Prevalence of exercise-induced oxygen desaturation after recovery from SARS-CoV-2 pneumonia and use of lung ultrasound to predict need for pulmonary rehabilitation

BACKGROUND

Persistence of breathlessness after recovery from SARS-CoV-2 pneumonia is frequent. Recovery from acute respiratory failure (ARF) is usually determined by normalized arterial blood gases (ABGs), but the prevalence of persistent exercise-induced desaturation (EID) and dyspnea is still unknown.

METHODS

We investigated the prevalence of EID in 70 patients with normal arterial oxygen at rest after recovery from ARF due to COVID-19 pneumonia. Patients underwent a 6-min walking test (6MWT) before discharge from hospital. We recorded dyspnea score and heart rate during 6MWT. We also investigated the possible role of lung ultrasound (LU) in predicting EID. Patients underwent a LU scan and scores for each explored area were summed to give a total LU score.

RESULTS

In 30 patients (43%), oxygen desaturation was >4% during 6MWT. These patients had significantly higher dyspnea and heart rate compared to non-desaturators. LU score >8.5 was significantly able to discriminate patients with EID.

CONCLUSION

In SARS-CoV-2 pneumonia, ABGs at discharge cannot predict the persistence of EID, which is frequent. LU may be useful to identify patients at risk who could benefit from a rehabilitation program.

Prognostic value of left and right ventricular strain in heart failure with reduced and preserved ejection fraction: a meta-analysis

Background

The association of speckle tracking echocardiography measures of left ventricular (LV) and right ventricular (RV) strain with clinical outcome in heart failure with reduced and preserved ejection fraction (HFrEF and HFpEF) has been extensively investigated. In fact, while the contribute of LV ejection fraction (LVEF) for prognosis is controversial, myocardial strain has proven to be a strong and independent prognostic predictor in many HF studies.

Purpose

The aim of this meta-analysis was to assess the prognostic value of LV global longitudinal strain (GLS) and free wall RV longitudinal strain (fwRVLS) by 2-dimensional speckle tracking echocardiography in patients with HFrEF, HF with mildly-reduced ejection fraction (HFmrEF) and HFpEF.

Methods

A systematic literature search of medical databases including Pubmed, Scopus, Ovid Online, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Scopus was performed using PRISMA principles. All relevant studies in English language reporting the predictive value of LV GLS and/or fwRVLS for mortality and/or cardiovascular events in HFrEF, HFmrEF and HFpEF, with follow up >6 months, were identified. Case reports/series and abstract congresses were excluded (Fig. 1). All-cause mortality and a composite endpoint of cardiovascular death, re-hospitalization for HF, cardiac transplantation, ventricular assist device implantation were analyzed. Hazard ratios (HR) were extracted from univariate and multivariate random-effects models reporting on the association of LV GLS and fwRVLS and outcome and described as pooled estimates with 95% confidence intervals (CI).

Results

Fifty studies (n=18276 patients) satisfied the inclusion criteria (35 studies in chronic HF, 15 studies in acute HF). Most studies (n=36) included patients with HFrEF, while 14 studies included patients with HFmrEF (n=3) and with HFpEF (n=11); thus HFmrEF and HFpEF were grouped together for the analysis. Overall, 48 studies included LV GLS (median value = −9% [from −17% to −11%], 17 studies included fwRVLS (median value = −18% [from −24% to −14%]). Over a median follow up of 32 [from 7 to 67] months follow up, 5618 (31%) had a cardiovascular event or died. LV GLS and fwRVLS were independently associated with all-cause mortality and the composite outcome, regardless of LVEF (Fig. 2), both in HFrEF (HR 1.26; 95% CI [1.15; 1.37]; p<0.01 for LV GLS and HR 1.06; 95% CI [1.03; 1.09]; p<0.01 for fwRVLS) and in HFpEF (HR 1.07; 95% CI [1.03; 1.12]; p<0.01 for LV GLS and HR 1.08; 95% CI [0.96; 1.21]; p<0.01 for fwRVLS).

Conclusions

These meta-analysis data demonstrate that LV and RV strain are associated with mortality and cardiovascular events in patients with HF, HFmrEF and HFpEF and may provide important additive prognostic information. These findings emphasize the potential usefulness of LV GLS and fwRVLS in clinical practice to improve the risk stratification and management of patients with HF regardless of LVEF.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking echocardiography as a promising tool for the prognostic assessment of patients with sarcoidosis

Background

Sarcoidosis is a chronic granulomatous disease characterized by multiorgan inflammatory involvement and recurrent relapses with significant impact on morbidity and mortality. The prognostic assessment of these patients is still challenging. Although the international guidelines didn't recommend basic transthoracic echocardiography (TTE) for diagnostic and prognostic assessment of sarcoidosis, speckle tracking echocardiography (STE) has emerged as more sensitive for the early detection of cardiac sarcoidosis and outcome.

Purpose

This prospective study aimed to assess the potential value of STE parameters for the prediction of major adverse cardiac events (MACE) and sarcoidosis relapse.

Methods

Consecutive patients with confirmed diagnosis of sarcoidosis who underwent transthoracic echocardiography (TTE) and subsequent pulmonary function tests (PFTs) were enrolled. Patients with acute events or treatment escalation between TTE and PFTs and previous cardiac surgery were excluded. All patients were followed for sarcoidosis relapse requiring increase in step-up therapy and MACE (cardiovascular death, cardiovascular hospitalizations, arrhythmias).

Results

172 patients were included (111 females, 57.4±12.6 years); 56 patients showed extrapulmonary localizations of sarcoidosis; at baseline, 99 patients were on steroid and/or immunosuppressive therapy. During a median follow up of 2217 days, 8 deaths (3 cardiovascular deaths), 23 MACE and 36 sarcoidosis relapses were reported. Patients with MACE were older (p=0.0022), but didn't show significant differences in PFTs and sarcoidosis phenotype. LV global longitudinal strain (GLS) was the only echocardiographic index to show significant differences (lower values) in patients with MACE (p=0.025). LV GLS ≤17.13% (absolute value) was identified as a fair predictor of MACE both with ROC curves (AUC=0.64) and Kaplan Meier analysis (Fig. 1).

No significant differences of demographic, clinical, functional, and therapeutic data were observed between patients with/without sarcoidosis relapse. TTE revealed a significant reduction of LV ejection fraction (p=0.0432), tricuspid annular plane systolic excursion (TAPSE, p=0.0272) and global peak atrial longitudinal strain (PALS, p=0.0012) in patients with relapse. Among these 3 parameters, PALS ≤28.5% showed to be the best predictor of sarcoidosis relapse with ROC (AUC=0.7155) and Kaplan Meier curves (Fig. 2).

Conclusions

Our results highlight a potential role of LV GLS and PALS as prognostic markers in sarcoidosis, suggesting the use of STE in the clinical management of these patients, regardless the evidence or the suspect of cardiac localizations of the disease.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The loss of left atrial contractile function predicts worse outcome in HFrEF: a speckle tracking study

Funding Acknowledgements

Type of funding sources: None.

Background

in chronic heart failure (HF), high cardiac pressure induces a progressive remodeling of small pulmonary arteries up to pulmonary hypertension development. At the end of left atrial (LA) conduit function, pulmonary and left heart end-systolic pressures equalize. This might affect LA systole.

Purpose

we investigated whether peak atrial contraction strain (PACS), measured by speckle tracking echocardiography (STE), was independently associated with outcome in HF with reduced ejection fraction(HFrEF).

Methods

168 outpatients with HFrEF and sinus-rhythm referred to our echo-labs were prospectively enrolled. After clinical and echocardiographic evaluation, off-line STE analysis was performed. The endpoints were cardiovascular (CV) death and HF hospitalization respectively. Spline knotted survival model identified the optimal cut-off value for PACS.

Results

The 152 included patients were stratified based on PACS < 8%(n = 76) or PACS≥8%(n = 76). Mean age was 61 ± 12, mean EF was 30 ± 9%. Characteristics of the two groups are presented in Table 1. Over a mean follow-up of 3.41 ± 1.9 years, 117 events (51 CV death, 66 HF hospitalizations) were collected. By univariate and multivariate Cox analysis, global PACS emerged as a strong and independent predictor of CV death and HF hospitalization, even after adjusting for age, sex, LV strain, E/e’, LA volume index (HR 0.6 per 5 unit decrease in PACS). Kaplan Meier curves showed a sustained divergence in event-free survival rates for the two groups (Fig.1).

Conclusions

The reduction of PACS significantly and independently affects CV outcome in HFrEF. Although limited to patients with sinus rhythm, it could offer additive prognostic information for HFrEF patients.

Table 1 Variable PACS < 8 PACS ≥ 8 P value Age 61.5± 11.4 61.8 ± 12.7 0.4 NYHA class >2 26% (n = 39) 11% (n = 17) <0.0001 NT pro BNP 2293.7 ± 1636 1335 ± 242 0.04 E/E’ ratio 16.1 ± 9.09 12.1 ± 7.09 0.0015 LV GLS -7.28 ± 3.4 -10.17 ± 3.2 <0.001 sPAP 40.5 ± 13.7 30.3 ± 9.3 <0.0001 LAVI 64.4 ± 20.4 45.5 ± 15.8 <0.0001 PALS 9.8 ± 4.9 20.2 ± 7 <0.0001 E, peak early diastolic “E” wave; E’, medium velocity of early mitral annulus descent; GLS, global longitudinal strain; LAVI, left atrial volume index; LV, left ventricular; PACS, peak atrial contraction strain; PALS, peak atrial longitudinal strain; sPAP, systolic pulmonary artery pressure. Abstract Figure. Fig.1

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

Background

For patients with severe mitral regurgitation (MR), new indices are needed to optimize surgical timing before irreversible myocardial dysfunction.

Purpose

We investigated the prognostic role of left atrial (LA) strain by speckle tracking echocardiography after mitral surgery for severe MR, and its association with LA fibrosis.

Methods

70 patients with primary severe MR undergoing echocardiography before mitral surgery were enrolled. Patients with other valvular disease > moderate, left bundle branch block, coronary artery disease, heart failure (HF), pacemaker implantation, heart transplantation, poor acoustic window, were excluded. The primary composite endpoint included HF and mortality; the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10). LA fibrosis was assessed by atrial biopsy specimens.

Results

Of 62 patients eligible, 32 had composite events (medium follow-up: 3.3±2.5 years for event-group, 7.6±1 years for non-event group). Characteristics of our study population are summarized in Table 1. With Kaplan-Meier analysis (Fig. 1), PALS provided a good risk stratification; it also was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was a strong association between PALS and secondary endpoint (NYHA: r2=0.11, p=0.04; Borg CR10: r2=0.10, p=0.02) and an inverse correlation between PALS <21% and LA fibrosis (r2=0.80; 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.

Figure 1

Funding Acknowledgement

Type of funding source: None

Use of bioactive materials and limited FOV CBCT in the treatment of a replanted permanent tooth affected by inflammatory external root resorption: a case report

BACKGROUND

Inflammatory external root resorption is one of the possible complications of replantation of an avulsed tooth. Several studies have shown that limited FOV CBCT is an efficient diagnostic support and in treatment planning of these cases in paediatric patients because of its high resolution combined with low radiation doses. The recent literature has suggested that Biodentine is an effective material for resolution of inflammatory root resorption.

CASE REPORT

This article describes the successful therapy of a replanted tooth affected by inflammatory root resorption. In the present case, a CBCT exam was performed to detect the extent of the damage, and the canal was filled with Biodentine in the apical third. At present, the threated tooth is asymptomatic, and the twelve months follow-up examination showed healing of periradicular hard tissues.

Lymphogranuloma venereum: an old, forgotten re-emerging systemic disease

Lymphogranuloma venereum (LGV) is a sexually transmitted infection endemic in parts of Africa, Asia, South America, and the Caribbean, but once was rarely observed in Western countries, where most cases were considered to be imported. However, recent outbreaks have been reported in Europe, Australia, New Zealand, the United States and Canada, mainly among HIV positive men who have sex with men, signaling LGV re-emergence. The etiological agent of LGV is Chlamydia trachomatis serotypes L1, L2 and L3, and current outbreaks are mostly sustained by L2b type. The clinical course can be classically divided into three stages: an initial papule, which may ulcerate at the site of inoculation, followed by regional lymphoadenopathy (second stage, generally unilateral). In the tertiary stage, lymphatic obstruction, with elephantiasis of genitalia, and rectal involvement can lead to the formation of strictures and fistulae that may require surgical treatment. Recent cases are observed mainly among HIV positive people, often co-infected with HCV and others STIs, engaging in high-risk sexual practices. The main clinical picture is a relative new entity characterized by progressive ulcerative proctitis, the so called anorectal syndrome. Diagnosis is often delayed, requires a high index of clinical suspicion and must rely on the use of nucleic acid amplification tests. The differential diagnosis of proctitis should include LGV infection. Gastroenterologists, coloproctologists, dermatologists and other specialists need to be aware of LGV proctitis to avoid diagnostic delay and progression of disease to the tertiary stage.

Assessing the magnitude of impact of volcanic ash deposits on Merino wool production and fibre traits in the context of a drought in North-west Patagonia, Argentina

Environmental variability is a key feature of arid and semiarid rangelands worldwide. Drought is one of the main sources of variation in most extensive livestock production systems in arid environments, with biophysical and socioeconomic implications. The effect of non-climatic disturbance factors, such as volcanic eruption and ash deposits, has been less documented in arid environments. The aim was to assess the magnitude of impact of volcanic ash deposits on Merino wool production and quality that took place in the context of a drought, by making a comparison along a gradient of ash deposition before and after a volcanic eruption. It was found that volcanic ash deposits in the context of a regional drought significantly affected Merino wool production and fibre quality traits in farms from North-western Patagonia, Argentina. The magnitude of the impacts differed among wool traits. It is argued that further research is needed on the impact of ash deposits on wool weights and quality, and that measures of livestock production should be included in environmental monitoring systems at regional and farm levels.