Publications by authors named "Sergio Mondillo"

261 Publications

Diagnostic and prognostic value of low QRS voltages in cardiomyopathies: old but gold.

Eur J Prev Cardiol 2020 Oct 25. Epub 2020 Oct 25.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy.

The interpretation of 12-lead resting electrocardiogram (ECG) in patients with a definitive diagnosis or with the suspicion of a cardiomyopathy represents a cornerstone for the diagnostic work up and management of patients. Although low electrocardiographic QRS voltages (LQRSV) detected by 12-lead resting ECG have historically been acknowledged by physicians, in view of recent evidence on the demonstration of myocardial scar by cardiac magnetic resonance and its relevance as a cause of sudden cardiac death even in young individuals, a new interest has been raised about the utility of LQRSV in the clinical practice. Beyond their diagnostic value, LQRSV have also demonstrated a prognostic role in different cardiomyopathies. The present review summarizes the diagnostic and prognostic value of LQRSV in cardiomyopathies, reporting the new evidence, primarily based on advanced imaging studies, supporting the clinical utility of this parameter.
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http://dx.doi.org/10.1093/eurjpc/zwaa027DOI Listing
October 2020

Speckle Tracking Echocardiography: Early Predictor of Diagnosis and Prognosis in Coronary Artery Disease.

Biomed Res Int 2021 2;2021:6685378. Epub 2021 Feb 2.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy.

Echocardiography represents a first level technique for the evaluation of coronary artery disease (CAD) which supports clinicians in the diagnostic and prognostic workup of these syndromes. However, visual estimation of wall motion abnormalities sometimes fails in detecting less clear or transient myocardial ischemia and in providing accurate differential diagnosis. Speckle tracking echocardiography (STE) is a widely available noninvasive tool that could easily and quickly provide additive information over basic echocardiography, since it is able to identify subtle myocardial damage and to localize ischemic territories in accordance to the coronary lesions, obtaining a clear visualization with a "polar map" useful for differential diagnosis and management. Therefore, it has increasingly been applied in acute and chronic coronary syndromes using rest and stress echocardiography, showing good results in terms of prediction of CAD, clinical outcome, left ventricular remodeling, presence, and quantification of new/residual ischemia. The aim of this review is to illustrate the current available evidence on STE usefulness for the assessment and follow-up of CAD, discussing the main findings on bidimensional and tridimensional strain parameters and their potential application in clinical practice.
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http://dx.doi.org/10.1155/2021/6685378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875622PMC
February 2021

Prescribing, dosing and titrating exercise in patients with hypertrophic cardiomyopathy for prevention of comorbidities: Ready for prime time.

Eur J Prev Cardiol 2020 Jun 17. Epub 2020 Jun 17.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy.

The benefits of physical activity are well established, leading to both cardiovascular and non-cardiovascular benefits, improving quality of life and reducing mortality. Despite such striking body of evidence, patients with hypertrophic cardiomyopathy are often discouraged by health professionals to practice physical activity and personalised exercise prescription is an exception rather than the rule. As a result, hypertrophic cardiomyopathy patients are on average less active and spend significantly less time at work or recreational physical activity than the general population. Exercise restriction derives from the evidence that vigorous exercise may occasionally trigger life-threatening arrhythmias and sudden cardiac death. However, while participation in competitive sports should be prudentially denied, hypertrophic cardiomyopathy patients can benefit from the positive effects of regular physical activity, aimed to reduce the risk of comorbidities and improve the quality of life. Based on this rationale, exercise should be prescribed and titrated just like a drug in hypertrophic cardiomyopathy patients, considering individual characteristics, symptoms, past medical history, objective individual response to exercise, previous training experience and stage of disease. Type, frequency, duration, and intensity should be defined on a personal basis. Yet exercise prescription in hypertrophic cardiomyopathy and its long-term effects represent major gaps in our current knowledge and require extensive research. We here review existing evidence regarding benefits and hazards of physical activity, with specific focus on viable modalities for tailored and safe exercise prescription in these patients, highlighting future developments and relevant research targets.
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http://dx.doi.org/10.1177/2047487320928654DOI Listing
June 2020

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete's heart.

Eur J Prev Cardiol 2020 Mar 25. Epub 2020 Mar 25.

Athlete's heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete's heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete's heart, providing clinical information useful to distinguish between physiological and pathological remodelling.
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http://dx.doi.org/10.1177/2047487320911850DOI Listing
March 2020

COVID-19 and Acute Coronary Syndromes: Current Data and Future Implications.

Front Cardiovasc Med 2020 28;7:593496. Epub 2021 Jan 28.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Coronavirus disease-2019 (COVID-19) pandemic is a global healthcare burden, characterized by high mortality and morbidity rates all over the world. During the outbreak period, the topic of acute coronary syndromes (ACS) has raised several clinical issues, due to the risks of COVID-19 induced myocardial injury and to the uncertainties about the management of these cardiologic emergency conditions, which should be organized optimizing the diagnostic and therapeutic resources and ensuring the maximum protection to healthcare personnel and hospital environment. COVID-19 status should be assessed as soon as possible. Moreover, considerably lower rates of hospitalization for ACS have been reported all over the world, due to patients' hesitations to refer to hospital and to missed diagnosis. As a result, short- and long-term complications of myocardial infarction are expected in the near future; therefore, great efforts of healthcare providers will be required to limit the effects of this issue. In the present review we discuss the impact of COVID-19 pandemic on ACS diagnosis and management, with possible incoming consequences, providing an overview of the available evidence and suggesting future changes in social and clinical approach to ACS.
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http://dx.doi.org/10.3389/fcvm.2020.593496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876078PMC
January 2021

Clinical management of young competitive athletes with premature ventricular beats: A prospective cohort study.

Int J Cardiol 2021 Feb 12. Epub 2021 Feb 12.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy. Electronic address:

Background: Premature ventricular beats (PVBs) are not an unusual finding and their interpretation is sometimes challenging. Unfortunately, few data on the characteristics of PVBs that correlate with the risk of an underlying heart disease are available in athletes.

Objectives: The aim of this prospective study was to investigate the diagnostic and prognostic value of PVBs characteristics in competitive athletes.

Methods: From a cohort of 1751 athletes evaluated at our sports cardiology centre, we enrolled 112 competitive athletes <40 years of age (mean age 21 ± 10 years) and with no known heart disease referred for PVBs. All athletes underwent physical examination, ECG, 12‑lead ambulatory ECG monitoring, exercise testing, and echocardiography. Further investigations including cardiac magnetic resonance were performed for abnormal findings at first-line evaluation or for specific PVBs characteristics.

Results: The majority (79%) of athletes exhibited monomorphic PVBs with a fascicular or infundibular pattern (common morphologies). A definitive diagnosis of cardiac disease was reached in 26 athletes (23% of the entire population) and correlated with uncommon PVBs morphology (p < 0.001) and arrhythmia complexity (p < 0.001). The number of PVBs/24-h was lower in athletes with cardiac disease than in those with normal heart (p < 0.05). During the follow-up a spontaneous reduction of PVBs and no adverse events were observed.

Conclusions: Infundibular and fascicular PVBs were the most common morphologies observed in athletes with ventricular arrhythmias referred for cardiological evaluation. Morphology and complexity of PVBs, but not their number, predicted the probability of an underlying disease. Athletes with PVBs and negative investigation showed a good prognosis.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.021DOI Listing
February 2021

Echocardiography for left ventricular assist device implantation and evaluation: an indispensable tool.

Heart Fail Rev 2021 Jan 11. Epub 2021 Jan 11.

Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.

Echocardiography is an indispensable tool in the evaluation, placement, management and follow-up of patients with left ventricular assist devices (LVAD). While transoesophageal echocardiography is the ideal tool in guiding the implantation procedure, transthoracic echocardiography is essential during the initial evaluation, patient selection and in the post-operative follow-up. This review attempts to summarize which parameters the echocardiographic assessment should focused on during each step. In particular, during the pre-operative assessment, it is of paramount importance to assess the presence of aortic regurgitation and most importantly to evaluate right ventricular function, since it is one of the strongest predictor of post-implant right ventricular failure. During the procedure, through transoesophageal echocardiography, it is possible to confirm the correct placement of the inflow cannula, to assess right ventricular function and to guide the choice of the right pump speed. Transthoracic echocardiographic is an essential part in the patient's follow-up once the LVAD has been implanted, in order to attest the onset of possible complications.
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http://dx.doi.org/10.1007/s10741-021-10073-1DOI Listing
January 2021

Survival in acute heart failure in intensive cardiac care unit: a prospective study.

Int J Cardiovasc Imaging 2021 Jan 3. Epub 2021 Jan 3.

Department of Cardiovascular Diseases, University of Siena, Siena, Italy.

The aim of this study is to identify the best predictors of mortality among clinical, biochemical and advanced echocardiographic parameters in acute heart failure (AHF) patients admitted to coronary care unit (CCU). AHF is a clinical condition characterized by high mortality and morbidity. Several studies have investigated the potential prognostic factors that could help the risk assessment of cardiovascular events in HF patients, but at the moment it has not been found a complete prognostic score (including clinical, laboratory and echocardiographic parameters), univocally used for AHF patients. Patients (n = 118) admitted to CCU due to AHF de novo or to an exacerbation of chronic heart failure were enrolled. For each patient, clinical and biochemical parameters were reported as well as the echocardiographic data, including speckle tracking echocardiography analysis. These indexes were then related to intra- and extrahospital mortality. At the end of the follow-up period, the study population was divided into two groups, defined as 'survivors' and 'non-survivors'. From statistical analysis, C-reactive protein (CRP) (AUC = 0.75), haemoglobin (AUC = 0.71), creatinine clearance (AUC = 0.74), left atrial strain (AUC = 0.73) and freewall right ventricular strain (AUC = 0.76) showed the strongest association with shortterm mortality and they represented the items of the proposed risk score, whose cut-off of 3 points is able to discriminate patients at higher risk of mortality. AHF represents one of the major challenges in CCU. The use of a combined biochemical and advanced echocardiographic score, assessed at admission, could help to better predict mortality risk, in addition to commonly used indexes.
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http://dx.doi.org/10.1007/s10554-020-02109-8DOI Listing
January 2021

The determinants of positivisation of anterior T-wave inversion in children.

J Sports Med Phys Fitness 2020 Dec 11. Epub 2020 Dec 11.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy -

Background: Anterior T-wave inversion (aTWI) can be a common electrical sign in cardiomyopathies but also a benign feature regressing with age in healthy children. Unfortunately, little is known about the age of positivisation of aTWI and its determinants in children and longitudinal data are not available. The aim of this longitudinal study was to identify the age and determinants of positivisation of aTWI in healthy children.

Methods: ATWI was observed in 331 healthy children. They were evaluated yearly until positivisation for a maximum period of 4 years. Positivisation of aTWI was observed in 312 children (94%). The weight, height/length and their respective percentiles at birth and at the time of positivisation of aTWI and weeks of gestation at birth were collected.

Results: Positivisation of aTWI occurred at a mean age of 13.0±2.0 years. When aTWI became positive, the majority of children had a height between 51° and 75° or over the 75° percentile. At the multivariate logistic regression analysis height, weight, percentiles of height and weight at the time of positivisation were identified as the strongest independent predictors of the positivisation of aTWI. No correlation was found for prematurity and anthropometrics characteristics at birth.

Conclusions: ATWI is a common feature of pediatric ECG, usually regressing with age. Height, weight, percentiles of height and weight at the time of positivisation were identified as determinants of TWI positivisation. These simple anthropometric characteristics should be used in addition to chronological age in order to interpret aTWI in children.
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http://dx.doi.org/10.23736/S0022-4707.20.11874-7DOI Listing
December 2020

Bicuspid aortic valve and sports: From the echocardiographic evaluation to the eligibility for sports competition.

Scand J Med Sci Sports 2021 Mar 10;31(3):510-520. Epub 2020 Dec 10.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults. Although a BAV may remain without clinical consequences for a lifetime, it can deteriorate in aortic valve stenosis and regurgitation and aortic dilatation. Unfortunately, the impact of regular training on patients with BAV and its natural course is not fully understood, although preliminary evidence suggests that the progression of valvular disease occurs primarily in an independent manner from sports practice. The current review aims to report how to perform a comprehensive echocardiographic examination in athletes with BAV and analyze the current literature on the influence of sports practice and how it impacts the aortic valve in athletes with BAV. The article also summarizes the current recommendations on sports eligibility and disqualification for competitive athletes with BAV.
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http://dx.doi.org/10.1111/sms.13895DOI Listing
March 2021

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study.

Diagnostics (Basel) 2020 Nov 13;10(11). Epub 2020 Nov 13.

Department of Cardiology, University of Medicine and Pharmacy "Carol Davila"-Euroecolab, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos. Fundeni 258, 022328 Bucharest, Romania.

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume-pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.
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http://dx.doi.org/10.3390/diagnostics10110946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7696899PMC
November 2020

Speckle tracking stress echocardiography: A valuable diagnostic technique or a burden for everyday practice?

Echocardiography 2020 12 4;37(12):2123-2129. Epub 2020 Nov 4.

Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy.

Non-invasive screening for early diagnosis of coronary artery disease (CAD) represents a key element in the never-ending challenge to reduce cardiac death. Stress/rest electrocardiogram often lacks diagnostic accuracy, especially in asymptomatic patients, in fact the latest guidelines for the diagnosis and management of chronic coronary syndromes (CCS) stated the superiority of functional imaging techniques for the detection of subtle myocardial ischemia and the evaluation of myocardial viability (MV). Stress echocardiography is the most accessible and inexpensive imaging method for the study of CAD, either with pharmacological or with exercise provocative stress, based on visual wall-motion assessment. However, in some cases, such as small coronary lesions or microvascular angina, it loses its diagnostic power, therefore requiring a more sensitive approach. Accordingly, in the last years many authors investigated the possible additive value provided by the integration of an advanced but easy-to-obtain technique, that is speckle tracking imaging, to stress echocardiography, reaching promising results; nevertheless, its use is not included in the latest recommendations for CCS. The present review discusses the potential benefits from using a combination of speckle tracking and stress echocardiography for the early detection of myocardial ischemia and the assessment of MV and its suitability in different clinical scenarios, basing on the available evidence.
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http://dx.doi.org/10.1111/echo.14894DOI Listing
December 2020

Zero-fluoroscopy catheter ablation of premature ventricular contractions at left coronary cusp near left main coronary artery.

Clin Case Rep 2020 Oct 22;8(10):1952-1956. Epub 2020 Jun 22.

Cardiology Department Azienda Ospedaliera Universitaria Senese Viale Bracci 1, Siena Italy.

The left coronary cusp is the commonest site of origin for coronary cusp PVC. Catheter ablation without fluoroscopy is highly effective, feasible, and safe but it could be related to risks because of proximity to the coronary arteries. The use of ICE integration allowed an improvement in the safety and efficiency of these procedures.
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http://dx.doi.org/10.1002/ccr3.3035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7562889PMC
October 2020

The right ventricle in "Left-sided" cardiomyopathies: The dark side of the moon.

Trends Cardiovasc Med 2020 Oct 13. Epub 2020 Oct 13.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy.

The right ventricle (RV) has long been regarded as the forgotten and neglected cardiac chamber and it has been overshadowed by the left ventricle (LV). However, in the last decades, important advances in non-invasive cardiac imaging, from myocardial deformation imaging to cardiovascular magnetic resonance (CMR), have overcome the challenges imposed by the complex anatomy of the right heart, leading to a deep understanding of cardiovascular physiology and pathophysiology. The importance of the RV in different cardiac disease is now unquestionable and the current evidence emphasizes the forgotten interdependent relationship between the right and the left heart and the pivotal role of RV dysfunction in determining functional performance and outcomes in many cardiac disorders and particularly in cardiomyopathies. The purpose of this review is to summarize the current evidence about the diagnostic and prognostic value of the right heart in the "left-sided" cardiomyopathies, highlighting the relevance to assess RV size and function by multimodality imaging techniques in order to obtain useful information for a proper diagnostic workup and for the prognosis.
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http://dx.doi.org/10.1016/j.tcm.2020.10.003DOI Listing
October 2020

Insight into Atrial Fibrillation in LVAD Patients: From Clinical Implications to Prognosis.

Pulse (Basel) 2020 Aug 28;8(1-2):2-14. Epub 2020 Apr 28.

Department of Cardiovascular Diseases, University of Siena, Siena, Italy.

The use of left ventricular assist devices (LVADs), whether for destination therapy or bridge to transplantation, has gained increasing validation in recent years in patients with advanced heart failure. Arrhythmias can be the most challenging variables in the management of such patients but the main attention has always been focused on ventricular arrhythmias given the detrimental impact on mortality. Nevertheless, atrial fibrillation (AF) is the most common rhythm disorder associated with advanced heart failure and may therefore characterize the LVADs' pre- and postimplantation periods. Indeed, the consequences of AF in the population suffering from standard heart failure may require a more comprehensive evaluation in the presence of or in sight of an LVAD, making the AF clinical management in these patients potentially complex. Several studies have been based on this subject with different and often conflicting results, leaving many questions unresolved. The purpose of this review is to summarize the main pieces of evidence about the clinical impact of AF in LVAD patients, underlining the main implications in terms of hemodynamics, thromboembolic risk, bleeding and prognosis. Therapeutic considerations about the clinical management of these patients are also made according to the latest evidence.
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http://dx.doi.org/10.1159/000506600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7506248PMC
August 2020

Left atrial strain as a pre-operative prognostic marker for patients with severe mitral regurgitation.

Int J Cardiol 2021 Feb 10;324:139-145. Epub 2020 Sep 10.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Background: In patients with severe mitral regurgitation (MR), additional echocardiographic indices could be helpful to optimize surgical timing before irreversible left heart myocardial dysfunction has occurred. We investigated the correlation of left atrial (LA) strain by speckle tracking echocardiography with prognosis after mitral surgery for severe MR, and its association with LA fibrosis.

Method: 71 patients with primary severe MR undergoing pre-operative echocardiographic assessment were initially enrolled. Exclusion criteria were: other valvular disease>moderate, history of coronary artery disease, heart failure (HF), hypertrophic cardiomyopathy, left bundle branch block, previous pacemaker implantation, heart transplantation, poor acoustic window. The primary endpoint was the occurrence of composite events (HF and mortality); the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10 class). LA fibrosis was assessed by atrial biopsy specimens in a subset of patients.

Results: Of 65 eligible patients, the primary endpoint occurred in 30 patients (medium follow-up: 3.7 ± 1 years for event-group, 6.8 ± 1 years for non-event group). After Kaplan-Meier analysis, peak atrial longitudinal strain (PALS) provided good risk stratification (5-year event-free survival:90 ± 5% for PALS≥21% vs 30 ± 9% for PALS<21%, p < 0.0001); it was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was also an association between PALS and the secondary endpoint (NYHA: r = 0.11, p = 0.04; Borg CR10: r = 0.10, p = 0.02) and an inverse correlation between PALS<21% and LA fibrosis (r 0.80, fibrosis: 76.6 ± 20.7% vs 31.9 ± 20.8%;p < 0.0001).

Conclusions: Global PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.
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http://dx.doi.org/10.1016/j.ijcard.2020.09.009DOI Listing
February 2021

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings.

Heart Fail Rev 2021 Mar;26(2):263-275

Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy.

Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.
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http://dx.doi.org/10.1007/s10741-020-10014-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895796PMC
March 2021

COVID-19 and the burning issue of drug interaction: never forget the ECG.

Postgrad Med J 2021 Mar 20;97(1145):180-184. Epub 2020 Aug 20.

Department of Medical Biotechnologies, Section of Cardiology, University of Siena, Siena, Italy.

The coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has been rapidly escalating, becoming a relevant threat to global health. Being a recent virus outbreak, there are still no available therapeutic regimens that have been approved in large randomised trials and so patients are currently being treated with multiple drugs. This raises concerns regarding drug interaction and their implication in arrhythmic burden. In fact, two of the actually used drugs against SARS-CoV2, such as chloroquine and the combination lopinavir/ritonavir, might determine a QT (the time from the start of the Q wave to the end of the T wave) interval prolongation and they show several interactions with antiarrhythmic drugs and antipsychotic medications, making them prone to an increased risk of developing arrhythmias. This brief review focuses the attention on the most relevant drug interactions involving the currently used COVID-19 medications and their possible association with cardiac rhythm disorders, taking into account also pre-existing condition and precipitating factors that might additionally increase this risk. Furthermore, based on the available evidence and based on the knowledge of drug interaction, we propose a quick and simple algorithm that might help both cardiologists and non-cardiologists in the management of the arrhythmic risk before and during the treatment with the specific drugs used against SARS-CoV2.
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http://dx.doi.org/10.1136/postgradmedj-2020-138093DOI Listing
March 2021

COVID-19 in patients with heart failure: the new and the old epidemic.

Postgrad Med J 2021 Mar 30;97(1145):175-179. Epub 2020 Jul 30.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread in nearly 200 countries in less than 4 months since its first identification; accordingly, the coronavirus disease 2019 (COVID 2019) has affirmed itself as a clinical challenge. The prevalence of pre-existing cardiovascular diseases in patients with COVID19 is high and this dreadful combination dictates poor prognosis along with the higher risk of intensive care mortality. In the setting of chronic heart failure, SARS-CoV-2 can be responsible for myocardial injury and acute decompensation through various mechanisms. Given the clinical and epidemiological complexity of COVID-19, patiens with heart failure may require particular care since the viral infection has been identified, considering an adequate re-evaluation of medical therapy and a careful monitoring during ventilation.
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http://dx.doi.org/10.1136/postgradmedj-2020-138080DOI Listing
March 2021

Safe performance of echocardiography during the COVID-19 pandemic: a practical guide.

Rev Cardiovasc Med 2020 06;21(2):217-223

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena 53100, Italy.

Coronavirus disease-2019 (COVID-19) outbreak has become a worldwide healthcare emergency, with continuously growing number of infected subjects. Considering the easy virus spread through respiratory droplets produced with cough, sneezes or spit or through close contact with infected people or surfaces, healthcare workers are further exposed to COVID-19. Particularly, echocardiography remains an essential diagnostic service which, due to the close contact with patients during the exam, provides echocardiographers high-risk of contagion. Therefore, the common modalities of performing echocardiography should be improved in this scenario, avoiding performing unnecessary exams, using the appropriate personal protective equipment depending on patients' status and location, optimizing time-effectiveness of the echocardiographic study and accurately sanitizing the environment and devices after each exam. This paper aims to provide a simple guide for the clinicians to balance between providing the best care to each patient and protecting themselves and other patients from the spread of the virus. It also proposes the use of the mnemonic PREVENT to resume the crucial indications to be followed for the execution of appropriate echocardiographic examination during the COVID-19 pandemic.
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http://dx.doi.org/10.31083/j.rcm.2020.02.90DOI Listing
June 2020

Usefulness of echocardiography to detect cardiac involvement in COVID-19 patients.

Echocardiography 2020 08 12;37(8):1278-1286. Epub 2020 Jul 12.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Coronavirus disease 2019 (COVID-19) outbreak is a current global healthcare burden, leading to the life-threatening severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, evidence showed that, even if the prevalence of COVID-19 damage consists in pulmonary lesions and symptoms, it could also affect other organs, such as heart, liver, and spleen. Particularly, some infected patients refer to the emergency department for cardiovascular symptoms, and around 10% of COVID-19 victims had finally developed heart injury. Therefore, the use of echocardiography, according to the safety local protocols and ensuring the use of personal protective equipment, could be useful firstly to discriminate between primary cardiac disease or COVID-19-related myocardial damage, and then for assessing and monitoring COVID-19 cardiovascular complications: acute myocarditis and arrhythmias, acute heart failure, sepsis-induced myocardial impairment, and right ventricular failure derived from treatment with high-pressure mechanical ventilation. The present review aims to enlighten the applications of transthoracic echocardiography for the diagnostic and therapeutic management of myocardial damage in COVID-19 patients.
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http://dx.doi.org/10.1111/echo.14779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404652PMC
August 2020

Electromechanical delay by speckle-tracking echocardiography: A novel tool to distinguish between Brugada syndrome and isolated right bundle branch block.

Int J Cardiol 2020 Dec 7;320:161-167. Epub 2020 Jul 7.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.

Background: The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB. The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and isolated complete RBBB in order to differentiate these conditions.

Methods: In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction.

Results: Standard echocardiographic parameters did not differ among the groups. The greatest right ventricular (RV) mechanical dispersion was found in RBBB. Mean absolute deviations (MADs) of time-to-peak longitudinal strain calculated for each left ventricular (LV) region were greater in patients with RBBB as compared to BrS (p < .01). No differences were found between BrS and controls (p = .36). MADs in the basal segments in RBBB group were greater than MADs found in BrS group and controls (37.3 ms vs. 26.7 ms and 29.0 ms, respectively, p < .05). The greatest differences were found in the antero-septal, anterior, lateral, and infero-septal basal segments.

Conclusions: Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.029DOI Listing
December 2020

Detection of oesophageal course during left atrial catheter ablation.

Indian Pacing Electrophysiol J 2020 Nov - Dec;20(6):221-226. Epub 2020 Jun 27.

Department of Medicine, Cardiovascular Section, Saint Eugene Hospital, Rome, Italy.

Background: Oesophageal changes and injuries were recorded after atrial fibrillation(AF) ablation procedures. The reduction of power in the posterior left atrial(LA) wall(closest to the oesophagus) and the monitoring of temperature in the oesophagus(OE) reduced oesophageal injuries. The intracardiac-echocardiography(ICE) with a Cartosound module provides two-dimensional imaging (2D) to assess detailed cardiac anatomy and its relationship with the OE. The aim of this study was to highlight the safety and feasibility of 3D-reconstruction of the oesophageal course in left atrial catheter ablation(CA) procedures without OE temperature probe or quadripolar catheter to guide ICE OE reconstruction.

Methods: 180 patients(PT) underwent left atrial ablation. AF ablation were 125(69.5%); incisional left atrial tachycardias(IAFL) were 37(20.6%); left atrial tachycardias(LAT) were 19(10.6%). The LA and pulmonary vein anatomies were rendered by traditional electroanatomic mapping(EAM) and merged with an ICE anatomic map. In 109 PT ICE imaging was used to create a geometry of the OE(group A). A quadripolar catheter was used in 71 PT to show OE course associated to ICE(group B).

Results: Ablation energy delivery was performed outside the broadest OE anatomy borders. The duration of procedures was longer in group B vs group A Fluoroscopy time was lower in Group A than Group B(Group A 7 ± 3.2 vs 19.2 ± 2.4 min; p < 0.01).

Conclusions: OE monitoring with ICE is safe and feasible. Oesophageal anatomy is complex and variable. Many PT will have a broad oesophageal boundary, which increases the risk of untoward thermal injury during posterior LA ablation. ICE with 3D construction of the OE enhances border detection of the OE, and as such, should decrease the risk of oesophageal injury by improving avoidance strategies without intra-oesophageal catheter visualization.
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http://dx.doi.org/10.1016/j.ipej.2020.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691774PMC
June 2020

Prescribing, dosing and titrating exercise in patients with hypertrophic cardiomyopathy for prevention of comorbidities: Ready for prime time.

Eur J Prev Cardiol 2020 Jun 17:2047487320928654. Epub 2020 Jun 17.

Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy.

The benefits of physical activity are well established, leading to both cardiovascular and non-cardiovascular benefits, improving quality of life and reducing mortality. Despite such striking body of evidence, patients with hypertrophic cardiomyopathy are often discouraged by health professionals to practice physical activity and personalised exercise prescription is an exception rather than the rule. As a result, hypertrophic cardiomyopathy patients are on average less active and spend significantly less time at work or recreational physical activity than the general population. Exercise restriction derives from the evidence that vigorous exercise may occasionally trigger life-threatening arrhythmias and sudden cardiac death. However, while participation in competitive sports should be prudentially denied, hypertrophic cardiomyopathy patients can benefit from the positive effects of regular physical activity, aimed to reduce the risk of comorbidities and improve the quality of life. Based on this rationale, exercise should be prescribed and titrated just like a drug in hypertrophic cardiomyopathy patients, considering individual characteristics, symptoms, past medical history, objective individual response to exercise, previous training experience and stage of disease. Type, frequency, duration, and intensity should be defined on a personal basis. Yet exercise prescription in hypertrophic cardiomyopathy and its long-term effects represent major gaps in our current knowledge and require extensive research. We here review existing evidence regarding benefits and hazards of physical activity, with specific focus on viable modalities for tailored and safe exercise prescription in these patients, highlighting future developments and relevant research targets.
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http://dx.doi.org/10.1177/2047487320928654DOI Listing
June 2020

The use of cardiac imaging in the evaluation of athletes in the clinical practice: A survey by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and University of Siena, in collaboration with the European Association of Cardiovascular Imaging, the European Heart Rhythm Association and the ESC Working Group on Myocardial and Pericardial Diseases.

Eur J Prev Cardiol 2020 Jun 12:2047487320932018. Epub 2020 Jun 12.

Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.

Aims: Pre-participation evaluation (PPE) is recommended to prevent sudden cardiac death in athletes. Although imaging is not advocated as a first-line screening tool, there is a growing interest in the use of echocardiography in PPE of athletes. This survey aimed to map the use of imaging in the setting of PPE and explore physician beliefs and potential barriers that may influence individual practices.

Methods: An international survey of healthcare professionals was performed across ESC Member Countries. Percentages were reported based on the number of respondents per question.

Results: In total, 603 individuals from 97 countries participated in the survey. Two-thirds (65%) of respondents use echocardiography always or often as part of PPE of competitive athletes and this practice is not influenced by the professional or amateur status of the athlete. The majority (81%) of respondents who use echocardiography as a first-line screening tool perform the first echocardiogram during adolescence or at the first clinical evaluation, and 72% repeat it at least once in the athletes' career, at 1-5 yearly intervals. In contrast, cardiac magnetic resonance is reserved as a second-line investigation of symptomatic athletes. The majority of the respondents did not report any barriers to echocardiography, while several barriers were identified for cardiac magnetic resonance.

Conclusions: Echocardiography is frequently used as a first-line screening tool of athletes. In the absence of scientific evidence, before such practice is recommended, large studies using echocardiography in the PPE setting are necessary.
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http://dx.doi.org/10.1177/2047487320932018DOI Listing
June 2020

The prognostic role of speckle tracking echocardiography in clinical practice: evidence and reference values from the literature.

Heart Fail Rev 2020 Mar 26. Epub 2020 Mar 26.

Department of Cardiovascular Diseases, University of Siena, Viale Bracci 1, Siena, Italy.

Speckle tracking echocardiography (STE) is a second-level echocardiographic technique which has gradually gained relevance in the last years. It allows semi-automatic quantification of myocardial deformation and function, overcoming most of the limitations characterizing basic echocardiography and providing an early detection of cardiac impairment. Today, its feasibility and usefulness are highly supported by literature. In particular, several studies demonstrated that STE could provide additional prognostic information beyond conventional echocardiographic and traditional clinical parameters. Moreover, a recent standardization of speckle tracking analysis regarding all cardiac chambers paved the way for the integration of STE in diagnostic and prognostic protocols for particular clinical settings. The aim of this review is to describe the prognostic role of STE in different clinical scenarios basing on currently available evidence.
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http://dx.doi.org/10.1007/s10741-020-09945-9DOI Listing
March 2020

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete's heart.

Eur J Prev Cardiol 2020 Mar 24:2047487320911850. Epub 2020 Mar 24.

Department of Medical Biotechnologies, University of Siena, Italy.

Athlete's heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete's heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete's heart, providing clinical information useful to distinguish between physiological and pathological remodelling.
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http://dx.doi.org/10.1177/2047487320911850DOI Listing
March 2020

Syncope in the Young Adult and in the Athlete: Causes and Clinical Work-up to Exclude a Life-Threatening Cardiac Disease.

J Cardiovasc Transl Res 2020 06 20;13(3):322-330. Epub 2020 Mar 20.

Faint&Fall Programme, IRCCS Istituto Auxologico Italiano, Milan, Italy.

Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. It is usually a benign event, but sometimes it may represent the initial presentation of several cardiac disorders associated with sudden cardiac death during physical activity. A careful evaluation is essential particularly in young adults and in competitive athletes in order to exclude the presence of an underlying life-threatening cardiovascular disease. The present review analyzes the main non-cardiac and cardiac causes of syncope and the contribution of the available tools for differential diagnosis. Clinical work-up of the athlete with syncope occurring in extreme environments and management in terms of sports eligibility and disqualification are also discussed.
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http://dx.doi.org/10.1007/s12265-020-09989-0DOI Listing
June 2020

Authors' response to "Utility of ACUTE-HF score in patients with acute heart failure".

Int J Cardiol 2020 02;301:153

Department of Cardiovascular Diseases, University of Siena, Italy.

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http://dx.doi.org/10.1016/j.ijcard.2019.11.110DOI Listing
February 2020

Identification of cardiac organ damage in arterial hypertension: insights by echocardiography for a comprehensive assessment.

J Hypertens 2020 04;38(4):588-598

Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples.

: Arterial hypertension, a widespread disease, whose prevalence increases with age, represents a major risk factor for cardiovascular events, causing damage in several organs, including the heart. In this context, echocardiography has a clear and pivotal role, being able to assess cardiac morphology and detect haemodynamic changes induced by this disease. 2018 European Society of Cardiology/European Society of Hypertension guidelines on AH identified main echo parameters such as left ventricular mass, relative wall thickness and left atrial volume, for detecting cardiac organ damage. The present review highlights the advantage of additional echocardiographic parameters such as diastolic measurement and both thoracic and abdominal aortic dimensions. An overlook on aortic valve should also be suggested to detect aortic regurgitation and stenosis, both frequent complications in hypertensive patients. In this kind of comprehensive assessment, the combination of standard and advanced echocardiography (speckle tracking echocardiography and, with a lesser extent, three-dimensional echocardiography) could be considered to improve the diagnostic accuracy, stratify prognosis and address management in arterial hypertension.
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http://dx.doi.org/10.1097/HJH.0000000000002323DOI Listing
April 2020