Ketty Savino

Cardiac involvement in sickle beta thalassemia (Sβ-thal) patients has been poorly investigated. We aimed to evaluate cardiac function and myocardial iron overload by cardiovascular magnetic resonance (CMR) in patients with Sβ-thal. One-hundred and eleven Sβ-thal patients consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) network were studied and compared with 46 sickle cell anemia (SCA) patients and with 111 gender- and age- matched healthy volunteers. Cine images were acquired to quantify biventricular function. Myocardial iron overload (MIO) was assessed by the T2* technique, while macroscopic myocardial fibrosis was evaluated by the late gadolinium enhancement (LGE) technique. In Sβ-thal and SCA patients, the morphological and functional CMR parameters were not significantly different, except for the left atrial area and left ventricular (LV) stroke volume, indexed by body surface area (p = 0.023 and p = 0.048, respectively), which were significantly higher in SCA patients. No significant differences between the two groups were found in terms of myocardial iron overload and macroscopic myocardial fibrosis. When compared to healthy subjects, Sβ-thal patients showed significantly higher bi-atrial and biventricular parameters, except for LV ejection fraction, which was significantly lower. The CMR analysis confirmed that Sβ-thal and SCA patients are phenotypically similar. Since Sβ-thal patients showed markedly different morphological and functional indices from healthy subjects, it would be useful to identify Sβ-thal/SCA-specific bi-atrial and biventricular reference values.

Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that refers to a spectrum of noninfectious lesions of cardiac valves that is most commonly seen in advanced malignancy. We describe a case report of a 63-year-old male with NBTE and multiple embolizations (encephalic, coronary, splenic, and renal). The patient was admitted to the emergency department for stroke. During hospitalization, the patient complained of left leg pain and a venous echo color Doppler of the lower limbs was performed, showing bilateral distal deep-vein thrombosis. A thoracoabdominal computed tomography scan, which was performed to rule out pulmonary embolism, revealed a primary lung cancer and subcarinal lymphadenopathy. As collateral findings, multiple ischemic lesions in the spleen and in both kidneys were identified. In addition, areas of subendocardial hypodensity compatible with ischemia were also highlighted. An electrocardiogram showed acute myocardial infarction and focused echocardiographic evaluation displayed hypokinesis of the lateral and posterior in the mid- and distal segments and aortic and mitral valve vegetations, confirmed by a transesophageal echocardiography. Empiric antimicrobial therapy was started; all blood culture sets were negative and the patient was apyretic throughout the hospitalization. These findings supported the hypothesis of NBTE with multiple embolizations during a hypercoagulable state associated with advanced lung cancer.

Primary cardiac lymphoma (PCL) is among the rarest heart neoplasms. Its estimated incidence is about 1%–2% among primary cardiac tumor and 0.5% of extranodal lymphoma. It usually causes heart failure, pericardial effusion, tamponade, and arrhythmias. Prognosis is poor; treatment is combined medical and surgical. We described the case of a 62-year-old male with PLC that presented with syncope and cardiac tamponade, submitted to R-CHOP therapy because of failure of surgery. Clinical state is stable 3 months after diagnosis and first chemotherapy cycle.

The availability of miniaturized ultrasound machines has changed our approach to many cardiovascular diseases. Handheld ultrasound imaging can be performed at the bedside, it is easy to use, and the information provided, although limited, is of unquestionable importance for a quick diagnosis that leads to early treatment. They have unique characteristics: Low cost, wide availability, safety, accuracy, and can be used in different clinical scenarios and by operators with different backgrounds. Image acquisition and interpretation is rapid and provides, in each situation, useful information for diagnosis, prognosis, and clinical and therapeutic management. This review focuses on the use of handheld ultrasound devices, describes differences with other equipment, their limitations, and the numerous advantages derived from their use.

Despite the availability of anti-hypertensive medications with proven efficacy and good tolerability, many hypertensive patients have blood pressure (BP) levels not at the goals set by international societies. Some of these patients are either non-adherent to the prescribed drugs or not optimally treated. However, a proportion has resistant hypertension (RH) defined as office BP above goal despite the use of ≥3 antihypertensive medications at maximally tolerated doses (one ideally being a diuretic). Diagnosis of RH based upon office measurements, however, needs confirmation through 24-h BP monitoring to exclude "white coat" RH since cardiovascular events and mortality rates follow mean ambulatory BPs. Standardized combination therapy based upon angiotensin converting enzyme inhibitors or angiotensin receptor blockers, amlodipine or other dihydropiridine calcium channel blockers and thiazide or thiazide-like diuretics has been advocated to treat RH with spironolactone as preferred fourth add-on drug. Interventional procedures such as renal denervation have been devised to treat RH and tested with insofar not positive results in series of patients not responding to medical treatment. It is unclear whether RH constitutes a specific phenotype of EH or should rather be considered a more serious form of uncontrolled hypertension. Whatever the case, its presence associates with an increased cardio- and cerebrovascular risk and deserves, therefore, particular care.

Structural changes in left and right cardiac chambers that occur in arterial hypertension (AH) may lead to an increased risk of atrial fibrillation. Considering that AH is currently the most common cardiovascular disease in the general population, it represents a major risk factor for atrial fibrillation development. This review explores the complex relationship between atrial fibrillation and AH, starting from its pathophysiological basis. It focuses on the role of echocardiography in the management of hypertensive and atrial fibrillation patients, with emphasis on what should be evaluated about left ventricular remodeling, diastolic and systolic function, left atrial (LA) size and function and right ventricular deformation in patients with AH.

Functional analysis and measurement of left atrium are an integral part of cardiac evaluation, and they represent a key element during non-invasive analysis of diastolic function in patients with hypertension (HT) and/or heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction remains quite elusive regarding classification, and atrial size and function are two key factors for left ventricular (LV) filling evaluation. Chronic left atrial (LA) remodelling is the final step of chronic intra-cavitary pressure overload, and it accompanies increased neurohormonal, proarrhythmic and prothrombotic activities. In this systematic review, we aim to purpose a multi-modality approach for LA geometry and function analysis, which integrates diastolic flow with LA characteristics and remodelling through application of both traditional and new diagnostic tools. The most important studies published in the literature on LA size, function and diastolic dysfunction in patients with HFpEF, HT and/or atrial fibrillation (AF) are considered and discussed. In HFpEF and HT, pulsed and tissue Doppler assessments are useful tools to estimate LV filling pressure, atrio-ventricular coupling and LV relaxation but they need to be enriched with LA evaluation in terms of morphology and function. An integrated evaluation should be also applied to patients with a high arrhythmic risk, in whom eccentric LA remodelling and higher LA stiffness are associated with a greater AF risk. Evaluation of LA size, volume, function and structure are mandatory in the management of patients with HT, HFpEF and AF. A multi-modality approach could provide additional information, identifying subjects with more severe LA remodelling. Left atrium assessment deserves an accurate study inside the cardiac imaging approach and optimised measurement with established cut-offs need to be better recognised through multicenter studies.