bluuebunny/crossref_metadata_2025 huggingface dataset:
TRANSTYRETIN CARDIAC AMYLOIDOSIS IN ELDERLY PATIENTS: ALWAYS A WILD TYPE?
Authors: Costantino J , Ballatore F , Marchionni G , Alfarano M , Vizza C , Chimenti C
Published: May 2024

Background

Transthyretin amyloidosis (ATTR) exists in two forms: a genetic form transmitted by autosomal dominant inheritance (ATTRv) and a wild type form (ATTRwt). Clinically, the hereditary form tends to have an early onset in adulthood and it is characterized by a particular tropism for nervous as well as cardiac tissue. In contrast, the "wild type" form has a later onset with major cardiac involvement and neurological manifestations usually limited to carpal tunnel syndrome.

Methods and Results

In our centre, from September 2021 to June 2023, 52 patients older than 70 years received a diagnosis of cardiac ATTR (87% male, 13% female, mean age 81±5y). In all patients, blood tests showed a significant and stable increase in the values of troponin Ths (0.079 microg/L±0.074) and NT–proBNP (2000±1800 pg/ml), with the absence of a monoclonal component in the blood and urine, and miocardial bisphosphonate scintigraphy positive grade 2/3. All patients underwent genetic testing by amplification of exons 2,3 and 4 of the TTR gene with subsequent sequencing. Unexpectedly, in 10 elderly (70%male, 30% female, mean age 77±4 y) patients (19%) the genetic test resulted positive with 4 different mutations of pathogenetic significance (Val30Met; Ile68Leu; Val142Ile;, Phe84Leu). Three patients showed peripheral neuropathy with the presence of carpal tunnel syndrome, while isolated carpal tunnel syndrome was present in the remaining 7 cases. The three patients with neurologic involvement started Patisiran therapy, and 7 patients were treated with Tafamidis. First–degree relatives (16 consanguineous, average age 49±12 years) agreed to be subjected to genetic screening; of these 9 (3 male and 6 females, age 47±8 years) were positive for the corresponding mutation and underwent echocardiogram, MRI and myocardial scintigraphy. These tests were normal in 8 probands, included in an annual follow–up protocol to identify an early manifestation of the disease, and was diagnostic for amyloidosis in 1 patient who started specific therapy.

Conclusions

Our experience shows that 19% of patients older than 70 years with a diagnosis of cardiac ATTR may be affected by a genetic form. Making genetic diagnosis in this context is particularly important for screening family members: current therapies are in fact much more effective if started early before organ damage occurs.
A VENTRICULAR TACHYCARDIA CASE NOT TREATABLE WITH TRANSCATHETER ABLATION DUE TO APICAL THROMBOSIS OF THE LEFT VENTRICLE RESOLVED WITH RADIOTHERAPY BASED ON THE NON–INVASIVE MAPPING SYSTE
Authors: Romanazzi I , Di Monaco A , Valenti N , Grimaldi M
Published: May 2024

The clinical case focuses on a 52–year–old man smoker, heavy alcohol consumer. In 2017 he began with sustained ventricular tachycardia (VT) effectively treated with DC–shock. The following ECG showed signs of anterior necrosis. Severe left ventricular (LV) dilatation, apical thrombosis and severe impairment of LV function were found on echocardiogram. Angiography was performed and LAD occlusion was found. Since of 68% necrosis of the LV at myocardial scintigraphy, no revascularization was performed. He underwent to a dual chamber ICD implantation and started oral anticoagulation therapy. In the following years recurrence of arrhythmic episodes, despite the optimization of antiarrhythmic therapy, led the patient to numerous hospitalizations. Unfortunately the persistence of the apical thrombosis, made transcatheter ablation NOT possible. The only chance for the patient remained stereotactic arrhythmia radioablation. But which area of the LV to highlight as responsible for the arrhythmia and how to program the radiotherapy treatment plan was a challenging problem. We proposed in March 2023 non–invasive mapping of arrhythmia using Cardioinsight. The patient performed heart high–resolution computed tomography (CT) for the anatomical reconstruction with precise spatial resolution of all LV aereas and surrounding structures. A 252–electrode vest is applied to the patient’s torso and connected to the system Cardioinsight. A programmed ventricular stimulation was performed using ICD inducing two VT morphologies. Through electroanatomical mapping we identified the mid LV antero–septal and infero–septal sites as target areas. Thanks to multidisciplinary team a personalized treatment plan was created to deliver an effective lesion in the target area and minimize exposure to nearby organs at risk. The treatment was generated, optimized and delivered by TrueBeam, lasted 3 minutes and no complications arose. The patient was quickly discharged in good clinical condition. After 3 months of clinical well–being he was hospitalized for a single episode of VT. Up to now no hospitalizations occurred. This treatment may represent a "bail–out" choice in patients with advanced heart failure with arrhythmic storm who have exhausted all other therapeutic options.
REAL–WORLD SINGLE CENTER EXPERIENCE WITH THE WEARABLE CARDIOVERTER DEFIBRILLATOR: SEX DIFFERENCES IN RISK STRATIFICATION FOR SUDDEN CARDIAC DEATH
Authors: Bolognesi M , Rossi L , Biagi A , Sticozzi C , Comastri G , Puccio F , Pisati M , Aschieri D
Published: May 2024

Background

Wearable cardioverter defibrillator (WCD) demonstrated an important role for prevention of sudden cardiac death in patients with advanced heart failure and reduced left ventricular ejection fraction. Although in randomized trial there are no gender difference in WCD use and defibrillator (ICD) implantation rate, real world data in female patients is lacking. Purposes: We aimed to describe the sex differences in WCD use, the rate of cardiac events detected with WCD and the rate of ICD implantation after WCD use in women in a real–world single center experience with reduced left ventricular ejection fraction or prior ventricular tachyarrhythmia.

Methods and Results

According with the current guidelines indications, between August 2017 and June 2023 ninety–six consecutive patients (mean age 66.0±11.1 years) received a WCD at Piacenza Hospitals and were retrospectively included in this analysis. There were no differences in clinical characteristics between female (18 patients, 18,8%) and male: in particular baseline left ventricular ejection fraction (LV EF) were similar between the two groups (29.5±5.2 vs 27.9±7.9, p=0.23) and no differences were found in the rate of ischaemic cardiopathy (66,6% vs 69,2% p=0.51). After 3–months follow up with WCD use, a similar rate of ventricular arrhythmias were found in the two groups (5.5% vs 3.8%, p=0.48) and no ventricular fibrillation was detected. The WCD usage period and median daily wear time were not different between female and male (55.2±50.6 vs 56.2±34.8 days p=0.53, 21.0±6.4 vs 23.1±1.5 hours p=0.48, respectively). However women presented a better LV EF improvement (12.2±9.7 vs 7.2±6.8, p=0.01), with a significant lower ICD implantation rate at the end of WCD use (55.5% vs 43.8%; p< 0.01).

Conclusions

In this real word analysis women presented a nice compliance using WCD. In spite of a similar burden of ventricular arrhythmic events, women presented a better LV EF improvement with a significant lower ICD implantation rate.
HYBRID STAGED REVASCULARIZATION OF SEVERE THREE–VESSEL DISEASE ENSURED SAFE MAJOR ONCOLOGIC GASTRIC SURGERY
Authors: Biolcati M , Bassi I , Cannata A
Published: May 2024

A 71–years–old man with multiple cardiovascular risk factors and an old history of paroxysmal AF (non–anticoagulated due to a single episode in youth) was diagnosed with a non–metastatic adenocarcinoma of gastric fundus judged resectable. During infusion of the third cycle of pre–operative CT with FLOT he experienced transitory chest pain with the development of sharpened T waves with a high J point in antero–lateral leads at the EKG during the symptom (fig. 1). The episode was at first considered compatible with vasospasm induced by 5–FU, but a CT scan was nonetheless performed showing a severe three–vessel CAD involving the left main coronary artery (fig. 2), confirmed by the coronary angiography. A normal systolic function was found at the cardiac ultrasound. After the multidisciplinary team including cardiologists, cardiac surgeons, anaesthesiologists, oncologists and gastric surgeons discussed the case, the patient was referred to an urgent off–pump single CABG of the LAD coronary artery with LIMA. That allowed the non–delayable program of total gastrectomy – which was conducted for weeks later – in a safe setting by revascularizing the prognostic vessel and avoiding the DAPT related to a PCI (an eventual bridge therapy with intravenous P2Y12 inhibitors during the first month of stenting of a critical coronary artery was considered at high risk); in addition, the choice of OPCAB prevented the augmented risk of complications of extracorporeal circulation described in oncologic patients such as bleeding and higher mortality (Vieira et al, 2012). Once no residual local or metastatic disease was established, a complete revascularization was performed in election few weeks later by PCI of the residual vessels, which avoided the problems related to a re–sternotomy of a possible second CABG with venous grafts. After six months, the patient was still alive and concluded the remaining two cycles of adjuvant CT safely.
LEAD–REVERSAL OF AN ICD: A RARE BUT POSSIBLE CAUSE OF INAPPROPRIATE SHOCKS AND FAILURE TO TREAT LIFE–THREATENING VENTRICULAR ARRHYTHMIAS
Authors: Freschini M , Notaristefano F , D‘Ammando M , Zingarini G , Barengo A , Giuranna M , Russo G , Della Torre M , Cavallini C
Published: May 2024

Introduction

Lead reversal of a dual–chamber (D–C) ICD is a rare but possible event that can occur during device implantation or at the time of generator replacement. The presence of DF–1 connector is a prerequisite for the switch between atrial and pace/sense ventricular lead. The effects may be deleterious for the patient.

Clinical Case

A 86 y–o man was admitted to the hospital for fatigue; ICD malfunction was suspected. Medical history included paroxysmal AF, ICD implantation for ischemic cardiomyopathy, generator replacement one year ago and access to ED for ICD–shock 3 months before: the device check showed an appropriate intervention on VT. Device was programmed in DDD–70 bpm and at the admission the surface ECG showed: a first spike not followed by electrical activity and a subsequent spike after the programmed AV which resulted in atrial depolarization; the latter was followed by spontaneous narrow QRS. Subsequently the ECG showed a paced QRS complex with another spike 80ms later inside the QRS (Fig.1a). The EGMs at device check are represented in Fig.1b. Impedance, threshold and lead sensing parameters were normal except for atrial threshold close to the programmed output. During sensing test the atrial EGM followed the ventricular EGM (Fig.2) and raised the suspicion of 1) atrial undersensing with T–wave oversensing, ruled out by testing different PVARP and atrial sensitivity; 2) Atrial lead dislodgement in the ventricle 3) atrial and ventricular lead connection switch. To better define the problem the threshold test was combined with the surface ECG recording: threshold tests in VVI and AAI showed respectively atrial and ventricular capture on the surface ECG (Fig.3a,3b), which confirmed the inversion of atrial and ventricular pace/sense connections. Subsequent surgical repositioning of the correct lead to the IS1 sensing/pacing RA and RV ports allowed resolution of this problem.

Discussion

Atrial and ventricular lead connection switch is only possible in DF–1 D–C ICD. Diagnosis can easily be missed if the device check is not combined with surface ECG. In this case once the diagnosis was made, it was possible to understand that the ICD–shock occurred 3 months before was inappropriately delivered on a SVT.

Conclusion

Atrial and ventricular lead switch diagnosis is complex and often requires additional manoeuvers. The confirmation is crucial to avoid both inappropriate shocks and the failure to treat life–threatening ventricular arrhythmias.
RIGHT VENTRICULAR DYSFUNCTION AND TRICUSPID VALVE SURGICAL CORRECTION: ROOM FOR STRESS ECHOCARDIOGRAPHY?
Authors: Pasquero M , Bocchino P , Gravinese C , Boretto P , Bellettini M , Angelini F , De Ferrari G
Published: May 2024

We report the case of a 50–years–old young woman with multi–operated rheumatic valvular heart disease; aortic, mitral, and tricuspid commissurotomy (1994); aortic valve replacement with bioprosthesis for endocarditis (1998); mitro–aortic replacement with mechanical prosthesis and tricuspid valve plastic repair (1999); mitral valve replacement and re–do of tricuspid plastic repair (2003). Concomitant conduction pathway disease (BAV II type 1 and RBB). The patient was admitted in June 2023 for wet & warm NYHA IV right heart failure with severe peripheral congestion and ascites. On echocardiography: LV with systo–diastolic compression, EF 51%; normo–functioning aortic prosthesis; dilated (TDA 24 cm2), hypokinetic (TAPSE 9mm,S‘ 4 cm/s,FAC 25%) right ventricole (RV), with poor load adaptation (load adaptation index 16, RVCPI 108 mm*mmHg, ePAPI 1.1); torrential IT, caval plethora with systolization of hepatic venous flow. Medical therapy was initiated with intravenous bolus diuretics, nitroglycerin and inotropic support (dobutamine 2.5 y). In order to define the best therapeutic strategy in the persistence of torrential IT and RV dysfunction we performed: trans–oesophageal echocardiography, showed massive IT from ring dilatation and wide flail of the septal flap not suitable for edge–to–edge correction, total–body angioTC, with no relevant findings, right cardiac catheterization, which documented pulmonary pressure and arteriolar resistances within limits (wedge 12 mmHg,PAP25/15/18 mmHg,RAP 11 mmHg,PAPI 0. 9,RVSWI 4.8) with reduced cardiac index (2.14 l/min/cm2) and stress–echocardiography with dobutamine that showed presence of RV contractile reserve (FAC 28%>39%). In consideration of the functional properties of the tricuspid valve, absence of pulmonary hypertension and given the presence of RV contractile reserve, patient underwent tricuspid valve replacement surgery with a bioprosthesis (SJ Epic 27 mm) in mini–thoracotomy with smooth postoperative course. At 3 months follow–up showed functional recovery (NYHA II), with good prosthetic function and partial reverse remodeling of the RV (TDA 14 cm2, FAC of 30%). In conclusion, by documenting right ventricular contractile reserve, stress echocardiography proved to be an important aid in predicting absence of RV failure in the immediate post–surgical period, presenting attractive prospects in the assessment of RV functional reserve in patients undergoing to corrective tricuspidal surgery.
ENOXIMONE AS A THERAPEUTIC OPTION IN STATUS ASTHMATICUS: A CASE REPORT
Authors: Michele C , Vera–Mondazzi L , Trunfio D , Giovanella E , Mohmed Ahmed Ibrahem H , Abd Almhmoid Sidiq M , Salah Ali Gubara H , Portella G , Masini F
Published: May 2024

Status asthmaticus is an acute exacerbation of asthma that is unresponsive to initial treatment with bronchodilators and can rapidly escalate into acute ventilatory failure. The clinical picture of severe asthma include agitation, drowsiness or confusion, breathlessness at rest, tachypnea, use of accessory respiratory muscles, tachycardia, and pulsus paradoxus. Pharmacological treatments include but are not limited to beta–2–mimetics, anticholinergic agents, magnesium sulphate, steroids and aminophylline. Asthma exacerbations can be triggered by interrupting chronic treatment: in war torn areas as Sudan it is mainly due to the abrupt lack of availability of drugs. A 58 years old 80 kg man with history of severe asthma presented to our triage complaining of severe dyspnea in the last 3 days, unresponsive to treatment with bronchodilators and systemic corticosteroids. He stopped his chronic therapy with budesonide/formeterol due to the unavailability of the drug. At the arrival he showed orthopnea, severe tachypnoea (60 breaths/min) and sinus tachicardia (130 bpm), silent chest and SpO2 86% on reservoir mask 15 l O2/min. The ABG showed pH7.27, pO2 47, pCO2 60. The chest Xray and the transthoracic echo were unremarkable. After receiving repeated nebulizers (salbutamol 5 mg + adrenaline 1 mg every 20’ for 2 h), iv hydrocortisone high dose (1 g), iv aminophylline 240 mg, iv magnesium sulphate 2 g, iv ketamine 100 mg there were neither clinical nor ABG improvement. Given the unavailability of drugs as ipratropium and sevofluorane and of treatments like V–V ECMO, a rescue trial with iv enoximone was performed, administrating 0.3 mg/kg iv bolus followed by 3 mg/kg/min continuous infusion, conbined with NIV to decrease the respiratory workload and salbutamol nebulizers. Improvement of the respiratory mechanics and of the gas exhange were immediate, leading to normal ABG, mild tachypnoea and mild chest wheezes after the administration of 200 mg of enoximone, with no cardiovascular side effects. The patient was discharged home on the 6th day, without respiratory symptoms. Enoximone acts as an inotrope by inhibiting PDE–3 activity and increasing intracellular cAMP levels in cardiac myocytes. Increasing intracellular cAMP is also the main mechanism of β2–agonists bronchodilators, and both experimental models and clinical experience suggest that enoximone can overcome the asthma–related β–receptors downregulation, providing a therapeutic role in status asthmaticus.
URIC ACID SIGNIFICANTLY CORRELATES WITH THE PRESENCE OF LOW–VOLTAGE AREAS AT THE ENDOCARDIAL MAPPING IN PATIENTS WITH NON–VALVULAR ATRIAL FIBRILLATION
Authors: Baroni M , Fortuna M , Maloberti A , Tognola C , Algeri M , Intravaia R , Leidi F , Colombo V , Ciampi C , Carbonaro M , Gigli L , Mazzone P , Giannattasio C
Published: May 2024

Background

Interest in the role of atrial substrate in maintaining Atrial Fibrillation (AF) is growing. Fibrosis is the culprit in the electrical derangement of the myocites. Many cardiovascular risk factors are known to be linked to atrial scarring; among them Uric Acid (UA) is emerging. The purpose of our study is to evaluate whether UA is associated with atrial fibrosis in AF patients.

Methods

81 patients who underwent radiofrequency transcatheter ablation for nonvalvular AF at the cardiological department of the Niguarda Hospital were enrolled. UA levels were analysed before the procedure as well as known predictors of atrial fibrosis. High density electroanatomic mapping of the left atrium was performed and patients were divided according to the presence or not of areas of pathological substrate (bipolar voltage < 0.5mV in sinus rhythm).

Results

19 patients showed a pathological atrial substrate. The population of patients with pathological atrial substrate was older (64.7±1.6 vs 58.2±10.9 years, p=0.032) and had more often a persistent phenotype of AF (84.3 vs 35.8%, p<0.001). UA levels were significantly higher in the pathological group (6.8±1.9 vs 5.3±1.4, p<0.001) as well as the prevalence of hyperuricemia (26.5 vs 6.5%, p=0.021). The association between uric acid and pathological atrial substrate remains significant even after correction for confounding factors (age, left ventricular dysfunction, valvular disease, AF phenotype and furosemide use).

Conclusions

In a population of patients who underwent atrial fibrillation’s ablation, higher uric acid’s levels were significantly associated with pathological left atrium’s substrate at electro–anatomical mapping.
ADDITION OF GLIFOZINE IN THE CARDIOLOGY OUTPATIENT SETTING: FOCUS ON BODY WEIGHT REDUCTION
Authors: Formigli D , Cocozza S , Parente A , Coppola G , Di Donato M , De Fortuna E , Franco V , Moscato F , Scherillo M
Published: May 2024

Rationale

Glyphozines (dapaglifozin and empaglifozin) have recently been made prescribable also for cardiologists in the setting of heart failure, diabetes mellitus and chronic renal failure. In clinical validation trials their use is associated with a poor reduction in body weight of between 1 and 2.5%.

Aim of the Work

To identify the benefit in terms of body weight reduction in outpatients after the addition of glyphozines.

Results

N=59 patients (69% male) who received a new prescription for glifozine at the outpatient cardiology visit in January 2023 according to AIFA indications were included in the analysis. The average age was 73 ± 8 years, with average weight and BMI of 78.9 ± 13.2 Kg and 28.7 ± 3.9 Kg/m2. The anamnesis shows a history of: previous ACS in 66%, AF in 19%, CCS in 10% and VHD in 8%. The AIFA indications for prescription were: T2DM 47%, HFpEF 25%, HFrEF 20%, CKD 7%. Concomitant therapies were: BB 76%, Diuretics 61%, ARB 46%, MRA and CCB 20%, ACEIs 19%, ARNI 8%, Ivabradine 8%, Ranolazine 7%. At an average FU of 8.7 ± 2.9 months there was an overall average weight and BMI reduction of 4.7%. On univariate analysis there was no significant difference in weight reduction between HFrEF, HFpEF, T2DM and CKD. Patients in concomitant therapy with loop or thiazide diuretics (n=36) to which glyfozine was associated instead presented a greater reduction in weight and BMI compared to patients without diuretics (n=23): - 5.6 ± 3 .8% vs - 3.3 ± 4.8% (p=0.027).

Conclusions

The addition of glifozine in patients who undergo periodic cardiological control is associated with a greater reduction in body weight when associated with concomitant diuretic therapy.
NON–INVASIVE VENTILATION IN HOSPTALIZED ACUTE HEART FAILURE IS ASSOCIATED TO SHORT–TERM MORTALITY
Authors: Livrieri A , Potenza A , Landriscina R , Sanasi M , Piscopo A , Sasanelli P , Demola P , Basile M , Gesualdo M , De Palo M , Caldarola P , Massari F , Scicchitano P
Published: May 2024

Background

Some patients with acute heart failure (AHF) are initially treated with noninvasive ventilation (NIV). Today, it is not full explored the prognosis of subjects hospitalized with AHF and treated with NIV.

Methods

We retrospectively evaluated subjects hospitalized with AHF between 2022 and 2023 in intensive care unit. We determined the association between and mortality at 90–days using Cox proportional hazard and Kaplan–Meier analyses.

Results

We included 191 subjects who were hospitalized with AHF. Ninenty–days mortality occurred in 24% subjects. Seventy–five subjects were treated with NIV (32%) and showed higher mortality when compared with for those without NIV (55% vs 35%, p<0.01). At 90–days, mortality was significantly associated with NIV (hazard ratio 2.3, 95% CI 1.3–4.0; p=0.005). Survival curves for mortality according to NIV use is in figure (logrank p= 0.004; chi–squared = 8.3). After adjustment for sex, age, BNP, renal and left ventricular functions, NIV treatment remained significantly associated to about 2–fold risk increase in mortality.

Conclusions

In subjects hospitalized with AHF the treatment with non–invasive ventilation was associated to short–term mortality independently from clinical parameters. This prognostic information should be weighted against structured trials in order to derive more specific clinical implications.
IMPACT OF DISCHARGE FROM A CARDIOLOGY UNIT ON OUTCOMES IN NON–ST ELEVATION MYOCARDIAL INFARCTION: AN ANALYSIS OF A NATIONWIDE ADMINISTRATIVE DATABASE
Authors: D‘Errigo P , De Luca L , Rosato S , Badoni G , Baglio G
Published: May 2024

Background

Current data on the prognostic impact of a specialist management of patients with acute coronary syndromes are scarce.

Aim

To evaluate the impact of the discharge of revascularized patients with Non–ST elevation myocardial infarction (NSTEMI) from a cardiology unit on their 1–year prognosis and to evaluate the differences in terms of effectiveness between discharge from a cardiology and non–cardiology unit and the whole management of the index hospitalization in a cardiology unit.

Methods

Retrospective nationwide cohort study enrolling consecutive patients older than 18 years admitted in 2019–2020 in Italy for a NSTEMI and undergoing percutaneous coronary intervention (PCI) within 48 hours from the index admission. Patients died within 30 days from the index admission were excluded from the analysis. Enrolled patients were classified based on the management department into: patients not discharged from a cardiology unit (group 1); patients not admitted but discharged from a cardiology unit (group 2); patients completely managed (admitted and discharged) in a cardiology unit (group 3). The outcome of interest was 1–year all–cause mortality. A Cox multivariate regression model was used to evaluate the impact of the management department on 1–year mortality.

Results

The study cohort consisted of 31950 NSTEMI events. Among them, 534 (1.6%) were allocated in group 1, 1160 (3.6%) in group 2 and 30256 (94.7%) in group 3. Patients completely managed by a cardiology unit were younger and less likely to be female than patients in other groups. The 1–year mortality was 14.4%, 8.4% and 3.8% (p<0.001) for group 1, group 2 and group 3, respectively (Figure). After adjustment for age, sex, and comorbidities, the hazard ratio (HR) for 1–year mortality was 2.4 (p<0.0001) and 1.7 (p<0.0001), in patients in group 1 and group 2, respectively, as compared with patients completely managed in a cardiology unit (group 3).

Conclusion

Complete management of index hospitalization or hospital discharge from a specialist unit alone improves the one–year prognosis of patients hospitalized with a diagnosis of NSTEMI in Italy.
A CASE OF ACUTE CORONARY SYNDROME IN DISGUISE
Authors: Pezzi L , Rossi D , Scollo C , Benedetti C , D‘Andria R , D‘Alleva A , Magnano R , Forlani D , Genovesi E , Vitulli P , Gallina S , Di Marco M , Paloscia L
Published: May 2024

A 56–year–old Caucasian woman with a silent cardiac history, a history of smoking, and a previous hip prosthesis surgery presented to the emergency department. She reported oppressive chest pain radiating to the left arm intermittently for about 2 days, precipitated by significant emotional stress at work. The 12–lead ECG revealed sinus bradycardia, symmetrically negative T waves in the anterolateral leads, and prolonged QTc interval (544 ms). The echocardiogram showed apical akinesia, basal hyperkinesia, and moderately depressed global systolic function (ejection fraction 45%). Laboratory tests indicated elevated myocardial necrosis enzyme levels (hs–TnI 549 pg/ml), negative inflammatory markers, normal electrolytes, hemogram within normal limits, and normal renal function. She was admitted with a working diagnosis of NSTEMI–ACS. On admission, the patient was asymptomatic for angina, and had stable vital signs, particularly a blood pressure of 120/70 mmHg and a heart rate of 55 bpm. Clinical examination revealed no abnormalities. The InterTAK score was 67. Coronary angiography revealed severe stenosis of the mid–left anterior descending coronary artery, treated with PTCA–DES. The intracoronary imaging (OCT) showed a plaque with characteristics of stability, leading to the consideration of the diagnosis of Takotsubo syndrome in patient with CAD. Subsequent echocardiography showed nearly complete recovery of systolic function. At the one–month follow–up, the patient exhibited preserved systolic function (EF 60%). This case highlights Takotsubo syndrome with concomitant coronary artery disease (CAD) as a bystander. According to Mayo Clinic criteria, the coexistence of severe CAD would exclude the diagnosis of Takotsubo. However, recent studies suggest the potential for coexistence, prompting the need for additional imaging modalities such as OCT and CMR to differentiate culprit from bystander lesions. Utilizing these techniques may alter the prevalence of Takotsubo syndrome, necessitating a reassessment of cases initially classified as NSTEMI–ACS.
EFFECTS OF VERY LOW CALORIE KETOGENIC DIET VS SLEEVE GASTRECTOMY ON CARDIO–METABOLIC PROFILE IN PATIENTS WITH OBESITY
Authors: Trapanese V , Giofrè F , Natale M , Cosentino F , Vatalaro C , Sergi S , Melina M , Armentaro G , Sciacqua A , Cloro C , Arturi F
Published: May 2024

Background

Obesity is a complex, multifactorial disease with deleterious effects on cardiac function. Currently, the obesity treatment is one of the most difficult challenges. Very low calorie ketogenic diet (VLCKD) has been proposed as an effective intervention for obesity. Furthermore, hyperketonemia induced by VLCKD is associated with beneficial cardiovascular effects. On the other hand, sleeve gastrectomy (SG) has been proven to be the most effective long–term weight management treatment. However, to date, it is still unclear whether the positive effects of SG on cardiovascular disease are mediated only by weight loss.

Aim

To evaluate the changes in anthropometric and metabolic parameters and in cardiac structure and function after treatment with SG or VLCKD. The results obtained in the two groups have been compared to verify if, in the short time, there were differences between these two treatments.

Methods

Twenty obese patients were enrolled. All the patients underwent a complete anthropometrical evaluation, laboratory determinations and echocardiogram evaluation. Ten patients have been treated with SG and 10 with VLCKD. The two group were comparable for weight loss: –26 kg (28%) after 3 months in patients treated with VLCKD and –25 kg (27.5%) after 6 months in patients treated with SG.

Results

An improvement in the anthropometric and metabolic profile was observed in all the patients. There were significant improvements in cardiovascular risk factors, including total cholesterol levels, triglyceridis, fasting glycemia, systolic and diastolic blood pressure, serum uric acid and HOMA–IR values. Similarly, the echocardiogram evaluation showed, in both groups of treatment, a reduction of the end–diastolic left ventricular volume, a reduction of the end–systolic left ventricular volume and a reduction of interventricular septal thickness and posterior wall thickness. Furthermore, an increase in the Ejection Fraction has been observed. No significantly differences between two groups were observed. Interestingly, in patients in treatment with VLCKD, a significant change in the global myocardial work efficiency (GWE) was observed.

Conclusion

Our data showed that VLCKD and SG have the potential to protect cardiometabolic health and myocardial remodeling in obese patients. VLCKD is a promising lifestyle intervention that can be used to prevent or treat cardiovascular disease. However, its effectiveness in the medium to long term must be evaluated.
DISCONTINUING DAPT: NOT JUST A MATTER OF SCORES BUT OF INTEGRATED EVALUATION? A KEY ROLE OF IMAGING IN A COMPLEX SCENARIO
Authors: Tamborrino P , Vitale C , Angelillis M , Galeotti G , Carluccio M
Published: May 2024

The duration of the dual antiplatelet therapy (DAPT) is a widely debated topic within the scientific community. The latest guidelines on acute coronary syndromes have supported the possibility of different therapeutic approaches tailored to patient characteristics. However, the clinical cardiologist‘s decisions are not always based on certain principles. The following case report is a practical example. Discussion: A 31–years–old man came to our attention after a resuscitated cardiac arrest due to ventricular fibrillation during a motorcycle race. His history was characterized by a previous acute myocardial infarction at the age of thirteen due to a traumatic dissection of the proximal left anterior descending (LAD) coronary artery and ascending aorta treated conservatively, with residual transmural necrosis of the mid and subendocardial anterior wall on cardiac MRI. At the admission, ECG showed ST–segment elevation in the anterior leads. Coronary angiography revealed occlusion of the proximal LAD coronary artery, treated with drug–eluting stent (ONYX 5.0 mm), with evidence of dissection and aneurysmal wall of that segment. The patient started a DAPT with aspirin and prasugrel. At discharge, echocardiogram evidenced a moderate left ventricular dysfunction (ejection fraction 34%) with signs of anterior and apical necrosis. Later, the patient was admitted for a subcutaneous defibrillator implantation, due to persistent moderate ventricular dysfunction. One year after revascularization, a lifelong DAPT strategy with downgrading to clopidogrel was considered the best choice for the following considerations: the young age of the patient, the low bleeding risk (PRECISE DAPT score 8), a not elevated DAPT score (value 2), the revascularization in the aneurysmal segment without an appropriate stent apposition (due to absence of a right sizing) and the previous dissection with sign of partial thrombosis at coronary CT. Conclusions: The anatomical complexity of angioplasty procedures and the delicate balance between ischemic and thrombotic risks have led to continuously evolving therapeutic strategies. The clinical scores currently available cannot often account for complex coronary anatomy. Thus, it‘s essential to consider a personalized approach, individualized on clinical and imaging characteristics, that encompasses ischemic and bleeding risk and procedural data for the appropriate treatment for each patient.
ICCU – ACQUIRED WEAKNESS IN ELDERLY PATIENT ADMITTED FOR ACUTE CARDIAC CRITICAL ILLNESS
Authors: Trotta M , Brunori L , Cestelli J , Chiocci E , Del Pinto M , Falchetti D
Published: May 2024

Over the last thirty years there has been a profound change in the demographic and epidemiological (1) profile of patients admitted to Intensive Cardiac Care Units (ICCU). Patients with multi–comorbidity and multi–organ failure have significantly increased; this resulted in an exponential extension of the ICCU stay. As related to what was said above, there has been an increase in weakness with consequent growth in medical–care complexity. In addition to these aspects, the increase in manifestations such as disorientation syndrome and delirium in these patients during hospitalization is of great importance. The pathophysiological characteristics of weakness acquired in ICCU are well known, while it is difficult in clinical practice to use neuro–pathophysiological diagnostics to describe its etiology (reduced peripheral nerve conduction velocity, reduced CMAP–compound muscle action potential, reduced muscle excitability, etc.). Given the complexity described, in our opinion it is essential to include the figure of a dedicated physiotherapist in medical nursing care in the ICCU. It would thus finally be possible to structure a multidisciplinary approach useful for the early rehabilitation of elderly and multi–morbid patients in order to reduce hospital stay (2), clinical complications and possible improvement in terms of clinical outcomes. Our group therefore has attempted to define a multidisciplinary intervention protocol through the use of rehabilitation assessment tools validated in patients admitted to ICCU aged 65 years and over. The protocol will provide for a randomization of patients consecutively admitted to our ICCU for an early structured multidisciplinary treatment vs usual care. A series of clinical–laboratory parameters will also be evaluated to define the incidence of the following complications: hyper–catabolic state, development of Acute Renal Failure with increase in creatinine >40% compared to baseline, infectious complications, clinically evident Congestive Heart Failure or episodes of left ventricular failure and NTproBNP trend during hospitalization. With the definition of this protocol, we would like to elaborate the numerous evidence in the literature on early rehabilitation intervention models (3), as there is no certain data in patients admitted to ICCU.
IRON DEFICIENCY ANEMIA AFTER CARDIAC SURGERY: IS THERE AN ADDED VALUE OF THERAPY WITH SUCROSOMIAL IRON ON TOP ON FERRIC CARBOXYMALTOSE? PRELIMINARY DATA
Authors: Venturini E , Giallauria F
Published: May 2024

Background

IDA after CS increases mortality, serious adverse events and length of stay; it also has a negative impact on the cardiac rehabilitation (CR) program. The FCM is the gold standard for IDA patients (P). However short–term treatment of IDA after CS using FMC or SI showed a significant similar improvement of key hematological parameters (HP) and in functional capacity . The aim of the study was to evaluate whether the use of both therapies had an additional positive effect.

Methods

26 consecutive IDA P, (normal ventricular function, mean age 71,5 ± 8y), after the admission in in in–patient Cardiac Rehabilitation were all treated with FCM (group A) and a part (group B, n 13) also with SI. The study design included a single dose of 1000 mg of FCM at T1 (at 8–10 days from CS) and after a dose of 60 mg of SI per day from T1 to T2 (the day of discharge 10 days after) until T3, 15 days after. Measures of efficacy included changes from baseline in HP and natriuretic peptides (NP).

Results

The data are shown in the Table. The statistical analysis was conducted with the Mann Whitney test (non–parametric). At baseline there were no differences in Vit B12, folate and reticulocytes. No P had a deficiency of Vit.B12 or of reticulocytes; 57% had a folate deficiency (higher prevalence in the group B, 4.0 ±2.1 vs. 9.5±11.7 ns). Hb and other HP increased significantly, with no differences between the two groups. The increase in Transferrin Saturation (Tsat) was greater (but ns) in group B with lower baseline level. The ferritin (F) level was much higher in group A; the delta is also significant. Iin group B the F remains stable, while in grupo A it doubles (+94%). No significant differences were observed in others parameters. The NP level was lower at T3 in group B; the data does not appear to be clinically relevant, for the different baseline values (the delta was not significant).

Conclusions

It is mandatory to look for folate deficiency, for optimal management of IDA after CS. The SI can mitigate the high levels of F, consequence of the inflammatory state following CS. Furthermore, it is known that FCM can induce a further increase in F may be due to a low–grade pro–inflammatory effect correlated to the high level of iron deposition in macrophages . Also relevant is the positive impact on TSAT with the possibility of reaching the guidelines–level more quickly. The increase in the number of cases will allow us to achieve more certain results.
LIPID–LOWERING THERAPY WITH PCSK9 INHIBITORS: FAMILIAL HYPERCHOLESTEROLEMIA VS GENERAL POPULATION OUTCOMES
Authors: Matteucci A , Alonzo A , Castello L , Spinelli A , Marino G , Schiaffini G , Di Fusco S , Aquilani S , Aiello A , Colivicchi F
Published: May 2024

Background

Dyslipidemic patients, particularly those with familial hypercholesterolemia (FH), are at increased risk of cardiovascular events and require beginning a full treatment. This study aims to compare the long–term effects of PCSK9i treatment in FH and non–FH dyslipidemic patients.

Methods

The study enrolled 381 dyslipidemic patients receiving PCSK9 inhibitors in our dyslipidemia outpatient clinic. FH was defined in accordance with the Dutch Lipid Clinic Network Criteria. The clinical data were collected in both groups and lipid profiles were monitored at 6, 12, and 36 months.

Results

In patients with FH baseline total cholesterol was significantly higher(260±54.8 mg/dL vs 212±51.3 mg/dL p < 0.001) as well as LDL cholesterol (181.4±51.7 mg/dL vs 137±45.1 mg/dL p < 0.001). A lipid reduction was observed in both groups at 6 months (LDL 69±41 mg/dL vs 62±37 mg/dL p = 0.20) at 12 (LDL 66±41 mg/dL vs 66±40 mg/dL p = 0.96) and 36 months (LDL 73±45 mg/dL vs 72±35 mg/dL p = 0.92).

Conclusions

PCSK9i treatment is highly effective in reducing LDL–C levels in both FH and non–FH dyslipidemic patients. The Achievement of similar LDL–C levels between these two groups in long–term follow–up could suggest that PCSK9i therapy is equally efficacious in both populations despite different dyslipidemia settings.
ROLE OF CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY (CCTA) IN SPONTANEOUS CORONARY ARTERY DISSECTION (SCAD)
Authors: Dell‘Aversana F , Tedeschi C , Ferrandino G , Tuccillo A , Scotto di Uccio F , Tuccillo B , Liguori C
Published: May 2024

Spontaneous Coronary Artery Dissection (SCAD) is a rare but insidious cause of myocardial infarction and sudden cardiac death especially in those who lacks of traditional cardiovascular risk factors. Although the most appropriate management of patients with SCAD is not clearly defined, it‘s essential to make an early diagnosis in order to follow a conservative approach. Nowadays, the role of Coronary Computed Tomography Angiography (CCTA) is consolidated in the study of atherosclerotic coronary pathology but its contribution in the diagnosis and follow–up of patients with SCAD does not apperar to be defined. The purpose of this study was to retrospectively investigate the diagnostic performance of CCTA and its role in the follow–up of patients with diagnosis of SCAD. We examined 307 patients admitted to emergency department for acute chest pain and an ECG diagnosis of STEMI from March 2021 to July 2023. 1 patient was diagnosed with type 2 SCAD on invasive coronary angiography (ICA) and 2 patients received a suspected diagnosis of SCAD at ICA and CCTA examination was performed to confirm the suspicion. CCTA examination showed the acute presence of Intramural hematoma (IMH) of the wall of left anterior descending artery (LAD) in 2 patients, confirming the angiographic suspect of SCAD type 2. All 3 patients were treated with conservatie therapy and subsequentely underwent CCTA of follow–up. The examination performed respectively 3 months, 45 days and 1 month after the acute event demonstrated the complete resolution of IMH in all patients and the patency of the vessel lumens. CCTA seems to be a feasible and effective imaging modality to detect the main findings of SCAD. It may play a crucial role in the management of patients with acute chest pain at low–intermediate risk of ACS in order to reduce the number of misdiagnoses. Furthermore, CCTA could facilitate follow–up of patients with diagnosis of SCAD given the high recurrency rate of this pathology. However, further large prospective studies are needed to clarify the role of CCTA in the diagnosis and in the follow–up of SCAD.
PREVALENCE OF FIBROMUSCULAR DYSPLASIA SCREENING IN SPONTANEOUS CORONARY ARTERY DISSECTION: DATA FROM A SINGLE SECONDARY CENTRE
Authors: Ferretti M , Guiducci V , Bosi D , Musto D‘Amore S , Pignatelli G , Demola P , Solinas E , Pergola V , Zedde M , Pascarella R , Navazio A , Mantovani F
Published: May 2024

Background

Extra–coronary involvement is identified in more than 50% of patients presenting with SCAD, mainly as fibromuscular dysplasia (FMD) pattern. This association might suggest that they share at least partially some pathomechanisms. However, no recommendations on FMD screening in SCAD patients exist to date in international consensus documents, and this is therefore left at clinician discretion.

Aim

We sought to determine the rate of FMD screening in historical cohort of patients with SCAD at our institution.

Methods

Observational retrospective study of all consecutive SCAD patients admitted to catheterization laboratory.

Results

From January 2015 to June 2021, 41 patients received a SCAD diagnosis and represented our study cohort. Mean age was 55 ± 11 years with a high prevalence of female gender (34 patients, 83%). Traditional risk factors showed a marked prevalence especially regarding smoke habits (12 patient, 30%) and dyslipidaemia (21 patients, 51%). Left anterior descending artery was the vessel more frequently involved (49%) followed by circumflex artery (41%) and right coronary artery (10%). SCAD was more frequently classified as type II (68%) followed by type IV (17%), type I (10%) and type III (5%) according to Saw classification. Screening for FMD was performed in 6 patients (12%) among the most recent SCAD diagnoses; of these 1 patients received a diagnosis of FMD, with involvement of carotid and mesenteric arteries. Table.

Conclusion

In our single centre experience, screening for FMD was historically performed in a minority of patients with a perceived trend for a systematic screening in more recent years, accordingly with the literature suggestions.
ROLE OF THE NURSE IN MANAGING INVASIVE BLOOD PRESSURE MONITORING
Authors: Rondo A
Published: May 2024

Introduction

Arterial blood pressure (BP) monitoring is an invasive system for directly tracking and measuring BP and finds its use in critically ill patients who require continuous hemodynamic monitoring and frequent arterial blood test. [1] Invasive monitoring requires the use of sophisticated equipment and specific skills for its management, which influence the quality of care, including the introduction of a catheter inside the arterial vessel. [2] Intra–arterial catheterization is considered the Gold Standard for a direct measurement of BP. [3] Therefore, the objective of this work is to outline the role of the nurse in the management of invasive BP monitoring, with particular attention to the possibility of independently managing the positioning of the arterial cannula itself.

Materials and Methods

A review was performed on the management of invasive BP monitoring, with a particular focus on the role of the nurse in arterial cannula positioning. The Pubmed database was consulted. The search strategy involved the use of Mesh terms and free terms, including "Hemodynamic Monitoring" “Vascular Access Devices” “Critical Care Nursing” “Arterial cannulation”. The terms used were combined together using the Boolean operator “AND”. The Code of Conduct for the Nursing ProfessionsMand the National Collective Labor Agreement were also examinatedand, along with everyday practice of professionals in this field of action.

Results

There are no studies in literature that clearly outline the role of the different professional figures in the management of invasive BP monitoring and there are no clear references regarding who is responsible for positioning the arterial cannula. The development of continuing education programs in the area of clinical reasoning skills for hemodynamic monitoring should be more emphasized. Furthermore, we should focus more on improving practical skills for hemodynamic monitoring. [4]

Conclusions

Advanced skills need to be officially acknowledge to the expert professional by the institutions they belong to, which should contribute to training by creating accredited company courses. Not only to protect assisted people and the professional, but also in order to enhance their work and give it the right recognition. Subsequently, studies could be carried out to evaluate the effective reduction in latency times between non–invasive monitoring and invasive monitoring on critically ill patients, if managed by the nurse.
LEAFLETS AND EXTRA–LEAFLETS HYPOATTENUATED LESIONS FOLLOWING TAVR
Authors: Lentini E , Moscarelli M , Sollami G , Fattouch K
Published: May 2024

Introduction

Subclinical leaflets thrombosis is a condition diagnosed with multi–detector computer tomography (MDCT) characterized by a meniscal–shaped hypoattenuated lesion of one or more leaflets. Transcatheter aortic self–expandable valves are commonly manufactured with pliable pericardium over a nitinol frame that forms the leaflets and the extra–leaflets components, such as the valve skirt. Little is known about extra–leaflets hypoattenuated lesions localization, including the anatomic sinus level.

Methods

This was an ambi–directional study. Fifty patients underwent MDCT at follow–up.

Results

At mean follow–up was of 12 months, hypoattenuated leaflet lesion with mild to severe restricted movement was detected in 8 individuals (16%); anatomic sinus lesion was identified in 9 patients (18%) with higher prevalence in the non–coronary sinus (16%); subvalvular lesion with a variable extension toward the valve inflow, was diagnosed in 8 patients (16%). In 4 patients (8%) the anatomic sinus thrombus was ‘in overlap’ with the leaflet thrombus; in 3 patients (6%) was in continuity with the subvalvular frame thrombus. Bicuspid valve was the only independent predictor associated with hypoattenuated lesions (adj OR 8.25 (95% CI: 1.38, 49.21), p=0.02).

Conclusions

This study demonstrated that hypoattenuated lesions could be identified not only at leaflet, but also at subvalvular and anatomic sinus level. The clinical relevance of such lesions remains uncertain.