bluuebunny/crossref_metadata_2025 huggingface dataset:
GENDER DIFFERENCES IN MORTALITY RISK AFTER TAVI: UNRAVELING THE ENIGMA THROUGH BODY COMPOSITION ANALYSIS
Authors: Casirati A , Somaschini A , Cornara S , Olivotti L , Giachello V , Astuti M , Botta M , Ghione M , Buscemi M , Cereda E , Caccialanza R , Bellone P , Cordone S
Published: May 2024

Introduction

In the context of Transcatheter Aortic Valve Implantation(TAVI), females often present with higher Society of Thoracic Surgeons(STS) mortality score values. Paradoxically, however, they tend to exhibit greater survival post–TAVI compared to males. Previous literature has shown that body composition(BC) may affect prognosis in cardiometabolic diseases. Specifically, increased visceral adipose tissue(VAT) and decreased skeletal muscle(SM) have been associated with worse outcomes, whereas subcutaneous adipose tissue(SAT) has shown a protective role. Nevertheless, whether these factors specifically interact with outcomes in relation to gender in patients treated with TAVI is still unknow.

Methods

Data of patients who underwent TAVI in 2010–2022 were collected. The areas of SM, VAT and SAT were measured from scans at the third lumbar vertebra of preoperative CT exams. Variables are expressed as median[25p–75p] or absolute number(%) and were compared by Mann–Whitney and Chi–square test as appropriate. Mortality analyses were performed through Kaplan–Meier curves with log rank test and Cox regression models.

Results

We enrolled 168 consecutive patients, including 89(53.3%) females. The median age was 84[81–86] years. In comparison to males, females exhibited higher values of STS mortality score (4.2[3.1–6.3] vs. 3.5[2.4–5.4], p=0.021) and SAT (189[111–242] vs. 135[92–170] cm2, p=0.001), along with lower values of SM (92[81–106] vs. 129[115–144] cm2, p<0.0001) and VAT (116[48–197] vs. 210[118–266] cm2, p<0.0001). Additional differences are detailed in Table 1. The overall 1–year mortality was 15.6%, with females exhibiting lower mortality rates compared to males (10.1% vs. 21.8%, OR=4.5, p=0.033), as illustrated in Figure 1. In the multivariate analysis, female sex emerged as an independent predictor of better survival after adjusting for the STS mortality score (HR=0.4, 95% CI 0.2–0.9, p=0.028).

Conclusions

In our cohort, female patients experienced lower 1–year mortality after TAVI compared to males. As females showed less SM and VAT and more SAT, we hypothesize that the interplay between muscle and adipose tissue, along with hormonal, inflammatory, and metabolic mechanisms, may create a more favorable cardiovascular environment, counteracting the higher pre–procedural STS mortality score. A distinct pattern of BC appears to be protective in female patients undergoing TAVI, and its evaluation could help optimize gender–specific risk stratification.
ATRIAL VOLTAGE ANALYSIS FOLLOWING VEIN OF MARSHALL ETHANOL INFUSION PREDICTS MITRAL LINE BLOCK
Authors: Taddeucci S , Garibaldi S , Nesti M , Landra F , Startari U , Panchetti L , Mirizzi G , Lionetti V , Piacenti M , Marchese P , Rossi A
Published: May 2024

Background

The vein of Marshall (VoM) is a promising target for atrial fibrillation (AF) treatment, matching with the ‘Coumel triangle‘ by housing triggers, autonomic connections, and serving as a substrate for perimitral flutters. Lateral mitral line (ML) represents a fundamental part for AF treatment, but achieving bidirectional block through endocardial ablations is challenging. VoM ethanol infusion (VOM–EI) facilitates ML block, with the newly–formed bipolar lesion serving as an effectiveness index. Voltage analysis assessment after VOM–EI in predicting ML block is poorly investigated.

Purpose

To compare unipolar and bipolar low–voltage areas (LVAs) along VOM trajectory after VOM–EI, and their role in predicting ML block.

Methods

We enrolled 59 patients undergoing catheter ablation of persistent AF or ML–dependent atrial flutter. High–density voltage mapping of left atrium was followed by VOM–EI and LA remapping. The area width difference was obtained and defined as ΔLVA. Normal bipolar voltage cutoffs were 0.50 mV in sinus rhythm or 0.29 mV in AF. Unipolar cutoffs were 2.7 mV and 1.1 mV, respectively. After VOM–EI, anatomical lesions included PVI, linear lesion for dome and ML isthmus. Systematic lines block validation was performed, defining ML block after coronary sinus (CS) electrograms sequence inversion (septal–to–lateral) during left atrial appendage pacing. Radiofrequency (RF) applications into the CS–great cardiac vein targeted epicardial gaps if present. Ablation time for ML block (AblTime) was obtained.

Results

In our cohort, 94.5% achieved ML block. Bipolar and unipolar low voltage areas after VOM–EI were 9,9 ± 6,9 cm2 and 12,2 ± 5,9 cm2 respectively. Bipolar ΔLVAs were significantly lower than unipolar ΔLVA (8.2 ± 6.5 cm2 vs. 9.4 ± 6.0 cm2; p=0.03) (Fig 1). A strong linear correlation between AblTime and bipolar ΔLVA (R: 0.76), and a significant correlation between AblTime and unipolar ΔLVA (R: 0.6) were found (Fig 2). Patients requiring RF applications into the CS for ML block (13/59, 22%) showed lower ΔLVAs in logistic regression for both bipolar (p<0.01) and unipolar (p=0.03) analyses.

Conclusions

VOM–EI induces unipolar LVAs wider than bipolar along the mitral isthmus trajectory. Unipolar and bipolar voltage analysis predicts a short time ML block achievement. Moreover, wider unipolar and bipolar LVAs following VOM–EI correlates with higher likelihood to avoid the targeting of epicardial gaps via the CS musculature.
AN ODD CASE OF GIANT INTRAPERICARDIAL MASS
Authors: Maurizi K , Vagnarelli F , Lofiego C , Capodaglio I , Patani F , Tofoni P , Brugiatelli L , Pietrucci F , Dottori M , Pupita G , Schicchi N , Fogante M , Esposto Pirani P , Dello Russo A , Perna G
Published: May 2024

A 70–year–old man was admitted to our emergency department (ED) for chest pain during the previous 3 days variable with breathing and chest movements. Clinical history included chronic coronary syndrome (2018: transient ST–segment elevation treated with PTCA + DES on proximal LAD), chronic kidney disease (CKD), chronic myeloid leukemia, chronic hepatitis B and C. At the ED an ECG showed atrial fibrillation (AF) with medium ventricular response (100 bpm). Transthoracic echocardiogram (TTE, Fig.1a, 1b, 1d) and transesophageal echocardiogram (TEE, Fig.1c) revealed a voluminous roundish iso–ipoechoic mass (“red star”) with regular and hyperechoic margin, apparently intrapericardial and close to the lateral wall of the left atrium, measuring 8 x 5.5 x 2 cm, without infiltrating the wall and without obstructing pulmonary veins return. Minimal pericardial effusion was present. On contrast TTE (Sonovue) there was no uptake of contrast agent (Fig.2a). The MRI (Fig.2b) showed a heterogeneous formation with slight late contrast enhancement consistent with intrapericardial hematoma. We submitted the case to cardiac surgeons who recommended close echocardiographic follow–up, given the absent hemodynamic impact of the mass. Management of pericardial hematoma in this clinical setting is controversial, it has limited available evidence, and thus there is significant variability in clinical practice. Due to AF, anticoagulant therapy with warfarin (imbricating with heparin) was initiated; anti–inflammatory treatment with ibuprofen and colchicine was prescribed. The patient was discharged in good general conditions. One month later we scheduled a follow–up visit with echo: a clear volumetric reduction of the intrapericardial hematoma was documented (Fig.3) and the patient reported a complete disappearance of the symptoms. We chose this case to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac/pericardial masses; among others, MRI certainly represents the gold standard in this field but also Sonovue contrast echocardiography is definitely useful. Furthermore, a multidisciplinary approach involving clinical cardiologists, radiologists and cardiac surgeons is essential.
NOSOCOMIAL ENDOCARDITIS ON AORTIC BIOPROSTHESIS, A CASE OF ACCELERATED ATHEROSCLEROSIS
Authors: Di Marino M , Genovesi E , D‘ Alleva A , Magnano R , Pezzi L , Gallina S , Vitulli P , Forlani D , Corazzini A , Di Marco M , Paloscia L
Published: May 2024

Male, 79 years old, presented to the ED with chest pain and hemodynamically instability. Approximately one month prior, he underwent aortic bioprosthesis implantation for severe aortic stenosis. Pre–intervention coronary angiography revealed diffuse atheromatous plaques, none of which were stenotic. Additionally, the patient‘s medical history included paroxysmal atrial fibrillation on NOAC, hypertension and COPD. Upon admission: NIBP 80/50 mmHg, HR 150 bpm, and oxygen saturation was 85%. ECG showed atrial fibrillation with ST–segment elevation from V1 to V5. Arterial blood gas analysis revealed pH 7.25 and lactate 6 mmol/L. He received inotropic and vasopressor support, and prompt coronary angiography was performed, revealing 99% stenosis of the mid left anterior descending artery at the bifurcation with the diagonal branch, which was treated with angioplasty and coronary stent placement (Fig.1). Transthoracic echocardiography demonstrated the presence of the aortic bioprosthesis with diffusely thickened leaflets consistent with multiple vegetations. Transesophageal echocardiography confirmed a nosocomial infectious endocarditis, with mild–to–moderate stenosis, and evidence of peri–prosthetic echogenic material directed towards the left atrium, suggestive of abscess. The patient reported low–grade fever and asthenia in the weeks prior. The systemic and local inflammatory state of the endocarditis contributed to an accelerated atherosclerotic process, destabilizing the plaque and resulting in its rupture. Blood cultures identified multidrug–resistant Staphylococcus hemolyticus, for which specific antibiotic therapy was started. The patient and his family declined cardiac surgery due to high operative risk. Follow–up TEE, after approximately six weeks of intravenous antibiotic therapy, showed reduced vegetations on the bioprosthetic valve leaflets, with evolution of the previously noted large echolucent cavity, along with two similar peri–prosthetic lesions. These findings were confirmed on contrast–enhanced CT. The patient, achieving hemodynamic stability, was discharged home, continuing intravenous antibiotic therapy (OPAT protocol). At the one–month post–discharge follow–up, the patient was asymptomatic and hemodynamically stable. A repeat TEE showed normally mobile bioprosthetic valve leaflets without vegetations, and the previously noted large cavity with internal flow, consistent with cleansed abscess (Fig.2–3).
CARDIAC IMPLANTABLE ELECTRONIC DEVICES IN DIFFERENT ANATOMICAL TYPES OF PERSISTENT LEFT SUPERIOR VENA CAVA: A CASE OF INNOVATIVE SOLUTION OF PACING
Authors: Valecce R , Montemurro M , Incampo G , Moramarco M , Bonfantino M
Published: May 2024

A male patient(pt)76y old hypertensive,smoker underwent a right vocal cord biopsy.At the end of that procedure he presented lightheadedness and fatigue,with junctional escapement rhythm at the mean ventricular rate of 45 bpm and marked sinus bradycardia unresponsive to therapy.He was transferred to the cardiology intensive care unit(ICU).ECG:no atrial activity with ventricular escapement rhythm at 40 bpm.Color Doppler CDE (CDE):mild uniform left ventricular hypertrophy,normal ventricular functionality with 60% LVEF,coronary sinus(CS) dilatation as persistence of left superior vena cava (PLSVC).Isoprenaline infusion was started.Evidence ECG monitoring of sporadic and symptomatic sinus pauses lasting up to 4600 msec.A pacemaker(PM)implant was indicated under ESC 2021 guidelines(GL).Phlebography was done in the cathlab which confirmed PLSVC draining into the CS and no anonymous vein connecting the right and left superior vena cava (LSVC) and right subclavian draining into the PLSVC was documented through right phlebography.In accordance with ESC GL,we implanted a leadless VVI PM.PLSVC is a congenital anomaly due to an abnormal CS development during early fetal life with an incidence ranging from 0.3% in the general population to 4.3%.In 8% of cases,it drains into the left atrium causing hemodynamic changes as a left–right shunt.In the vast majority of cases it drains into the CS and remains asymptomatic.The unexpected presence of a PLSVC can complicate PM implantation,increasing the procedure time or forcing the operator to reinitiate the procedure on the right if a right SVC is present.In our case,both venous accesses were abnormal.The pt was a candidate for PM implantation via PLSVC as already demonstrated in the literature but this approach would have used the only upper venous access available,impacting the feasibility of future upgrading procedures.An epicardial PM implantation could have been an alternative but this approach was considered anachronistic.We opted for the implantation of a leadless VVI PM.This is recommended by ESC GL in class IIB.Essential information that contributed to our decision was knowing that the pt was a caregiver of a bedridden relative and needed to carry heavy weights as soon as possible after discharge.This choice ensured our pt a minimally invasive implant with the same length of stay as a transvenous PM,low infection risk,and preserved only venous access,albeit abnormal,for potential future procedures.
HYPOCALCEMIC CARDIOMYOPATHY PRESENTING AS HEART FAILURE EXACERBATION DUE TO UNTREATED PRIMARY HYPOPARATHYROIDISM: A CASE REPORT
Authors: Mapelli M , Nepitella A , Ferdico S , Formenti A , Baggiano A , Campodonico J , Ranieri M , Vettor G , Sambenedetto M , Basso C , Agostoni P
Published: May 2024

Introduction

Hypocalcemic cardiomyopathy (HC) is a rare and potentially reversible cause of heart failure (HF). Primary hypoparathyroidism, due to accidental damage to the parathyroid glands during thyroid surgery, is one of the most common causes of hypocalcemia. Identifying this etiology is crucial.

Case Report

A 54 y.o. patient affected by arterial hypertension and hypothyroidism, presented to our hospital with HF. He underwent total thyroidectomy 20 years earlier. An echocardiogram revealed a dilated cardiomyopathy with systolic dysfunction (LVEF 22%), reduced right ventricular function and elevation in pulmonary artery pressure. ECG showed sinus rhythm, QTc 470 msec. BNP was increased (1888 pg/ml) and troponin value normal. Blood calcium and phosphorus values were not performed on admission. Intravenous diuretic therapy led to good clinical response and disease–modifying therapy (bisoprolol, sacubitril/valsartan, eplerenone) was started and uptitrated. Coronary CT excluded significant coronary lesions. Cardiac MRI showed increased native T1–T2 values and an intramyocardial "patchy" distribution of late gadolinium enhancement involving the interventricular septum. Endomyocardial biopsy excluded the presence of viral DNA/RNA and signs of active inflammation. After few days an episode of dysarthria, spatial/temporal disorientation and muscle spasms was reported. Urgent brain CT was performed, which excluded acute ischemic or hemorrhagic events, but diffuse basal ganglia calcification. Blood tests revealed severe hypocalcemia in the setting of primary hypoparathyroidism (total calcium 1.57 mmol/L, ionized calcium 0.61 mmol/L, PTH 8,8 pg/ml). Trousseau‘s sign ("obstetrician’s hand”) was positive, suggesting the presence of latent tetany. Hypocalcemia was corrected with calcium carbonate and calcitriol administration. On ECG QTc was 522 msec with subsequent normalization. In the following days, progressive neurological improvement was reported. After a week he was discharged in good status. At follow–up we observed a progressive improvement in biventricular systolic function with complete normalization of LVEF and ventricular volumes at 9 months.

Conclusion

HC must be suspected when a patient presents with myocardial dysfunction, neuro–muscular signs and QT prolongation on ECG. Diuretics administration may aggravate hypocalcemia by increasing urinary calcium excretion. Normalization of calcium concentration could lead to complete recovery.
ALL THE ROADS LEAD TO THE MYSTERIOUS DISEASE
Authors: Polito D , Piscione M , Nafisio V , Ussai G , Grogioni F
Published: May 2024

A 58–year–old man with familiarity for sudden cardiac death was accepted to the hospital for dyspnea. Two years before he underwent cardiac angiography which showed a significative lesion of the descending artery which was treated with the placement of a drug eluting stent. For the appearance of an atrio–ventricular block 2:1, a permanent pacemaker was implanted. A transthoracic echocardiogram demonstrated: mildly dilated left ventricle with a reduced global systolic function (calculated ejection fraction was of 25%). Computed tomography with intravenous contrast of the chest showed upper, mid and lower multifocal nodularity with irregular margins with predominantly peri –bronchial distribution. The patient underwent bronchoscopy with endotracheal ultrasound and multiple transbronchial biopsies. Bronchoalveolar lavage (BAL) was negative for fungi infections, bacteria (including Mycobacterium Complex), and malignant cells. Endobronchial biopsies revealed non–necrotizing, well–formed granulomas embedded in dense hyaline sclerosis. Also the ratio of CD4+/CD8+ cells was within limits. FDG PET–TC scan showed: multiple enhancing areas in the lungs and lymph nodes probably of an inflammatory nature and therefore compatible with pulmonary sarcoidosis. A high dosage cortisone therapy was started, the patient was transferred to undergo endomyocardial biopsy, subsequently tested positive for multisystemic disease. Sarcoidosis is a rare disease with extremely heterogeneous clinical presentations. Actually, it is characterized by non–necrotizing granulomas, aggregates of epithelial cells, macrophages, multinucleated giant cells and CD4+ T lymphocytes, which infiltrate different tissues. When symptomatic, cardiac sarcoidosis includes conduction abnormalities, arrhythmias and ventricle dilation with hearth failure. Rhythm disorders, which rang from first to third degree, are the most common manifestation together with atrial fibrillation and ventricular tachyarrhythmias which can be explained with reentrant mechanisms from the granulomatous scar. Both atria–ventricular blocks and history of ventricular tachycardia elevate the risk for sudden cardiac death, which may be the first and unique manifestation of the disease. If myocardial involvement is extensive, cardiac sarcoidosis can present with hearth failure.
UNEXPECTED RIGHT ATRIAL MASS IN A YOUNG WOMAN: AN UNPLEASANT SURPRISE
Authors: Mastroberardino S , Piccirillo F , Fiorentino M , Grigioni F , Ussia G
Published: May 2024

Introduction

Atrial masses represent a diagnostic challenge as the differential diagnosis includes a broad spectrum of formations. Thrombus is the most common form of non–neoplastic mass, whereas cardiac tumors are rare. We reported a case of a young woman with high–grade endometrial stromal sarcoma, complicated by cardiac metastatic dissemination.

Case Report

A previously healthy woman of 36–years old, without medical history, underwent abdominal ultrasound due to frequent menorrhea. As suspicious uterine formation was observed, an abdomen magnetic resonance (MRI) was performed, showing a large formation located in correspondence of uterine corpus and fundus. Indeed, she underwent hysterectomy plus bilateral salpingectomy, and the subsequent histological examination revealed a high–grade endometrial stromal sarcoma (ESS). Consequently, the patient was hospitalized to undergo a total body computed tomography (CT) for tumor staging and to start chemotherapy (potential cardio–toxic). A trans–thoracic echocardiogram (TTE) showed normal function of LV, without valvulopathies. However, in correspondence of right atrium (RA) roof, a large, rounded mass, hypomobile and iso/hyper–echogenic, without extension into Superior Vena Cava, was detected. The total body CT confirmed the presence of a hypodense mass in the RA, and secondary lesions within left large pectoral muscle and right inferior lung lobe were founded. Thus, a Cardiac MRI was performed, showing a solid formation, with lobulated margins and oval morphology, at the level of the posterior wall of the RA, of about 2.5 x 1.8 cm and with longitudinal extension of about 3 cm, hypomobile and with a wide implant base. The lesion appeared heterogeneously hypo–isointense in T1–weighted images and hyperintense in T2–weighted images; in Delayed–Enhancement acquisitions, the formation resulted hyper–intense, more evidently in long–inversion recovery sequences. Indeed, considering clinical condition, right atrial location and morphological features, the diagnosis of secondary lesion of the ESS was entertained. First–line chemotherapy regimen was started. After 6 months follow–up the patients remained asymptomatic; at TTE, the cardiac mass resulted unchanged. Unfortunately, after 13 months, the patient died.

Conclusion

A multimodality imaging approach to the evaluation of atrial masses is crucial for obtaining a non–invasive evaluation to provide the appropriate therapeutic approach.
AN UNUSUAL “BLACKBERRY SHAPED” MASS OF DUBIOUS INTERPRETATION (OUT OR IN THE JUGULAR VEIN?) IN A PATIENT WITH METASTATIC MELANOMA. A SPECIAL IMAGING CLINICAL CASE
Authors: Fioretti A , Leopizzi T , Strippoli S , Garofalo M , Pesola F , Pizzutilo P , La Forgia D , De Luca R , Oreste D , Galgano G , De Giosa A , Saliani P , Scicchitano P , Zito A , Oliva S
Published: May 2024

A 43 y–o woman, without cardiovascular risk factors, was diagnosed with BRAF+ IIIC melanoma of unknown origin with bilateral axillary lymph node metastases. She started a combined treatment with vemurafenib, cobimetinib (braf/mek inhibitors) and atezolizumab (PDL1 inhibitor) as neoadjuvant therapy, followed after 6 weeks by surgical treatment (that showed pathological complete response) and adjuvant immunotherapy with atezolizumab hitherto ongoing. A serial CT–scan revealed a 0.9x1.3 cm mass (Fig.1) close to the right jugular vein (RJV) with increased contrast enhancement susceptible of vessel ectasia by the radiologist who expressed uncertainty about its site (intra or extravascular?) and asked for further imaging assessment. Therefore, a duplex ultrasound (DU) was performed with the detection of a 0.6x1.2 cm endovascular mobile “blackberry shaped” mass in the RJV and the indication for a vascular surgery evaluation. The patient started enoxaparin 1 mg/Kgx2/die s.c. according to “ex iuvantibus therapy”. However, the vascular surgeon diagnosis confirmed the undetermined site of the mass. The patient decided for a second DU opinion and reached our Cancer Angiology Lab, where a novel DU detected a deep vein thrombosis (DVT) of the RJV (Fig.2–Fig.3). Enoxaparin was replaced with edoxaban 60 mg 1 cp/die since the patient preferred a more manageable root of administration for the requested long–term anticoagulant treatment. After 2 months a DU follow up showed no regression of the mass. Accordingly, the patient proceeded with edoxaban 60 mg/die without any side effects, whereas still in treatment with immunotherapy.

Conclusions

Thromboembolism is the second leading cause of death in malignancy. Overall, biomarkers and thrombotic risk factors related to patient, tumor and anticancer regimens favor the development of cancer associated thrombosis. Delay in DVT diagnosis and, mostly, in the initiation of a full and long–term anticoagulant treatment, like in this case, enables a chronic evolution of the clot which makes its timely regression more challenging.
A CURIOUS CASE OF CRYPTOGENIC MYOCARDIAL INFARCTION
Authors: Peano V , Gallone G
Published: May 2024

Introduction

Myocardial Infarction with Non–Obstructive Coronary Artery disease (MINOCA) is an increasingly recognized clinical entity requiring a comprehensive and precise work–up to detect the correct diagnosis and to appropriately institute treatment strategies. We report a case explanatory of a rare cause of MINOCA, highlighting the importance of a comprehensive diagnostic algorithm.

Case

A 55 years old man with an intermediate cardiovascular risk profile and no prior medical history presented to the emergency department. He experienced typical chest pain at rest 6 days prior to admission, but refused to attend the hospital and, instead, performed outpatient labs on day 5 demonstrating elevated high sensitivity troponin I (Hs–TnI, 3192 ng/L). At admission, the patient was asymptomatic and well compensated. The ECG was normal, echocardiography revealed a mid–basal inferior hypokinesia, and lab. exams showed a hs–TnI of 159 ng/L. The coronary angiogram was normal: no atherosclerosis was present and, upon independent revision of the images from experienced operators, no coronary dissection, myocardial bridges or emboli were observed. Ventriculography ruled–out ongoing Takotsubo Cardiomyopathy, nor the history was suggestive of any trigger. No clinical, ECG and echocardiographic features of myocarditis or cardiomyopathy were present and a classic troponin curve was observed. No clinical features of endocarditis were present. No ventricular or atrial arrhythmias were detected on continuous monitoring. A working diagnosis of MINOCA was established. Cardiac magnetic resonance revealed a focal area of transmural late gadolium enhancement and T2–based enhancement of the inferior mid–basal wall consistent with acute myocardial damage. In the suspect of an embolic source, transesophageal echocardiogram documented the presence of a patent foramen ovale (PFO) with characteristics at high embolic risk: large aneurysmatic fossa ovale type 4 LR (Olivares Reyes) with left to right shunting at baseline which increased during Valsalva maneuver, prominent Chiari network and Eustachian valve. Given the high probability of association between PFO and systemic embolism phenomena, percutaneous closure of the PFO was proposed.

Conclusion

With this case we want to highlight the importance of the correct and precise diagnostic work up in this emerging pathology in the field of cardiology for a better definition of the therapeutic strategy.
TREATMENT OF CALCIFIC CORONARY STENOSIS WITH SHOCKWAVE: A CASE REPORT
Authors: Faraci A , Adorno D , Messana D , Grimaudo R , Sucato V , Novo G
Published: May 2024

Introduction

Woman 72 years old, suffering from hypertensive ischemic heart disease, type II diabetes mellitus with accessory circulatory complications and pure hypercholesterolemia. He arrives at our cath lab urgently for ST–segment elevation myocardial infarction (STEMI). We proceed with coronary angiography to treat the culprit lesion. On the coronary angiographic picture, thrombotic occlusion is found at the proximal edge of the stent previously implanted in the middle right coronary artery, the left coronary artery shows mild diffuse atheromasia in the absence of angiographically significant stenosis. An attempt is made to reopen the vessel with multiple pre–dilations with semi–compliant and non–compliant balloon catheters without obtaining complete expansion. Given the impossibility of implanting the stent, dilation is performed with a 2.5x20mm medicated balloon for one minute and the use of Shockwave intravascular lithotripsy (IVL) is planned as a second step.

Methods

IVL involves the generation of pulsatile sound waves in the target site aimed at combating the occurrence of microfractures of the calcific tissue, modifying the compliance of the vessel, without however damaging it. In detail, the system is composed of an electrical pulse generator, a connection cable and a balloon catheter. After the standard preparation of the balloon with a mixture of saline solution/contrast medium, it is advanced on a 0.014" guide up to the level of the stenosis to be treated.

Results

After preparation and use of the shockwave intravascular lithotripsy (IVL) system with a 2.5x12 mm balloon, 5 cycles of 10 pulses were delivered for a total of 50 pulses. Dilation follows with a non–compliant 2.5x15 mm balloon with optimal expansion of the balloon. We then proceeded with the implantation of the 2.75x16 mm drug–eluting stent in the middle section overlapping with the stent already present. Obtaining a good final angiographic result and adequate coronary flow (TIMI 3).

Conclusions

The use of coronary intravascular lithotripsy made it possible to optimize the result of the previously failed angioplasty, pursuing an excellent angiographic result with limited risks, compared to other debulking systems.
DOUBLE ST–ELEVATION, DOUBLE OCCLUSION?
Authors: Ajmone F , Mancone M , Sardella G , Tocci M , Bruno E , Improta R , Di Pietro G , Giansante A , Vizza C , Colantonio R
Published: May 2024

Case Presentation

A 71–year–old woman was referred to our outpatient clinic for two episodes of chest pain during last two days. Her past medical history was remarkable for arterial hypertension, obesity, diabetes mellitus type 2 treated by oral hypoglycaemic agents complicated by diabetic maculopathy.

Diagnostic Work–Up

At the presentation, the patient was symptomathic for chest pain, hemodynamically stable. The ECG showed synus rhythm, left–axis deviation, Q wave and ST–elevation from V2 to V5 and in DIII and ST–elevation in DII and aVF (FIGURE 1). Transthoracic echocardiography revealed concentric hypertrophy, mildly reduced LV ejection fraction (EF 45%) with akinesia of intreventricular septum and apex, without severe valvulopathies and no pericardial effusion. Given the clinical data the patient was addressed to urgent coronary angiography that showed LAD occlusion at the end of his proximal tract and right coronary artery occlusion at the beggining of his second tract (FIGURE 2); furthermore omo and etero–coronaric collaterals for right coronary artery area were detected. By using a workhorse guidewire flow was restored in both coronary arteries and PTCA was performed with 3 DES on LAD and other 2 DES on right coronary artery (FIGURE 3). The patient was transferred to our coronaric intensive unit care after the procedure; no complications were noticed during the hospitalization. A week after the patient was discharged in good general health.

Conclusion

Multiple simultaneous coronary occlusions are reported in literature, yet the accurate incidence and physiopathology of this occurrence is still uncertain. Probably the symphathetic system activation caused by first coronary occlusion could promote an increased basal platelets activation and then the second coronary occlusion. Our case shows that during coronary angiography identifying a culprit lesion may be delicate and cardiologists should be prepared to manage multiple coronary occlusions.
WAITING FOR A CONCERT IN SUMMER HEAT: A TRANSIENT ST ELEVATION IN A YOUNG MAN
Authors: Benzoni G , Perelli F , Bilo B , Giuliano A , Parati G , Brambilla R
Published: May 2024

A 22–year–old man, without prior cardiological history, was waiting for a concert to start many hours in summer heat. Suddenly he started to feel chest pain, dyspnea, and palpitations. Electrocardiogram (EKG), registered from first aid responders, showed a ST elevation in V1–V3 leads and ventricular repolarization alterations in inferior leads. The patient was brought to Emergency department (ED) where a new EKG resulted normalized, blood test samples showed High Sensitive Troponin T (HsTn) 35 ng/L (at plateau in three seriate measures), serum creatinine 2.0 mg/dL, total Creatine Kinase 646U/L, Ck–MB 10.6 ng/mL, Reactive C Protein (RCP) 1.2 mg/dl. The toxicological evaluation was negative. Transthoracic Echocardiography (TTE) did not show any regional ventricular kinesis alterations nor valvular defects, global systolic function was preserved. A Coronary Computed Tomography (CT) scan showed an intramyocardial bridge on Anterior Descending (DA) Coronary Artery associated to 7 mm pericardial effusion without coronary stenosis. A Cardiac Magnetic Resonance (CMR) with gadolinium was performed, which did not show (in T2 mapping sequences) oedema nor Late Gadolinium Enhancement (LGE). Considering a coexistence of Brugada syndrome pattern at EKG, an Ajmaline testing was performed, which resulted negative. Discussion: Dehydration due to any intake of water after standing many hours in summer heat could have been the trigger for a vasospasm of DA that in this patient has a partially intramyocardial course. This anatomical finding was not known until CT scan was performed. Our diagnostic hypothesis of a vasospasm on DA is supported by EKG alterations and elevation enzymes of myocardionecrosis, in absence of any coronary stenosis. Elevated creatinine values in the absence of other renal concomitant comorbidities were suggestive for acute dehydration too. Differential diagnosis took also into consideration myo–pericarditis, especially for the pericardial effusion finding revealed by CT scan: this diagnosis was not confirmed through CMR but also by the evolution of clinical conditions of our patient. We discharged the patient, asymptomatic with normalized renal function after some intravenous hydration and we prescribed a calcium channel blocker. At a follow up visit, three months after the acute event, our patient was in good clinical condition and denied occurrence of any other similar events.
THE GLA D313Y MUTATION IN FABRY DISEASE: DIAGNOSTIC DILEMMAS AND THERAPEUTIC CONSIDERATIONS
Authors: Dall‘Ospedale V , Valsania T , Di Spigno F , Matrone B , Novara P , Tedeschi A , Turchio P , Bolognesi M , Aschieri D
Published: May 2024

Fabry disease is a genetic disorder caused by mutations in the GLA gene, which encodes alpha–galactosidase A, leading to enzyme dysfunction and subsequent accumulation of glycosphingolipids. In the classical form, it occurs in childhood or early adolescence with renal, cardiac, and neurological involvement, resulting in a poor prognosis. The GLA D313Y is a missense mutation resulting in a significant reduction of enzyme activity in plasma, while leukocyte enzyme activity remains within normal limits, leading to a "pseudo–deficiency" of enzyme activity with uncertain pathogenicity. In literature, it has been observed that individuals with this mutation may present predominantly with central neurologic manifestations, characterized by multifocal white matter lesions. Historically they do not receive indications for initiating enzyme replacement or molecular chaperone therapies. We present the case of a man affected by arterial hypertension and history of chronic lower limb pain who experienced a lacunar stroke at the age of 35. The GLA D313Y mutation was identified and enzyme activity assay in plasma was within normal limits, precluding the initiation of enzyme replacement therapy. Over the following years, he suffered two additional ischemic strokes, a progressive decline in renal function to stage 3, and acute coronary syndrome. Transthoracic echocardiography revealed hypertrophic non–obstructive cardiomyopathy (SIVd 20 mm) with normal biventricular ejection fraction. Cardiac magnetic resonance showed late gadolinium enhancement of inferior junctional and inferior wall in middle segment (Fig.1). Considering the patient‘s clinical conditions involving multi–organ impairment, an enzymatic activity test was performed on leukocytes, revealing a reduced activity. This prompted the decision to initiate enzyme replacement therapy. This case report supports the hypothesis that the D313Y mutation may be associated with a later presentation and not only neurological involvement. In our experience, it’s mandatory to proceed with the determination of leukocyte enzyme activity in presence of normal enzyme activity in plasma. As an alternative, the detection of glycosphingolipids’ accumulation could be useful, but myocardial and renal biopsy poses a high bleeding risk, especially in anticoagulated or antiaggregated patients. The authors propose considering the initiation of therapy in patients with the D313Y mutation who exhibit significant organ involvement.
STRESS–INDUCIBLE MYOCARDIAL ISCHEMIA DUE TO A VENTRICULO–CORONARY FISTULA: WHAT WE KNOW
Authors: Testa S , Gallina S , Renda G , Ricci F
Published: May 2024

Coronary fistulas represent communications that form between the coronary arteries and a heart chamber or a large vessel. The real incidence is not known as well as their real clinical impact. Typically congenital, they can also develop following surgery. The treatment of fistulas remains complex: in the past surgical treatment was opted for, currently percutaneous closure is preferred although many hemodynamists prefer a conservative approach. We describe the case of a man with stress–inducible ischaemia, probably due to the presence of a ventriculo–coronary fistula. 58–year–old Caucasian man arrives for coronary angiography following a positive ergometric test for signs and symptoms of reduced coronary reserve. The patient had recently undergone a cardiac MRI that showed an hypertrophic cardiomyopathy with partial end systolic obliteration of the apex with areas of intramyocardial fibrosis in middlewall distribution. Coronary angiography showed an epicardial coronary circulation free from angiographically significant lesions with evidence, however, of a ventriculo–coronary fistula (departing from the anterior interventricular artery). Since other causes were excluded, the hypothesis was that the fistula could be the cause of stress–inducible myocardial ischemia, through a coronary steal mechanism.
A "PARADOXICAL" MINOCA
Authors: Sarti A , Cocco M , Campo G , Tonet E
Published: May 2024

Background

The acronym MINOCA refers to myocardial infarction with normal or near–normal coronary arteries on invasive angiography. We report a case of MINOCA caused by paradoxical coronary embolism due to a right–to–left shunting through a patent fossa ovalis. Integrated multimodality imaging diagnostic work–up has been crucial for identifying the mechanism underlying MINOCA.

Case Report

A 48–year–old male was admitted to the Coronary Care Unit for sudden–onset oppressive chest pain lasting 1 hour, radiating to the left arm; no specific changes in ST–segment on a 12–lead ECG and elevated high–sensitive troponin I (peak value 1562 ng). Transthoracic echocardiography showed normal dimensions and function of the cardiac chambers and excluded valvular and pericardial diseases. Given the characteristics of the chest pain, we performed an urgent coronary angiography that showed normal epicardial coronary, including testing for epicardial coronary spasm and microvascular dysfunction. We also used Optical Coherence Tomography on LAD e RCA to rule out critical stenosis and sign of plaque instability. To investigate the etiology of myocardial damage the patient underwent a cardiac magnetic resonance (CMR) imaging that yielded the following findings: hypokinesis of the inferior–middle segment of the left ventricle associated myocardial edema and near transmural LGE. These features were consistent with a recent ischemic injury. Additionally, CMR showed an atrial septal aneurysm and a channel–like pattern of the interatrial septum, raising the suspicion of patent foramen ovale (PFO). The transesophageal echocardiography and transcranial Doppler with bubble test confirmed the presence of a PFO responsible for right–to–left shunting. Atrial fibrillation was excluded with ECG telemetry throughout the entire 7day hospitalization.

Conclusions

Based on the result of the overall clinical–instrumental evaluation, MINOCA caused by paradoxical coronary embolism due to a right–to–left shunting through a PFO was considered the most plausible diagnostic hypothesis. The patient underwent to interventional percutaneous closure of PFO and was discharged with no symptoms or complication at the follow–up.
CARDIOGENIC SHOCK DUE TO SPONTANEOUS CORONARY ARTERY DISSECTION
Authors: Catellani D , Paoli G , Tadonio I , Grossi S , Niccoli G
Published: May 2024

Spontaneous coronary artery dissection (SCAD) is an important but rare cause of myocardial infarction (MI) in young adults, particularly women. Current guidelines recommend conservative treatment, given the low angiographic success and the high complication rate of percutaneous coronary intervention. However, in SCAD patients presenting with STEMI or cardiogenic shock the needs of urgent revascularization is critical and PCI may be life threatening. We present a case report occurs in our Hospital of a 42–year–old young woman without cardiovascular risk factors or notable comorbidities which was admitted to our emergency department for typical chest pain. At admission the patient had a cardiovascular arrest from refractory ventricular fibrillation who was rescued according to ACLS protocol. After resumption of ROSC, EKG showed anterolateral STEMI (FIGURE 1). Bedside echocardiography showed a severe reduction in systolic function (EF 30%) due to akinesia of the apex, septum and antero–lateral wall, with absence of noticeable valvulopathy, pericardial effusion or pathological findings in the right heart sections. Therefore the patient underwent to Cath–lab for emergent coronary angiography that showed ostial DA subocclusion with SCAD type 2a on middle tract (Figure 2) IVUS (intravascular ultrasound) imaging confirmed the diagnosis of SCAD, served to guided angioplasty on the LM–DA axis and to confirme optimal stent placement (FIGURE 3). Subsequently, the course was complicated by a double shock component: first SCAI C cardiogenic shock that requested or IMPELLA CP implantation and second haemorrhagic shock due to profound hepatic bleeding because of traumatic injury caused by prolonged resuscitation maneuvers. Mechanical ventricular support ensured haemodynamic stability to allow percutaneous embolisation of the hepatic arteries and patient stabilization. Once the haemorrhagic focus was treated and cardiac function recovered, the patient‘s condition gradually improved leading to a rapid weaning of haemodynamic and respiratory support. No neurological sequelae were observed after the acute phase.

Conclusions

1) Urgent revascularization in patients with SCAD and high clinical instability is life threatening. IVUS imaging is crucial to confirm the diagnosis and guide the procedure. 2) The IMPELLA support in this case provided short–term haemodynamic support in a double component of shock.
UNRAVELING GENDER DISPARITIES AND PROGNOSTIC INSIGHTS IN MODERATE AORTIC STENOSIS: A RETROSPECTIVE STUDY
Authors: Guareschi A , Donisi L , Pasero G , Mallardi G , Faggiano A , Faggiano P , Bursi F , Santangelo G , Carugo S
Published: May 2024

Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries, associated with reduced survival if severe AS remains untreated. Recent reports note unfavorable outcomes in moderate AS (mAS) patients, challenging optimal intervention timing. Variations in pathophysiology linked to sex differences, involving sex hormones, activation of the renin–angiotensin–aldosterone system, and dysregulation in collagen synthesis, have been observed. Yet, limited data exists on sex–specific differences in mAS outcomes. This single–center, retrospective study included 150 patients (median age 79±13 years, female sex 48%) diagnosed with mAS who underwent comprehensive echocardiography in IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico of Milan from July 2022 to October 2023. Clinical data, encompassing demographics details and therapy, were obtained via record reviews and phone interviews. Death verification relied on the ‘Sistema Informativo Socio–Sanitario Regione Lombardia’ database. Echocardiographic records were digitally stored and post–processed by four independent investigators using Medimatic ComPACS workstation. Men were significantly younger than women (75±10 vs 79±9.7 years, p= 0.016). They exhibited lower left ventricular (LV) ejection fraction, larger LV end–systolic volume and stroke volume compared to women (54±7 vs 59±10%; p=0.028. 55±36 vs 31±13 ml; p<0.001. 83±18 vs 75±18 ml; p=0.030). Men had significantly smaller aortic valve (AV) area index to body surface area (BSA) (0.6±0.09 vs 0.7±0.1 cmq/mq; p<0.001) and lower doppler velocity index (0.32±0.07 vs 0.38±0.11; p<0.001) than women. Coronary artery disease and smoking were more frequent in men (53.3 vs 46.7%; p=0,002. 52.6 vs 47.4%; p<0.001). In survival analysis, 15% of women and 30.8% of men experienced events, with male gender independently associated with the composite outcome (all–cause mortality and AV replacement) over a mean follow–up time of 200 ± 133 days, showing a median survival of 244±16 vs 255±15 days for females (p–value=0.025). In multivariable analysis including relevant clinical variables (hemoglobin and AV index to BSA), male sex remained independently associated with the composite outcome (hazard ratio 2,01; CI 1.0–4.17; p=0.05). Women diagnosed with mAS exhibited a lower incidence of AV replacement and all–cause mortality. These findings may suggest the existence of different clinical and echocardiographic phenotypes among patients with AS.
RELATION BETWEEN CALCIUM METABOLISM AND DEVELOPMENT OF AORTIC VALVE STENOSIS
Authors: Ferrari V , Mazzanti C , De Biase L
Published: May 2024

The role of calcium metabolism in the development of degenerative Aortic Valve Stenosis (AVS) is not completely understood. Valvular cell modifications and passive calcification can be both involved in the diseases. Vitamin D (Vit D) and Parathyroid Hormone (PTH) are important factor in calcium regulation and data on their modification in AVS are scanty. Their potential role in AVS prevention is not yet identified. Osteocalcin can be considered a marker of calcification and its potential usefulness in identification of patient at risk for AVS was not studied. In order to correlate calcium metabolism to AVS development we have studied PTH, Vit D and Osteocalcin in a population of patients with AVS. We recruited 100 patients admitted in our Cardiac Surgery Unit for AVS confirmed by electrocardiogram, echocardiogram and hemodynamic evaluation. Subjects with rheumatic or congenital valvulopathy and infectious endocarditis were excluded from the study. Calcium, phosphorus, calcium–phosphorus ratio (Ca/P ratio), PTH, Vit D, renal function and osteocalcin were measured in each patient. In our population, 93.5% of patients had low levels of Vit D (<30 ng / ml), 42.4% had elevated levels of PTH (>38.4 pg / ml) and 28% had low levels of osteocalcin (<14 ng / ml). 87% of the population had normal calcium levels (8.4–10.2 mg / dl) and 93.3% had normal levels of phosphoremia (2.7–4.5 mg / dl). Defining as normal a Ca/P ratio between 1.5 and 2.5, 60.7% of our population had high levels of Ca/P. In conclusion, our findings suggest that patients suffering from AVS have abnormal levels of factors involved in the regulation of calcium metabolism. Some factors can be target for preventive therapies.
The platform fix: analyzing mechanisms and contradictions of how digital platforms tackle pending urban-economic challenges
Authors: Repenning Alica , Hardaker Sina
Published: May 2024

Digital platforms, such as Google, Amazon, or Instagram, provide a promising spatial fix to urban-economic problems by leveraging technology and data while connecting stakeholders and overcoming spatial barriers to make urban life, consumption, sales, and production more efficient. This article contributes to the debate on digital platforms in economic geography by advancing the emerging lens of the platform fix, adopting a critical standpoint concerning the solutionist viewpoint that presents platforms as a fix for various challenges. The article develops its perspective against the background of 57 semi-structured interviews, 200 conducted standardized questionnaires, and long-term on/offline observations. We aim to provide a platform fix perspective revealing how digital platforms redefine spatial interactions, addressing economic challenges through spatial fixes while becoming established as indispensable infrastructures; however, platform fixes often fail to address underlying issues, leading to platform dependencies and the instrumentalization of actors. Therefore, we suggest a cautious application of urban platforms as solutions and critically evaluate the formation of public–private platform partnerships.