bluuebunny/crossref_metadata_2025 huggingface dataset:
PROGNOSTIC PERFORMANCE OF MECKI SCORE IN HEART FAILURE PATIENTS WITH NON–VALVULAR ATRIAL FIBRILLATION TREATED WITH EDOXABAN
Authors: Mapelli M , Mattavelli I , Salvioni E , Bonomi A , Capra N , Vignati C , Cattadori G , Agostoni P
Published: May 2024

Background

Risk stratification in heart failure (HF) is crucial for clinical and therapeutic management. The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score is a validated HF model to assess the risk of cardiovascular mortality, urgent heart transplantation and Left Ventricle Assist Device implantation at 2 years. The score integrates cardiopulmonary exercise test (CPET) parameters with hemoglobin, serum sodium, kidney function (MDRD), left ventricle ejection fraction, peak oxygen consumption [% pred] and VE/VCO2 slope. Non–valvular atrial fibrillation (NVAF) is a common feature in HF patients. Recently, direct oral anticoagulants (DOACs) were introduced as an alternative VKAs and have now emerged as the preferred choice. Aim of the study was to assess the reliability of the prognostic evaluation by MECKI score also in HF patients treated with Edoxaban for NVAF.

Methods

We prospectively enrolled consecutive outpatients with HF and NVAF treated with Edoxaban. Each patient underwent a maximal ramp–protocol CPET and a blood sampling for complete blood count, serum electrolytes and renal function. This population was matched for age and sex by propensity score with a retrospective group of HF patients with NVAF treated with VKA belonging to the MECKI score registry.

Results

83 patients with HF and NVAF treated with Edoxaban were enrolled. Median follow up was 814[608–1052] days. A control population was identified in the multicentric MECKI score database (n=7800) by selecting all consecutive patients with HF and NVAF treated with VKA (n=844). The population was propensity score–matched for age and sex. Table 1 compares the main population characteristics. MECKI score performs equally well in predicting the outcome in the two groups (AUC matched population 0.73193, AUC Edoxaban group 0.6557, p=ns) (Figure 1).

Conclusion

MECKI score power was confirmed also in the new population treated with Edoxaban with a slightly higher performance respect to patients treated with VKA.
ICU NURSES AND VAD ADHERENCE TO INS 2021
Authors: Patimo M , Fiorini J , Pezzuto M , Grimaldi M
Published: May 2024

Background

Continuous updates and evidence–based nursing practices are vital for quality patient care. In 2021, the Infusion Nursing Standard (INS) have updated vascular access device (VAD) guidelines. Evaluating nurses’ VAD knowledge according to these guidelines will improve caring quality, particularly for ICU patients that need a functioning VAD.

Aim

To evaluate the knowledge of ICU nurses regarding VADs according to the latest INS 2021 guidelines.

Material and methods

A cross–sectional study was conducted on a sample of nurses providing direct care to ICU patients. A web survey was administered using the “Nurses’ Knowledge and Self–Efficacy on Vascular Access” instrument, which assesses nurses’ knowledge and self–efficacy in relation to short (SPC) and long peripheral canula (LPC), PICC, and PORT, as for INS 2021 guidelines. The survey consisted of 32 items with four closed–answer options, of which only one was correct. Competence and skill levels were calculated by summing the correct responses and standardizing the result to 100.

Results

Some 35 nurses have enrolled, with an average age of 37 years (SD= 10.80), including 16 men and 19 women, working in UTIC, ICU and Stroke Unit. The highest adherence score (97%) has been registered for the PICC flushing technique before and after each use. The lowest result (14%) has been obtained regarding the performing method of blood sampling from a central VAD. Other positive results have been achieved in the selection of the correct placement sites for all VAD types, with score exceeding 90%. The second part of the questionnaire, which focused of nurses’ self–confidence, showed that nurses felt most confident in SPC section, followed by the PORT section, LPC, and lastly, PICC.

Conclusions

ICU nurses have a good level of competence and self–efficacy about the VAD management, adhering to the 2021 INS guidelines, although gaps have been identified in the management of SPC and some techniques and despite the high self–confidence expressed directly by nurses. Healthcare organizations should continuously monitor the ICU nurses’ competencies and skills level to implement targeted intervention and ensure the application of evidence in clinical practice, thereby improving the patients’ quality of care.
USE OF CARDIAC CONTRACTILITY MODULATION: OUR EXPERIENCE
Authors: Lamaida N , Masarone D , Uran C , Cerciello A
Published: May 2024

Introduction

Despite strong advances in diagnostic and treatment, heart failure (HF) remains the single largest cause of mortality in the western world.Cardiac contractility modulation (CCM) is a relatively new electrical device–based technique proposed for enhancing ventricular contractile strength of the failing myocardium independent of the synchrony of myocardial contraction. Two prospective randomized multicenter studies have demonstrated improvements in NYHA functional classification, quality of life. CCM therapy is recommended for patients in sinus rhythm with a left ventricular ejection fraction (LVEF) ≥25–35%, NYHA class III and normal QRS duration, as this subgroup of patients seems to benefit most from the therapy. Our Center has started its experience with CCM therapy in the population of HF patients with averagely reduced EF (HFmEF) to avoid acting late when the patient is already a candidate for ICD implantation.

Methods

Our initial experience with CCM therapy in patients with HFmEF concerns 5 patients (4 M and 1 F) implanted from May 2023 to November 2023 with the following data (expressed in median and interquartile range): mean age 62 (range 57– 67aa); with EF 38% (35–38%), all with primary dilated heart disease, QRS preserved/not widened 100 ms (100–110) in maximal medical therapy and (including sacubitril/valsartan and SLGT2 inhibitors) with evaluation through questionnaires of the quality of life (QoL) MLWHFQ with value 44 (44–50) and KCCQ 40 (39.1–40). For three of them there had been at least one hospitalization for heart failure in the last year.

Results

The follow up (FU) is still short (the first patient implanted reached a FU of 6 months) but in the three patients who reached three months of FU an increase in EF was found with a median value of 41% (43–39,5) and an improvement in QoL assessed on the MLWHFQ questionnaires with a value of 18 (27–15) and KCCQ with a value of 72.7 (70–73). None of the five patients have currently had hospitalizations for heart failure.

Conclusions

In our initial experience, CCM proves to be an effective therapy already in the short term, in terms of improvement in EF, QoL and no hospitalization for heart failure. What is highlighted in the literature is confirmed: that is, by acting early we avoid the worsening of EF with consequent ICD implantation, which can be avoided by using all the other weapons available to slow down the progression of heart disease.
A STRANGE CASE OF PULMONARY HYPERTENSION
Authors: Soriente L , Ardovino P , Scalcione M , Sasso C , Aliberti C
Published: May 2024

PH is a haemodinamic and pathophysiological state that can be found in multiple clinical conditions.Chronic hemolytic anemia as sickle cell disease (SCD) is complicated by PH with 30 % of prevalence and worse prognosis.PH in SCD is multifactorial including vasoconstriction, proliferation, obstructive remodelling of the pulmonary vessel wall; inflammation and thrombosis in situ play a role in the pulmonary vascular disease.We have observed a 44–yr old woman affected by sickle cell who developed dyspnoea (WHO–FC III) without chest pain or fever. Transthoracic ecocardiography revealed moderate–severe tricuspid with a gradient of 70 mmHg with an assumed right atrial pressure di 20 mmHg estimated by inferior vena cava, right atrial and ventricular dilatation, reduced TAPSE 16 mm, Ryan index 0.8 with normal size and ejection fraction of left ventricular.Electrocardiogram provided right axial deviation.Computed angiography was normal and ventilation /perfusion lung scan showed an elevated probability for CTEPH. BNP was 921 pg /ml and lung diffusion capacity for carbon monoxide was slight decreased .Prophylactic transfusion during crisis to decrease the frequency of these and new direct anticoagulants were started. After two weeks the patient was in WHO–FC II and transtoracic echocardiography showed a slight tricuspidal regurgitation with a pressure gradient of 40 mmHg with TAPSE of 20 mm and Ryan index was normal.In the new guidelines SCD is moved into Group 5 and our patient was not subjected to specific therapy for pulmonary hypertension. DOAC has showed a reasonable alternative to VKAs for VTE.
INSOMNIA DUE TO HYPERTRIGLYCERIDEMIA CAN BE TREATED BY ROSUVASTATIN/EZETIMIBE
Authors: Fazio G
Published: May 2024

Background

Metabolic syndrome associated with elevated fasting triglyceridemia (TG) is often associated with insomnia. The new guidelines of ESC for dyslipidemia advice the statin and/or ezetimibe treatment like fist line therapy in patients with hypertriglyceridemia, also before then fibrates or omega 3 We examined the impact of rosuvastatin/ezetimibe treatment in reduction of insomnia in patents with hypertriglyceridemia.

Methods

In this study was enrolled a group of 148 patients with hypertriglyceridemia and insomnia. Patients were screened for severe insomnia, defined by a score of four or more on the three Hamilton Depression Rating Scale (HDRS) sleep items, and for HTG characterized by TG≥200mg/dL. The duration of sleep was evaluated with smartwatch every 7 days Mean age was 61,12 years. All patient was admitted in ambulatory of cardiology and were in wash out treatment for dyslipidaemic syndrome. In all we added 20 mg of rosuvastatin plus 10 mg of ezetimibe daily to therapy and reassessed patients after 30 days.

Results

Rosuvastatin/ezetimibe treatment was effective as add–on therapy in reduction of insomnia . All treated patients reported an improvement in symptoms. After 30 days, insomnia disappeared in 69% of patients and was reduced in 21% of patients. The number of the sleeping hours improved from 5:35 min to 7:25 minutes. Therapy was well tolerated in 99% of patents, and stopped only in 2 cases.

Conclusions

Our initial experience with rosuvastatin/ezetimibe in hypertriglyceridemia treatment suggests that this therapy may play a role in the treatment of insomnia.
ACS: MANAGEMENT IN A FIRST LEVEL ED
Authors: Petrelli G , Lattanzio F , Giorgini P , Iachetti M , Orlandi J , Rubini G , Zotti M , Concetti G , Bizzarri M
Published: May 2024

The DIDO is the time between the patient‘s arrival in a center without haemodynamics and the departure by ambulance towards the center with haemodynamics. It affects the D2B and the patient‘s prognosis and is an indicator of the effectiveness of the performance on STEMI care when it is less than 30 minutes. From 2009, a protocol was developed on the management of PCI in our hospital, whose primary objective was the containment of DIDO within 30 minutes. After the application of this protocol we went to evaluate our performance on patients who arrived consecutively from 1 January 2022 to 31 December 2022 at the San Benedetto del Tronto ED, Spoke centre not equipped with haemodynamics. Inclusion criteria: age over 18 years, chest pain <12 hours, discharge diagnosis of STEMI ACS. Excluded 2 patients with cardiac arrest admitted to the ICU, 2 patients with diagnostic uncertainty centralized subsequently, 2 patients with no indication for PCI in emergency admitted to the Cardiac Intensive Care Unit, there are 35 patients, 10 females (29%) and 25 males (71%), with an average age of 64.57 years. Comorbidities were present in 71% of patients (cardiovascular pathologies, diabetes and obesity), while in 29% of patients no comorbidity was present. No comorbidity was observed in 60% of patients between 18 and 55 years and in 30% of patients between 65 and 75 years. We evaluate our performance by comparing the trend, over the years, of this indicator. A reduction in the average DIDO was achieved from 56 minutes in 2014 to 33 minutes in 2022 reaching the value of 17 minutes in 75% of cases. The percentage of cases outside the cut off is 25.71%. We tried to hypothesize the causes responsible for a DIDO>30 minutes: an inappropriate attribution of the priority color code to Triage, the presence of comorbidities. In reality, as well as data from international literature, cases of DIDO >30 minutes were associated with delay accumulated for necessary specialist consultations for difficult to interpret ECGs and the delay of the transport the patient to the Hub hospital. To conclude is necessary direct centralization of STEMI ACS patients from 118 to haemodynamics and reduce centralization decision–making times by identifying criteria facilitating the transfer decision in cases of difficult–to–interpret ECGs.
TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE
Authors: Falagario A , Basile P , Caragnano V , Totaro Fila G , Scialpi A , Nestola P , Pestrichella V , Iliceto S
Published: May 2024

Case Report

A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF.

Discussion

We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.
A TAKOTSUBO SYNDROME TRIGGERED BY HYPOCALCEMIA: THE IMPORTANCE OF ELECTROLYTE BALANCE IN CANCER PATIENTS
Authors: Dicorato M , Falagario A , Basile P , Carella M , Carulli E , Forleo C , Guaricci A , Santobuono V , Ciccone M
Published: May 2024

Introduction

Takotsubo Syndrome (TTS) is characterized by a transient left ventricle (LV) systolic dysfunction usually occurring in postmenopausal women after intense physical or emotional stress.

Case Report

A 75–year–old female patient without a history of heart disease was admitted to our hospital for sudden onset of painful muscle spasms associated with a burning sensation in hands and feet. She also reported peri–oral numbness, dysphagia and nausea. She received, at the age of 68, a diagnosis of metastatic serous ovarian cancer BRCA wild–type at IV stage, treated with surgery and chemotherapy and actually receiving palliative care. On arrival, physical examination revealed Chvostek’s sign and Trousseau’s sign. Laboratory exams displayed a severe hypocalcemia without any other electrolyte derangement and a normal cardiac troponin. The first ECG showed sinus tachycardia with a reduced R–wave progression from lead V1 to V4 and no QT prolongation. Therefore, a treatment with intravenous magnesium and calcium gluconate was immediately started. Subsequently, a marked increase of cardiac troponin was observed, without evidence of chest pain or dyspnea. The transthoracic echocardiography was highly suggestive for TTS with a severe LV systolic dysfunction and an apical ballooning shape. When transferred to our ward, the ECG revealed diffuse ST–segment elevation with concomitant ST–segment depression in leads aVR and V1, requiring an urgent coronary angiography, which found normal coronary arteries. Thus, a guideline directed medical heart failure (HF) therapy was initiated, going forward to correct the serum calcium. Patient’s conditions improved rapidly, and systolic function completely recovered after the restoration of the calcium levels.

Discussion

Among the potentials TTS–triggers, electrolyte impairment is rarely described. Specifically, hypocalcemia is rare and its occurrence in cancer patients may have several causes, from chemotherapy to malnutrition. Moreover, the chronic inflammatory state associated with malignancies may increase cardiac adrenoceptor sensitivity, predisposing frail patients to TTS. Heart involvement and hospitalization can suddenly worsen prognosis especially in end–stage cancer. Therefore, an accurate monitoring of serum electrolytes should be provided in this setting. Calcium replacement and HF therapy are pivotal in this scenario.
ADVERSE EVENTS ASSOCIATED WITH GLP1–RECEPTOR AGONISTS TREATMENT IN DIABETIC PATIENTS WITH HIGH CARDIOVASCULAR RISK: A META–ANALYSIS
Authors: Pozzi A , Cirelli C , Rea F , Merlo A , Iorio A , Iacovoni A , Corrado G
Published: May 2024

Background

GLP1–receptor agonists (GLP1–RA) have been associated with a reduction of cardiovascular (CV) outcomes in diabetic patients with high cardiovascular risk. However, these drugs have some adverse effects. The aim of this study was to assess the relative risk (RR) of adverse effects in patients with a high risk of developing CV disease treated with GLP1–agonists.

Methods

we considered randomized controlled trials (RCTs) aimed to assess the cardiovascular effects of GLP1–RA in diabetic patients with high CV risk. The following outcomes were explored: pancreatitis, severe hypoglycemia, renal and urinary serious adverse events (SAE), gastrointestinal SAE and AE, pancreatic cancer, and neoplasms.

Results

8 RCTs, enrolling 60008 patients, were included in the analysis. There was no difference between GLP1–RA and placebo in the risk of pancreatitis (RR 0.99; 95% CI 0.73–1.35; p=0.972), severe hypoglycemia (0.93; 95% CI 0.76–1.15; p=0.501), renal and urinary SAE (0.94; 95% CI 0.82–1.07; p=0.339), pancreatic cancer (RR 0.98; 95% CI 0.56–1.70; p=0.936) and neoplasms (RR 1.02; 95% CI 0.95–1.09; p=0.547) (Fig 1 A e B). Conversely, GLP1–agonist treatment was associated with an increased risk of gastrointestinal AE (RR 1.95; 95% CI 1.23–3.06; p=0.004) (Fig 2). However, when gastrointestinal SAE were considered, GLP1–agonists demonstrated similar risk compared to placebo (RR 1.09; 95% CI 0.92–1.28; p= 0.318) (Fig 2).

Conclusion

in diabetic patients with high cardiovascular risk, the treatment with GLP1–RA has been associated with an increased risk of gastrointestinal AE. No difference in severe gastrointestinal AE has been associated with GLP1–RA.
TRANSOESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY IN PEDIATRIC PATIENTS WITH VENTRICULAR PRE–EXCITATION
Authors: Catucci S , Lombardi M , Maiorano A , Massari E , Meliota G , Pirolo T , Vairo U
Published: May 2024

Introduction

The transoesophageal electrophysiological study (SETE) is a simple, semi–invasive and highly reliable test for risk stratification in patients with ventricular pre–excitation. In paediatric subjects, symptoms may be nonspecific or poorly reported; hence the usefulness of the study in guiding the therapeutic strategy. The guidelines also suggest performing it in all asymptomatic patients with ventricular preexcitation above 8 years of age.Purpose of the study: to evaluate the inducibility of re–entry tachycardia at SETE in paediatric patients with ventricular pre–excitation.

Materials and Methods

We observed 21 patients aged between a few days of life and 12 years (average age 11 years); 14 of them had constant and 7 intermittent pre–excitations. The latter were subjected to the study as they reported dubious symptoms either due to sports activities or due to a previous diagnosis of neonatal TPS. The study was performed by carrying out the protocols of continuous atrial stimulation at increasing frequencies, programmed atrial stimulation with single, double, and triple extra stimulus and atrial stimulation with burst.

Results

Of the 21 patients, 8 (38.1%) were inducible. Of the 14 patients with constant ventricular pre–excitation, 5 had tachycardia upon return to the study (35.7%), 4 of which were symptomatic due to previous TPS. Therefore, only one patient with constant and asymptomatic ventricular pre–excitation was inducible. Of the 7 patients with intermittent ventricular preexcitation (documented by Holter or exercise test), 3 developed TPS at SETE (42.8%): all these patients complained of heart palpitations but did not have a documented arrhythmia. On the contrary, all patients with intermittent ventricular preexcitation and asymptomatic were found to be non–inducible. In patients in whom it was possible to calculate the effective antegrade refractory period of the anomalous pathway, shorter refractory period showed greater inducibility. Non–sustained atrial fibrillation was induced in only two patients.

Conclusions

SETE demonstrates a good correlation between symptoms and inducibility especially in patients with intermittent ventricular pre–excitation. In fact, if the manifest pre–excitation disappears with growth in about a third of patients, the retrograde conduction capacity of the pathway often persists. The study also allows us to identify patients with constant pre–excitation but pathway at low risk.
SAFETY OF SGLT2 INHIBITORS IN ACTIVE CANCER PATIENTS: RATIONALE AND STUDY DESIGN OF TOSCA TRIAL
Authors: Canale M , Fabiani J , Delle Donne M , Colombi L , Lupo A , Barletta V , Capati E , Orso F , Arena G , Frediani L , Pasanisi E , De Caterina R , Zucchelli G , Emdin M , Casolo G , Camerini A
Published: May 2024

Background

SGLT2 inhibitors have dramatically improved the outcome of heart failure patients with both preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction. Cancer patients have been excluded (or not enrolled) from pivotal trials so data on safety in such population are lacking. We aimed to collect evidence on safety and activity of empagliflozin and dapagliflozin in active cancer patients.

Study Design

TOSCA is a retrospective/prospective multicentre observational trial now enrolling cancer patients receiving SGLT2i for both HFpEF, HFmrEF and HFrEF. Inclusion criteria included active cancer (histologically confirmed current cancer or history of cancer in previous 3 yrs), heart failure (HF) and SGLT2i therapy for HF. Exclusion criteria were age <18yrs, non–melanoma skin cancer and localised cervical cancer undergone radical treatment. Primary objective is assessing the safety of SGLT2i in active cancer patients expressed as percentage of toxicity (in particular hypoglycaemia, genital and urinary infections, acute renal failure, fractures, diabetic ketoacidosis and thromboembolic events) compared to side effects reported in phase III RCTs. Secondary objective is assessing the efficacy (change in EF, NYHA class variation, hospital/ER admissions for HF, need for diuretics) and exploratory objectives are time course variation of cardiac biomarkers, efficacy in the treatment of cardiac toxicity and drug–drug interactions with anticancer or supportive care drugs. A three months minimum follow–up will be required for every enrolled patient. Planned sample size is 80 patients (to be increased to a maximum of 200 cases) equally distributed between the two study cohorts. Relevance of expected results: SGLT2i are one of the pillars of HF treatment; the proof of safety (and activity) in active cancer patients could allow a wider cancer population to benefit of their efficacy in reducing cardiovascular mortality and could provide the rational basis for RCTs testing their role as cardio–protective strategy.
A NEW PROJECT OF A SPECIFIC EXERCISE PROTOCOL FOR AMBULATORY CARDIOVASCULAR REHABILITATION SPECIFIC FOR HEART FAILURE: REPORT OF THE FIRST EXPERIENCE
Authors: Fontana A , Vincenzi A , Rabbiosi P , Maffioli F , Ipsaro S , Merlo A
Published: May 2024

The indication to cardiovascular rehabilitation (CV rehab) was recently upgraded to I A in the European guidelines (GL) for the treatment of heart failure (HF), along with the four pharmacologic pillars. According to this change, we have implemented our CV rehab protocol to include specific exercises for patients (pts) with HF. We present our management of HF pts in CV rehab. According to GL, all pts with HF should receive CV rehab in order to improve their quality of life and reduce readmissions for HF. We can admit up to 18 day–hospital (DH) pts, and starting from October 2023, we implemented a specific excercise protocol for HF pts. They are screened by the physiotherapist on admission day, and all the following activities are tailored based on this initial physical assessment. It includes the 6–minute–walking test (6MWT), the short physical performance battery (SPPB) for the evaluation of lower limbs strenght, and the explanation of the Borg scale. The SPPB evaluates equilibrium, speed and ability to stand up and sit down with a 0–12 score: a score < 6 indicates extreme frailty which contra–indicates training; a score between 7–9 indicates a frail pt, and a score 10–12 indicates a pre–frail pt. Based on this classification, different types of training are proposed: continuous training (CT), exercise training (ExT), interval training (IT) –further distinguished in low intensity (LIT) and high intensity (HIT)–; inspiratory muscle training (IMT) and resistance strength training (RST). At every DH access, pts exercise for 90 minutes alternating RST, IMT and aerobic training on cyclette (HIT). In each case, every 3–4 minutes of effective exercise an absolute pause of up to 90 seconds is observed. Moreover, the "talk test" ensures that at every moment during excercise the pt can talk without dyspnoea. A nurse teaches basic sanitary notions (correct therapy intake, healthy lifestyle, symptoms recognition); a nutrition expert counsels pts about dietary intake; a psycologist supports pts with group and indivisual sessions, whereas the cardiologist optimizes therapy according to laboratory findings, which are modified by the physical training. In this way, the multidisciplinary team–approach to the HF pt allows for a better care of each individual. So far, our pts have appreciated this initiative and are willing to come back again and again. We plan to collect clinical data of all pts treated with this approach and test its efficacy over a two–year period.
EPIDEMIOLOGICAL FRAMEWORK OF MYOCARDITIS DURING SARS–COV–2 PANDEMIC AND VACCINATION CAMPAIGN
Authors: Bonini J , Dal Passo B , Vitagliano A , Bugani G , Pallotti M , Casella G
Published: May 2024

Rationale

Myocarditis is an inflammatory condition of cardiomyocytes whose clinical course can be heterogeneous. Etiologies include infections (mostly viral), drugs or toxic exposures or auto–immunity, while few cases have been reported in association with vaccines (following, mainly, attenuated smallpox vaccine). Estimated prevalence is 2–22 cases/100000 people/year, with greater frequency in males aged 30–40. Since SARS–CoV–2 outbreak and vaccination campaigns there is growing interest in their association with myo–pericardial inflammatory conditions, with incidence reports of 1–5/100.000 and 1–5/1.000.000 respectively among vaccinated and unvaccinated subjects (as part of COVID–19) and relatively higher incidence in males after second (mRNA) vaccine administration.

Study Design and Objective

We designed this observational registry and included patients with CMR–confirmed myocarditis diagnosis admitted to Maggiore Hospital in Bologna from March 2017 to April 2023. Primary goal was to conduct an epidemiological analysis on myocarditis incidence in the era of SARS–CoV–2 and respective vaccination.

Results

We enrolled 48 patients, among which 37 were diagnosed during SARS–CoV–2 pandemic. 86% were male, and mean age at diagnosis was 31 years old; the vast majority did not show major modifiable CV risk factors (apart from cigarette smoking: 42%) or previous/comorbid CV conditions. Median LVEF (by CMR) at diagnosis was 56%, with 3 patients (6%) with LVEF < 47%. Median hsTnI and CRP peaks were respectively 7317 ng/L and 4,5 mg/dl. We reported 6 (12.5%) arrhythmic events during index hospitalization (1 patient had sustained VT and 5 had non–sustained VT). 8 out of 37 patients with myocarditis during SARS–CoV–2 outbreak reported previous COVID–19, with a median time of 130 days from infection, but only 1 had myocarditis as part of its clinical course. 16 patients had already received at least one SARS–CoV–2 vaccine dose (median: 2 doses) at diagnosis, with a median time of 117 days from dose administration (only two patients were diagnosed < 30 days from last administration).

Conclusions

Myocarditis epidemiology of our cohort seems to reflect available incidence data; furthermore, myocarditis as part of COVID–19 course or occurring shortly after vaccination appears to be an uncommon event. Our cohort consisted only of low or intermediate risk presentations. Data about diagnosis in the “COVID era” suggest a relative “underdiagnosis” in the previous period.
OUT–OF–HOSPITAL FLUID INFUSION IN THE SHOCK PATIENT: A SYSTEMATIC REVIEW OF THE LITERATURE
Authors: Palmieri T , Boni D , Conte A
Published: May 2024

This paper considers nursing in the critical care area and more specifically as the main topic, the use of volemic replacement fluids in the broad pathology of shock, applicable by the EMS. Shock is an acute, life–threatening pathological condition of the patient leading to cell and tissue hypoxia resulting in cell death and dysfunction of vital organs. The mechanism leading to such suffering may be decreased intake, increased consumption, improper oxygen utilization, or a combination of these three circumstances. The main cause turns out to be circulatory failure, clinically better known as hypotension. The literature demonstrates how important and critical fluid infusion appears to be in this type of patient. The following review of the bibliography aims to identify and collect the various scientific evidences by evaluating the best solution to infuse, the right dosage, and the target pressor to achieve depending on the type of shock: hypovolemic, distributive, cardiogenic, obstructive. The identification of the best infusible solution is one of the key points of acting in these scenarios as well as the target pressor set (permissive hypotension); it has emerged from the consultations that in the out–of–hospital setting colloids are not recommended because of the consequences compared to crystalloids. In the last decade, special attention is paid to permissive hypotension, that is, the target pressor to be achieved depending on the type of shock, showing how inappropriate fluid administration, in terms of quantity and type of substance to be used, is counterproductive to outcome. The literature shows how an abundant infusion of fluids can alter coagulation or sometimes induce the patient to ARDS; there is also evidence of how in hypovolemic shock the infusion of saline is not recommended, preferring a balanced solution, while in myelic shock saline is preferred.
ISCHEMIA WITH NON–OBSTRUCTIVE CORONARY ARTERY DISEASE (INOCA): A SINGLE CENTRE EXPERIENCE
Authors: Monaco S , Di Serafino L , Ciaramella L , Carbone C , De Rosa M , Mitrano L , Esposito G
Published: May 2024

Background

Myocardial ischemia with non–obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced quality of life, myocardial infarction and heart failure. INOCA is usually under–diagnosed precisely. We report our experience for endotype characterization, tailored therapy and short term follow up.

Methods

Thirty–five patients presenting with clinical presentation of chronic ischemic heart disease requiring coronary angiography for diagnosis, who referred to our department between October 2022 and December 2023 were included. All patients with acute coronary syndrome (ACS), prior artery bypass grafting (CABG), presence of obstructive CAD (stenosis > 70% or FFR < 0.80), sever valvular heart disease and EF < 40% were excluded. All patients were clinically evaluated and subjected to validated questionnaires to characterize angina and quality of life. Subsequently, functional coronary angiographic evaluation was carried out, through the bolus thermodilution method using adenosine, including a study of the fractional flow reserve (FFR), the determination of coronary flow reserve (CFR), and the index of microvascular resistance (IMR), specific for the microvascular district. Finally, acetylcholine test to evaluate the presence of any epicardial vasospasm. Based on the results of these evaluations, 4 endotypes can be identified: microvascular dysfunction (CMD), vasospastic angina (VSA), both CMD and VSA and non–cardiac chest pain.

Results

The majority of patients were female (63%), with hypertension (86%), hyperlipidemia (86%) and diabetes (23%). They presented with typical angina (87%) and half of them (60%) undergone provocative ischemia tests (76% tested positive). Following functional coronary angiographic evaluation, 57% patients had a diagnosis of INOCA, of these 30% microvascular dysfunction (CMD), 40% vasospastic angina (VSA), 30% both CMD and VSA. The acetylcholine test was performed in all patients, resulting positive in 14 out of 35 (40%). Each patient was prescribed a personalized therapy. Short term follow–up was performed with a general improvement in symptoms following optimized medical therapy.

Conclusion

INOCA is a heterogeneous nosological entity, underdiagnosed and often poorly treated. Invasive functional angiography is helpful to identify endotypes and appropriate therapy with a significant clinical benefit.
TWO YEARS–EXPERIENCE OF REFERENCE REGIONAL CENTER FOR SPORTS IN PEOPLE WITH HEART DISEASE: CARDIOMYOPATHIES CASE SERIES
Authors: Vessella T , Giorgiano F , Pegoraro C , Merlo L , Barra B , Meneguzzo G , Sarto P
Published: May 2024

Whether patients with cardiomyopathies can exercise or not and what is the right dose in terms of intensity and frequency has always been a debated topic in cardiology and even today there are few indications in this regard. There are many elements to take into account in order to formulate a correct exercise prescription. First of all, the patient: his/her awareness of pathology, years since diagnosis, sports he/she practiced, volume of training he/she carried out. Then the pathology: phenotype, genetic mutations, history of cardiac arrest, presence of an ICD, risk of arrhythmic events. At the end, sports/exercise: it is important to distinguish between competitive sport and physical exercise and to consider that there are different training modalities and different possible intensities whose determination often requires more parameters than just heart rate. All these aspects are integral part of our "Julian Ross‘ Second Half" program that includes medical and psychological assessment, two moments of counselling, a period of supervised training and, finally, the return to physical activity with modalities and intensities compatible with the pathology. Our current series includes 45 patients with cardiomyopathies (39 men and 7 women, 19 hypertrophic cardiomyopathies mean age 44 years ± 17, 22 arrhythmogenic cardiomyopathies mean age 35 years ± 18 and 4 dilated cardiomyopathies mean age 19 years ± 4). We offered these patients a personalized exercise prescription after performing a complete risk stratification and a cardiopulmonary exercise stress test. All patients were prescribed aerobic and resistance training with intensities depending on the pathology, the ventricles involved, evidence of exertional obstruction, exertional arrhythmic burden, specific mutations etc. Both during supervised training sessions at our gym and the average follow–up of 18 months, we didn‘t recorded any cardiovascular major events. None of the patient who followed our indications showed a worsening of the pathology in terms of arrhythmic burden and ventricular involvement, while there was an increase in VO2 max.

Conclusions

Our case series demonstrate, even though in a short follow–up period, that aerobic and resistance training prescribed in a personalized way does not lead to a worsening of the disease and to adverse outcomes in an average follow–up of 18 months.
"UNUSUAL" ATRIAL FLUTTER: A CASE REPORT
Authors: Diella N , Sacchetta D , Genovesi E , Lombardi E , D‘Alleva A , Cappelli C , Di Marco M , Paloscia L
Published: May 2024

A 64–years old male patient was admitted in the Emergency Department with signs of heart failure in a setting of dilated hypokinetic cardiomyopathy with severe depression of left ventricular ejection fraction and no severe coronary artery disease. In the previous medical history: systemic arterial hypertension, obesity, dysthyroidism due to amiodarone, history of atrial fibrillation treated by transcatheter ablation in the left atrium with pulmonary veins isolation (PVI) and the creation of an anterior line in 2010. The ECG documented an atrial flutter rhythm 2:1 probably typical (Fig. 1). An indication was therefore made for hospitalization in Cardiology. After the restoration of a good hemodynamic state, given the persistence of the atrial tachyarrhythmia, an indication for transcatheter ablation was formulated. The electrophysiological study highlighted an activation sequence suggestive of typical common flutter (cranial–caudal right atrial activation; proximal–distal left atrial activation). We then proceeded to ablate the cavo–tricuspid isthmus without interrupting the arrhythmia. Therefore, left and right atrial electroanatomical mapping was performed which confirmed the right isthmic block and documented the left origin of the flutter, showing conduction gaps in the ostia of the pulmonary veins and in the previous anterior ablation line between the mitral annulus and the right superior pulmonary vein (RSPV) (Fig 2,3). Ablation of these gaps effectively stopped the arrhythmia. At the end of the procedure, after stimulation via atrial bursts of up to 200 msec there was no induction of arrhythmias. One month after the procedure, there was an improvement in the contractile function of the left ventricle. Discussion: This clinical case offers us an example of how the analysis of the surface ECG alone is not sufficient to adequately describe the complexity of the arrhythmic substrate characterizing an arrhythmia such as atrial flutter or atrial fibrillation. The electrophysiological study through electroanatomical reconstruction of endocavitary activation proves indispensable for the correct identification and consequent treatment of these complex arrhythmias, with clear clinical benefits for the patient.
A THICKENED LEAFLET: INFECTION OR SOMETHING ELSE?
Authors: Corsi E , D’Aiello I
Published: May 2024

Background

Prosthetic valve thrombosis is a rare but serious complication of valve replacement; it occurs more often in mechanical valves, but it can also be observed in bioprosthesis. It is associated with significant morbidity and mortality, thus the necessity of a prompt diagnosis and adequate treatment.

Case Description

A 81–years–old woman presented to the ED for progressive worsening dyspnoea and abnormal heart beat. She had undergone mitral plasty some years before and, few months before the access, a new cardiac surgery had been performed with implantation of a mitral bioprosthetic valve, tricuspid annuloplasty and LAA closure. After discharge she had been hospitalized for genitourinary tract infection, and twice for heart failure and atrial flutter. During this period, the anticoagulant therapy had to be modified for difficult warfarin management, and, after an appropriate period, had been switched to NOAC. At the admission to our ICU, the patient presented pulmonary oedema and transthoracic echocardiogram showed mitral prosthetic valve dysfunction with thicked and ipomobile leaflets and increased transvalvular gradient. In the suspect of IE empiric antibiotic therapy was introduced; UFH and inotropic support was also administered. The patient promptly undergone to TOE, that confirmed the severe thickening of the bioprosthetic valve leaflets resulting in severe stenosis, rising thus the suspect of bioproshetic thrombosis, that was found to be extended to inferior and superior vena cava. Despite the ongoing therapy, the patient hemodynamic kept worsening, and in the end fibrinolytic therapy was administered with rapid improvement in clinical conditions and bioprosthetic transvalvular gradient fall. During the following hospitalization the patient clinical and hemodynamical status kept recovering, and a new TOE confirmed the almost complete resolution of the thrombosis. The patient was then shift again to warfarin and discharged; during the hospitalization IE was excluded. A TOE performed after one month of oral anticoagulation confirmed the regular function of the mitral bioprosthesis.

Conclusion

This case shows a subtle but life–threatening case of prosthetic valve thrombosis and underlines the importance of searching for this condition even in biological prosthetic valves. It also shows the role of TOE in the diagnosis and management, and lets some questions open about anticoagulation therapy.
AGENESIS OF THE LEFT PERICARDIUM: REPORT OF A CASE
Authors: Placci A , Palumbo A , Suma S , Tadonio J , Niccoli G
Published: May 2024

We report a case of left pericardial agenesis in a 61 year old man presenting palpitations, without syncope. Clinical picture was not specific on clinical field: atypical chest pain, systolic murmur 2/6 Levine on the second left interspace were found. ECG showed sinus rhythm, clockwise deviation of axis in the precordial leads and incomplete right bundle branch block. Frequent isolated polymorphic premature extrabeats. Holter ecg was perfomed: frequent polymorphic extrabeats (9834/24 ore) with some couplets and triplets, without sustained ventricular tachycardia episodes. Starting metoprololo 100 mg per day the arrhythmic burden decreases significantly. Chest X–ray showed marked levocardia and dilatation of pulmonary trunk. Levocardia increased with the patient on the left side. Levoposition of the heart, lung interposition between the diaphragm and the base of the heart and between the aorta and pulmonary artery Echocardiography showed a classic abnormal swinging motion of the heart in the chest, a paradoxical interventricular septal movement, apparent right–sided heart enlargement, with unusual bulging of the apex of the right ventricle. Magnetic resonance imaging (currently the gold standard for diagnosing) confirmed the absence of the left pericardium, and a left pericardial agenesia diagnosis was performed Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. We analyze the diagnostic problems and the prognostic doubts of this rare congenital anomaly.
A CHALLENGING CASE OF PERCUTANEOUS ATRIAL SEPTAL DEFECT CLOSURE
Authors: Carluccio R , Riegler L , Forni A , Molinari R , Parlati A , Quaranta G , Pastore F , Zambrano A , Santoro G , D‘Andrea A
Published: May 2024

ASDs account for 13% of all congenital heart diagnoses at birth but remain asymptomatic until adulthood, when atrial arrhythmias, paradoxical embolization or pulmonary hypertension can develop. A 46–year–old woman, without significant cardiovascular history, was admitted to Cardiology Department for dyspnea at exertion. TTE showed an ASD OS type with large left–to–right shunt (Qp/Qs >1.5) and right heart volume overload, dilated right chambers (RVD0: 50 mm) with good longitudinal ventricular function (TAPSE: 29 mm), moderate tricuspid regurgitation with PAPs estimated of 45 mmHg (TAPSE/PAPs: 0.64). TEE confirmed the presence of a 2 cm circular defect (2.01 cm at 61°, 1.98 cm at 91°, 1.92 cm at 98°), posterior and with a small IVC rim (PS rim: 0.571 cm at 0°, PI rim: 0.670 cm at 59°, IVC rim: 0.466 cm at 112°) but eligible to percutaneous closure. ASD was intra–procedure measured in 3 different TEE planes (0°, 45° and 90°) estimating the device size by adding 30% to the largest measurement (2.53 cm considering an ASD of 1.95 cm). With sizing balloon ASD balloon–stretched diameter resulted 2.25 cm at fluoroscopy and 2.56 cm with stop–flow CDUS technique. The procedure was therefore performed with the implantation of a 2.6 cm device, with good angiographic and echocardiographic final result. At 1–month follow–up TTE, device resulted in proper position without trivial leak, right chambers were less dilated (RVD0: 42 mm) with good longitudinal ventricular function (TAPSE: 32 mm), residual mild tricuspid regurgitation with PAPs estimated of 42 mmHg (TRV: 3.06 m/s, TAPSE/PAPs: 0.76).