bluuebunny/crossref_metadata_2025 huggingface dataset:
DEEP SEPTAL LEFT VENTRICULAR PACING VS HIS BUNDLE PACING: A SINGLE–CENTER EXPERIENCE COMPARISON
Authors: Marinaccio L , Putorti F , Marmai A , Migliore F
Published: May 2024

Introduction

Right ventricular apical pacing (RVAP) causes ventricular dyssynchrony, impairing ventricular function. Biventricular pacing (BVP) improves on RVAP but still has a non–physiological activation pattern. Alternative pacing sites like His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBaP) address this issue. However, HBP implantation has higher capture thresholds and longer procedures, increasing peri–procedural risks and reducing battery life. LBBaP, defined by MELOS study, resolves the capture threshold issue but may not consistently achieve successful implantation due to strict electrocardiographical signs of success. Deep Septal Left Ventricular Pacing (DSLVP) is an alternative, but more studies are needed.

Aim

This study compares HBP and DSLVP, assessing their hemodynamic impact on left ventricular systolic function over a year through semestral re–evaluation. We also evaluate implantation success rates, capture thresholds, and sensing amplitude during follow–up.

Methods

This observational retrospective study included 51 patients eligible for bradycardia/resynchronization therapy according to guidelines. Among them, 35 received successful HBP implants, while 16 initially underwent BVP failure and later received DSLVP based on individual anatomic considerations. Patients underwent follow–ups at 6 months and 1 year, where we collected echocardiographic data, capture thresholds, and sensing amplitudes.

Results

Both pacing systems demonstrated a comparable increase in Ejection Fraction (EF) from implantation to the end of the follow–up period (HBP: 40% to 46%, p < 0.47; DSLVP: 40% to 48%, p < 0.01). DSLVP did not significantly narrow QRS duration before and after implantation (146 ms vs. 136 ms, p = 0.2). HBP had a 97% implantation success rate (34 out of 35 patients), while DSLVP achieved a 100% success rate (16 out of 16 patients). Capture thresholds and sensing amplitudes remained satisfactory for both techniques, with no significant increases during follow–up (DLVSP: 0.55 V vs. 0.58 V, p > 0.05; HBP: 1.24 V vs. 1.38 V, p > 0.05). However, HBP had significantly higher capture thresholds than DSLVP at both implantation (0.55 V vs. 1.24 V, p < 0.002) and follow–up (0.58 V vs. 1.38 V, p < 0.01).

Conclusion

DSLVP offers comparable hemodynamic benefits at implantation and post–implantation results to HBP. Lower capture thresholds in DSLVP extend battery life, making it a valid alternative to HBP.
ablate and pace with conduction system pacing, Rovigo's experience
Authors: Porcelli G , Zanon F , Marcantoni L , Pastore G , Valenza S , Deluca F
Published: May 2024

Background

Several clinical data demonstrate that atrio ventricular junction (AVJ) ablation, followed by cardiac pacing, in atrial fibrillation (AF) with uncontrollable heart rate is beneficial. There are still limited data about conduction system pacing (CSP) in that setting.

Aims

To analyse if this “ablate and pace” strategy is feasible with good electrical results (ECG and parameters) and clinical outcomes (heart failure (HF) admission, ejection fraction (EF) and NYHA class). To analyse also differences between his bundle pacing (HBP) and left bundle branch area pacing (LBBAP) in this setting. Methods. This is an observational retrospective single center study involving 30 patients of which 11 had a HBP and 19 a LBBAP from March 2019 to June 2023 (medium follow up 33 ± 18 month). The implant procedure was performed with both stylet driven or lumenless lead. After 2 ± 2 weeks was performed the AVJ ablation. The electrical parameters were measured at the implant and every 6 – 12 months. The patients had an echocardiographic and clinical evaluation every 6 – 12 months. There was nobody with a NYHA class IV.

Results

The procedure was performed without complication in all patients. There were a rising in the EF (49,9 ± 14,6 vs 54,2 ± 10,4% p = 0.004). There weren’t HF admission and only 2 patients died (not for cardio–vascular causes) during follow up. There were also a decrease in NYHA class in every patient (at least one NYHA class less). 17 (57%) patients had normal ventricular conduction, only 4 (13%) had LBBB, 4 (13%) RBBB. There were not statistical difference between the QRS duration pre and after implant (129 ± 35 vs 125 ± 24 ms p = 0,06). The threshold measured at the implant were stable both in the HBP (0,75 ± 0,34 vs 1,3 ± 0,8 V @ 0,4 ms p = 0,14) and in the LBBAP (0,93 ± 0,3 vs 0,89 ± 0,3 V @ 0,4 ms p = 0,49). The LBBAP presented higher values of sensing compared with HBP (17,5 ± 7,4 vs 6,3 ± 3,3 mV p = 0,04) and less procedural (63 ± 32 vs 95 ± 41 min, p = 0,02) and fluoroscopic time (2,6 ± 2,4 vs 7,5 ± 4,1 min, p = 0,04) compared with HBP.

Conclusion

The CSP is feasible and safe in the setting of “ablate and pace” and results in a clear increasing in EF and clinical status of patients with good and stable ECG features and electrical parameters during follow up; the CSP indeed represent a valuable alternative to BVP in this setting. LBBAP performed better than HBP in terms of procedural and fluoroscopic time and of higher sensing values.
THROW YOUR LEAD OVER THE OBSTACLE: A CHALLENGING CRT UPGRADING
Authors: Valenza S , Pastore G , Marcantoni L , Deluca F , Porcelli G , Zanon F
Published: May 2024

High percentage of right ventricular pacing could lead to pacing induced cardiomyopathy in a non–negligible proportion of patients. Cardiac resynchronization therapy upgrading could represent an option to improve ventricular function, reducing heart failure hospitalizations. A 82 yo male was admitted to hospital with symptomatic heart failure. He had history of complete AV block treated with dual chamber pacemaker implantation five years earlier following coronary artery bypass graft surgery, bioprosthetic aortic valve replacement and septal myectomy. He had also history of cardiac arrest occurred in the context of acute coronary syndrome treated with PCI so that ICD implant was not considered at that time, and two more HF hospitalizations in previous years. Progressive LVEF decline was documented since PM impantation until last echo showed severe left ventricular dysfunction (EF 20% from baseline EF 60%). The ECG showed sinus rhythm and wide paced QRS (206 ms) with 100% pacing percentage. A CRT device upgrading was planned. Baseline venography initially showed pervious axillary–subclavian left axis, but unfortunately the guidewire encountered a complete occlusion before entering the superior vena cava. Nevertheless, dye contrast injection documented the presence of a proximal collateral branch (fig A) having a vertical course in the thorax and reaching the lateral wall of the left ventricle with an extrapericardic course then entering the right heart through inferior vena cava. Using a IM 5Fr sheath (usually used by interventional cardiologists to cannulate internal mammary artery) we could reach this branch, inserting a guidewire and finally advancing a quadripolar lead (Fig B–C) which reached the lateral left ventricular wall. LV capture was confirmed when pacing from the three proximal poles, while the distal one caused phrenic nerve capture. The quadripolar lead was connected to the LV port of a three chamber PM along with previous implanted leads thus obtaining biventricular pacing. QRS paced was 50 ms shorter than baseline. No peri–procedural complications occurred. Lead–related venous occlusion might represent an obstacle to CRT upgrade requiring high technical expertise. The presence of a complete venous occlusion might cause procedural failure, particularly in hospitals without surgical facility. In this case, the presence of a collateral branch reaching the lateral wall of the left ventricle allowed to successfully complete the CRT upgrade.
USE OF LIFE–VEST AND COMPLEX RE–IMPLANTATION OF CRT–D IN PATIENT WITH POCKET INFECTION BY MULTIRESISTENT S. AUREUS AND PERSISTENCE OF LEFT SUPERIOR VENA CAVA
Authors: Sorvillo G , Olivieri F , Rainone A , Quercia E , Violante A , Mazza A , Corrado L , Colangelo G , Luisi I , Calvanese C , Riccio G
Published: May 2024

Patient with primary hypokinetic dilated cardiomyopathy, previously underwent coronary angioplasty with stent implantation on MO branch and subsequent implantation of CRT–D in right subclavian region for persistence of left superior vena cava and complicated left sided implantation; hypertensive, dyslipidaemic, diabetic. Repeated subsequent surgery for shock channel malfunction with re–implantation of right ventricular lead. He came to our observation for infection of the CRT–D pocket by multiresistant Staphylococcus Aureus treated by intravenous antibiotic therapy and explantation of the infected device. We therefore proceeded to discharge the patient with Life–Vest as a bridging strategy until re–implantation and continued with long–acting antibiotic therapy administered every fortnight. After about 8 weeks, once the presence of infectious/inflammatory processes has been ruled out, CRT–D reimplantation is performed, after prophylaxis with Vancomycin, in the right subclavian region under sterile conditions and in the absence of complications. The management of cardiac device infections represents a challenge for the cardiologist especially in the complex patient with a history of re–interventions in which multi–resistant pathogens are often found. This clinical case demonstrates how collegial patient assessment and long–term protection strategies, such as the use of a Life–Vest, can achieve the diagnostic–therapeutic goal.
PREVALENCE OF ELEVATED LOW DENSITY LIPOPROTEIN CHOLESTEROL (LDL–C) LEVELS IN ADULT PATIENTS WITH COMPLEX CONGENITAL HEART DISEASE
Authors: Liguori C , Siracusa A , Orlando A , Franzese R , Borrelli N , Barracano R , Scognamiglio G , Sarubbi B
Published: May 2024

Background

Thanks to advances in both medical care and surgical techniques, survival for adult patients with congenital heart disease (ACHD) has significantly increased over recent years, with about 90% of them now reaching adulthood. However, as CHD patients grow older, their relative risk of developing coronary artery disease (CAD) increases. Elevated low–density lipoprotein cholesterol (LDL–C) levels play a pivotal role in the genesis of CAD in the general population. Limited data exist on the prevalence of hyperlipidemia in the ACHD population. Patients with complex CHD should be considered at increased risk for CAD, mainly related to to the severity of the CHD and aging. For this reason, it could be reasonable to apply targets used for patients at high risk of CAD. Our study aimed at describing the overall prevalence of elevated LDL–C levels in a contemporary cohort of adult patients with complex CHD.

Materials and Methods

This is a single–centre retrospective study. All adults with complex CHD who attended the outpatient clinic at our tertiary centre from January 2000 to April 2023 were included. Demographic, clinical and laboratory data were obtained in all patients from medical records and our dedicated databases.

Results

A total of 230 patients with complex CHD were included in the present study (mean age 35±11 years, 124 male, mean follow up of 117±80 months). One hundred forty–three (63%) of them showed biventricular physiology, whereas 86 (37%) patients showed univentricular heart physiology. Eighty patients from our cohort underwent Fontan operation. Twenty patients (9%) showed oxygen saturation at rest lower than 90%. Mean levels of LDL–C was 87±28 mg/dl, with 184 patients (78%) showing LDL–C levels ≥ 55 mg/dl.

Conclusion

Our study demonstrated that, despite their relatively younger age, elevated LDL–C levels are not uncommon in patients with severe CHD. ACHD patients with complex anatomy, such as patients after Fontan operation, should be considered at increased risk of ischaemic events and treated accordingly. Further research and international collaboration are therefore paramount to understand whether and if these patients should be treated with lower lipid drugs as for the general population.
A LABILE EQUILIBRIUM: THE CONTROVERSIAL ROLE OF BETA–BLOCKERS IN A CASE OF MID–VENTRICULAR TAKOTSUBO SYNDROME
Authors: Falagario A , Pedio E , Antonacci A , Colucci C , Mannarini A , Camassa N , Pansini M , D‘Agostino C
Published: May 2024

Case Report

Takotsubo syndrome (TTS) is a non–ischemic heart disease mimicking acute coronary syndrome. The mid–ventricular variant is almost rare (15% of TTS cases). A 62 years old woman was referred to our hospital for oppressive chest pain radiating to the jaw lasting at least 30 minutes after an attempted strangulation by a family member. She denied any conventional cardiovascular risk factor; she was taking beta–blockers (BB) to reduce symptomatic and idiopathic premature ventricular complexes (PVCs) burden. On arrival, the patient was hemodynamically stable, reporting only swallowing difficulties. Physical examination revealed neck bruising and irregular pulse. The initial ECG showed sinus rhythm with a heart rate of 62 bpm, PVCs and a biphasic T wave in lead aVL. Hs–cTnI first dosage was 145 pg/mL. Transthoracic echocardiography (TTE) found moderate left ventricular (LV) dysfunction and severe hypokinesis of mid septal and mid inferior segments. Coronary angiography revealed normal coronary arteries. Left ventriculogram showed hypokinesis of the midventricular section with a hyperdynamic base and apex suggestive of mid–ventricular variant of TTS. After a few hours, she experienced a lipothymic episode and telemetry showed marked sinus bradycardia followed by multiple sinus pauses. A TTE was immediately performed, demonstrating a worsening LV ejection fraction with new development of severe symmetrical akinesia of the LV apex. Successively, psychotherapy was started. Wall motion abnormalities and LV systolic function completely recovered over a few days. At present the patient is in good health status.

Discussion

domestic violence against women is prevalent, but it is often omitted as a potential stress trigger that affects their hearts. In Italy, it’s reported that 32% of women had experienced physical violence. Strangulation is very uncommon as cause of TTS and psychotherapy may prevent recurrences and recover in a shorter time. Bradycardia due to atrioventricular block and asystole has been described in the acute phase of TTS and it is often attributed to BB therapy. Although BB have been proposed to add further benefit of blunting the effect of catecholamine excess, their use should be used cautiously in the acute phase of TTS. Moreover, beta–adrenoceptor hypersensitivity may generate a parasympathetic drive when on BB infusion, provoking a worsening LV dysfunction and a transient sick sinus syndrome as we described.
CARDIAC REHABILITATION AND PSYCHOLOGICAL TREATMENT: CONTRASTS IN ANXIETY, DEPRESSION AND ILLNESS PERCEPTION LEVELS
Authors: Greco A , Zenoni E , Bariletti I , Quarenghi F , Viscardi L , Rizzola G , Brivio F , Soddu I , Anselmi Kaiser M , Bigoni A , Giudici V , Lanfranchi F
Published: May 2024

Background

Investigating the relationship between psychological factors and cardiovascular diseases (CVD) has long been a focal point of previous research. Researchers have primarily focused on identifying possible predictive factors for CVD’s development and examining patients’ responses during acute or chronic phases, but less is known about the role of cardiac rehabilitation and the types of psychological treatments on patients’ psychological status.

Aims

The aim of this study is to compare anxiety, depression, and illness perception levels of patients affected by different cardiovascular diseases at the beginning (t0), at the end (t1), and three months after a cardiac rehabilitation program (t2) in which patients were involved in three different types of psychological treatments: psychoeducational intervention group, progressive muscle relaxation training integrated with Jacobson‘s technique and imaginative stabilization techniques, individual counseling.

Methods

In this study were involved patients with recent episodes of Acute Coronary Syndrome (ACS), heart failure (HF) or cardiac surgery undergoing cardiac rehabilitation between January 2023 and August 2023 at ASST Bergamo Est. To assess anxiety, depression and illness perception levels of participants we used self–report questionnaires that included the Hospital Anxiety and Depression Scale (HADS) and the Brief Illness Perception Questionnaire (Brief–IPQ). Patients could be assigned to different psychological treatments based on their clinical condition.

Results

The study involved 181 participants, namely N=36 ACS cases (19.9%), N=25 CHF (13.8%), and N=120 cardiac surgery (66.3%). As shown in Table 1, males were 71.3% (N=129) and the average age was 65.96 years old (SD=11.904). One hundred–sixty einght patients participated in psychoeducational intervention group, 120 in relaxation training, and 35 in individual counseling. Statistically significant differences in anxiety, depression, and illness perception levels were observed at the program‘s initiation (t0) and upon completion (t1 and t2) in relation to the psychological treatments: individual counseling had a better impact on levels of anxiety and depression and on the development of a more adequate perception of illness.

Conclusions

The type of psychological treatment during cardiac rehabilitation appears to give different results in terms of psychological status, self–care and disease management of patients.
EFFICACY AND SAFETY OF COLCHICINE FOR THE TREATMENT OF MYOPERICARDITIS
Authors: Collini V , Andreis A , De Biasio M , Massimo I
Published: May 2024

Background

Clinical trials have evaluated the efficacy and safety of colchicine only in simple pericarditis, excluding cases of concomitant myocarditis.

Objectives

To evaluate the efficacy and safety of colchicine for the treatment of the first attack of acute pericarditis with concomitant myocardial involvement.

Methods

Double–centre retrospective cohort study, analysing consecutive patients admitted for first attack of pericarditis with myocarditis. Patients who received colchicine in addition to conventional therapy constituted the study group, while patients who received only conventional therapy constituted the control group. The primary efficacy end point was the time to the first recurrence. Propensity score matching was used to generate 2 groups of patients with similar baseline characteristics. Colchicine–associated side effects were analysed as safety end–point.

Results

A total of 175 patients (mean age 46 (SD 40) years, 25% females, 88% with idiopathic/viral etiology, 79 (45%) treated with colchicine) were included. After a median follow up of 25.3 (IQR 8.3 – 45.6) months, 58 (33%) patients had recurrences. The propensity score generated 73 pairs of patients. In this population a lower incidence of recurrence (respectively 19% vs. 45%; p=0.001) and a longer event–free survival (p=0.05) was observed among patients receiving colchicine. In multivariable analysis women (HR 2.28, 95% CI 1.23 to 4.24; p=0.009) and corticosteroid use (HR 2.17, 95% CI 1.12 to 4.19; p=0.021) were independent risk factors for recurrences. Colchicine–associated side effects were mild and occurred in 3 (2%) patients.

Conclusions

In patients with first attack of pericarditis associated with myocardial involvement, colchicine was safe and efficacious for the reduction of recurrences.
REMOTE MONITORING IN CRYPTOGENIC STROKE
Authors: Pastore I , Ferrieri A , Benedetto L , Carretta D , D‘Agostino C
Published: May 2024

Introduction

In the neurological field, one of the pathologies that receives the most attention due to its etiopathogenetic complexity is cryptogenic stroke. In the literature, a significant percentage of cryptogenic stroke is associated with Paroxysmal Atrial Fibrillation (FAP). With this study we wanted to compare our data with those of the literature and evaluate the incidence of remote control in promoting patient adherence to anticoagulant therapy, also analyzing the incidence of possible stroke recurrences in the monitored patients.

Methodology

All patients admitted to the Stroke Unit with cryptogenic stroke were evaluated with the ESUS SCORE. Patients who tested positive following the administration of the score underwent Loop Recorder (ILR) implantation for prolonged cardiac monitoring. Patients who showed episodes of FAP during monitoring were subsequently referred to the Stroke Unit to start anticoagulant therapy. A close telephone follow-up was subsequently carried out (every 15 days) to evaluate adherence to therapy and any stroke recurrences.

Results

43 patients with cryptogenic stroke coming from the Stroke Unit and implanted by our center with Loop Recorder were evaluated. Among these 43 patients, 16 (37%) presented at least one episode of FAP, while 27 (63%) have not yet had any FAP event since the date of device implantation. In 60% of patients with FAP the duration of the event is greater than 5 hours. The time period between the stroke and the first FAP event in 6 out of 16 patients is approximately 1 month. Two patients presented the first episode within 7 days, while 8 patients within 10 months. In the telephone follow-up performed, 100% adherence to anticoagulant therapy was recorded, resulting in a recurrence of stroke in 0% of patients.

Conclusions

From the results obtained it was possible to conclude that the use of remote monitoring associated with close telephone follow-up allows the diagnosis of FAP and guarantees better patient adherence to anticoagulant therapy, significantly reducing stroke recurrences.
INTEGRATED CLINICAL PATHWAY FOR PATIENTS WITH HEART FAILURE DIAGNOSIS
Authors: Corazzola D , Surian C , Pontalti M , Moroder R , Unterhuber V , Di Gaetano R , Giacometti M , Oberhollenzer R
Published: May 2024

Patients diagnosed with HEART FAILURE undergo a diagnostic/therapeutic protocol that includes a DIAGNOSTIC FRAMEWORK with potential PATIENT AND/OR CAREGIVER MANAGEMENT, managed by the CARDIO–CLINICAL PSYCHOLOGY SERVICE operating within the Cardiology Division of the Bolzano Health District. The cardiopsychological pathway includes: First diagnostic phase: involves an assessment through a semi–structured interview with possible support from psychometric tests. Constructs related to mood and therapeutic adherence are investigated. Second therapeutic phase: involves supportive discussions using cognitive/behavioral methods, focusing on acceptance and adaptation to the disease. The purpose of this observational work is to establish a standardized multidisciplinary protocol to support cardiac facilities in managing heart failure. Improving patient management through integrated work aims to stabilize the disease progression, increase therapeutic adherence, enhance mood, and optimize the perception of quality of life.

Case Study

Patients YEARS 2021–2023 Heart Failure Center Category/Year 2021 2022 2023 Average Age 72 71 70 Gender F 72 M172 F 89 M221 F 101 M270.

Conclusions

The integrated approach in heart failure care becomes crucial to anticipate the recognition of factors hindering patient stabilization and defining a care path that meets the patient’s needs. Integrating the work of professionals such as physicians, nurses, and psychologists helps improve patient management, working towards a shared path for the delicate balance that the nature of the pathology entails. The goal of the multidisciplinary team is not only clinical improvement but, from a systemic perspective, accompanying the patient in the disease process with attention to what is crucial for the individual patient.

Bibliography

Heo S., Lennie T.A., et all. Quality of life in patients with heart failure: Ask the patients, Heart & Lung, Volume 38, Issue 2, 2009,Pages 100–108,ISSN 0147–9563 Hallas C.N., Wray J., et all. Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure, Heart & Lung, Volume 40, Issue 2, 2011, Pages 111–121, ISSN 0147–9563 Celano CM, Villegas AC, et all. Depression and Anxiety in Heart Failure: A Review. Harv Rev Psychiatry. 2018 Jul/Aug;26(4):175–184 Dal Lin C.,Migliorini R., et all. Approccio integrato nella cura della coronaropatia in "PNEI REVIEW" 2/2017, pp 71–80.
A VERY COMPLEX CLINICAL CASE OF ACUTE CORONARY SYNDROME COMPLICATED BY THROMBOSIS AND INTRACRANIAL HAEMORRHAGE
Authors: Sorvillo G , Olivieri F , Rainone A , Quercia E , Violante A , Mazza A , Russo M , Colangelo G , Corrado L , Luisi I , Calvanese C , Riccio G
Published: May 2024

Female patient, 62 years old, with a remote clinical history of colon adenocarcinoma, arrived at the emergency–urgency department for chest pain; clinical, ECG and laboratory evaluation revealed a ACS NSTEMI and was performed angioplasty with DES implantation on the LAD and Cx branch and DAPT was started with ASA 100 mg/day and ticagrelor 90 mg x 2/day. On echocardiographic re–evaluation, the appearance of left ventricular thrombosis was noted, in the absence of obvious ventricular dysfunction, and she underwent parenteral anticolagulant treatment with heparin sodium. In the following days, the patient manifested a right sensory–motor hemisyndromes and aphasia, for which she underwent encephalous CT and cranial AngioTC, which did not show any images referable to steno–occlusive alterations of the intra– and extracranial arterial vessels. After neurological consultation, the indication for thrombolytic and/or interventional neuroradiological treatment was excluded. At the 24–hour CT check–up a large area of cortical–subcortical hypodensity appeared in the left occipito–temporo–parietal area. At subsequent CT scans, hyperdense areolae appeared, which could be attributed to haemorrhagic infarction, for which anticoagulant therapy was postponed and DAPT was suspended due to the very high haemorrhagic risk. In the next days, due to ECGgraphic changes (ST elevated in the anterior leads), the patient underwent a new emergency coronarographic study and intrastent thrombosis of the LAD branch was found, subjected to mechanical thromboaspiration with a good final result. After the procedure we started treatment with ASA 75 mg/day and enoxaparin 4000 IU/day. At subsequent check–ups progressive reduction of haemorrhagic areas in the brain. She therefore underwent neurological re–evaluation with indication to start NAO therapy (dabigatran 110 mg x 2/day) and SAPT with ASA 100 mg/day. The hospital stay was complicated by left femoral–popliteal DVT at the site of previous femoral CVC placement. Haematochemical and genetic screening revealed a positive ANA 1:320 (AC–8/AC–19), a homozygous mutation in the gene for MTHFR C677T and a heterozygous mutation in the gene for Leiden Factor V H1299R. Antithrombotic treatment in the patient with ACS and intracranial haemorrhage represents a challenge for the cardiologist and neurologist. This clinical case is a food for thought on how many obstacles can be encountered on the way to correct antithrombotic therapy.
VASOSPASTIC INFARCTION STARTED WITH PULSELESS ELECTRICAL ACTIVITY CARDIAC ARREST
Authors: Scordato F , Giunta N , Peritore G , Zambelli G , Smecca I
Published: May 2024

We report the case of a 48–year–old female with a special history of ischemic heart disease. It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged. She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022. During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose. In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates. No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed. Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero–septal and inferior wall in toto, suggesting recent ischemia; EF was 31%. During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose. The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting. In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.
IMPROVING THE KNOWLEDGE, RISK STRATIFICATION AND OUTCOMES IN ADVANCED HEART FAILURE. THE ISMETT HEART FAILURE REGISTRY
Authors: Nuzzi V , Manca P , Mulè M , Cipriani M
Published: May 2024

Background

Advanced heart failure (AdHF) accounts for approximately 10% of patients in HF clinics worldwide. Clinical management of patients with AdHF remains challenging and most of the available studies focus on chronic but not advanced HF. Registry studies may provide important insights into this specific population.

Methods

All consecutive patients referred to our centre for AdHF therapies candidacy (left ventricular assist device (LVAD), heart transplant (HTx)) are prospectively studied and enrolled in the registry. On the same day, all patients undergo a comprehensive clinical and instrumental examination, including electrocardiogram, echocardiography, extended laboratory tests and right heart catheterisation. Most patients also undergo a cardiopulmonary exercise test and, in the case of a non–ischaemic aetiology, cardiac magnetic resonance imaging and genetic testing, if not already performed. Echocardiography is also performed to assess advanced echocardiographic measures (biventricular and atrial strain, myocardial work, 3–D chambers assessment).

Results

Forty–five patients were enrolled from March 1, 2023 to December 22, 2023 (enrolment rate 4.5 patients/month). Mean age was 54 years and 2/3 were male. Median disease duration was 69 (28–165) months. Non–ischemic HF was the most common aetiology with a NYHA IV prevalence of 4% (all others were in NYHA III). 31% of patients had chronic kidney disease and overall liver function was preserved. 67% of patients were treated with sacubitril/valsartan, > 90% were taking beta–blockers (median dose 4.8 mg bisoprolol–equivalent dose) and 84% SGLT2 inhibitors. Both standard and advanced echocardiography showed features of advanced disease. Over a median follow–up of 4 (2 – 6) months 2 (4%) patients died, 5 (11%) underwent urgent HTx and 8 (18%) underwent LVAD implantation. For most variables, there was a trend showing that patients with events were sicker but, currently, the sample size limited the statistical power.

Conclusions

A systematic comprehensive evaluation of patients with AdHF evaluated for advanced HF therapies could help to reduce the knowledge gap for this high–risk HF population.
UNLOADING STRATEGIES IN ADVANCED HEART FAILURE: THE ROLE OF POINT–OF–CARE ULTRASOUND
Authors: Del Giudice C , Caputo A , D‘Arienzo D , Delle Femmine F , Liccardo B , Amarelli C , Marra C , Loffredo F , Varricchio A , Golino P
Published: May 2024

Patients with advanced heart failure (HF) exhibit repeated episodes of fluid retention (pulmonary and/or systemic congestion) and/or of reduced cardiac output at rest (peripheral hypoperfusion) requiring hospitalization along with diuretics/inotropic infusion. Pulmonary artery catheter (PAC) provides haemodynamic information to guide the therapy, however PAC is invasive and time consuming. Point of care ultrasonography (POCUS) represents a promising diagnostic tool at the bedside, performed by the physician to assess non invasively volume status, cardiac output and monitor decongestive therapy. Recently, abnormal Doppler flow patterns due to increased right atrial pressure have been described in the hepatic, portal, and intrarenal veins. Thus, the recent venous excess ultrasound score (VExUS) has been used to describe fluid status along with the diameter and collapsibility of the inferior vena cava. Furthermore HF patients show high filling pressures, therefore they often require mechanical or medical unloading. In this regard, point of care ultrasound represents a valid tool to monitor non invasively the filling pressures and the responsiveness to those treatments. Here, we illustrate with several clinical cases where VExUS/POCUS were pivotal in clinical management.
A RARE CASE OF ACUTE BIVENTRICULAR DYSFUNCTION IN SYSTEMIC SCLEROSIS
Authors: Iezzi L , Palermi A , Cieri C , Testa S , Gallina S
Published: May 2024

Systemic sclerosis (SSc) is a rare immune–mediated rheumatic disease characterized by diffuse vasculopathy leading to multiorgan fibrosis. We report the case of a 61–year–old man who was diagnosed with SSc one year before. At the time of diagnosis, the patient exhibited exertional dyspnea (NYHA II–III) due to mild signs of interstitial impairment at chest HRCT and stage 3b of chronic kidney disease. Echo was performed, showing severe impairment of the right ventricular systolic function in the absence of LV dysfunction. Right heart catheterization (RHC) was unremarkable (mPAP 19 mmHg, PCWP 16 mmHg). Several months later, despite immunosuppressive treatment, the patient experienced clinical worsening, in the absence of remarkable worsening of Echo and RHC parameters. Therefore, he was started with mycophenolate mofetil and tocilizumab. After 60 days of second line therapy, the patient presented to the ER with severe resting dyspnea (NYHA IV), in a clinical–laboratory data of acute heart failure due to new onset left ventricular dysfunction (EF 36%), and severe impairment of renal function (AKI on CKD). ECG (figure 1) showed chaotic ectopic atrial rhythm with prolonged atrio–ventricular conduction and frequent polymorphic premature ventricular contractions. This report presents a rare case of primary myocardial involvement in SSc, where right ventricular failure was the initial cardiac manifestation, rapidly progressing to severe biventricular dysfunction. As a potential cause of biventricular systolic dysfunction, we ruled out both drug–induced cardiotoxicity and autoimmune or infectious myocarditis, based on consistently negative results for inflammation and viral markers. We assumed fibrosis to play a significant role in this case of heart failure, as supported by electrocardiographic features of several conduction disturbances. Unfortunately, second level imaging with cardiac magnetic resonance was rejected by patient because of claustrophobia, and coronary angiography was excluded because of severe renal impairment. Patient was successfully empirically treated with diuretics, antiarrhythmic therapy, peritoneal dialysis and levosimendan. After 40 days of hospitalization, we reported complete regression of left ventricular systolic disfunction (last Echo showing EF 50%), and the patient was discharged in decent hemodynamic stability.
TWO YEARS OF EXPERIENCE OF THE REGIONAL CENTER FOR SPORT IN YOUNG PEOPLE WITH HEART DISEASE: ANALYSIS OF CRITICAL ISSUES AND BARRIERS
Authors: Vessella T , Merlo L , Pegoraro C , Giorgiano F , Barra B , Meneguzzo G , Sarto P
Published: May 2024

The aim of our study was to identify the critical issues of our clinical–psychological–sports management program of young ex–athletes patients judged unfit for competitive sport following the diagnosis of heart diseases potentially at risk of sudden death. In these two years, 114 patients have been referred to our Center, with an average age of 28 years +– 17. Of these, 13 have decided not to join the program. 7 dropped out of the prescription program at follow–up. The most common critical issues are the following:

Psychological and motivational

Difficulty in achieving a complete awareness of the pathology by the athlete and parents (if minor) Psychological problems related to diagnosis and unfitness (anxiety, anger, sense of isolation, depressive symptoms) Difficulty in accepting therapy when needed Patient adherence to prescription Failure to enjoy prescribed physical activity.

Clinical

Difficulty in communicating the diagnosis and prognosis Difficulty in correctly determining training intensities (hrr, thresholds, lactate?) Influence of therapy schedule on training frequencies Difficulty in Monitoring the Prescribed Activity.

Organizational

Difficulty in testing and monitoring all types of prescribable activities Resistance on the part of sports clubs to accept the return of these former athletes without the competitive certificate The identification of these "limits" has allowed us to adapt and modify the phases of the project in progress, reducing the number of non–adhesions and dropouts in the last year.

Conclusions

Prescribing exercise in athletes with conditions at risk of sudden death is a challenge for the future. In addition to a detailed knowledge of heart disease and a correct risk stratification, it is however essential to work on patient awareness and consider a series of psychological, motivational, logistical aspects aimed at optimizing the adherence of these ex–athletes, to prevent the prescription letter from translating into something unworkable, not understood, and therefore not followed.
QUALITY OF LIFE AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION: SINGLE CENTRAL STUDY
Authors: Picciani A
Published: May 2024

Aims

The objective of this study is to provide an overview of the quality of life (QoL) before and after TAVI, of the patients undergoing this procedure, at the U.O.S.D. Hemodynamics of the Chieti. Since QoL is a multidimensional concept, it is studied through items that include physical limitation, the frequency of symptoms, social limits, general well–being and the relative functional status.

Methods and Results

The study provided for the administration of a questionnaire: the Kansas City Cardiomyopathy Questionnaire 12 (KCCQ12), in two steps: 1) Administration of the questionnaire by telephone, two weeks before the TAVI; 2)Administration of the questionnaire by telephone two weeks after the TAVI implantation. The time span of the duration of the study is defined by the period between October 2022 and October 2023. For the study, 76 patients were selected who met the inclusion criteria. The statistical processing of the KCCQ–12 questionnaire data was performed by comparing the averages of the samples observed before and after the TAVI implantation. The statistical analysis was performed with the use of Student‘s T for paired data, a fundamental tool in comparing the scores of the averages obtained from each domain present in KCCQ12. We can say with a 95% confidence interval that patients before implantation have an average score lower than the post–implantation score. Based on the analysis carried out, we can say that the quality of life has improved in patients who have performed TAVI in a statistically significant way.

Conclusions

The study focuses on changes in quality of life after the TAVI procedure, a topic that is gaining increasing importance in addition to standard clinical goals, such as survival and the NYHA functional class. The objective improvement of the quality of life is perceived already two weeks after the treatment, at the same time determining an indirect benefit in terms of economic and social costs.In conclusion, we can say that patients with severe symptomatic aortic stenosis who underwent TAVI, analyzed with this study, found an improvement in their quality of life in a short time, infact the minimal invasiveness of the procedure, is able to minimize the time postoperative recovery, the time of hospitalization and rehabilitation, necessary instead in the case of more invasive interventions.
SAFETY AND EFFICACY OF TRANSCATHETER AORTIC VALVE REPLACEMENT FOR NATIVE PURE AORTIC VALVE REGURGITATION: SINGLE–CENTER EXPERIENCE
Authors: Cavalli G , Vallabini A , Spatuzza P , Braccio M , Alemanni R , Russo E , Siena P , Palladino M , Gallo N , Greco F , Di Marco L , Pacini D , Cassese M
Published: May 2024

Background

TAVR has become the standard of care for high–risk patients with aortic stenosis. Considering unique procedural challenges posed by native pure aortic regurgitation (NPAR), our aim was to evaluate early and mid–term results of off–label treatment with new generation devices.

Materials and Methods

We retrospectively enrolled 61 consecutive patients, who underwent TAVR for NPAR between 2017 and 2023, because deemed ineligible for surgery. Mean logistic and Euroscore II were 17,07±11 and 5,62±5,9, though they did not accurately reflect surgical ineligibility: 7 patients (11,5%) had active cancer and 5 (8,2%) end–stage liver failure. Patients with valve calcifications or stenosis were excluded. A CT scan was obtained to choose device model and size, and access site. A percutaneous VA ECMO support was used in patients at higher risk for hemodynamic instability and procedural failure. Local anesthesia was preferred whenever feasible. Primary endpoints were technical and device success. Secondary endpoint was clinical efficacy at 1 year.

Results

Mean age was 75,69±9,01. Considering the high–risk population, we adopted local anesthesia in 56 patients (91,8%), reducing ICU admission and stay (27,9% and 1,98±6,51days). Mean aortic annulus diameter, perimeter and area were 25,5±2,16mm, 82,2±5,84mm and 520,04±74,32mm2. Consequently, the most frequently implanted prostheses were Evolut R/Pro 34 (41%), Sapien 3/Ultra 29 (26,2%) and Accurate neo M (9,8%). Approximately half of the population (54,1%) was shortly supported (24,46±24,7 minutes) with fem–fem VA ECMO, reducing hemodynamic instability due to rapid pacing. However, no increase in vascular complication was observed (p=0,58). One intraprocedural death was recorded (1,6%). Although 30–day mortality was 8,2%, primary outcomes were significantly better in the second half of the population (p=0,044 and p=0,036), reflecting the role of a standardized approach and surgeons’ higher expertise. Only 4 paravalvular leaks (6,6%) were detected at 1–month follow–up, 3 mild and 1 moderate (1,6%). Mean follow–up was 18,54±18,48 months. Clinical efficacy at 1 year was 76,3%, available for 38 patients.

Conclusions

TAVR is still considered an off–label approach for NPAR because of increased stroke volume and absence of annular and leaflet calcification. Nonetheless a standardized approach, with the aid of brief VA ECMO support for complex cases, should be considered a safe and valid option for inoperable patients.
CASE REPORT OF SNARING–ASSISTED TAVR UNDER CEREBRAL EMBOLIC PROTECTION: THE "CHAPERONE” WITH “TOP HAT" TECHNIQUE
Authors: Casilli F , Medda M , Montonati C , Cerutti C , Donatelli F
Published: May 2024

A 84–year–old woman was admitted for effort dyspnea (NYHA class II–III) in severe aortic stenosis (peak/mean gradient 107/61 mm Hg, aortic valve area 0.5 cm2) with high surgical risk (STS PROM 8%). Pre–operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, ‘gothic’ aortic arch (AA) and multiple calcific stenosis of both iliac–femoral vessels, severely tortuous. We planned a transfemoral implantation of a 29–mm self–expandable Evolut R valve (Medtronic) under complete cerebral protection (CP) with TriGuard™ system and delivery advancement ‘snaring–assisted’. The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino–tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp). The snaring procedure of self–expanding transcatheter heart valve (THV) has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the ‘gotic’ and calcific AA. The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses. In order to guide the advancement of the THV through the AA we preventively inserted a 20–mm AndraSnare catheter from the contra–lateral femoral artery. The THV was advanced on the snared guidewire, and the tip of the THV was ensnared and then pulled in order to be detached from the calcified wall of the ascending aorta, allowing the valve to be steered (“Chaperoned”) through them moreover without any interference with the CP system (“Top Hat”). At the macroscopic analysis of CP device there were also present small debris of calcium. Finally no complications related to the vascular accesses occurred. On the basis of our experience the risk–benefit balance of implementing CP with device (and specifically with TriGuard™ system) needs to be deeply evaluated because it requires a great care: a) to avoid uncontrolled movement of the device once opened, b) to avoid aggressive contacts with the aortic wall during complex maneuvers, c) the CP system requires a dedicated vascular femoral access (8F). To our knowledge, this is the first case of snaring–assisted TAVR under complete cerebral embolic protection with TriGuard™ system.