Publications by authors named "Francesco Faletra"

107 Publications

The structural heart disease interventional imager rationale, skills and training: a position paper of the European Association of Cardiovascular Imaging.

Eur Heart J Cardiovasc Imaging 2021 Feb 10. Epub 2021 Feb 10.

Dept of Cardiology, Oslo University Hospital, Pb 4950 Nydalen, 0424, Oslo, Norway.

Percutaneous therapeutic options for an increasing variety of structural heart diseases (SHD) have grown dramatically. Within this context of continuous expansion of devices and procedures, there has been increased demand for physicians with specific knowledge, skills, and advanced training in multimodality cardiac imaging. As a consequence, a new subspecialty of 'Interventional Imaging' for SHD interventions and a new dedicated professional figure, the 'Interventional Imager' with specific competencies has emerged. The interventional imager is an integral part of the heart team and plays a central role in decision-making throughout the patient pathway, including the appropriateness and feasibility of a procedure, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. However, inherent challenges exist to develop a training programme for SHD imaging that differs from traditional cardiovascular imaging pathways. The purpose of this document is to provide the standard requirements for the training in SHD imaging, as well as a starting point for an official certification process for SHD interventional imager.
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http://dx.doi.org/10.1093/ehjci/jeab005DOI Listing
February 2021

Apical Hypertrophic Cardiomyopathy Masked by Takotsubo Syndrome.

J Cardiovasc Echogr 2020 Jul-Sep;30(3):174-176. Epub 2020 Nov 9.

Cardiac Imaging Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

We describe the case of a 66-year-old female presented to our emergency department (ER) with acute chest pain and diagnosed with Takotsubo syndrome that initially prevented from suspecting an apical hypertrophic cardiomyopathy at echocardiography.
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http://dx.doi.org/10.4103/jcecho.jcecho_46_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799070PMC
November 2020

Multimodality imaging anatomy of interatrial septum and mitral annulus.

Heart 2020 Dec 22. Epub 2020 Dec 22.

National Heart and Lung Institute, London, UK.

The detailed anatomy of the interatrial septum (IAS) and mitral annulus (MA) as observed on cardiac magnetic resonance, computed tomography and two-dimensional/three-dimensional transthoracic and transesophageal echocardiography is reviewed. The IAS comprises of two components: the septum primum that is membrane-like forming the floor of the fossa ovalis (FO) and the septum secundum that is a muscular rim that surrounds the FO. The latter is an enfolding of atrial wall forming an interatrial groove. Named Waterston's groove, it is filled with adipose tissue on the epicardial side. Thus, the safest area for transseptal puncture (TSP) is within the limits of the FO floor, which provides direct interatrial access. While crossing an intact septum is a well-established procedure, TSP is a more complex and time-consuming procedure in the presence of patent foramen ovalis, aneurysmal FO or atrial septal defect closure devices. MA comprises two distinctive segments: an anterior-straight and a posterior-curved segment. The posterior MA is a thin, discontinuous fibrous 'string', interspersed with adipose tissue, where four components converge: the atrial and ventricular musculature, epicardial adipose tissue and the leaflet's hinge line. In parts of where this fibrous string is deficient or absent, the posterior leaflet is inserted directly on ventricular and atrial myocardium rendering the MA less robust and producing an 'asymmetric' dilation. The marked vulnerability of posterior MA to calcifications might be due to its insertion on the crest of ventricular myocardium being subject to friction injury due to the contraction and relaxation of LV.
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http://dx.doi.org/10.1136/heartjnl-2020-318127DOI Listing
December 2020

Anatomy of Mitral Valve Complex as Revealed by Non-Invasive Imaging: Pathological, Surgical and Interventional Implications.

J Cardiovasc Dev Dis 2020 Nov 4;7(4). Epub 2020 Nov 4.

Department of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland.

Knowledge of mitral valve (MV) anatomy has been accrued from anatomic specimens derived by cadavers, or from direct inspection during open heart surgery. However, today two-dimensional and three-dimensional transthoracic (2D/3D TTE) and transesophageal echocardiography (2D/3D TEE), computed tomography (CT) and cardiac magnetic resonance (CMR) provide images of the beating heart of unprecedented quality in both two and three-dimensional format. Indeed, over the last few years these non-invasive imaging techniques have been used for describing dynamic cardiac anatomy. Differently from the "dead" anatomy of anatomic specimens and the "static" anatomy observed during surgery, they have the unique ability of showing "dynamic" images from beating hearts. The "dynamic" anatomy gives us a better awareness, as any single anatomic arrangement corresponds perfectly to a specific function. Understanding normal anatomical aspects of MV apparatus is of a paramount importance for a correct interpretation of the wide spectrum of patho-morphological MV diseases. This review illustrates the anatomy of MV as revealed by non-invasive imaging describing physiological, pathological, surgical and interventional implications related to specific anatomical features of the MV complex.
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http://dx.doi.org/10.3390/jcdd7040049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712333PMC
November 2020

Imaging for Patient's Selection and Guidance of LAA and ASD Percutaneous and Surgical Closure.

JACC Cardiovasc Imaging 2021 Jan 15;14(1):3-21. Epub 2020 Jul 15.

Marcus Heart Valve Center Piedmont Heart Institute Atlanta, Atlanta, Georgia, USA.

This review comprises 2 main subjects: the percutaneous and surgical closure of the left atrial appendage (LAA) and atrial septal defect (ASD). The aim of the authors was to provide a detailed description of: 1) anatomy of LAA, normal interatrial septum, and the various types of ASD as revealed by noninvasive imaging techniques; 2) preprocedure planning of secundum ASD and LAA percutaneous closure; 3) key steps of the procedural guidance emphasizing the role of 2-dimensional/3-dimensional transesophageal echocardiography; and 4) surgical closure of LAA and ASD.
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http://dx.doi.org/10.1016/j.jcmg.2019.06.032DOI Listing
January 2021

WorldwIde SurvEy on Clinical and Anatomical Factors Driving the Choice of Transcatheter Aortic Valve pRostheses.

Front Cardiovasc Med 2020 20;7:38. Epub 2020 Mar 20.

Division of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland.

Following the success of the first human transcatheter aortic valve replacement (TAVR) in 2002, multiple transcatheter heart valves (THVs) have become available. However, guidelines or expert consensus on how to optimize THV choice according to patients' anatomical and clinical characteristics is missing. This survey-based study aimed to identify patient-specific characteristics deemed important in the choice of THV type. A web-based survey including 39 questions was completed by 71 experienced TAVR operators from 23 countries with a median TAVR volume of 88 procedures in the year prior to survey completion (IQR 61-180). The survey covered five topics: access, aortic annulus/leaflets, aortic root, left ventricular function and clinical characteristics. Factors with the most impact on THV choice were reported to be a calcified sinotubular junction, valve-in-valve procedure, annular dimension >575 mm, femoral diameter ≤ 5.0 mm, low coronary ostia, calcification at the annular level and/or protruding into the left ventricular outflow tract, and need for post TAVR PCI. Also, in case of off-label use of THVs to treat bicuspid aortic valve disease and isolated aortic regurgitation, the choice of THV type was reported to be important. This survey-based study identifies key patient characteristics that impact THV selection. As such, we present a guide, based on current practice, of which THV types are best suited to these different patient-specific characteristics. A patient-tailored THV choice is likely to optimize TAVR outcomes.
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http://dx.doi.org/10.3389/fcvm.2020.00038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098951PMC
March 2020

Mitral annulus morphometry in degenerative mitral regurgitation phenotypes.

Echocardiography 2020 04 30;37(4):612-619. Epub 2020 Mar 30.

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Objectives: Degenerative mitral regurgitation (DMR) is classified into different phenotypes based on the extent of leaflet degeneration. Our aim is to demonstrate that phenotype complexity predicts the extent of structural abnormalities of mitral annulus (MA).

Methods And Results: Seventy-five patients with DMR and severe valve regurgitation and 23 patients with normal mitral valve were studied using 3D transesophageal echocardiography. Classification of DMR was done by allocating each 3D echocardiography result under five categories: fibroelastic deficiency (FED), FED+, forme fruste, Barlow's disease Mitral annular disjunction (BD MAD)- or BD MAD+. MA was reconstructed in early systole and in end systole. We tested for a trend toward enlargement and flattening of MA in end systole and for a difference in MA dynamics from early systole to end systole with a worsening of DMR phenotype, in the whole spectrum of subjects ranging from controls to BD MAD+. A significant trend was observed toward larger anteroposterior diameter, intercommissural diameter, annulus circumference, and annulus area (P < .001). A reduction was found in annulus height to commissural width ratio (P = .003): This indicates a progressive MA flattening. Prolapse height and prolapse volume tended to be larger (P < .001).

Conclusion: Based on the extent of leaflet degeneration, DMR is classified into different phenotypes. As the disease progresses, a related increase in MA size is found, with rounder annular shape, loss of saddle shape, and increase in height and volume of leaflet prolapse. The most pronounced alterations are found in BD MAD+.
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http://dx.doi.org/10.1111/echo.14647DOI Listing
April 2020

Ridges and Pouches: A Case Series of Anomalous Atrial Septal Fusion.

CASE (Phila) 2020 Feb 4;4(1):7-17. Epub 2019 Dec 4.

CardioVascular Center, Tufts Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.case.2019.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026535PMC
February 2020

Capillary Hemangioma of the Left Ventricle.

J Cardiovasc Echogr 2019 Jul-Sep;29(3):126-128

Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

We present the case of a young woman complaining of aspecific symptoms of malaise and dyspnea admitted to our Cardiology Department for investigations. Two-dimensional (2D)/3D transthoracic echocardiography showed an echogenic, sessile mass adhering to the midsegment of the posterior interventricular septum. The patient refused transesophageal echocardiography. For further investigation, a cardiac magnetic resonance imaging was performed, which raised suspicion of a benign tumor. Ultimately, the patient underwent uncomplicated cardiac surgery with total excision of the mass. Histopathology examination revealed a capillary hemangioma.
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http://dx.doi.org/10.4103/jcecho.jcecho_31_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6829755PMC
November 2019

"Where is the Heart?" When Cardiac Magnetic Resonance Imaging Helps if Echocardiography is Inconclusive.

J Cardiovasc Echogr 2019 Apr-Jun;29(2):82-85

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Cardiovascular magnetic resonance (CMR) is the gold standard technique to comprehensively assess cardiac structure and function. A 64-year-old male, planned for surgical coronary revascularization, underwent transthoracic and transesophageal echocardiography for a mitral regurgitation, with an eccentric jet of unclear mechanism; these examinations were inconclusive because of the lack of adequate visualization of the cardiac structures. A CMR was then performed to quantify mitral regurgitation and, additionally, it documented a giant hiatus hernia with gastric sliding into the thorax. In this case, CMR helped to better define the severity of a valvular disease and provided ancillary information from the extracardiac findings.
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http://dx.doi.org/10.4103/jcecho.jcecho_18_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657467PMC
August 2019

The Intrusive Nature of Epicardial Adipose Tissue as Revealed by Cardiac Magnetic Resonance.

J Cardiovasc Echogr 2019 Apr-Jun;29(2):45-51

Cardiac Imaging Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

The epicardial adipose tissue (EAT) refers to the deposition of adipose tissue fully enclosed by the pericardial sac. EAT has a complex mixture of adipocytes, nervous tissue, as well as inflammatory, stromal and immune cells secreting bioactive molecules. This heterogeneous composition reveals that it is not a simply fat storage depot, but rather a biologically active organ that appears playing a "dichotomous" role, either protective or proinflammatory and proatherogenic. The cardiac magnetic resonance (CMR) allows a clear visualization of EAT using a specific pulse sequence called steady-state free precession. When abundant, the EAT assumes a pervasive presence not only covering the entire epicardial surface but also invading spaces that usually are almost virtual and separating walls that usually are so close each other to resemble a single wall. To the best of our knowledge, this aspect of cardiac anatomy has never been described before. In this pictorial review, we therefore focus our attention on certain cardiac areas in which EAT, when abundant, is particularly intrusive. In particular, we describe the presence of EAT into: (a) the interatrial groove, the atrioventricular septum, and the inferior pyramidal space, (b) the left lateral ridge, (c) the atrioventricular grooves, and (d) the transverse pericardial sinus. To confirm the reliability in depicting the EAT distribution, we present CMR images side-by-side with corresponding anatomic specimens.
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http://dx.doi.org/10.4103/jcecho.jcecho_22_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657468PMC
August 2019

Use of Contemporary Imaging Techniques for Electrophysiological and Device Implantation Procedures.

JACC Cardiovasc Imaging 2020 03 17;13(3):851-865. Epub 2019 Jul 17.

Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Recent technological advances in cardiac imaging allow the visualization of anatomic details up to millimeter size in 3-dimensional format. Thus, it is not surprising that electrophysiologists increasingly rely upon cardiac imaging for the diagnosis, treatment, and subsequent management of patients affected by various arrhythmic disorders. Cardiac imaging methods reviewed in the present work involve: 1) the prediction of arrhythmic risk for sudden cardiac death in patients with heart disease; 2) catheter ablation of atrial fibrillation or ventricular tachycardia; and 3) cardiac resynchronization therapy. Future integration of diagnostic and interventional cardiac imaging will further increase the effectiveness of cardiac electrophysiological procedures and will help in delivering patient-specific therapies with ablation and cardiac implantable electronic devices.
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http://dx.doi.org/10.1016/j.jcmg.2019.01.043DOI Listing
March 2020

Sustained Improvement of Left Ventricular Strain following Transcatheter Aortic Valve Replacement.

Cardiology 2019;143(1):52-61. Epub 2019 Jul 15.

Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.

Purpose: Left ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has become a widespread technique for patients with severe AS considered inoperable or high risk for open surgery. This procedure could have a positive impact in LV mechanics. The aim of the study was to evaluate the effect of TAVR on LV function recovery, as assessed by myocardial deformation parameters, both immediately and in the long term.

Methods: One-hundred nineteen consecutive patients (81.2 ± 6.9 years, 50.4% female) from 10 centres in Europe with severe AS who successfully underwent TAVR with either a self-expanding CoreValve (Medtronic, Minneapolis, MN, USA) or a mechanically expanded Lotus valve (Boston Scientific, Natick, MA, USA) were enrolled in a prospective observational study. A complete echocardiographic examination was performed prior to device implantation, before discharge and 1 year after the procedure, including the assessment of LV strain using standard 2D images.

Results: Between baseline and discharge, only a modest but statistically significant improvement in GLS (global longitudinal strain) could be seen (GLS% -14.6 ± 5.0 at baseline; -15.7 ± 5.1 at discharge, p = 0.0116), although restricted to patients in the CoreValve group; 1 year after the procedure, a greater improvement in GLS was observed (GLS% -17.1 ± 4.9, p < 0.001), both in the CoreValve and the Lotus groups.

Conclusions: Immediate and sustained improvement in GLS was appreciated after the TAVR procedure. Whether this finding continues to be noted in a more prolonged follow-up and its clinical implications need to be assessed in further studies.
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http://dx.doi.org/10.1159/000500633DOI Listing
January 2020

Anatomy of mitral annulus insights from non-invasive imaging techniques.

Eur Heart J Cardiovasc Imaging 2019 Aug;20(8):843-857

Cardiac Morphology Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK.

The mitral annulus (MA) is not a continuous ring of connective tissue from which are suspended mitral leaflets. Instead, it is a much more complex structure made up of a mix of fibrous, muscular, and adipose tissues. MA is a key structure in any type of mitral valve repair and recently it has been targeted for transcutaneous devices. Thus, a deep understanding of MA anatomy has never been more important. Traditionally, cardiac anatomy has been described using anatomic specimens. Currently, sophisticated non-invasive techniques allow imaging of MA with a richness of anatomical details unimaginable only two decades ago. The aim of this review is to provide a better understanding of the peculiar aspects of MA as they are revealed through these imaging techniques and discuss clinical implications related to this complex structure.
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http://dx.doi.org/10.1093/ehjci/jez153DOI Listing
August 2019

3-Dimensional Echocardiography in Imaging the Tricuspid Valve.

JACC Cardiovasc Imaging 2019 03;12(3):500-515

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy; IRCCS, Instituto Auxologico Italiano, S. Luca Hospital, University of Milano-Bicocca, Milan, Italy. Electronic address:

Tricuspid regurgitation (TR) is an independent predictor of death. Lately, emerging technologies for the treatment of TR have increased the interest of physicians. Due to the complex 3-dimensional (3D) geometry of the tricuspid valve (TV) and its anterior position in the mediastinum, conventional 2D echocardiography is unsuitable to study the anatomy and pathophysiologic mechanisms of the regurgitant TV. 3D echocardiography has emerged as a very cost-effective imaging modality with which to: 1) visualize the TV anatomy; 2) define the mechanism of TR; 3) measure the size and geometry of the tricuspid annulus; 4) analyze the anatomic relationships between TV apparatus and surrounding cardiac structures; 5) assess volumes and function of the right atrium and ventricle; and 6) plan surgical repair or guide and monitor transcatheter interventional procedures.
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http://dx.doi.org/10.1016/j.jcmg.2018.10.035DOI Listing
March 2019

Revisiting Anatomy of the Interatrial Septum and its Adjoining Atrioventricular Junction Using Noninvasive Imaging Techniques.

J Am Soc Echocardiogr 2019 05 22;32(5):580-592. Epub 2019 Feb 22.

Cardiac Morphology Unit, Royal Brompton Hospital and Imperial College, London, United Kingdom.

Interest in the anatomy of the interatrial septum (IAS) and its adjoining atrioventricular (AV) junction has risen enormously in the past two decades with the simultaneous evolution of left-sided percutaneous structural heart disease and complex electrophysiologic procedures. These procedures require, in fact, a direct route to the left atrium through the IAS. Thus, a thorough understanding of the complex anatomy of the IAS and AV junction is essential for performing a safe and effective transseptal puncture. There is a large amount of literature carefully describing the anatomy of the IAS and AV junction. These studies are based almost exclusively on anatomic specimens. Conversely, in this review the authors emphasize the role of noninvasive imaging techniques, in particular cardiac magnetic resonance, two- and three-dimensional transesophageal echocardiography, and computed tomography in visualizing specific aspects of the normal IAS and AV junction. Where appropriate, the authors present images side by side, with corresponding anatomic specimens.
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http://dx.doi.org/10.1016/j.echo.2019.01.009DOI Listing
May 2019

Transcatheter Repair of Severe Functional Tricuspid Insufficiency Using a Mitral Clip System: Transgastric Views Are the Key for an Effective Guide.

JACC Cardiovasc Imaging 2019 03 15;12(3):554-558. Epub 2018 Nov 15.

Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

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http://dx.doi.org/10.1016/j.jcmg.2018.09.010DOI Listing
March 2019

Imaging-based tricuspid valve anatomy by computed tomography, magnetic resonance imaging, two and three-dimensional echocardiography: correlation with anatomic specimen.

Eur Heart J Cardiovasc Imaging 2019 01;20(1):1-13

Cardiac Morphology Unit, Royal Brompton Hospital and Imperial College, Sydney St, Chelsea, London, UK.

Interest on tricuspid valve (TV) (and hence in TV anatomy) has increased in the last two decades with the awareness that functional tricuspid regurgitation (FTR) is an insidious disease progressively leading to untreatable right heart failure and eventually to death. Medical therapy may alleviate symptoms, while surgical therapy may improve outcome but it is associated with high mortality and recurrence of significant regurgitation. Nowadays, an increasing number of left valve diseases are successfully treated through a percutaneous transcatheter approach. The negative impact that the untreated FTR may have in these patients has highlighted the necessity of developing transcatheter solutions also for FTR and numerous catheter devices for treating FTR are currently under evaluation. The essential pre-requisite for an effective and safe surgical or transcatheter therapy is a deep knowledge of the normal TV anatomy. In this review, we describe the anatomy of TV and surrounding structures as revealed by computed tomography, cardiac magnetic resonance, 2D/3D transthoracic echocardiography, and 2D/3D transoesophageal echocardiography emphasizing strengths and weaknesses of each of these imaging tools. To confirm the anatomical fidelity of these imaging modalities, where appropriate, the non-invasive images where presented, side-by-side, with corresponding images from anatomic specimens.
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http://dx.doi.org/10.1093/ehjci/jey136DOI Listing
January 2019

Access Sites for TAVI: Patient Selection Criteria, Technical Aspects, and Outcomes.

Front Cardiovasc Med 2018 17;5:88. Epub 2018 Jul 17.

Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

During the last ten years, transcatheter aortic valve implantation (TAVI) has become a reliable and valid alternative treatment for elderly patients with severe symptomatic aortic valve stenosis requiring valve replacement and being at high or intermediate surgical risk. While common femoral arteries are the access site of choice in the vast majority of TAVI patients, in up to 15-20% of TAVI candidates this route might be precluded due to the presence of diffuse atherosclerotic disease, tortuosity or small vessel diameter. Therefore, in order to achieve an antegrade or retrograde implant, several alterative access routes have been described, namely trans-axillary, trans-aortic, trans-apical, trans-carotid, trans-septal, and trans-caval. The aim of this paper is to give a concise overview on vascular access sites for TAVI, with a particular focus on patient's selection criteria, imaging, technical aspects, and clinical outcome.
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http://dx.doi.org/10.3389/fcvm.2018.00088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056625PMC
July 2018

Radiological exposure of patients undergoing transcatheter aortic valve implantation in contemporary practice.

J Cardiovasc Med (Hagerstown) 2018 Oct;19(10):579-585

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Radiological exposure associated with transcatheter aortic valve implantation (TAVI) is unknown and might impact on broadening indications to lower risk patients. Radiological exposure of TAVI patients and its predictors are herein reported.

Methods: Radiological exposure derived from exams/procedures performed within 30 days preceding/following TAVI were acquired and converted into effective-dose. Total effective-dose was defined as the sum of each single dose derived from diagnostic/therapeutic sources. Univariable and multivariable analyses were performed to recognize correlates of exposure.

Results: Seventy-five patients aged 82.6 ± 6.0 years with a median Euroscore II 3.6 [IQR 1.93-6.65] were analysed. Median total effective-dose was 41.39 mSv [IQR 27.93-60.88], with TAVI accounting for 47% of it. Age (coefficient -0.031, 95% CI -0.060 to -0.002; P = 0.031) and previous history of cerebrovascular accidents (CVA; coefficient -0.545; 95% CI -1.039 to -0.010; P = 0.046) resulted as inversely correlated to total effective-dose (log-transformed), whereas left ventricular ejection fraction (LVEF) less than 50% (coefficient 0.430, 95% CI 0.031-0.828; P = 0.035) was directly associated.

Conclusion: Multiple radiological sources are responsible for the observed exposure, with TAVI being the prominent source. Age is inversely related to the radiological exposure.
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http://dx.doi.org/10.2459/JCM.0000000000000692DOI Listing
October 2018

Which Cardiac Structure Lies Nearby? Revisiting Two-Dimensional Cross-Sectional Anatomy.

J Am Soc Echocardiogr 2018 09 27;31(9):967-975. Epub 2018 Jun 27.

Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Two-dimensional (2D) transthoracic echocardiography is one of the most used diagnostic tools in clinical cardiology. Similarly, 2D transesophageal echocardiography is considered an indispensable tool for cardiologists and cardiac anesthesiologists worldwide. However, because of their tomographic nature, both techniques display only thin cut planes of a given area of the heart, which are far from representing the "anatomic reality." It is widely accepted that experienced echocardiographers are able to reconstruct mentally a three-dimensional image of any cardiac structure on the basis of their interpretation of multiple tomographic slices. However, this may not be the case with less experienced echocardiographers. In particular, the authors noticed that less experienced echocardiographers are almost totally unaware of which structures lie "nearby" a given 2D tomographic plane, that is, what is adjacent in the elevation plane. In this article, the authors report the use of three-dimensional transesophageal echocardiographic images to discover which structures are located nearby (i.e., "behind" and "in front") the corresponding 2D cross-sections. The authors believe that this novel use of three-dimensional echocardiography is a unique aid to disclose what cannot be seen in a given 2D cross-section, thereby expanding our understanding of 2D echocardiographic anatomy. This may be an effective method to encourage all to "think" in three dimensions, even when they use 2D echocardiography.
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http://dx.doi.org/10.1016/j.echo.2018.04.014DOI Listing
September 2018

Immediate improvement of left ventricular mechanics following transcatheter aortic valve replacement.

Cardiol J 2018 20;25(4):487-494. Epub 2018 Jun 20.

Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain, Spain.

Background: Left ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has become a widespread technique for patients with severe AS considered inoperable or high risk for traditional open-surgery. This procedure could have a positive impact in LV mechanics. The aim of this study was to evaluate the immediate effect of TAVR on LV function recovery, as assessed by myocardial deformation parameters.

Methods: One-hundred twelve consecutive patients (81.4 ± 6.4 years, 50% female) from 10 centres in Europe with severe AS who successfully underwent TAVR with either a self-expanding CoreValve (Medtronic, Minneapolis, MN) or a mechanically expanded Lotus valve (Boston Scientific, Natick, MA) were enrolled in a prospective multi-center study. A complete echocardiographic examination was performed at baseline and immediately before discharge, including the assessment of LV strain using standard two-dimensional images.

Results: Echocardiographic examination with global longitudinal strain (GLS) quantification could be obtained in 92 patients, because of echocardiographic and logistic reasons. Between examinations, a modest statistically significant improvement in GLS could be seen (GLS% -15.00 ± 4.80 at baseline;-16.15 ± 4.97 at discharge, p = 0.028). In a stratified analysis, only women showed a significant improvement in GLS and a trend towards greater improvement in GLS according to severity of systolic dysfunction as measured by LV ejection fraction could be noted.

Conclusions: Immediate improvement in GLS was appreciated after TAVR procedure. Whether this finding continues to be noted in a more prolonged follow-up and its clinical implications need to be assessed in further studies.
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http://dx.doi.org/10.5603/CJ.a2018.0066DOI Listing
May 2019

Echocardiographic-fluoroscopic fusion imaging for transcatheter mitral valve repair guidance.

Eur Heart J Cardiovasc Imaging 2018 07;19(7):715-726

University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.

The echocardiographic-fluoroscopic fusion imaging is a new imaging system which has recently become available, with the proposal to facilitate catheters and device navigation during catheter-based structural heart disease interventions. Several reports have described the early developments and the first clinical experiences, but literature focusing on the practical applications of fusion imaging technology to mitral valve transcatheter interventions, and on its potential advantages and current limitations, is still limited. In this review, we, therefore, describe the role of this novel imaging system during Mitraclip, Cardioband, and paravalvular leak closure interventions. The technical principles and the fluoroscopic anatomy of the interatrial septum and mitral valve are also described.
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http://dx.doi.org/10.1093/ehjci/jey067DOI Listing
July 2018

Integrated Assessment of Left Ventricular Electrical Activation and Myocardial Strain Mapping in Heart Failure Patients: A Holistic Diagnostic Approach for Endocardial Cardiac Resynchronization Therapy, Ablation of Ventricular Tachycardia, and Biological Therapy.

JACC Clin Electrophysiol 2018 01 6;4(1):138-146. Epub 2017 Nov 6.

Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland; Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Objectives: This study sought to test the accuracy of strain measurements based on anatomo-electromechanical mapping (AEMM) measurements compared with magnetic resonance imaging (MRI) tagging, to evaluate the diagnostic value of AEMM-based strain measurements in the assessment of myocardial viability, and the additional value of AEMM over peak-to-peak local voltages.

Background: The in vivo identification of viable tissue, evaluation of mechanical contraction, and simultaneous left ventricular activation is currently achieved using multiple complementary techniques.

Methods: In 33 patients, AEMM maps (NOGA XP, Biologic Delivery Systems, Division of Biosense Webster, a Johnson & Johnson Company, Irwindale, California) and MRI images (Siemens 3T, Siemens Healthcare, Erlangen, Germany) were obtained within 1 month. MRI tagging was used to determine circumferential strain (E) and delayed enhancement to obtain local scar extent (%). Custom software was used to measure E and local area strain (LAS) from the motion field of the AEMM catheter tip.

Results: Intertechnique agreement for E was good (R = 0.80), with nonsignificant bias (0.01 strain units) and narrow limits of agreement (-0.03 to 0.06). Scar segments showed lower absolute strain amplitudes compared with nonscar segments: E (median [first to third quartile]: nonscar -0.10 [-0.15 to -0.06] vs. scar -0.04 [-0.06 to -0.02]) and LAS (-0.20 [-0.27 to -0.14] vs. -0.09 [-0.14 to -0.06]). AEMM strains accurately discriminated between scar and nonscar segments, in particular LAS (area under the curve: 0.84, accuracy = 0.76), which was superior to peak-to-peak voltages (nonscar 9.5 [6.5 to 13.3] mV vs. scar 5.6 [3.4 to 8.3] mV; area under the curve: 0.75). Combination of LAS and peak-to-peak voltages resulted in 86% accuracy.

Conclusions: An integrated AEMM approach can accurately determine local deformation and correlates with the scar extent. This approach has potential immediate application in the diagnosis, delivery of intracardiac therapies, and their intraprocedural evaluation.
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http://dx.doi.org/10.1016/j.jacep.2017.08.011DOI Listing
January 2018

Overview of mitral regurgitation in Europe: results from the European Registry of mitral regurgitation (EuMiClip).

Eur Heart J Cardiovasc Imaging 2018 05;19(5):503-507

Department of Cardiology, CIBERCV, University of Alcala, Hospital Ramon y Cajal, Carretera de Colmenar Km 9, 100, 28034 Madrid, Spain.

Aims: To determine the prevalence of mitral regurgitation (MR) in a large cohort of consecutive patients undergoing clinically indicated echocardiography and to examine the distribution of primary and secondary MR.

Methods And Results: All patients undergoing an echocardiographic study in 19 European centres within a 3-month period were prospectively included. MR assessment was performed as recommended by the European Association of Cardiovascular Imaging (EACVI). MR was classified according to mechanism as primary or secondary and aetiologies were reported. A total of 63 463 consecutive echocardiographic studies were reviewed. Any degree of MR was described in 15 501 patients. Concomitant valve disease of at least moderate grade was present in 28.5% of patients, being tricuspid regurgitation the most prevalent. In the subgroup of moderate and severe MR (n = 3309), 55% of patients had primary MR and 30% secondary MR. Both mechanisms were described in 14% of the studies. According to Carpentier's classification, 26.7% of MR were classified as I, 19.9% of MR as II, 22.4% of MR as IIIa, and 31.1% of MR as IIIb.

Conclusion: To date, this is the largest echocardiography-based study to analyse the prevalence and aetiology distribution of MR in Europe. The burden of secondary MR was higher than previously described, representing 30% of patients with significant MR. In our environment, degenerative disease is the most common aetiology of primary MR (60%), whereas ischaemic is the most common aetiology of secondary MR (51%). Up to 70% of patients with severe primary MR may have a Class I indication for surgery. However, the optimal therapeutic approach for secondary MR remains uncertain.
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http://dx.doi.org/10.1093/ehjci/jey011DOI Listing
May 2018

Tiara Valve Implantation in a Patient With Previously Implanted Mono-disk Mechanical Aortic Prosthesis.

Semin Thorac Cardiovasc Surg 2018 5;30(2):160-163. Epub 2018 Mar 5.

Cardiology Department, Cardiocentro Ticino Foundation, Lugano, Switzerland.

Transcatheter mitral valve replacement with the Tiara valve can be performed in inoperable patients with severe functional regurgitation. Risk of left ventricular outflow tract obstruction can be prevented using preoperative 3D imaging and 3D-printed models. However, in the case of mono-disk mechanical prostheses previously implanted in aortic position (Bjork-Shiley), there is an additional risk of mechanical interference leading to reduced leaflet motion and aortic valve dysfunction. Hereafter, we describe the case of a patient with a 27-mm mono-disk mechanical aortic valve implanted in 1978, a EuroSCORE II of 18%, and a Society of Thoracic Surgeon score (mortality) of 16% who successfully underwent a transapical Tiara valve implantation.
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http://dx.doi.org/10.1053/j.semtcvs.2018.02.028DOI Listing
November 2018

3D transesophageal echocardiography: A new imaging tool for assessment of mitral regurgitation and for guiding percutaneous edge-to-edge mitral valve repair.

Prog Cardiovasc Dis 2017 Nov - Dec;60(3):305-321. Epub 2017 Oct 19.

Mayo Clinic, Rochester, MN, United States.

Real time three dimensional transesophageal echocardiography (3D TEE) is probably the most powerful and convincing imaging method for understanding the complicated multiform morphology and for evaluating geometry, dynamics and function of degenerative and functional mitral valve (MV) regurgitation. Moreover, color Doppler 3D TEE has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. 3D TEE has been shown to be of enormous value in helping surgeons to perform MV repair. In addition, due to its ability to show a "panoramic" view of the "theater" where the procedure takes place, it has become an indispensable companion of 2D TEE during percutaneous edge-to-edge repair. A novel hybrid imaging modality where echocardiography is merged with fluoroscopy, may in the future further improve guidance of this and other complex percutaneous transcatheter interventions.
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http://dx.doi.org/10.1016/j.pcad.2017.10.001DOI Listing
August 2018

Echocardiographic-Fluoroscopic Fusion Imaging in Transseptal Puncture: A New Technology for an Old Procedure.

J Am Soc Echocardiogr 2017 Sep 7;30(9):886-895. Epub 2017 Jun 7.

King's College Hospital, London, United Kingdom.

In an era of catheter-based structural heart disease and left-side electrophysiologic interventions, transseptal puncture (TSP) is probably the most common transcatheter procedure. Experienced interventional cardiologists and electrophysiologists may safely perform TSP using fluoroscopic guidance alone. However, at present TSP is usually the first step in complex percutaneous catheter-based structural heart disease procedures and necessitate a precise site-specific TSP. Thus, in these procedures most interventional cardiologists perform TSP under fluoroscopic and two- or three-dimensional transesophageal echocardiographic guidance. The EchoNavigator system may provide a solution by fusing fluoroscopic and transesophageal echocardiographic images. In this review, the authors describe advantages and limitations of this new imaging system in guiding TSP and suggest specific echocardiographic-fluoroscopic fusion imaging perspectives that may facilitate TSP, making it potentially easier and safer.
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http://dx.doi.org/10.1016/j.echo.2017.05.001DOI Listing
September 2017

Speckle-Tracking Layer-Specific Analysis of Myocardial Deformation and Evaluation of Scar Transmurality in Chronic Ischemic Heart Disease.

J Am Soc Echocardiogr 2017 Jul 13;30(7):667-675. Epub 2017 May 13.

Department of Cardiology, CCT: Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Identification of the extent of scar transmurality in chronic ischemic heart disease is important because it correlates with viability. The aim of this retrospective study was to evaluate whether layer-specific two-dimensional speckle-tracking echocardiography allows distinction of scar presence and transmurality.

Methods: A total of 70 subjects, 49 with chronic ischemic cardiomyopathy and 21 healthy subjects, underwent two-dimensional speckle-tracking echocardiography and late gadolinium-enhanced cardiac magnetic resonance. Scar extent was determined as the relative amount of hyperenhancement using late gadolinium-enhanced cardiac magnetic resonance in an 18-segment model (0% hyperenhancement = normal; 1%-50% = subendocardial scar; 51%-100% = transmural scar). In the same 18-segment model, peak systolic circumferential strain and longitudinal strain were calculated separately for the endocardial and epicardial layers as well as the full-wall myocardial thickness.

Results: All strain parameters showed cutoff values (area under the curve > 0.69) that allowed the discrimination of normal versus scar segments but not of transmural versus subendocardial scars. This was true for all strain parameters analyzed, without differences in efficacy between longitudinal and circumferential strain and subendocardial, subepicardial, and full-wall-thickness strain values. Circumferential and longitudinal strain in normal segments showed transmural and basoapical gradients (greatest values at the subendocardial layer and apex). In segments with scar, transmural gradient was maintained, whereas basoapical gradient was lost because the reduction of strain values in the presence of the scar was greater at the apex.

Conclusions: The two-dimensional speckle-tracking echocardiographic values distinguish scar presence but not transmurality; thus, they are not useful predictors of scar segment viability. It remains unclear why there is a greater strain value reduction in the presence of a scar at the apical level.
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http://dx.doi.org/10.1016/j.echo.2017.03.015DOI Listing
July 2017

Anatomic characterization of cavotricuspid isthmus by 3D transesophageal echocardiography in patients undergoing radiofrequency ablation of typical atrial flutter.

Eur Heart J Cardiovasc Imaging 2018 01;19(1):84-91

Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland.

Aims: Radiofrequency ablation (RFA) is the treatment of choice of cavotricuspid isthmus (CTI)-dependent atrial flutter. Procedural time is highly variable due to anatomical structures. This study aimed to characterize CTI anatomy by transesophageal 3D echocardiography imaging (3D-TEE) to identify anatomic structures related to longer ablation time.

Methods And Results: Thirty-one consecutive patients (mean age 67.3 ± 11.5 years, 22 males) underwent CTI-ablation procedure. Before ablation, TEE was performed and 3D-TEE images were acquired to evaluate CTI anatomy qualitatively as well as perform measures of CTI morphological features. The electrophysiologist performing RFA was blinded to 3D-TEE data. Bidirectional block of CTI was achieved in all patients without procedural complications after a median ablation time of 11 (IQR 7-14) min. Patients with RFA time ≥11 min (Group 2) presented lower left ventricular ejection fraction (51.1 ± 17.0 vs. 59.5 ± 6.6%, P < 0.010), a larger left atrium (46.2 ± 8.4 vs. 39.9 ± 9.4 mm, P < 0.058), and, more frequently, a right atrial pouch (12/16 patients vs. 4/15, P = 0.012) compared with patients with RFA time < 11 min (Group 1); CTI pouch was significantly deeper in Group 2 compared with Group 1: telediastolic (TD) pouch depth was 10.4 ± 4.5 vs. 6.3 ± 1.5 mm (P = 0.003) and telesystolic (TS) depth 12.8 ± 4.4 vs. 7.0 ± 1.4 mm (P < 0.001), respectively. TD isthmus length, prominent pectinate muscle, and presence of an Eustachian ridge (ER) did not differ between the two groups.

Conclusion: Routine pre-procedural 3D-TEE imaging is extremely helpful in qualitative and quantitative evaluation of CTI anatomy in patients undergoing RFA for symptomatic typical atrial flutter. Detection of a deep right atrial pouch was found to be associated with significantly prolonged CTI ablation time to achieve bidirectional block.
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http://dx.doi.org/10.1093/ehjci/jew336DOI Listing
January 2018