bluuebunny/crossref_metadata_2025 huggingface dataset:
P223 MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY (MINS): A RETROSPECTIVE ANALISYS OF OUR LAST TWO YEARS OF WORK
Authors: Tufano N
Published: May 2023

Introduction

Myocardial injury is defined as an elevation of troponin due to ischemic causes, with or without clinical signs. In the myocardial injury after noncardiac surgery (MINS), troponin elevation usually occurs without signs of ischemia. The etiology of this perioperative pathology, is in most cases based on a mismatch between oxigen supply and demand. Recently, expert consensus and european guidelines suggest the implementation of diagnostic tools for perioperatory screening of patients at risk of MINS. Aims: to evaluate the clinical course of patients who have experienced MINS in the last two years in our hospital, in order to identity the lacks of our diagnostic and terapeutic tools.

Methods

we retrospectively evaluated 122 consecutive patients who experienced MINS in the perioperative period from january 2021 to december 2022. For each patient, we have collected data regarding clinical, strumental and laboratoristics characteristics, such as biomarkers, risk factors and type/urgency of surgery.

Results

more than half of patients with MINS (54%) had a low patient–related risk, whereas only 17% of them had a high risk. Regarding the surgery–related risk, only a third of patients (33.6%) had high risk related to the type or urgency of surgery, whereas two thirds of them (66.3%) had low or intermediate risk related to surgery. Combining these risks, resulted that only a minority of patients (5%) had both patient related and surgery–related risk, whereas less than a half (42%) of patients had a high patient related or high surgery related risk. Instead, most of the patients (68%) had low patient–related risk or low surgery related risk. All patients had a pre–operative electrocardiogram. More than a half (54,9%) of patients had a pre–operative transthoracic echocardiography. Large majority (95,6%) of patients had a pre–operative troponin.

Conclusion

careful assessment with patient–related and surgery–related cross risk, such as adoption of common diagnostic tools did not allow us to adopt an effective peri–operative screening for patients at risk of MINS.
P226 A STRANGE CASE OF ISOLATED RIGHT VENTRICULAR DYSFUNCTION
Authors: Tadiello E , Bilato C
Published: May 2023

Introduction

In Europe, approximately 29% of the population aged between 15 and 64 have used illicit drugs. Italy is at the top of this ranking. Description 45–year–old female, no previous cardiology events. She enters the Emergency Department for typical chest pain following alcohol and cocaine abuse. EKG (see figure 1) detects sinus tachycardia and mild non–specific changes in ventricular repolarization. Blood tests reveal an increase in Troponin T levels (305 ng/L, NV < 14 ng/L, then decreased with subsequent measurements) and D–dimer (902 mg/mL, NV < 500 mg/mL). Echocardiography reveals a non–dilated right ventricle with severe systolic dysfunction (TAPSE 11 mm). No signs of pulmonary hypertension but a dilated and hypocollapsing inferior vena cava is noted. Abnormal motion of the interventricular septum with systolic d–shape is present (see figure 2). Left ventricle appears normal. Pulmonary angio–Tc was negative for embolic phenomena and coronary angiography detects no lesions on coronary arteries. At discharge, right ventricular systolic dysfunction and septal d–shape were completely regressed (see Figure 3).

Discussion

Cocaine is a strong systemic adrenergic agonist, which can cause vasospasm of small arterioles of the cardiac microcirculation with possible formation of intracoronary thrombi. Peculiarity of this case is the selective and reversible involvement of the right ventricle, an extremely rare presentation as evidenced by the almost absence of scientific literature on the subject (there is only a similar case report published on the American Journal of Emergency Medicine in 2015). Reversible damage from vasospasm and/or intracoronary thrombosis localized to the marginal branch of the right coronary artery, induced by cocaine use, is conceivable. D–shape of the interventricular septum associated with right ventricular dilatation is likely caused by acute right ventricular failure causing volume overload in the right sections. Take home message Drugs abuse is a widespread problem among the population. Cocaine intake is associated with important adverse cardiovascular effects. A rare presentation can be isolated right ventricular ischemia associated with acute right heart failure.
P227 THE UNEXPECTED CONSEQUENCES OF A 30 METERS FALL
Authors: Palazzini M , Sormani P , Ammirati E , Bossi I , Soriano F , Colombo P , Gentile P , Garascia A , Oliva F , Oreglia J
Published: May 2023

Introduction

Acute myocardial infarction (AMI) is a rare but often lethal consequence of a blunt cardiac trauma. Falls leading to coronary artery dissections are rare, thus underlining the lack of experience in their management. Case report description: a 55–year–old male patient with type 2 diabetes and no relevant past medical history was admitted to our hospital facility after a 30–meter fall during rock–climbing. On arrival, he was hemodynamically and neurologically stable. He underwent a full trauma evaluation: multiple facial bones fractures were diagnosed. An electrocardiogram revealed a QS morphology of the QRS and ST elevation in the precordial lead from V1 to V3 with reciprocal ST depression in the inferior leads. High sensitivity (hs) Troponin T was slightly elevated (49 ng/L, normal values <14 ng/L). A cardiac ultrasound documented a left ventricular dysfunction (LVEF 40%) with akinesia of mid–apical antero–septal and anterior walls. Biomarkers further increased with Troponin reaching 199 ng/L and creatinine phosphokinase–MB 24,7 ug/L (normal value <5 ug/L). Coronary angiography demonstrated proximal occlusion of the left anterior descending (LAD) coronary artery with an image consistent with traumatic coronary artery dissection, confirmed by a cardiac CT scan showing the proximal occlusion of the LAD with retrograde perfusion of its downstream portion. Considering the left ventricular dysfunction, the elevation of cardiac biomarkers (peak CK–MB 187 ug/L, peak hs troponin T 5400 ng/L) and the acceptable hemorrhagic risk in spite of the need for facial surgery, a coronary angioplasty was performed. A dual antiplatlet therapy with acetilsalicidic acid and clopidogrel began. Nine days later the patient underwent the maxillo–facial surgery: clopidogrel was stopped provisionally and a bridge strategy using tirofiban was chosen. Post–operatory was uneventful. A full recovery of cardiac function was assessed after one year (LVEF of 55%).

Discussion

Few cases of blunt cardiac trauma with coronary artery dissections have been reported and treated successfully, with the LAD being the most frequently involved vessel (76%). If urgent non–cardiac surgery can be postponed, a percutaneus revascularization eventually followed by tirofiban as bridge therapy can be suggested, carefully considering the risk of stent thrombosis and the hemorrhagic risk conveyed by the trauma itself.
P228 MINOCA/TYPE 2 IMA: WHEN WE HAVE TO EXIT FROM STANDARD DIAGNOSTIC FLOW–CHART
Authors: Cante L , Bassanelli G , Lenatti L , Bianchi A , Farina A
Published: May 2023

MINOCA is an Acute Myocardial Infarction (AMI), defined on the basis of Fouth Universal Definition, in absence of epicardial coronaries stenosis >50%. This definition is very broad, including typical mechanisms of type 1 and type 2 AMI. Diagnostic flow–chart recommended by ESC and AHA includes imaging tests, coronary physiology and cardiac MRI. Here we present the case of 71–year–old man who underwent aortic bioprosthesis implantation (Trifecta n.25) and atrial septal defect (ASD) closure in 2019. In December 2022, the patient arrived in the Emergency Department (ED) with anterior STEMI, apical akinesia and angiographic evidence of distal left anterior descending (LAD) artery occlusion. Whereas angiographic feature was compatible with an embolic phenomenon, we performed in the 1st day transesophageal echocardiogram (TEE) that showed a voluminous, rounded mass (maximum diameter 1.2 cm) isoechoic, mobile, adherent to the aortic side of left coronary cusp. Despite the absence of clinical features of an acute infection (apyrexia and negative CRP/PCT) and the atypical mass localization for endocarditis, we took 3 sets of blood cultures and we required an immediate cardiac surgical consultation. In consideration of high estimated embolic risk, patient underwent urgent cardiac surgery with aortic bioprosthesis explantation, annular malacia (probable abscess) explantation and Carpentier n.23 biological prosthesis implant. Histological examination of the removed mass showed exudative material with intense acute inflammation. According to counseling of infectious disease specialist, we started an empiric antibiotic therapy with intravenous vancomycin and gentamicin. Given persistence of 3rd degree atrioventrocular block, patient underwent definitive pacemaker implantation. Cultures on blood and on explanted valve were negative and patient was discharged without further complications after 4 weeks of antibiotic therapy. In our opinion, this clinical case underlines the importance of an individualized diagnostic–therapeutic approach in patients with MINOCA, also considering rare etiologies and involving various medical specialist (clinical cardiologist, echocardiographer, surgeon).
P236 THE EARLY USE OF A PARTICULAR HEMODIALYTIC FILTER DURING SCA–STEMI COMPLICATED BY MULTIORGAN FAILURE
Authors: Dell'Aversana S , Ambrosio A , Lieto A , Golia B
Published: May 2023

A 66–year–old man, hypertensive, obese and avid smoker, in apparent good health until, due to the onset of typical chest pain associated with vomiting and algid sweating, he went to the PS where a diagnosis of acute coronary syndrome with ST–segment elevation was made. As per the guidelines, antithrombotic therapy was administered and transfer to the HUB center was arranged to perform urgent coronarography; thrombotic occlusion of the I M.O. branch was revealed and treated with angioplasty and drug–eluting stent implantation. On admission to the NICU, the patient presented hypotensive, tachycardic and with repeated episodes of rectorrhagia and vomiting intermingled with blood. Cardiac echocolorDoppler showed mild reduction in global kinesthesia (FE 45%) with hypo–akinesis of the inferior and lateral walls, circumferential pericardial effusion that was not hemodynamically significant, dilated and fixed inferior vena cava with mild increase in systolic pulmonary artery pressure. On suspicion of gastro–intestinal ischemic damage, supported by the clinical and laboratory findings (creatinine increase with anuria for more than 12 hours and severe signs of hepato–pancreatic insufficiency) CT scan with mdc was performed showing hepato–renal hypoperfusion. Therefore, on suspicion of multi–organ dysfunction syndrome, renal replacement therapy was started in CVVHD mode with filter for clearance of medium molecular weight molecules (cut–off 40 kDa) to reduce possible cytokine and myoglobin damage. Already from the first hours of treatment, there was a rapid and exponential improvement in clinical–laboratory parameters with resumption of diuresis. During hospitalization, two episodes of paroxysmal atrial fibrillation treated with electrical and pharmacological cardioversion were detected; given a CHA2DS2VASc score 3 and a HAS–BLED score 2, triple antithrombotic therapy was initiated. At follow–up, there was improvement in echocardiographic parameters (minimal residual pericardial dislodgement and inferior vena cava of normal caliber and respiratory collapsibility) and clinical–laboratory.
P240 PREOPERATIVE OPTIMISATION FOR A PATIENT WITH HEART FAILURE UNDERGOING MAJOR NON–CARDIAC SURGERY: AN EXAMPLE OF COLLABORATION BETWEEN THE MULTIMODAL PREHABILITATION CENTRE AND THE HEART FAILURE CLINIC AT CAREGGI UNIVERSITY HOSPITAL
Authors: Testa G , Livi F , Foti L , Verga F , Salucci C , D‘Errico G , Perini E , Fiorindi C , Cianchi F , Ficari F , Scaringi S , Tognozzi C , Amatucci S , Marmorale S , Ungar A , Romagnoli S , Orso F , Baldasseroni S , Baldini G
Published: May 2023

Introduction

Heart failure (HF) is a risk factor for postoperative mortality in major non–cardiac surgery. Collaboration between the Multimodal Preoperative Prehabilitation unit (MPP) and Heart Failure Clinic (HFC) could allow optimization of heart failure therapy and negative prognostic factors such as reduced functional capacity (FC), malnutrition, and sarcopenia to improve the prognosis of these patients. Case report: Mrs. C.M. is a 58–year–old patient who presents to the MPP unit in anticipation of total colectomy for drug–refractory ulcerative colitis. Mrs. C.M. has a past medical history significant for heart failure with reduced ejection fraction (EF 25%) of presumably valvular–arrhythmic etiology. She underwent tricuspid annuloplasty and mitral replacement surgery some years ago and is affected by atrial fibrillation. At the MPP unit, Mrs. C.M. had a reduced FC and was malnourished and sarcopenic. Blood tests showed iron deficiency anemia. Heart failure therapy (NYHA II) was not optimized according to guidelines. Therefore, the patient started multimodal prehabilitation consisting of aerobic and resistance exercise, nutritional intervention, intravenous iron infusion, and optimization of HF therapy. After the patient was evaluated at the HFC, she started empagliflozin, sacubitril/valsartan, and ranolazine; intermittent levosimendan therapy was also performed. She also underwent cardiac NMR, which showed non–ischemic fibrosis, and coronary angiography, which was negative. Finally, she underwent PM–ICD implantation. After six months of multimodal prehabilitation, there was an increase in EF (38% vs. 25%), a reduction in NT–proBNP (700 vs 4988 pg/mL), and mitigation of HF symptoms. There was also a marked improvement in FC (383 vs 269 meters at 6–minute walking test), nutritional status (stage B vs stage C at PG–SGA test), and muscle strength (handgrip strength test 14.6 vs 8.5 kg). Considering the excellent preoperative optimization response, it was decided to proceed with surgery after a collegial discussion (anesthetist, heart failure cardiologist, surgeon, and patient).

Conclusions

Multimodal preoperative prehabilitation, based on the collaboration between the Multimodal Preoperative Prehabilitation Unit and Heart Failure Clinic, can effectively improve the preoperative functional capacity of HF patients.
P248 HOW COVID–19 PANDEMIC HAS CHANGED EPIDEMIOLOGY OF PATIENTS WITH ACUTE CORONARY SYNDROME WITHOUT ST–T ELEVATION. DATA OF SINGLE CENTER
Authors: Sacco W , Campisano M , Camellini M , Bagni E
Published: May 2023

Background

In recent years, the COVID–19 pandemic has led to a profound change in the epidemiological framework and incidence of cardiovascular diseases, as described in numerous reports. This condition can be attributed to various factors including reduction of hospitalizations for ACS (acute coronary syndrome) already widely discussed and documented, reduction of programmed cardiological follow–up and last but not least, the unfavorable effects of the lock–down period on life style and current health status of cardiac patients and the general population. The aim of our study was to evaluate how the characteristics of patients referred to our Cardiology Unit affected by ACS without elevation of the ST–T segment have changed in the post–pandemic phase. We analyzed the data fo the year 2022 and in particular the average age of incidence, the difference between the two sexes and the variation in the incidence of cardiovascular risk factors compared to 2021. The results showed an important reduction in the mean age of ACS incidence of about 2 years, a confirmed prevalence in males compared to females, a statistically significant increase in newly diagnosed dyslipidemia, especially in young patients, and the uncorrected primary prevention management of other cardiovascular risk factors. These data can be explained considering important changes in the lifestyle of the general population in terms of increased sedentary, poor eating habits during the pandemic phase and poor control of cardiovascular risk factors, also due to the absence of ambulatorial follow–up.

Conclusions

These data direct our future measures in the careful and punctual early correction of cardiovascular risk factors starting from outpatient visits, in primary prevention and in the optimization of therapy with aggressive correction of the pathologies encountered during the hospitalization and prevention phase secondary.
P250 CLINICAL PREDICTORS OF ONE–YEAR MORTALITY AFTER ACUTE CORONARY SYNDROME: THE APULIA PONTE ACS REGISTRY
Authors: Scicchitano P , Locuratolo N , Basile M , Sublimi L , Rutigliano D , Palumbo V , Bonfantino V , Paolillo C , Spadafina T , Lillo A , Di Martino L , Massari F , Caldarola P
Published: May 2023

Background

Risk stratification in patients discharged from hospital after coronary syndrome (ACS) play a central role in the management the patients during follow–up. The aim of study was to evaluate the clinical predictors of one–year mortality after ACS.

Methods

We analysed data from 2011 participants of Apulia Ponte ACS who were on one–year follow–up. The APULIA PONTE ACS (PDTA per il follow–up integrato ospedale–territorio del paziente dopo SCA e/o rivascolarizzazione miocardica) Project had been created in order to guarantee a dedicated outpatient follow–up in patients who underwent coronary revascularization and/or ACS by creating a dedicated network among Hub/Spoke centers, outpatient clinics, local cardiologists, general practitioners, and home management of the disease. The primary endpoint was all–cause mortality. We used Cox proportional hazards regression analysis to identified prognostic markers and ROC curve analysis to assess their optimal cut–offs.

Results

At 1–year follow–up, death occurred in 61 patients (3.0 %). The mortality was significantly higher in patients with non–STE–ACS asn compared to patients with STE–ACS (3.0% vs 1.9%, p<0.04). Age, heat rate, systolic blood pressure and left ventricular function remained independent predictor of mortality, while ACS type was no longer associated with death. The optimal cut–offs for death occurrence were age >73 years, heart rate >67 bpm, systolic blood pressure <120 mmHg, and left ventricular ejection fraction <40%. When a score based on the number of these prognostic variables was used (range 0–4), it was significantly associated with mortality (HR 3.1, 95% CI 2.5–3.9, p<0.0001, and area under the ROC curve = 0.81, p<0.0001). A score >1 showed a predictive positive value = 8% and predictive negative value = 99%.

Conclusions

Age, heart rate, systolic blood pressure, left ventricular function at discharge after ACS provide independent and complementary prognostic information independent from ACS type. Our results suggest that the combination of four clinical variables can provide an easy prognostic approach in patients with ASC after hospital discharge potentially useful for personalized care.
P251 EFFECTS OF PIRFENIDONE ON SCAR SIZE AND VENTRICULAR REMODELING AFTER MYOCARDIAL INFARCTION: A PRECLINICAL STUDY
Authors: Aimo A , Burchielli S , Aquaro G , Barison A , Musetti V , Masotti S , Pucci A , Modena M , Passino C , Emdin M
Published: May 2023

Background

An intense fibrotic response after myocardial infarction (MI) may lead to scar expansion and left ventricular (LV) remodeling, increasing the risk for ventricular arrhythmias and heart failure. Pirfenidone is a drug currently approved for the treatment of idiopathic pulmonary fibrosis, and reduces LV fibrosis in patients with heart failure and preserved ejection fraction. We aimed to characterize the different profiles or protein expression in the infarct zone in rats receiving or not receiving pirfenidone on top of standard therapy for MI.

Methods

Male Wistar rats were randomized to: sham procedure (group 1; n=13), reperfused MI induced by surgical ligation of the left anterior descending artery (LAD) for 45 minutes (group 2; n=17), reperfused MI plus standard therapy (aspirin, angiotensin–converting enzyme inhibitor, beta–blocker, and also mineralocorticoid receptor antagonist [MRA]) (group 3; n=17), reperfused MI plus pirfenidone alone (group 4; n=17), reperfused MI plus standard therapy and pirfenidone (group 5; n=17). Rats surviving LAD ligation and reperfusion underwent cardiac magnetic resonance (CMR) after 72 hours and 30 days from MI, and were sacrificed the day after the second CMR exam. The primary endpoint was the change in late gadolinium enhancement (LGE) mass as a percentage of LV mass.

Results

Forty–six rats survived until the second CMR. Percent changes in LV end–diastolic and end–systolic volume (p=0.370 and 0.423, respectively), ejection fraction (p=0.236) and mass (p=0.815) did not differ significantly between rats on pirfenidone plus standard therapy compared with those receiving standard therapy alone. The decrease in LGE mass was significantly greater in rats on pirfenidone plus standard therapy vs. those on standard therapy alone: –22.0% (interquartile range, –37.1 to –5.7, range –51.1 to +37.5) vs. +1.9% (–7.7 to +12.5, range –19.8 to +56.5), p=0.029.

Conclusions

Pirfenidone had additive effects to standard therapy for MI (including an MRA) in reducing LV fibrosis in a rat model of reperfused MI, while it did not further improve LV function, volumes or mass.
P256 AN UNUSUAL CASE OF PACEMAKER MALFUNCTION WITH NON COMMON ELCTROCARDIOGRAPHIC PRESENTATION AND UNEXPECTED ECHOCARDIOGRAPHIC FINDING
Authors: Minardi A , Franchina G , Marini C , Pala M , Fiorista L , Lucreziotti S
Published: May 2023

This clinical case shows the diagnostic challenge and the management of a 79 y–o male with recent hospitalization for infero–lateral STEMI undergoing primary PCI of Right Coronary Artery with 2 DES and following DDDR MRI PM (pacemaker) implantation due to the development of persistent 2:1 Atrio–Ventricular Block. One month later, admission at Emergency Department for syncope. Normal parameters were found at laboratory analyses. The electro–stimulator activity evaluation showed a PM malfunction with ventricular capture failure. Thus, the increase of PM output up to electric ventricular capture (8 Volt/120 msec) was performed, but the following Electrocardiogram showed a PM–induced rhythm with RBBB–morphology. Then, the bedside Echocardiogram showed an apparent presence of a linear hyper–echogenic image into left ventricle with no inter–ventricular septal defect neither inter–ventricular shunt, inter–atrial septal hypermobility with no evident inter–atrial shunt at rest; while a chest Radiography identified the atrial and ventricular leads with no accurate individuation of their position. The patient was admitted in Intensive Cardiac Care Unit with confirmation of intermittent failure to ventricular capture and RBBB–morphology during PM–induced rhythm at telemetry monitoring. Due to Electrocardiographic and Echocardiographic findings, a strong suspect of abnormal position of the ventricular lead into left ventricle through a possible PFO has been raised. A chest Computed Tomography was performed confirming the anomalous position of the ventricular lead: it reached the left atrium through an inter–atrial defect/patent foramen ovale (PFO), then crossing the mitral valve up to left ventricle. The PM–lead repositioning was scheduled two days after. After positioning of temporary stimulator lead in right ventricle, the ventricular lead has been withdrawn from left–side chambers and positioned into septal–apical right ventricle; furthermore, the position of right atrial lead has been optimized (because of frequent spontaneous passage to the left atrium through the PFO, during manual maneuvers) thus obtaining good stability of the device. During the following days, the telemetry monitoring showed a PM–induced rhythm, without capture nor sensing failure. The chest Radiography confirmed the correct position of leads and the pre–discharge Echocardiography showed a LVEF 57% with no valvular pathology and with atrial and ventricular leads into right–side chambers.
P257 UNIQUE UNEXPECTED COURSE OF A S–ICD LEAD: DIAGNOSTIC CHALLENGES AND SAFE CLINICAL AND INTERVENTIONAL MANAGEMENT
Authors: Cataldi C , Persi A , Percoco F , Bacà M , Perna F , Pelargonio G , Micheli C , Canitano S , Kol A
Published: May 2023

In this report we present a case of subcutaneous cardioverter defibrillator (S–ICD) implantation complicated by pneumothorax (PNX), in the absence of alteration of electrical parameters nor lung parenchyma involvement. After implantation in secondary prevention (1995) of an abdominal transvenous defibrillator (TV–ICD) via the left subclavian vein, a replacement (2009) with a new contralateral TV–ICD system, and the withdrawal of the proximal edge of the right ventricular (RV) lead in the abdominal region, a 78–years–old man presented in our center for pocket erosion. The trans–esophageal echocardiography was suspect for vegetations, while PET/CT and blood cultures were negative. Transvenous extraction of the right–sided ICD system was performed (the original RV lead was left in place due to his complex course), then the patient underwent implantation of a S–ICD with the intermuscular 2–incision technique. In the end of this well tolerated procedure the electrical parameters were optimal, the defibrillation test was effective and the position of the S–ICD was judged correct on the chest X–ray. Few hours later, the patient complained for local pain and progressive respiratory failure. A chest CT showed a PNX at the lateral insertion of the lead, which reached the pleural space, along the left scissure (Fig.1). During lead repositioning, programmed with stand–by thoracic surgery, the lead was easily disconnected from the generator through the lateral incision, pulled–back through the subxiphoid one and tunneled in the correct plane without complications (Fig.2). Serial chest CT confirmed PNX resolution. The patient was discharged in 8 days. At the 1–month follow–up visit electrical parameters were stable, in absence of infective complications. In literature there are few cases of PNX, so that it’s challenging to define their risk factors. We assume that, despite a correct implantation technique, a barrel chest configuration and the aging of the fascia favored the wrong tunnelling. In conclusion, PNX is a rare and unexpected complication of S–ICD implantation and can go unnoticed when of limited dimensions, in the absence of clinical and radiological signs nor alteration of electrical parameters. Fluoroscopic and CT imaging is recommended for diagnosis. Thoracic surgery is useful during repositioning of the lead, which can also be performed by simple traction. CT imaging is of utmost importance for planning such a procedure and predicting its complexity.
P259 S–ICD OFFERS A POTENTIAL SYNERGISTIC THERAPY FOR HEART FAILURE PATIENTS WITH AN INDICATION FOR ICD IMPLANTATION AND CANDIDATES FOR CCM IMPLANTATION
Authors: Adamo F , Mahfouz K , Colaiaco C , Finamora I , Danisi N , Santini L , Ammirati F
Published: May 2023

CCM (cardiac contractility modulation) is a very promising therapy in heart failure patients as it allows, by increasing intracellular calcium handling, an improvement in cardiac contractility, ejection fraction, and patient quality of life. It delivers high–energy (7.5 V) and long–duration (about 20 milliseconds) pulses in absolute refractory period through the use of two leads on the right ventricular septum. It is indicated in patients with narrow QRS (< 130 msec) and ejection fraction between 25 and 45%. Therefore, a large proportion of patients suitable for CCM therapy also have an indication for ICD implantation. The coexistence of an ICD (single–chamber or dual–chamber) and CCM presupposes the presence of 3 leads in the right ventricle and possibly a catheter in the right atrium if a dual–chamber ICD is used. The presence of numerous leads increases the risk of infection, mechanical complications, and damage on the leads. In view of the above, the strategy we propose in patients with concomitant indication for ICD and CCM is the use of the subcutaneous defibrillator (S–ICD) in patients with potential indication for CCM, narrow QRS, no pacing indication, and ejection fraction <35%, thus limiting the number of leads and the risk of complications. In our center, we have started using this strategy with excellent clinical results and in the absence of complications. One of the cases treated with this strategy is a 60–year–old patient with nonischemic dilated myocardiopathy, ejection fraction 34%, QRS < 130 msec, NYHA class III, despite therapy with beta blockers, ARNI, SGLT2–i, MRA at the maximum dose. The patient, also considering the potential future need for CCM implantation, underwent S–ICD implantation. After 3 months, NYHA class III with reduced quality of life persisted (MLHFQ 82). Therefore, the patient successfully underwent CCM implantation, with marked improvement in symptoms (MLHFQ 71) and ejection fraction (43%) 3 months later. This strategy avoided the placement of additional leads in the right ventricle while ensuring protection from potentially fatal arrhythmias and improvement in contractile function and symptoms. We suggest the use of the subcutaneous defibrillator (S–ICD) in all patients in whom there might be an indication for the use of CCM and no need for pacing, ensuring maximum efficacy and reducing the risk of infection and leads related complications.
P261 OUT–OF–HOSPITAL CARDIAC ARREST (OHCA): TWO–YEAR OBSERVATIONAL STUDY
Authors: Condello C , Gasparetto N , Cacciavillani L , Orazio S , Betta D , Menegon V , Bussola M , Ferramosca M , Zanatta P , Cernetti C , Iliceto S
Published: May 2023

Background

Cardiac arrest is the third cause of death in Europe. It is a medical emergency characterized by high mortality and morbidity. Myocardial infarction is the leading cause of cardiac arrest. Data collection through national and international registries is essential to advance knowledge and improve diagnostic and therapeutic practices. Purpose: we assess the epidemiological impact of OHCA within a territory of approximately 300.000 inhabitants and follow patients’ intrahospital clinical pathway with the aim to identify possible predictors of survival and neurological outcome.

Methods

an electronic database is used to collect and share data across the Emergency Medical Services (EMS) and reference Cardiologists. Respectively, the EMS collects out–of–hospital patient data, whereas Cardiologists collect all information about intrahospital progress.

Results

during an observation period of two years, 100 patients with OHCA were enrolled. The majority were male and the average age was 65 years old. The first rhythm identified was shockable in 41% of the cases. Witnesses performed cardiopulmonary resuscitation and used automatic external defibrillator respectively in 57% and 10% of the cases. Only 34% of the victims obtained ROSC and were admitted into the cardiac intensive care unit and half of them died before discharge. Within this group, cardiac arrest was caused by myocardial infarction in 46% of the cases. Of these, culprit lesion was located in the left anterior descending artery in 46,2 % of the cases. It appears that a blood pH value below 7,04 – measured at the arrival in Emergency Department – is a poor prognostic predictor of ROSC, with a 79% sensitivity and 86% specificity (AUC 0,81, 95% CI 0,644 – 0,977). On the other hand, a plasma level of lactic acid expresses multiorgan damage secondary to cardiac arrest and therefore represents a predictor of survival and neurological outcomes, but not ROSC.

Conclusion

during the two years of observation, the incidence of OHCA turned out to be slightly lower compared to the data available in the literature. Mortality remains extremely high: only 12% of the population survives, of which 16% with poor neurological outcome. Blood gas analysis, if correctly interpreted, could be an optimal tool to target therapeutic choices for cardiac arrest victims. Further studies with a higher sample size will be needed to validate this data.
P263 EFFICACY AND SAFETY OF THE LIFEVEST® WEARABLE DEFIBRILLATOR IN PATIENTS WITH NEWLY DETECTED ISCHEMIC AND NONISCHEMIC HYPOKINETIC DILATED HEART DISEASE: EXPERIENCE FROM OUR CENTER
Authors: Della Volpe F , Giulia C , Biagini F , Mariani T
Published: May 2023

Introduction

The wearable defibrillator (WCD) is indicated in patients at risk of sudden cardiac death who do not have short term indication for implantation of a definitive device. Efficacy in the recognition and treatment of ventricular tachyarrhythmias has been demonstrated in the context of postinfarction ischemic heart disease, while little evidence is currently available in other clinical settings. The aim of the study was to evaluate the efficacy and safety of WCD in an unselected population of patients with ejection fraction (EF) <35% and newly detected myocardial infarction (MI) or nonischemic dilated cardiomyopathy (NIDCM) pending optimization of medical therapy.

Methods

All patients with FE <35% admitted to our department from 2017 to 2022 after MI or with newly found NIDCM and discharged with WCD (LifeVest® Zoll) were enrolled as part of a prospective registry. The indication was considered in patients with nonsustained ventricular arrhythmias during hospitalization. Clinical and medical history data were collected for each subject; follow–up was conducted until the end of device monitoring, recording any events and therapies delivered.

Results

Of the 22 subjects enrolled, 19 (86%) were male. The mean age was 57±10 years. Fifteen patients had newly encountered NIDCM (68.2%) and 7 had been discharged after MI. Ninety–five percent of patients were on beta–blockers, 68% on ACE inhibitors, 5% on Sartan, 32% on Sacubitril Valsartan, 81% on Antialdosteronics, 9% on SGLT2i. The mean duration of treatment was 68±33 days. A statistically significant increase in EF was observed at the end of treatment in the two subgroups (MI 40%±8 vs. 32%±3, p 0.03. NIDCM 39%±9 vs. 31%±6 p 0.002). No arrhythmic events or inappropriate discharges were recorded. At the end of treatment, 41% of patients had indication for definitive defibrillator implantation, with no difference in the two subgroups (MI 28% Vs NIDCM 46% p 0.115).

Conclusions

In a population of patients discharged on optimal medical therapy, a significant increase in EF at follow–up was observed with no significant differences in definitive ICD implantation between the subgroup of patients with recent MI or newly found NIDCM. WCD therapy was found to be safe in the absence of need for appropriate shocks.
P264 THE RELATIONSHIP BETWEEN MEAN DAILY HEART RATE AND THE INCIDENCE OF CARDIAC ARRHYTHMIAS IN PATIENTS WITH WEARABLE CARDIAC DEFIBRILLATOR
Authors: Matteucci A , Pignalberi C , Pandozi C , Magris B , Meo A , Schiaffini G , Russo M , Galeazzi M , Mocini D , Aquilani S , Colivicchi F
Published: May 2023

Background

The wearable defibrillator (WCD) is a useful device to prevent sudden cardiac death (SCD) due to fatal arrhythmias in patients in which an implantable cardioverter defibrillator (ICD) is not currently indicated. Measurement of mean daily heart rate and related variability (HRV) has proved to be useful in identifying patients at increased arrhythmic risk of SCD and in patients with chronic heart failure (CHF), although the specificity and predictive accuracy of fatal arrhythmic events is still relatively limited. We analyzed the mean HR of patients with WCD to determine their impact on the incidence of fatal and non–fatal arrhythmic events.

Methods

We enrolled 7 patients with WCD and optimal medical therapy by monitoring daily HR and variability over a 30– 90 day follow–up. Monitoring was performed remotely, analyzing both trends acquired by the devices, daily ECG recordings, and telephone surveillance.

Results

Men constituted 71.4% of the population, with a mean age of 69.1±10.3 yrs, and an ejection fraction of 30.7%±8.7. The devices were worn for 36±24 days, with a daily adherence of 23.8±0.23 hrs. The trend in mean HR showed a progressive, although non–significant reduction (77.5±10.2 bpm vs 66.5±11.9 bpm p=0.08). No fatal arrhythmic events were recorded during monitoring. Two non–fatal arrhythmic events were recorded from patient discharge.

Conclusions

Mean daily HR is a predictor of cardiac death, independent of other risk factors in patients with cardiovascular disease. Although the small sample size doesn‘t provide a convincing correlation, it is conceivable that reducing mean HR may contribute to a decrease in fatal cardiac arrhythmias. Further studies are needed to confirm these insights.
P266 SUBCUTANEOUS DEFIBRILLATOR USE LIMITATION IN PATIENT AFFECT BY ARRHITMOGENIC CARDIOMYOPATHY IN REAL WORLD
Authors: Agus E , Casula M , De Toni C , Scalone A , Schintu B , Setzu A , Tola G , Corda M
Published: May 2023

Introduction

The prevention of sudden cardiac death (SCD) through the implantation of a defibrillator (ICD) represents one of the fundamental milestones in the management of arrhythmogenic cardiomyopathy (ACM). Individual characteristics of the patient and of the disease can help in the selection of the device [transvenous (TV) or subcutaneous (S–ICD) defibrillator]. The objective of this study is to evaluate the major factors limiting S–ICD implantation in a real–world ACM patient population.

Methods

This multicenter retrospective observational study enrolled consecutive patients undergoing ICD implantation in primary or secondary prevention for ACM at the participating centers. The population was subdivided according to the execution of the preimplant S–ICD screening test and its result. Baseline clinical and instrumental data were analyzed to identify predictors of passing the screening test.

Results

21 ACM patients (67% men) who underwent 24 S–ICD or TV–ICD implant procedures were enrolled. 70.8% of patients (N=17) were screened for S–ICD. Screening was not performed in 4 patients (17%): in one case due to an indication for resynchronization therapy and in three patients because they were implanted in the pre–S–ICD era. Screening failed in 53% of cases. The cause of the failures were the low voltages of the QRS (100% of the failures) and a poor stability of the trace in the different positions tested for significant variation of the QRS/T ratio (37.5% of the failures). No significant difference was noted between the clinical and instrumental characteristics of the two subgroups (Table 1), although the patients who passed the screening showed a trend towards a greater QRS amplitude in DI (0.52±0.29 vs 0.28±0.17 mV – P= 0.07) and to present a positive QRS in DI (100% vs 50%; P=0.08 – Table 2).

Conclusions

The use of the S–ICD in patients with ACM could be limited by some intrinsic characteristics of the disease. In a real–world cohort of patients affected by ACM, the presence of low QRS voltages on the surface ECG and positional morphology variations allowed S–ICD use in half of the patient candidates.
P267 ASSOCIATION BETWEEN EARLY MODIFICATION OF LEFT ATRIAL VOLUME AND RIGHT VENTRICULAR FUNCTION AFTER TRANSCATHETER EDGE–TO–EDGE REPAIR FOR MITRAL REGURGITATION
Authors: Bonelli A , Guasti S , De Sanctis G , Spanò F , Santambrogio G , De Chiara B , Belli O , Musca F , Casadei F , Garascia A , Oreglia J , Bruschi G , Oliva F , Giannattasio C , Moreo A
Published: May 2023

Background

Transcatheter edge–to–edge repair (TEER) for severe mitral regurgitation (MR) is a therapeutic option in patients at high surgical risk. Post procedural reverse remodeling of the left ventricle, the left atrium (LA) and the right ventricle (RV) was shown to be associated with reduced symptoms and mortality.

Methods

In this retrospective study we have assessed consecutive patients with functional severe MR from February 2015 to July 2022. LA and RV structure and function have been evaluated before the procedure and at the discharge and they were correlated with symptoms.

Results

In the present study, 52 patients (69% males, mean age 65.2±10.2 years and mean left ventricular ejection fraction 28.8±5.7%) were included. No differences about baseline clinical and echocardiographic characteristics were reported in the group of patients who had LA volume reduction (n=31) and those who did not (n=21). In the overall population we have detected a significant increase of tricuspid annular plane systolic excursion (TAPSE), S‘ wave at Tissue Doppler and the ratio between TAPSE and systolic pulmonary artery pressure (SPAP), together with a significant reduction of SPAP (respectively, p=0.034, p=0.003, p<0.001 and p<0.001). Compared to patients who did not have LA volume reduction, the other group showed a significant increase of TAPSE/SPAP (from 0.40±0.17 to 0.52±0.21 mm/mmHg, p=0.002) and S’ wave (from 8.7±1.6 to 9.4±1.7 cm/s, p=0.005) and a reduction of SPAP (from 50.3±14.3 to 38.9±11.5 mmHg, p<0.001). LA volume modification from baseline to the discharge was associated with the modifications of SPAP (B coefficient 0.55, 95% confidence interval 0.09, 1.02, p=0.022) and TAPSE/SPAP (B coefficient –4.06, 95% confidence interval –7.78, –0.33, p=0.033), even at the multivariable analysis (respectively, B coefficient 0.61, 95% confidence interval 0.07, 1.14, p = 0.027 e B coefficient –4.82, 95% confidence interval –9.43, –0.23, p=0.040). Lastly, NYHA class improved in the group of patients who had LA volume reduction (p=0.011).

Conclusion

In this retrospective study an association between early modification of LA volume and RV functional parameters has been described. After TEER, RV function improved, particularly in the group of patients who had LA volume reduction. The latter have shown an improvement of symptoms at the discharge.
P268 CORONARY FLOW VELOCITY RESERVE REDUCTION IS ASSOCIATED WITH CARDIOVASCULAR, CANCER, AND NON–CANCER, NON–CARDIOVASCULAR MORTALITY
Authors: Tuttolomondo D , Gaibazzi N
Published: May 2023

Background

Coronary flow velocity reserve (CFVR) measured in the left anterior descending artery during high–dose vasodilator stress echocardiography interrogates both epicardial and microcirculatory coronary function and has been inversely associated with chronic inflammation and microvascular dysfunction, as well as with the presence of obstructive coronary artery disease. Microvascular dysfunction and chronic inflammation are common mechanisms of disease in cardiovascular (CV) and non–CV conditions. We aimed to assess whether CFVR is associated with all–cause death, but more specifically with CV, cancer, and non–CV and noncancer (NCVNC) mortality, independently and increasingly over other demographic, clinical, and echocardiography variables.

Methods

One thousand two patients who underwent stress echocardiography were followed for a median of 8.2 years, with clinical, regional wall motion abnormalities (RWMAs), and CFVR data. The independent prognostic value of RWMA and CFVR regarding CV, cancer, or NCVNC mortality was evaluated adjusting for clinical variables. A prespecified subgroup of subjects with no RWMA or revascularization procedures during follow–up was also analyzed (n = 752), to exclude most participants with possible coronary artery disease and remove such confounding from the assessment of the potential association of CFVR and mortality.

Results

A total of 161 patients (16%) died, 63 deaths being CV (39%), 52 from cancer (32%), and 46 (29%) from NCVNC causes. In comparison to CV mortality, cancer and NCVNC mortality were not associated with an ischemic RWMA at univariable analysis, while a CFVR < 2 was significantly associated with each category of cause–specific mortality. A CFVR < 2 or ≥2 separated a group of patients with 8–year 14.6% versus 1.2% CV mortality, 10.3% versus 0.4% cancer mortality, and 9.5% versus 1.5% NCVNC mortality.

Conclusions

The reduction of CFVR is independently associated with CV, cancer, and NCVNC death in a population clinically referred for suspected/known coronary artery disease. CFVR can act as a marker or a mechanism preceding and predicting mortality from a wide variety of diseases.
P270 THE IMPORTANCE OF INTEGRATED IMAGING IN THE DIFFICULT DIFFERENTIAL DIAGNOSIS OF A LEFT INTRACARDIAC MASS IN YOUNG ADULT
Authors: Guasti S , Musca F , Bonelli A , De Sanctis G , Intravaia R , Casadei F , Occhi L , Spano‘ F , Belli O , De Chiara B , Santambrogio G , Pedrotti P , Quattrocchi G , Giannattasio C , Moreo A
Published: May 2023

The patient is a 34–year–old man who comes to the emergency room with mild hemoptysis, asthenia, low–grade fever, night sweats and weight loss. Cardiac auscultation reveals a diastolic murmur at the cardiac apex. Transthoracic and transesophageal echocardiograms are performed and show an isoechoic thickening encompassing the posterior leaflet, cranially involving the atrial septum and the lateral wall up to the inlet of the left atrial appendage and inferiorly involveing the subvalvular apparatus with diffuse thickening and chordal fusion. Functionally it determines a moderate mitral stenosis with an average gradient of 10 mmHg and a valve area of ​​1.1 cm2 and a mild–moderate regurgitation with an anteriorly directed eccentric jet. At this point we needed to make the differential diagnosis considering as possible etiologies infective endocardic vegetation, thrombosis, primary and secondary neoplasms, aseptic vegetation and inflammatory or rheumatic valvulitis. We therefore begin our diagnostic work–up by performing a scintigraphy with labeled leukocytes, which does not show the presence of hyperuptake areas referable to infective endocarditis, and a PET scan which shows, in addition to the increased uptake at the cardiac level, an area of ​​greater concentration of the metabolic tracer in the gastric area (between the body and the fundus). Given the confirmation of metabolically active tissue, the patient performed cardiac magnetic resonance with contrast medium which confirmed the presence of pathological tissue with inhomogeneous late post–contrast enhancement. After collegial discussion, due to the high risk of biopsy of the mitral lesion, which was poorly separable from the cardiac structures, given the other localization of the disease at the gastric level, it was decided to perform an EGDS with relief of an ulcerated lesion on the gastric fundus which is subjected to biopsy and histological typing. We then arrive at the diagnosis of “undifferentiated pleomorphic sarcoma”. Sarcoma is the most frequent histological type of primary malignant cardiac tumors. The clinic is characterized by constitutional symptoms, obstruction of the valve inflow or outflow tract, thromboembolism, and arrhythmias. It has a poor prognosis: 6–12 months from diagnosis. In conclusion, we reiterate the importance of integrated imaging to arrive at the final diagnosis, each method with a specific objective.