomini (46% vs 23%; p<0,001). Il pattern geometrico più rappresentato nei soggetti con
ipertrofia era quello eccentrico in entrambi i gruppi. Nelle donne l’AP era significativamente più
elevata rispetto agli uomini (12,0±6,4 mmHg vs 8,6±6,1 mmHg; p<0,0001) e il TT dell’onda riflessa
era più breve (91±24 msec vs 113±36, rispettivamente; p<0,0001), indici del ritorno al cuore di onde
riflesse più ampie e precoci. La PWV era simile negli uomini e nelle donne (10,1±2,5 m/sec vs
10,4±2,1 m/sec, rispettivamente; p>0,05). Conclusioni: Le donne diabetiche hanno un profilo di rischio più elevato rispetto agli uomini
diabetici, come dimostra la maggiore prevalenza di obesità, sindrome metabolica e ipertrofia cardiaca
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75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
e la presenza di onde pressorie più ampie e precoci. Questi elementi possono contribuire alla prognosi
relativamente più severa nelle donne diabetiche rispetto agli uomini.
O322
LA RIDUZIONE DELLA PROTEINA C REATTIVA NON È ASSOCIATA AD UNA
RIDUZIONE DEL RISCHIO CARDIOVASCOLARE E DELLA MORTALITÀ NEI
PAZIENTI TRATTATI CON STATINE. UNA META-ANALISI DI 22 STUDI
RANDOMIZZATI.
GIANLUIGI SAVARESE (B, C), GIUSEPPE MC ROSANO (D), ANTONIO PARENTE (A),
CARMEN D´AMORE (A), MARTIN F REINER (C), GIOVANNI G CAMICI (C),
BRUNO TRIMARCO (A), PASQUALE PERRONE FILARDI (A)
(A) DIPARTIMENTO DI SCIENZE BIOMEDICHE AVANZATI, UNIVERSITÀ DEGLI STUDI
DI NAPOLI “FEDERICO II“; (B) ISTITUTO DI RICOVERO E CURA A CARATTERE
SCIENTIFICO SAN RAFFAELE PISANA, ROMA; (C) CENTER OF MOLECULAR
CARDIOLOGY, UNIVERSITY OF ZURICH, SWITZERLAND; (D) CARDIOVASCULAR AND
CELL SCIENCES RESEARCH INSTITUTE, ST GEORGE´S UNIVERSITY OF LONDON,
UNITED KINGDOM
Background. L’associazione tra livelli di proteina C reattiva (PCR) e rischio di eventi cardiovascolari
(CV) è stata riportata in numerosi studi. Tuttavia, non è chiaro se ad una riduzione dei livelli di PCR
corrisponda una parallela riduzione del rischio di eventi clinici. L’obiettivo di questo studio è stato di
investigare mediante una meta-regressione di studi randomizzati, se variazioni dei livelli di CRP siano
associati ad una modifica del rischio di infarto del miocardio, stroke morte per tutte le cause e morte
CV.
Metodi. Sono stati individuati mediante MEDLINE, Cochrane, ISI Web o Science e Scopus tutti gli
studi che arruolavano pazienti trattati con statine e che riportavano i livelli di PCR al baseline e al
termine del follow-up, gli eventi CV (infarto del miocardio e stroke), mortalità CV e per tutte le cause.
La meta-analisi è stata effettuata per verificare l’effetto del trattamento con statine sugli outcomes
prespecificati. L’analisi di meta-regressione è stata svolta per testare la relazione tra variazione dei
livelli di PCR e gli outcomes. E’ stata effettuata l’analisi di sensibilità per ricercare potenziali variabili
confondenti (variabili demografiche, Detsky quality score, durata del follow-up e anno di
pubblicazione) in grado di modificare i nostri risultati. E’ stata testata la presenza di un eventuale bias
di pubblicazione mediante il test di Mecaskill.
Risultati. Sono stati inclusi nell’analisi 22 studi che arruolavano un totale di 54,213 pazienti. La
meta-analisi ha mostrato che il trattamento con statine riduceva significativamente il rischio di morte
per tutte le cause dell’8% (RR: 0.920; CI: 0.876 a 0.966; p=0.001), il rischio di infarto del miocardio
dell’11% (RR: 0.890; CI: 0.842 a 0.940; p<0.001), il rischio di stroke del 10.3% (RR: 0.897; CI:
0.817 a 0.984; p=0.022) e l’outcome composito (che comprendeva morte CV, infarto del miocardio
e stroke) dell’8% (RR: 0.920; CI: 0.888 a 0.953; p<0.0001), mentre il rischio di morte CV non era
significativamente ridotto (RR: 0.955; CI: 0.882 a 1.035; p=0.260). L’analisi di meta-regressione ha
mostrato che ad una riduzione dei livelli di PCR corrispondeva una riduzione del rischio di infarto
del miocardio (RC: 0.016; CI: 0.001 a 0.031; p=0.036), ma il rischio di stroke (RC: 0.008; CI: -0.037
a 0.054; p=0.703), morte CV (RC: -0.009; CI: -0.024 a 0.005; p=0.186) e per tutte le cause (RC: 0.006; CI: -0.018 a 0.005; p=0.273) rimaneva invariato, così come il verificarsi dell’outcome
composito (RC: 0.005; CI: -0.015 a 0.026; p=0.580).
Conclusioni. Questi risultati dimostrano che la riduzione dei livelli di PCR indotta dalla terapia con
statine è associata ad un ridotto rischio di infarto del miocardio, ma non di stroke, e non ha nessun
impatto sulla mortalità CV e per tutte le cause in pazienti ad alto rischio CV. Questi dati suggeriscono
che sebbene la PCR possa essere utilizzata come marker surrogato di rischio di infarto del miocardio,
essa non dovrebbe essere impiegata per valutare l’efficacia della terapia con statine.
SIC | Indice Autori
294
75° CONGRESSO NAZIONALE
della Società Italiana di Cardiologia
Roma, 13 – 15 dicembre 2014
O323
IMPACT OF DIABETES ON FIBRINOGEN LEVELS AND ITS RELATIONSHIP WITH
PLATELET REACTIVITY AND CORONARY ARTERY DISEASE: A SINGLE-CENTRE
COHORT STUDY.
GABRIELLA DI GIOVINE (A), MONICA VERDOIA (A), ETTORE CASSETTI (A),
ALON SCHAFFER (A), LUCIA BARBIERI (A), PAOLO MARINO (A), GIUSEPPE DE
LUCA (A)
(A) AOU MAGGIORE DELLA CARITA´DI NOVARA
Background. Previous reports have suggested an association between elevated fibrinogen and CAD.
Few studies have so far investigated the impact of diabetes on fibrinogen levels and its association
with coronary artery disease (CAD) as evaluated by coronary angiography in diabetic patients that
are therefore the aims of the current study.
Methods. We measured fibrinogen in 3280 consecutive patients undergoing coronary angiography.
Samples were collected at admission for fibrinogen levels assessment. Coronary disease was defined
for at least 1 vessel stenosis > 50% as evaluated by QCA.
Results. Diabetes was observed in 1201 out of 3280 patients. Diabetic patients were older with more
hypercholesterolemia, hypertension, higher BMI, more renal failure, previous MI or coronary
revascularization (p<0.001, respectively) and smoking (p=0.001). Diabetics were more often on
ACE-inhibitors, ARBs, b-blockers, calcium-antagonists, diuretics, statins (p<0.001, respectively),
and ASA (p=0.004). Diabetics displayed higher glycemia and HbA1c (p<0.001), higher creatinine
and triglycerides (p<0.001) but lower total and HDL cholesterol (p<0.001) and haemoglobin
(p<0.001). Diabetics had higher fibrinogen levels (p=0.003), however neither diabetes nor glucose
homeostasis parameters resulted as independent predictors of hyperfibrinogenemia. Furthermore,
among diabetic patients, higher fibrinogen levels did not affect platelet reactivity and were not
associated with the prevalence of CAD (adjusted OR[95%CI]=0.99 [0.82-1.19], p=0.9). Similar
results were found for severe CAD (adjusted OR[95%CI]=0.94 [0.82-1.08], p=0.40).
Conclusions. Our study showed that diabetes and glycemic control are not independent predictors of
hyperfibrinogenemia. Among diabetic patients, elevated fibrinogen is not associated with platelet
reactivity and the prevalence and extent of CAD.
Linear regression analysis showing the absence of relationship between fibrinogen levels and value
of glycemia at the admission (A, graph on the left side) and HbA1c (B, graph on the right side).
SIC | Indice Autori
295