Chronic ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction and severely affects cardiovascular mortality and morbidity. Multiple pathophysiologic mechanisms, such as left ventricular (LV) remodeling and dysfunction, annular dilation/dysfunction, and mechanical dyssynchrony, are involved in generating IMR, each of them having different weight. However, the prerequisite to initially creating regurgitation is the presence of local or global LV remodeling that alters the geometrical relationship between the ventricle and valve apparatus. In the wide spectrum of patients with chronic IMR, the assessment of some echocardiographic parameters, such as tethering pattern, leaflet motion, origin and direction of the regurgitant jets, allows one to identify different specific subgroups of patients subjected to different therapeutic approaches. The aim of medical and/or surgical therapy is to ameliorate heart failure symptoms, and improve LV remodeling and function and the intermediate/long-term outcome. The targets of surgical MV repair involve annulus, leaflets, chordae and ventricles. The restricted annuloplasty is the most commonly adopted surgical procedure that improves heart failure symptoms but not survival when compared to medical therapy and is also subject to a high incidence of late failure (approximately 30%). There are some preoperative echocardiographic predictors of failure that include valve (degree of valve remodeling, jet characteristics), ventricular (degree of remodeling, diastolic dysfunction) and surgical factors.

No abstract

The degree of FMR is associated mainly with mitral deformation indices. The regional dyssynchrony also has an independent association with ERO but with a minor influence; however, it is not a determinant of FMR in patients with ischaemic LV dysfunction.

Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.

Aims The angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (HFrEF). Favourable effects on haemodynamic and functional parameters have been observed in patients with HFrEF undergoing ARNI therapy, using standard transthoracic echocardiography. Global longitudinal strain (GLS) assessment uses a semi‐automatic procedure to provide a reliable and repeatable method that improves the detection of early changes of contractile function. We aimed to assess the effects of ARNI on GLS and myocardial mechanics in patients with HFrEF. Methods and results Thirty patients with New York Heart Association class II–III HFrEF were treated with ARNI and monitored using standard echocardiographic examination and GLS measurements at baseline, 3 months, and 6 months. ARNI therapy resulted in a significant reduction of ventricular volumes and a significant increase in left ventricular ejection fraction at 6 months but not 3 months by standard transthoracic echocardiography (left ventricular ejection fraction from 28 ± 8% at baseline to 34 ± 12% at 6 months, P < 0.001). Non‐significant differences in the size of the left atrium, right ventricular function, and pulmonary pressures were found at 6 months. By using GLS, there was a progressive improvement of all strain parameters by 3 months. The improvement showed a progressive trend over time and maintained significance at 6 months: GLS 4ch −7.2 ± 4.8% at baseline vs. −7.5 ± 3.9% at 3 months (P = 0.025) and − 9.2 ± 5.2% at 6 months (P = 0.0001); AVG GLS −6.9 ± 4.3 at baseline vs. −7.9 ± 4.2 at 3 months (P = 0.04) and − 8.8 ± 4.4 at 6 months (P = 0.035); GLS endo 8.2 ± 4.8 at baseline vs. −9.0 ± 4.8 at 3 months (P = 0.05) and − 10.1 ± 5.1 at 6 months (P = 0.001). Conclusions Sacubitril/valsartan induces an early benefit on left ventricular remodelling, which is captured by myocardial strain and not by standard echocardiography. Strain method represents a practical tool to assess early and minimal variations of left ventricular systolic function.

No abstract

No abstract

C ardiac tamponade during percutaneous coronary intervention is a rare but serious complication that can occur after coronary perforation. Even more infrequent is a tamponade subsequent to a localized left atrial hematoma. In the literature, we found just 5 similar cases, and all of them underwent surgical intervention. [1][2][3][4] The surgical option, using a median sternotomy or left thoracotomy approach, was taken in the first hours after the procedure because of progressive hemodynamic deterioration. In 4 of them, it consisted of hematoma drainage and atrial decompression; in 1 patient, the surgical option was vessel wall repair. We report our experience of a patient who sustained this complication as a consequence of a large right coronary dissection. The patient was treated conservatively with a successful outcome.A 65-year-old man, previously treated with coronary artery bypass graft surgery and coronary percutaneous revascularization, was still symptomatic with effort angina refractory to maximal medical treatment. Myocardial scintigraphy showed evidence of inducible ischemia in the inferolateral left ventricular wall. He was hospitalized in our institution to attempt to recanalize the chronic occlusion of the right coronary artery (RCA). During the procedure, a subintimal dissection occurred in the middistal segment of the right coronary artery ( Figure 1A and 1B), and in the more distal part of the posterolateral vessel, it resulted in a perforation of an atrial branch. Perivascular dye staining and contained extravasation were observed, although no pericardial opacification was noticed at fluoroscopy. After a few minutes, hemodynamic instability occurred, requiring dopamine support. The transthoracic echocardiogram showed a voluminous left atrial mass that almost obliterated the left atrial chamber. No pericardial effusion was present (Figure 2A and 2B). Protamine was administered to neutralize the heparin given during the procedure. Aspirin and clopidogrel were stopped.The patient was transferred to coronary care unit for monitoring and treatment. Hemodynamic instability (pulmonary congestion and hypotension) was treated with dopamine (10 ␥ · kg Ϫ1 · min Ϫ1 ) and high-dose diuretic infusion. Cycles of facemask continuous positive airway pressure ventilation were used. A transesophageal echocardiogram showed a hypoechogenic, inhomogeneous, vacuolated large spheric mass (55ϫ60 mm in dimension) occupying a large portion of the left atrium. Flow obstruction was detected with color Doppler examination of mitral inflow ( Figure 3A through 3C). A magnetic resonance examination clearly characterized the hemorrhagic nature of the mass (Movie I in the online Data Supplement and Figure 4). A new angiographic evaluation the day after the procedure excluded an ongoing blood supply to the hematoma, and the RCA was occluded proximally.Therapeutic options were discussed with the intensive care physicians and cardiac surgeons. We decided on conservative management. Dopamine was definitively withdrawn on the eighth ...