bluuebunny/crossref_metadata_2025 huggingface dataset:
P413 A CASE OF PERIPARTUM DILATED CARDIOMYOPATHY WITH SEVERE BIVENTRICULAR DYSFUNCTION
Authors: Pezzi L , Magnano R , Verrengia E , D‘Alleva A , Forlani D , Vitulli P , Fulgenzi F , Genovesi E , Di Marco M , Paloscia L
Published: May 2023

Woman, 38 aa, without cardiovascular risk factors with the exception of the tobagic habit; In anamnesis recent Caesarean cut about six months ago for a placenta with the central, complicated by hemorrhagic shock and consequent virgonecontomy. It came to our observation sent by the emergency room, where it had gone by on the onset of about 20 days of heart disease, nightlife dyspnea and fattening dyspnea, associated with the recent appearance of marked edemas declining in the lower limbs bilaterally. At the entrance to the ward, the patient presented himself vigilant, apipperic and tachipnoic. The feedback of turgor of the jugular and of extended edemas extended up to the upper third of the leg bilaterally was also reported. The ECG evidenced a sinus tachycardia and signs of left ventricular overload. The hematochimic tests, including myocardionecrosi markers, were in the norm, with the exception of the pro–bnp which was increased with a value of 5263 pg/ml (cutoff <125 pg/ml). A trastracic echocardiogram was carried out which highlighted a dilated left ventricle with normal parietal thicknesses, global hypocinesia and severely depressed systolic function (FE 28%), a biatrial dilation with dilated and hypocinetic right sections (15mm tapse), to the Doppler color, an insufficiency Mutral valve of moderate and tricuspidal grade of severe grade with an estimated paps of 55 mmhg and a lower cava dilated cava and poorly collapsed with the inspirium. For further diagnostic deepening, a cardiac MRI was performed which confirmed the framework of two–hundred dilation with severe reduction of systolic function (LVEF 25%; RVEF 20%) and showed a post–control myocardial strengthening of the lateral pericardium with extension to be paid by the Subpicardio homosede. A high dosage diuretic therapy and anti–scompense therapy with progressive improvement of the hemodynamic picture was then set. The patient was discharged at home in protected discharge after positioning of wearable defibrillator; It was then checked after 30 days from discharge with a recovery feedback almost complete with the contractile function and followed later over time with periodic follow–ups.
P416 A RARE CASE OF CHEST PAIN
Authors: Sarubbi M , Pittorino L , Capasso R
Published: May 2023

81–year–old woman, affected by arterial hypertension, paroxysmal atrial fibrillation treated with DOACs. She came to our emergency service for oppressive chest pain emerging after two weeks from the implantation of a dual–chamber pacemaker. The EKG showed 1 mm ST segment elevation in leads DII and aVL. Global and segmental function were normal, mild pericardial effusion along right chambers was reported on the echocardiogram. This case was managed as a STE–ACS and then the patient was given dual antiplatelet therapy and unfractioned heparin and taken to the cath lab. The coronary angiography didn’t show any significant stenosis. She was admitted to CCU, where pericardial effusion was noticed to be significantly increased. A CT scan revealed the ventricular pacemaker lead projecting into the pericardial sac with a 13 mm hemorrhagic pericardial effusion. Antithrombotic therapy was stopped and colchicine was started. The patient refused to undergo a trans–venous lead extraction. She was asymptomatic and hemodinamically stable at the time of discharge and was given a follow up program. This case shows a subacute complication of pacemaker implantation, in which antithrombotic agents administration made the real diagnosis to be shown after the increase of pericardial effusion. Ventricular lead perforation is a rare condition (0.1–0.8%). Some risk factors can be old age, female sex, anticoagulants, DMARDs and NSAIDs, the ventricular lead being positioned along the right ventricular free wall. Symptoms and signs depend on lead position. Diagnosis can be made by echocardiography, chest X–ray, CT scan. The best treatment for this patients is debated. In hemodinamically unstable patients an emergency treatment is recommended, while it is unclear which therapeutic option should be offered in the other cases. Lead perforation can be managed with transvenous or surgical lead extraction or a conservative treatment with a watchful waiting strategy can be performed. Acute, subacute and symptomatic perforations could better benefit from invasive strategies, otherwise chronic and asymptomatic cases could be followed up during time without invasive treatment.
P417 THE REBUS OF POCKET INFECTION
Authors: Dentico A , Ferrieri A , Altieri T , Carretta F , D‘Agostino C , Carretta D
Published: May 2023

Introduction

Guidelines define pocket infection as an infection limited exclusively to the generator pocket. This is clinically associated with local signs of inflammation. Often, however, the infection also involves leads which constitute an entrance door for cardiac and systemic infection. The pocket infection is a big puzzle for deciding the type of approach to adopt, conservative or aggressive? Our study aims to identify the significant predictive criteria to develop a score that identifies patients most at risk of endocarditis and sepsis.

Materials and Methods

66 patients undergoing extraction for pocket infection were enrolled. Before extraction, all patients underwent instrumental and laboratory investigations to search for vegetation or culture positivity.

Results

Of the 66 patients, 61 presented vegetations and/or positive culture of the leads. The statistical analysis made it possible to assign a score to each sign and/or symptom (see table) with the creation of a score with a maximum cut–off of 5. The 61 positive patients had a score greater than/equal to 5. The score structured in this way demonstrated a predictive value of 92.4%, resulting positive in 61 out of 66 patients.

Conclusion

In patients with pocket infection, the identification of a highly predictive score of endocarditis or sepsis on leads allows the clinician to easily identify patients at higher risk to be rapidly referred to tertiary centers for the most suitable treatment of the clinical situation without having to carry out particular tests, often difficult to perform (PET/CT), and allows the electrophysiologist, who will have to carry out the extraction procedure, to have a precise indication in class I. The study we have started is a preliminary study which has the limit of the number of patients enrolled. We intend to increase the number of patients thanks to collaboration with other centers that carry out extractions. However, this study, based on the data obtained so far, could be a guide for the management of patients with pocket infection who often create embarrassment in decision–making on the therapy to be adopted, even due to the lack of clarity of the guidelines.
P422 CARDIOTOXICITY ASSOCIATED WITH IMMUNE CHECKPOINT INHIBITORS: A CLINICAL CASE
Authors: Frascaro F , Pavasini R , Marchini F , Bianchi N , Zanarelli L , Sanguettoli F , Meossi S , Guardigli G
Published: May 2023

We reported a case of 46–year–old women without cardiovascular risk factors, with a diagnosis of relapsed metastatic melanoma undergoing treatment with immune check–point inhibitors (ICI), ipilimumab and nivolumab. A transthoracic echocardiogram was performed before starting the treatment that showing normal indices of biventricular function and a normal value of global longitudinal strain (GLS). After the third immunotherapy cycle, she presented to the hospital for diplopia and blurred vision; in the suspicion of ICI–related toxicity, muscle–specific enzymes and troponin I high sensitivity (TnI hs) were assayed and were found elevated (TnI hs 712 ng/L). Brain natriuretic peptide (BNP), electrocardiogram (ECG) and echocardiogram were within the limits. Given the positivity of cardiac markers in an asymptomatic patient, it was concluded for grade I ICI–related toxicity. Immunotherapy was discontinued and the patient was admitted to the cardiology intensive care unit. She underwent telemetry monitoring and a cardiac magnetic resonance (CMR) were performed showing a thin stria of sub–epicardial oedema along anterior wall without late gadolinium enhancement or altered kinetics. During hospitalization, patient was treated with methylprednisolone 1g i.v. for the first days with benefit and she was discharged with oral prednisolone, reducing the dose by 10 mg/week under clinical, ECG and TnI surveillance. I.v. immunoglobulins were started due to myopathy involvement. The tapering of corticosteroids after 15 days caused a flare–up of troponin levels, which resolved after increasing the steroid dosage. After a thorough discussion between experts, it was decided to resume ICI treatment. Myocarditis is a severe complication of ICI that occurs in 0.27–1.14% of patients and develops early. Surveillance should be done by biomarker assay, as major cardiac events occur in up to 40% of patients with normal ejection fraction. The clinical diagnosis includes the cTn elevation with 1 major criterion (CMR positive for Lake Louis criteria) or 2 minor criteria. The treatment strategy consists of interruption of ICI therapy, immunosuppressive agents and cardiac monitoring. Current guidelines recommend permanently ending ICI therapy when patients develop grade 3 or 4 toxicities; conversely, it may be considered again in case of grade 1 (asymptomatic biomarker elevation) or 2 (biomarker elevation and mild symptoms) toxicity.
P423 RELAPSE OF ACUTE MYELOID LEUKEMIA WITH CARDIAC INFILTRATION: A CASE REPORT
Authors: Caldarella Y , Carrer A , Possamai M , Betta D , Favero L , Cernetti C , Iliceto S , Gasparetto N
Published: May 2023

We describe the case of a 42–year–old man who presented to the emergency department suffering from asthenia, dyspnea and tachycardia. The patient had been diagnosed, two years earlier, with acute myeloid leukemia (AML), treated with two lines of chemotherapy and allogeneic bone marrow transplantation from a family donor. Atrial fibrillation with rapid ventricular response was documented at the ECG. The echocardiogram showed moderate left ventricular dysfunction in the presence of dishomogeneous thickening of left and right ventricular wall and a severe circumferential pericardial effusion causing cardiac tamponade, with the need of urgent pericardiocentesis. AML relapse was documented at the laboratory tests. The suspected cardiac involvement was investigated with cardiac MRI which documented thickening and diffuse late gadolinium enhancement at the level of the left and right ventricular wall, the interatrial septum and the atria walls. The pericardium and the epicardial fat were also thickened and endowed with contrast enhancement. A lymphocyte assay was performed on pericardial fluid and showed the presence of a blast population (approximately 27% of white blood cells) with variable expression of myeloid antigens. The clinical, radiological and finally immunophenotypic picture therefore concluded with relapse of acute myeloid leukemia with myocardial and pericardial infiltration. Acute myeloid leukemia usually presents with symptoms related to bone marrow failure. Clinically significant cardiac involvement is rare but should be considered when cardiorespiratory symptoms occur. Cardiac manifestations include coronary artery disease, heart failure, conduction disturbances, myocarditis, pericarditis, and pericardial effusion. Understanding the underlying pathophysiology and recognizing potential cardiac manifestations could help in the early diagnosis, evaluation, and treatment of these patients. Echocardiography or cardiac MRI could reveal morphological, structural and signal abnormalities of the cardiac structures and therefore should raise the suspicion of a possible myocardial infiltration by leukemia cells, both in patients with a positive history of leukemia and in those in whom cardiac involvement could represent the first manifestation of a hematological pathology.
P426 IMPLEMENTATION OF MODULAR NURSING IN THE CARDIOLOGY CONTEXT: EXPERIENCE AND RESULTS IN THE CONEGLIANO HOSPITAL
Authors: Mazzariol E , Canzian M , Cesaro M , Tonegutti M , Bottega M , Migotto S , Coppe A , Mantovan R , Salemi M
Published: May 2023

Introduction

In response to regional requirements and the ever–increasing complexity of the needs of the patients, the UOC Health Professions of the ULSS 2 Marca Trevigiana Company, in collaboration with the team of the Cardiology UOC of the Conegliano Hospital decided, in the year 2022, to start a Field Training project (FSC) oriented towards the implementation of Modular Nursing (MN) in the specific context.

Methods

The project involved all the staff of the Cardiology, Hemodynamics, and Intensive Care Unit, with the contribution of the Coordinator and the support of the Health Professions Unit. 4 working groups were therefore formed, relating to the User Path in the care setting, Nursing Handover, Management of care–organizational resources and Indicators of the quality of care. Furthermore, we surveyed to collect the perception of the care staff concerning Relationship Time, Clinical Risk, Safety of Professional Action, and Continuity of Care.

Results

During the process, each working group presented the results of the work developed, which were: the description of the admission and discharge paths, the structuring of a Handover model based on the SBAR method, the definition of standard Care Plans for care cases, the analysis of the data deriving from the collection of defined indicators and the perception of the care staff pre–post implementation of the Care Model. The first data that emerged shows a 26% decrease in phlebitides observed in patients and an average reduction of 4 minutes in the Handover process. Furthermore, the survey conducted shows how nurses, with the introduction of the NM, perceive they have more time for the relationship with patients and family members (42.6%), a reduction (65%) of interruptions in the management of drug therapy, and an improvement in the quality of information given and received during the handover (95.6%) between shifts.

Discussion

The data collected demonstrates how the implementation of the MN has had positive effects not only on the organizational well–being and the working methods of the assistance staff but has also contributed to better management of assistance needs. Moreover, in this first phase, the increase in the Safety of Care provided emerges, thus, the continuity of care even after discharge.
P441 CARDIO–VASCULAR RISK STRATIFICATION IN T2DIABETES IN ITALY AND USE OF NEW DRUGS (SGLT2I AND GLP1–RA):DATA FROM THE AMD ANNALS:
Authors: Manicardi V , Russo G , Rocca A , Rossi M , Suraci C , Pintaudi B , Di Cianni G , Di Bartolo P
Published: May 2023

The AMD Annals are an initiative of computerized data collection by the Italian diabetes services, to evaluate the quality of the care provided to people with Type 1 and Type 2 Diabetes (T2D), which has been taking place for 15 years now. In 2019 the ESC/EASD Guidelines stratifying Diabetics according to cardio–vascular risk (CV) and the latest national (July 2021) and international Guidelines (LG) put new drugs with high cardio–renal protection at the forefront, such as the SGLT2i and the GLP1–RA: the ANNALS 2021 extracted the data of the year 2019, pre–pandemic, and the collection of the year 2021 is underway. AIM OF THE STUDY was to stratify T2D according to CV risk and to evaluate the prescribing appropriateness of the new drugs according to the Italian guidelines (ISS–AMD–SID).

Design and Methods

The 282 diabetes centers who sent the data are equipped with information systems able to guarantee the standardized extraction of the information necessary for the creation of the AMD Data File. The data analyzed concern socio–demographic, clinical and volume of activity characteristics: 46 indicators based on Revision 8 of June 19, 2019 (AMD Annals website).

Results

The T2D seen in the year 2019 were 531732 (57.3% M and 42.7% F, 67.3% aged > 65 years, and 32.9% aged > 75 years). 6.5% were new diagnoses. All monitoring indicators, with favorable and unfavorable outcome, have improved compared to previous years: 52% of T2D have HbA1c <= 7.0% (53 mmol/mol), 65% have LDL cholesterol < 100 mg/dl, 53.2% have blood pressure values ​​< 140/90 mmHg, 39.5% are obese. 29.1% have GFR < 60 ml/min*1.73 m2 and 6.7% have GFR< 30 ml/min. Use of drugs: further reduction to 16.7% of the use of sulfonylureas and glinides; stable at 32% insulin; new drugs are on the rise (DPPIVi: 22%; GLP1–RA: 15.9%; SGLT2i: 16.6%). Risk stratification according to the ESC/EASD classifies 20.8% of T2DM at high and 78.6% at very high CV risk and only 0.6% are at moderate risk, but only 32.5% of patients are treated with cardio–renal protection drugs.

Conclusions

The 2019 AMD Annals show an overall improvement in the quality of care provided, and a doubling of the use of new drugs, but we are still far from the appropriateness of treatment according to the new Italian guidelines of 2021. We hope that the 2022 Annals campaign, which has just finished, will offer a change of roote
P451 PREDICTIVE VALUE OF INITIAL ASSESSMENT IN IDENTIFYING SYNCOPE TYPE (HYPOTENSIVE/BRADYCARDIA)
Authors: Ferrieri A , Dentico A , Altieri T , Carretta F , D'Agostino C , Carretta D
Published: May 2023

Introduction

Syncope manifests itself according to two main mechanisms: the hypotensive phenotype, in which the prevalent mechanism is represented by the reduction of blood pressure values, and the bradycardia phenotype, in which the reduction in heart rate prevails. The Tilt–Test plays an important role in the diagnosis and study of syncope. The request for tilt–test execution in the last 2 years has progressively increased, also in consideration of the closure of the syncope units present in peripheral hospitals and the covid–19 pandemic. The requests for tilt execution did not always appear to be appropriate or, in any case, the diagnosis emerged already evident at the initial evaluation. The purpose of the study is to evaluate the diagnostic value of the initial evaluation in identifying the type of syncope starting from the bradycardia/hypotensive phenotype, in order to select the patients who need to perform the examination.

Methods

The procedure followed by our center for all patients referring to the syncope unit consists in carrying out an initial evaluation, the clinical evaluation of the patient according to the GIMSI protocol, carrying out the head–up tilt test and carotid sinus massage, and, in certain patients, loop recorder implantation. In this study, the initial evaluations of 58 patients who underwent the tilt test were considered, making an assessment of the phenotype of each, which was subsequently compared with the actual result of the test.

Results

The evaluation parameters chosen were: the presence and type of syncope and prodromes before the test, traumatic and/or driving syncope, blood pressure and baseline heart rate. The patients who at the initial evaluation presented a hypotensive phenotype were 23, those with a bradycardia phenotype 24, while those with a mixed phenotype 11. We then went on to consider the results of the test performed, evaluated on the basis of the VASIS classification. From the data comparison we had a correlation of the phenotype in 72% of the patients, while in 28% it was not possible to predict the phenotype.

Conclusions

Through these data we can therefore see how the initial evaluation allows early identification of the type of syncope in 72% of patients, selecting the patients who actually need the examination to be performed, in the face of an ever–increasing request.
P452 VASOVAGAL SYNCOPE AND COVID–19
Authors: De Laura D , Lavolpe V , Mancini L , Campanella C , Resta M , Sassara M , Buquicchio F , Ligurgo L , Corriero F , Caldarola P
Published: May 2023

Scope. The aim of the study was to evaluate how the Covid–19 state of emergency affected the activity of the Syncope Unit (SU). During the lockdown, the outpatient activities of the SU were suspended(1). Materials. From March 2020 to March 2021, approximately 95 patients booked for the Tilt–up test were medically evaluated by teleconsultation and televiewer. Vasovagal syncope (VVS) (61%), orthostatic hypotension (OH) (5%) was diagnosed. The patients were trained, through television and video tutorials, in the use of counter pressure maneuvers (PCM) and tilt training, while dietary indications were provided and the importance of adequate oral hydration and the need to take, as recommended by the guidelines, 2–3l of water per day. We retrospectively observed the result at the end of the lockdown period: patients with VVS and OH called by the SU no longer needed to perform tilt up tests because they had obtained a significant reduction in syncope in 90% of cases.

Discussion

Reflex syncope is the most frequent, representing 21% of all types of syncope (2). Accurate history and physical examination are necessary for the diagnosis, sometimes a guided path in the SU in the unexplained forms. The indicated therapy is non–pharmacological (increase the salt and water content in the diet, avoid triggers, tilt training)(2) and, especially in young people, has been shown to prevent recurrences(2). Back pressure maneuvers (PCM) are effective in preventing syncope(3); oral hydration increases blood volume and improves symptoms(4).

Conclusions

The Covid–19 state of emergency, through the use of telemedicine tools, has made it possible to reach the diagnosis of reflex syncope through an accurate anamnestic evaluation, has allowed patients to be reassured about the benignity of the events and has motivated patients to implement the recommended non–pharmacological therapies. This has made it possible to reduce the number of tilt tests to be performed when the SU reopens.
P454 ARRHYTHMIC RISK AND REPOLARIZATION ALTERATIONS ON THE ECG UNCOVERED BY AN ISOPRENALINE TEST
Authors: Perniciaro V , Caccavo V , Di Monaco A , Katsouras G , Quadrini F , Romanazzi I , Sgarra L , Troisi F , Mangini F , Grimaldi M
Published: May 2023

A 62–year–old man came to our attention for a syncopal episode that occurred during a competitive race, without prodromes, lasting a few seconds, with total, spontaneous regression and without issues. On ECG sinus bradycardia, HR 46/min and QRS fragmented in V1. During monitoring were documented many polymorphic premature ventricular complex (PVC) and polymorphic nonsustained ventricular tachycardia (NSVT). Coronary angiography showed normal coronary arteries. The Isoprenaline test was performed (intravenous infusion of Isoprenaline 0.2 mg in 100 ml of physiological solution at variable speed until obtaining a HR increase of at least 20% compared to baseline). As HR increased, a clear epsilon wave in V1 became evident. Also documented numerous polymorphic PVC and polymorphic NSVT. Cardiac magnetic resonance (MRI) was performed with documentation of findings suggestive of primary cardiomyopathy with biventricular phenotypic expression with a clear left prevalence. All these elements placed the patient at high arrhythmic risk. An implantable cardiac defibrillator was then performed. The isoprenaline–induced increase in heart rate made the epsilon wave manifest, which is an expression of an extremely delayed depolarization caused by the fibroadipose replacement of portions of the myocardium (as documented by cardiac MRI). It was also possible to exclude a J–wave syndrome in which the alterations are of repolarization and are due to the epi–endocardial electrical gradient which increases and becomes more evident at lower heart rates. The test with isoprenaline has therefore allowed us to distinguish depolarization disorders from repolarization disorders and to direct us towards the former.
P460 HIGH RESOLUTION ATRIOGRAM ANALYSIS AS A PREDICTIVE TOOL OF ATRIAL FIBRILLATION IN STROKE PATIENTS
Authors: Rizzo M , Imperio G , Calcagnini G , Censi F , Urani C , Tanzilli A , Tanzilli G , Miraldi F , Strano S
Published: May 2023

In patients (Pts) with ischemic stroke in addition to acute management, it is essential to prevent new episodes, first identifying the source of the stroke event. The primary objective of the study is to determine whether the parameters of duration, morphology (divided into the three factors optimal model order fitting, number of maximum and minimum and zero–crossing), and variability of the P wave, calculated with appropriate algorithms from high resolution recordings, correlate with the risk of developing atrial fibrillation (AF) in ischemic stroke Pts. As a secondary goal we have analyzed the differences of factors that are currently used in clinical practice for risk stratification.

Methods

and materials : 63 Pts with stroke ischemic were recruited,8 Pts excluded for finding of other arrhythmias during hospitalization,5 for incomplete data, reducing the sample to 50. In the Pts was recorded EKG track in high resolution with the Cardionica(R) device. We obtained,with special algorithms above mentioned,the parameters of duration, morphology and variability. The population studies as stratified in two groups based to continuous ECG monitoring data: those with AF detected and those without AF (control group).

Results

in the analysis of the P wave we found a significant difference in the parameter "number of zero crossings", that is the number of times the P wave crosses the isoelectric line reversing its polarity, the average of which was 1,60 (0,69) in the group of Pts that then developed AF and 0,97( 0,66) in the control group, with a p–value<0,01. Differences in the other parameters of the P wave didn’t reach statistical significance.

Conclusions

The search for other predictive factors that allows a better stratification of the risk of developing AF is crucial to optimize the prevention of new stroke events. The study showed that the hight resolution parameters of P wave morphology, is significantly associated with increased incidence of AF, therefore the analysis of the P wave is potentially useful in the assessment of the risk of developing AF after a first stroke event. A greater number of Pts and a long–term follow up could definitely confirm the better predictive parameter to stratify the AF probability among the other parameters of the P wave.
P461 ECG MONITORING TO DETECT ATRIAL FIBRILLATION IN PATIENT WITH CRYPTOGENIC ISCHEMIC STROKE
Authors: Bolognesi M , Guidetti D , Rossi L , Biagi A , Immovilli P , Aschieri D
Published: May 2023

Backgroound It’s Known that atrial fibrillation ( AF) is related to 20 % of ischemic stroke, but it is also found in one third of cryptogenetic, lacunar, atherotrombotic stroke. After stroke cardiac test are reccomended . 24 h holter ECG has a diagnostic yield about 1 – 5 % .Nowadays exists diagnostic test for ECG monitoring with a major diagnostic yield, but they are reccomended only in selected stroke patients

Methods

We considered consecutively 256 pazienti hospitalized in Neurology Division with ischemic stroke or transient ischemic attack ( TIA) from February to December 2022 recepient of 24 h or 72 h Holter ECG executed in Cardiology division. We evaluated AF registration, < 30 sec atrial tachicardia ( TA) and cerebral lesions.

Results

Out of 256 patients, with average 77±19 anni years, 149 ( 58%)were males and 105 ( 42%) females with average CHA2DS2VAS 4. AF was detected from 24 – 72 h Holter ECG 24 h – 72 in 11 patients ( 3,9%)with average age 84 years and CHA2DS2VASC 5 . The effective diagnotic yield was 3,1%. Considering cerebral injury imaging of acute stroke iun patients with AF, 3 patient had cortical injury ( one of these with early Hemorragic infarction), 2 con lesioni cortico– subcortical lesions, 2 lacunar lesions e 3 without lesions. We found < 30 seconds atrial tachicardia in 20 patients ( 8%) with average age 80 years e CHA2Ds2VAS 5 Cerebral lesions of these patients were : 5 lacunar lesions, 5 cortical lesion in multiple region, 3 cortico subcortical, 1 corticali, 2 lesions from atherotrombotic etiology, 4 without lesions

Conclusions

In out experience we confirm a 24 – 72 h Holter ECG low diagnostic yield to AF diagnosis more frequent in older patients with high CHA2DSAVSC score. Porolonged ECG monitoring can be considered in parients with cortico subcortical or cortical in multiple territories and with < 30 seconds AT detected at 24 – 72 holter ECG .
P464 ELEVATED SPONTANEOUS INR: THE COMPLEXITY OF REAL LIFE BETWEEN CARDIOLOGY AND HEMATOLOGY
Authors: Prenna E , Maffè S , Paffoni P , Facchini E , Bergamasco L , Careri G , Franchetti Pardo N , Paino A , Ariotti S , Dellavesa P
Published: May 2023

Direct acting oral anticoagulants (DOACs) have guaranteed safety and convenience of use in anticoagulated patients. DOACs only require monitoring of hepato–renal function. But how to handle a patient with persistently elevated INR (International Normalized Ratio) in the absence of anticoagulant therapy? We present the case of a 77 years old woman with hypertension and hypothyroidism. The patient was admitted to our division for high frequency atrial fibrillation with initial heart failure. The patient gradually improved with rate control therapy (metoprolol and digoxin) and a few diuretic therapy. The echocardiogram didn’t showed anything significant. Laboratory tests showed a persistently elevated INR, even after she achieved clinical stability. Liver funcion tests and abdomen echography were normal. Patient’s CHA2DS2–VASc risk score was 3 with indication to anticoagulant therapy. We opted for rate control therapy because, in the absence of a diagnosis, there was uncertainty as to start or not anticoagulation therapy, with the doubt whether the persistently high INR corresponded to real anticoagulation. We didn‘t want to expose the patient to bleeding risks by initiating a DOAC. Blood tests showed mild to moderate factor X deficiency with prolonged dRVVT (diluited Russel Viper Venom time) but normal aPTT (activated partial thromboplastin time). Factor X (FX) deficiency is a rare hereditary bleeding disorder characterized by decreased antigen and/or activity of FX leading to mild to severe bleeding symptoms. Severe congenital form manifests itself early while heterozygous patients are often asymptomatic. Indeed, no previous literature data are reported about use of DOACs in this kind of patient. In mild to moderate FX deficiency there are no known contraindications for the use of anticoagulant therapy. According to the hematologist we started low–dose dabigatran, the only DOAC that acts by directly inhibiting thrombin. Regular 6 months follow–up. In conclusion this case was particularly challenging because of the lack of indications about how to manage these patients. The complexity of patients in real–life goes beyond the guidelines, which must therefore be adapted to the individual case
P466 PREDICTORS OF RECURRENT CEREBRAL ISCHEMIA AFTER PATENT FORAMEN OVALE CLOSURE: A SINGLE CENTER EXPERIENCE WITH A LONG–TERM FOLLOW–UP
Authors: Gurgoglione F , Cattabiani M , Vignali L , Solinas E , Dizdari C , Benatti G , Tadonio I , Barocelli F , Tuttolomondo D , Nicolini F , Ardissino D , Niccoli G
Published: May 2023

Aims

Transcatheter patent foramen ovale (PFO) closure has been shown to lower recurrent stroke in patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) with an indication for closure. However, the incidence of recurrent stroke is not negligible and underlying pathogenic mechanisms remain largely unknown. We sought to evaluate the prevalence of recurrent CS/TIA and to assess its predictors after transcatheter PFO closure.

Methods

We enrolled consecutive patients who underwent PFO closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2006 and 2021. For each subject, CS/TIA index event was diagnosed after exclusion of alternative etiologies, PFO features were characterized by transesophageal echocardiography (TEE), the Risk of Paradoxical Embolism (ROPE) score was retrospectively assessed and the presence of migraine was investigated. Clinical follow–up was scheduled with outpatient visits at 3 – 12 months and yearly thereafter device implantation; the primary outcome was the recurrence of any ischemic neurological event.

Results

We enrolled a total of 169 patients with mean Risk of Paradoxical Embolism (ROPE) score at hospital admission of 6.4 ± 1.5. The primary indication for PFO closure was previous CS (94 [55.6%] subjects), followed by TIA (75 [44.4%]). Among patients with complete outcome data (n= 154), after a median follow–up of 112 months, recurrent cerebral ischemia occurred in 13 [8.4%], with an annualized rate of 0.92/100 patients. The presence of obesity [OR 5.268, p = 0.018], ROPE score < 7 [OR 5.991, p = 0.035] and migraine [OR = 5.932 p = 0.012] were independent positive predictors of recurrent stroke/TIA after PFO closure.

Conclusion

In our study, recurrent cerebral events after PFO closure were not negligible, with an annualized rate of 0.92/100 patients, consistent with prior research. Multiple heterogeneous predictors were identified: the presence of obesity, ROPE score < 7 and migraine were independent positive predictors of recurrent stroke/TIA after PFO closure
P474 A PIVOTAL ROLE OF THE MULTIDISCIPLINARY TEAM IN THE BRIDGING THE PATIENT TO HEART TRANSPLANTATION
Authors: Domanskaya E , Enea G
Published: May 2023

The complexity of care of the patients affected by advanced heart failure (AHF) requires a dedicated team led by cardiologists and consists of nurses, physical therapists, patient care coordinator, nurse educator, dietician, anesthesiologists, and perfusionists. Multidisciplinary team “ has been shown to reduce the risk of hospitalization, death, and health care costs in randomized controlled trials”1. AHF is characterized by the progressive worsening of the clinical conditions of the patient unresponsive to the optimal medical therapy. Therefore, the short–term mechanical circulatory supports as Intraaortic Balloon Pump (IABP) may represent a valid strategy for optimizing and bridging the patient affected by AHF to the heart transplant2. A 52 years old lady with the diagnosis of the AHF and associated cachexia and sarcopenia has admitted in emergency. Despite of the high dose of inotrope severe hypotension required a IABP support to provide an adequate organs perfusion. Left ventricular assist device therapy has been rule out: the patient originated from the other country lives alone so no caregiver may be designed and trained to provide a support during the period following the LVAD’s implantation. For over than 130 days the patient well tolerates a treatment with inotrope at low dosage under continuously IABP support without a complications. Dedicated nurse in collaboration with the physical therapist provide a self mobilization of the patient with ambulatory IABP that is favorable to strengthen the level of her autonomy during the pre–transplant period. The out of bed position was performed by patient every day maintaining an acceptable level of muscle trophism to make the cardiac transplant program attainable. The patient was ambulating during almost every day sessions of the physical therapy covering the distance about 260 meters. A comfort environment, a quality of sleeping and an unchanged sleep–wake cycle are factors that enhance the patient’s experience. After more than five months of hospitalization, the patient receives her new heart. Heart–failure associated cachexia and sarcopenia, one of the most critical issues in the patients with AHF were regressed as a result of intensive physical activity and regular mobility of the patient. Synergic effort and expertise of each member of the multidisciplinary team has been a significant impact to successfully bridges critically ill lady to her complete recovery after the heart transplantation.
P475 RECURRENT CORONARY ARTERY VASOSPASM COMPLICATED BY CARDIAC ARRESTS IN HEART TRANSPLANT RECIPIENT: AN UNUSUAL ENEMY
Authors: Tedeschi A , Palazzini M , Gentile P , Conti N , Ianni U , Perna E , D'Angelo L , Masciocco G , Foti G , Ammirati E , Verde A , Garascia A
Published: May 2023

Even if coronary vasospasm (CV) is considered a rare phenomenon in heart transplant (HT) recipients, during routine coronary angiography asymptomatic CV may be observed. We report the case of a 30–year–old male who underwent HT in 2007 for dilatative cardiomyopathy. He was maintained on tacrolimus and mycophenolate mofetil and had no significant rejection or coronary allograft vasculopathy (CAV) demonstration. In December 2020 patient presented with cardiac arrest preceded by angina. Coronary angiography demonstrated diffuse spasm of the right coronary artery (RCA) with resolution after intracoronary nitrate administration. An endomyocardial biopsy (EBM) revealed no signs of cellular rejection whilst cardiac magnetic resonance showed signs of acute rejection (Fig.1). Moreover, two major histocompatibility complex (MHC) Class 2 donor–specific antibodies (DSAs) were positive with a high title. Treatment for antibody–mediated rejection (AMR) was initiated with steroids and plasmapheresis, followed by immunoglobulin infusion. Cardiac defibrillator was implanted before discharge. In August 2021, patient experienced a second cardiac arrest. Left heart catheterization found diffuse CV and after nitrates administration, proximal critical stenosis of RCA was pointed out and treated with stent insertion (Fig. 2–3). EMB and DSAs assessment were both negative. The patient was discharged after medical therapy optimization for CV prevention including the switch from mycophenolate to everolimus. After two more episodes of ACS with angiography finding of CV we decided to empirically treat the patient with weekly photopheresis sessions. Despite aggressive AMR management, a third ACC occurred in March 2022. The patient was finally reintroduced to the HT waiting list. Most CV episodes run without any symptoms due to the denervated heart post–transplant so probably re–innervation occurred in our patient. Calcium channel blockers, nitrates, and beta–blockers failed in CV prevention, suggesting ineffectiveness in HT recipients because of a different pathogenetic mechanism when compared to healthy subjects. Furthermore, documentation of coronary disease progression after the second ACC supports the hypothesis that CV could be the first manifestation of CAV. An intriguing hypothesis would be the presence of pathological vasoreactivity in the donor‘s heart, ascribable to an “inherited” endothelial dysfunction that could last be exacerbated by multiple factors, including AMR.
P476 TOLERATED SUSTAINED VENTRICULAR FIBRILLATION IN LVAD RECIPIENT: THE WALKING DEAD
Authors: Mauriello A , Maratea A , Amarelli C , Maiello C , Loffredo F , Liccardo B , Golino P
Published: May 2023

A 73–year–old man comes to the cardiac surgery clinic, due to the onset of an arrhythmic storm. In 1999, the patient was diagnosed with dilated cardiomyopathy with finding of a pathogenic mutation of the MYH7 gene by NGS panel analysis. Because of severely reduced systolic function despite OMT and left conduction delay, he underwent CRT–D implant in class IA. The patient‘s course was characterized by multiple exacerbations and a worsening course of ventricular dysfunction (EF 20%), such as to configure a picture of advanced heart failure, INTERMACS III (frequent flyer). Approximately 6 months later, the patient was admitted with signs of hypoperfusion refractory to inotrope therapy and significant congestion. In consideration of age, frailty and irreversible renal dysfunction, the patient was excluded from the transplant list. Therefore, he was a candidate for mechanical support as destination therapy, through the implantation of the Heart Mate III. At admission, the patient was monitored with evidence of ventricular fibrillation (image 1) and relative hemodynamic stability. The vital parameters reported a BP of 90/76 mmHg, FC not evaluable and SpO2 of 80%. For this reason, in anesthesiological assistance, asynchronous external defibrillation (200 J) was performed with restoration of the pacing rhythm. The monitoring of the LVAD showed a series of alerts: a reduction of the Pump Flow and phases of reduction of the Pulse Index (image 2). Event monitoring of the CRT–D revealed that the patient developed an arrhythmic storm, with appropriate but ineffective several shocks. The 8 shocks were followed by the interruption of the device therapies, but the patient, despite the ventricular fibrillation, had preserved perfusion. Medical therapy was optimized (mexiletine add–on) and CRT–D was rescheduled.

Conclusions

The presence of LVAD ensures a satisfactory cardiac output during arrhythmias that would lead to hemodynamic compromise. For this reason it is possible to identify patients who autonomously come to our observation in "cardiac arrest".
P478 HEART TRANSPLANT IN SARS–COV2 POSITIVE RECIPIENT: MANAGEMENT PROTOCOL OF WORLD‘S FIRST CASE
Authors: Giovannico L , D‘errico Ramirez A , Parigino D , Fischetti G , Concetta L , Santeramo V , Giuseppe F , Antonio C , Bavaro D , Saracino A , Grasso S , Bottio T , Milano A
Published: May 2023

During SARS–CoV2 pandemic, transplant programs had to devise strategies to deal with the possibility of COVID–19–positive donors and recipients. In March 2022, a 60–year–old man with dilated cardiomyopathy on the transplant waitlist was admitted to our Unit as a possible donation was presented. On arrival, he tested positive for SARS–CoV2. The patient had no clinical evidence of COVID–19; he had completed the vaccination cycle; chest X–rays did not show interstitial pneumonia. Aware of the increased risk, we proceeded with the transplant. Sotrovimab, a novel anti–viral agent specific for COVID–19, was administered. Prophylactic antibiotics were started. He received anti–thymocyte immunoglobulins 125 mg for 2 days and methylprednisolone 1 g after aortic declamping and then 125 mg TID for 2 days for induction immunosuppression. Maintaining therapy included corticosteroids and tacrolimus. On the 7th day the patient tested negative at SARS–CoV2 swab. As kidney function worsened, hemodialysis was started. On the 17th day signs of cellulitis of the left thigh appeared, and inflammation indices (CRP, PCT) rose. A hemoculture positive for A. baumannii (MDR–AB) was obtained; hence the patient was treated with Cefiderocol and Colistine. A Cytosorb filter was added to the hemodialysis and Pentaglobin was started. After 3 weeks, hemodynamics started to improve, inotrope support was suspended, with reduction of inflammation indices, negative hemocultures, recovering kidney function. After two weeks, the patient abruptly presented fever, marked hypotension and dyspnea. He underwent intubation, inotrope therapy, broad–spectrum antibiotic therapy, intravenous Immunoglobulins and a cycle of Polymyxin B Hemoperfusion. Nevertheless, hemodynamics decidedly failed. Chest X–rays showed bilateral pneumonia. Hemocultures were positive for MDR–AB. Leukopenia developed (WBC 0,10). Three days after the first signs of a new infective episode, the patient had died. Notwithstanding the difficulties of SARS–CoV2 pandemic, tempestive diagnosis and treatment allow transplant programs to proceed unhindered.
P492 NARRATIVE OF PATIENTS WITH ACUTE CORONARY SYNDROME: FROM THE EVENT TO THE END OF A CARDIAC REHABILITATION PROGRAM
Authors: Brugin E , Cordero M
Published: May 2023

Background

Acute Myocardial infarction (AMI) is often a sudden event that requires urgent and invasive therapeutic measures. After AMI, patients enter the world of chronic diseases with strong personal repercussions.

Purpose of the Study

To investigate experience of patients with AMI and how it evolves at different stages of the treatment pathway in order to help health professionals to improve and to individualise different aspects of treatment.

Material and Methods

A semi–structured diary outline and Plutchik‘s wheel of emotions (on which the patient had to underline his three predominant emotions) was proposed to 30 patients affected by AMI: 10 within 48 hours of the event, 10 immediately before and 10 immediately after a cardiac rehabilitation program (CRP). Narrative about the experience related to the IMA moment was collected in each phases, while aspects concerning current situation and CRP were added to the traces proposed before and after cardiac rehabilitation. The texts produced by patients were analysed using specific methods of Narrative Medicine (Kleiman‘s, Lowner/Robinson‘s and Frank‘s classification). Plutchik‘s wheel results were processed as word–cloud.

Results

Negative emotions dominate in narratives collected during acute phase (FIG 1) where themes such as hopelessness, uncertainty, loss of control, guilt are recurrent. Sometimes tendency towards progression is identifiable, but always inside a narrative structure that conveys a precariousness experience. In the phase preceding CRP, most violent negative emotions disappear and positive emotions surface (FIG 2). The desire to understand situation becomes a main narrative theme and trust in health professionals appears as a coping element. Also in still narratives, elements of progression are evident, sometimes predominant. A prevalent restitution component emerges with strong expectations in CRP results. At the end of CRP, a further positive change in emotions is evident (FIG 3). All narratives become in progression and quest elements sometimes appear.

Conclusions

Narratives show an evolution of AMI patients experience from acute event to the end of CRP. Our study allowed to obtain useful elements to improve the approach to the AMI patient during the acute phase, to ameliorate anamnestic collection in the post–acute phase and to individualise rehabilitation pathway making it more customized and effective.
The divergence of mean phenotypes under persistent directional selection
Authors: Devi Archana , Speyer Gil , Lynch Michael
Published: May 2023

Numerous organismal traits, particularly at the cellular level, are likely to be under persistent directional selection across phylogenetic lineages. Unless all mutations affecting such traits have large enough effects to be efficiently selected in all species, gradients in mean phenotypes are expected to arise as a consequence of differences in the power of random genetic drift, which varies by approximately five orders of magnitude across the Tree of Life. Prior theoretical work examining the conditions under which such gradients can arise focused on the simple situation in which all genomic sites affecting the trait have identical and constant mutational effects. Here, we extend this theory to incorporate the more biologically realistic situation in which mutational effects on a trait differ among nucleotide sites. Pursuit of such modifications leads to the development of semi-analytic expressions for the ways in which selective interference arises via linkage effects in single-effects models, which then extend to more complex scenarios. The theory developed clarifies the conditions under which mutations of different selective effects mutually interfere with each others’ fixation and shows how variance in effects among sites can substantially modify and extend the expected scaling relationships between mean phenotypes and effective population sizes.
The Tropical Manin–Mumford Conjecture
Authors: Richman David Harry
Published: May 2023

In analogy with the Manin–Mumford conjecture for algebraic curves, one may ask how a metric graph under the Abel–Jacobi embedding intersects torsion points of its Jacobian. We show that the number of torsion points is finite for metric graphs of genus ${g\geq 2}$, which are biconnected and have edge lengths that are “sufficiently irrational” in a precise sense. Under these assumptions, the number of torsion points is bounded by $3g-3$. Next, we study bounds on the number of torsion points in the image of higher-degree Abel–Jacobi embeddings, which send $d$-tuples of points to the Jacobian. This motivates the definition of the “independent girth” of a graph, a number that is a sharp upper bound for $d$ such that the higher-degree Manin–Mumford property holds.