A left atrial thrombus too big to embolize.
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Aged↗
Biomedical subjects
Patrizio Lancellotti
Publications and source records attributed to Patrizio Lancellotti.
Exercise ventilation inefficiency in heart failure: pathophysiological and clinical significance.
Heart failure (HF) is a complex syndrome characterized by myocardial dysfunction and a poor prognosis. Among multiple markers of severity, an exercise ventilation inefficiency has important clinical and prognostic value. The pathophysiology determining exercise ventilatory inefficiency is complex and not definitively clarified. Three different mechanisms have been identified: (i) increased dead space, (ii) early occurrence of lactic acidosis, and (iii) abnormal chemoreflex and/or metaboreflex activity. Besides its prognostic value, abnormal ventilation can be influenced by pharmacological and non-pharmacological therapies such as beta-blockers, selective cyclic 3'-5' guanosine monosphosphate phosphodiesterase inhibitors, physical training, and nocturnal continuous positive airway pressure. There is an increasing interest for the exercise periodic breathing, which is frequently associated with HF syndrome and has prognostic importance. The precise mechanisms sustaining exercise periodic breathing are not fully defined but ventilatory and metabo-haemodynamic hypotheses have been proposed.
Adrenergic beta-Antagonists↗
Left ventricular dyssynchrony and dynamic functional mitral regurgitation: relationship or association?
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Humans↗
Quantitative analysis of semi-supine exercise echocardiography--influence of age on myocardial Doppler imaging indices.
OBJECTIVES: This study was performed to evaluate the feasibility of quantitative analysis of exercise echocardiography using pulsed wave Doppler myocardial imaging (DMI) and to examine the relation between age and DMI parameters at rest and during graded exercise in normal subjects. METHODS AND RESULTS: Seventy-two healthy volunteers were divided into three age groups (group I, age < or = 40 years, group II, age 41 - 59 years and group III, age > or = 60 years), and underwent a semi-supine exercise echocardiogram. Peak systolic velocity (SV), time to peak SV (TPV), systolic velocity time integral (VTI) and peak diastolic velocities (VE and VA) were measured off-line. There was a heterogeneity in DMI parameters between different myocardial walls and a gradient was found between basal and mid segments. Both persisted during exercise. Group I had significantly higher TPV than groups II and III. Increase in workload was accompanied by an increase in velocities, while TPV decreased. Differences between groups persisted throughout exercise. CONCLUSIONS: Off-line measurements of DMI parameters are feasible during exercise. SV and E decline as age increases while A increases. SV already increases at low charge exercise and may serve as a quantitative marker for the detection of myocardial viability. Change of the absolute DMI velocity values during exercise may provide a better indicator of ischaemia or viability than the absolute values themselves.
Adult↗
Effect of dynamic left ventricular dyssynchrony on dynamic mitral regurgitation in patients with heart failure due to coronary artery disease.
In patients with heart failure, exercise-induced increases in mitral regurgitation (MR), which convey a poor prognosis, are related to the dynamic distortion of mitral valve geometry. It was hypothesized that dynamic MR may also be related to intermittent changes in left ventricular synchronicity during exercise.
Aged↗
Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis.
BACKGROUND: In patients with asymptomatic valvular aortic stenosis, exercise testing may help to stratify the clinical risk. However, data are limited, and the role of quantitative exercise Doppler echocardiography has never been investigated. METHODS AND RESULTS: Sixty-nine consecutive patients with severe asymptomatic aortic stenosis (aortic valve area <1 cm2) who prospectively underwent quantitative Doppler echocardiographic measurements at rest and during semisupine exercise test were followed up for 15+/-7 months. Of these, 26 had an abnormal response to exercise [occurrence of > or =1 of the following findings: angina, dyspnea, > or =2 mm ST segment depression, or fall or small (<20 mm Hg) rise in systolic blood pressure during the test] and 18 presented cardiac events during follow-up (symptoms in 2 patients, acute pulmonary edema in 2, aortic valve replacement in 12, and cardiac death in 2). In univariate analysis, patients who had cardiac events exhibited a higher increase in both peak (29+/-16 versus 22+/-14 mm Hg; P=0.019) and mean (23+/-8 versus 12+/-7 mm Hg; P=0.000003) transvalvular pressure gradients, whereas the left ventricular ejection fraction reached at peak stress was lower. These patients experienced more frequently symptoms during exercise (14 of 18 versus 12 of 51; P=0.0008). By multivariate Cox regression analysis, independent predictors of cardiac events were as follows: an increase in mean transaortic pressure gradient by > or =18 mm Hg during exercise (P=0.0015), an abnormal exercise test (P=0.0026), and an aortic valve area <0.75 cm2 (P=0.0031). Exercise Doppler echocardiographic findings provided incremental prognostic value over resting echocardiographic and exercise electrocardiographic parameters. CONCLUSIONS: Quantitative Doppler exercise echocardiography could be useful to identify a high-risk subset of patients with asymptomatic valvular aortic stenosis and help for clinical decision making.
Adult↗
Chronic ischaemic mitral regurgitation: exercise testing reveals its dynamic component.
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Chronic Disease↗
Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation.
AIMS: In patients with heart failure and chronic ischaemic mitral regurgitation (MR), the mortality risk is related to the quantified severity of MR at rest and its dynamic changes during exercise. The impact of dynamic MR on long-term mortality, hospital admission for heart failure, and major adverse cardiac events has never been investigated. METHODS AND RESULTS: We prospectively studied 161 patients with chronic ischaemic left ventricular (LV) dysfunction and at least mild MR who underwent quantitative measurement of the effective regurgitant orifice (ERO) of MR at rest and during semi-supine exercise test and who were followed up for 35+/-11 months. The 20 patients who underwent surgery were censored at the time of operation. Of the 141 patients who were treated medically, 23 died, 22 required hospitalization for heart failure, 4 had nonfatal myocardial infarction, and 11 developed unstable angina. By multivariate analysis, an exercise-induced increase in ERO by > or =13 mm(2) and a greater increase in transtricuspid pressure gradient during exercise emerged as predictors of mortality and of hospital admission for heart failure. MR severity under basal conditions (ERO> or =20 mm(2)) was an independent predictor of only cardiac death. Greater LV volumes at rest and lack of contractile reserve during exercise were additional independent markers of poor outcome. CONCLUSION: In patients with ischaemic heart disease and LV dysfunction, large exercise-induced increases in MR identify patients at high risk of morbidity and of death.
Aged↗
Global and regional parameters of dyssynchrony in ischemic and nonischemic cardiomyopathy.
In this study, color tissue Doppler imaging was used to assess global and regional mechanical dyssynchrony in patients with ischemic cardiomyopathy and those with idiopathic dilated cardiomyopathy. Potential differences in the area of latest mechanical activation could have practical implications regarding lead positioning and the success rate of biventricular pacemaker implantation.
Aged↗
Effect of cardiac resynchronization therapy on functional mitral regurgitation in heart failure.
Cardiac resynchronization therapy (CRT) reduces functional mitral regurgitation (MR) at rest. This study assessed exercise-induced changes in MR in patients with heart failure who were helped by CRT. The determinants of these exercise-induced changes in MR were analyzed in asynchronous and resynchronized left ventricles.
Echocardiography, Doppler↗
The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema.
BACKGROUND: Acute mitral regurgitation may cause pulmonary edema, but the pathogenetic role of chronic ischemic mitral regurgitation, a dynamic condition, has not yet been characterized. METHODS: We prospectively studied 28 patients (mean [+/-SD] age, 65+/-11 years) with acute pulmonary edema and left ventricular systolic dysfunction and 46 patients without a history of acute pulmonary edema. The two groups were matched for all baseline characteristics. Patients underwent quantitative Doppler echocardiography during exercise. Exercise-induced changes in the left ventricular volume, the ejection fraction, the mitral regurgitant volume, the effective regurgitant orifice area, and the transtricuspid pressure gradient were compared in patients with and without acute pulmonary edema. RESULTS: The two groups had similar clinical and baseline echocardiographic characteristics. They also had similar exercise-induced changes in heart rate, systolic blood pressure, and left ventricular volumes. In the univariate analysis, patients with recent pulmonary edema had a much higher increase than did the patients without pulmonary edema in mitral regurgitant volume (26+/-14 ml vs. 5+/-14 ml, P<0.001), the effective regurgitant orifice area (16+/-10 mm2 vs. 2+/-9 mm2, P<0.001), and the transtricuspid pressure gradient (29+/-10 mm Hg vs. 13+/-11 mm Hg, P<0.001). In the multivariate analysis, exercise-induced changes in the effective regurgitant orifice area (P<0.001), in the transtricuspid pressure gradient (P=0.001), and in the left ventricular ejection fraction (P=0.02) were independently associated with a history of recent pulmonary edema. CONCLUSIONS: In patients with left ventricular systolic dysfunction, acute pulmonary edema is associated with the dynamic changes in ischemic mitral regurgitation and the resulting increase in pulmonary vascular pressure.
Acute Disease↗
Predictors of rapid QRS widening in patients with coronary artery disease and left ventricular dysfunction.
To assess the predictors of rapid QRS widening in patients with chronic ischemic left ventricular dysfunction, 82 patients who underwent > or =2 electrocardiograms and exercise Doppler echocardiography were studied. In a multivariate analysis, left ventricular end-diastolic volume, a large increase in mitral regurgitant volume during exercise, and diabetes emerged as independent predictors of QRS widening.
Aged↗
Electrocardiographic changes during dobutamine stress testing in patients with recent myocardial infarction: relation with residual infarct artery stenosis and contractile recovery.
OBJECTIVE: The identification of viable but jeopardized myocardium after acute myocardial infarction (AMI) is of great importance for selecting patients who could benefit from a revascularization procedure. The aim of the study was to determine the accuracy of the dobutamine stress electrocardiogram (ECG) 1) for detecting significant stenosis of the infarct-related artery and 2) for predicting the occurrence of contractile recovery. METHODS AND RESULTS: Ninety-four patients underwent dobutamine stress ECG and quantitative angiography within the first week after AMI. A follow-up resting echocardiogram was obtained in all patients at 1 month. Significant stenosis of the infarct-related artery was detected in 76 patients and functional recovery occurred in 56 patients. Dobutamine stress induced ST-segment elevation in 44 patients, ST-segment depression in 17 and T-wave normalization in 34. Increase in QT dispersion and dobutamine ST elevation were more sensitive than chest pain and ST-segment depression (79% and 53% vs. 24% and 17%, respectively; p<0.05) for detecting significant infarct-related artery stenosis. Four independent variables were selected for predicting contractile recovery: > or = 20 ms increase in QT dispersion from baseline to low-dose dobutamine (p = 0.00016), dobutamine-induced ST-segment elevation (p = 0.0009), elective angioplasty of the infarct-related artery (p = 0.001) and T-wave normalization (p = 0.005). CONCLUSIONS: The analysis of predischarge dobutamine stress ECG is useful for predicting residual stenosis of the infarct-related artery and contractile recovery in the affected area. QT dispersion changes during the test are the most accurate parameter.
Coronary Angiography↗
Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction.
OBJECTIVES: We sought to examine the determinants of exercise-induced changes in ischemic mitral regurgitation (MR) in patients with left ventricular (LV) dysfunction. BACKGROUND: In the post-myocardial infarction (MI) phase, ischemic MR contributes to worsening of symptoms and of LV dysfunction. METHODS: In this study, 70 patients in the chronic, post-MI phase, with LV ejection fraction <45% and at least mild MR, underwent semi-supine exercise Doppler echocardiography. The effective regurgitant orifice (ERO) of MR was quantified at rest and during exercise. Exercise-induced changes in ERO were compared with changes in mitral deformation and in local and global LV remodeling. RESULTS: The wide range of exercise-induced ERO changes that were observed was unrelated to the degree of MR at rest (r = 0.20). Effective regurgitant orifice changes correlated best with changes in mitral deformation (i.e., differences in systolic mitral tenting area, systolic annular area, and coaptation height) (p < 0.0001). Posterior displacement of the papillary muscles was associated with larger changes in the ERO in both infarct groups. In patients with inferior MI, a decrease in the ERO was related to improvement in wall motion (r = 0.68). The independent predictors of ERO changes during exercise were changes in systolic annular area for all infarct categories, in tenting area and wall motion score in the global population and those with inferior infarction, and in apical displacement of mitral leaflets for patients with anterior MI. CONCLUSIONS: The degree of MR at rest is unrelated to exercise-induced changes in EROs, which are related to those in local LV remodeling and in mitral deformation but not those in global LV function.
Echocardiography, Doppler↗
Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction.
BACKGROUND: In the post-myocardial infarction phase, mortality risk is related to the severity of mitral regurgitation (MR). Ischemic MR is a dynamic condition that can be studied during exercise. Whether the assessment of exercise-induced changes in the degree of MR provides prognostic information is unknown. METHODS AND RESULTS: Ninety-eight consecutive patients with chronic ischemic left ventricular dysfunction and at least mild MR who prospectively underwent quantitative measurement of the regurgitant volume and the effective regurgitant orifice (ERO) of MR at rest and during semisupine exercise test were followed up for 19+/-8 months. The 16 patients who underwent surgery were censored at the time of operation. Of the 82 patients who were medically treated, 9 (11%) died. No clinical data demonstrated a distinction between survivors and nonsurvivors. By multivariate Cox regression analysis, independent predictors of cardiac death were an increase in ERO by > or =13 mm2 (P=0.0045) during exercise, an ERO >20 mm2 at rest (P=0.01), and a shorter mitral deceleration time (P=0.044). Half of the patients with exercise-induced significant increases in MR who died had moderate MR at rest. In contrast, none of the 14 patients with a decrease in MR at exercise displayed cardiac death. CONCLUSIONS: In patients with ischemic MR and left ventricular dysfunction, quantitative assessment of exercise-induced changes in the degree of MR provides independent prognostic information. Significant exercise-induced increases in MR unmask patients at high risk of poor outcome.
Aged↗
Detection and clinical usefulness of a biphasic response during exercise echocardiography early after myocardial infarction.
OBJECTIVE: The aim of this study was to determine the accuracy of exercise echocardiography (EE) for detecting infarct-related artery (IRA) stenosis and predicting functional recovery early after acute myocardial infarction (AMI). BACKGROUND: Dobutamine stress echocardiography is widely used for identifying jeopardized myocardium. The clinical usefulness of a biphasic response detected during EE has never been investigated. METHODS: A total of 114 consecutive patients with a first AMI and > or = 2 dyssynergic segments in the infarct-related territory underwent semi-supine continuous EE 6 +/- 2 days after AMI. Quantitative coronary angiography was performed in all patients after EE. A follow-up echocardiogram was obtained one month later. RESULTS: Ninety-seven patients had significant (> or = 50%) IRA stenosis, and 26 had multivessel disease. Residual ischemia was identified in 77 patients (biphasic response in 62 and worsening response in 15). The sensitivity and specificity of ischemia during EE for predicting IRA stenosis were 75% and 76%, respectively. The sensitivity of a biphasic response was higher than the sensitivity of a worsening response (61% vs. 14%, p < 0.0001). Wall motion abnormalities induced in other vascular territories were specific (97%) and moderately sensitive (62%) for the detection of multivessel disease. Functional recovery was observed in 75 patients. Two independent variables predicted contractile recovery: contractile reserve during EE (p < 0.0001) and elective angioplasty of the IRA (p = 0.002). A biphasic response, but not sustained improvement, predicted reversible dysfunction (73% vs. 9%, p < 0.0001). CONCLUSIONS: A biphasic response can be detected during exercise. Exercise echocardiography is an accurate tool for detecting IRA stenosis and predicting functional improvement early after AMI.
Cardiotonic Agents↗
Persistent negative T waves in the infarct-related leads as an independent predictor of poor long-term prognosis after acute myocardial infarction.
This study sought to determine the long-term prognostic significance of persistent or transient negative T waves in infarct-related leads. After acute myocardial infarction (AMI), QRS and T wave alterations may resolve. No clinical study has investigated the prognostic importance of persistent versus transient negative T waves. We studied 147 consecutive patients with first AMI and >/=2 negative T waves in the infarct-related leads on the electrocardiogram. One hundred twenty patients developed Q waves. Patients were followed clinically for 60 +/- 21 months. T-wave normalization was observed early (before hospital discharge) in 34 patients and late (at 4 +/- 1 months) in 65. Thirty patients had Q-wave regression. Adverse outcome occurred in 57 patients. There were 23 hard events (cardiac death in 12 patients and nonfatal AMI in 11). Patients with early or late T-wave normalization had similar event-free survival curves that diverged rapidly from that of patients with persistent negative T waves, who had a worse outcome (p <0.0001). Patients with or without Q-wave regression had similar survival curves. Using multivariate Cox regression analysis, higher end-systolic volume (hazard ratio [HR] 1.01, p = 0.007), the presence of multivessel disease (HR 3.33, p = 0.009), and persistent negative T waves (HR 2.92, p = 0.024) predicted hard events. Persistent negative T waves 4 months after first AMI were independently associated with a worse outcome, whereas Q-wave regression has no long-term prognostic importance.
Adult↗