Giampaolo Luzi

Bedside pressure–flow variables in cardiogenic shock (CS) incompletely characterize ventricular energetics and coupling. We prospectively derived bedside pressure–volume (PV) loop surrogates from paired pulmonary artery catheter and echocardiographic data in 68 patients (263 paired assessments) with acute myocardial infarction–related CS (AMI-CS) or heart failure–related CS (HF-CS) during microaxial support, intra-aortic balloon pump (IABP) support, or medical therapy. In AMI-CS with microaxial support, arterial elastance decreased (−1.22 mm Hg/ml) with improved coupling (ventriculoarterial coupling [VAC] −1.42), stroke work increased (+140 mm Hg·ml), and pressure–volume area declined (PVA −103 mm Hg·ml), yielding an efficiency rise from ~32% to ~40%, suggesting unloading. In HF-CS, microaxial support reduced elastance modestly (−0.35) with probable efficiency gain (+5%) but heterogeneous PVA changes. In AMI-CS treated with IABP, coupling improved (VAC −0.42) with modest energetic augmentation, whereas HF-CS showed pressure and energy amplification (end-systolic pressure +23.9 mm Hg; PVA +220.6 mm Hg ·ml). Without mechanical support, AMI-CS demonstrated reduced elastance and pressure, while HF-CS exhibited ventricular dilation (end-diastolic volume [EDV]/end-systolic volume ESV increase) with higher energetic demand. Pressure–volume–derived metrics identify device-specific energetic signatures not fully captured by conventional hemodynamic assessment and may provide mechanistic insight into ventricular unloading strategies; validation against conductance catheter–derived PV measurements remains warranted.

Background: Circulatory support escalation is often required during cardiogenic shock (CS) treatment. Currently, no large-scale data is available to inform how escalation strategies integrate in contemporary CS management and affect outcomes. Methods: We assessed the frequency, outcomes, and prognostic implications of escalation from a retrospective international registry of CS patients from 4 cardiac intensive care units. Escalation was defined as any incremental change in the circulatory support strategy after an initial bundle of care was established for at least 4 hours. Results: Among 602 consecutive CS patients, escalation was required in 30%. Patients were escalated to inotropes/vasopressors (36%), IABP (39%), Impella (14%) or V-A ECMO (11%). Escalation was associated with a higher hospital mortality rate (43% vs 21%; p adj 3.42; 95% CI 2.21-3.35) and a greater transition to heart replacement therapies (23% vs 5%; p adj 6.01; 95% CI 3.31-11.27), when adjusted for age, sex, chronic kidney disease, markers of CS severity on admission, CS etiology, and admission source. Escalation was associated with a higher risk of complications including acute kidney injury, major bleeding, and stroke. These outcomes occurred more frequently with high-profile mechanical circulatory support (Impella, V-A ECMO). Complications mediated 24% (95%CI 9-40%) of the association between escalation and hospital death. Escalated patients were successfully discharged alive in 42%. Age, SCAI B to C stage at escalation, TAPSE at escalation, and mean urinary output ≥1 mL/kg/hour in the 6 hours preceding escalation were independently associated with successful escalation when adjusted for sex, chronic kidney disease, and markers of CS severity on admission and at time of escalation. Conclusions: Circulatory support escalation is prevalent in patients treated for CS. Escalation is associated with a higher risk of hospital death, complications and transition to HRT, consistently with the intrinsically higher risk profile and expected trajectory of escalated patients. However, outcomes may differ according to the specific escalation strategy. Resorting to escalation in younger patients, in less severe CS stages, when the right ventricular function and urinary output are still preserved is associated with a higher chance of subsequent survival.

Aim: To compare the accuracy of 2D and 3D tricuspid valve reconstructions of TTE versus TEE for screening patients with TR who are candidates for surgical or transcatheter interventions. Methods: Consecutive 42 patients with diagnosis of symptomatic and significant TR were enrolled. Each patient underwent a 2D/3D TTE and a 2D/3D TEE on the same day. Parameters for RV dimension and function evaluation were acquired on a 2D examination from the RV focused apical window for TTE and 4 mid‐esophageal chambers for TEE. 3D reconstructions were made to visualize the structures and parameters to be studied (tricuspid annulus, leaflets, annulus area, annulus perimeter, valve area). The leaflets gap was obtained from the transgastric view (for TEE) and from 3D reconstructions (for TTE). The GLIDE score (Gap, jet Location, Image quality, chordal structure Density, En‐Face TR jet morphology), a simple, five‐component score that can predict a successful T‐TEER, was calculated for TTE and TEE. Results: TR grade, function and dimension of RV, tricuspid annulus parameters, coaptation gap and total GLIDE‐score analyzed at TTE and TEE did not show any statistically difference ( p > 0.05) except for the number of leaflets that were better determined by TEE instead of TTE ( P < 0,001). Conclusions: TTE is an excellent initial screening tool for evaluating patients who are candidates for transcatheter repair or surgical intervention for significant TR. However, TEE provides superior visualization of the valve leaflets and should be performed in patients with favorable anatomical characteristics identified on TTE.

Aims: Left ventricular assist device (LVAD) implantation is an established therapy for advanced heart failure, either as bridge-to-transplantation (BTT) or destination therapy (DT). The Italian National Transplant Center supported the development of the Italian multicentre registry for mechanically assisted circulatory support (ITAMACS). We report the first analysis of the ITAMACS registry, focusing on durable intracorporeal LVADs. Methods: All durable LVAD implantations performed in Italy between January 2010 and December 2021 were collected, including follow-up data, and submitted by participating centres to a centralized database. Demographic characteristics, procedural variables, and clinical outcomes were analysed. Survival was assessed using Kaplan–Meier analysis, and Cox proportional hazards models were used to identify independent predictors of long-term mortality. Results: A total of 1061 patients from 12 centres underwent durable LVAD implantation. BTT was the indication in 40.5% and DT in 38.8% of cases; 14.8% of patients were in INTERMACS class 1, and 16.3% underwent minimally invasive implantation. Overall survival at 1, 3, and 5 years was 73%, 54%, and 42%, respectively. On multivariable analysis, older age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01–1.04) and redo surgery (HR 1.25, 95% CI 1.02–1.55) were associated with higher mortality, whereas INTERMACS class >1 (HR 0.66, 95% CI 0.50–0.87) and BTT indication (HR 0.63, 95% CI 0.48–0.83) were protective. Conclusion: ITAMACS is the first national registry reporting real-world outcomes of durable LVAD therapy in Italy. These data provide an overview of national practice and may support optimization of LVAD programs and patient care.

The hemodynamic consequences of the aortic stenosis (AS) on supraortic trunks may have a po-tential role in the diagnosis of concomitant internal carotid artery (ICA) stenosis by dampening blood flow velocity. To investigate the effect of AS on ICA blood flow we evaluated carotid and vertebral blood flow velocity indexes in patients undergoing transcatheter aortic valve implanta-tion (TAVI). Eighty-five patients admitted for endovascular treatment of a severe AS underwent supra-aortic Duplex ultrasound (DUS) examination prior and after TAVI to be enrolled in the study. Patients with other cardiac impairments that could configure a confounding factor were excluded. Pa-tients with symptomatic or severe ICA stenosis defined according to NASCET criteria were ex-cluded. Forty-five patients of a median age of 80 years met the study inclusion criteria. The peak systolic velocity (PSV) of the assessed supraortic arteries increased after TAVI: respectively common ca-rotid artery (CCA) 64 ± 17 cm/s vs 78 ± 23 cm/s, p= 0,01; ICA 68 ± 23 cm/s vs 96 ± 35 cm/s, p= 0,01; vertebral artery (VA) 45 ± 14 cm/s vs 52 ± 15 cm/s, p=0,03. Similarly, the end diastolic velocity (EDV) increased after TAVI: respectively CCA 13 ± 6 cm/s vs 15 ± 7 cm/s, p=ns; ICA 20 ± 9 cm/s vs 24 ± 9 cm/s, p= 0,01; VA 9 ± 4 cm/s vs 11 ± 4 cm/s, p=0,01. Consistently, the mean acceleration time (AC) decreased after TAVI: respectively CCA 0,17 ± 0,05 s vs 0,12 ± 0,05 s, p= 0.01; ICA 0,1 8 ± 0,05 s vs 0,12 ± 0,04 s, p= 0,01; VA 0,16 ± 0,05 s vs 0,11 ± 0,05 s, p=0,02. Severe AS significantly affects supra-aortic arteries blood flow as assessed by duplex, by de-creasing both PSV and EDV and increasing AC. This study suggests that carotid ultrasound cri-teria to assess ICA stenosis severity should be re-evaluated in larger multicenter studies to vali-date their predictive values in patients with concomitant AS.

Background: Dialysis is a rare but serious complication after transcatheter aortic valve replacement. We analyzed the large multicenter TRITAVI (transfusion requirements in transcatheter aortic valve implantation) registry in order to develop and validate a clinical score assessing this risk. Methods and Results: A total of 10 071 consecutive patients were enrolled in 19 European centers. Patients were randomly assigned (2:1) to a derivation and validation cohort. Two scores were developed, 1 including only preprocedural variables (TRITAVIpre) and 1 also including procedural variables (TRITAVIpost). In the 6714 patients of the derivation cohort (age 82±6 years, 48% men), preprocedural factors independently associated with dialysis and included in the TRITAVIpre score were male sex, diabetes, prior coronary artery bypass graft, anemia, nonfemoral access, and creatinine clearance 2 . Additional independent predictors among procedural features were volume of contrast, need for transfusion, and major vascular complications. Both scores showed a good discrimination power for identifying risk for dialysis with C‐statistic 0.78 for TRITAVIpre and C‐statistic 0.88 for TRITAVIpost score. Need for dialysis increased from the lowest to the highest of 3 risk score groups (from 0.3% to 3.9% for TRITAVIpre score and from 0.1% to 6.2% for TRITAVIpost score). Analysis of the 3357 patients of the validation cohort (age 82±7 years, 48% men) confirmed the good discrimination power of both scores (C‐statistic 0.80 for TRITAVIpre and 0.81 for TRITAVIpost score). Need for dialysis was associated with a significant increase in 1‐year mortality (from 6.9% to 54.4%; P =0.0001). Conclusions: A simple preprocedural clinical score can help predict the risk of dialysis after transcatheter aortic valve replacement.

A 73–year–old woman came to our observation to perform a routine echocardiographic examination. The patient had arterial hypertension, dyslipidemia, hypothyroidism, and paroxysmal atrial fibrillation. She underwent a bilateral mastectomy for breast cancer about 5 years ago, and she was undergoing chemotherapy and radiation therapy for a stage IV lung adenocarcinoma. The clinical evaluation was normal, as was the electrocardiogram. The transthoracic echocardiographic evaluation showed the presence of a rounded formation with variable echogenicity, with an irregular surface (4 x 3 cm), adherent to the interatrial septum at the level of the fossa ovalis, which did not hinder the excursion of the mitral valve. No other significant cardiac abnormalities were detected.Transesophageal echocardiography confirmed the presence of atrial mass adhered to the oval fossa (panels A, B). of coarsely rounded shape, and variable echogenicity, in the absence of interference with the movement of the valve leaflets and of anomalies of the interatrial septum (panel C). Coronary angiography showed right–dominant coronary circulation (panel D) and mild stenosis of the mid–left anterior descending artery. Abundant arterial perfusion of the atrial mass, with several vessels originating from the circumflex artery, was also evident at the coronary angiography (panels E, F). The patient underwent cardiac surgery; the surgical exeresis of the left atrial mass was performed through right mini–thoracotomy (panels I and L). Because the neo–formation was adherent not only to the atrial septum but also to the left atrial roof, to obtain a radical excision, a large portion of the atrial wall and the septum were removed and totally reconstructed with the pericardium. The main artery supplied the mass–related vascular network was ligated. The postoperative course was uneventful, and the patient was discharged at home on day six. The pre–discharge echocardiography and the cardiac magnetic resonance ( panels G, H) showed the absence of any residual mass in the left atrium that appears anatomically reshaped, no shunt at the level of the interatrial septum, and preserved ventricular function of both ventricles. Histological analysis confirmed the diagnosis of atrial myxoma. At the six–month follow–up the patient was asymptomatic and the echocardiography was superimposable to discharge. Open in new tab Download slide

The objective of our study is to evaluate safety, hemodynamic performance and durability of the new generation aortic bioprosthesis with Resilia Tissue. RES-ITA Registry is the Italian multicenter registry created in 2017, enrolling patients who underwent isolated or combined AVR with Resilia tissue valve. The Registry was recently recognized by SICCH as the official national registry of Resilia tissue valve implantations, with Potenza’s Cardiac Surgery Unit as its coordinating center. Isolated AVR (50%) was performed predominantly through an upper J mini-sternotomy or a right anterior mini-thoracotomy, while combined procedures (50%) were performed in full sternotomy and included associated CABG, ascending aorta surgery, mitral valve repair or replacement, aortic annulus enlargement. For all patients, clinical and echocardiographic assessment were evaluated at discharge, 30 days, 6 months and every year after surgery. Between June 2017 and March 2022, about 1000 patients were included, coming from 13 Italian cardiac surgery centers. During last year, 6 more Italian centers have asked to join the Registry. Mean age was 57±11 years. Mean Euroscore II was 2.24±3.01%. Redo surgery was performed in 11%. Most frequently implanted valve sizes were 23 mm (30%), 25 mm (27.7%) and 27 mm (19%). Two-year freedom from all-cause mortality for isolated AVR and for all patients was 97.4±1.3% and 95.7±1.1%, respectively. Two-year freedom from major paravalvular leaks (≥2+/4) was 98.4±0.8; freedom from prosthesis thrombosis was 96.7±2 and freedom from prosthesis dysfunction (according to VARC-2 criteria) was 96.7±1.7. Mean gradient was 13.3±8.3 mmHg and maximum gradient was 23.2±16.2 mmHg at 2-year follow-up. The new generation aortic prosthesis with RESILIA tissue demonstrates versatility of use, safety, good early and mid-term outcomes and hemodynamic performance. Further investigations and longer follow-up are needed to evaluate long-term durability.

Dipeptidyl amino-peptidase 3 (DPP3) is an aminopeptidase that is released into circulation upon cell death. DPP3 is involved in the degradation of angiotensins, enkephalines, and endomorphines. It has been shown that circulating DPP3 (cDPP3) plasma concentration increases in cardiogenic shock (CS) patients and correlates with high mortality risk. Cardiogenic shock is a life-threatening syndrome associated with organ hypoperfusion. One of the common causes of CS is acute myocardial infarction (AMI). This study aimed to investigate if cDPP3 levels are associated with CS severity and the need for ventilation in patients suffering from CS. Fifteen patients with CS were included in this study. Six patients were invasively ventilated. The values of cDPP3 were higher in ventilated patients than in non-ventilated patients at admission, 3 h, and 24 h after admission in the intensive care unit. Patients with pulmonary hypertension at admission also showed high cDPP3 values at all time points. Furthermore, high cDPP3 levels were associated with reduced stroke volume. Our results suggest that cDPP3 could predict CS progression and guide therapy escalation.