bluuebunny/crossref_metadata_2025 huggingface dataset:
COMBINED ENDOSCOPIC MITRAL REPAIR AND DIRECT CORONARY ARTERY BYPASS VIA BILATERAL MINI–THORACOTOMY
Authors: Squiccimarro E , Margari V , Kounakis G , Visicchio G , Pascarella C , Carbone C , Paparella D
Published: May 2024

Emerging evidence upholds minimally invasive approaches as the foremost surgical intervention for heart valve diseases, addressing detriments associated with traditional cardiac surgery. Yet, the comprehensive adoption of minimally invasive coronary surgery is disproportionately low, not to mention concurrent coronary and valve procedures. Bilateral mini–thoracotomy (MT) has been suggested as a feasible and safe technique for diverse isolated cardiac procedures. In 2021–2023, 7 patients were treated with minimally invasive mitral repair (MVr) and direct coronary artery bypass (MIDCAB): age was 66±4 years, 5 were males, and EuroSCORE II (%) was 2.6±1.2. For the procedure, a double–lumen endotracheal tube was employed, and heparin was administered. The right internal jugular vein was cannulated percutaneously. The MIDCAB involved a anterolateral left MT at the fifth intercostal space (IS). The left internal thoracic artery (LITA) was harvested under direct vision using a retractor. Mini–pericardiectomy was performed to facilitate off–pump anastomoses on the left anterior descending artery using a stabilizer, along with intracoronary shunts. Transit time flowmetry was performed. A right groin incision exposed the femoral vessels for echo–guided cannulation as per Seldinger. Endoscopic MVr was accomplished via a right MT above the nipple, at the fourth IS. A soft–tissue retractor and trocars at the fourth and sixth IS enabled 3D thoracoscopy and CO2 insufflation. After adjusting for selective ventilation, the chest was accessed for pericardiectomy. An aortic needle inserted via the main incision facilitated cardioplegia delivery and aortic venting. Cardiopulmonary bypass was established and aortic clamping achieved by Chitwood clamp at the second IS. Cardioplegia was delivered with the LITA graft temporarily closed. All patients received ring annuloplasty, 4 had posterior leaflet resection, 3 neochordal repair, and 2 had concomitant monopolar ablation and linear left atrial appendage closure. All patients were discharged healthy, after graft evaluation via computerized tomography. We report favorable outcome, satisfactory surgical times, early mechanical ventilation discontinuation (4±2 hours) and discharge from intensive care unit (3±1 days). No patient died at follow–up (maximum 2 years). In conclusion, minimally invasiveness should be embraced to ensure acceptance among patients and favorable long–term results, even when facing multifactorial pathology.
PERCUTANEOUS CORONARY INTERVENTIONS IN PATIENTS TREATED WITH ORAL ANTICOAGULANT THERAPY: BASELINE CLINICAL CHARACTERISTICS OF THE PERSEO REGISTRY
Authors: Sciahbasi A , Gargiulo G , Giacoppo D , Talarico G , Calabrò P , Zilio F , De Rosa S , Talanas G , Tebaldi M , Andò G , Rigattieri S , Misuraca L , Cortese B , Musuraca G , Lucci V , Guiducci V , Renda G , Zezza L , Versaci F , Giannico M , Caruso M , Fischetti D , Colletta M , Santarelli A , Larosa C , Iannone A , Esposito G , Tarantini G , Musumeci G , Rubboli A
Published: May 2024

Background

International guidelines recommend a dual antithrombotic therapy (DAT) with direct oral anticoagulant (DOAC) for patients on chronic oral anticoagulant therapy (OAT) undergoing percutaneous coronary intervention with stent implantation (PCI–S). However, the implementation of practice Guidelines in the “real world” is often a complex exercise. Aim of the multicenter prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) registry was to evaluate the management of the different antithrombotic regimens strategies in patients with an indication for OAT undergoing PCI–S in a “real world” setting and its association with clinical outcomes.

Methods

The PERSEO registry has been designed to enrol patients requiring OAT and treated by PCI–S in 25 Italian Cardiology Centres. No exclusion criteria have been defined. The primary end–point was a combined measure of efficacy and safety outcome (NACE), including major bleeding events + major adverse cardiac and cerebral events at one year follow up in patients treated with DOAC compared to vitamin K antagonists.

Results

From February 2018 to February 2022, a total of 1233 patients were enrolled: mean age 74±9 years, 900 males and 333 females. The primary indication for OAT was atrial fibrillation (1066 patients, 87%) while an acute coronary syndrome was the leading reason for PCI–S (789 patients, 64%). Of those, 271 patients had an ST elevation myocardial infarction at admission. Mean CHA2DVAS2C score and HASBLED score were respectively 4±2 and 4±1. Six patients died during hospitalization and 1227 were discharged alive: 1027 on triple antithrombotic therapy (oral anticoagulant and dual antiplatelet therapy), 196 patients on DAT (oral anticoagulant and single antiplatelet therapy) and 4 patients on oral anticoagulant alone. The majority of patients enrolled were discharged on DOAC (1006 patients, 82%), whereas only a minority received vitamin K antagonists (221 patients, 18%).

Conclusions

The Italian PERSEO Registry is the largest prospective observational study comparing different antithrombotic strategies in patients with an indication for OAT undergoing PCI–S in a “real world” setting. Baseline characteristics, depicted a population at high thrombotic and haemorrhagic risk. In agreement with current guidelines the majority of patients were discharged on DOAC, yet the use of a DAT was still limited to a minority of the patients included.
SAFETY AND EFFICACY OF A LIGHT ANTITHROMBOTIC REGIMEN AFTER LEFT ATRIAL APPENDAGE OCCLUSION: INSIGHTS FROM THE LOGIC (LEFT ATRIAL APPENDAGE OCCLUSION IN PATIENTS WITH GASTROINTESTINAL OR INTRACRANIAL BLEEDING) INTERNATIONAL MULTICENTER REGISTRY
Authors: Gallo F , D‘Amico G , Della Rocca D , Mazzone P , D‘Angelo G , Bordignon S , Casu G , Giannini F , Berti S , Barbierato M , Natale A , Themistoclakis S , Ronco F
Published: May 2024

Background

Antithrombotic therapy (AT) after left atrial appendage occlusion (LAAO) in patients with non–valvular atrial fibrillation (NVAF) has the purpose of preventing device related thrombosis (DRT), avoiding embolic events; nevertheless, the correct antithrombotic regimen after LAAO is still under debate.

Aims

Aim of this substudy of the observational LOGIC registry was to describe the efficacy and safety of a light antithrombotic regimen, comprising single antiplatelet therapy or none, compared to a standard antithrombotic regimen, after a successful LAAO.

Methods

Patients with NVAF that underwent LAAO were previously included in the LOGIC registry. Patients receiving single or no AT were considered as light therapy group, while other regimen were considered as standard regimen group. Outcomes of interest were: death from any causes and cardiovascular death, ischemic stroke, transient ischemic attack and systemic embolization, any bleeding and major bleeding at 12 months. Results. Six hundred and twenty–eight patients were considered in the analysis, 31.4% received a light antithrombotic regimen. There were no differences in overall and cardiovascular mortality (5.1% Vs 6.7%, p=0.426 and 2.0% Vs 1.4%, p=0.553 respectively). Cerebrovascular stroke and transient ischemic attack were similar between the two groups (1.5% Vs 1.4%, p=0.898 and 1.5% Vs 1.3%, p=0.847). Light regimen was not associated with an increased rate of systemic embolism (1.0% Vs 0.7%, p=0.447 and HR 0.88 [95% CI: 0.34 – 2.27; p=0.79]).

Conclusions

An AT regimen based on single or no antithrombotic therapy after LAAO seems to be safe in patients with high–bleeding risk, without increasing cerebrovascular or peripheral ischemic events.
CORONARY INFLAMMATION ON CHEST COMPUTED TOMOGRAPHY AND COVID–19 MORTALITY
Authors: Tuttolomondo D , Gaibazzi N
Published: May 2024

Aims

The main factors associated with coronavirus disease–19 (COVID–19) mortality are age, comorbidities, pattern of inflammatory response and SARS–CoV–2 lineage involved in infection. However, the clinical course of the disease is extremely heterogeneous, and reliable biomarkers predicting adverse prognosis are lacking. Our aim was to elucidate the prognostic role of a novel marker of coronary artery disease inflammation, peri–coronary adipose tissue attenuation (PCAT), available from high–resolution chest computed tomography (HRCT), in COVID–19 patients with severe disease requiring hospitalization.

Methods and Results

Two distinct groups of patients, admitted to Parma University Hospital in Italy with COVID–19 in March 2020 and March 2021 (first and third wave peaks of COVID–19 pandemic in Italy, with prevalence of wild–type and B.1.1.7 SARS–CoV–2 lineage, respectively) were retrospectively enrolled. The primary endpoint was in–hospital mortality. Demographic, clinical, laboratory, HRCT data and coronary artery HRCT features (coronary calcium score and PCAT attenuation) were collected to establish which variables were associated with mortality. Among the 769 patients enrolled, 555 (72%) were discharged alive and 214 (28%) died. In multivariable logistic regression analysis age (p<0.001), number of chronic illnesses (p<0.001), smoking habit (p=0.006), P/F ratio (p=0.001), platelet count (p=0.002), blood creatinine (p<0.001), non–invasive mechanical ventilation (p<0.001), HRCT visual score (p<0.001) and PCAT (p<0.001), but not the calcium score, were independently associated with in–hospital mortality.

Conclusion

Coronary inflammation, measured with PCAT on HRCT, was independently associated with higher mortality in patients with severe COVID–19, while the pre–existent coronary atherosclerotic burden was not associated with adverse outcomes after adjustment for covariates.
HFPEF AND GLYCEMIC VARIABILITY: GHIDD TRIAL
Authors: Fazio G
Published: May 2024

Background

Recently the guidelines of European Association of Preventive Cardiology reported that the prevalence of diabetes mellitus in patients with diastolic heart failure (HFpEF) is around 31%.

Purpose

In our study we evaluated the non diabetic patients with HFpEF with Glunovo® to evaluate the glycaemic variability in this population.

Methods

100 patients with HFpEF admitted to cardiology units of 4 Italian centres on the major islands were enrolled consecutively. Glunovo® was applied to each enrolled patient for 7 days, At the end of the glycaemic monitoring were calculated for each patient the glycaemic variability and the incidence of hyperglycaemia and hypoglycaemia. Glycaemic variability refers to a blood glucose value of ≥ 200 mg / dL or ≤ 59 mg / dL detected more than 3 times in a day for at least 4 days. Overall, 43 males and 57 females were enrolled with a mean age of 69.3 years (39–87 years). All patients underwent a timely glucose measurement at admission which excluded the presence of hyperglycaemia. No potentially hyperglycaemic drugs were added to the treatment during the hospital stay.

Results

In 94 of the 100 patients enrolled it was possible to conclude the analysis, detecting the glycaemic variability, the point glycaemia values and the estimated glycated haemoglobin value. A glycaemia ≥200 mg/dL was found in 53 patients (56%) while a high glycaemic variability was found in 51 patients (54%). A blood glucose value <59 mg / dl was found in 48 patients (51%). Only 5 times the estimated glycated Hb values were> 7%. 32 of the patients who had at least 3 punctual glucose values ≥200 mg/dL were prescribed an oral glucose load curve, which in 100% of cases confirmed the diagnosis of diabetes.No statistically significant differences were found based on age group or sex. In the control group, consisting of 10 patients without DHF undergoing continuous glucose monitoring at one of the participating cardiology units, an unknown hyperglycaemia was found in only 1 patient (10%) and a glycaemic variability in only 1 patient (10%).

Conclusions

Our experience suggests an incidence of hyperglycaemia and glycaemic variability more then 65% in patients affected by HFpEF. If our data were reproducible on a large scale, a so high prevalence of diabetes in patients with HFpEF cold explain the efficacy of SGLT–2 inhibitor and GLP–1 Agonist in this class of patients.
SUDDEN DEATH IN THE WOMEN: EPIDEMIOLOGICAL DIFFERENCES IN THE BOLOGNA METROPOLITAN AREA
Authors: Carinci V , Cardelli L , Gamberini L , Semeraro F , Bugani G , Casella G
Published: May 2024

Bakground

It is a well known fact that men (M) are more likely to suffer of out of hospital cardiac arrest (OHCA) than women (W). Women account for 20–40 % of all OHCA, probably due to a minor prevalence of coronaric disease.

Methods

Our retrospective study considered all OHCA occurred in the Bologna metropolitan area (456.200 inhabitants) between 2009 and 2019. We considered all Pts, admitted alive at the hospital, presenting a NON STEMI ECG or a nondiagnostic ECG. We excluded Pts with STEMI ECG and extra cardiac causes of cardiac arrest or missing follow up. For each patient demographic informations, initial cardiac rhythm (ventricular fibrillation/ventricular tachycardia (VF/VT), asystole, or pulseless acticity (PEA)) and in hospital mortality, have been collected

Results

We evaluated 2072 OHCA, 1394 m (67%, age 66±13 yrs) and 678 w (33%, age 72±17 yrs, p< 0.04). The prevalent initial rhythm was VF/VT in m (38% m vs 19% w), and PEA in w (35% m vs 49% w). Survival at hospital discharge has been 13,8% in m and 11,5% w We analyzed data of 146 pts presenting with non STEMI ECG or non diagnostic ECG: 46 w (31,5%) and 100 m (68,5%). Mean age was 60±18 yrs in w and 62 ±17 yrs in m (p = 0,552). The initial rhythm was VF/VT in 54,5% of w and 75,5% of m (p = 0,01), PEA in 25% w and 16,5% m (p = 0,192) and asystole in 20,5% w and 8,5% m (p = 0.054) 30 over 46 w (65%) underwent a coronaric study against 83 m over 100 (83%) (p = 0,021); between these pts, 6 w (13,6%) underwent percutaneous angioplasty against 30 m (30,0%) (p = 0,037). In the pts underwent to invasive study, mortality has been 40% for the w and 23% for the m (p = 0,095). In the conservative arm mortality was 62,5% for the w and 47% for the m (p = 0,49). Total mortality has been 47,8% for the w and 27 % for the m (p = 0,015) A multiparametric analysis matching mortality versus age, sex, initial rhythm VF/VT and witnessed cardiac arrest (Tab 1) showed that male sex has been indipendently associated to lower mortality OR 0.37 (95% CI 0.16 – 0.86).

Conclusions

In the Bologna metropolitan area, women represent 37% of OHCA. In the group of pts without ST elevation ECG, women represent equally only 31%, but show mean age and prevalence of initial rhythm VF/VT similar to men. Men and women had different access to coronaric study and present different mortality rate. This topic of research has great scientific relevance and its results deserve further studies to investigate the differences pointed out
EVALUATING PRO–ATHEROSCLEROTIC ACTIVITIES IN EPICARDIAL AND PERICARDIAL ADIPOSE TISSUE AND EXPLORING THEIR POTENTIAL AS CELLULAR MODELS FOR ASSESSING PATIENT RESPONSIVENESS TO THERAPEUTICS
Authors: Quarta S , Massaro M , Calabriso N , Scoditti E , Carluccio M , Cardetta F , Santarpino G
Published: May 2024

Background

Hypertrophy of epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT) as in obesity is associated with several cardiac risk factors and higher carotid intima–media thickness, suggesting a pathogenic role of both cardiac fat tissue in the development of atherosclerosis. Curbing epicardial and pericardial adipose tissue dysmetabolism and associated inflammation may represent a novel therapeutic target to prevent coronary atherosclerosis.

Purpose

Evaluate pro–atherogenic properties of EAT and PAT, development a feasible method for isolation of adipocytes and evaluate the adipocyte response to therapeutics and micronutrients.

Methods

EAT and PAT were collected from coronary patients undergoing CABG (coronary patients) and from patients undergoing aortic or mitral valve surgery (valvular patients). Basal tissue expression of pro–inflammatory and pro–atherogenic genes was evaluated by rt–PCR. Then adipocytes were isolated and characterized. Finally, we tested the adipocyte ability to challenge vascular endothelium end their responsivity to cytokines and to the cardio–protective nutraceutical docosahexaenoic acid(DHA).

Results

Basal expression of inflammatory genes in adipose samples was higher in coronary patients than in valvular patients. Adipocytes isolated from these fat pads were pure and can be sub–cultured for several days without losing viability and retaining the ability to respond to pro–inflammatory stimuli. Concordantly, their secretome was able to “inflammate” vascular endothelial cells and sustain the recruitment and adhesion of monocyte to endothelial surface. On the other hand, the exposure of adipocytes to DHA resulted in a downregulation of MCP–1, CXCL10, IL–6 and MMP–9 expression(p< 0.05) and in the upregulation of metabolic gene UCP–1 and –2 and PPARγ(p< 0.05) while leaving unaffected the expression of adiponectin.

Conclusion(s)

Our data confirm the proatherogenic role of EAT in determining coronary atherosclerosis and suggests a similar pathogenic role for PAT. Furthermore, we propose a new efficient method for isolating adipocytes from PAT, obtaining cells that can be used as a potential bioreactor to test the response of adipose tissues to drugs and nutraceuticals.
A CLASH OF CHOLESTEROL TITANS: STATIN–INTOLERANT VS. STATIN–TOLERANT PATIENTS ON PCSK9 INHIBITORS IN LONG TERM FOLLOW–UP
Authors: Matteucci A , Alonzo A , Castello L , Spinelli A , Marino G , Schiaffini G , Di Fusco S , Aquilani S , Aiello A , Colivicchi F
Published: May 2024

Introduction

Statin intolerance remains a clinical challenge in the management of dyslipidemia. This study aimed to investigate whether patients with statin intolerance, receiving PCSK9 inhibitors, exhibit lipid profile improvement different from those obtained in those without statin intolerance.

Methods

In this monocentric outpatient study we enrolled 381 dyslipidemic patients receiving PCSK9 inhibitors. Statin intolerance was defined according to ESC criteria. Patients were divided into two groups, clinical data were collected, and lipid profiles were monitored regularly for a total of 36 months.

Results

Among the statin–intolerant patients, there was a higher proportion of women compared to those on statin therapy (38.6% vs 27.2% p = 0.051), although among intolerants the majority were men (69% vs 31% p = 0.023). Statin–intolerant patients had higher baseline total cholesterol (242±29.8 mg/dL vs 221±26.3 mg/dL p < 0.001) and LDL cholesterol (161.4±39.7 mg/dL vs 147±37.1 mg/dL p = 0.010). Interestingly, lipid reduction in both groups became comparable as early as 6 months (LDL 67±37 mg/dL vs 63±39 mg/dL p = 0.42) and continued to be similar at 12 and 36 months of follow–up (LDL 74±44 mg/dL vs 69±29 mg/dL p = 0.62).

Conclusion

PCSK9 inhibitors effectively lower lipid levels in both statin–intolerant and statin–tolerant dyslipidemic patients. Statin–intolerant patients seem to have similar management and can achieve cholesterol levels comparable to patients on statin therapy.
POST–ENDOCARDITIS MOBILE THROMBUS IN PULMONARY VALVE: A UNIQUE CASE REPORT OF ACUTE PULMONARY EMBOLISM
Authors: Ciampi C , Ossola P , Massaro S , Tavasci E , Lobiati E , Riva B , Bianchi A , Lenatti L , Triggiani M , Farina A
Published: May 2024

Background

Infective endocarditis results from a complex interplay among bacterial virulence factors, coagulation, and hemodynamics.Native pulmonary valve endocarditis is a very rare phenomenon. Similarly, the development of a thrombus on the pulmonary valve is uncommon. In the following clinical case, these two rare events appear interconnected.

Clinical Case

A 66–year–old male presented to the emergency department with a history of weight loss, asthenia, and fever lasting two months, partially relieved by empirical antibiotic therapy. Initial diagnostic tests revealed sinus tachycardia and a slight increase in inflammation markers. A chest radiograph showed pulmonary consolidation, leading to further investigation with a CT pulmonary angiogram. This identified a large mass at the pulmonary valve, with a suspicion of thrombosis, accompanied by right segmental pulmonary embolism and associated pulmonary infarction. A transthoracic echocardiogram confirmed the presence of two iso–anechoic masses adherent to the pulmonary valve, predominantly on the anterior and left cusps, as seen in 3D reconstruction. Dysfunction or dilation of the right ventricle, as well as vegetations on the other valves, were ruled out. The patient was urgently admitted to the cardiac intensive care unit. Empirical antibiotic therapy was initiated due to suspected endocarditis, and blood cultures were performed, which resulted negative. Despite being classified as intermediate–low risk for pulmonary embolism severity, considering the imminent risk of embolization from the identified mass, cardiothoracic surgery was performed. The procedure involved replacing the pulmonary valve with a bioprosthesis and removing the two neoformations. Pathological analysis indicated endocarditis of the pulmonary valve with transmural ulcerative inflammation and a thrombotic nature of the two masses. The culture of the valve was negative, suggesting a possible resolution of the infectious process. The postoperative period was stable, and the patient was subsequently enrolled in a cardiac rehabilitation program, with indications to continue anticoagulant therapy until reevaluation and antibiotic therapy with ceftriaxone and vancomycin for up to six weeks post–surgery. As far as we know, this is the first time in the literature that thrombus formation on a native pulmonary valve following endocarditis has been documented.
FIRST ITALIAN CASE OF TRANSCATHETER TREATMENT OF AORTIC REGURGITATION IN L–VAD PATIENT WITH A DEDICATED DEVICE
Authors: Tavana K , Buzzatti N , Saccocci M , Monaco F , Longoni M , Maisano F
Published: May 2024

In patients with L–VADs, aortic valve regurgitation is a relatively frequent complication often associated with high mortality. Surgical approaches are extremely complex and often lead to poor outcomes. TAVI can be a feasible solution but it is usually extremely challenging due to the absence of calcification and stenosis. We report the case of a 56–year–old man who underwent LVAD implantation 4years ago as destination therapy for dilated myocardiopathy and chronic multiple myeloma. During the last year, he progressively developed severe pure aortic regurgitation. Last month, he was admitted to our center for heart failure symptoms and recurrent ventricular arrhythmias (VT/VF). The patient was considered at high risk for surgery and evaluated for a transcatheter approach. Due to the absence of calcification and a relatively large annulus, we decided to use the JenaValve Trilogy prosthesis, the only THV CE approved for aortic regurgitation treatment. Unlike other types of THV (self– or balloon expandable), this is specifically designed for AR and does not require significant oversizing to allow correct anchoring. Another advantage in this setting is the possibility of avoiding the reduction of the LVAD flow due to the reduced risk of embolization and the possibility of proceeding to direct implantation without ventricular rapid pacing thanks to the direct anchoring method onto the native aortic leaflets. In this patient, a JenaValve size L bioprosthesis was implanted transfemorally under general anesthesia with an excellent result. The post–operative echocardiography showed a perfectly implanted prosthesis with no intraprosthesis regurgitation and only a mild anterior paravalvular leak with a subsequent improvement of all hemodynamic parameters. In our opinion, when feasible, the JenaValve implant can be a safe and effective therapeutic option in patients with active LVAD devices at high operative risk.
LEFT BUNDLE BRANCH PACING AND IMPROVEMENT OF AORTIC STENOSIS: A SUCCESSFUL AND UNUSUAL CLINICAL CASE
Authors: Astuti G , Mingoia G , Comparato F , Leggio G , D’Angelo F , De Michele G , Ciaramitaro G , Puccio D , Coppola G , Corrado E
Published: May 2024

Introduction

The dyssynchronous electrical activation of the ventricles may worsen underlying aortic stenosis. Left bundle branch pacing (LBBP) via a transventricular septal approach could be an alternative physiological pacing modality for patients with atrioventricular block (AVB), allowing the preservation of left ventricle synchronization and a decrease in left ventricular end–systolic volume.

Case Report

We report the case of a 77–year–old woman admitted for lower limb edema, easy fatigue and orthopnea. Her cardiological history included chronic heart failure with preserved ejection fraction, chronic coronary syndrome and severe aortic stenosis treated with coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR). Subsequently, transcatheter valve–in–valve aortic valve implantation (TAVI) was performed due to prosthetic aortic valve stenosis. The admission EKG revealed bigeminal sinus rhythm, first–degree AVB and left bundle branch block (LBBB). Close EKG monitoring during hospitalization revealed 2:1 AVB. The color–Doppler echocardiogram revealed preserved ejection fraction (EF 55%) and mild to moderate mitral steno–insufficiency. Doppler study indicated variability in the transvalvular aortic gradient. When evaluated on the beat following atrioventricular block, a pattern of severe aortic stenosis emerged (Vmax 4.15 m/s; Gmax/Gmed 68/41 mmHg), while the subsequent conducted beat exhibited a spectrum consistent with moderate aortic stenosis (Vmax 3.91 m/s; Gmax/Gmed 61/33 mmHg). Considering the conduction disorder and the history of left bundle branch block, it was decided to perform cardiac resynchronization therapy using left bundle branch pacing with a dual–chamber pacemaker (Biotronik Edora 8 DR). After device implantation, the EKG revealed an electrically induced rhythm with left anterior hemiblock–like (LAHB) morphology. A follow–up echocardiogram showed a reduction in transvalvular aortic gradient (Vmax 3.52 m/s; Gmax/Gmed 49/25 mmHg), indicating improvement of the aortic stenosis.

Conclusion

In atrioventricular block, anomalous electrical conduction causes an increase in left ventricular end–systolic volume, resulting in a condition of hyperflow through the ventricular outflow tract. Left bundle branch pacing, by resynchronizing atrioventricular and biventricular activity, ensures adequate diastolic filling and reduces the aortic transvalvular gradient, thereby improving aortic stenosis and clinical conditions.
HUGE EPICARDIAL LIPOMATOSIS AND BUTTERFLY APEX OF THE RIGHT VENTRICLE: DIAGNOSITC PITFALLS IN A PATIENT REFERRED FOR SUSPECTED ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
Authors: Brugiatelli L , Lofiego C , Vagnarelli F , Capodaglio I , Patani F , Maurizi K , Tofoni P , Pietrucci F , Silenzi M , Tassetti L , Dello Russo A , Perna G
Published: May 2024

A 68–year–old woman affected by dyslipidemia had a clinical history notable for T wave inversion (TWI) in the lateral and precordial leads from 2008, with a normal echocardiogram (TTE) and a normal coronary angiogram in 2009. No family history of cardiomyopathy or sudden cardiac death. Given the persistence of these alterations (TWI extending from V1–V6 and in lateral leads), in 2019 TTE was repeated, but did not show any significant findings. Consecutive Holter ECG were performed and no significant arrhythmias or ventricular ectopics were recorded. Therefore, a cardiac magnetic resonance (CMR) was performed elsewhere in 2019 and reported the presence of a dyskinetic segment close to right ventricular (RV) apex, epicardial lipomatosis extending from the right ventricle to the left ventricular (LV). No wall motion abnormalities nor late gadolinium enhancement (LGE) area were noted. This MRi findings together with ECG repolarization abnormalities raised the suspiscion of arrhythmogenic right ventricular cardiomyopathy (ARVC). Therefore, the patient was referred to our Center. ECG was repeated and showed TWI in the precordial and lateral leads (Fig.1). TTE showed normal left and right ventricular function/ mass and normal RV dimensions. The patient underwent Coronary angiography that confirmed the absence of CAD. Cardiac MRI was repeated and showed massive epicardial lipomatosis surrounding right and left ventricle (Fig 2a, red arrows). In this T1–weighted DIR image there is hyperintense tissue that surrounds the left and right ventricle, which is more evident when compared with normal myocardium. The adipose nature of this finding was further confirmed with T1–mapping sequences (Fig 2b, yellow arrow). T1 mapping showed low T1 values (300–500 ms) near the right ventricle, compatible with adipose tissue. What seemed to be a dyskinetic apical segment was re–interpreted as “butterfly apex” (Fig 3, red arrow), a little–known anatomic variant that could be mistaken for a RV wall abnormality. Moreover, this segment is not usually involved in isolation in ARVC. Genetic testing for ARVC resulted negative.

The final diagnosis was that of epicardial lipomatosis and butterfly apex presenting with T wave inversion in the precordial leads. No further criteria suggesting ARVC was present. We chose this case because it is emblematic of many potential pitfalls that might occur in the diagnostic pathway of ARVC.
ROLE OF ENDOMYOCARDIAL BIOPSY IN ASYMPTOMATIC CARRIERS OF TRANSTHYRETIN MUTATION: A CASE REPORT
Authors: Costantino J , Ballatore F , Marchionni G , Alfarano M , Frustaci A , Vizza C , Chimenti C
Published: May 2024

Introduction

There are two forms of cardiac amyloidosis (ATTR–CM) from Transthyretin, one wild–type (ATTRwt) and one hereditary (ATTRv), with autosomal dominant transmission. The introduction of new specific therapies has made it possible to block the progression of the disease. The success of these therapies is mainly linked to the early treatment. For this reason, early diagnosis represents a fundamental objective.

Case Report

A 56–year–old man came to our attention due to a mutation of pathogenetic significance in the gene coding for TTR (Ile68Leu). The genetic test was performed following the diagnosis of ATTRv in a first–degree relative (brother aged 58, with onset of symptoms at around 55 years). In medical history he reported a history of bilateral carpal tunnel confirmed by electroneurography and trigger finger. Blood tests showed normal levels of NT–proBNP and TroponinThs (74 pg/mL and 0.005 mcg/L). The ECG showed RS at 60 bpm with normal AV and IV conduction, normal voltages and no changes in ventricular repolarization. The echocardiogram and MRI showed no signs suggestive of amyloidosis. The scintigraphy with bone tracers did not highlight partological hyperfixation in the heart (Perugini score 0). In consideration of the similar age of onset of the disease in the affected brother (predicted time of disease onset, PADO) and the presence of carpal tunnel, which typically precedes the onset of cardiac amyloidosis by a few years, after informed consent, the patient underwent endomyocardial biopsy. Unexpectedly, histological and immunohistochemical analysis revealed the presence of initial transthyretin amyloid deposits. The patient underwent therapy with Tafamidis and after two years of follow–up he did not show disease progression.

Conclusions

The experience of this case underlines how the most used methods for the evaluation of ATTRv carriers do not always allow an effective evaluation of cardiac involvement, now widely recognized as the prognostic factor with the greatest impact on survival. In carriers reaching PADO age, endomyocardial biopsy could be considered an option for identifying subclinical cardiac involvement by starting therapy early and improving quality of life and the prospect of long–term survival.
TO CUT OR NOT TO CUT: CUTTING BALLOON FOR LESION PREPARATION BEFORE DRUG COATED BALLOON ANGIOPLASTY
Authors: Facci G , Bottardi A , Venturi G , Mugnolo A , Zamboni A , Bacchion F , Morando G
Published: May 2024

Background

There are limited data on the use of DCB in calcified lesions. In particular, evidence regarding the use of cutting balloon before DCB angioplasty is scarce.

Methods

We retrospectively analyzed our internal registry between May 2017 and May 2023 to retrieve intrastent restenosis angioplasty performed with DCB. We divided our population according to the use of cutting balloon as debulking technique before DCB. The objective of the study was to compare the two population in term of procedural success (primary endpoint defined as absence of flow–limiting dissection or residual stenosis>30% or bail–out to stent strategy) and 6 months target lesion revascularization (secondary endpoint).

Results

Between May 2017 and May 2023 one hundred and six (106) ISR were treated with DCB–angioplasty at our center: twenty–four were prepared with cutting–balloon, mostly because of high calcification burden, while eighty–two only with conventional NC balloon before DCB strategy. Procedural success was achieved in all patients analyzed (100%). Therefore, there were no differences in procedural success between the two groups. In the cutting balloon group, mainly for unstable angina, a new angiography was performed for 4 patients: one underwent target vessel revascularization (4.1%) while three target lesion revascularizations (12.5%). In the second group, seven out of 82 presented stable angina and needed new angiography resulting in target lesion revascularization (9,1%) due to severe ISR (two underwent surgical revascularization, five percutaneous with DCB). Therefore, cutting balloon was not associated with increased TLR (HR 2.7; 95% CI 0.70–10.52; p 0.147).

Conclusion

Lesion preparation with cutting balloon represent a valid strategy in the setting of in stent restenosis before DCB angioplasty in term of procedural success and 6 months risk for target lesion revascularization. Our monocentric registry presents the limitation of a small number which did not allow for any adjustment and a short follow up period but provides an overview of a real–world experience.
REAL WORLD USAGE OF RANOLAZINE FOR ANTIARRHYTHMIC PURPOSES: SINGLE CENTER EXPERIENCE
Authors: Braia V , Manai R , Bocchino P , Angelini F , Gallone G , De Lio G , Pidello S , Saglietto A , Boretto P , Marcelli G , Melis D , Giannino G , Gravinese C , Frea S , Raineri C , De Ferrari G , Dusi V
Published: May 2024

Introduction

Ranolazine is a late sodium current blocking drug developed as an antianginal agent, with good preliminary efficacy data even for antiarrhythmic purposes (both at atrial and at ventricular level).

Objectives

To evaluate patients’ clinical characteristics and antiarrhythmic efficacy of ranolazine in subjects with a history of atrial and/or ventricular arrhythmias, isolated or repetitive.

Patients and methods

we included patients who received a first prescription of ranolazine for antiarrhythmic purposes in our center from 1/2022 to 11/2023 and evaluated the survival free from major arrhythmic relapses/ablation.

Results

93 patients were enrolled (66±13 years, 15% women): 59% with arterial hypertension, 26% diabetics, 46% with post–ischemic dilated heart disease, 32% with primary cardiomyopathy (including 11% with hypertrophic cardiomyopathy, 10% with LMNA, 14% with TTN), 46% with implantable cardioverter defibrillator, 9% with pacemaker. The mean LV ejection fraction was 42 ± 15%, the mean serum creatinine 1 ± 0.3 mg/dL. Half (50%) had a history of atrial arrhythmias in the 6 months before starting the drug, mainly paroxysmal atrial fibrillation (AF), 67% of ventricular arrhythmias (VAs), mainly isolated and repetitive premature ventricular beats (PVB, 47% of the total), but also sustained or treated VAs (n=18, 19%). Overall, 18% of patients had already undergone AF ablation, 13% ventricular tachycardia ablation, 3% cardiac sympathetic denervation. Finally, 95% of patients were on beta–blocker therapy and 28% were on amiodarone. Ranolazine was prescribed at an average initial dose of 535± 150 mg. The majority (54%) of patients (n=50) had a follow–up longer than 3 months (median 9 months, IQR 6–14); in 6% the drug was stopped due to intolerance and the average dose at the last FU was 641 ± 150 mg. Twenty–eight percent of patients with paroxysmal/persistent atrial arrhythmias had relapses, requiring ablation in 6%. Among patients with major VAs, 57% suffered recurrences, but only 19% required ablation (invasive in 2 cases, non–invasive in 1 case). Finally, among the patients with PVBs, none suffered major VAs or required PVB/VA ablation.

Conclusions

This is the largest available case–series reporting about the real–world usage of ranolazine for antiarrhythmic purposes. Our single center experience supports ranolazine’s good safety and tolerability and shows encouraging efficacy results in terms of clinical stabilization of complex patients.
THE HEART‘S ABILITY TO "SELF–DEFIBRILLATE": A SPECIAL CASE OF IDIOPATHIC VENTRICULAR TACHYCARDIA
Authors: De Luca P , Sollazzo V , Benvenuto A , De Luca A
Published: May 2024

Background

In ventricular tachycardia the heart rate is significantly increased. The main cause is an underlying heart disease (previous myocardial infarction or cardiomyopathy). Dysionia (hypokalemia and hypomagnesemia), acidemia, hypoxia, side effects of drugs contribute; Long QT syndrome is associated with torsade de pointes. Idiopathic ventricular tachycardia is not linked to a heart disease that can be diagnosed with currently available tests. A protection mechanism that the heart applies in the presence of ventricular tachycardia has been discovered: a sort of self–defibrillation.

Clinical Case

A forty–year–old smoker comes to the emergency room suffering from heart palpitations, dizziness and syncope. Physical examination: hypotension and asthenia. ECG: sinus rhythm with single and paired ventricular extrasystoles, monomorphic. Blood tests normal. Echocardiogram: mitral prolapse. Admitted to Internal Medicine, the patient presents a brief loss of consciousness; ECG: non–sustained ventricular tachycardia treated effectively with beta–blockers and amiodarone. Transferred to Cardiology: negative instrumental investigations for structural heart disease; on the Holter ECG, runs of non–sustained ventricular tachycardia. Discharged with beta–blockers. Asymptomatic at follow–up.

Conclusions

By studying the electrical dynamics underlying ventricular tachycardia, it was found that in the presence of rapid cardiac rhythms, complex electrical oscillations are established which lead to a sort of "self–defibrillation" of the heart. The electrical signals that precede the spontaneous termination of a ventricular tachycardia are characterized by an oscillatory dynamic of impulses with different durations from one beat to the next called alternans; when alternans increase, there is a greater susceptibility on the part of the heart to self–termination of the arrhythmic event, highlighting its cardio–protective effect as a defense mechanism triggered by the heart to resynchronize. It is therefore possible to develop new drugs and devices that exploit as a mechanism of action the increase in alternans during arrhythmic events and therefore the cardioprotective mechanism of the heart itself. A possible future clinical application could be the design of a low–energy implantable cardiac defibrillator, compared to current ones whose effectiveness is limited by the painful electric shocks that characterize them.
TRIPTANS: HOPE FOR THE BEST, PREPARE FOR THE WORST
Authors: Polito D , Piscione M , Bianco S , Segreti A , Ussai G , Grigioni F
Published: May 2024

The estimated prevalence of headaches in the population is 66%. According to recent guidelines, basic analgesics, nonsteroidal anti–inflammatory drugs (NSAIDs), or acetaminophen are frequently used as first–line treatment for mild migraine attacks. A triptan is added when analgesic–resistant attacks occur. So these drugs are used as a second–line medication for mild migraines and a first–line medication for moderate to severe headaches. A correlation between spontaneous coronary artery dissection (SCAD) and triptans has already been reported in the literature. If myocardial infarction is more common in patients with cardiovascular risk factors, SCAD seems more frequent in young and smoker females. What is interesting is the speculation of the pathophysiological mechanisms of SCAD after triptans use. A possible option may consist in the fact that the dissection of the anterior descending artery is due to circumferential shear stress caused by these drugs, combined with smoking habits and estrogen deprivation. These latters influence the immune system and the circulating progenitor cells, which are reduced and less active to replace senescent endothelial cells. That is why an intimal flap is formed so that the blood would enter the media and the dissection would be perpetuated. The suspension of the drug is necessary to prevent the vasoconstriction of the vessel from exacerbating the wall stress caused by smoke and sexual hormones deficiency.
THE ENIGMA OF THE ‘SMOKER‘S PARADOX‘ : RESULTS FROM A SINGLE–CENTER REGISTRY OF PATIENTS WITH STEMI UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION
Authors: Paradossi U , De Caterina A , Raccis M , Dossi F , Bianchi G , Palmieri C , Berti S
Published: May 2024

Background

Smoker’s paradox usually refers to the common observation of a favourable outcome of smoker patients in acute myocardial infarction. The interpretation of this phenomenon is still controversial and not fully explained. We aimed at assessing whether smoking could be associated with mortality in a large cohort of prospectively enrolled patients with ST segment elevation myocardial infarction (STEMI) referred to primary percutaneous coronary intervention (PCI).

Methods

From April 2006 to December 2018 a population of 2456 STEMI patients treated with primary PCI were prospectively enrolled in the MATRIX registry. Ischemic time, clinical, demographics, angiographic data and 1–year follow–up were collected.

Results

Among 2546 patients admitted with STEMI 1007 (41%) were current smokers. Smokers were 10 years younger and had lower crude in–hospital and 1–year mortality (1.5% vs 6%, p<0.0001 and 5% vs 11%, p<0.0001), shorter ischemic time (203 [147–299] vs 220 [154–334] minutes, p=0.002) and shorter decision time (60 [30–135] vs 70 [36–170] minutes, p=0.0063). After propensity–matching, age, cardiogenic shock and low TIMI score were associated with in–hospital mortality, while smoking habit was still associated with reduced mortality. Smoking was also associated with reduced death rate at 1–year follow–up (HR 0.54, 95% CI [0.37 – 0.78]; p<0.001).

Conclusions

Our data show a protective link between smoking status and mortality in patients with STEMI, the so called “smoker’s paradox”. This could be explained not only by the shorter ischemic time and younger age of the smoking population but also by a specific pathogenetic effect of smoking underlying the onset of STEMI and response to therapies.
LONG–TERM EFFECT OF RADIOTHERAPY: A CASE OF PREMATURE ONSET OF INFRA–HISIAN CONDUCTION DISEASE
Authors: Rosso J , Vio R , Quinto L , Vitale R , Marras E , China P , Themistoclakis S
Published: May 2024

New chemotherapy agents and radiotherapy have improved mortality and survival of patients with neoplastic diseases; however, such therapies can cause significant side effects. One of the main concerns about mediastinal radiotherapy is the occurrence of cardiovascular side effects a long time after the treatment. This is an important issue – especially for thoracic neoplasms with long term survival, such as Hodgkin‘s lymphoma– because of the increase in cardiovascular morbidity and mortality. We report the case of a 40 years old male with infra–Hisian atrioventricular block developed progressively about twenty years after receiving radiotherapy for Hodgkin lymphoma. The patient experienced episodes during effort of abrupt and sudden reduction of the cardiac frequency and a syncope due to effort with finding of remarkable bradycardia. He was subsequently admitted for asthenia, dyspnea due to mild–moderate effort and bradycardia found at the self monitoring. The electrocardiogram showed atrioventricular block 2:1 with right branch block and left anterior fascicular block. Heart rate monitoring after the admission showed almost persistent 2:1 AV block. We performed a transthoracic echocardiography showing valvular thickening attributed to former radiotherapy in the absence of any clinical history of interest. A RMC was performed and it excluded the presence of edema or pathologic late gadolinium enhancement. We performed an electrophysiologic study that showed impairment of the infra–Hisian conduction system. With continuous atrial stimulation with RR cycle 620 me we documented infrahisian Wenckebach point. Therefore, a dual chamber pacemaker was implanted. This case rase the need for new studies evaluating the incidente of radiation induced heart disease. Clinicians must pay attention to bradyarrhythmia–related symptoms in patients whit previous exposure to chest radiation because of possibile premature onset of conduction disturbances.
STERNAL WOUND INFECTION AFTER CARDIAC SURGERY: LOOKING FOR INTERACTIONS BETWEEN PERIOPERATIVE VARIABLES AND PATHOGEN AGENTS
Authors: Gatti G , Radesich C , Savonitto G , Rizzi J , Munaretto L , Maurel C , Costantino V , Gripshi F , Franzese I , Barbati G , Rodriguez Garcia A , Busetti M , Luzzati R , Sinagra G , Mazzaro E
Published: May 2024

Background

Sternal wound infection (SWI) can be a major complication of cardiac surgery. Both the risk factors and the pathogens agents are well known today. Yet, possible interactions between perioperative variables and pathogens have not been explored.

Methods

Between Jan 1st, 2006 and Nov 30, 2023 (∼18 years), perioperative data of all patients undergoing cardiac operations through median sternotomy at the Cardio–Thoraco–Vascular Department of the University Hospital of Trieste, Italy, were recorded prospectically in a computed database. Every patient developing a sternal complication was followed in a dedicated outpatient clinic and, in the presence of infection, the causative pathogen was always searched for by cultural examination of tissue speciments. Different strategies of unsupervised clustering were applied to find groups of patients with similar clinical, surgical and microbiological profiles.

Results

Of 9,680 consecutive cardiac surgery patients, 516 (5.3%) experienced a SWI that involved superficial soft tissue in 25.6% of cases, deep soft tissue in 51%, sternal bone in 16.7%, or mediastinum in 6.8% of cases. Staphylococcus aureus, coagulase–negative Staphylococci, Enterobacteriaceae, and Pseudomonas aeruginosa were pathogens in 100 (19.4%), 158 (30.6%), 89 (17.2%) and 36 (7%) patients, respectively; other pathogens, polymicrobial and negative cultures were found in 27 (5.2%), 26 (5%) and 80 (15.5%) patients, respectively. Following statistical analyses, significant associations were found between the Pseudomonas aeruginosa etiology of SWI and some variables such as female gender (p<0.0001) and preoperative renal failure (p=0.008); significant associations between the Pseudomonas aeruginosa etiology were found also with more serious forms of sepsis (p=0.025), as well as with early postoperative death (p=0.02) and complications such as acute kidney injury (p=0.006), multiple transfusion (p=0.003), and prolonged mechanical ventilation (p=0.005).

Conclusion

For women having renal impairment and undergoing cardiac surgery through median sternotomy, in the case of SWI, the Pseudomonas aeruginosa etiology may be more frequent and a really life–threating complication.