bluuebunny/crossref_metadata_2025 huggingface dataset:
P221 ASSOCIATION BETWEEN AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE AND A SEVERE DILATED CARDIOMYOPATHY: A CASE REPORT
Authors: Cavallone E , Feneziani A , Franco E , Rovera C , Moretti C
Published: May 2023

Autosomal dominant polycystic kidney disease (ADPKD) is caused by mutations in PKD1 and PKD2 genes, encoding polycystin 1 and 2. We report the case of a 51–year–old woman with arterial hypertension and stage V chronic kidney disease from polycystic kidney disease, without a significant family health history. She was admitted to our Cardiology Ward for worsening dyspnea, dependent oedemas and a 3/6 systolic heart murmur detected. Blood tests showed mild anemia and hyperkalemia, severe renal failure (creatinine 6 mg/dl) and normal both liver and thyroid function. The ECG showed sinus rhythm with normal atrioventricular conduction, low voltage in precordial leads and non–specific repolarization disturbances. Hemodialysis and intravenous decongestion therapy were started. A transthoracic two–dimensional echocardiography was performed and a dilated left ventricle with severe global systolic dysfunction (EF 25%) was documented, with severe secondary mitral regurgitation (MR) with a central jet (EROA 0,5 cm2). A possible bicuspid aortic valve was suggested with moderate aortic regurgitation. CT scans showed small pleural and pericardial effusions, polycystosis affecting both kidneys and liver. Coronary CT showed a subcritical interventricular artery stenosis and confirmed a bicuspid aortic valve. Magnetic resonance angiography was negative for intracranial aneurysms. Finally, genetic testing revealed a heterozygous pathogenic mutation of PKD1 gene (c.9622del G p.Ala3208Hisfs*108 exone 28). Maximum tolerated heart failure therapy was prescribed after discharge, resulting in symptoms reduction but only mild echocardiographic improvement (EF 30% with severe MR). An edge–to–edge transcatheter mitral valve repair was proposed. In literature we learn that PKD1 mutations are linked to various cardiomyopathies: hypertrophic, dilated, left ventricular non compaction. We report the association of ADPKD with a complex dilated cardiomyopathy with severe secondary MR, an aortic congenital defect and an associated subcritical coronary artery stenosis. Further investigations are needed to study the genetic aspect of the ADPKD when associated with different cardiac anomalies.
P225 CICU–COVID: SMALL NUMBERS BUT BIG DIFFERENCES
Authors: Piemonte F , Carraturo A , Damiano S , De Angelis A , Forte R , Leccia A , Lirato C , Molaro M , Penna G , Petitto M , Piemonte M , Puzio E
Published: May 2023

For about 2 months (from 13 January to 15 March 2022) our CICU–Cardiology department (spoke for the AMI network) of the "San Giovanni di Dio" Hospital of Frattamaggiore (Naples) has assumed the role of CICU–COVID for Local Health Authority Napoli 2 Nord. We analyzed data regarding patients hospitalized in our department from January to August, selected on the basis of the presence of SARS–COV2 infection at admission, and we noted some substantial differences between the two populations, despite in the small sample examined. Patients hospitalized with Covid were, on average, of older age (73 vs 66.3 years old) and their hospitalization was on average longer (9 days vs 6.5), with differences both in the percentage of patients hospitalized for acute myocardial infarction (46.4 % in non–Covid patients vs 34% in Covid patients) and in the type of myocardial infarction: in fact, among the Covid patients who arrived at the ward with a heart attack diagnosis, STEMIs were more numerous (53.3% vs 15.7 of the non–Covid patients) . This may be due to the fact that in the period in which we have acted as Covid–CICU we have also accepted patients with STEMI who otherwise would have been hospitalized in the CICU HUB. Furthermore, the Covid patients were mostly affected by other chronic pathologies: in particular diabetes (40.8% of Covid patients and 18.4% of non–covid patients) and heart failure (54.5% in Covid patients vs 38, 9% in non–Covid). Finally, we examined the data regarding intra–hospital and 6–month mortality, and here too we found substantial differences: 16 of the 44 patients hospitalized with covid (36% of the total) died within 6 months of admission (18.1% in hospital ), while among non–covid patients 6–month mortality was 7% and intra–hospital mortality was 2%. In detail, the difference in mortality between the two groups of patients with myocardial infarction was even more marked, being the 6–month mortality 33.3% in Covid patients and 2.2% in non–Covid. Again, the group of Covid patients who died was affected by diabetes in a much higher percentage than the non–covid (56% vs 28.6%) These data come from a very small sample but nevertheless indicate that the simultaneous infection with SARS–COV2 dramatically worsens the prognosis of patients who normally refer to the CICU–Cardiology departments, and that some associated pathologies affect the prognosis even more significantly than others.
P229 ROLE OF GENDER IN MINOCA PATIENTS
Authors: Tattilo F , Sansonetti A , Amicone S , Bergamaschi L , Armillotta M , Angeli F , Andrea S , Impellizzeri A , Canton L , Suma N , Bodega F , Fedele D , Paolisso P , Rinaldi A , Foà A , Casella G , Galié N , Pizzi C
Published: May 2023

Background

Myocardial Infarction (MI) with Non–Obstructive Coronary Arteries (MINOCA) accounts above 6 % of patients presenting with acute MI (AMI) and it’s known to be more prevalent in females. Differences in terms of clinical features and prognosis in MINOCA patients according to gender have been poorly understood. Purpose: To evaluate clinical and prognostic differences between male and female patients with MINOCA.

Methods

We included all consecutive patients with AMI undergoing coronary angiography between 2016 and 2020 in our multicentric Registry. We considered as MINOCA all patients fulfilling the European Society of Cardiology diagnostic criteria. We analyzed the baseline clinical characteristics of MINOCA patients by dividing the population according to gender. We performed a multivariate logistic regression analysis including all AMI patients to determine independent predictors of MINOCA at admission. We considered the composite endpoint (MACE) of death, re AMI, stroke and heart failure at follow–up (FU, mean of 36 ± 14.8 months). Outcomes were evaluated also using Kaplan–Meier survival curves.

Results

Among 289 patients affected by MINOCA, 191 were female (66%). Males were more frequently smokers (56.1% vs 33.9 %, p=0.001) while females were older (68.9± 13.1 vs 58.4±14.5 years, p=0.0001), more affected by hypertension (69.3% vs 55.1%, p=0.017) and dyslipidemia (65.6% vs 49%, p=0.005), more frequently on beta–blockers (39% vs 20%, p=0.002) and statins (33% vs 19%, p=0.015) and had a lower degree of coronary stenosis (9.1% vs 15.5%, p=0.019) than males. During follow–up, females had more MACE (33% vs 19.3%, p=0.015), also shown at Kaplan Meier curves (χ2 = 5.997, p=0.014). Finally, multivariate analysis revealed that age is an independent predictor of MINOCA (HR 1.04, CI 1.01–2.07, p=0.006), rather than sex, diabetes, and hypertension.

Conclusions

In our MINOCA population, females had a higher incidence of MACE than males: this could reflect the different pathogenesis of myocardial damage in our subgroups. Statins and estrogens have a well–known protective role towards the progression of atherosclerosis, but they have less impact on other causes of MINOCA more frequent in females.
P233 ACUTE CORONARY SYNDROME AFTER WASP BITE (KOUNIS SYNDROME)
Authors: Gagliardi P , Lanzillo G , Marinoni B , Petracci B , Baldi E
Published: May 2023

Kounis syndrome (KS) is defined as an acute coronary syndrome (SCA) associated with an anaphylactic reaction. A 64–year–old sports man with no previous cardiovascular disease arrived at the emergency room of our Hospital for dyspnoea and chest pain arising during physical activity e preceded by a syncopal episode. During the physical activity (cycling) the patient reported that he had felt an insect bite sensation, with no possibility of precisely identify it. Parameters an admission were: BP 85/45 mmHg, HR 70 bpm, on ECG signs of early repolarization (Fig. 1), blood tests rise in hsTNI (328 ng/L), normal D–dimer. The transthoracic echocardiogram showed no motion abnormalities. In the suspicion of KS, therapy was set up only with ASA and statin, avoiding any drug commonly used to treat allergic reactions that could have worsen the hemodynamic and vasomotor situation by further reducing the coronary perfusion. During hospitalization, in consideration of the clinical picture and cardiovascular risk factors (dyslipidemia and previous smoking), was performed coronary angiography, which showed no obstructive lesions, but during the first injection of contrast showed vasospasm of the ostium of the right coronary artery, dominant (Fig. 2 – left), resolved spontaneously (Fig. 2 – right). The post–procedural hsTNI peak (3953 ng/L) and the presence of the European paper wasp i77 antigen to the serological dosage of the allergens supported the pathophysiology of acute coronary syndrome concomitant with allergic reaction and supported the diagnostic hypothesis of KS type I (without underlying coronary artery disease). The patient was discharged with calcium channel blocker therapy, to reduce coronary vasospasm which characterizes KS, and short–term follow–up was planned with blood tests, exercise stress test and cardiological visit which were normal. KS, though rare, is a clinical entity that should not be underestimated, especially in allergic patients with evidence of SCA without coronary occlusions. The data available in the literature are scarce and it is not clear the medium and long term prognosis. It therefore seems reasonable to follow up the patients as outpatient cardiology visits especially in the first months after the event and schedule instrumental tests control.
P244 CARDIOVASCULAR REHABILITATION IN PATIENTS WITH CARDIAC RESYNCHRONIZATION THERAPY
Authors: Pescatore V , Grassi M , Brugin E , Compagno S , Zanella C , Giada F
Published: May 2023

Background

Patients with a CRT–D devices represent an emerging population of subjects with chronic heart failure (CHF) who, according the current guidelines, must be referred to a cardiovascular rehabilitation (CR) program. Aims. The aims of the study were to evaluate in CRT–D recipients the feasibility, safety and efficacy of a physical exercise program, in a outpatient CR setting, to evaluate the need for an individual optimization of device programming.

Methods

Twenty–six CRT–D recipients underwent clinical and functional investigations, comprehensive of symptom–limited cardiopulmonary exercise testing, during which device programming were evaluated in order to obtain an adequate increase in heart rate and to maintain resynchronization therapy during exercise. They underwent a program of physician–supervised sessions of exercise training consisting of three 90 min visit/week.

Results

Baseline patients characteristics: male sex 77%; age 69±10 years; non–ischaemic cardiomyopathy 65%; ejection fraction 38±7 %; atrial fibrillation 12%. No adverse events occurred during training. The peak oxygen uptake has been significantly increased (from 12,6±6 to 17±9ml/kg/min). During cardiopulmonary exercise testing “Brady” functions has been reprogrammed in 10 patients (38%); no modifications to the "tachy" functions of the device were necessary.

Conclusions

Cardiac rehabilitation in CRT–D recipients is safe and effective. Device brady programming during exercise may be warranted in selected patients.
P246 HOW TO OPTIMIZE THE EFFICACY OF CCM THERAPY: MULTIPARAMETRIC EVALUATION AND CASE REPORT
Authors: Manes M , Vanzillotta E , Cassano S , Lopez A
Published: May 2023

We implanted a Cardiac Contractility Modulation (CCM) device in a 66–year–old man with congestive acute heart failure (AHF) refractory to optimized medical therapy and non–responder to CRT–D since 2015. The patient was evaluated multiple times and declared ineligible for a new heart by several heart transplant centers. Effective periodic Levosimendan treatments were performed before the implantation.. However hospitalizations still occurred monthly. The Echo exam, on the day of the implant, showed a left ventricular ejection (LVEF) fraction of 25%, PAPS of 30 mmHg, and E/E’ of 26. Interrogation of the CRT–D revealed an AF burden of 35% and several episodes of tachyarrhythmia at high frequency (130 bpm). The benefits of CCM therapy were almost immediate with the disappearance of breathlessness and the absence of hospitalizations for seven months. Only in June 2022, the patient was admitted to the ER for HF symptoms. At the admission, the heart rate was 125 bpm and, by performing the follow–up of the CCM device, the percentage of delivered therapy was low (<20%) due to the high heart rate. The interrogation of the ICD showed a reduced AF Burden (19 %). However, in the two weeks before the admission, several episodes of organized supraventricular tachycardia (SVT) conducted 1:1, at a rate of around 140 bpm, were recorded and stopped the CCM the device from delivering any impulse, in the absolute refractory period. In the HF Diagnostics implemented in the ICD, we also noticed an indication of fluid overload consistent with a steep reduction of intrathoracic impedance in the exact same time frame. Consequently, we increased the dosage of BB to reduce the heart rate and allow CCM delivery to reach a percentage higher than 80% within the 24 hours timespan. The clinical status of the patient improved immediately in the next following days. The HF diagnostics of ICD, after three weeks from discharge, revealed an increase in intrathoracic impedance and a decrease in hypervolemia which were consistent with the improved symptoms reported by the patient. Finally, the echocardiographic exam at 6 months from the implant showed an EF of 32, PAPS of 30 mmHg, and E/E’ of 12 which justified a decrease in the score of the Minnesota Living with Heart Failure Questionnaire (MLWHF) from 80 (before CCM) to 36 after the implantation. A multiparametric evaluation of CCM delivery must be performed during the patient‘s follow–up to maximize the efficacy of the therapy itself.
P247 QRS INDEX TO PREDICT CARDIAC RESYNCHRONIZATION THERAPY RESPONSE: A TRICENTRIC STUDY
Authors: Madaudo C , Prezioso A , Bonni‘ E , Mascioli G , Pecora D , Ciaramitaro G , La Greca C , Zanchi S , Cuccia C , D‘Ardia G , Novo G , Galassi A , Corrado E , Coppola G
Published: May 2023

Background

Several studies have evaluated the role of QRS duration (QRSd) or QRS narrowing as predictor of response to cardiac resynchronization therapy (CRT) in order to reduce non–responders. However, their results have been conflicting. In our study we analyzed retrospectively a cohort of patients from three centers to better correlate the association between the relative change in QRS narrowing index (QI) and clinical outcome and prognosis in patients who underwent CRT implantation.

Methods

We included 398 patients in whom a CRT device was implanted in accordance with current guidelines in our three centres. Baseline clinical variables, echocardiographic parameters and pharmacological therapies were included. QRS duration before and after CRT implantation and QI [(pre implant QRS duration – QRS duration during CRT)/pre implant QRS duration × 100] were measured.

Results

Respect to echocardiographic follow up at 6 months, a significant improvement in all parameters (EF, LVEDV, LVESV) was observed. In 68% of patients, LVESV decreased by 10% or more. QI was significantly related to reverse remodelling (r = + 0.22; 95% CI: 0.11 to 0.32, p = 0.001). The cut–off value of QI that predicted best LV reverse remodelling after 6 months of CRT was 12.25% (sensitivity 65,49%, specificity 75%, area under the curve 0.7, p = 0.001). Regarding clinical outcomes at 12 mounths, a statistically significant difference was found between patients with a QI < 12.25%, and those with a QI > 12.25%, in terms of NYHA class worsening (p 0,04). Another statistically significant difference was found analyzing the relation between QI and the causes of deaths, the mean of the QI of patients who died from cardiovascular causes was lower than patients who died of other causes. (p 0,0179).

Conclusions

Therefore decrease in QRSd after CRT initiation was related to greater echocardiographic reverse remodelling and better outcome from death or cardiovascular hospitalization. Even if larger studies are needed, QI seems to be an easy–to– measure variable that could be used or evaluated to predict CRT response.
P260 INCIDENCE, CHARACTERISTICS, AND OUTCOMES OF OUT–OF–HOSPITAL CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION IN THE GENERAL POPULATION: DATA FROM A SINGLE–CENTER LONG–TERM REGISTRY
Authors: Bricoli S , Bolognesi M , Pelizzoni V , Biagi A , Rossi L , Ferraro S , Novara P , Matrone B , Nani S , Bertocchi S , Aschieri D
Published: May 2023

Out–of–hospital cardiac arrest (OHCA) is a major public health problem, and ventricular fibrillation (VF) is the most frequently encountered initial rhythm when cardiac disease is the cause of the arrest. It can be treated with successful defibrillation, if prompt intervention, otherwise it rapidly progresses to non–shockable rhythms, with survival rates ranging from 3 to 10%. The early defibrillation strategy led to a significant improvement in outcome; although Automated External Defibrillators (AEDs) are still used in <3% of OHCAs. All consecutive OHCAs registered in Piacenza from January 2013 to June 2022 in which CPR was initiated were analysed. "Progetto Vita", the first European early defibrillation project, was born in Piacenza in 1999, with the aim of improving the diffusion of AEDs in public places, sports centres, workplaces and homes, in order to allow timely treatment of the OHCA by non–medical personnel (citizens, police…) awaiting the arrival of advanced emergency services (EMS). During the review period, 3,124 patients were treated for OHCA; 323 had VF; VF occurred predominantly at home (73%), in men (75%); the mean age was 70 years. CPR by lay citizens was performed in 35 cases (11%) with a survival rate of 63%. AED used by lay or police was used in 30 cases (9%) with a survival rate of 77%. Cardiac comorbidities were observed in 67 patients (21%), predominantly male, with CAD being the most common disease. The main characteristics are listed in Table 1. There were 237 deaths (73% fatality rate), 41 (17%) recorded after EMS arrival. Among hospitalized patients, VF was related to coronary artery disease (70%) and STEMI was the most frequent manifestation. Overall, 87 (27%) patients survived and were hospitalized. Multivariate logistic regression analysis showed that layman CPR (OR 2.52, 95% CI 1.04, 6.1, p=0.04) and AED use (OR 7.15; 95% CI 2.66, 19.19, p<0.001) were both independent predictors of survival. VF in the general population is still poorly predictable and mortality remains high: the implementation of the diffusion of public AEDs seems effective in improving survival.
P262 PREDICTORS OF ICD IMPLANTATION: THE ROLE OF THE WEARABLE CARDIOVERTER DEFIBRILLATOR
Authors: Bolognesi M , Rossi L , Biagi A , Bricoli S , Sticozzi C , Comastri G , Aschieri D
Published: May 2023

Background

Previous studies established a role for the wearable cardioverter defibrillator (WCD) In patients with transient risk of sudden cardiac death ( SCD) . In clinical trials, nearly 40% of patients received implantable cardioverter–defibrillator (ICD) implantation at the end of WCD use. It’ unknown if WCD can be usefull in final ICD implantation indication.

Objectives

We aimed to describe the clinical predictors of ICD implantation rate at the end of WCD use in a real–world single center experience.

Methods and results

Between August 2017 and June 2022, 60 consecutive patients receiving a WCD at Piacenza Hospitals were retrospectively included in this analysis: : mean age 66.9±11.9 years, 56.6% with ischaemic cardiomyopathy, 38.3% with dilated cardiomyopathy, 5% after implantable cardioverter–defibrillator explant. A total of 34 participants (56.6%) received implantable cardioverter–defibrillator (ICD) implantation at the end of WCD use. We evaluated clinical features related to ICD implantation rate with Chi Square test and Student’s t test. Female sex was related with no ICD implantation ( ICD 5,9% vs no ICD 23,1%, p= 0,03), whilst Low ejection fraction at beginning of evaluation was related with ICD implantation ( ICD 27.1±9.3 vs no ICD 33.1±11.9, p=0,03). Although in our population there weren’t shock of WCD, the strongest clinical predictor was arrhythmic event recordered at WCD monitoring both non sustained ventricular tachicardia, sustained ventricular tachicardia and supraventricular tachicardia ( ICD 20 vs no ICD 0, p < 0,01). Age ( ICD 66.6±11.9 vs NO ICD 67.4±11.9, p=0,7) and etiology of cardiopathy both ischemic and non ischemic ( ICD 52% vs no ICD 53,8%, P=0.5) were not factors associated with ICD implantation.

Conclusion

In our study the rate of ICD implantation after wearing time of WCD is consistent but slightly major to European registries. Arrhythmic Event recordered at WCD monitoring is related with ICD implantation, so WCD, when it is used, may be a further help in final ICD implantation.
P265 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 , Pisati M , Ferdenzi E , Aschieri D
Published: May 2023

Background

Previous studies established a role for the wearable cardioverter defibrillator (WCD) in patients with transient risk os sudden cardiac death ( SCD) . The WEARIT–II Registry highlighted an higher burden of ventricular and atrial arrhythmic events in women than in men, in spite of a similar ICD implantation rates.

Objectives

We aimed to describe the sex differences in WCD use and compliance. Moreover we reviewed the rate of cardiac events detected with WCD and the rate of ICD implantation in women in a real–world single center experience.

Methods and results

Between August 2017 and June 2022, 60 consecutive patients receiving a WCD at Piacenza Hospitals were retrospectively included in this analysis: mean age 66.9±11.9 years, 56.6% with ischaemic cardiomyopathy, 38.3% with dilated cardiomyopathy, 5% after implantable cardioverter–defibrillator explant. 8 patients were women (13.3%). Women and men presented similar clinical characteristics. Median WCD usage period and median daily wear time were not different between women and men (49.6±25.3 vs 51.8±32.8 days, 23.6±0.3 vs 23.1±1.7 hours, respectively). No ventricular fibrillation was detected in the monitoring period. Non–sustained ventricular tachycardia and atrial arrhythmias were similar between women and men. However, ICD implantation rate at the end of WCD use was significantly lower in women than and men (25% vs 61.5%; p< 0.01).

Conclusions

In this real word analysis WCD was underused in women despite a nice compliance. A similar burden of ventricular and atrial arrhythmic events were detected, with a lower ICD implantation rate at the end of WCD use in women than in men.
P277 MULTIFACTORIAL RECURRENT CHYLOUS ASCITES: THE CASE REPORT OF A PATIENT WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFPEF), LIVER DISEASE AND PAST ABDOMINAL SURGERY
Authors: Pandolfi A , Vicenzi M , Carugo S
Published: May 2023

Chylous ascites is the accumulation of triglyceride–rich fluid in abdominal cavity. It is caused by lymphatic ducts injury, usually as consequence of surgery, neoplasia, or infection. Rarely, it can also occur from heart failure, pericarditis, or cirrhosis. We report the case of a 66–year–old man electively hospitalized for acute renal failure and anasarca state. The cardiological history was significant due to acute myocardial infarction treated with CABG, PM implantation for complete AV block, atrial fibrillation, and type 2 diabetes mellitus. The entero–hepatological history started in 2019 when, two months after abdominal surgery for an incarcerated hernia, he developed chylous ascites and chylotorax. Starting from 2021, the patient presented recurrent episodes of tense ascites, requiring periodic paracentesis. Haematological and infectious disease evaluation resulted negative, liver biopsy showed congestive hepatopathy with fibrosis, while venous catheterization found high right filling pressure with not portal hypertension. Patient was treated with Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Metformin 1500 mg, Enalapril 20 mg, and Simvastatin 20 mg. During the hospitalization other paracentesis confirmed the chylous nature of the effusion, echocardiography (despite very bad acoustic windows) showed preserved left ventricle systolic function (LVEF 55%), 3rd degree LV diastolic disfunction, and dilatation of right ventricle, atria, and inferior Vena Cava. Right heart catheterization confirmed the presence of LV restrictive physiology, combined pulmonary hypertension, and ruled out the diagnosis of constrictive pericarditis. In hospital treatment focused on resolving acute renal failure and hypervolemia through intravenous diuretic and Albumin and on optimizing cardiological therapy. The patient was discharged with the following treatment: Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Canrenone 100 mg b.i.d., Empagliflozin 10 mg, Simvastatin 20 mg, and indication to hypo–lipidic diet. This case highlights how the coexistence of different predisposing factors of chylous ascites (past abdominal surgery, heart failure and liver disease) can amplify each other. Recognizing the single role of each of them is of pivotal importance to elaborate targeted treatment. Moreover, in literature, there are some cases of chylous ascites associated with constrictive pericarditis and with severe heart failure, but to our knowledge not with coexistence of HFpEF.
P282 PAUCISYMPTOMATIC POST–COVID MYOCARDITIS IN A YOUNG ATHLETE DURING THE DIAGNOSTIC INVESTIGATIONS BEFORE RETURNING TO COMPETITIVE PRACTICE, POSSIBLE USEFULNESS OF THE GLS ANALYSIS
Authors: De Masi De Luca G , Papadia P , Prete G , Coluccia G , Palama‘ Z , Accogli M
Published: May 2023

It is now known that the Covid19 infection can cause myocardial inflammatory damage. Several studies have shown that the echocardiographic parameter of the global longitudinal strain (GLS) was reduced compared to the general population even in paucisymptomatic patients. A young competitive athlete came to our observation for the diagnostic investigations before returning to competitive practice (return to play protocol) after Sars–Cov2 infection. The electrocardiogram did not show significant abnormalities as well as spirometry examination. Negative inflammation indexes and markers of myocardial damage were observed. The cycloergometer test showed no signs of myocardial distress, rapid chronotropic increase and dyspnea at 100W work load. HolterECG was performed showing 830 isolated ventricular ectopic beats. Echocardiographic examination showed preserved left ventricular systolic function (FEVS 59% – Simpson method) with a moderate reduction of GLS parameter –16,9%. The cardiopulmonary exercise test (CPET) showed an early anaerobic threshold and a normal pVO2max but not in line with the presumed range for a top–level athlete. Putting together the symptoms described, the CPET data and GLS parameter, despite the negative first–level investigations he underwent MRI that documented a myocardial edema in the mid–basal region of inferior and inferolateral walls of the left ventricle. Suitability for competitive practice was blocked, a gradual physical readaptation path was started and therapy with low–dose bisoprolol was set. An important clinical improvement is reported at the 6–month follow–up with evidence of normalization of the GLS parameter –23%. The CPET howed a realignment of the HR/VCO2 curve with a late threshold and increment of pVO2max. The 6–month control MRI examination showed almost no signs of myocardial inflammation and so the patient was made suitable for returning to competitive sport. In our case first–level investigations did not support any hypothesis of myocardial inflammation. The presence of stress symptoms confirmed by CPET data but especially the reduction of GLS parameter led to a deepening investigation with MRI that confirmed the presence of myocardial inflammatory lesion. Our case suggests that within a “return to play” protocol for athletes with recent SarsCov2 infection, the analysis of left ventricular systolic function by GLS may represent an additional useful element to be considered in support of standard investigations.
P285 DESIGN OF A NETWORK FOR THE IN–SERVICE MANAGEMENT OF ACUTE CORONARY SYNDROMES IN THE PROVINCE OF TERAMO
Authors: Massacesi C , Core A , Di Eusanio M , Di Francesco G , Di Saverio M , Marini L , Rolando M , Gregori G
Published: May 2023

Acute Coronary Syndrome (ACS) are events due to the rupture/erosion of a coronary atherosclerotic plaque, with activation of the coagulation cascade and critical reduction of the flow, which is expressed in a spectrum of clinical scenario ranging from infarction with ST elevation (STEMI)1, to non ST elevation ACS (NSTE–ACS)2. Timely reperfusion therapy, either pharmacological or via percutaneous coronary intervention (PCI)1, is indicated for patients with STEMI. Patients with NSTE–ACS should undergo initial risk stratification, followed by invasive evaluation, depending on the patient‘s risk profile2. (Figure 1). It is necessary to create an effective network among hospitals, to make available the fastest and most effective therapy for the greatest number of patients with ACS. The European Society of Cardiology (ESC) guidelines suggest the implementation of such regional networks1. Achieving this goal is possible only by sharing a common protocol. The province of Teramo was equipped with a cardiological network in 2011. There are 2 simple structures, a structure with a spoke CCU (Giulianova) and the Hub structure with CCU and Cath–lab (Teramo). The simple structures refer to the Hub center when direct access to cath–lab is required and to spoke CCU for those patients who do not require immediate coronary angiography. Spoke CCU unit refers to Hub center for the access of patients with ACS to the cath–lab3. On the basis of epidemiological data4 it can be expected that in the province of Teramo there are about 230–250 STEMI and 450–500 NSTE–ACS/year. Teramo‘s cath–lab performed 248 primary PCIs on STEMI, and 390 PCIs on NSTE–ACS. In the spoke CCU in 2021, there were 1005 patients hospitalized with ACS. Almost all of them were transferred/transported for coronary angiography according to risk stratification. There were 326 patients discharged with a diagnosis of ACS undergoing PCI. That data made it necessary to transport the patient in hemodynamics for angiography study and interventional procedure, and possible retransfer to the spoke center. This strategy is called service. The advantages and safety of this procedure have already been described7. The implementation of service strategy would make a clear increase in interventional procedures foreseeable (ideally the approximately 100 patients with ACS accessing the Spoke CCU should undergo PCI with adequate timing in 70% of cases) and an optimization of work for the centers and of patient care.
P290 EXTRACORPOREAL MEMBRANE OXYGENATION SYSTEM AS A BRIDGE TO REPARATIVE SURGERY IN VENTRICULAR SEPTAL DEFECT COMPLICATING ACUTE MYOCARDIAL INFARCTION
Authors: Chivasso P , Miele M , Colombino M , Triggiani D , Cafarelli F , Leone R , Masiello P , Mastrogiovanni G , Iesu S
Published: May 2023

Introduction

Post–infarct ventricular septal defect (VSD) is a life tethering complication of acute myocardial infarction which is associated to high in–hospital mortality (90–95%). The optimal peri–operative management including timing of surgical correction is still debated. There is a large body of evidence demonstrating that surgical repair is also associated to poor post–operative outcomes due to cardiogenic shock and multiorgan failure (MOF). The use of extracorporeal membrane oxygenation (ECMO) system in adult cardiac surgery is not routine, occurring in a minority of critically ill patients, typically postoperatively. Here we present our single centre experience of patients with post–infarct VSD managed preoperatively with ECMO support as a bridge to definitive surgical closure. Materials and methods Between February 2020 to July 2021, 5 patients presented to our unit with diagnosis of post–infarct VSD and were managed with preoperative veno–arterial (V–A) ECMO implantation and enrolled in our study. Clinical parameters (such as mean arterial pressure, central venous pressure, ECG, pulmonary artery pressure), blood tests, trans–thoracic and trans–esophageal echocardiography, chest X–rays have been evaluated both before and after surgery. Primary end–point was all causes in–hospital mortality.

Results

Three (60%) patients were male and mean age was 70,4 (60–78) years. All patients underwent surgical repair. ECMO was positioned between 1 and 9 days prior to surgical correction, giving the chance to reduce the pharmacological inotropic support while still reverting the MOF as demonstrated by the reduction of AST, ALT, bilirubin level, decreased CVP and systemic lactate levels. Two (40%) patients were successfully weaned off from the mechanical support and discharged home in good clinical conditions. Two (40%) patients developed MOF after surgery leading to the exitus.

Conclusions

We postulate that the use of V–A use preoperatively in patients with cardiogenic shock secondary to post–infarct VSD is appropriate and where feasible should be considered. It allows restoration of haemodynamic stability and resolution of MOF. This provides for a delayed surgical repair with a likely higher chance of operative success and reduced mortality.
P305 MULTIVESSEL SUBACUTE STENT THROMBOSIS
Authors: Carpinella G , D‘Andrea D , Furbatto F , Moscato R , Serino F , Mauro C
Published: May 2023

The presence of comorbidities such as psychiatric pathologies negatively influences the prognosis of patients with acute cardiovascular events. A 62–year–old male patient suffering from arterial hypertension, dyslipidemia, ischemic heart disease, treated 3 years earlier with PCI of LAD, Cx e RCA (EF 45%), and schizophrenia, is hospitalized with a diagnosis of NSTEMI. Coronary angiography shows: eccentric stenosis 70% proximal to the pre–existing stent in the middle LAD; Intrastent occlusion of the middle circumflex branch with omocoronary rehabilitation and ulcerated critical plaque in the proximal segment of the right coronary artery with mild intrastent restenosis in the middle. The patient refuses cardiac surgery, so angioplasty with ultra–thin drug–eluting stents is performed. The patient starts DAPT with clopidogrel, choosing a combination formulation to promote compliance, with discharge on the fourth day. Three days after discharge, the patient returns with anterior STEMI, with multivessel intrastent thrombotic closure (LAD, Cx, RCA), so angioplasty with paclitaxel–releasing balloon is performed on LAD and with NC balloons on the right coronary artery; impossibility to obtain total recanalization of the circumflex branch due to the non–transit of guides, even hydrophilic and of different weights. During angioplasty and for the following 12 hours, bolus and infusion of tirofiban is administered due to the high thrombotic burden. The choice of the second antiplatelet agent in this second procedure fell on prasugrel. The patient is discharged on the sixth day and a long conversation is held with his wife regarding the correct management of the home therapy. One year later, the patient a dual–chamber ICD was implanted at another centre, with correct and regular assumption of home therapy. Our case demonstrates an infrequent form of multivessel thrombosis during STEMI. The presence of schizophrenia influences negatively the evolution of the natural history of ischemic cardiopaty. The psychiatric substrate exposes to a greater number of cardiovascular events, given the reduced therapeutic compliance, also as regards the choice of appropriate therapeutic strategies. A joint path between the hospital, local medicine and the family environment would be desirable in order to correctly manage this type of patient.
P311 PULSED INFUSIONS OF LEVOSIMENDAN IN OUTPATIENTS WITH ADVANCED HEART FAILURE
Authors: Falletta C , Gaziano M , Lo Cascio M , Urso O , Floresta A , Scaccianoce M , Cicerone C
Published: May 2023

Background

Several non–randomized studies and small registries showed the efficacy of pulsed levosimendan infusion in relief of symptoms and preventing hospitalization in patients with advanced heart failure excluded by age or comorbidity from heart transplant program Aim of the study to describe the experience of pulsed levosimendan infusion in patient with advanced heart failure followed by the Division of Cardiology at "Villa Sofia" Hospital in Palermo Materials and methods we collected data of patient with adavced heart failure (NYHA III–IV) with reduced ejection fraction, who underwent pulsed levosimendan infusione at Division of Cardiology at "Villa Sofia" Hospital. Reduction of NYHA class, body weight and Nt–pBNP were examined as outcome indicators

Results

Between July 2021 an December 2022, fifhteen levosimendan infusion were made in five patient with advanced heart failure. Levodimendan was adminestered for a 24–hours infusion, as therapeutic day–hospital regimen. in the population of analysis, the following mean parameters were recorded at admission: NYHA class 3.2, furosemide dose 390mg, Nt–pBNP 10710pg/ml, body weight 72.8Kg, glomerualr filtration rate (GFR MDRD) 44ml/min. At discharge, the following mean parameters were recorded: NYHA class 2.1, Nt–pBNP 9225pg/ml, body weight 70.7Kg. One patient dead of sudden cardiac death during follow–up, one patient refused to continue treatment, the remaining three patient are still on treatment.

Conclusions

In our center experience, pulsed levosimendan infusion in patient with advanced heart failure determined an improvement of clinical and instrumental signs of congestion. Patients treated reported a subjective improvement of symptoms and of quality of life, also as a consequence of the reduction of the hospitalizations for heart failure. Although data ara scarce, they can be considered representative of a pilot experience of an integrated modality of assistance for patient with advanced heart failure, in which the sinergy between cardiology ward, a strict follow–up at the heart failure outpatient clinic are essential to obtain a good outcome in patient with such high complexity and frailty.
P313 AN UNUSUAL CASE OF SEVERE LEFT VENTRICULAR DYSFUNCTION: MILANESE ‘BREAKING BAD‘
Authors: Guareschi A , Pasero G , Galasso M , Calcagnino M , Gherbesi E , Palazzini M , Settepani F , Vicenzi M , Garascia A , Carugo S
Published: May 2023

A 39–year–old Filipino man was admitted for dyspnea and lower limb edema for about a month, in combination with stable cardiac enzymes movement (TnT 128>78>115 ng/dl), fluctuating unspecific inflammatory profile and hepatic impairment. Trans–thoracic echocardiography confirmed heart failure (HF) in a setting of eccentric left ventricular hypertrophy, diffuse hypokinesia and severe global functionreduction. Despite the absence of typical chest pain, the presence of cardiovascular (CV) risk factors (DMT2, smoking, dyslipidemia), previous alcoholism and the finding of widespread ventricular repolarization ECG changes seemed to suggest an ischemic or multifactorialorigin of the HF. After the finding of a critical trivascular coronary artery disease on coronarography and a pulmonary nodule on chest CT, the cardiac magnetic resonance (CMR) confirmed the diagnosis of severe dilated HF with evidence of a diffuse wall signal hyperintensity in STIR sequences and a intramyocardial and subepicardial patchy LGE pattern of non–ischemic meaning. The possible ischemic etiology was thus overlaid with an inflammatory disease, leading to assume sarcoidosis or myocarditis be the cause of HF. The main screening tests (ACE and immunologic–infectious profile) were negative a a PET/CT scan confirmed a diffuse cardiac inflammation with no focal hypercaptant lesions. Therefore, sarcoidosis was ruled out, and an endomyocardial biopsy (BEM) was performed, and resulted, however, inconclusive. Following, an unexpected finding revealed through a more scrupulous anamnesis: a long–time abuse of a methamphetamine (MDMA) prevalent in the Filipino community called Shaboo. This type of MDMA is accompanied by multiple CV system impacts, including MDMA–associated cardiomyopathy (MACM), a clinical picture compatible with the findings obtained by CMR and BEM performed. After discussion in Heart Team and therapeutic optimization, the patient was candidate for coronary artery bypass. Thus, with the correct diagnostic definition and treatment of HF triggers, an improvement in clinical and left ventricularfunction was marked (EF 45%). Monitoring will allow evaluation of the evolution of the changes found at CMR and will document eventually reversibility of MACM after protracted abstention from MDMA abuse.
P319 MID VENTRICULAR TAKOTSUBO SYNDROME IN A PATIENT WITH COVID 19 PNEUMONIA: A CASE REPORT
Authors: D’ Elia R , Pompa A , Ciccarelli M , Vecchione C , Galasso G
Published: May 2023

Background

Takotsubo Syndrome (TTS) is an acute and transient myocardial disfunction associated with chest pain, electrocardiographic changes and minimal myocardial enzymatic release mimicking acute myocardial infarction but without significant coronary artery disease. Physical or emotional stress play a central role in the pathogenesisof this cardiomyopathy. Several variants have been described including the classic type, reverse Takotsubo, midventricular type and focal type. Mid ventricular Takotsubo is characterized by circumferential mid–ventricular hypokinesia with hypercontractility of base and apex. This atypical variant is one of the most rare form that occurs in 15% of patients with Takotsubo syndrome. We report a Takotsubo case with mid–ventricular pattern in a postmenopausal woman with COVID–19 interstitial pneumonia.

Clinical case

A 56–year–old female patient was admitted to our intensive cardiac care unit for acute chest pain and dyspnea. In clinical history hypertension, dyslipidemia, anemia and schizophrenia were documented. COVID–19 molecular test was positive. CT scan showed multiple ground–glass opacities bilaterally. Hemodynamic parameters were normal but ECG showed ST–segment elevation and T waves inversion in the lateral precordial leads. Troponin–I was elevated and peaked at 1704 ng/mL. A transthoracic echocardiogram showed ballooning of the midventricular segments with hyperkinesis of the basal and apical segment. Coronary angiography showed normal coronaries. The patient was treated with beta–blockers and intravenous fluid infusion. After 10 days in hospital, echocardiography showed normalization of regional contractility and improvement of ejection fraction. The patient was discharged in good condition.

Conclusions

Recent studies have reported an increase in TTS incidence during the COVID–19 pandemic. SARS-CoV-2 infection induces physical and psychological stress in patients, which may lead to an increase in the risk of TTS development. The pathophysiology of COVID-19-induced TTS still remains unclear. The mortalityrate of TTS is higher (36.5%) in COVID–19 patients.
P335 TEMPORAL TRENDS (2003–2018) OF IN–HOSPITAL AND 30–DAY MORTALITY IN PATIENTS HOSPITALIZED WITH ACUTE HEART FAILURE IN LOMBARDY
Authors: Trombara F , Marenzi G , Cosentino N , Leoni O , Poggio P , De Metrio M , Rubino M , Bonomi A , Oliva F , Agostoni P
Published: May 2023

Introduction

Limited and controversial temporal trend of in–hospital mortality of patients hospitalized with acute heart failure (AHF) have been reported. We evaluated whether, in AHF hospitalized patients, the rate of in–hospital and 30–day mortality, and 30–day re–hospitalization for AHF changed in the last 15 years.

Methods

We examined administrative data from Lombardy (∼10.000.000 inhabitants), Italy. We analyzed data of all adults hospitalized for AHF from 2003 to 2018 in Lombardy. Patients were stratified according to hospitalization period: 2003–2006; 2007–2010; 2011–2014; 2015–2018. The primary study endpoint was the comparison among periods of in–hospital mortality, while secondary endpoints were 30–day mortality and re–hospitalization for AHF temporal trends.

Results

During the study period, 414,164 patients were hospitalized with a primary diagnosis of AHF. The in–hospital and 30–day mortality in the entire cohort showed a progressive increase over time (from 6.7% to 8.5% and from 12.4% to 14.5%, respectively). Thirty–day re–hospitalization for AHF was 2% showing a progressive decrease across years. However, patient’ complexity, as inferable from number of comorbidities, increased in most recently hospitalized patients. After matching for age, gender, and admission ward, the study population included 78,884 patients in each study period. In the matched population, after further adjustment for major comorbidities, the risk of in–hospital and 30–day mortality and of the 30–day risk of AHF re–hospitalization progressively decreased from one period to the following one by 1% (95% confidence interval [CI] 0%–2%), 2% (1%–3%) and 10% (8%–12%), respectively.

Conclusions

In our study, the greater patients’ complexity largely accounted for the continuing rise in early mortality observed in patients hospitalized with AHF. This work was partly financed by the Italian Ministry of Health and the Lombardia Region (Grant NET–2016–02364191; EASY–NET).