bluuebunny/crossref_metadata_2025 huggingface dataset:
SAFETY AND EFFICACY OF PFO CLOSURE DEVICES IMPLANTATION AND CLINICAL OUTCOMES: A SINGLE–CENTER LONG–TERM REVIEW
Authors: Varotto L , Sgreva S , Dotto A , Cardillo G , Piccolo S , De Boni A , Bonanno C
Published: May 2024

Introduction

Patent foramen ovale (PFO) is present in up to 25% of the general population, and it is a relevant cause of cryptogenic stroke. The current standard of care for selected patients with PFO and cryptogenic stroke is transcatheter closure, but the risk of post–closure–new–onset atrial fibrillation (AF) has been described. Published trials report a 3.6%–5.8% prevalence of recurrent ischemic stroke and 2%–6.6% incidence of postimplant AF, and some authors assume that to protect from one embolic stroke aetiology, there is the risk of creating another one. We aimed to investigate the efficacy and safety of device implantation in a single–center study, but as well as the long–term clinical outcomes up to over 16 years of follow–up.

Methods

This is a prospective, non–randomised study in Vicenza, from February 2007 to July 2021, enrolling 200 consecutive patients addressed to PFO closure, with implantation of various devices. A research was performed via telephone interviews and clinical follow–up reports on outcomes of percutaneous PFO closure. The main endpoint was recurrence of stroke/transient ischemic attack (TIA). Other outcomes included new–onset AF, major bleeding, serious adverse events, and device–related complications. All–cause mortality was examined too.

Results

Two–hundred patients were enrolled over 14 years; 106 (53%) were men. Mean age was 49±10 years, ROPE score was 5.9±1.5. All patients had a device implanted and technical success was 99.5% (number of devices per case 1.0±0.07). Post–procedural trivial residual shunt was observed in 2 patients. Procedural success, defined as no serious adverse device–related event or large shunt, was 198/200, resulting in 99% success rate. The incidence of recurrent stroke/TIA and AF was the same (2.5%), so the rate of both recurrences was 2.7 events per 1000 patient–years. Adverse events occurred in 8 patients: 1 access site hematoma, 1 supraventricular tachycardia, 4 deep vein thromboses and 2 pulmonary embolisms. Four patients died from malignancies, 1 from sudden death and 1 from stroke.

Conclusions

Our review represents one of the largest cohort of PFO patients treated with devices, and shows that their use is associated with high procedural success and low adverse events on a long–term follow–up (mean follow–up of 9.4 years). The efficacy and safety results are lower than those reported by randomized studies, probably due to good patient selection and effective cardio–neurological teamwork.
PERCUTANEOUS CLOSURE OF PATENT FORAMEN OVALE AFTER A FAILED DEVICE–CLOSURE ATTEMPT: A HIGH–VOLUME SINGLE CENTRE EXPERIENCE
Authors: Giordano M , Gaio G , Marzullo R , Scognamiglio G , Altobelli I , Gaudieri G , Palladino M , Cappelli Bigazzi M , Della Cioppa N , Golino P , Sarubbi B , Russo M
Published: May 2024

Introduction

Persistence of patent foramen ovale (PFO) has been associated with cryptogenic stroke due to a paradoxical systemic embolism. In these cases, a percutaneous closure allows to decrease the risk of redo cerebral ischemic events. However, the presence of a complex anatomy might prevent a correct device–deployment with a high–risk o residual shunt and/or device embolization. We describe our experience about alternative technique after a failed device closure attempt.

Methods

We reviewed six cases wherein the device was not able to close effectively the PFO. In these cases, alternative techniques and skills were adopted to close the PFO.

Results

From 2021 to 2023, 194 PFO were closed in the congenital catheterization laboratory of Monaldi Hospital (Naples). In the most of cases (188/194 pts, 96.9%) an effective device closure was obtained. However, in 6 cases (3.1%) the device failed to have a PFO closure. In these 6 patients, the PFO anatomy was characterized by: a severe hypertrophy of the septum secundum (2 cases, 33%), an aneurysmatic interatrial septum (3 cases, 50%), a long stiff tunnel (6 cases, 100%). In three cases a deviceless suture–mediated system (NoblestichTM) was effective to achieve a complete PFO closure; whereas, in two cases a combined approach (suture–mediated system followed by a device deployment) allowed to achieve a complete PFO closure. In a patient with Ebstein anomaly and significant cyanosis due to right–to–left PFO shunt, a partial PFO closure (with mild residual right–to–left shunt) was obtained after NoblestichTM deployment. In this setting, the partial PFO closure was effective to achieve a significant improvement of the patient’s arterial saturation and the procedure stopped without to complete the PFO closure with a device.

Conclusion

Trans–catheter device closure is often effective to achieve a complete PFO closure. However, in some circumstances, the device was unable to have an appropriate PFO closure. A suture–mediated system or a combined approach (suture–mediated system with concomitant device deployment) are effective to achieve the PFO closure in these complex scenarios.
FOLATES–RELATED AND BONE MARROW DISORDERS PROMOTE ATRIAL CARDIOMYOPATHY INPATIENTS AFFECTED BY PAROXYSMAL ATRIAL FIBRILLATION VIA BOTH EPCS AND ENDOTHELIAL DYSFUNCTION
Authors: Sgarra L , Grimaldi M , Caccavo V , Troisi F , Katsouras G , De Santis V , Potenza A , Montagnani M
Published: May 2024

Background

Atrial Cardiomyopathy (AC) has been recently postulated to explain those embolic strokes not due to atrial fibrillation (AF) and paradoxical embolism. Pathogenic mechanisms underlying AC are still largely unknown. Folate cycle disorders (FD) are a yet underrated pro–thrombotic dysmetabolism. FD could hinder both endothelial and circulating endothelial progenitor cell (EPCs) functioning, therefore providing one–shot explanation to both atrial fibrosis and endothelial dysfunction (ED).

Purpose

This study aims to enquire for the hypothesis that: 1) atrial fibrosis (AFib) would relate to FD (intended as both: a)MTHFR C677T inherited mutations and b)bone–marrow function disorders, here referring to erythropoiesis diversions) and 2) AF patients would show dysfunctional EPCs.

Methods

We studied 59 consecutive patients admitted to the cardiology Unit of the General Hospital“F.Miulli”, with preserved EF, subjected to AF ablation. AFib was quantified in term of percentage of bipolar peak–to–peak voltage points below 0,5mV with respect to the wholeness of picked points. Blood count cell was evaluated at the admission. MTHFR C677T genotypes and serum folate were assessed. EPCs isolation and characterization were performed by cytometry analysis (CD45, CD34, CD133, VEGFR2 and KDR). EPCs functional wound healing assay was performed to determine the percentage of EPCs able to "fix the wound” and compared with matched–controls.

Results

Baseline characteristics did not differ between Sample and Control groups (Fig. 1 – Left Table). % of Afib significantly differs between C677T MTHFR homozigosis patients (n=15) with respect to non–C677TMTHFR homozygosis patients (n=44) (Fig.1 – Right graph. – p < 0,02). Once univariate analysis was performed, subsequent multivariate analysis highlight highest fit, once merged RBC, RDW–SD and folates values were inputed (Fig.2 – superior graph. – R2=0,39;p=0,0001). Either RBC, RDW–SD and folates coefficient reached significance (p < 0,0001; p < 0,01; p < 0,05 respectively). Number of EPCs signifi cantly differs between AF patients and matched controls (Fig 2 – inferior graph. –p < 0,001).

Conclusions

Our findings support the hypothesis that genetically determined folates dysmetabolism (MTHFR dysfunction) promotes AFib via a complex cardiac–bone marrow networking involving circulatingEPCs and unraveled by erythropoiesis diversions. Such results suggest a pathogenic role of folate cycle disorders in the AC development.
HEART FAILURE WITH RELAPSING ATRIAL FIBRILLATION: BELOW THE SURFACE
Authors: Trifirò S , Ghiadoni L
Published: May 2024

Advances in pharmacologic and device therapy have greatly improved prognosis of patients with HFrEF. However, the typical clinical course is still characterized by recurring symptoms, worsening functional status and risk of frequent hospitalizations. A 72–years–old male patient with arterial hypertension, poorly controlled T2DM, TIA and chronic kidney disease presented to Cardiology service in 2018 with dyspnoea on effort and first evidence of EF 35% at echocardiography. He was admitted for elective coronary angiography, which demonstrated limited coronary heart disease of circumflex artery and its first marginal branch, treated by PTCA and stenting. CMR confirmed severe LV dysfunction, but also revealed extensive fibrotic areas with ischaemic and non–ischaemic patterns beyond revascularized regions. With such evidences, HF treatments were intensified, with titration of disease– modifying therapies and DOAC was added for asymptomatic paroxysmal AF. CRT–D was implanted for QRS of 160 msec, which was narrowed to 130 msec. Nevertheless, in one–year time the patient presented worsening of symptoms with several hospital admissions for acute HF and AF with fast rate. A switch to rhythm–control strategy was hence chosen. DCCV was performed, after an initial deferral for thrombosis of LAA due to poor adherence to DOAC. However, three–days after DCCV, the patient presented again to emergency services for dyspnoea, left upper flank pain and AF with fast rate. He was admitted to Acute Medicine Unit and treated with high flow O2, iv Furosemide and Digoxin, analgesics. CT chest and abdomen with contrast was performed in the suspicion of systemic venous thromboembolism for persistent type 1 respiratory failure, raised D–dimer and elevated liver function tests, despite appropriate anticoagulation. CT revealed an unexpected left superior pulmonary vein thrombosis, splenic and small left renal infarcts. The patient was discharged after recovery on subcutaneous heparin. At 15–day review, the patient was in stable conditions and awaiting completion of coagulation screening tests. This case study addresses some important aspects in the care of HF. An accurate assessment of HF aetiology and recurrent triggers, a timely planning of pharmacologic and device treatments, alongside with management of co–morbidities, therapeutic adherence and appropriate anticoagulation, can provide the clinician powerful tools to accomplish the difficult task of managing HF below the surface.
USE OF DAPAGLIFLOZIN FOR HEART FAILURE WITH REDUCED EJECTION FRACTION IN ITALIAN CLINICAL PRACTICE (EVOLUTION–HF ITALY): INTERIM ANALYSIS AT 6 MONTHS OF FOLLOW–UP
Authors: Orso F , Carugo S , Ameri P , Di Lenarda A , Iacoviello M , Indolfi C , Mortara A , Perrone Filardi P , Ungar A , Volpe M , Volterrani M , Granelli V , Ceracchi M , Pluchinotta F , Mastromauro F , Merlo A , Cosentino N , Gnesi M , Metra M , Rosano G
Published: May 2024

Background

Dapagliflozin is a sodium–glucose cotransporter–2 inhibitor (SGLT2i) approved for the treatment of Heart Failure (HF); however, real–world data on the use of dapagliflozin in the setting of HF with reduced Ejection Fraction (HFrEF) are scarce. EVOLUTION–HF Italy is part of a wider initiative aimed at filling these gaps with Real–World Evidence studies in 13 European countries.

Aims

The primary aim of the study is to describe characteristics of patients starting dapagliflozin for HFrEF and treatment patterns including discontinuation of dapagliflozin. Patient Reported Outcomes (PROs) are investigated as secondary aims, including Kansas City Cardiomyopathy Questionnaire (KCCQ), Medication Adherence Report Scale (MARS–5), and 6–Minutes Walking Test (6MWT). This abstract reports interim analysis (IA) results after 6 months of follow–up.

Methods

EVOLUTION–HF is a descriptive, observational, longitudinal study, which enrolled patients ≥18 years of age initiating dapagliflozin according to the approved HFrEF label; those with previous SGLT2i treatment were excluded. The enrollment window was 14–45 days after dapagliflozin initiation, and follow–up lasts up to 1 year.

Results

256 participants (mean age 68.5±11.6 years, 75.8% males) were enrolled in 11 Italian sites between April 2022 and April 2023; baseline clinical characteristics are reported in Figure 1. On average, Left Ventricular Ejection Fraction (LVEF) was 31.9%. Most participants had HF in NYHA class II (69.1%) and with ischaemic aetiology (55.7%); 31.7% were hospitalised for HF in the previous year. Cardiovascular treatments at baseline are detailed in Figure 2: 66.4% of patients were treated according to guideline–directed medical therapy for HFrEF (ARNI or ARB or ACEi + BB + MRA + SGLT2i). Follow–up visits at Month 6 were completed by 99 patients at the time of the IA (Figure 3). At 6 months, when compared with baseline, NTproBNP values lower and clinical status (as assessed by KCCQ score) improved, with patients being highly adherent to HF therapies.

Conclusions

The interim analysis presented in this abstract indicates signs of clinical improvement 6 months after initiation of dapagliflozin. At study completion (April 2024), EVOLUTION–HF Italy will generate robust evidence on real–world use of dapagliflozin among Italian patients with HFrEF, including relevant information on treatment pattern, clinical parameters, and quality of life.
PSYCHOMETRIC PROPERTIES OF THE KCCQ–12 IN A EUROPEAN COHORT OF PATIENTS WITH HEART FAILURE
Authors: Iovino P , Dollaku H , Alvaro R , Pucciarelli G , Rasero L , Vellone E
Published: May 2024

Background

Despite medical advances, patients with heart failure continue to suffer from poor quality of life due to worsening symptoms and functional limitations. Therefore, it is important to understand the multidimensional facets of quality of life in these patients. The Kansas City Cardiomyopathy Questionnaire is a commonly used quality of life assessment tool worldwide. However, However, there is still a lack of knowledge about its psychometric properties.

Purpose

The aim of this study was to investigate the psychometric properties of the KCCQ–12 and its measurement invariance in a cohort of European patients with heart failure.

Methods

Participants (n=510, median age=72, IQR=18, 58% males) completed the KCCQ–12 alongside measures of clinical psychosocial severity. A confirmatory factor analysis was used to establish factorial validity; internal consistency was determined using the Omega coefficient and the model–based internal consistency coefficient. Zero–order correlations between the KCCQ–12 scores and clinical and psychosocial measures were performed to test convergent validity. Multigroup confirmatory factor analysis was conducted to test measurement invariance across patients with preserved vs reduced ejection fraction.

Results

Confirmatory factor analysis confirmed a four–factor solution, with the domains of physical limitations, symptom frequency, quality of life, and social interference. Internal consistency was excellent (Omega coefficients ranging from 0.83 and 0.90, and internal consistency index of 0.94). The KCCQ–12 scores significantly correlated with ejection fraction, New York Heart Association class, quality of life, anxiety, depression, symptom burden, and the KCCQ–23 Overall Summary score, which adequately supported the convergent validity of the KCCQ–12. Measurement invariance was confirmed at the partial scalar and strict level.

Conclusions

These findings support the validity and reliability of the KCCQ–12, both in patients with reduced and preserved ejection fraction. Hence, this version can be confidently used both in research and clinical practice to measure quality of life of heart failure patients.
THE CHALLENGING SCENARIO OF DYSPNEA IN THE ELDERLY: DUE MORE TO CONGESTION OR INFLAMMATION?
Authors: Cosmi D , Tarquini B , Mariottoni B , Cosmi F
Published: May 2024

Introduction

Elderly patients hospitalized due to acute heart failure often have a concomitant acute lung disease. Establishing the role of each disease in a clinical picture of acute cardiopulmonary syndrome can be challenging. A common thread of these diseases is inflammation; a hyperinflammatory response determines more serious symptoms and a worse prognosis.

Purpose

We evaluated the effectiveness of a treatment with dexamethasone in patients with acute cardiopulmonary syndrome and strong inflammatory response.

Materials and Methods

We evaluated 302 consecutive HFPEF (heart failure with preserved ejection fraction) patients ≥80 years of age, with concomitant symptoms attributable to acute bronchitis, pneumonia, or COPD exacerbation, hospitalized due to worsening dyspnoea, with an NT–proBNP ≥3,000 pg/ml, and a finding X–ray of lung congestion with or without a consolidation. Reactive C Protein (CRP) was measured. Patients with SARS–CoV–2, indication to corticosteroids for other clinical conditions or need for mechanical ventilation were excluded. The 112 patients with CRP>20 mg/dl were randomized into 2 groups: 56 patients were treated open–label with dexamethasone at a dose of 8 mg iv/day for a maximun of ten days, in addition to the usual therapies, while the same number of patients were treated with the usual therapy. In both groups antibiotics were administered based on procalcitonin guided protocl. Clinical recovery time, length of hospitalization, in–hospital mortality, need for a new hospitalization and mortality at one month were evaluated.

Results

The mean age of patients was 89±5 years in the dexamethasone group and 88±5 in the usual therapy group. The results are shown in Table 1. Patients treated with dexamethasone experienced a faster clinical recovery and a shorter length of hospitalization. No significant differences were found regarding either in–hospital mortality or need for rehospitalization and mortality at 30 days. Notably, PCT guided treatment led to an average reduction in duration of antibiotic therapy from 8 to 5 days.

Conclusions

Very elderly patients with acute cardiopulmonary syndrome and hyperinflammatory state have a favorable response to dexamethasone therapy added to the usual therapy in terms of clinical improvement and length of hospitalization. Our case history is small to evaluate a possible improvement in mortality. These findings need to be consolidated from double–blind randomized controlled trials.
SERUM OSMOLARITY ON ADMISSION ACUTE HEART FAILURE AND SHORT–TERM MORTALITY
Authors: Livrieri A , Scicchitano P , Pinto M , Abruzzese S , Tangorra M , Trotta F , Cannito A , Caldarola P , Massari F
Published: May 2024

Background

Serum osmolality has been reported to be infuenced by well–known prognostic factors such as arginine vasopressin, the renin–angiotensin–aldosterone system, and natriuretic peptides, which suggest that osmolality itself could be also associated with the prognosis of heart failure. However, previous studies in acute heart failure (AHF) reported conflicting results on the prognostic role of serum osmolality.

Methods

We conducted a retrospective cohort study in subjects hospitalized with AHF between 2022 and 2023 in order to determine the association between serum osmolality at admission and 90–days mortality using Cox proportional hazard and Kaplen–Meier models.

Results

The study group consisted of 166 AHF patients (male 51%), mean age of 80 ± 9 years) with serum osmolarity 282± 11 mOsm/L and 90–days mortality equal to 23%. At univariate analysis, osmolality was significantly associated with mortality (HR 0.96, 95% CI 0.94–0.96). The optimal cut–off values for mortality was <280 mOsm/L (AUC 0.61; VPV 33 VPN 84). After adjustment for sex, age, BNP, renal and left ventricular functions, osmolality remained significantly and independently associated with mortality (HR 0.97, 95% CI 0.95–0.99).

Conclusions

Lower levels of serum osmolality on admission were related to short–term mortality in patients with AHF, suggesting that this could help stratify the risk of early mortality.
A CASE OF PULMONARY HYPERTENSION ASSOCIATED WITH MYELOFIBROSIS: THERAPEUTICAL CHALLENGES FROM ACUTE TO CHRONIC SETTING
Authors: Bignami L , Picariello C , Diaferio A , Porcelli G , Deluca F , Marcantoni L , Maddalozzo A , Ribichini F , Zanon F
Published: May 2024

A 85–year–old female was transferred to our ICCU for acute heart failure from one of our spoke hospitals. The patient had a long history of chronic myelofibrosis, treated with fedratinib as a second–line agent after ruxolitinib failure. During a recent hospital admission, transthoracic echocardiography already showed signs of severe pulmonary hypertension (PH) with right ventricular (RV) dysfunction, so diuretic was started. On admission the patient presented showed consistent with acute on chronic kidney injury (serum Cr 3.2 mg/dl), stable anemia (Hb 9.2 mg/dl) and markedly elevated Nt–proBNP. A pulmonary CT–scan excluded acute pulmonary embolism and lung parenchymal alterations, with a clear dilation of main pulmonary artery. Transthoracic echocardiography (figure 1) confirmed precapillary PH phenotype diagnosis. Electrocardiogram (figure 2) showed sinus rhythm; incomplete RBBB, T wave inversion in V2 to V4. The patient was initially treated with high dose furosemide, low flow oxygen; but later she needed multiple cycles of inotropes, vasopressors and combined diuretic therapy (metolazone and acetazolamide) to stabilize the clinical setting. The patient also experienced episodes of paroxysmal high ventricular rate atrial flutter. After resolution of volume overload, a right heart catheterization was performed and findings were consistent with severe precapillary pulmonary hypertension: PA pressure 90/58/40 mmHg, normal PCWP, high PVR, mild cardiac index reduction. Due to critical clinical situation, Sildenafil 20 mg was started as an off–label therapy for PH (group 5). Subsequently, the patient experienced gradual but constant hemodynamic and clinical improvement and was discharged in NYHA class II. At 1 month control, patient was stable, echocardiogram revealed improvement in right ventricle dimension, systolic function and right atrial enlargement. At three months, patient is still in an intermediate risk class for PH, so we are evaluating a combination therapy (either endothelin receptor antagonist or prostanoids), taking into account anemia and thrombocytopenia. Take home message: PH can be a complication of hematological disorders as myelofibrosis, included in “mixed” forms (group 5) of PH. In our patient, after a challenging management for acute right heart failure, an off–label PDE–5 inhibitor stabilized the clinical scenario: more data are needed on PH drugs use in this setting where up to now therapeutic strategies are lacking.
HOW TO IMPLEMENT TELEMEDICINE IN A HEALTHCARE TRUST: THE "TEELEMEBII" STRATEGY
Authors: Rocca P , Marta B
Published: May 2024

In this abstract we describe the “TEELEMEBII" strategy adopted by Healthcare Trust Bergamo Est to allow Telemedicine‘s development and to encourage a new healthcare managment model (the results obtained in terms of telemedicine processes activated are riported in a dedicated abstract). The “TEELEMEBII" strategy is composed of 7 steps (Figure 1): T: Top–down The Strategic Management analyses the feasibility of the project. If successful, a Manager with technical skills in the field of telemedicine and managerial competencies is appointed. In some cases, it is possible to set up a small group of professionals. E: Experiences The Manager, or the working group, performs a mapping of existing telemedicine experiences in the company. E: Experts While analysing experiences, the Manager identifies the professionals who already have expertise in the telemedicine field. This phase aims to identify a multidisciplinary Team composed of physicians, nurses, clerks, IT–technicians, management engineer etc., that is proposed to the Strategic Management. LE: LEgitimacy The Strategic Management analyses the proposal and the Constitution of the Telemedicine Team is legitimized through a formal act with the appointment of a Coordinator, the members and the adoption of a regulation. The organizational model of the Team is of a matrix type (Figure 2). ME: MEthod Once established, the Team defines a working method, a common language and specific tools for the organization of activities. B: Bottom–up The Team meets health professionals, explaining the aims of telemedicine and showing fields of application. The Team welcomes proposals from professionals themselves, following a bottom–up logic. For each new emerging project, a Working Group is created (see Figure 2). Adopting the logic of process analysis, the group maps the ordinary process at first, useful to effectively design the activities in telemedicine. It is composed of a member of the Telemedicine Team, with the role of Manager, and professionals who are directly involved in the project to be activated. II: Implementation of the HybrId model The model presented is Hybrid: the Strategic Direction legitimizes the activity of the Telemedicine Team and the Working Groups, while from below the requests made by the Operational Units are evaluated by the Team, which periodically reports them to the Strategic Direction for approval. The Telemedicine Team Coordinator is the interface between the two levels.
CHANGES IN METABOLIC PROFILE, CARDIAC STRUCTURE AND FUNCTION FOLLOWING BARIATRIC SURGERY
Authors: Giofrè F , Trapanese V , Natale M , Melina M , Vatalaro C , Cosentino F , Sciacqua A , Armentaro G , Segura Garcia C , Currò G , Cloro C , Arturi F
Published: May 2024

Background

Obesity is associated with alterations in cardiac structure and haemodynamics leading to cardiovascular mortality and morbidity. It is associated with cardiac remodeling resulting in hypertrophy of the left ventricle (LV) with a predominantly concentric pattern. LV remodeling and fibrosis induce mechanical and electrical dysfunction of the myocardial tissue, an increase in cardiac output, an increase of myocardial workload and mean arterial pressure. Bariatric surgery has been proven to be the most effective long–term weight management treatment.

Objective

Aim of our study was to investigate the changes in both anthropometric and metabolic parameters and in cardiac structure and function after bariatric surgery.

Methods

Fourty six obese patients treated with bariatric surgery were enrolled. All the patients at baseline and at 6 and 12 months underwent a complete anthropometrical evaluation, laboratory determinations and echocardiogram evaluation. The insulin resistance has been assessed by HOMA–IR.

Results

As expected, an improvement in the anthropometric and metabolic profile was observed in all the patients treated with bariatric surgery. Six and 12 months after bariatric surgery, there were significant improvements in cardiovascular risk factors, including reduction in both total and LDL–cholesterol levels, systolic and diastolic blood pressure, serum uric acid levels, fasting glycemia and fasting insulin levels, glycated hemoglobin and HOMA–IR values. Similarly, the echocardiogram evaluation showed a significant reduction of the end–diastolic left ventricular volume (P<0.05 and P<0.005, respectively), a significant reduction of the end–systolic left ventricular volume (P=0.003 and P=0.005, respectively) and a significant reduction of interventricular septal thickness and posterior wall thickness. On the other hand, a significant increase in the Ejection Fraction (P<0.001 and P<0.001, respectively) and in the E/A Ratio (P<0.05 and P<0.05, respectively) after bariatric surgery had been observed. Left ventricular mass decreased significantly after bariatric surgery (P<0.001).

Conclusions

Our data showed an increase of the systol function, an increase of the left ventricular diastolic compliance and a reduction in subclinical cardiac organ damage. Therefore, significant weight loss obtained with bariatric surgery may lead to reverse cardiac remodeling, associated with beneficial effects on myocardial structure and systo-diastolic function.
CAROTID PLAQUES TREATED WITH BEMBEDOIC ACID: A 7% OF REDUCTION IN 6 MONTHS
Authors: Fazio G
Published: May 2024

Bempedoic acid were indicated to be able to reduce the hypercholesterolemia add on to statin and ezetimibe therapy. We investigated the effect of the same treatment in carotid atherosclerosis after a follow up of 6 months.

Methods

A continuous series of 22 patients were enrolled in a prospective analysis. All patients started a therapy with bempedoic acid for hypercholesterolemia add on to rosuvastatin or atorvastatin plus ezetimibe therapy for an insufficient reduction of cholesterol. The mean of LDL dosage was 101 mg/dl. All patients were high or very high–risk patient. In all patients the bempedoic acid was added to optimal medical therapy without new symptoms in ambulatory. The recruitment period was long 1 month. After the recruitment the patient was follow for other 6 month. At the start and at the end of the follow–up we evaluated. The atherosclerosis was evaluated in an ultrasound doppler of carotids The data was collect in excel and analysed by the Q–R–Calc program.

Results

The mean age of patients was 68 age, 44% female. 33% was diabetic patients. Hypertension was present in 73%, hypercholesterolemia in 100%. 11% was smokers. 94% were Caucasian patients. The mean of Weight was 75 kg at the first control. The mean height 174 cm. All patients performed a cardiological control in which the medical doctor prescribed bempedoic acid. 100% of patients assumed a statin, 100% ezetimibe. After 6 month the mean LDL was 78 mg/dl. The doppler showed plaques in 89% of patients. The mean plaques occluded the lumen for 37% before the bempedoic acid and 30% after with a reduction of 7% (p:0,03%) In 50% of patients, we revel a reduction of atherosclerosis (in this subgroup the reduction was 11%).

Conclusion

The bempedoic acid add on to statin therapy reduced the carotid. atherosclerosis for 7% in a continuous series of 23 patients.
FRUCTOSE EXACERBATES ANTHRACYCLINE AND HER–2 BLOCKING AGENT MEDIATED CARDIOTOXICITY THROUGH NLRP3 AND MYD88 MEDIATED PATHWAYS: NEW ROLES OF SWEETENERS IN CARDIO–ONCOLOGY
Authors: Quagliariello V , Iovine M , Giacobbe I , Giordano V , Arianna R , Barbato M , Izzo F , Maurea F , Bisceglia I , Inno A , Canale M , Maurea N
Published: May 2024

Background

Combinatorial therapy based on anthracyclines and HER–2 blocking agents increases the risk of cardiomyopathy in women with breast cancer. Fructose is a monosaccharide associated with high risk of diabetes, non–alcoholic fatty liver disease, atherosclerosis and visceral obesity. A high fructose diet is a potential cardiometabolic risk factor and may increase cardiac risk in women with breast cancer treated with cardiotoxic drugs.

Purpose

In this study, we highlighted the role of sweeteners fructose in the worsening of cardiotoxicity induced by combinatorial therapy anthracycline–HER2–blocking agents.

Methods

Human cardiomyocytes were pre–exposed with doxorubicin combined to trastuzumab (at 300 and 1000 nM) for 48 and 72h alone or combined to fructose at 0.25, 1 and 2.5 mM. After the incubation period, we performed the following tests: determination of cell viability, through mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4–hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro–inflammatory studied were also performed (activation of NLRP3 inflammasome; expression of peroxisome proliferator–activated receptor–α; transcriptional activation of p65/NF–κB and secretion of cytokines involved in cardiotoxicity (Interleukins 1β, 8, 6, CXCL–12).

Results

High fructose increases significantly cell mortality of cardiomyocytes exposed to doxorubicin and trastuzumab thorugh the activation of NLRP–3 and Myd–88 expression. Intracellular Ca++ levels were also increased of 4 times compared to non–fructose exposed cardiomyocytes; MDA and 4–HNA levels were increased of 48,3 and 51,2 % compared to non–fructose exposed cells (p<0.001). Fructose increases IL–1, IL–6 and CXCL–12 expression in cardiomyocytes in a concentration dependent manner, compard to doxorubicin–trastuzumab group (p<0.05).

Conclusion

Data of the present study indicate that fructose induces a pro–inflammatory phenotype in human cardiac cells exposed to anticancer cardiotoxic drugs, providing even more data on the harmful role of fructose as a key player of cardiotoxic phenomena.
FIBROSIS QUANTIFICATION IN RISK STRATIFICATION OF HYPERTROPHIC CARDIOMYOPATHY
Authors: Procopio M , Leo I , Borguezan Daros C , Bisaccia G , Licordari R
Published: May 2024

Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is the gold–standard modality to assess myocardial scar. The extent of myocardial fibrosis is proportional to the risk of adverse outcomes and LGE is ≥15% of LV mass is one of the criteria for prophylactic implantable cardioverted defibrillator. Currently, there are various methods of quantifying the size of LGE which are unlikely to be interchangeable; data about the most reproducible one in Hypertrophic Cardiomyopathy (HCM) are sparse. The aim of our study was to compare the intra–observer and inter–observer reproducibility of 5 LGE quantification techniques in patients with HCM. 100 patients with HCM (apical pattern, n = 34; non–apical patterns, n = 66) undergoing CMR were assessed. A European Association of Cardiovascular Imaging (EACVI) level III operator quantified LGE using 5 techniques: 2SD, 5SD, 6SD, full width half maximum (FWHM) and manual thresholding methods and repeated the same measurements after 1 month, in order to assess intra–observer variability. The analysis was also performed by one EACVI level I operator and one EACVI level III operator in order to assess inter–observer variability. LGE volume was calculated in all patients and in patients with apical HCM and intra–observer and inter–observer variability were assessed. Assessment of LGE volume was highly reproducible when measured by two expert operators with all methods apart from the 2SD method, in which the size of LGE was greater. There was high intra–observer agreement with all methods, the manual one being that with the best intra–observer reproducibility (ICC 0.97 (95% CI 0.95–0.98). Both the FWHM (ICC 0.93, 0.87–0.96) and the 6SD methods (ICC 0.93, 0.88–0.96) yielded the highest inter–observer reproducibility between the expert operators. Inter–observer reproducibility between the EACVI level III and the EACVI level I operators was poor across quantification methods. Intra–observer and inter–observer reproducibility were high with manual and FWHM methods in the apical variant. In patients with HCM, LGE quantification techniques are not interchangeable and reproducibility depends on the method and operator expertise. The FWHM and the 6SD methods were the most reproducible methods in all patients; the first one was also the most reproducible method in apical HCM alongside the manual method. Whether various LGE quantification methods have different diagnostic and prognostic impact should be further investigated.
EFFECT OF ANTI–PCSK9 ANTIBODIES ON ARTERY STRUCTURE AND FUNCTION: THE NIGUARDA HOSPITAL COHORT
Authors: Maloberti A , Toscani G , Busti A , Tognola C , Intravaia R , De Censi L , Galasso M , Daus F , Giani V , Gualini E , Garofani I , Riccio A , Biolcati M , Fabbri S , Algeri M , Merlini P , Giannattasio C
Published: May 2024

Background

PCSK9 inhibitors antibodies (PCSK9–i) are a valid option to reduce LDL cholesterol in patients who failed to reach therapeutic target with maximized lipid–lowering therapies or in patient with statins intolerances. These antibodies reduce the frequency of new cardiovascular events, however if this effect is due only to LDL reduction or also to an improvement in arterial function and structure is yet to be proved. Our study aim was to evaluate aortic stiffness (Pulse Wave Velocity – PWV), carotid’s Intima–Media Thickness (IMT) and endothelial function (brachial Flow Mediated Dilatation – FMD) in patients treated with Alirocumab and Evolocumab.

Methods

This is a monocentric prospective longitudinal study on patients who received PCSK9–i administrations at the Niguarda Hospital’s cardiovascular rehabilitation and prevention unit. They underwent 3 evaluations of PWV, FMD and IMT (T0 the same day of the first injection, T1 after 6 months and T2 after 12 months of therapy).

Results

39 patients concluded the 12 months period. The group average age is 66.8 ± 7.6 years, most of them were male (64.1%). LDL cholesterol average levels were significantly reduced by the therapy (128.3 ± 27.7 vs 44.7 ± 29.3 mg/dL, p<0.001), however, there were no significant changes in PWV (10.2 ± 3.0 vs 10.6 ± 2.5 m/s, p=0.404), FMD (8.6 ± 7.0 vs 8.9 ± 7.4 %, p=0.560) and IMT (768.7 ± 175.4 vs 733.5 ± 147.2 µm, p=0.270) values.

Conclusions

It was not possible to prove a significant effect of PCSK9–i on vascular properties, however, the stability of these indexes may suggest a deceleration of the atherosclerotic disease which it could have worsen in this population, especially considering the risk factors of our patients.
AN OUT OF HOSPITAL CARDIAC ARREST SURVIVOR WITH PRESUMED EMBOLIC MYOCARDIAL INFARCTION: ROLE OF MULTI–MODALITY IMAGING
Authors: Campobasso N
Published: May 2024

Background

Myocardial infarction with non–obstructive coronary arteries (MINOCA) refers to a puzzling clinical entity that is characterized by symptoms suggestive of acute coronary syndrome, demonstrates troponin elevation with inconclusive coronary angiogram. The underlying pathophysiologic mechanisms include atherosclerotic cause or non–atherosclerotic causes, such as coronary dissection or coronary embolus. A standardized approach that includes multimodality imaging is necessary to determine underlying aetiology and direct appropriate treatment.

Case Summary

A 57–year–old male was admitted to our hospital after experiencing cardiac arrest after physical exercise (swimming) treated immediately with cardiac pulmonary resuscitation and two defibrillator–delivered electrical shocks for shockable rhythm before return of spontaneous circulation. Relevant abnormal bloods included a hs–Troponin I elevation. Invasive coronary angiography demonstrated non–obstructed coronary arteries. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated akinesia and an area of subendocardic late gadolinium enhancement in the inferior–lateral wall. This pattern was in keeping with an ischaemic cause, as a recent embolic myocardial infarction. Further investigations, including contrast bubble echocardiogram, were performed in order to identify a cause and source of the embolic infarction and led to the diagnosis of tunnel–like patent foramen ovale with right to left shunting, then confirmed on trans–oesophageal echocardiogram. The patient was treated as myocardial infarction most likely due to embolic phenomena in the presence of a PFO. Therefore, a transvenous ICD was implanted for secondary prevention and the patient underwent percutaneous closure of the PFO.

Discussion and Conclusion

MINOCA can occur in 5–15% of all acute coronary syndromes and represents a working diagnosis. It is important to identify the underlying aetiology of their presentation to appropriately manage them. In particular, where cardiac MRI demonstraded LGE areas ichaemic patterns, myocardial infarction due to secondary embolism should be considered and the next step in clinical management is to identify potential sources of emboli performing further assessments. Multi–modality imaging with cardiac MRI and echocardiogram (transthoracic, contrast bubble and trans–oesophageal) is important in correctly identifying any source of emboli and the diagnosis of any intra–cardiac shunt.
SPONTANEOUS CORONARY ARTERY DISSECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION IN A MIDDLE–AGED MAN: WHAT YOU WOULDN’T EXPECT
Authors: Roma A , Tontodonato M , Golia E , Coletta S , Ianniciello A , Mercone G , Limatola M , Rucco M , Pariggiano I , Calabrò P
Published: May 2024

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute non atherothrombotic coronary syndrome. It predominantly affects female sex. Both diagnosis and therapeutic decision–making are challenging due to its unpredictable course and recurrence rate. We describe a case of a 50y old man with chest pain(CP), referred to our cathlab for primary percutaneous coronary intervention(PCI) through the Emergency Medical Service, with an anterior ST–segment elevation myocardial infarction(STEMI) detected on ECG. A type 2b SCAD starting from the Left Main(LM) involving proximal Left Anterior Descending (LAD) artery and circumflex artery(Cx) was detected. PCI with Drug–Eluting Stent(DES) implantation on LM and proximal LAD was deemed necessary due to ongoing ischemia and LM involvement. IntraVascular UltraSound(IVUS) on LAD and LM showed good stent deployment and confirmed a non–obstructive SCAD of Cx,left untreated. Patient was started with dual antiplatelet therapy and after 5 days in our cardiac intensive care unit(ICU) he was moved to cardiology unit. Few hours later he had recurrence of CP and an Inferior STEMI was detected. A progression of SCAD of the Cx with critical flow limitation in its proximal tract was found at coronary angiography. Then PCI with DES release was performed using a T and Small Protrusion technique on LM–LAD–Cx and cutting–balloon was used to fenestrate intima with a successful drainage of the intramural hematoma (IH) in the distal portion. Our case represents an uncommon presentation of SCAD, as STEMI involving a male patient. In a recent large cohort of SCAD patients only 10% were men. Male SCAD patients are younger, have less frequently prior MI, depression, emotional stress triggers and are less likely to have associated fibromuscular dysplasia. More often they report physical stress triggers and a more subtle clinical presentation. Conservative management remains the mainstay of treatment in the absence of ongoing ischemia, hemodynamic instability, or LM involvement. When PCI is indicated, it is often associated with an unfavorable course (difficult wiring of the lesion, propagation, and potential milking of the IH along the vessel).Cutting balloon technique has been increasingly used in the interventional approach to SCAD. Several questions remain unanswered about appropriate antithrombotic regimen, duration of ICU observation and the opportunity to perform coronary imaging to review the disease prior to a safe discharge.
NON–INVASIVE ASSESSMENT OF CARDIAC HEMODYNAMICS BY BIO–IMPEDANCE IN A PATIENT WITH HEART FAILURE AND EXCELLENT RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY
Authors: Giannotti Santoro M , Puccioni E , Pro F , Lapira F , Talini E , Vecchi A , Pasanisi E
Published: May 2024

Patient Presentation

We present a 78–year–old patient admitted to our Cardiology Unit for chronic heart failure with severe left ventricular dysfunction, atrial fibrillation, and recent percutaneous aortic valve replacement and an NYHA IIb class. His therapy was fully optimized. The patient was evaluated during the recovery period. An echocardiogram confirmed severe left ventricular dysfunction (LVEF = 30%). The ECG demonstrated atrial fibrillation with episodes of severe bradycardia and tachycardia. The QRS duration was 145 msec.

Diagnosis and Management

Cardiac pacing implantation was indicated for heart rate stabilization. To assess the patient‘s clinical status and optimize therapy, we performed a non–invasive bio–impedance Cardiac hemodynamic evaluation using the NICaS device before the implantation (Figure 1). This device provides accurate(1,2,3) information on cardiovascular, respiratory, and fluid parameters in a non–invasive and reproducible manner (Figure 2). The analysis revealed a low stroke volume (47 ml), low stroke index (26.0 ml/m2), low cardiac output (3.34 L/min), low cardiac index (1.85 L/min/m2), high peripheral resistance (2344 dyn*s/cm5), and high body water (38.0 kg) (see Figure 3). The patient underwent cardiac resynchronization therapy and defibrillator (CRTD) implantation. The patient was discharged with the same therapy as admission, except for the addition of a low dose of digitalis to improve rate control. Follow–Up: The first follow–up was performed after 3 months. Electronic control revealed regular device function, with ventricular pacing of 99%. The patient showed an improvement in dyspnea, with a NYHA class of I. The echocardiogram showed a significant improvement in the left ventricular ejection fraction (50%). We performed a repeat analysis with NICaS, demonstrating improvement in all hemodynamic parameters (Figure 3): stroke volume 60 ml (+13 ml), stroke index 35.5 ml/m2 (+9.5), cardiac output 5.11 L/min (+1.77), cardiac index 3.02 L/min/m2 (+1.17), peripheral resistance 1236 dyn*s/cm5 (–1108).

Conclusion

The non–invasive bioimpedance–based system – Nicas, allows for the accurate assessment and monitoring of the patient‘s hemodynamics. In our patient, the implantation of a CRTD has led to a significant improvement in clinical status, left ventricular ejection fraction, and all hemodynamic parameters, clearly demonstrated through an easy–to–use office non–invasive modality.
CARDIOGENIC SHOCK IN A PATIENT WITH SEVERE AORTIC VALVE STENOSIS AND MULTIVESSEL CORONARY DISEASE: ADVANCED THERAPEUTIC STRATEGIES
Authors: Agostini N , Guida G , Falcone S , Musazzi A , Castiglioni B
Published: May 2024

We describe a case of a 58 years old man. He was referred to emergency room for episodes of vomiting and epigastric pain for about a week. Upon admission he was confused with systolic–diastolic blood pressure values ​​70/40 mmHg, heart rate 120 bpm, sinus rhythm. pO2 was 80 mmHg and SO2 in air 97%. Lactate values 10, blood sugar > 300 mg/dl. The electrocardiogram showed sinus tachycardia with the results of antero–septal necrosis and incomplete left bundle branch block. The fast echocardiogram showed a dilated left ventricle with severe depression of the ejection fraction (EF about 10–15%), severe low flow–low gradient aortic valve stenosis (AVA bidimensional was approximately 0.9 cm²), severe mitral valve insufficiency due to a dual mechanism. The dimension of Inferior vena cava was 1.5 cm, collapsible. There was thrombotic stratification in the apex of the left ventricle and VA coupling was 2. The patient was admitted to the ICU with stage C cardiogenic shock according to SCAI classification. We found a value of PVC 3 mmHg. After fluide challenge there was an increase in blood pressure values to 100/60 mmHg. Noradrenaline vasopressor was started and subsequently a low dose of adrenaline. Blood pressure values maintained around 90/60 mmHg and undergo a sudden drop after increasing the dosage of the vasopressor. Diuresis was approximately 50 ml/h, lactates clear completely after approximately 4 hours. After 6 hours, due to a new sudden reduction in blood pressure, the patient was referred for IABP and coronary angiography control. In the context of multivessel coronary artery disease and cardiogenic shock he was therefore a candidate for urgent cardiac surgery of aortic valve replacement, by–pass and mitral anulovalvuloplasty. This case gave us the opportunity to analyze how to proceed in such a critical conditions with the below conclusions: a) the choice of vasopressors and inotropes is limited in case of severe aortic valve stenosis b) the presence of left ventricular intracavitary thrombosis limits the choice of ventricular assistance system c) in case of cardiogenic shock and severe aortic valve stenosis the patient must be a candidate for valve replacement surgery as soon as possible.