bluuebunny/crossref_metadata_2025 huggingface dataset:
TAFAMIDIS FOR TREATMENT OF TRANSTHYRETIN CARDIAC AMYLOIDOSIS: A REAL WORLD EXPERIENCE
Authors: Vagnarelli F , Brugiatelli L , Lofiego C , Capodaglio I , Patani F , Tofoni P , Maurizi K , Pietrucci F , Romandini A , Contadini D , Lanari A , Bianco M , Terzi F , Paci M , Olivieri R , Flori M , Dello Russo A , Perna G
Published: May 2024

Background

A regional network for cardiac amyloidosis (CA) was created in 2019 with the aim of enhancing disease awareness among physicians and favoring appropriate access to innovative diagnostic tools/therapies. The network includes all 14 Cardiology Departments and outpatient clinics from 5 Local Health Units. Therapies for variant (ATTR–v) and wild–type (ATTR–wt) CA have recently become available in Italy. Selected centres with expertise in cardiomyopathies were identified to prescribe new modifying disease drugs. Tafamidis is the first medication approved for the treatment of ATTR–C. The landmark ATTRACT trial showed a reduction in cardiovascular mortality and cardiovascular–related hospitalization in patients treated with tafamidis compared to placebo. From October 2021 tafamidis can be prescribed in Italy according to AIFA criteria (only NYHA I/II patients eligible).

The aim of our study is to present the experience of our Network in prescribing tafamidis and to compare the clinical baselibe characteristics of our population and the ATTRACT trial population.

Methods

Thanks to our network , 189 patients with ATTR–CA were referred to our Center. 58 ATTR patients were treated with tafamidis according to AIFA criteria, while 5 patients with variant–TTR and neuropathy received patisiran iv. The causes of exclusion from tafamidis therapy are shown in figure 1. We prospectively collected all the patientst treated with tafamidis from January 2022 until November 2023. All the data about clinical characteristics, laboratoy findings ECG, echo, bone scintigraphy and concomitant treatment were collected during routin follow–up visits anc compared to those of ATTRACT trial population.

Results

The main findings of our study are summarized in Table (fig,2) The age of our population was similar to that of the patients enrolled in the ATTR–ACT trial (75,94 ± 11.4 vs. 74,5±7.2, P = 0.21). Of note, our population does not include patients in NYHA class III as the AIFA prescriptive criteria exclude these patients from treatment in Italy. this implies a substantial difference in the distribution of the NYHA class compared to the attract population (p = 0.001). The outcome of our patient was excellent, the drug was well tolerated. Conclusions: Implementing specific clinical network provided excellent results, allowing a precise phenotype/genotype characterization and favoring appropriate access to specific disease–modifying drugs.
EFFICACY OF PERCUTANEOUS STELLATE GANGLION BLOCK ACCORDING TO VENTRICULAR ARRHYTHMIA CYCLE: A SUB–ANALYSIS OF THE STAR STUDY
Authors: Baldi E , Rordorf R , Compagnoni S , Dusi V , Sanzo A , Gentile F , Frea S , Gravinese C , Cauti F , Iannopollo G , De Sensi F , Gandolfi E , Frigerio L , Crea P , Zagari D , Casula M , Sangiorgi G , Persampieri S , Dell‘Era G , Patti G , Colombo C , Mugnai G , Notaristefano F , Barengo A , Falcetti R , Perego G , D’Angelo G , Tanese N , Currao A , Sgromo V , De Ferrari G , Savastano S
Published: May 2024

Introduction

The percutaneous stellate ganglion block (PSGB) is an effective treatment for electrical storm. The STAR study (184 PSGBs performed on 131 patients in 19 Italian centers) demonstrated a significant reduction in delivered electrical therapy (ATP/shock) in patients with electrical storm comparing both the 12 hours before and after PSGB, and 1 hour before and after PSGB. The current aim is to assess whether the efficacy of PSGB is influenced by the arrhythmias’ cycle length prior to the procedure.

Methods

This is a sub–analysis of the STAR study. We divided PSGBs into two groups according to the cycle length of the arrhythmia preceding PSGB: the fastVT–VF group included PSGBs performed following a ventricular tachycardia (VT) with a cycle <400 msec or a ventricular fibrillation (VF), whereas the slowVT group included PSGBs performed following a VT with a cycle ≥400 msec.

Results

The cycle length of the arrhythmia was available for 170 PSGBs. The fastVT–VF group included 127 PSGBs, performed on males in 83% of cases, with a mean age of 65±12 years, ejection fraction (EF) of 28±13% and ischaemic aetiology in 64%, while the slowVT group included 45 PSGBs, performed on males in 84% of cases, with a mean age of 68±13 years, EF of 24±11% and ischaemic aetiology in 60%. Comparing the number of electrical therapies delivered between the hour after and before PSGB in the two groups separately there was a significant reduction for both fastVT–VF group (Hodges–Lehmann median difference –3.5 [95%CI –4 to –2.5], p<0.001) and slowVT group (Hodges–Lehmann median difference –0.5 [95%CI –2 to 0], p=0.03). Comparing the difference in electrical therapies delivered in the first hour after PSGB compared to the previous hour between the two groups, a significantly greater reduction was observed for fastVT–VF group than for slowVT group (–2 [IQR –6 to 0] vs 0 [IQR –2 to 0], p<0.001). Considering the whole population, having a fast VT–VF was significantly associated with a reduction in therapies delivered in the hour following PSGB both at univariable analysis (OR 3.5, 95%CI 1.7–7, p<0.001) and after correction for the number of therapies delivered in the hour before (OR 2.5, 95%CI 1.1–5.6, p=0.03).

Conclusions

PSGB is an effective procedure to reduce the number of electrical therapies delivered in patients with both fast and slow ventricular arrhythmias, but the extent of benefit seems greater in those with fast ventricular arrhythmias or ventricular fibrillation.
MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY
Authors: Squiccimarro E , Margari V , Kounakis G , Visicchio G , Pascarella C , Carbone C , Paparella D
Published: May 2024

The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.
ROLE OF CORONARY CT IN THE EMERGENCY ROOM IN THE PATIENTS WITH CHEST PAIN
Authors: Verde M , Cavalieri A , Matera S , Macali L , Buffa V , Madau M , Petrolati S , Taberini L , Terranova A , Polletta B , Stolfi A , Gabrielli D
Published: May 2024

Objective

Assess the use of Coronary CT in patients attending the emergency room (ED) with chest pain and/or doubtful signs/symptoms of acute coronary syndrome (ACS).

Background

Patients coming to the ED for chest pain are an important challenge. According to the guidelines (ESC 2023) it is necessary a fast selection between those who need hospitalization and urgent coronary angiography (rule–in) and those who can be discharged home (rule–out). However, it is difficult to obtain an early diagnosis and therefore patients often need a prolonged observation.

Materials and Methods

We subjected to Coronary CT 104 patients (pts) with symptoms and/or alteration of parameters suspected for ACS (ECG, echocardiography, high sensitivity troponin) arrived in the cardiological holding (cardiological observation) of the San Camillo Forlanini Hospital from the emergency room. Clinical–instrumental data, incidence of positive results on Coronary CT and concordance with coronary angiography, waiting time for the examination and length of hospitalization were retrospectively evaluated.

Results

The average age of the pts was 56 ± 2 years, 65 men (62.5%) 39 women (37.5%). Coronary CT exams were performed on the first day after admission to the ED in 83% of cases. Pts presented with chest pain (61% noncardiac, 13% cardiac), and/or palpitations (10%), and/or dyspnea, presyncope, or syncope (overall 16%). CT was performed in 79% of cases due to the association of symptoms and instrumental findings (ECG 54% of cases, hs troponin 34%, echocardiogram 12%); in 21% only for clinical findings. Coronary CT excluded obstructive coronary artery disease in 95 out of 104 pts (91.3%) and was positive in 6/104 pts (5.8%), with coronary angiographic correspondence in 5 cases. In 3/104 (2.9%) the test resulted doubtful/positive (angiographic confirmation in a single case). Only 8.7% of pts underwent coronary angiography (those with positive or doubtful CT result). In all pts with chest pain only (21%) the Coronary CT was negative. Troponin positivity (34% of pts) was not strictly associated with the presence of coronary artery disease: in 94% of pts with positive hs troponin (average value 500 pg/mL) the CT scan did not show critical lesions. The average stay of pts with negative Coronary CT was 1.5 days.

Conclusions

Coronary CT can significantly reduce the use of coronary angiography and the length of stay in pts coming in ED with chest pain and/or doubtful signs/symptoms of ACS.
IMPACT OF DIFFERENT P2Y12 INHIBITORS IN ACUTE CORONARY SYNDROME PATIENTS WITH SEVERE CHRONIC KIDNEY DISEASE: INSIGHTS FROM THE CORALYS REGISTRY
Authors: Giacobbe F , Giuseppe G , Stefano S , Arianna M , Andrea G , Sagazio E , Marchini F , Wanha W , De Filippo O , Bruno F , D‘Ascenzo F , De Ferrari G
Published: May 2024

Background

The impact of the most potent P2Y12i ticagrelor and prasugrel after acute coronary syndrome in patients with chronic kidney disease (CKD) remains unclear. Indeed, this condition is associated to both higher thrombotic and hemorragic risk, as a consequence newer P2Y12i are seldom used. Most evidence comes from real–world study but is limited to GFR under 60 ml/min whereas no data are available regarding patients with severe CKD (stages IV–V).

Methods

Consecutive patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and severe CKD defined as GFR under 30 ml/min not on dialysis from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of Net Clinical Adverse Events (NACE) defined as MACE (a composite of cardiovascular death, myocardial infarction and unplanned revascularizations) in addition to major bleedings (classified as BARC 3–5) was our primary endpoint. MACE and their single components, all bleedings, major bleedings and hospitalizations for heart failure were the secondary ones.

Results

Of 14699 patients in the CORALYS registry, 257 presented with severe CKD not on dialysis and had available data on antiplatelet regimen at discharge. Patients were divided into two groups according to the type of P2Y12i prescribed at discharge: 193 (75.1%) were given clopidogrel while 64 (24.9%) with ticagrelor or prasugrel. Our cohort was predominantly male (153, 59.5%) with an average age 75.8 ± 10.9 years old. Average GFR was 21.8 ± 6.3 ml/min. Over a median follow–up of 459 days. Ticagrelor and Prasugrel were associated to lower rates of NACE compared to Clopidogrel, driven by an excess of CV mortality and myocardial infarction (77 (39.9%) vs 16 (25.0%), Adj Hr 0.41 95%CI 0.23–0.74, p=0.03). No difference was reported regarding overall bleeding events (5.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.81) and major bleedings 1.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.15).

Conclusions

In ACS patients treated with PCI with severe CKD ticagrelor and prasugrel were associated to lower risk of NACE, MACE, CV death and myocardial infarction compared to clopidogrel. Regarding bleedings, no significative difference was reported despite a relative increase of major bleedings in the group treated with newer P2Y12i.
DAPAGLIFLOZIN EFFECT ON CARDIOPULMONARY, ECHOCARDIOGRAPHIC FUNCTION, BIOMARKERS AND NYHA CLASS IN HFREF PATIENTS
Authors: Mapelli M , Mattavelli I , Salvioni E , Mantegazza V , Garlaschè A , Vignati C , Gugliandolo P , Capovilla T , Paganin C , Nepitella A , Piotti A , Caputo R , Nava A , Campana N , Agostoni P
Published: May 2024

Background

Sodium–glucose co–transporter–2 inhibitors (SGLT2i) are currently a standard therapy for patients with heart failure with reduced ejection fraction (HFrEF).

This study aims to assess the effects of Dapagliflozin on exercise capacity, cardiac biomarkers, fluid retention, renal and pulmonary function. Methods: We prospectively enrolled stable HFrEF outpatients (left ventricular ejection fraction, LVEF<40%, New York Heart Association, NYHA, class II or III) eligible for SGLT2i and performed serial cardiopulmonary exercise tests (CPET), pulmonary function tests (spirometry and diffusing capacity of the lungs for carbon monoxide, DLCO), laboratory and echocardiographic assessments before and after 6 months of treatment, to evaluate effects on exercise capacity, ventricular remodelling, cardiac biomarkers, fluid retention, renal and pulmonary function.

Results

49 patients (86% males, age 64±12 years) on optimal medical therapy (84% on sacubitril/valsartan; 98% on β–blockers, 84% on MRAs) were evaluated. We observed an increase in LVEF (32.8±7.1 vs. 35.5±8.3%; p<0.001) and a reduction in left ventricular end–diastolic (EDV) and end–systolic (ESV) volumes (EDV: 209±83 vs. 199± 77 mL, p=0.004; ESV: 143±73 vs. 133± 68 mL, p<0.001). There were no significant changes in peak oxygen uptake, while ventilatory efficiency during exercise (VE/VCO2 slope) showed a significant improvement (fig.1). Hemoglobin (Hb) and hematocrit levels improved, while renal function sodium and potassium levels remained stable, as did blood urea nitrogen, while BNP, NT–proBNP, ST2, and hs–TNI did not reach statistical significance in this sub–population. NYHA functional class improved, together with a significant decrease of MECKI (Metabolic Exercise test data combined with Cardiac and Kidney Indexes) score, from 3.9% to 2.7% with a positive impact on 2–year prognosis.

Conclusion

Medium–term treatment with Dapagliflozin demonstrated beneficial effects on LV remodelling, ventilatory efficiency and functional status. An improvement in VE/VCO2 slope and MECKI score paralleled with an enhancement in echocardiographic parameters and NYHA class was observed. Our study did not detect medium–term effects on spirometry values, DLCO, fluid retention and NT–proBNP. These results suggest that some favourable effects could unfold over a longer period of time. Further studies with longer follow up are desirable to assess Dapagliflozin effects even in such a well–treated HF population.
WEARABLE CARDIOVERTER DEFIBRILLATOR IN PATIENT WITH TRANSIENT RISK OF SUDDEN CARDIAC DEATH : SINGLE CENTRE EXPERIENCE
Authors: Bolognesi M , Rossi L , Biagi A , Sticozzi C , Comastri G , Puccio F , Pisati M , Aschieri D
Published: May 2024

Background

Cardiovascular disease is still the first cause of death, with sudden cardiac death ( SCD) as a first presentation in 25% of cases, related to coronary artery disease. Implantable cardioverter defibrillator (ICD) demontrated a reduction of SCD in high risk patients with good functional status. However the risk of SCD should be transient, so the use of a wearable cardioverter defibrillator (WCD) is considered in current guidelines and in clinical practice. The purpose of this study was to investigate the safety and the adherence to WCD in a real world population; moreover we reviewed the rate of ICD implantation after WCD use.

Methods

We considered consecutively 96 patients discharged from Piacenza cardiology department for potentially transient high risk of SCD, weared a WCD from August 2017 to June 2023. The patients were discharged in high risk mode of SCD with WCD protection and followed through remote monitoring or outpatient.A clinical and echocardiographic evalutation was performed at baseline and repeated at the end of the WCD use period.

Results

Out of 95 patients , with average age 66,0 ±11,1 years old and baseline average left ventricular ejection fraction (LVEF) 28,6±7,5, 81,2% were males, 72,9% suffered from arterial hypertension, 26% diabetes mellitus, 13,5% peripheral vascular disease, 14,6% chronic renal failure, 4,1% previous stroke.66% of these patients weared WCD for severe systolic disfunction in ischemic cardiac disease after recent myocardial infarction, after percutaneous coronary intervention or coronary artery bypass graft, 4% after removal of an infected ICD, 6% whilst awaiting completion of diagnostic tests (chanalopathies/right arrhythmogenic ventricular cardiomyopathy), 24% newly diagnosed cardiomyopathy. The average wearing time of WCD was 22,7±3,1 hours daily. We received these events: 1 sustained ventricular tachicardia, 2 non sustained ventricular tachicardia, 5 atrial fibrillation with 3 T wave oversensing. One patient recedived inappropriate shock. One death was detected due to severe heart failure. After 56,0±37,8 days of average wearing time 52% of patients were scheduled for ICD implantation.

Conclusions

In our experience we may consider that WCD use is effective, safe and with a good adherence in all patients. The WCD allows saving resources preventing inapprpriate ICD implantation in patient with transient SCD risk.
IMPACT OF POLYVASCULAR DISEASE ON LONG–TERM PROGNOSIS IN PATIENTS WITH ACUTE CORONARY SYNDROME. A PROSPECTIVE COHORT STUDY IN ITALY
Authors: D‘Errigo P , Mureddu G , Rosato S , Altamura V , Faggiano P , Ceravolo R , Badoni G , Baglio G
Published: May 2024

Background

Atherothrombosis should be considered a systemic disease that may involve one or more than one vascular beds. Data on the impact of polyvascular disease on long–term prognosis in patients with acute coronary syndrome (ACS) are still scarce.

Aim

To assess the prevalence of symptomatic polyvascular disease in a cohort of patients with ACS and to investigate the impact on long–term outcomes of single versus multiple vascular beds involvement.

Methods

We analyzed a nationwide, comprehensive, and universal administrative database of consecutive patients older than 40 years admitted for a new episode of ACS in 2013–14 in Italy. Patients with ACS were stratified according to the presence of Peripheral Arterial Disease (PAD) only, Cerebrovascular Disease (CeVD) only, PAD and CeVD (PAD+CeVD) or neither (noPAD/noCeVD). A Cox proportional hazard multivariate model was used to evaluate the impact of PAD only, CeVD only and PAD+CeVD on 5–year MACCE.

Results

331320 new episode of ACS were identified. Among them, 24491 (7.4%) were patients with PAD only, 16269 (4.9%) with CeVD only and 4710 (1.4%) with PAD+CeVD. The 5 years MACCE was 42.6%, 64.7%, 66.1 and 72.2 (p<0.001) for noPAD/noCeVD, PAD only, CeVD only and PAD+CeVD, respectivelly. After adjustment for age, sex, and comorbidities, the hazard ratio (HR) for 5–year MACCE was 1.30 (p<0.0001), 1.39 (p<0.0001), and 1.46 (p<0.0001) in patients with PAD only, CeVD only, and PAD+CeVD, respectively, as compared with patients without PAD and CeVD.

Conclusion

Polyvascular disease represents a major risk factor in patients with ACS. The simultaneous involvement of three vascular beds further increases the risk of long–term outcomes. Greater effort should be directed toward identification of subclinical/clinical atherosclerosis of beds different from coronary for a better risk stratification.
HYPERTRIGLYCERIDEMIA IN PATIENTS WITH ACUTE AND CHRONIC CORONARY SYNDROME: PREVALENCE AND THEIR ASSOCIATION WITH EXTREME CARDIOVASCULAR RISK AND LEFT VENTRICULAR FUNCTIONHYPERTRIGLYCERIDEMIA IN PATIENTS WITH ACUTE AND CHRONIC CORONARY SYNDROME: PREVALENCE
Authors: Maloberti A , La Rosa A , Toscani G , Caccia A , Gualini E , Pezzoli S , Morelli M , Busti A , Colombo V , Tognola C , Algeri M , Intravaia R , Pirola R , Giannattasio C
Published: May 2024

Objective

Hypertriglyceridemia prevalence in Acute and Chronic Coronary Syndrome (ACS and CCS respectively) patients in the era of very low LDL target is still unknow. The objective of our study is to evaluate the prevalence of triglyceride levels above 150 or 200 mg/dL despite statin therapy and LDL cholesterol at targets in ACS and CCS subjects enrolled in a Cardiac Rehabiliatitation (CR) program.

Methods

This cross–sectional observational study was conducted at the Niguarda Hospital (Milan, Italy). Patients undergoing CR after ACS/CCS from January 1, 2012, to March 28, 2023, were included. Data on demographic, clinical, laboratory, and instrumental variables were collected.

Results

The study population consisted of 740 patients with a mean age of 64.3±10.7 years, predominantly male (81.7%). Triglyceride levels significantly decrease during the CR period (131.1±63.8 vs 116.9±75.9 mg/dL; p < 0.001) similarly to LDL cholesterol (107.9 ± 38.8 mg/dL vs 69.9 ± 25.9mg/dL, p<0.001). 50.8% of the subjects reach the LDL cholesterol target. The percentage of patients with triglycerides >150 mg/dL at CR ends was 17.8% (15.6% when considering only patients that reach the LDL target of 55 mg/dL) while it is only 6.8% for triglycerides >200 mg/dL (5.9% when considering only patients that reach LDL target). Patients with triglycerides >150 mg/dL had higher baseline BMI, LDL cholesterol and uric acid with lower ejection fraction at CR ends. Hypertriglyceridemia significantly correlates with extreme CV risk (R= 0.08, p= 0.025). At multivariate analysis, FE (dependent variable) was significantly associated with triglycerides (beta= – 0,145, p= 0,026) and systolic BP (beta= 0,137, p= 0,032).

Conclusion

Despite high intensity statin therapy and lower LDL cholesterol targets, a substantial proportion of patients in cardiac rehabilitation still had elevated triglyceride levels. This study highlights the potential role of Icosapent Ethyl in managing hypertriglyceridemia in these patients.
PACING NEEDS IN CLIP‘S ERA: HIS–BUNDLE PACING AFTER TRICUSPID TRANSCATHETER EDGE–TO–EDGE REPAIR (TEER)
Authors: D‘Amore S , Chieffo E , Dossena C , Carrozzi C , Cacucci M , Landolina M
Published: May 2024

An 85 year–old man with permanent atrial fibrillation and previous inferior wall and right ventricle STEMI treated with percutaneous primary angioplasty in 2013, was referred to our attention to extreme low ventricular rate, daytime pauses of 6 seconds symptomatic for dizziness found in a ECG Holter registration. After the myocardial infarction, the patient developed a severe tricuspid regurgitation (TR) owing to annular dilatation from adverse right ventricular remodeling so, in June 2022, owing to high cardiac surgery risk, the patient was successfully treated with percutaneous transcatheter implantation of three TriClip NT devices on posteroseptal, anteroseptal and anteroposterior commissures. The degree of TR improved from severe to moderate with mild tricuspid stenosis. Permanent pacemaker implantation was indicated. We decided to implant a conduction system pacing lead (His–bundle pacing) mainly for 3 reasons: (1) the presence of three tricuspid clips would have made it very difficult to advance a ventricular pacing catheter through the neo–orifices of the valve; (2) the high risk of clip displacement during catheter maneuvering across the valve plane; (3) a physiologic pacing such as His–bundle pacing seemed more appropriate given the need for high rate of ventricular pacing, in order to avoid further worsening of ventricular function. A Medtronic 3830 ventricular lead was inserted via the axillary vein through the His–dedicated Medtronic deflectable sheat (SelectSite C304–HIS) and in right anterior oblique fluoroscopic view the lead was advanced into the right atrium and we looked for a His bundle potential. It was decided to use the deflectable introducer in order to reach the Koch triangle with fine and precise movements without even accidentally interfering with the clips. The lead tip was screwed to the antero–septal edge of Koch’s triangle, showing optimal parameters of sensing, impedance, and pacing thresholds. Paced QRS was narrow as spontaneous QRS and a selective His–bundle paced QRS was seen on 12–leads. The fluoroscopy time was 10.9 minutes and a Total Dose Area Product (DAP) of 1.9 mGy/m2. The patient was then discharged 2 days later, asymptomatic. At the 1–month and 6–months visits all the pacing parameters was in the normal range and optimal His–bundle pacing treshold. Our case report demonstrates that His–bundle pacing in a patient with a complex transcatheter edge–to–edge tricuspid valve repair could be a safe and feasible option.
AN ACUTE MYOCARDIAL INFARCTION IN A VERY YOUNG MAN DUE TO HYPERHOMOCYSTEINEMIA
Authors: Cangemi S , Barone G , Zabbia D , Vinci D , Lombardo A , Inglese F , Caiolo A , Geraci G
Published: May 2024

Introduction

A young 17–year–old boy smoker and obese was admitted to our cardiology unit for continuous oppressive chest pain radiating to the left arm that had arisen three days earlier. In the emergency room, he had performed blood tests with evidence of an increased troponin and an electrocardiogram that showed mild ST–elevation in inferior leads with ST depression in aVL. We performed an urgent transthoracic echocardiography examination that was unremarkable Investigation Once diagnosed with acute ST–segment elevation myocardial infarction, the patient underwent emergency coronary angiography. Coronary angiography highlighted an intermediate stenosis of the first branch diagonal to the proximal tract and a possible occlusion of the periapical branch of the anterior descending artery. It was decided not to perform PTCA as we could not exclude a distal coronary dissection and considering the vessel was of small caliber. We decided to complete the diagnostic process by performing a cardiac MRI showing edema in the apex and distal inferior wall and transmural gadolinium enhancement at the level of the septum and inferior wall of the distal section. In the context of the damaged wall a focal area of hypointensity to be referred to the "no–reflow" phenomenon Management The patient was treated with DAPT, low molecular weight heparin and high dose statin. A few hours after the coronary angiography the patient stopped having chest pain and remained asymptomatic for the rest of the hospital stay. We performed complete blood tests including with evidence of hyperhomocysteinemia. The lipid panel was normal. Hematological consultation recommended folate and Vitamine B12 treatment. After 12 months the patient is asymptomatic, has stopped smoking and continues to take DAPT. He repeated the echocardiogram which showed no alterations. Genetic testing was performed after hospital discharge and was positive for Methylenetetrahydrofolate reductase (MTHFR) homozygous mutation

Conclusion

Our clinical case shows a rare case of acute myocardial infarction in a very young person. Diagnosis and treatment were complicated by the extreme distality of the occlusion and the few modifiable risk factors identified (smoker, obesity and hyperhomocysteinemia). Hyperhomocysteinemia is an often underestimated cardiovascular risk factor associated with a high risk of cardiovascular events and multivessel coronary disease that should be sought in all young patients with AMI.
SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY
Authors: Zecchino S , Cerrato E , Pavani M , Varbella F
Published: May 2024

Background

The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy.

Methods

We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis < 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months.

Results

Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups.

Conclusions

This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.
LIMITATIONS IN THE USE OF SUBCUTANEOUS DEFIBRILLATOR IN PATIENTS WITH LOW BODY MASS INDEX
Authors: Floris R , Demontis M , Carboni G , Marini R , Mancosu M , Frau B , Farris F , Racis M , Delogu G
Published: May 2024

Introduction

Subcutaneous defibrillator is an effective and widely used tool in clinical practice but the presence of large fluctuations in the body mass index and the reduction of subcutaneous tissue may limit its application to all patients.

Case Report

In 2014, a 51–year–old woman underwent implantation of a dual–chamber transvenous defibrillator with left subclavian vein approach in secondary prevention for long Qt syndrome (LQT3). About 6 years after implantation she presented a ventricular lead breakage due to subclavian crush syndrome and was subjected to multiple inappropriate shocks due to lead failure. For this reason, the transvenous defibrillator was replaced with a single–chamber pacemaker for atrial stimulation and a subcutaneous defibrillator was implanted (Fig.1). In the following years the patient lost 14 kg and in the first months of 2022 she complained of the onset of stabbing pain in the precordial region near the upper face of the left sixth rib on the midclavicular line (Fig.2). Over the months, this symptomatology has become increasingly limiting and poorly responsive to normal analgesics but only to opiates; furthermore the pain has also occurred after a few weeks at the left parasternal level along the course of the distal portion of the subcutaneous catheter. For this reason, after discussing the case with the patient, we proceeded to implant a new transvenous lead via left subclavian vein and upgrade to a dual–chamber defibrillator. Subsequently, in the same operating session, the subcutaneous defibrillator was removed, finding only a modest traction resistance of the catheter in the parasternal area, resolved with the use of a 10 French introducer used as a sheet to debride the course of the same from the fibrotic adhesions (Fig .3). In the days following the procedure, the patient reported a progressive total disappearance of the pain symptoms. Reassessed after one year, the patient reports subjective well–being with total absence of chest pain and good quality of life.

Conclusions

The subcutaneous defibrillator represents an important resource for the management of the main ventricular arrhythmias, especially in patients with a high risk of infection and with a long life expectancy. The presence of a stable amount of subcutaneous tissue is a necessary condition to guarantee the tolerance of the lead over time and to avoid chronic pain situations that can lead to its removal.
POST–ROSC ECG PREDICTS SURVIVAL AFTER OUT–OF HOSPITAL CARDIAC ARREST. THE PROGRESS SCORE
Authors: Lopiano C , Pontremoli S , Bendotti S , Primi R , Currao A , Sechi G , Marconi G , Ronchi V , Contri E , Panni G , Sgotti D , Zorzi E , Cazzaniga M , Piccolo U , Bussi D , Ruggeri S , Facchin F , Soffiato E , Centineo P , Reali F , Baldi E , Compagnoni S , Quilico F , Vicini Scajola L , Fasolino A , Savastano S
Published: May 2024

Background

Prognostic assessment of patients following out–of–hospital cardiac arrest (OHCA) is critical to guide care after return of spontaneous circulation (ROSC). The ECG acquired after ROSC in patients with OHCA has proven to be crucial not only for its diagnostic role but also for its prognostic purposes. Indeed, certain electrocardiographic features have been shown to be directly correlated with an increased risk of mortality. We developed a score (PROGRESS–SCORE) that can predict 30–day mortality risk in post–OHCA patients, identifying three risk classes: low (0–4), intermediate (5–7) and high (8–26). The current aim is to validate PROGRESS–SCORE in a new cohort of patients.

Materials and Methods

We retrospectively applied the PROGRESS score to prospectively collected data. Post–ROSC ECGs of patients enrolled from 1/1/2015 to 31/12/2022 from the Lombardy Cardiac Arrest Registry (LombardiaCARe) were collected. Predictors considered were: age >62 years, female sex, presence of more than 1 segment with ST elevation, QRS >120 ms, and diagnostic pattern for Brugada Syndrome. Three risk groups were identified according to the previous classification: low (0–4), intermediate (5–7) and high (8–26). Calibration was assessed by plotting the observed proportions of events against the predicted probabilities: the Harrel–c, derived from a univariable Cox regression, was assessed for discrimination, taking into account the risk category as the independent variable.

Results

A total of 792 post–ROSC ECGs were collected: 490 males (61.9%) with a median age of 70 years; median ECG acquisition time from ROSC was 7 minutes (4.2 – 21.0). 348 (43.9%) patients survived to 30 days and 335 (42.3%) died. Mortality was similar between the intermediate–risk and low–risk groups (HR:1.2[95%CI,0.8–1.9]; p:0.35), but higher in the high–risk group than in the low–risk group (HR:1.9[95%CI,1.3–2.8];p:0.001).

Conclusions

Our results show that post–ROSC ECG can discriminate patients at high risk of mortality after OHCA. This provides a possibility for risk stratification in post–ROSC care, which is essential in order to guide resource allocation. Consequently, the application of our score would help personalization of care.
WEARABLE CARDIOVERTER–DEFIBRILLATORS IN CLINICAL PRACTICE IMPLEMENTATION OF THE ANMCO POSITION PAPER FOR APPROPRIATE USE OF THE WEARABLE CARDIOVERTER DEFIBRILLATOR
Authors: Matteucci A , Alonzo A , Castello L , Marino G , Spinelli A , Di Fusco S , Colivicchi F
Published: May 2024

Introduction

Wearable cardioverter–defibrillators (WCD) have emerged as a valuable tool in the management of patients at risk for life–threatening arrhythmias. These devices offer a non–invasive and temporary solution, providing continuous monitoring and the potential for prompt defibrillation when needed. In this study, we explore the indications for WCD and evaluate arrhythmic events through comprehensive monitoring.

Methods

From November 2022 to December 2023, we conducted an outpatient follow–up of 18 patients receiving WCD. Regular check–ups and comprehensive echocardiography were performed to optimize therapy based on specific indications for each patient.

Results

The average age of the patients was 59.3±17.4 years, with 79% being male. Among the cohort, 58% had hypertension, and a similar percentage comprised smokers and individuals with dyslipidemia, while 32% were diabetic. The indications for receiving WCD were: de novo diagnosis of dilated cardiomyopathy with reduced ejection fraction in 9 (50%) patients, recent acute coronary syndrome and ejection fraction < 35% in 5 (28%), cardiac electronic device infections in 3 (17%) patients and myocarditis with electrical instability in 1 (5%) patient. Patients were in optimal medical therapy (OMT) tailored to their specific comorbidities, with 84% on renin–angiotensin–aldosterone system inhibitors, 95% on beta–blockers, 53% on mineralocorticoid receptor antagonists, 53% on sodium–glucose cotransporter–2 inhibitors, and 37% on antiarrhythmics. The average follow–up was 64±45 days according to specific etiology, with a daily wearing time of 22.9±1.1 hours. No device interventions were recorded. At the end of the follow–up period, 6 (33%) patients still required implantable cardioverter–defibrillator (ICD). Among these, 4 patients (22%) underwent to ICD implantation, 3 for secondary prevention, and 1 for primary prevention, while notably, 2 (11%) patients, declined the procedure.

Conclusions

The use of wearable cardioverter–defibrillators in the outpatient setting for patients at risk of life–threatening arrhythmias allowed to optimize therapy and restrict the indications for ICD, in our cohort up to 67%, with a good safety profile due to the low incidence of device interventions.
ARRHYTHMOGENIC MITRAL VALVE PROLAPSE PRESENTED WITH OUT–OF–HOSPITAL CARDIAC ARREST
Authors: Tarantino G , Colonna P , Scardapane A , Troccoli R , Rodio D , D‘Agostino C
Published: May 2024

Despite mitral valve prolapse is generally a benign condition, consistent data regarding it as cause of sudden cardiac death have been arisen. Among the poor–prognosis determinants, mitral annular disjunction plays a paramount role. We discuss the case of a young with mitral valve prolapse presented with resuscitated OHCA.

Introduction

Mitral valve prolapse (MVP) is the most common valvulopathy and its prognosis is usually excellent in the absence of relevant mitral regurgitation. However a recent meta–analisys demonstrated a significant link between MVP and sudden cardiac death (SCD). Among the features that raise the risk there is the mitral annular disjunction (MAD). MAD consists of the systolic separation of the mitral annulus from the ventricular myocardium at the level of the posterior leaflet. Independent from the presence of MAD, a recent scientific consensus has identified the elements which constitute the so called arrhythmic mitral valve complex/phenotype: 1) MVP 2) frequent or complex ventricular arrhythmias 3) absence of any other well–defined arrhythmic cause.

Case Presentation

A 32–year–old woman without any relevant medical history was collapsed; immediately her relatives called 118 and CPR was started. When the EMT arrived, the ECG showed ventricular fibrillation, and 6 DC shock were needed to restore spontaneous circulation. Once in the ED, she underwent urgent coronary angiography resulted negative. The ECG showed sinus rhythm at 65 bpm, infero–lateral negative T waves. A transthoracic echocardiogram (TTE) was carried out and it underlined a slightly depressed ventricular function (E.F. 53%), hypokinesia of the mid–apical septum, a mitral valve prolapse with moderate mitral regurgitation and mitral annular disjunction of 10mm, data concordant with the cardiac magnetic resonance (CMR) and transoesophageal echocardiography (TEE) thereafter performed. Viral and autoimmune screenings resulted negative. The patient underwent dual chamber TV–ICD implantation in secondary prevention.

Discussion

AMVP is a challenging entity because of the need of early identification of the patients affected by the arrhythmic phenotype for whom is indicated a lifelong follow up and in selected cases ICD implantation in primary prevention of SCD. Even if globally rare, SCD among patients affected by MVP is not a statistically dismissible event and in the small available post mortem studies it accounts for 4% to 7% of otherwise unexplained deaths.
THE COMPLEX WORLD OF NON CRITICAL CORONARY ARTERIES DISEASE
Authors: Aleksova A , Fluca A , Munaretto L , Chiaradia V , Barbati G , Derin A , D‘Errico S , Di Lenarda A , Hiche C , Sinagra G , Janjusevic M
Published: May 2024

Background and Aim

Acute coronary syndrome (ACS) with non–critical coronary arteries represents a major diagnostic, therapeutic and prognostic challenge for clinicians. The aim was to compare clinical–anamnestic characteristics and assess the prognosis of three cohorts with ACS with non–critical coronary arteries i.e. Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), type 2 myocardial infarction (MI) and Takotsubo syndrome (TTS).

Methods

In this single center observational study, 18223 patients who underwent coronary angiography between 2005 and 2022 were retrospectively analyzed. The final cohort included 676 patients with initial presentation as NSTEMI (301 MINOCA, 237 type 2 MI and 138 TTS).

Results

The median age was 68±11, with the TTS population being the oldest (72±10, p<0.01), presenting greater hypotension (p<0.01), tachycardia (p<0.01), and fewer cardiovascular risk factors, such as diabetes (p<0.01) and hypertension (p<0.01). The TTS cohort had worse LVEF on admission (p<0.01) and on discharge (p<0.01) (Fig. 1). At Kaplan–Meier analysis, patients with type 2 MI were more prone to the composite endpoint, while the TTS group was less likely (p<0.01) (Fig. 2). In the overall cohort, ACEi/ARB therapy on admission was an independent predictor of the composite endpoint (HR: 1.58;p=0.01), while dual antiplatelet therapy (DAPT) (HR: 0.59;p=0.01) and statin (HR: 0.71;p=0.03) at discharge were protective. After stratification according to diagnosis, ACEi/ARB therapy remained a negative predictor only in the type 2 MI cohort (HR: 2.03;p=0.01) as well as beta–blocker therapy at admission in TTS (HR: 2.97;p=0.03), while statin therapy remained protective in the MINOCA (HR: 0.51;p=0.01) and DAPT therapy in the TTS group (HR: 0.21;p=0.04) at discharge. Although a substantial number of patients with all three diagnoses achieved the endpoint, the multivariable Cox regression analysis indicated that type 2 MI, in addition to older age, male gender, worse LVEF, and anemia, is an independent factor for worse outcomes (Fig. 3).

Conclusions

Among all cohorts, T2 MI were associated with worse outcome. The use of DAPT in TTS and Statins in the MINOCA group showed a protective role. Since the TTS population was more compromised, BB use in the ADHF phase of TTS could predict a poorer outcome as much as ACEI/ARB use at admission could be a marker of greater early LV impairment of the T2 MI cohort, which was an independent predictor for worst outcome.
SINGLE CENTER EXPERIENCE IN SURGICAL TREATMENT FOR ACTIVE ENDOCARDITIS BEFORE AND AFTER COVID–19 PANDEMIC
Authors: Mikus E , Fiorentino M , Fiaschini C , Zucchetta F , Sangiorgi D , Calvi S , Tripodi A , Savini C
Published: May 2024

Background

Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life–threatening condition. The impact of COVID–19 on diagnosis and outcome of surgical treatment of IE is uncertain.

The aim of this study was to analyze the incidence, characteristics and outcomes of surgically treated IE before and after the COVID–19 pandemic.

Methods

This study retrospectively analyzed data of 536 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided in two groups depending on the date of operation: before (n=393) and after (n=142) COVID–19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied.

Results

We noticed a significant increase (p=0.006) in the prevalence of infective endocarditis admitted for surgery throughout the years, comparing it to overall hospitalizations in our cardiac surgery department (Figure 1). Patients from the post COVID cohort (after march 2020) had more comorbidities such as diabetes (29.6% vs 16.3% p=0.001), hypertension (71.1% vs 59.5% p=0.015), and preoperative kidney injury requiring dialysis (9.2% vs 2.5% p=0.002), but median additive and logistic Euroscore were not statistically different. In the post COVID group, we observed a greater prevalence of S. Aureus related endocarditis (24.5% vs 15.4% p=0.026), and a consequent reduction in S. non Aureus related endocarditis (12.2% vs 20.1% p=0.048) (Figure 2), a decrease of aortic valve replacement (43.0% vs 53.9%), while the number of mitral valve replacement ad repair resulted to be higher (21.1% vs 15.0% and 6.3% vs 4.3% respectively) (Figure 3). No differences in the two groups concerning early death but also death or relapse at one year after surgery. Data obtained by the multivariable analysis identify the preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality stratifying by time periods in analysis.

Conclusions

The incidence of surgical treated IE significant increase after COVID–19 pandemic with a higher incidence of mitral involvement instead of aortic valve. Despite the pandemic and the delay in surgical timing, results in terms of mortality and outcomes have improved and were largely unaffected by the COVID–19 pandemic.