bluuebunny/crossref_metadata_2025 huggingface dataset:
668 TWO CATHETERS (DDD) OR ONE (VDD) FOR ATRIO-VENTRICULAR BLOCK? COMPLICATION RATES OVER A MORE THAN 20 YEARS EXPERIENCE
Authors: Agbariah Andrea , Ruzzarin Alessandro , Manfrin Massimiliano , Donazzan Luca
Published: December 2022

Background

in patients with atrio-ventricular block and spared sinus node function dual chamber (DDD) pacing or ventricular (VDD) pacing are considered as an alternative in clinical practice. Literature lacks validated data on the best treatment choice in this situation. Decision should be made balancing risk and benefit ratio of a single or dual lead procedure.

Aims

to compare complication rates of DDD and VDD implants in a single center experience.

Methods

data from consecutive patients who underwent DDD or VDD implantation in our institution between January 2000 and December 2021 were included in the analysis. Complications consisted of catheter dislodgements (i.e. dislodgements needing a repositioning procedure), catheter related problems (i.e. lead problems needing a substitution) and infections (i.e. pocket infections or lead infections needing antibiotic therapy or extraction). The need of an upgrading procedure in VDD recipients was not considered as a complication but as a further procedure. The rate of generator replacement and its longevity was also recorded.

Results

we performed 2499 pacemaker implantations, among them 1435 (57,4%) were DDD and 1064 (42,6%) were VDD. The majority of DDD and VDD recipients were male (836 patients, 58,3% and 609 patients, 57,2% respectively). The VDD population was significantly older (77,7 years old vs 75,5 years old, p<0,01) at the time of implant.

Complications occurred more often in the DDD than in the VDD group, without reaching statistical significance (7,3% vs 5,7% p=0,13). No statistical difference was found in catheter displacement rate between DDD and VDD cohorts (4,9% vs 3,8%, p=0,21). In the first group, dislodgements were more frequent for the atrial catheter (41) than the ventricular (29).

Catheter-related problems occurred in 25 (1,7%) with a DDD and in 5 (0,5%) patients implanted with a VDD (p<0,01). Infections were also more frequent in patients with dual-chamber pacemakers (1,5%, 22 patients) than in those with single-chamber pacemakers (1,3%, 14 patients) (p=0,67).

Twenty (1,9%) VDD recipients needed upgrading to DDD mode during the follow-up due to chronotropic incompetence, whereas a single patient with a DDD underwent a CRT upgrading to relieve the symptoms of heart failure. During the study period, we changed 121 DDD and 140 VDD generators. Mean device duration was similar in both groups: 91,3 months and 93,3 months (p=0,43).

Conclusions

VDD implantation was the more frequent choice for elderly patients. No significant complications difference occurred in in patients implanted with DDD and with VDD pacemakers, although catheter-related problems occur more frequently in the former population. A small proportion of VDD recipients needed to upgrade the device to DDD. Both pacing choices are equally effective in atrio-ventricular block.
276 CIRCULATING FORMS OF PLASMA TRANSTHYRETIN IN PATIENTS WITH WILD-TYPE TRANSTHYRETIN AMYLOIDOSIS AND EFFECTS OF TREATMENT WITH TAFAMIDIS
Authors: Chiara Sanguinetti , Minniti Marianna , Panichella Giorgia , Vergaro Giuseppe , Aimo Alberto , Castiglione Vincenzo , Caponi Laura , Paolicchi Aldo , Emdin Michele , Franzini Maria
Published: December 2022

Introduction

Transthyretin (TTR) is a homotetrameric 55-KDa plasma protein that transports thyroxin and retinol complexed to retinol-binding protein (RBP). TTR misfolding and aggregation can lead to the extracellular deposition of amyloid (ATTR) representing one of the most frequent forms of amyloidosis in elderly. Aim of this study is to develop a native electrophoretic method to characterize circulating TTR in plasma samples of ATTR patients before and during treatment with tafamidis, a TTR stabilizer.

Methods

Plasma from ATTR patients (n=6), collected before (T0) and during tafamidis treatment, and plasma of healthy controls (n=6) were obtained from Fondazione Toscana G. Monasterio (Pisa, Italy). Plasma samples were separated on a native 4–20% Tris-Gly polyacrylamide gel. Western blot analysis was performed with anti-TTR (DAKO) or anti-RBP (Siemens Healthineer) antibodies. Proteins were detected by Clarity ECL substrate (BioRad).

Results

Circulating forms of TTR were qualitatively similar between ATTRwt patients at T0 and controls. In both groups, the most represented forms were: TTR dimers or trimers (∼37-50 kDa), TTR tetramers complexed with RBP protein in 1:1 ratio (∼80 kDa,) or 1:2 ratio (∼100 kDa), and high molecular weight (MW) aggregates (>150 kDa). Neither TTR monomers nor the tetramers were visible. RBP protein was detectable in association with TTR tetramers and some of the higher MW fractions (∼150 kDa, >250 kDa). Following tafamidis treatment, all ATTRwt patients displayed a progressive increase of the intensity of the band corresponding to TTR-RBP complexes, in agreement with the drug stabilizing action on TTR tetramers. Interestingly dimers and trimers, detectable at T0, were progressively lost during tafamidis treatment.

Conclusions

The native electrophoretic allowed us to detect several circulating TTR fractions. Data suggest a similar pattern of circulating TTR both in patients and healthy control: TTR tetramer exists only complexed with RBP and in equilibrium with low and high MW forms. Furthermore, the method allowed to appreciate the stabilizing effect of tafamidis on circulating TTR tetramers complexed with RBP. The study of circulating TTR fractions can expand our knowledge on mechanisms triggering its destabilization even when not mutated.
490 NT-PROBNP AND HIGH-SENSITIVITY TROPONIN T HOLD DIAGNOSTIC VALUE IN CARDIAC AMYLOIDOSIS
Authors: Castiglione Vincenzo , Aimo Alberto , Prontera Concetta , Masotti Silvia , Musetti Veronica , Nicol Martin , Cohen-solal Alain , Logeart Damien , Georgiopoulos Georgios , Chubuchny Vladyslav , Giannoni Alberto , Clerico Aldo , Buda Gabriele , Patel Kiara N , Razvi Yousuf , Patel Rishi , Wechalekar Ashutosh , Lachman Helen , Hawkins Philip N , Passino Claudio , Gillmore Julian , Emdin Michele , Fontana Marianna , Vergaro Giuseppe
Published: December 2022

Background

Cardiac amyloidosis (CA) is associated with an elevation of natriuretic peptides and troponins, predicting outcome. Nevertheless, the diagnostic yield of these biomarkers has not been extensively investigated.

Aim

To evaluate the diagnostic performance for CA of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT).

Methods

Patients with suspected CA (n=1,149) underwent a diagnostic work-up in 3 Centers in Italy, France (n=343, derivation cohort), and United Kingdom (n=806, validation cohort). Biomarker values with either 100% sensitivity or ≥95% specificity were selected as rule-out/rule-in cut-offs, respectively.

Results

In the derivation cohort, 227 patients (66%) had CA, and presented with higher NT-proBNP and hs-TnT. NT-proBNP 180 ng/L and hs-TnT 14 ng/L were selected as rule-out cut-offs, and hs-TnT 86 ng/L as rule-in cut-off. NT-proBNP <180 ng/L or hs-TnT <14 ng/L were found in 7% of patients, ruled out without false negatives. In the validation cohort, 20% of patients (2% false negatives) had NT-proBNP <180 ng/L or hs-TnT <14 ng/L, and 10% showed both biomarkers below cut-offs (0.5% false negatives). These cut-offs refined CA prediction when added to echocardiographic scores in patients with a hematologic disease or an increased wall thickness. In the validation cohort, the 86 ng/L hs-TnT cut-off ruled in 20% of patients (2% false positives).

Conclusions

Cardiac biomarkers can refine the diagnostic algorithm in patients with suspected CA. NT-proBNP <180 ng/L and hs-TnT <14 ng/L reliably exclude the diagnosis (Figure), both in the overall population and subgroups referred for either AL-CA or cardiac (pseudo)hypertrophy.
73 WHICH IS THE CULPRIT OF THIS MYOCARDIAL INFILTRATION?
Authors: Cumitini Luca , Rossi Lidia , Giubertoni Ailia , Airoldi Luisa , Casali Giovanni , Boldorini Renzo , Patti Giuseppe
Published: December 2022

Introduction

Myocardial infiltration by primary cardiac neoplasm is a rare condition and the pathological spectrum includes more widespread benign cell types, providing exceptional diagnostic and therapeutic challenges. Refractory heart failure, pericardial effusion and arrhythmias due to infiltrative mass are the most common clinical manifestations. Multimodality imaging, with echocardiography, computed tomography and magnetic resonance imaging, is essential to determine the characteristics of a cardiac tumor.

Clinical case: A 35-year-old man without cardiovascular risk factors presented with two months of shortness of breath and weight loss. A previous history of acute myeloid leukemia undergoing allogenic bone marrow transplant was reported. Transthoracic echocardiography revealed an apical thrombus in left ventricle with inferior and septal hypokinesia conditioning mildly reduced ejection fraction, circumferential pericardial effusion without cardiac tamponade and abnormal right ventricular thickening (Figure 1). The cardiac magnetic resonance imaging confirmed diffuse thickening of the right ventricular free wall (maximum diameter 30 mm), suspected for myocardial infiltration, extending to the right atrium and left ventricle with an ischemic pattern of the inferior wall (Figure 2). No coronary artery disease was found by coronary angiography, but the right coronary artery was incorporated by the pathological tissue in chest computed tomography scan. Cardiac positron emission tomography demonstrated the presence of neoplastic tissue with increased metabolic activity, whose similar characteristics were also evident in the ascending aorta and aortic arch. Being the percutaneous endomyocardial biopsy inconclusive, a pericardiectomy was performed through a median sternotomy incision, showing widespread cardiac neoplastic infiltration. Histopathological analysis, done on samples taken by surgical myocardial biopsy, revealed tissue involvement by a rare and aggressive cardiac anaplastic large T-cell non-Hodgkin lymphoma (ALK -, Ki-67 90%). Few days after surgery, the patient developed a refractory cardiogenic shock and unluckily died before establishing an adequate therapy.

Conclusion

Primary cardiac lymphoma is very infrequent and the non-specificity of the symptoms makes the diagnosis extremely challenging and often limited to autopsy findings. Our case highlights the importance of an appropriate diagnostic algorithm that can allow an early diagnosis and an adequate therapy of this otherwise fatal pathology. In this condition surgical removal of the tumor in not indicated, being chemotherapy the only effective treatment. However, because of rarity, data are lacking to produce definitive regarding guidelines.
358 A POSSIBLE RARE CASE OF VENTRICULAR LIPOMATOSIS: A STIMULUS FOR A PANORAMA OF FATTY CARDIAC LESIONS
Authors: De Gaetano Fabrizio , Losi Valentina , Tamburino Corrado , Monte Ines Paola
Published: December 2022

We exhibit the case of a 75 years-old man who undertook cardio-oncological assessment for Non-Hodgkin Lymphoma: baseline echo revealed typical features of lipomatous hypertrophy of the interatrial septum (LHIS) and an apical hypoechoic left ventricle (LV) lesion. Five years before, the patient performed MRI (Magnetic Resonance Imaging), which confirmed LHIS, but superabundant epicardial fat extended to the right ventricle and the apical junction between the two ventricles, both characterized by normal ejection fraction, and surrounded the origin of the pulmonary trunk. LV lateral and inferior walls presented lipomatous metaplasia foci and no history or ECG sign of previous myocardial injury could be pointed out. A slight band of late gadolinium enhancement at the basal infero-lateral wall of LV was highlighted. The patient referred episodes of fainting: the Holter-ECG showed pronounced bradycardia which couldn't be explained by other secondary causes. So a bicameral pace-maker was implanted. During our ambulatory evaluation, we decided to repeat MRI, which showed no difference in comparison with the previous one, so excluding malignant degeneration of the fatty mass surrounding the heart. Despite older age and the lack of sudden cardiac death family history we searched for pathognomonic arrhythmogenic cardiomyopathy (ACM) mutations. In consideration of the new evidence of the metabolic risk associated with abundant epicardial fat (EF) we asked for updated laboratory dosage of plasma glucose, LDL cholesterol and triglycerides and we recommended stricter control of blood pressure.

From 4% to 52% of cardiac mass is made up of fat but only EF interacts with myocardium and coronary arteries. Anomalous growth of fat in the heart can present itself as LHIS, excessive lipomatous infiltration or cardiac lipomas (real capsulated tumors) but also ACM is histologically characterized by fibrofatty replacement of cardiomyocites. Overabundant and inflammed EF is now considered a surrogate of metabolic risk and is associated with multivessel coronary disease, the finding of chronic total occlusions (CTO) and microvascular angina.

Identifying fatty heart lesions and defining their clinical and prognostic role remains an intriguing challenge. We suggest a general binary way to follow: the “mechanic one” for lipomas or lipomatous infiltration, that is paying attention to compression phenomena or the generation of arrhythmias, and the “metabolic one”, in other words optimizing cardiovascular prevention when EF is too much. A careful research of imaging features of ACM can't be omitted.
361 PATISIRAN EFFICACY ON MYOCARDIAL FUNCTION IN H-ATTR PATIENTS EVALUATED WITH THE USE OF CMR AND SPECKLE TRACKING ECOCARDIOGRAPHY
Authors: Cannizzo Noemi , Di Lisi Daniela , Damerino Giuseppe , Di Caccamo Leandro , Galassi Alfredo Ruggero , Novo Giuseppina
Published: December 2022

Introduction

Hereditary transthyretin amyloidosis (h-ATTR) is a complex, systemic infiltrative disease characterized by extracellular deposition of transthyretin in different organs. Infiltrative cardiomyopathy and polyneuropathy represent two of the most common and severe manifestations of this pathology. Patisiran is a double-stranded interfering RNA drug, used to stop expression of TTR in h-ATTR. It is recommended in the treatment of cardiac h-ATTR with polyneuropathy or polyneuropathy alone. Recent studies showed the efficacy of Patisiran in slowing the progression of the disease, improving myocardial deformation indices, biomarkers and functional capacity.

Aim

We aimed to illustrate the efficacy of Patisiran on myocardial function and to evaluate the role of Speckle Tracking Echocardiography (STE) and Cardiac Magnetic Resonance (CMR) as markers of subclinical cardiac efficacy of Patisiran in two h-ATTR patients (males, with mean age 55 ± 1,4 years old) with infiltrative cardiomyopathy and polyneuropathy who were scheduled to receive this drug.

Materials and Methods

Before receiving Patisiran (T0) the following tests were performed: cardiovascular physical examination, complete echocardiogram including STE. All these exams were repeated after 6 months or 1 year (T1). CMR was performed at the baseline and three years after.

Results

The CMR evaluation showed, after the use of Patisiran, a significant reduction of myocardial mass (average reduction -13,29%) and myocardial walls thickness (average septal reduction -13,65%). After 1 year follow up myocardial performance indices were also improved: GLS values (average gain 2,3 pt), and myocardial work values (average increase GWI +311,5, GCW +188,5, GWW -114,5, GWE +5,5 pt) at echocardiography.

Conclusion

The results of our experience showed, according to evidences suggested by the APOLLO trial, the efficacy of Patisiran, in patients with cardiac h-ATTR and polyneuropathy, in reducing myocardial mass and improving myocardial function.

STE and CMR could represent useful tools to study cardiac function in A-TTR patients undergoing Patisiran.
391 NEUROLOGICAL DISORDERS AND TAKOTSUBO SYNDROME: CLINICAL FEATURES AND OUTCOMES. RESULTS FROM A MULTICENTER PROSPECTIVE EUROPEAN REGISTRY OF 2300 PATIENTS.
Authors: Vitale Enrica , Santoro Francesco , Cetera Rosa , Ragnatela Ilaria , Mallardi Adriana , Leopizzi Alessandra , Matera Annalisa , Correale Michele , Iacoviello Massimo , Brunetti Natale Daniele
Published: December 2022

Background and aims

Takotsubo syndrome (TTS) is an acute heart failure syndrome featured by a reversible left ventricular systolic dysfunction. However, few data have been reported about prevalence of non-cardiovascular comorbidities as chronic neurological disorders in TTS patients.

Aim of this study was to compare clinical features, short- and long-term outcome among TTS patients with history of neurological disorder.

Methods

2301 patients with TTS were enrolled in a multicenter prospective European registry from July 2002 to November 2021. Clinical features, in- and out-of-hospital MACE, laboratory and imaging data were collected and a long-term follow-up was performed.

Results

Prevalence of history of neurological disorder was 17% (n= 400 pts). Most represented neurological conditions were previous cerebrovascular disorders (ischemic stroke and transient ischemic attack, 36.2%), followed by neurodegenerative disorders (30.7%, including cognitive disorders and motion disorders), tensive migraine (10%) and epilepsy (9.5%).

Neurological Patients developed TTS more frequently after a physical trigger (46.2% vs 33.8%, p<0.01). Sepsis (10%), acute neurological trigger (9.5%) and extreme activity/trauma (8.5%) where the type of physical trigger more prevalent.

During hospitalization neurological patients had longer in-hospital stay (10±11 days vs 8±8 days, p<0.01) and experienced more often in-hospital complications (27% vs 16%, p=0.0001) mainly driven by cardiogenic shock and in-hospital death (12% vs 7.6%; 6.5% vs 2.8%, respectively p<0.01).

Long-term mortality was higher in patients with history of neurological disorders (23.5% vs 10%, p<0.01), with a mean follow up of 2.5 ± 5.8 years.

Conclusions

Patients with history of neurological disorders and TTS have different clinical features and worse prognosis with higher short-term and long-term mortality.
340 TELENURSING: MANAGEMENT OF LOOP RECORDER IMPLANTED IN PATIENTS WITH PREVIOUS CRYPTOGENETIC STROKE
Authors: Morelli Francesca
Published: December 2022

Introduction

According to the latest studies, atrial fibrillation is associated with an increase in death of 1,5 - 1,9%. The main cause of this increase in mortality is ischemic stroke, secondary to detachment of emboliÂ starting from thrombus in the left atrium or in the left auricle. To date, the data indicate that the cause of stroke in the course atrial fibrillation is 14,7% throughout Italy.

The loop recorder is a small device that is implanted in the patientâ€™s subcutis through a minimally invasive procedure and allows you to go to record any arrhythmias. After implantation, it is fundamental to monitor and manage the device to recognize an arrhythmia, make a diagnosis and intervene promptly.

One of the indications for the implantation of the loop recorder is precisely the presence of a previous cryptogenic stroke. Atrial fibrillation, being the cause of stroke, requires long - term monitoring to be diagnosed.

In recent years there has been an increase in systems and modernization of this device which allows not only monitoring and diagnosis, but also timely intervention for a possible subsequent stroke episode.

Purpose

The study that was conducted in the Hemodynamics Department of the Santa Maria Goretti Hospital in Latina analyzes the data related to the loop recorder system for cryptogenic stroke. The patients who have performed the implant are monitored, thanks to remote assistance, and after some time the atrial fibrillation is evaluated in how many of these patients. The final goal is therefore to evaluate the benefit of this preventive intervention.

Materials and methods

There have been several researches that have made it possible to carry out the study on more than twenty patients. First, datas have been collected among all the people who implanted loop recorders, looking for the "previous cryptogenic strokeâ€as the reason for the implant. Once this type of patient was taken into consideration, real monitoring was carried out in the following months. Data collection and analysis were carried out on the database of Medtronic, Abbot and Biotronick which are the manufacturers of all devices that allow telemonitoring.

Results

The study demonstrated the benefit of implanting this device, based on a precise diagnosis, which cannot be obtained in a short time. About 70% of the patients taken into consideration were diagnosed with atrial fibrillation and this made it possible to intervene in the most suitable way to prevent an eventual recurrence of stroke.
555 ADHERENCE AND PERSISTENCE OF PCSK9 INHIBITORS IN CLINICAL PRACTICE: THE REAL-WORLD ITALIAN EXPERIENCE (AT-TARGET-IT STUDY)
Authors: Marzano Federica , Basile Christian , Paolillo Stefania , Cesaro Arturo , Buonocore Davide , Asile Gaetano , Abbate Vincenza , Vicidomini Francesca , Maria Spaccarotella Carmen Anna , Spirito Giulio , Maloberti Alessandro , Iannuzzo Gabriella , Ciccone Marco Matteo , D´alleva Alberto , Corleto Antonella , Brunetti Natale Daniele , Indolfi Ciro , Gargiulo Paola , Perrone-filardi Pasquale
Published: December 2022

Introduction

Hypercholesterolemia is a major risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) are recommended in patients with documented ASCVD or Familial Hypercholesterolaemia (FH), not achieving LDL-C target while treated with maximally tolerated dose of lipid-lowering therapy (LLTs). In this conext, single country real-life data, reporting use of PCSK9i in clinical practice are needed.

Purpose

AT-TARGET-IT is an observational, retrospective, IV phase registry, involving 10 Italian sites, designed to study adherence and persistence of PCSK9i (either Evolocumab or Alirocumab) in patients with ASCVD or FH.

Methods

All clinical and demographic characteristics were recorded at the time of first prescription and at the latest observation preceding inclusion in the study. Adherence was calculated as Medical Possession Ratio (MPR), defined as the ratio between the drug units dispensed during the treatment period and the duration of the treatment period itself. Persistence was defined as therapeutic continuity from the start of treatment upon enrollment and was assessed at the time points of 6, 12 and 18 months from prescription.

Results

798 patients were enrolled. In the overall population, mean age was 62 years (±7.8) and the majority were male (66%). Patients were followed for a median time of 19.33 months. 760 patients (95.2%) showed high adherence to therapy, 13 (1.6%) partial adherence, and 25 (3.1%) no adherence. At 6 month 99.7% of patients enrolled in the study remained on therapy; there were 519 and 423 patients in the study with a follow up of at least 12 and 18 months respectively. Persistence in these groups was 98.1% and 97.5%, respectively. Overall, 28 patients (3.5%) discontinued therapy. No differences in adherence and persistence were found between patients on Alirocumab or Evolocumab.

Conclusion

The AT-TARGET-IT registry study demonstrated that, in a large single-country real-world population, PCSK9i therapy is extremely successful in routine clinical practice, very high adherence and persistence.
1125 AN UNDER-RECOGNIZED CAUSE OF VENTRICULAR ARRHYTHMIAS AND SUDDEN CARDIAC DEATH: A CASE REPORT
Authors: Coletti Federica , Ricottini Elisabetta , Appetecchia Alessandro , Salvati Giuseppe , Mega Simona , Ussia Gian Paolo , Grigioni Francesco
Published: December 2022

Mitral annular disjunction (MAD) is a structural abnormality which is commonly seen in patients with myxomatous mitral valve disease and mitral valve prolapse. MAD is a marker of severe disease including a higher need for mitral valve intervention and more arrhythmic events, which can be a cause of sudden cardiac death (SCD).

A 72-years-old man with several cardiovascular risk factors (hypertension, diabetes mellitus, obesity, previous smoking, family history of cardiovascular diseases, chronic kidney disease) experienced two pre-syncopal episodes. Therefore, he was referred to a 24-hour Holter EKG that showed a non-sustained ventricular tachycardia (VT). A transthoracic 2D echocardiogram evidenced a mitral valve prolapse with mild regurgitation, normal left and right heart dimensions and function. Elective coronary angiography was performed to rule out an ischemic aetiology of ventricular arrhythmias (multiple cardiovascular risk factors and strong familiarity for coronary artery disease). The coronary angiography revealed a stenosis of 30% of left anterior descending artery and an intermediate stenosis of right coronary artery. A myocardial perfusion scintigraphy was performed to evaluate the intermediate coronary stenosis. The scintigraphy showed numerous focal perfusion abnormalities non indicative for coronary disease but rather for a degenerative or inflammatory disease. Indeed, we decided to perform a cardiac magnetic resonance (CMR). The CMR revealed a MAD with detachment of the root of the mitral annulus from the postero-lateral ventricular myocardium during systole, without areas of myocardial fibrosis evidenced by late gadolinium enhancement (LGE). Factors for high risk of SCD, such as fibrosis affecting the infero-basal left ventricle free wall or the papillary muscles, family history of SCD, personal history of complex ventricular arrhythmias, were not represented in our case. Therefore, we opted for a medical therapy with beta-blockers and a careful follow-up.

MAD is an under-recognized cause of ventricular arrhythmias and SCD, generally associated to mitral valve prolapse. Echocardiography and CMR can identify and quantify MAD. A comprehensive evaluation, including multimodality imaging and clinical history, is mandatory for risk stratification of SCD and for optimal treatment.
456 NATURAL HISTORY AND CLINICAL BURDEN OF MODERATE AORTIC STENOSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Morelli Martina , Galasso Michele , Soriano Francesco Stefano , Nava Stefano , Da Pozzo Caterina , Esposito Giuseppe , Piccaluga Emanuela , Bossi Irene , Montalto Claudio , Oreglia Jacopo Andrea , Giannattasio Cristina
Published: December 2022

Objectives

The aim of this study was to assess the natural history and clinical burden of moderate aortic stenosis and to investigate the interaction of left ventricular ejection fraction and of age with prognosis.

Background

The mortality risk of patients with moderate aortic stenosis is not well known but recent studies suggested that it might negatively affect prognosis.

Methods

A systematic research was conducted on PubMed. The inclusion criteria were: 1) inclusion of patients with moderate aortic stenosis; 2) report of the survival at 1-year follow-up (minimum). Incidence ratios related to all-cause mortality in patients and controls of each study were estimated and then pooled using a fixed effects model. Meta-regression analysis was performed to assess the impact of left ventricular ejection fraction and age on the prognosis of patients with moderate aortic stenosis.

Results

Fifteen studies and 11,596 patients with moderate aortic stenosis were included. All-cause mortality was significantly higher among patients with moderate aortic stenosis than among controls: 10.7% (95% CI: 0.1010-0.1136) vs 4.5% (95% CI: 0.0438-0.0454) at 1-year, 17.7% (95% CI: 0.1692-0.1854) vs 7.6% (95% CI: 0.0754-0.0775) at 2-year, 23.0% (95% CI: 0.2204-0.2387) vs 9.9% (95% CI: 0.0973-0.0997) at 3-year, 27.9% (95% CI: 0.2685-0.2899) vs 11.9% (95% CI: 0.1177-0.1203) at 4-year, and 32.4% (95% CI: 0.3125-0.3360) vs 14.2% (95% CI: 0.1402-0.1430) at 5-year follow-up. Left ventricular ejection fraction did not significantly impact on the prognosis of patients with moderate aortic stenosis (estimate = -0.0020; 95% CI: -0.0078-0.0038; p = 0.4584), unlike of age (estimate = 0.0067; 95% CI: 0.0007-0.0127; p = 0.0323).

Conclusions

Moderate aortic stenosis is not a benign disease. Further studies are necessary to confirm the prognostic impact of this valvulopathy and the possible benefit of the aortic valve replacement.

All-cause mortality of patients (red) vs controls (black) at 1-, 2-, 3-, 4- and 5-year follow-up.
889 ATRIOVENTRICULAR BLOCK, AN UNUSUAL CLINICAL PRESENTATION OF CALCIFIED BICUSPID AORTIC VALVE
Authors: Pisani Elena , Bartolini Simone , Sani Francesca , Signorini Umberto , Milli Massimo , Beltrami Matteo
Published: December 2022

Background

Bicuspid aortic valve (BAV) is the most frequent congenital valve disease in adults. It is often associated with other congenital cardiac defects. Sometimes it is associated with aortic dilatation. BAV is an heterogeneous disease with varying valve morphology (asymmetrical cusp size and rafe), annulus geometry and size, asymmetrical calcification of the aortic valve and left ventricular outflow tract.

Case Report

A 32 year-old male patient was diagnosed with bicuspid aortic valve after several cardiologic visits for eligibility to competitive sport. Since April 2021 he developed a progressive exertional dyspnea for strenuous efforts. In February 2022, he was referred to our department after a Holter ECG showed a bradyarrhythmia with complete atrioventricular block. The echocardiography evaluation demonstrated a preserved ejection fraction and a bicuspid aortic valve with a mild-moderate regurgitation. The coronary computed tomography showed a thick and calcified bicuspid aortic valve with a coarse calcification of the anterior cuspid that involve the pars membranacea of the interventricular septum. The ergometric exercise demonstrated chronotropy incompetence. The tomography confirmed the mildy aortic root dilatation. Therefore, an MRI was performed and reported a small laminar LGE on the infero-lateral wall of the left ventricle, of unclear significance. He underwent Dual-Chamber permanent pacemaker implantation. A conservative approach was preferred over valvular replacement, considering the mild aortic root dilatation on a background of mild-to- moderate aortic insufficiency.

Conclusion

Our case is unusual given the bicuspid aortic valve concomitant with atrioventricular block, which was connected with the location of the calcification. Thus, the aim of our case report is, to describe a complication to this condition which, although rare, represents a different clinical presentation of the pathology itself in a young adult.
317 IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR IN ARRHYTMIC MITRAL VALVE PROLAPSE: YOU'LL BE CONSIDER IT FOR PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH?
Authors: Pittorru Raimondo , Cecere Annagrazia , Marra Martina Perazzolo , Migliore Federico , Iliceto Sabino
Published: December 2022

A 50-year-old female with a history of bileaflet mitral valve prolapse (MVP) was admitted to our Department for persistent palpitation. Physical examination revealed a mid-systolic click, followed by a mid-to-late apical systolic murmur. The electrocardiogram showed sinus rhythm with negative T-waves in inferior leads and repetitive polymorphic premature ventricular contractions (PVCs) with a right bundle branch block pattern and superior axis morphology suggestive of a possible origin from the posterior papillary muscle. The echocardiography confirmed normal ventricular ejection fraction, bileaflet MVP with moderate regurgitation, systolic curling and mitral annulus disjunction. Exercise stress testing demonstrated an increase of polymorphic PVCs during maximum effort. The cardiac magnetic resonance showed an underlying late gadolinium enhancement at the level of the papillary muscles and in the inferobasal region. After a multidisciplinary evaluation, a transvenous implatable cardioverter defibrillator (ICD) was implanted for primary prevention without clear indications deriving from current guidelines. After eleven years, the patients experienced two appropriate shocks due to polymorfic ventricular tachycardia while she was sleeping. Furthermore, the patient underwent successful mechanical transvenous lead extraction and ICD re-implantation for lead failure. During this hospitalization a subsequent echocardiography detected severe ventricular dilatation with moderate systolic disfunction.

Conclusion

Our report demonstrated that MVP represents potentially cause of life-threatening ventricular arrhythmias and tachycardia induced cardiomyopathy. Beta-blockers are often inadequate in order to reduce PVCs burden. We need more arrhytmic predictors to assestment of sudden cardiac death risk and evaluate ICD for primary prevention. Obtain left ventricular function recovery is difficult and it requires a multidisciplinary approach. It will be important in the future to better define the role will play cathether ablation and mitral valve repair or replacement to prevent malignant arrhytmias.
322 TRICUSPID VALVE REGURGITATION AFTER TRANSVENOUS LEAD EXTRACTION: WE NEED TO KNOW MORE
Authors: Pittorru Raimondo , Dall´aglio Pietro Bernardo , Migliore Federico , Micciolo Matteo , D´onofrio Augusto , Iliceto Sabino , Gerosa Gino
Published: December 2022

Since 2003 a 73-year-old man was submitted to a pacemaker implantation because of atrio-ventricular block. After fourteen years, upgrading to CRT-D was made due to recovery for acute heart failure in a dilated cardiomyopathy with severe left ventricular systolic dysfunction. In 2019 and 2020 he presented pocket erosion therefore underwent to a submuscular reimplantation. After one year, he came to Arrhythmology outpatient appointment with inflammatory signs of the CRT-D pocket. The patient was started on Meropenem and Vancomicin. Transthoracic (TTE) and transesophageal echocardiogram didn't reveal any vegetation on valvular apparatus or on leads. The patient was submitted to transvenous lead extraction (TLE) with bidirectional rotational mechanical sheats and a epicardial lead on postero-lateral left ventricular wall was implanted. The post-procedural TTE showed a moderate to severe organic tricuspid valve regurgitation with annular dilatation despite the patient was asymptomatic. There weren't flail leaflets or tricuspid valve damage. The reimplantation of right atrial and ventricular leads was hindered by complex venous anatomy documented by intraprocedural phlebography. After Heart Team discussion, we agreed to tricuspid valve repair with annuloplasty ring and other two epicardial leads - right atrial and ventricular - was implanted. We achieve a successful result without complications. The patients was discharged without symptoms; the device interrogation showed good assessment of lead impedances, sensing thresholds, and capture thresholds.

Conclusion

The mechanisms of tricuspid valve regurgitation following TLE are complex. There isn't a standardized best practice to approach this phenomenon. It's important after TLE to assess tricuspid valve structure and function with TTE in order to understand the incidence of underlying potential mechanism and how to prevent it. Complex venous anatomy could direct the choice toward epicardial leads implantation.
221 NONBACTERIAL THROMBOTIC ENDOCARDITIS WITH ATYPICAL PRESENTATION AS OVERT CONGESTIVE HEART FAILURE
Authors: Restelli Davide , Trio Olimpia , Poleggi Cristina , Cusma´ Piccione Maurizio , Manganaro Roberta , Certo Giuseppe , Zito Concetta , Ando´ Giuseppe
Published: December 2022

Introduction

Non-Bacterial Thrombotic Endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or, rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography.

Case presentation

An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep vein thrombosis. On physical examination, he was apyretic, mildly hypotensive and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed “thrombotic” thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed in the diagnostic workup and prescribed palliative care.

Discussion

Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo-density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about treatment of NBTE and the only role of anticoagulation to prevent systemic embolism.

Conclusions

We report a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging played a crucial role for the final diagnosis.
951 PROGNOSTIC IMPACT OF DISPROPORTIONATE FUNCTIONAL MITRAL INSUFFICIENCY IN PATIENTS UNDERGOING PERCUTANEOUS “EDGE-TO-EDGE“ VALVE REPAIR
Authors: Velardi Silvia , Polimeni Alberto , Mongiardo Annalisa , Spaccarotella Carmen , Messina Chiara , Vizzari Francesca , Velato Letizia , Di Costanzo Assunta , Scebba Jacopo , Estévez-loureiro Rodrigo , D´ascenzo Fabrizio , Indolfi Ciro
Published: December 2022

Aims

The ideal phenotype of patients with functional mitral regurgitation (FMR) who benefit most of transcatheter edge-to-edge repair (TEER) is still unclear. Some studies have suggested that patients with disproportionate FMR may have a better outcome. The purpose of this study is to evaluate the prognostic value of proportionate versus disproportionate FMR, in patients undergoing TEER with MitraClip system.

Methods and Results

The multicenter observational MITRA-CTV registry includes 200 patients with moderate-severe (3+) to severe (4+) FMR undergoing MitraClip, between March 2013 and June 2021, at three European institutions such as Magna Graecia University of Catanzaro, University of Turin (Italy) and University of Vigo (Spain). Patients were defined as having proportionate or disproportionate FMR if their EROA/LVEDV (left ventricular end diastolic volume) ratio was ≤ or > from the median value (0.15), respectively. The primary endpoint was the composite of death from all causes and rehospitalizations for HF, at 1-year follow-up. The secondary endpoint was composed of the individual components of the primary endpoint and cardiovascular death. Patients with disproportionate FMR had higher EROA (0.47±0.2 cm2 vs 0.27±0.1 cm2) and smaller ventricles (LVEDV: 207 ± ml vs 239 ± 83 ml) than those with proportionate FMR. Procedural success was achieved in 95% of patients. Notably, 30-day residual MR was comparable in patients with disproportionate versus proportionate FMR. There were 4 (2%) deaths during hospitalization, and the median hospital stay after the procedure was 9 days (IQR 7- 9 days). At Kaplan-Meier analysis, an EROA/LVEDV ratio both higher and lower than the median value (0.15) was not associated with an increased incidence of the primary endpoint of death and rehospitalization for HF (HR 1.17 CI 95%[0.72;1.90],p=0.50). The only independent predictors of clinical outcomes at 1 year were: the presence of CKD (HR 4.11 95% CI[1.73;9.75], p=0.0014) and a post TMVR hospital stay >10 days (HR 2.53 95% CI[1.24;5.18],p=0.0111).

Conclusion

In our study, there were no significant differences in outcome in patients with proportionate versus proportionate FMR undergoing TEER with Mitraclip system.
1130 ZEBRA HOOFBEATS: A RARE CASE OF STEMI IN GRANULOMATOUS NECROTIZING AORTITIS
Authors: Facci Gabriele , Alberti Giorgia , Dotto Alberto , Briani Francesco , Benfari Giovanni , Pighi Michele , Ribichini Flavio
Published: December 2022

We present the unusual case of an AMI STEMI, complicated by ventricular fibrillation, in a 26 years old caucasic male patient, affected by necrotizing and granulomatous aortitis, in the context of a primary immunodeficiency.

Initially the patient was referred to the Cardiology Unit for worsening dyspnea and fatigue. In his medical history he has primary immunodeficiency complicated by multiple opportunistic infections.

We performed an echocardiography that revealed an aneurismatic ascending aorta (58 mm) with associated significant aortic valvular regurgitation. He was later referred to heart surgery OR where Bentall-De Bono operation was performed. Two years later he developed a lateral STEMI, complicated by ventricular fibrillation. The coronary angiography, performed in foreign country, showed total occlusion of the circumflex coronary artery with diffuse aneurismatic coronary disease, granulomatosis and ulcerative lesions. A percutaneous revascularization approach was tried, but ineffective.

Actually the patient, during follow up, presents dilatative post-ischemic cardiopathy with moderate ejection fraction reduction, initial aortic bioprosthesis failure. We noted at follow up echocardiograms early dilatation of the native aortic arch (35 mm), suggesting a progressive disease.

In conclusion, AMI's etiology includes many non atherosclerotic mechanisms that should be considered alongside common causes.

This case shows a rare cause of STEMI in a very young male patient, and teaches us that aortitis is a progressive and complex pathology, often involving multiple arteriosus districts, that needs close follow-up and integrated management.
Permutation Module Decomposition of the Second Cohomology of a Regular Semisimple Hessenberg Variety
Authors: Cho Soojin , Hong Jaehyun , Lee Eunjeong
Published: December 2022

Regular semisimple Hessenberg varieties admit actions of associated Weyl groups on their cohomology spaces of each degree. In this paper, we consider the module structure of the cohomology spaces of regular semisimple Hessenberg varieties of type $A$. We define a subset of the Białynicki–Birula basis of the cohomology space, which becomes a module generator set of the cohomology module of each degree. We use these generators to construct permutation submodules of the degree two cohomology module to form a permutation module decomposition. Our construction is consistent with a known combinatorial result by Chow on chromatic quasisymmetric functions.
The Impact of COVID-19 Prevention Measures on Interagency Hotshot Crews in 2020
Authors: Belval Erin , McCaffrey Sarah , Finney Trevor , Calkin David , Greer Shane
Published: December 2022

In the 2020 fire season, the fire management community developed and tested a wide range of new practices to meet challenges posed by the coronavirus pandemic. To better understand the effectiveness of different innovations and which should be considered for more permanent use, we surveyed Interagency Hotshot Crew (IHC) superintendents in January 2021. We focused on identifying innovations that, regardless of COVID-19, the IHCs would want to keep and why, as well as those that proved problematic. The survey focused on paperwork, briefings, and fire camp and incident command post setup. Results found clear benefits from many of the changes to operational efficiency and crew health and wellbeing; challenges were generally tied to logistical and communication issues. The results of this survey speak to the logistics of running large incident command operations and could be applied both outside the US and outside the field of wildland fire management.

Study Implications: There may be meaningful benefits beyond mitigation of COVID-19 spread for continuing to use virtual paperwork, virtual briefings, and dispersed camp setups while supporting large fire suppression operations. Operational efficiency was seen as a clear benefit of many of these changes, with the often-mentioned advantage to a particular practice enabling crews to spend more time on the fireline. The new practices also appear to contribute to overall crew physical health. However, the benefits to crew health, efficiency, and effectiveness will need to be assessed against the increased logistical support required from incident management teams.
In-hospital Outcomes for COVID-19 Patients in the Military Health System: Comparison of Military and Civilian Facility Treatment
Authors: Herrera-Escobar Juan P , Wang Joyce Y , Ye Jamie , Dalton Michael K , Koehlmoos Tracey , Schoenfeld Andrew J , Weissman Joel S , Cooper Zara
Published: December 2022

Introduction

Beneficiaries of TRICARE, an insurance program of the military health system, can choose to receive care within the private sector (fee-for-service) or direct (budget-based facilities with salaried providers) care setting. Previous studies in several specialties have shown that there are disparities in both resource utilization and outcomes between the two settings. In this study, we sought to determine differences in outcomes between coronavirus disease 2019 (COVID-19) patients treated in the private sector versus direct care.

Materials and Methods

Using TRICARE claims data, we identified patients admitted to the hospital for COVID-19 between March and September 2020. Cases were classified, according to the facility where they were admitted for treatment, as private sector or direct care. We abstracted patient sociodemographic characteristics, comorbid conditions, and outcomes including in-hospital mortality, intensive care unit (ICU) admission, ventilator use, in-hospital complications, and 30-day readmission. We used multivariable regression models, adjusted for covariates, to determine the association between health care settings and outcomes.

Results

A total of 3,177 patients were included. Of these, 2,147 (68%) and 1,030 (32%) received care in the private sector and direct care settings, respectively. The average age of the study cohort was 52 years (SD = 21), and 84% had at least one medical comorbidity. In adjusted analyses, we found significant differences in the rates of ICU admission, with patients treated in private sector care having lower odds of being admitted to the ICU (odds ratio, 0.64; 95% CI, 0.53-0.76). There were no significant differences in the rates of in-hospital mortality, ventilator use, in-hospital complications, and 30-day readmissions.

Conclusion

With the exception of ICU admission rates, which are higher in the direct care setting, we encountered comparable hospital-based outcomes for patients treated for COVID-19 within the military health system, whether care was received under private sector or direct care.