bluuebunny/crossref_metadata_2025 huggingface dataset:
THE “BACK TO THE FUTURE” OF CARDIOTHORACIC SURGERY: HIGH–RISK INTERVENTIONAL PROCEDURE TURNED DOWN TO CONVENTIONAL CARDIAC SURGERY
Authors: Totaro P , Aiello M , Pelenghi S
Published: May 2024

Background

Structural interventional cardiology has been introduced at the beginning of our century to address high–risk patient suffering from severe aortic stenosis. Since then several technique and technology have been proposed to address an increasing population of patients and mitral valve diseases have been also addressed. While several authors are pushing up the indications for structural interventional procedures, however, we are experiencing some situations were conventional surgery is considered an alternative to high risk interventional procedures. Here we present a peculiar case of “back to the future” in cardiothoracic surgery.

Case Description

A 76 yo female patient, was referred to our Division from a peripheral Hospital suffering from severe aortic stenosis and coronary artery diseases. Medical history of the patient included persistent AF, COPD, arterial peripheral vascular disease, moderate chronic renal insufficiency and moderate dilatation of ascending aorta. Patient was previously assessed by another Centre and a percutaneous treatment (PTCA+TAVI) was proposed. Due to further admission for cardiac failure–related symptoms, however, patient was urgently referred to our Division. Fig 1 and 2 summarized clinical findings. “Heart team” evaluation, based also on the product specialist evaluation, considered the patient not suitable for interventional procedure due to the high risk of sub–optimal medium–term prognosis. Due to further clinical deterioration an extremely high–risk surgical procedure was mandatory.

Results

Surgical procedure included a sutureless aortic valve replacement, a MV plasty, a double coronary graft + a cpmbined carotid endoarterectomy. Postoperative course was free from significant complications and the patient was discharged to rehabilitation clinic on 15th postoperative days.

Conclusion

Despite interventional procedure are continuing to increase either as number of procedure either as complexity of diseases treated, conventional cardiac surgery remains still the only option for treatment in many clinical scenario. As a sort of “back to the future” situation, patient originally referred for interventional procedures are turned down due to the high risk of sub–optimal results. In such condition conventional cardiac surgery, performed with high level of accuracy could represent the last and only treatment option for high risk patients.
TEN YEARS OF TRANSESOPHAGEAL ELECTROPHYSIOLOGICAL STUDIES IN YOUNGER THAN 40 YEARS PEOPLE WITH A WOLFF–PARKINSON–WHITE SYNDROME
Authors: Toniolo M , Muser D , Rebellato L , Daleffe E , Imazio M
Published: May 2024

Background

The electrophysiological evaluation of Wolff–Parkinson–White syndrome (WPW) is recommended in people older than five–years to detect the risk of life–threatening arrhythmias. The purpose of this retrospective single–center study was to determine the feasibility of transesophageal electrophysiological study (EPS) in an outpatient setting among young people between 10 and 37 years old and to evaluate its prognostic role.

Methods

Electrophysiological study (EPS) was indicated in 60 consecutive people (48 males, 81%; mean age 19 ± 7 years) between january 2012 and october 2023. The test was indicated for manifest WPW, either for palpitations (n=11, 18.6%), unexplained dizziness (n=1, 1.7%), or for sport eligibility in asymptomatic people (n=47, 79.6%). An accessory pathway (AP) was considered to have a short refractory period and carry an increased risk for sudden cardiac death when the effective refractory period (ERP) was ≤240 ms, or if an atrioventricular (AV) reentrant tachycardia precipitating pre–excited atrial fibrillation was induced.

Results

EPS was performed in all but one person, without sedation. The main difficulty lied in passing the catheter through the nose. Programmed atrial stimulation at cycle length of 500 ms with one decremental extrastimulus was performed in all people to determinate the refractory period of the AP and the AV node. Physical activity during the test, or isoproterenol infusion was performed in 45 out of 59 people. The AP ERP was determined in the majority of case (54 out 59 people) and was between 200 and 360 ms (mean 270 ± 34 ms). Orthodromic reentrant tachycardia was induced in 10 (16.9%) cases, in 5 asymptomatic people and 5 patients with palpitations. Atrial fibrillation was induced in 13 cases. Antidromic tachycardia was never induced. Ten people (16.9%) were deemed at increased risk of life–threatening arrhythmias while 49 (83.1%) patients were deemedat low risk. Eight out of 10 (80%) high risk pts and only 5 out of 49 low risk patientss underwent catheter ablation of the AP. After a median follow–up of 57 months, all 49 patients defined at low risk were alive, without syncope or sudden cardiac arrest events.

Conclusions

In young patients with WPW syndrome, transesophageal EPS can be performed in an outpatient setting with an excellent tolerability and shows a high specificity (negative predictive value of 100%) to role out patients at increased risk of life–threatening arrhythmias.
A HEART–POUNDING RECOVERY PHASE
Authors: Paffoni P , Maffè S , Bergamasco L , Facchini E , Prenna E , Ariotti S , Ticozzi S , Franchetti Pardo N , Paino A , Dellavesa P
Published: May 2024

Background

Bidirectional ventricular tachycardia is a rare form of ventricular tachycardia that shows dual QRS morphologies alternating beat–to–beat. First reported as a complication of digoxin treatment, then in other conditions including myocarditis, sarcoidosis, catecholaminergic tachycardia, and Andersen–Tawil syndrome, rare are the cases in acute myocardial ischemia.

We present a case of 69 years old men, dyslipidemic, with an acute coronary syndrome in 2020, treated with PTCA and stent on left anterior descending artery, coronary angiography showed residual subcritical stenosis of left main. At electrocardiogram presence of left bunble brabch block (LBBB). After one year a stress myocardial scintigraphy was performed, stopped at 90% of maximal heart rate, without symptoms; during recovery phase after 22 seconds a wide QRS (170ms) tachycardia with morphology LBBB began (Figure 1), without symptoms, spontaneously interrupted after 50 s. After one minute another wide QRS tachycardia started, bidirectional (Figure 2), with interruption after 40 s. The patient did not present troponin elevation, not alteration in blood tests. No other arrhythmias were recorded, only bradycardia without pauses, shorts episodes of atrial fibrillation. Echocardiography confirmed left ventricular ejection fraction 40%.

The results of myocardial scintigraphy was only fixed basal septal ipoperfusion, confirmed by the presence of late enhancement on cardiac MRI. Coronary angiography showed distal left main stenosis involving interventricolar anterior artery origin, treated with PTCA + stent. In the following months, given reduction in NYHA class, brady–tachy atrial arrhythmic disease, left ventricular ejection fraction 35% and poor chances of drug therapy, ICD CRT was implanted. At 2–year follow–up no more ventricular arrhythmias were recorded.

Conclusions

Point of interest of this case is appearance of two complex different ventricular arrhythmias in the recovery phase of the stress test with paucisymptomatic patient and no arrhythmias during exercise test. The origin mechanism probably involves triggered activity from after–depolarizations, abnormal automaticity, and reentry. The fixed hypoperfusion area on myocardial scintigraphy and septal scar on cardiac MRI can be involved in the genesis of the bidirectional ventricular tachycardia; complete resolution of the arrhythmias after coronary revascularization, support ischemic hypothesis for the origin of arrhythmias.
VENTRICULAR ARRHYTHMIAS IN A UNEXPECTED CARDIAC MAGNETIC RESONANCE
Authors: Tansella D , Pittorru R , Perazzolo Marra M
Published: May 2024

Background

Electrical storm in a widespread inflammation of the myocardium represent a very challenge condition and recognizes a broad spectrum of etiology.

Case Presentation

A 59–year–old man, without significant prior medical history, came to our attention because, following an emergent hernioplasty procedure, he displayed anterior ST–segment elevation and elevated troponin levels (150.000 ng/L). An echocardiogram revealed an estimated left ventricular ejection fraction (EF) of 39% with anterior hypokinesia. Coronary angiography showed no abnormalities. Cardiac magnetic resonance imaging demonstrated ring–like edema and ring–like late gadolinium enhancement in the left ventricle on T2–weighted and PSIR sequences, with no involvement of the right ventricle. Additionally, there was an increase in extracellular volume. Despite several laboratory tests to investigate infectious or autoimmune causes, the etiology remained inconclusive. To further explore the cause, an endomyocardial biopsy was performed. However, the patient experienced an unstable electrical storm three days later.

Management

Recurrent ventricular tachycardia (VT) was initially treated with esmolol, amiodarone, and procainamide, but with limited success. Due to VT–induced hemodynamic instability, the patient was sedated with propofol and intubated. Endomyocardial biopsy (EMB) confirmed lymphocytic myocarditis. In light of the hemodynamic instability and refractory electrical storm, the patient was promptly cannulated for veno–arterial extracorporeal membrane oxygenation (VA–ECMO) and started on methylprednisolone. Although there was an apparent resolution of VT, the patient experienced new episodes, necessitating percutaneous stellate ganglion block and an upgraded treatment plan that included mycophenolate mofetil. Given the high burden of arrhythmias, severe ventricular dysfunction, and the lack of response to medications, the patient is now awaiting cardiac transplantation.

Conclusion

Transmural edema and ring–like late gadolinium enhancement (LGE) in the early phase are predictors of a poor prognosis. In cases of hemodynamic deterioration and refractory electrical storms, it is crucial to promptly initiate mechanical support. Cardiac transplantation remains the sole treatment option for individuals who do not respond to antiarrhythmic and immunosuppressive drugs.
MYOCARDITIS: VIRUS OR DESMOSOME?
Authors: Dei L , Re F , Gabrielli D , Sciarra L , Romano S
Published: May 2024

Patient Profile

Female, 56 yo, arterial hypertension, FH of autoimmune diseases, no history of sudden death. Medical History: • At the age of 46: Hospitalized for chest pain. Coronary angiography: negative. Diagnosis: myocardial ischemia with normal coronary arteries. • 2018: Hospitalized again for angina. ECG showed low voltages, flat T–waves in the inf–lat. leads. Coronary angiography: negative.

Biopsy

Mild hypertrophy and cytoplasmic vacuolization, minimal increase in interstitial fibrosis, no necrosis or inflammatory infiltrates. Mild nonspecific cardiomyopathy. Viral DNA test positive for HHV–6. Serology: HHV–6 in blood (neg), IgG HHV–6 (pos), IgM (neg). Diagnosis: myocarditis due to HHV–6. • San Camillo Cardiomyopathy Center: Echocardiogram: basal ant–lat. hypokinesia, EF 60%. Therapy: Bisoprolol 3.75 mg, Ramipril 5 mg, Ranolazine 1000 mg. MRI: basal transmural ant–lat. and subepicardial lateral LGE. Oedema and hypokinesia coexists. Subacute myocarditis. MRI at 1 year: mild left ventricular dilation, EF 60%, meso–subepicardial LGE in the ant–lat and inf mid–basal regions without oedema. Serial Holter ECGs: frequent polymorphic ventricular ectopics, couplets, and runs. CPET: normal exercise capacity, pVO2 19.4 (ml/min)/kg (90%).

Genetic testing

VUS in DSC, probably pathogenic, and VUS in ABCC9, PKP2, DSP (2 mutations) with uncertain clinical significance. • In 2022: Readmitted for angina. Elevated Troponin levels. Coro CT angiography: negative. MRI: EF 45%, akinesia of the apex and apical lat. wall; diffuse LGE and edema. Pericardial effusion. Patient refused biopsy. Discharged after recovery (EF 52%) with the diagnosis of recurrent myocarditis. Empagliflozin added. • Follow up. ECG: progression of repolarization abnormalities (TWI in V1–V3 + inf.–lat. leads). Biopsy: fibroadipose replacement, no necrosis or inflammatory infiltrates. Chronic myocarditis and sequels. Viral tests: negative. CPET and stress echo: VO2peak 20.7 (ml/kg)/min (88%), normal work capacity. Very rare monomorphic PVCs. EF 50%, preserved contractile reserve.

Conclusions

Diagnosis of left dominant arrhythmogenic cardiomyopathy with a typical pattern for hot phases of myocardial inflammation. The first episode could have been triggered by a viral infection on a predisposing genetic substrate. Nadolol 40 mg x2 was introduced. The possibility of ICD implantation was discussed, and patient refused. A six–month follow–up was planned. Family screening results were negative.
POST-HOC STRATIFICATION OF THE RISK OF INFECTION IN EXTRACTED PATIENTS
Authors: Benedetto L , Ferrieri A , Pastore I , Carretta D , D‘Agostino C , Dentico A
Published: May 2024

Introduction

Infection represents one of the most widespread and feared complications of CIED implantation procedures. Most of the time this could even evolve into endocarditis on electrocatheters or septic shock, to the point that the only life-saving therapy becomes the transvenous extraction of electrocatheters. For this reason, the problem often arises of preventing these infectious conditions by carrying out an infectious risk assessment before the implant so as not to incur these complications over time. This study aims to stratify post-hoc the infectious risk of patients extracted in our center to validate the introduction and use of scores for the pre-implantation assessment of infectious risk.

Methodology

We evaluated 163 patients who underwent transvenous extraction of leads, of which 130 due to pocket infection/endocarditis on leads or sepsis. In these patients, a post-hoc assessment of the risk of infection was made according to the UPCM score, a score created by the University of Pittsburgh. A score value greater than or equal to 7 identifies patients who are more likely to develop an infection over time. This score takes into account risk factors such as: early reoperation, type of device implanted (CRTD vs ICD/PM), presence of more than 2 catheters in place, replacement or revision of the device, use of temporary pacing, intake of corticosteroids or anticoagulants oral, renal function, fever within 24 hours before implantation, presence of diabetes or heart failure, male gender. We then paid particular attention to patients who had undergone an upgrade procedure or to those who had undergone an extraction procedure twice.

Results

Of the 130 patients in our center who underwent extraction for infection, 112 had a score greater than or equal to 7; On the other hand, 18 were those with a score lower than 7. The average value was found to be 22.9.

Conclusions

The identification of a score that can be evaluated before the CIED implantation procedure can be an excellent aid in identifying fragile patients who could suffer from infection in the long or short term. By doing this, further alternatives to the transvenous implant could be evaluated, such as the implantation of a leadless pacemaker or subcutaneous ICD in non-PM dependent patients eligible for this.
PREVENTIVE REHABILITATION CARDIOLOGY AS A POSSIBLE SETTING FOR THE MULTIDISCIPLINARY OUTPATIENT CLINIC FOR HEART FAILURE. THE CREATION OF A HEART FAILURE NETWORK BETWEEN THE DIFFERENT LEVELS OF CARE
Authors: Saporiti L , Moroni L , Rizza C , Scalabrino N , Guzon S , Picozzi A , Anzà C
Published: May 2024

Preventive Rehabilitative Cardiology (CPR) is a possible ideal setting for a Heart Failure (HF) Outpatient Clinic because it allows a specialized multidisciplinary team to be involved in the follow–up of the patient with Chronic Heart Failure (CHF). In the ESC 2021 Heart Failure Guidelines, two cornerstones in the management of patients with CHF are multidisciplinarity (meant as taking charge of the patient not only by the cardiologist but by several health figures, medical and non–medical, through the creation of a team) and the precocity and completeness of therapeutic optimization interventions. These two aspects of the process of taking care of patients with CHF are prerogatives widely developed in CPR. Outpatient cardiac rehabilitation pathways have developed effectively, albeit marginally, in CPR. In an increasingly clear differentiation of roles and in the perspective of the creation of a HF network, in order to optimize paths and resources, it therefore seems useful that CPR takes charge of the chronicity of the HF patient also through its continued outpatient management in the context of a HF Outpatient Clinic. The CPR of Castellanza–Multimedica has adopted a PDTA that aims to guarantee a multidisciplinary management for the patient suffering heart failure. Educational materials and working documents have been produced to encourage an exchange among professionals, and a framework of multidisciplinarity. Future work objectives include the structuring of an increasingly effective and two–way network with level II and III centres not belonging to Multimedica Group and direct access to the clinic not only upon referral from the GP, with whom active collaboration projects are underway, but also directly from the local DEAs, as well as the activation of televisit and teleconsultation programs. A first pilot study was performed to compare endurance versus interval physical training cycles in outpatients with HFrEF. RESULTS: in 5 years of activity, 196 patients were treated: 33 patients (16,8%) were sent to other centres or lost to follow–up, 16 (8,1%) were discharged with re–referral to the GP and Level I outpatient clinics or to the chronic disease programme (PAI), 29 (14,7%) died. Of the 119 patients with active follow–up as of 31/12/2023, 109 (91,5%) are on beta–blocker therapy, 70 (58,8%) on ARNI, 32 (26,8%) on ACEI–sartane for a total of 102 (85,7%) on RAASI, 106 (89,0%) patients on MRA, 87 (73,1%) on glyphozine, 73 (61,3%) on quadruple therapy.
EARLY USE OF SACUBITRIL/VALSARTAN FOLLOWING ACUTE DECOMPENSATED HEART FAILURE WITH REDUCED EJECTION FRACTION: FEASIBILITY AND UNVEILING FACTORS
Authors: Alonzo A , Matteucci A , Castello L , Marino G , Spinelli A , Di Fusco S A , Colivicchi F
Published: May 2024

Introduction

Sacubitril/Valsartan plays a pivotal role in treating heart failure with reduced ejection fraction (HFrEF), reducing cardiovascular mortality and hospitalizations. Despite its effectiveness, real-world data indicate persistent underprescription due to management complexity, modest tolerability, therapeutic inertia and regulatory constraints. The TRANSITION study in acute decompensated heart failure (ADHF) demonstrated the feasibility of initiating Sacubitril/Valsartan in hospitalized patients with HFrEF. Our study aims to establish the safety and tolerability of early Sacubitril/Valsartan prescription during ADHF hospitalization and investigate reasons of its underprescription. We present preliminary data from 20 consecutive ADHF patients admitted to our department between August and October 2023.

Methods

We collected data from patients with HFrEF diagnosis according to current guidelines. Patient data were documented during hospitalizations, and therapeutic regimens at admission were compared with those at discharge. We also reported systolic arterial pressure, creatinine levels, glomerular filtration rate and kaliemia values.

Results

Patients had a mean age of 75±12.8, and 80% were men. The mean ejection fraction was 30.7% ± 5.6. BMI was 26.9±4.3, and 40% of the patients had diabetes. The mean hospital stay was 5.4 ± 4.1 days. The utilization of Sacubitril/Valsartan at admission was 25% up to 75% at discharge (p = 0.001). Concurrently, beta-blocker usage increased from 55% to 90% (p = 0.013), SGLT2 inhibitors from 55% to 75% (p = 0.001), and MRAs from 30% to 80% (p = 0.001). Systolic arterial pressure decreased not significantly (p = 0.189) as well as the glomerular filtration rate (p = 0.51). Kaliemia remained stable from 4.09±0.45 mEq/l to 4.14±0.45 mEq/l (p = 0.72). The prescribed dosage of Sacubitril/Valsartan was 50 mg bid in 80% of patients, 100 mg bid in 13,3% and 200 mg in 6,6%. Among patients who didn’t receive Sacubitril/Valsartan, four patients had an absolute contraindication represented by a GFR < 30 ml/min and one patient didn’t receive the drug due to an episode of cardiogenic shock.

Discussion

Our analysis highlights the underutilization of ARNi in HFrEF and the feasibility of early Sacubitril/Valsartan use in ADHF. The optimization of the therapy during hospitalization had no significant impact on key parameters. Advanced renal dysfunction represents the major limitation of Sacubitril/Valsartan prescription.
PSYCHOLOGICAL STRESS ALTERATION AND CV MODIFICATION IN CARDIOVASCULAR DISEASE OUTPATIENTS. THE ABC STUDY ON HEART DISEASE
Authors: Berton G , Mahmoud H , Cordiano R , Selvestrel E , Palmieri R , Merotto D , Dariod M , Visentin P
Published: May 2024

Introduction

Psychological stress is one of the most common patient complaints. Its influence on the physiology of the cardiovascular system, and on the aetiology and outcomes of cardiovascular disease (CVD) has been the object of intense investigation. In fact, current knowledge points to a “brain–heart axis” that is especially important in individuals with pre–existing CVD.

Aim

Evaluation of psychological stress reactivity and its cardiovascular effects in CVD outpatients.

Methods

Patients presented to the outpatient cardiology clinic of Conegliano General Hospital in the last 5 years were divided into 2 groups according to the presence or absence of stress symptoms based on the patient’s self–assessment psycho–emotion questionnaire.

Results

415 patients were included in this preliminary analysis. Patients‘ mean age was 66±18 years and 57% were males. Coronary artery diseases were registered in 93(22%) patients and 231 (56%) patients reported stress symptoms. They shared most demographic and clinical characteristics with patients who did not report stress symptoms. However, males were more frequent among patients with no stress. Interestingly, we observed no difference in systolic blood pressure values (SBP) between both groups, (148±21 Vs 145±23 mmHg, p= 0.15) for symptomatic and non–symptomatic patients respectively. Although, symptomatic patients had significantly higher values of diastolic blood pressure (DBP) than non–non–symptomatic patients, (81±10 Vs 77±11 mmHg respectively, p<0.02). Using multivariable linear regression models, age was an independent predictor for higher SBP values (β±SE= 0.5±0.1, p<0.0001), yet male gender and psychological stress were independent predictors for higher DBP values (β±SE were (2.9±1.1, p=0.007) and (4.3±1.1, p<0.0001) respectively). Results Kept true even with repeated BP measurements, Figure 1. Subgroup analysis revealed the same results among non–CAD patients. Yet, for CAD patients stress was not an independent predictor for higher BP values, full–adjusted β±SE were (1.9±5.0, p=0.69) and (3.7±22.3, p=0.10) for SBP and DBP, respectively.

Conclusion

Psychological stress alterations are associated with a significant increase in DBP values, chiefly in non–CAD–outpatients.
EXERCISE PRESCRIPTION IN CARDIOVASCULAR PREVENTION: PRELIMINARY DATA OF A FIVE YEARS ACTIVITY OF SPORTS MEDICINE UNIT –ULSS 2 TREVISO
Authors: Giorgiano F , Vessella T , Merlo L , Pegoraro C , Barra B , Meneguzzo G , Michieletto F , Russo F , Sarto P
Published: May 2024

Physical exercise plays a pivotal role in primary and secondary prevention of non–communicable chronic diseases. Nonetheless, to date, exercise prescription to chronically ill subjects is not yet in line with guidelines indications. In Veneto region, the goal of reducing the gap between guidelines and their actual application has been pursued for several years thanks to a regional “model”of exercise prescription in chronic disease. However, regional data indicative of the real clinical impact of this "model" are lacking. We evaluated the impact of the regional model on a population of chronically ill people visited at our Clinic between 2014 and 2019. In this period, 366 subjects living in the province of Treviso (Veneto region, Italy) with a history of heart disease and/or diabetes have been admitted to our facility and have been provided with precise indications (in the form of prescription) about physical exercise to be practiced in secondary prevention. For each subject, adherence to the exercise prescription was assessed. The study population was therefore divided into 3 classes of activity in accordance with the physical activity practiced during the observation period: 0=not adherent at all at the exercise prescription (no exercise practice phase); 1= practice of unstructured physical activity/ not monitored physical exercise and/or not completely adhering to the exercise prescription in terms of intensity, duration and frequency; 2= practice of structured and monitored physical exercise, completely adherent to exercise prescription provided. By this way, any temporary suspension and subsequent resumption of the activity was considered and the period of cessation of the activity during the monitoring period was taken into account for each subject. Data on “health expenditure”, was collected for each subject at time zero as new hospitalizations and deaths were analyzed following our intervention (exercise prescription letter delivery). According to a preliminary analysis of our data, time spent in practicing exercise in class 1 and 2 lead to a significant improvement in survival and less hospitalizations for considered pathologies. Furthermore, time spent in class 2 exercise practice (structured and monitored physical exercise, at target for intensity, duration and frequency), seems to determine even greater protection compared to unstructured physical activity or structured but not monitored and/or non–targeted physical exercise (class 1).
IMPLANTABLE MEDICAL DEVICES: A NON INVASIVE AND COSMETIC FRONTIER FOR WOUND CLOSURE
Authors: Lacquaniti A , Coroselli C , Russo A , Marcheselli A , Ficili S
Published: May 2024

Cardiovascular implantable electronic devices (CIEDs) implantation procedures have undergone continuous improvement. Every aspect of the procedure can contribute to these improvements, including incision closure.

The aim of this study was to assess the accuracy and validity of a non–invasive method using adhesive skin closure strips for wound closure of CIEDs in older adults, instead of surgical suture, evaluating parameters such as infection, erythema, skin reaction, itching, pain, oedema, time for closure, cosmetic outcomes and patients’ satisfaction.

A retrospective study was carried out in 152 subjects (mean age 81 +9.3 years).undergoing application of adhesive strips after CIEDs substitution/implant and 132 usual care control subjects (mean age 76.6+8.9). Variables considered were: age, gender, risk factors for wound complications. Wound evaluation was conducted by using the Visual Analogue Scale (VAS) and the Patient and Observer Scar Assessment Scale (POSAS). Operative time for closing the incision and for removing sutures or strips were significantly lower in both application and removal in the adhesive strip group. At follow–up evaluations, each parameter considered by evaluation of the patients and staff was significantly better than in the control group. Fewer complications were observed in the patients undergoing wound closure wit adhesive strips. Previoulsy, to the best of our knowledge, the use of adhesive strips in closing surgical wounds of patients undergoing CIEDs implant/replacement has never been considered. Adhesive strips for wound closure of CIEDs incision are characterized by shorter procedural time, optimal early and late cosmetic results, fewer complications in older patients and is cheaper. Its use for CIEDs wound closure is reasonably supported.
SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD) WITH CARDIAC ARREST AT PRESENTATION: A SUBANALYSIS FROM THE DISCO REGISTRY
Authors: Giacobbe F , Bruno F , Brero M , Fernando M , Rolfo C , Benenati S , Quadri G , Chiara C , Infantino V , Buccheri D , Bernelli C , Bettari L , Gonzalo N , Pavani M , Scappaticci M , De Filippo O , Boi A , Erriquez A , Musumeci G , Chinaglia A , Patti G , Porto I , Escaned J , De Ferrari G , Varbella F , D‘Ascenzo F , Cerrato E
Published: May 2024

Introduction

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (AMI), which primarily affects young women without traditional cardiovascular risk factors, often presenting as sudden cardiac death. This study aims to investigate the prevalence, characteristics, predictors, and outcomes of cardiac arrest in SCAD patients.

Methods

The DISCO IT/SPA registry, an international retrospective multicenter study, enrolled 375 SCAD patients from 26 centers in Italy and Spain. Patients were categorized based on the presence or absence of cardiac arrest at admission. Data on demographics, clinical presentation, treatment, angiographic findings, and outcomes were collected. Angiograms were independently reviewed, and outcomes included major adverse cardiovascular events (MACE) and in–hospital bleeding.

Results

Among 375 SCAD patients, 20 (5.3%) presented with cardiac arrest. Both groups were similar in age, gender distribution, and conventional risk factors, except for a lower prevalence of dyslipidemia in the cardiac arrest group. ST–segment elevation myocardial infarction (STEMI) presentation and angiographic type 2b were independent predictors of cardiac arrest. Revascularization was more frequent in the cardiac arrest group. In–hospital outcomes, except for longer hospitalization, did not differ. On follow–up (average 21 months), MACE rates were similar between groups.

Conclusions

Cardiac arrest is a notable complication in SCAD, mostly presenting with ventricular fibrillation. The prognosis of SCAD patients presenting with cardiac arrest did not differ from those without, reporting a similar rate of events both in–hospital and during long–term follow–up. STEMI presentation and angiographic type 2b were identified as independent predictors of cardiac arrest in SCAD.
THE INTELLIGENT USE OF ADRENALINE
Authors: Ortello A , Comparato F , Puccio D , Corrado E
Published: May 2024

Case Report

A 52–year–old patient experienced anterior and inferior ST–elevation myocardial infarction, leading to cardiogenic shock necessitating invasive hemodynamic and pharmacological support. During angiography, an intra–aortic balloon pump (IABP) was inserted, and a norepinephrine infusion along with dobutamine was initiated, showing partial clinical and laboratory improvement. Critical disease in all three vessels was detected, prompting angioplasty with stenting of the right coronary artery and left anterior descending artery. Echocardiography revealed severe reduction in left ventricular systolic function (ejection fraction 10%). Despite revascularization and intensive support, the patient‘s hemodynamic status deteriorated (SCAI D), necessitating the addition of adrenaline (0.03 μg/kg/min) to the ongoing dobutamine infusion, suspending noradrenaline. Subsequent days showed gradual improvement, allowing for withdrawal from amine support and discontinuation of the IABP. Follow–up included a cardiac MRI displaying severe systolic dysfunction (EF 21%), extensive ischemic–pattern delayed enhancement across three–vessel distribution. Given the persistent severe left ventricular dysfunction, the patient underwent subcutaneous defibrillator implantation for primary prevention after optimizing anti–remodeling therapy. Despite optimized medical therapy and cycles of levosimendan, the patient experienced heart failure exacerbation, requiring hospitalization (INTERMACS 3). Considering the clinical condition and absence of contraindications, the patient was listed for heart transplantation. Due to refractory hemodynamic instability despite inotropic agents, a left ventricular assist device was implanted as a bridge to transplantation. Roughly 6 months later, the patient successfully underwent heart transplantation without acute complications.

Conclusions

Very low doses of adrenaline demonstrate increased sensitivity to β2 receptors over α receptors, thereby enhancing mean arterial pressure and peripheral perfusion. At the cardiac level, it induces an increase in both heart rate and coronary blood flow, while peripherally reducing resistances, predominantly due to the prevalence of β2 receptors in skeletal muscle. This improvement contributes to the enhancement of ventricular–arterial coupling. In conditions characterized by a primary pump deficit, such as cardiogenic shock, the use of low–dose adrenaline emerges as a valid therapeutic option.
CASE REPORT: SELF–EXPANDING TRANSCATHETER VALVE IMPLANTATION (ACURATE NEO 2) IN A VERY SMALL NATIVE AORTIC ANNULUS
Authors: Casilli F , Medda M , Trovati L , Marchese G , Donatelli F
Published: May 2024

We present the case of a 74–year–old female, symptomatic for dyspnea on exertion, evaluated by our Cardiac Team for severe aortic valve (AV) stenosis. The transesophageal echocardiography showed a stenotic tricuspid AV (valve area of 0.51 cm2, peak and mean gradients of 75 mmHg and 43 mmHg respectively), normal left ventricle (LV) ejection fraction without significant intraventricular gradient. Pre–operative thoraco–abdominal computed tomography angiography showed an AV without significant calcifications, an aortic annulus perimeter of 51.7 mm (area of 207,8 mm2) and a left ventricular outflow tract (LVOT) perimeter of 45.3 mm with elliptical shape (area of 149,9 mm2). The TAVR procedure was performed with an ‘off–label’ implantation of a SE THV with supra–annular location of leaflets (Acurate Neo 2 23 mm), without any predilation. The post–procedural transthoracic echocardiographic study highlighted the correct positioning of the bioprosthesis without significant protrusion in the LVOT and without any interference with the mitral valve apparatus. The main clinical, technical and procedural considerations have been: According to recommendations, the minimum perimeter of 56.5 mm and the minimum area of 254 mm2 represent the lower limits of the sizing guidelines for THV currently available. We used a SE valve with supra–annular location of the leaflets that offers a potential advantage over BE valves and intra annular SE valves, ensuring a larger effective orifice area. We avoided pre– and post–dilatation to reduce the risk of annular damage and/or rupture The precision of THV implantation (with minimal protrusion in LVOT) was maximized when the rapid pacing during phase 2 of the valve deployment was utilized. A short period of DAPT can be considered in order to prevent a potential increase of thromboembolic events secondary to small aortic valve area. In our opinion the main goal is to prevent high implantation and commissural misalignment in order to facilitate the subsequent coronary percutaneous interventions if needed. Even prophylactic coronary stenting (‘chimney fashion‘) should be avoided unless absolutely necessary. These technical considerations applies also to allow a subsequent valve–in–valve (VIV) procedure, if indicated. To our knowledge, this is among the smallest native aortic annulus so far described and treated percutaneously in a tricuspid stenotic aortic valve with a self–expanding (SE) THV Acurate Neo 2.
SEVERE MITRAL INSUFFICIENCY FROM RHEUMATIC DISEASE: A CASE REPORT
Authors: Testa S , Ricci M , Gallina S , Renda G , Ricci F
Published: May 2024

Acute rheumatic fever continues to be a major health problem in many parts of thw world. It’s more common in low–income or developing parts of the world. Antibiotics for bacterial infections may not be available in these areas. In developed countries, cardiac involvement is quite rare. Although traditionally considered to be a disease associated with poverty, rheumatic fever continues to persist even among the middle–class population in developed countries. Children and teenagers with intreated strep infections are the most likely to get rheumatic fever. Signs of heart damage can develop years after the infection. Rheumatic heart disease is the result of valvular damage caused by an abnormal immune response to Streptococcus pyogenes infection. After multiple episodes of rheumatic fever, progressive fibrosis of the heart valves can occur: mitral regurgitation is the most common valvular lesion. We report the case of a 13–year–old, Italian, middle–class girl with rheumatic mitral valve involvement. A 13–years–old comes to the clinic for onset of worsening dyspnea ad easy fatigability. History turns out to be negative for cardiovascular disease and history of recent infections. Echocardiographic examination showed a dilated left ventricle (VTD 148ml, 98 m/mq) with preserved chinese. Severe dilatation of the left atrium with atrio–aortic ratio 2.3 and atrial volume 91 ml/mq. The mitral valve presented a myxomatous, thickened leaflets, predominantly the posterior which appeared retracted and hypomobile with thickening of the subvalvular apparatus with coaptation deficit along the entire coaptation rhyme realizing severe degree insufficiency (CV 7mm, ERO 0.8 cm2, CO 39 l/min). A small cleft at the level of A1, main lesion jet (A1–P3–P2) was also visible. The Echocardiographic appearance suggested outcomes from rheumatic disease so antistreptolysin titer and anti–DNase B antibodies were assayed with high levels found. Penicillin prophylaxis was therefore initiated. For the continuation of the therapeutic course, the case was discussed collegially and a valve replacement rather tan repair was advocated because the valvular and subvalvular apparatus were far too damaged.
CLINICAL CHALLENGE: AORTITIS IN THE EMERGENCY DEPARTMENT
Authors: Renon F , Depaoli A , Quaglia P , Carignola R , Cingolani M , Suppo U , Cannillo M , Grosso Marra W
Published: May 2024

A 67 yo woman presented to the ED for a sustained episode of palpitations and acute chest pain. Past medical history: suspected psoriatic arthritis previously treated with steroids and hydroxychloroquine; previous suspicion of rheumatic polymyalgia and Horton arteritis, regressed with steroids; gastroesophageal reflux disease; mild hypercholesterolemia and a family history of premature coronary artery disease. In the ED the patient was hemodynamically stable. On physical examination: tachyarrhythmic heart sounds with no murmurs. The peripheral arterial pulses were preserved and symmetrical. The remaining physical examination was unremarkable. ECG: atrial fibrillation at 150 bpm. The D–dimer was increased, normal hs–troponin and normal haemoglobin. On echocardiography: normal biventricular structure and function; normal aortic root with dilatation of proximal ascending aorta (47 mm), without visible intimal flaps. The anterior wall of the proximal ascending aorta was thickened. A moderate circumferential pericardial effusion was present, without signs of hemodynamic impact. On suspicion of an acute aortic syndrome with possible intramural haematoma of an ascending aortic aneurism, an urgent CT scan was ordered. It showed a severe dilatation of ascending aorta (52 mm) involving of the proximal aortic arch. The anterior aortic wall was thickened (5 mm), without clear images of IMH, aortic dissection or penetrating ulcer. The pericardial effusion had a supra–fluid density without blood density. A repeated CT at 6 hours showed no changes. The case was suggestive of an inflammatory aetiology. The patient was admitted to the cardiac intensive care unit. A PET–CT scan showed signs of an inflammatory disease of the great vessels. A serological autoimmunity screening was negative. The patient was diagnosed with inflammatory aortitis (giant cell vs Takayasu arteritis) and started on high dose iv glucocorticoid therapy. Given the high risk of severe aortic complications, adjunctive therapy with tocilizumab was prescribed. The therapy was gradually tapered, with subsequent switch to oral steroids plus tocilizumab. At one and a half month of follow–up, a CT scan was repeated, documenting stable aortic diameters and the disappearance of the abnormal thickness and of the enhancement of the aortic wall. A follow–up PET–CT scan has been scheduled at 6 months time. An elective aortic intervention has been indicated after remission of the inflammatory phase.
CLINICAL CASE OF A VERY YOUNG PATIENT AFFECTED BY CAD
Authors: Di Liberto I , Geraci S , Pilato G , Vaccaro G , Milazzo D , Caramanno G
Published: May 2024

Young patient of 24 years old, smoker, dyslipidemic and family history of coronary artery disease (CAD). He was admitted to emergency room for chest pain after moderate effort in December. EKG was normal, troponin was negative and echocardiography showed left ventricle with normal contractility. Blood chemistry test showed LDL 130 mg/dL, Triglycerides 200 mg/dL e Lipoprotein (a) 16 nmol/L. Elective cardiovascular exercise test resulted positive for signs and symptoms of cardiovascular ischemia (Figure 1). Coronary angio–TC showed 60% stenosis of proximal LAD and intramyocardial bridging of mid LAD. Subsequently elective coronary angiography confirmed the description of coronary angio–TC; contextually optical coherence tomography (OCT) was performed and showed fibrous cap rupture of proximal LAD (Figure 2 – 3). The patient was discharged with indication of medical therapy (Cardioaspirina 100 mg, Atorvastatina 40 mg, Bisoprololo 1,25 mg). CAD is a chronic condition usually occurring after the sixth decade of life. However, some populations experience this disease prematurely. In the last few decades, different studies have shown an increased incidence of CAD in very young people. The prevalence of CAD reported in very young people is 1–16%. Clinical and interventional management of CAD in very young people is still subject of discussion today. The literature showed how risk factors such us current smokers, dyslipidemia, and family history of CAD are significantly associated with the existence of severe CAD in patients of ≤40 years. The above risk factors are present in this patient, therefore we opted for correct them by medical therapy and follow–up by OCT at 6 months. The patient was stable and asyntomatic for chest pain at 1 month telephone follow–up.Figure 1.Figure 2.Figure 3.
ST SEGMENT DEPRESSION: MUCH ADO ABOUT NOTHING
Authors: Cherubini S , Gioffrè L , De Luca L , Casteli F , Ciolli A
Published: May 2024

Introduction

ST depression in ECG trace is classically used to assess the cardiac ischaemia. Several other causes of ST depression, like hypokalaemia, digoxin therapy, left ventricular hypertrophy, left bundle branch block can be easily excluded. Sometimes the ST segment depression during tachycardia is observed in young healthy people where ischemic background is rare.

Case Report

We present the case of an asymptomatic and without cardiovascular risk factors 29–years–old man who performed, during occasional sport visit, an ECG showing sinus tachycardia with diffuse ST segment depression. The ECG obtained at the presentation in Emergency Department of our hospital confirmed sinus tachycardia at 140 beats per minute and diffuse ST segment depression. This finding persisted during the following six hours and slowly regressed with normalization of the heart rate. The same ECG alteration was founded during an exercise test when the heart rate rised up to 90 bpm. A coronary angiography showed anatomically normal and angiographically free of stenosis coronaries; the functional study, using Fractional Flow Reserve (FFR), Coronary Flow Reserve (CFR) and Index of Microcirculatory Resistance (IMR), currently gold standard for the functional study of microcirculation, was normal. No alterations were founded at the cardiac magnetic resonance. Due to a previous resting ECG suspected of ventricular preexcitation, an electrophysiological study was performed and showed neither accessory pathways nor inducibility arrhythmias. The asymptomatic and hemodynamically stable patient was discharged and an ambulatorial follow–up was planned.

Conclusion

This case emphasizes the ever–present difficulty of attributing unequivocal etiological meanings to electrocardiographic alterations.
A CASE REPORT OF AN ASYMPTOMATIC PATIENT WITH TYPE 2 WELLENS’ SYNDROME AND RENAL CARCINOMA
Authors: Floris R , Demontis M , Carboni G , Palmas S , Boi A , Delogu G
Published: May 2024

A 65–year–old male with renal cell carcinoma, previously treated with nephrectomy and recently diagnosed with lung metastases, presented to the cardiology clinic for investigations before starting chemotherapy. He reported a history of ischemic heart disease, a non–ST–elevation myocardial infarction for which he refused coronary angiography in 2005, and a negative maximal stress test for ischemia in 2017. Additionally, the patient reported insulin–dependent type 2 diabetes mellitus and well–controlled arterial hypertension. The patient was referred for a cardiological evaluation due to a reported short–term rhythmic heartbeat without other cardiological symptoms. Cardiological parameters were stable (blood pressure: 140/95 mmHg; heart rate: 42 bpm, and oxygen saturation without oxygen supplementation: 98%). Physical examination was normal. Laboratory investigations did not show elevated levels of high–sensitivity troponin I, and only signs of mild chronic kidney disease were observed. The initial ECG showed sinus bradycardia with deeply inverted T–waves in the extended anterior area (Fig. 1), which were not present in an ECG performed one month earlier. There was no reported chest pain. An echocardiogram examination demonstrated hypertensive heart disease with marked hypokinesia of the mid–apical portion of the anterior wall and anterior interventricular septum, together with a moderate reduction in global systolic function (LV ejection fraction: 40%). The patient was hospitalized, and underwent coronary angiography the following day. He had a low–risk score (GRACE: 95 pts) As shown in Fig. 2, there was evidence of long sub–occlusive stenosis of the proximal part of the anterior descending coronary artery that was treated with angioplasty and a single drug–eluted stent placement, resulting in a good angiographic result. After the procedure, there was a rapid recovery of regional kinetics but a slower normalization of the electrocardiographic morphology (Fig. 3).

Comment

Wellens‘ syndrome identifies a particular subtype of unstable angina characterized by the appearance of ischemic changes on the ECG,. The clinical risk assessment of this subgroup of patients with ACS, apparently having a more benign prognosis due to their definition as unstable angina with a low GRACE risk score, potentially has an evolution toward a large myocardial infarction if not promptly diagnosed.