bluuebunny/crossref_metadata_2025 huggingface dataset:
C14 A PROMISING SURGICAL TECHNIQUE IN PATIENTS WITH ATRIAL FUNCTIONAL MITRAL REGURGITATION: HYPER–DOWN–SIZING ANNULOPLASTY
Authors: Innelli P , Prestipino F , Manzan E , Telesca M , D‘Ascoli R , Paternoster G , Stabile E , Luzi G
Published: May 2022

Objective

Atrial functional mitral valve regurgitation is a less common form of functional mitral regurgitation with normal leaflet motion and morphology, preserved dimension and function of left ventricle, associated with atrial fibrillation ad/or left atrial dilatation. Several factors are involved into the etiology, such as mitral annular dilation and insufficient leaflet remodeling, atriogenic leaflet tethering, loss of annular saddle shape and contractility, changes in heart rate.

Methods

Eleven consecutive patients with atrial functional mitral regurgitation, mean age 65 ± 12 years, normal left ventricle dimension and ejection fraction greater than 50% underwent mitral valve repair via right mini–thoracotomy in case of isolated mitral and tricuspid valve surgery or via median sternotomy in case of combined procedures. Concomitant procedures include tricuspid valve repair in 1 patient and coronary artery bypass in 5 patients. All patients presented an increased dimension of left atrium (mean left atrial volume: 90 ± 23 ml); mitral annular dimension was investigated with trans–esophageal echocardiography before operation. In all patients was implanted a downsized complete rigid annuloplasty ring with asymmetrical design of two sizes smaller respect to measured intercommissural distance. Clinical outcomes of patients and echocardiographic findings related to mitral regurgitation recurrence and left ventricle function were followed in the time.

Results

At discharge, any patient present a residual mitral regurgitation greater than mild, mean trans–mitral gradient was 2.5 ±2.1 mmHg. During the follow–up period of 24 ± 5 months, the New York Heart Association functional class significantly improved from 2.5 ± 0.4 to 1.5 ± 2.1. In three patients occurred cardiac rhythm disturbances requiring hospital stay, only one patient developed a greater than mild mitral regurgitation, reoperation was not becessary in any case. Left atrial volume decreased from 90 ± 23 ml to 58 ± 30 ml.

Conclusions

Mitral annuloplasty with downsized ring is a safe and effective procedure in patient with atrial functional mitral regurgitation in the same way of patient with functional mitral regurgitation due to ventricular dilation and tethering. The comforting clinical and echocardiographic outcome in our small group of patient encourage future studies in this particular group of patients.
C15 DOES THE DISTANCE BETWEEN RESIDENCY AND IMPLANTING CENTER AFFECT THE OUTCOME OF PATIENTS SUPPORTED BY LEFT VENTRICULAR ASSIST DEVICE? A MULTICENTER ITALIAN STUDY ON RADIAL MECHANICALLY ASSISTED CIRCULATORY SUPPORT (MIRAMACS) ANALYSIS
Authors: Lechiancole A , Loforte A , Trumello C , Scandroglio M , Gliozzi G , Comisso M , Iacovoni A , Terzi A , Maiani M , Musumeci F , De Bonis M , Pacini D , Livi U
Published: May 2022

Background

Patients with LVAD require continuous monitoring and care, and since Implanting Centers (IC) are more experienced in managing LVAD patients than other health care facilities, the distance between patient residency and IC could negatively affect the outcomes.

Methods

Data of patients discharged after receiving a LVAD implantation between 2010 and 2021 collected into the MIRAMACS database were retrospectively analyzed. The population was divided into two groups: A (n = 175) and B (n = 141), according to a distance between patient residency and IC ≤ or >of 90 miles. The primary end–point was freedom form Adverse Events (AEs), a composite outcome composed by death, cerebrovascular accident, hospital admission because of GI bleeding, infection, pump thrombosis or right ventricular failure. Secondary end–points were incidences of mortality and complications. All patients were followed–up regularly, according to participating centers protocols, by means of clinical visits, telemonitoring and local care–sharing.

Results

Baseline clinical characteristics and indications for LVAD did not differ between the two groups (Figure 1). Mean duration of support was 25.5±21 months for Group A and 25.7±20 months for Group B (p = 0.79). At 3 years, freedom from AEs was similar between Group A and B (p = 0.32, Figure 2), and there were no differences in rates of mortality and LVAD–related complications (Figure 2).

Conclusions

Distance from the IC does not represent a barrier to successful outcome, as long as regular and continuous follow–up is provided. Telemonitoring could offer several benefits, including early detection of complications and continuous evaluation of patient conditions and data of the pump. Moreover, it seemed to reduce the patient anxiety related to the device, increasing direct communication with the VAD–team. On the other hand, shared health programs with local facilities remains an attractive way to follow–up patient, provided that LVAD specific resources and trained staff are available. The dissemination of LVAD–specific care knowledge is also important to face urgent or emergent needs in the rapidly enlarging population of LVAD patients, by empowering local healthcare facilities.
C18 ROLE OF THREE DIMENSIONAL ECHOCARDIOGRAPHY IN IMAGING AND SURGICAL DECISION MAKING OF AORTO–LEFT ATRIAL FISTULA
Authors: Galzerano D , Di Michele S , Alhamshari A , Jazzar Y , Al Sergani A , Sishamma E , Alsanei A , Pergola V , Di Giannuario G , Vriz O
Published: May 2022

A 63–year–old female known case of diabetes, hypertension, dyslipidemia and chronic kidney disease underwent mitral valve (MV) replacement because of severe regurgitation (RGT). Few weeks after, she was admitted due to decreased level of consciousness, drowsiness, abdominal distension and fever. Laboratory investigations showed positive blood cultures for Staphylococcus aureus and elevated inflammatory markers. Brain computed tomography (CT) revealed multiple infarcts due to systemic embolization. Transthoracic echocardiography (TTE) showed bioprosthesis (BP) leaflets coated by a mass causing significant obstruction (peak/mean=17/8 mmHg) with mild intravalvular RGT. Mild thickening of aortic valve (AV) cusps with mild RGT and moderate tricuspid RGT were also noted. Left and right ventricles were normal in size and function. A transesophageal echocardiography (TEE) (Figure 1) showed BP leaflets coated by a mass with a mobile vegetation attached on the atrial surface (10x9mm) causing severe obstruction and mild intravalvular RGT. A periaortic abscess, surrounding the left and the non–coronary cusps and involving the mitro–aortic fibrosa was also found. A fistula between the aortic root and the left atrium was detected by color Doppler and CW Doppler (systodiastolic high velocity shunt) (Figure 1). Further three dimensional (3D) analysis allowed to anatomically locate the position of the fistula which started close to the ostium the left coronary (LC) artery, passing through the mitroaortic fibrosa and opening anteriorly next to the strut of the BP (Figure 2). Contrast cardiac CT was advised but it was not performed to avoid further kidney impairment. The consensus was to perform redo–surgery. Therefore, the patient underwent MV cleaning of abscessual area, reconstruction of the aortic annulus with AV replacement. A coronary artery bypass surgery on LC artery was also necessary as the ostium was narrowed during the reconstruction of the area. Echocardiographic findings were confirmed at surgery. In our case 3DTEE accurately delineated cardiac anatomy and provided crucial anatomic details useful in the surgical planning. It is also important to highlight that the diagnosis may be challenging as the jet may be misinterpreted as mitral RGT. In this context, 3D imaging offers incremental value, as it is able to offer a clear view of the mitral valve.3DTEE was particularly helpful in our setting because the patient was at high risk to perform contrast study.
C21 ACTIVE STAND TEST IN ALTERNATIVE TO HEAD UP TILT TEST AS NEUROMEDIATE SYNCOPE’S PREDICTOR IN COVID–19 PANDEMIC’S ERA: EXPERIENCE OF SINGLE CENTER
Authors: Dentico A , Ferrieri A , Epicoco G , Troccoli R , Carretta F , D‘Agostino C , Carretta D
Published: May 2022

Introduction

The Head Up Tilt Test is an exam that, with prolonged orthostatic stress, allows you to diagnose neuromediated syncope, but has the drawback of being a test that requires time, space and dedicated equipment. During the Covid pandemic, our Syncope Unit was limited both in terms of space and access. Not being able to perform the HUTT, it was decided to replace it with the Active Stand Test, a test that allows you to evaluate changes in blood pressure and ECG in a few minutes.

The purpose of this study is to evaluate the effectiveness of the Active Stand Test as an alternative to HUTT in situations where the latter cannot be performed. Material and Method: In the period 2020–2021, 53 patients were treated for syncope at our center. These patients underwent initial evaluation, Active Stand Test and carotid sinus massage. The Active Stand Test was positive in 8 patients. In order to have a long–distance follow–up, a remote–controlled loop recorder was implanted in all patients. Two categories of patients were thus identified: asymptomatic patients for syncope, in whom no relevant symptoms or arrhythmias were found, and symptomatic patients for syncope. The first were followed only with remote control and telephone follow–up, symptomatic patients were reconvened for clinical re–evaluation.

Results

Of the total 53 patients, 34 were asymptomatic patients with syncope and with no significant arrhythmia recordings and 19 were symptomatic patients with syncope. Of these, 5 were symptomatic for paroxysmal AVB and were implanted with PM, 1 for NSVT was protected with Life Vest; the 13 symptomatic without AVB (syncope of unknown origin) continued the follow–up. Among the latter we find the 8 patients who tested positive when performing the Active Stand Test carried out upon enrollment. The 34 patients asymptomatic for syncope were subsequently recalled to perform a HUTT.

Conclusions

The emergence of the Covid–19 pandemic has led to a greater enhancement of the function of the Syncope Unit, making it the place of choice for the etiological diagnosis of syncope. This allowed for an important selection of the tests necessary to arrive at an etiological diagnosis of syncope. In a situation where the execution of the HUTT is difficult, the Active Stand Test made it possible to manage patients for the diagnosis of neuromediated syncopes.
C35 SUCCESSFUL PERCUTANEOUS TREATMENT OF A GIANT CORONARY ANEURYSM IN THE EMERGENCY SETTING
Authors: Quadri G , Tomassini F , Rolfo C , Franzè A , Cerrato E , Chinaglia A , Tizzani E , Minniti D , Varbella F
Published: May 2022

In 2008, a 60–year–old man with an anterior STEMI and cardiogenic shock underwent coronary angiography: a thrombotic occlusion in the mid–LAD, distal to a coronary aneurysm, was successfully treated with DES. (Fig. A). In 2020, the patient was readmitted with NSTE–ACS and cardiogenic shock. The coronary angiography showed severe stenosis after the proximal–LAD aneurysm and occlusion of the previously implanted stent (Fig. B, Panel B1 and B3). A very slow distal coronary flow was provided by a huge epicardial collateral branch emerging from a second giant coronary aneurysm; furthermore, a severe stenosis in the proximal–LCX was present (Fig. B. Panel B1,2). The patient was judged inoperable by the cardiac surgeon. After IABP positioning, a DES was implanted in the LCX. The LAD was then approached. TIMI 3 flow was achieved after a challenging procedure requiring both coronary and peripheral interventional tools: 3 DES (yellow dotted–lines), 8 coronary and 1 peripheral covered stents (green solid–lines) and 6 coils were used to treat the stenosis and exclude the coronary aneurysms. (Fig. B, Panel B3,4). Both DAPT and oral anticoagulation were prescribed at discharge. A 4–month coronary angiography confirmed the good procedural result. (Fig. C). This case shows the unexpected enlargement of a coronary aneurysm through the years and the presence of a new uncommon epicardial communication, necessary to overcome a chronic coronary occlusion. It highlights the importance of knowing different interventional techniques and using non–conventional tools to approach complex coronary anatomies, such as aneurysmatic disease, whose treatment is often challenging, especially in complicated clinical scenarios.
C36 ATRIAL SEPTAL DEFECT CLOSURE WITH A NEW OCCLUDER DEVICE, EXPERIENCE ON 100 PATIENTS
Authors: Castaldi B , Sirico D , Di Candia A , Cuman M , Cantinotti M , Di Salvo G , Santoro G
Published: May 2022

Background

This perspective, observational study evaluated safety and efficacy of the GORE® Cardioform ASD Occluder (WL Gore & Associates, Flagstaff, AZ), compliant and potentially innovative prosthesis recently approved for closure of ostium secundum atrial septal defects (ASD).

Methods

100 unselected patients with significant ASD were submitted to trans–catheter closure with GORE® Cardioform ASD Occluder at two high–volume Italian Pediatric Cardiology centers. Primary endpoints were procedural success and safety. Secondary endpoints were closure rate and clinical safety at 1–month and 6–month follow–up.

Results

Patients‘age and weight were 7.8 (6.0–13.6)and 26.1 (20.0–54.0), respectively. ASD diameter was 17.4 + 4.4, resulting in QP/QS of 1.7 ± 0.7 (median 1.6). 33 patients presented an asd larger than 18mm in diameter. 58% of defects were considered complex based on the following characteristics: deficient rim(s) (except aortic rim), aneurismal/multi–fenestrated and ASD size/pt weight ratio >1.2. Device placement was successfully achieved in all but two patients (98%), in whom it embolized early after deployment, resulting in rescue surgical repair. No cross–over with different devices was recorded. Median procedure and fluoroscopy times were 54 and 11 min, respectively. Major adverse events were recorded in 7 pts. Complete closure rate was 87.3% at discharge, rising to 95.5% (39/42 pts) at 1 month evaluation, and 100% at 6 months without cardiac or extra–cardiac adverse events. “Complex” procedures were more time–consuming but as effective and safe as the “simple” ones.

Conclusions

The GORE® Cardioform ASD Occluder device was highly effective and versatile in closure of ASDs with different anatomy and size, even in challenging settings.
C41 AN UNUSUAL CASE OF “PULMONARY EMBOLISM”
Authors: Nannelli C , Ferraro N , Farsad M , Cemin R
Published: May 2022

Background

Pulmonary vein stenosis (PVS) is a complication of catheter–based radiofrequency ablation (RFA) for atrial fibrillation (AF), caused by a vascular response which leads to replacement of necrotic myocardium with collagen. Clinical presentation can mimic pulmonary embolism (PE) and usually appears some months after procedure.

Case report

A 65–year–old man was hospitalized in March 2021 with a complaint of worsening dyspnoea on exertion, over the course of one month. He had a past medical history of persistent atrial fibrillation, because of which he underwent four pulmonary vein ablations (both RFA and crioablation), the last one in 2019. The previous echocardiogram showed a high systolic pulmonary arterial pressure (sPAP of 75 + 5 mmHg) with normal right ventricular function and dimensions. Despite D–dimer at admission was negative, a CT pulmonary angiography was performed and showed occlusion of left superior pulmonary vein and a severe stenosis of right superior pulmonary vein; ventilation–perfusion scintigraphy (V/Q scan) demonstrated widespread decreased perfusion of both superior lung lobes. The patient underwent angioplasty of right pulmonary vein and after the procedure sPAP greatly decreased (35 mmHg).

Discussion

Despite its reduction in incidence and its short–term presentation from procedure, severe symptomatic pulmonary vein stenosis must be considered among complications of ablation for atrial fibrillation. Delayed symptoms can also present years after procedure, even if in literature few similar cases are described. Ventilation–perfusion scintigraphy is a very sensible method to assess the functional significance of pulmonary vein stenosis and it also relates with symptoms’ severity. It should be performed in case of a high clinical suspicion, considering that the characteristic ventilation–perfusion mismatch of this condition can be seen in other diseases too, over all pulmonary embolism.

Conclusions

This case report emphasizes the importance of a thorough anamnesis and an exact interpretation of diagnostic imaging to correctly identify this AF ablation complication and optimize the patient’s therapeutic management. It must be considered that PV stenosis can develop late and with unusual symptoms, mimicking other diseases, like pulmonary embolism, which has the same scintigraphic imaging.
C46 A RARE CASE OF LANGERHANS CELLS HISTIOCYTOSIS CARDIO–VASCULAR INVOLVMENT
Authors: Talarico M , Renne S , Valiante G , Levato M , Chirillo P , Ceravolo R
Published: May 2022

A 54–year–old woman presented at our department for clinical follow–up. She was affected by hypertension, hypercholesterolemia, diabetes insipidus and autoimmune hypotiroidism in substitutive therapy. She had chronic coronary syndrome treated by medical therapy after unsuccessfull left anterior descending artery percutaneous revascularization and underwent to left common iliac artery stenting. The echo–doppler study showed a thickening of both common and internal carotid. Moreover, the patients underwent a skin biopsy of nodular, purple lesions which showed a xanthomatous infiltration suggestive of Langherans cell histiocytosis (CD1A+ e S100+). A subsequent PET–TC total body demonstrated a FDG uptake tissue around the great vessels and a focal increased uptake in the proximal thirds of the left tibia and in the distal thirds of fibula. The patient underwent to a new skin biopsy which confirmed histiocytosis (S100+, langherin+, CD1a+, BRAFV600E negative) and to a negative bone biopsy. Since the diagnosis of histiocytosis was confirmed the association of mercaptopurine and steroid therapy was started. In our department we performed a follow–up echocardiography which showed normal left and right ventricle dimensions and a good bi–ventricular function (LVEF according to Simpson 55% and FAC 50%) and surprisingly a focal right atrial wall thinckening of 3 mm. Therefore, the cardiac MRI showed no oedema in triple T2, no late gadolinium enhancement inIR–GRE T1 and at the posteriori wall of the right ventricle a focal thickening of 2.3 x 2.4 cm of increased intensity and a disomogenous enhancement after contrast agent administration (Figure 1); the same non stenotic tissue was showed along the aortic arch and the discending aorta (Figure 2). The MRI characteristic of these cardio–vascular lesions are consistent with the diagnosis of Langeran’s cells histiocytosis.
C53 DONOR–DERIVED CELL–FREE DNA (DD–CFDNA)–BASED ASSESSMENT OF CORONARY ALLOGRAFT VASCULOPATHY IN HEART TRANSPLANTED PATIENTS
Authors: Bulfoni M , Dralov A , Ferrara V , Marcon B , D‘Aurizio F , Nalli C , Di Nora C , Sponga S , Beltrami A , Livi U , Curcio F
Published: May 2022

Introduction

Cardiac Allograft Vasculopathy (CAV) is a leading cause of long–term graft dysfunction and failure after Heart Transplant (HTx). Early diagnosis is crucial to tailor therapeutic strategies. Despite advancements in cardiac imaging, the standard for CAV diagnosis remains coronary angiography. Donor–derived cell free DNA (dd–cfDNA) is a novel marker of graft injury in solid organ transplants. Elevations in dd–cfDNA levels may reflect CAV development during subclinical inflammation, thus it could represent a non–invasive method of surveillance for CAV rejection in apparently stable post–transplant patients. Given these premises, we decided to evaluate the potential of dd–cfDNA as alternative diagnostic biomarker for CAV.

Materials and Methods

31 blood samples from patients who underwent heart transplant at our institution in the last 10 years, were analyzed by Next Generation Sequencing (NGS) according to CareDx Alloseq protocol. The cfDNA was extracted starting from 2mL of plasma (Qiagen). Sequencing was performed on the Illumina Miseq platform. Troponin T (hs–TnT) and NT–proBNP (Brain Natriuretic Peptide) were measured by automated immunoassay analysers. All statistics were performed by STATA software and significance was set at p < 0.05.

Results

Heart transplant recipients were divided into 2 groups: 16 patients with known CAV status and 15 patients who had not (no–CAV). No significant differences between the two populations were observed, aside from time from HTx (177.28± 84.99 months in CAV vs 93.20 ± 84.39 months in no–CAV; p = 0.033). A significant difference in dd–cfDNA fraction was found between CAV and no–CAV patients (p = 0.03); with mean values of 0,41% e 0,13%, respectively. Neither NT-proBNP (p = 0.08) nor hs–TnT (p = 0.31) concentrations were significantly different between the two groups, but a positive correlation was found between the two biomarkers (r 0.6966; p = 0.0013). A trend of linear relationship emerged between cfDNA and NT-proBNP levels (r 0.4155; p = 0.08).

Conclusions

With this study, we demonstrated the feasibility of evaluating dd–cfDNA in long–term heart transplanted patients and its possible association with CAV development. Further investigations are warranted to explore a possible association between dd–cfDNA levels other circulating biomarkers and CAV progression. The definition of “homogeneous” subgroups of patients according to a “risk score” will allow to better manage their follow up and improve their prognosis.
C58 LONG–TERM SURVIVAL OF PATIENTS ADMITTED FOR A FIRST AMI EVENT AND MANAGED WITH MYOCARDIAL REVASCULARIZATION OR CONSERVATIVE APPROACH IN ITALY
Authors: De Luca L , D‘Errigo P , Mureddu G , Rosato S , Badoni G , Seccareccia F , Baglio G
Published: May 2022

Background

The long–term clinical benefits of myocardial revascularization in a contemporary cohort of patients with acute myocardial infarction (AMI) are unclear. We aimed to compare the overall mortality rates at 8 years of patients admitted in Italian hospitals with a first AMI managed with or without myocardial revascularization during the index event.

Methods

This is a national retrospective cohort study that enrolled patients admitted with a first AMI in 2012 in all Italian hospitals. The outcome of interest was all–cause mortality at 8 years. Time to events was analyzed using a Cox multivariate regression model.

Results

A total of 97,271 patients with AMI were admitted to an Italian hospital in 2012. Patients with a previous AMI or myocardial revascularization (n = 27,350) have been excluded from this analysis. Among the remaining 69,921 AMI events, 56.6% underwent a percutaneous coronary intervention (PCI) or a coronary artery by–pass grafting (CABG) during the index admission. The crude 8–year survival was 0.76% for patients treated with PCI or CABG in the index admission and 0.34% for patients managed with a conservative approach (Figure 1). Considering the differences in risk factors, the invasive approach showed a significantly lower risk of long–term mortality compared to the conservative management (hazard ratio=0.55; 95% confidence intervals 0.53–0.56) (Figure 2).

Conclusions

In a contemporary nationwide cohort of patients at their first AMI episode, those who underwent a myocardial revascularization during the index event presented an adjusted 45% relative risk reduction in overall mortality at 8–year follow–up compared with those treated only medically.
C65 POST–DISCHARGE ARRHYTHMIC RISK STRATIFICATION OF PATIENTS WITH ACUTE MYOCARDITIS AND LIFE–THREATENING VENTRICULAR TACHYARRHYTHMIAS
Authors: Gentile P , Merlo M , Peretto G , Ammirati E , Sala S , Della Bella P , Aquaro G , Imazio M , Potena L , Campodonico J , Foà A , Raafs A , Hazebroek M , Brambatti M , Cercek A , Nucifora G , Shrivastava S , Huang F , Schmidt M , Muser D , Van De Heyning C , Van Craenenbroeck E , Aoki T , Sugimura K , Shimokawa H , Cannatà A , Artico J , Porcari A , Colopi M , Bussani R , Barbati G , Garascia A , Cipriani M , Agostoni P , Pereira N , Heymans S , Adler E , Camici P , Frigerio M , Sinagra G
Published: May 2022

Aims

The outcomes of patients presenting with acute myocarditis and life–threatening ventricular arrhythmias (LT–VA) are unclear. The aim of this study was to assess the incidence and predictors of recurrent major arrhythmic events (MAEs) after hospital discharge in this patient population.

Methods and Results

We retrospectively analysed 156 patients (median age 44 years; 77% male) discharged with a diagnosis of acute myocarditis and LT–VA from 16 hospitals worldwide. Diagnosis of myocarditis was based on histology or the combination of increased markers of cardiac injury and cardiac magnetic resonance (CMR) Lake Louise criteria. MAEs were defined as the relapse, after discharge, of sudden cardiac death or successfully defibrillated ventricular fibrillation, or sustained ventricular tachycardia (sVT) requiring implantable cardioverter–defibrillator therapy or synchronized external cardioversion. Median follow–up was 23months [first to third quartile (Q1–Q3) 7–60]. Fifty–eight (37.2%) patients experienced MAEs after discharge, at a median of 8 months (Q1–Q3 2.5–24.0 months; 60.3% of MAEs within the first year). At multivariable Cox analysis, variables independently associated with MAEs were presentation with sVT [hazard ratio (HR) 2.90, 95% confidence interval (CI) 1.38–6.11]; late gadolinium enhancement involving ≥2 myocardial segments (HR 4.51, 95% CI 2.39–8.53), and absence of positive short–tau inversion recovery (STIR) (HR 2.59, 95% CI 1.40–4.79) at first CMR.

Conclusions

In this international multicentre study, patients discharged free from HTx or LVAD after an acute myocarditis complicated by LT–VA had a recurrence of MAEs during follow–up of 37.2%, after a median time of 8 months. Initial CMR pattern and sVT at presentation stratify the risk of arrhythmia recurrence.
C72 THE EFFECTS OF BATRIATIC SURGERY ON CARDIO–METABOLIC PROFILE AND CARDIAC REMODELING
Authors: Ventura M , Giofrè F , Lucà S , Pelle M , Zaffina I , Forte V , Cloro C , Melina M , Miceli S , Sciacqua A , Segura Garcia C , Currò G , Arturi F
Published: May 2022

Background

Obesity is associated with cardiac remodeling resulting in hypertrophy of the left ventricle (LV) with a predominantly concentric pattern. LV remodeling and fibrosis induce mechanical and electrical dysfunction of the myocardial tissue, an increase in cardiac output, an increase of myocardial workload and mean arterial pressure.

Objective

To evaluate the impact of bariatric surgery, and therefore of anthropometric and cardio–metabolic variations, on cardiac structure and function.

Methods

Twenty–six obese patients treated with bariatric surgery were enrolled. All the patients at baseline and at 6 and 12 months underwent a complete anthropometrical evaluation, laboratory determinations and echocardiogram evaluation. The IR has been assessed by HOMA–IR. The patients were divided into two groups: the first group (8 patients) carried out a follow–up at 6 months post–surgery; the second group (18 patients) at 12 months post–surgery.

Results

As expected, an improvement in the anthropometric and metabolic profile in patients treated with bariatric surgery was observed. Echocardiographic data showed a significant increase in the Ejection Fraction (P < 0.001) and the E/A Ratio (P < 0.001) 6 months after bariatric surgery, a significant reduction in the Interventricular Septum thickness at 6 months (P < 0.001) and at 12 months (P < 0.002) post–surgery and a significant reduction in the Left Ventricular Mass at 6 months (P = 0.02) and at 12 months (P = 0.05) after bariatric surgery. A reduction no significant in the Left Ventricular posterior wall thickness has been observed.

Conclusions

Our data showed an increase of the systolic function, an increase of the left ventricular diastolic compliance and a reduction in subclinical cardiac organ damage. Therefore, significant weight loss obtained with bariatric surgery may lead to reverse cardiac remodeling, associated with beneficial effects on myocardial structure and systo-diastolic function.
C78 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID REGURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION
Authors: Pugno Vanoni F , Biroli M , Cannata F , Pagliaro B , Pellegrino M , Villaschi A , Gasparini G , Ardino L , Vrinceanu E , Loiacono F , Pini D
Published: May 2022

Introduction

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are a known cause of morbidity and mortality in heart failure (HF) patients. Maximal up–titration of guideline–directed medical therapy (GDMT) for HF may not be enough to reduce the severity of the valve’s incompetence and patients’ symptoms. The development and successful results of transcatheter therapies for mitral/tricuspid disease have opened new therapeutic opportunities when surgery is not feasible. Accurate valve regurgitation’s mechanisms evaluation is essential to choose the best treatment option. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate–to–severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients.

Methods

We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF unit between January 2020 and June 2021. All patients with echocardiographic evidence of ≥ 3+/4+ MR and/or TR were included (treated ones were excluded), and a thorough echocardiographic images review was conducted. A full collection of patients’ clinical, laboratory and therapy regimens details was performed as well.

Results

Of the 1260 analyzed patients, 173 (13.7%) exhibited ≥3+/4+ MR and/or TR and were included in the registry. Table 1 shows the main clinical/echocardiographic characteristics. Mean age was 80±7 years, median ejection fraction was 45% (IQR=33–55). All patients were treated with maximal tolerated doses of GDMT and, if appropriate, with cardiac devices/myocardial revascularization. ≥3+/4+ MR and/or TR was observed in 92 (7.3%) and 117 (9.3%) patients, respectively. Patients with isolated significant MR were 56 (4.4%), with isolated significant TR were 81 (6.4%); the remaining 36 (2.8%) had both MR/TR. Among patients with significant MR, 50 (54%) had functional/secondary valvular defect (details in Figure 2): the majority (41,82%) presented a ventricular etiology (asymmetric tethering in 18/41) while 9 (18%) an atrial one (atriogenic tethering in 3/9).

Conclusion

Despite optimized GDMT, the prevalence of patients with hemodynamically significant valvular defects was considerably high in our HF population. This is the first registry to comprehensively detail atrioventricular valve regurgitations’ mechanisms in a wide real–life cohort of HF outpatients. Further studies are needed to identify reasons for potential undertreatment and patients who would benefit the most from percutaneous correction of their valvular defects.
C79 LONG–TERM OUTCOME IN PATIENTS UNDERGOING HIGH–RISK PERCUTANEOUS CORONARY INTERVENTION WITH THE SUPPORT OF IMPELLA CP: A SINGLE CENTER EXPERIENCE
Authors: Azzarelli S , Tomasello S , Franchina A , Milluzzo R , Scardaci F , Di Giorgio A , Argentino V , Amico F
Published: May 2022

Background

Nowadays use of the Impella for high–risk percutaneous coronary intervention (PCI) is increasing worldwide. The aim of this study is to evaluate in–hospital and long–term outcomes of patients treated for high–risk PCI with the use of Impella CP device.

Methods

This is a single center registry, which enrolled all consecutive patients treated at Cannizzaro Hospital for high–risk PCI with the use of Impella CP. Data were prospectively entered into a dedicated database.

Results

From January 2019 to December 2021, 16 patients were enrolled of which 75% were male. The clinical presentation at admission was an acute coronary syndrome in 87.5% of cases (myocardial infarction in 13 patients, unstable angina in 1 subject). The mean left ventricular ejection fraction at admission was 35 ± 7.6%. Ten subjects (62.5%) had diabetes treated with insulin in 90% of cases. The Syntax score was 29 ± 12.3 and the mortality STS score was 8.1 ± 10.4. Left main disease involved 8 (50%) patients, whereas a 3–vessels disease was present in 56% of cases. In most cases –14 (87.5%) patients– the Impella CP was introduced through the femoral artery with percutaneous access, whilst only in 2 (12.5%) subjects a surgical access was necessary. An anatomical complete revascularization was performed in 7 (43.8%) patients. For a total of 2 ± 1 vessels treated for patient and 3 ± 1.3 lesions undergoing PCI, 3 ± 1.8 stent were implanted with a mean total stent length of 81 ± 44.3 mm. In all cases, the Impella CP device was placed in left ventricle before PCI and removed a few minutes after the end of procedure, with a mean duration of mechanical circulatory support of 2.7 ± 0.8 hours. Only 1 (6.2%) patient died in hospital due to sepsis, whereas a clinically–evident bleeding occurred in 5 (31.3%) subjects (4 were access–site bleeding) and 4 (25%) patients underwent red blood cells transfusion; no acute limb ischaemia or aortic/left ventricle injury occurred. On a mean follow–up of 13 months from procedure date, any myocardial revascularization occurred in 2 (12.5%) patients, of whom 1 (6.2%) was a target–vessel revascularization. Four (25%) patients died but only 1 (6.2%) due to cardiac death: 2 subjects died as result of sepsis following pneumonia and 1 sepsis complicating gangrene.

Conclusion

Our study demonstrates the feasibility and efficacy of high–risk PCI protected by Impella CP, showing an acceptable long–term clinical outcome in a very high risk cohort of patients.
P2 IMPACT OF CATHETER ABLATION ON ARRHYTHMIC STORM: A SINGLE–CENTER EXPERIENCE
Authors: Cutolo A , Bellin A , Antonucci A , Cavalli G , China P , Quinto L , Vitale R , Themistoclakis S
Published: May 2022

Background

Arrhythmic storm (AS) is a medical emergency whom management is multidisciplinary and includes antiarrhythmic medications, sedation and mechanical circulatory support, as well as catheter ablation, a procedure that is gaining growing relevance in clinical practice, supported by guidelines.

Methods and Aims

It is a retrospective observational study of patients admitted to Cardiology Department of Ospedale dell’Angelo for AS from 2016 to 2021. The primary endpoint was the rate of arrhythmic recurrences and their clinical predictors; the secondary endpoint was a composite of all– cause death, LVAD or cardiac transplant. Successful CA was defined as no inducibility of any VT at the end of the procedure.

Result

We evaluated 74 patients. Catheter ablation (CA) was performed in 56 patients, while in the other 18 patients, the treatment of the arrhythmic emergency was limited to medical therapy. At a median follow–up of 10 months (range 4–36 months), the overall arrhythmic recurrence rate was 39.1% and AS recurrence occurred in 11% of patients; the incidence of the composite end–point of all–cause death, LVAD implant or cardiac transplant was 20.2%. B–blockers (85% vs 100%, p = 0.025) and successful CA (60% vs 88.6%, p = 0.021) were associated with less arrhythmic recurrences. At multivariate analysis, a successful CA was an independent predictor of arrhythmic recurrence free survival (HR 0.32, [0.11–0.94], p = 0.039), and of ICD shocks free survival (HR 0.087, [0.02–0.37], p = 0.001). ICD shocks at admission (8.06 ± 9.8 vs 3.18 ± 4.24, p = 0.005), NYHA class III–IV (46.6% vs 5%, p = 0.001), medical treatment (53.3% vs 83%, p = 0.031), ICD shocks during follow–up (53.3% vs 18,6%, p = 0.004) and AS recurrence (33.3% vs 10.1%, p = 0.039) were associated with an increased rate of the secondary endpoint.

Conclusions

In our real world experience of patients admitted for AS, CA was a predictor of arrhythmic recurrence free survival and may have a role in improving quality of life and prognosis by reducing ICD shocks. CA was an independent predictor of the reduced incidence of all–cause death, LVAD implant or cardiac transplant, although this finding might reflect a more severe cardiac disease of the medically treated patients than a real benefit of CA on mortality.
P6 MICRA AV AS AN INNOVATIVE THERAPEUTIC OPPORTUNITY IN PATIENTS WITH A PAROXYSMAL ATRIOVENTRICULAR BLOCK OR AN ADVANCED OR PERSISTENT TYPE II 2ND–DEGREE ATRIOVENTRICULAR BLOCK
Authors: Dentico A , Ferrieri A , Epicoco G , Troccoli R , Carretta F , D‘Agostino C , Carretta D
Published: May 2022

Introduction

Micra AV is the technological evolution of Micra VR. It’s a monocameral leadless pacemaker that works like a VDD PM, synchronizing atrial activity with the ventricular one. The purpose of the study is to evaluate the response of Micra AV in patients with a paroxysmal atrioventricular block, in which a low percentage of stimulation is expected, and in patients with AVB with normal atrial activity.

Materials and Method

From August 2020 to June 2021 in our center were implanted 11 Micra AV: 4 for advanced AVB, 3 for a paroxysmal AVB and 4 post–extraction. To all patients it was given remote monitoring to guarantee a constant remote follow–up. For each one, were analyzed the values measured at the implant’s moment and those of periodic remote follow–ups, paying particular attention at the device’s percentage of stimulation. Furthermore, a questionnaire was submitted to detect the psychophysical condition, the way in which the device interferes in everyday life, any physical pain, the emotional state, always correlating post–operative with the pre–operative. Particular attention was paid to the decrease in the incidence of adverse events or post–operative complications. In this way, it was possible to focus the study on 3 aspects: technician, quality of post–implant life and the device’s approval.

Results

All patients no longer presented syncopes during a follow–up ranging from a minimum of 5 to a maximum of 10 months. About the analysis made on the percentage of stimulation, the results were obtained by dividing patients into 2 groups based on the nature of the block. Almost all patients with advanced AVB presents a percentage of stimulation that doesn’t exceed 20%; in subjects with paroxysmal AVB this remains below 2%. The results of the questionnaire instead show how the leadless PMs are more appreciated both for a lower aesthetic impact, and for minor functional consequences linked to the lack of catheters who often limit the patient. This results in a better patient–device relationship and better acceptance of the leadless device.

Conclusions

The use of a Leadless PM in patients with syncope is still to be deepened and for this we will have to follow these patients over time to have a wider cases. A certain data is that these PMs are more appreciated as they have less impact on the quality of patients’ life.
P15 AN OLD MYOCARDIAL INFARCTION UNMASKED BY UPGRADE TO HIS BUNDLE PACING: A CASE REPORT
Authors: Marinaccio L , Patrassi L , Vetta F , Marchese D
Published: May 2022

Case Report

We report the clinical case of a 71–year–old man who was implanted with a dual–chamber PMK for complete atrioventricular block in 2012. In 2013 he was treated with two percutaneous coronary intervention (PCI) and stenting of the left anterior descending coronary artery (LAD) and right coronary artery (RCA).In March 2021, he was referred to our hospital for acute heart failure. Transthoracic echocardiography showed diffuse hypokinesis, with a left ventricular ejection fraction (LVEF) of 28% (46% six months earlier). ECG showed atrial flutter and paced ventricular rhythm with notch of the QRS complex in all 12 leads (Figure B). After achieving good clinical compensation with intravenous diuretics, the patient underwent coronary angiography with evidence of an unchanged coronary situation compared with 2013; Given the constant right ventricular pacing in the apex, we considered the LVFE decline as a consequence of pacemaker–induced cardiomyopathy (PICM)5 and a successful upgrade to HB pacing was performed. The surface ECG showed selective HB pacing with QRS width comparable to the native ECG (Figure A) but different morphology, because of evidence of QS complexes in V3–V6 and II, III, aVF (Figure C); physiological pacing obtained with selective HBP had made evident electrocardiographic signs of a previous myocardial infarction (MI).

Discussion

Very difficult is the diagnosis of a previous MI during RV pacing; to date, although considered questionable, we have only the criteria of Kochiadakis and colleagues (Figure 2A): – Notch of 0.04–second duration on the ascending limb of the S–wave of leads V3, V4, or V5 (Cabrera‘s sign). – Notching of the ascending stroke of the R wave in leads I, aVL, or V6 (Chapman‘s sign).– Q waves of 0.03 second duration in leads I, aVL, or V6. – Notch of the first 0.04 seconds of the QRS complex in leads II, III, and aVF. – Q wave of 0.03 seconds duration in leads II, III, and aVF. Occurring through the normal conduction system, HB pacing should generate a physiological myocardial repolarization resulting in a paced QRS complex with morphology and duration equal to the basal ECG, without alterations in the ventricular repolarization phase. As proof of the above, it was possible to appreciate that the transition from RV pacing to selective HB pacing allowed to unmasked the signs of a previous infero–lateral IMA, showing clear QS complexes in II, III, aVF, V3–V6.

Conclusion

Extremely old age should not discourage PM implantation, when indicated; age is obviously predictor of long–term death but is not predictor of precocious mortality. Acute periprocedural complication rate is low and generally comparable to that of younger populations.
P17 DOACS EFFECTIVENESS AND SAFETY: FURTHER CONFIRMATIONS FROM REAL WORLD EXPERIENCE
Authors: Ciavolella M , Cianfrocca M , Braccioli C , Ceccacci R , Bisegni S , De Carolis M , Ciavolella F , Bidolli F , Frongillo D , Sarli G
Published: May 2022

The present analysis is aimed to evaluate the use and results of direct oral anticoagulants (DOACs) in the past years, in a group of patients presenting with multiple comorbidies and at medium–high thromboembolic risk. In the past years, our outpatient Center followed 929 patients (mean age at admission 76.5 + 9.2 years, range: 29–99 years, 501 men), 848 with non–valvular atrial fibrillation/flutter, and 81 with recent phlebopulmonar thromboembolism (PPTE). An anamnesis of previous cardiovascular events were present in 302 patients (32.5%): coronary artery disease (146), carotid or peripheral atherosclerosis (109), cerebral stroke or ischemia (116). Initial CHA2DS2–VASc and HASBLED score were respectively 3.9 and 2.3 points. Patients were initially treated with Apixaban (A) (301, 89 with reduced dose, according to clinical–prescriptive characteristics), Dabigatran (D) (332, 256 with low dose), Edoxaban (E) (161, 83 with reduced dose), Rivaroxaban (R) (135, 53 with reduced dose). All patients were followed–up periodically (every 6 months) with both clinical and instrumental controls (electrocardiogram, blood tests, etc.), re–evaluating risk factors, in order also to check indication and dosage appropriateness. After a mean follow–up of 3.8 years (range: 6 montsh–9 years), for a total of 3530.2 years*patient, 57 patients (6.1%) had stopped DOAC therapy, because of: severe renal failure (12), repeated bleeding (6), clinical criteria (19), mechanical valve insertion (7), detection of thrombophilia (5), left atrial appendage occlusion (3), frailty (5). In the remaining 872 patients, 33 strokes (7 relapses), 11 PPTE, 17 major bleedings, 24 clinically relevant bleedings, and 71 minor bleedings, occurred. DOAC dose reduction occurred in 101 patients (11.6%: 31on A, 25 on D, 16 on E, 29 on R), because of clinical criteria (28), renal failure (56), bleedings (17). A replacement with other DOACS occurred in 104 patients (11.9%: 7 on A, 71 on D, 5 on E, 21 on R), because of renal failure (29), digestive disorders (27), bleedings (32), thrombotic events (6), lactose intolerance (3), allergic reactions (7). Clinical–and instrumental periodical control of patients treated with DOACs confirmed their effectiveness and safety, even in a population at medium–high thromboembolic risk. Additionally, such a management may allow also a greater prescribing appropriateness, as well as a safer and reliable follow–up over time of these patients.
P19 ECHOGRAPHIC EVALUATION OF INFERIOR VENA CAVA AND FLUID CHALLENGE RESPONSE IN PAROXYSMAL ATRIAL FIBRILLATION: A PRELIMINARY STUDY
Authors: Cavallaro M , La Montagna C , Casaretti L , Aprile A , Corbacelli C , Ponticelli P , Tuccillo A , Irace L , Tuccillo B
Published: May 2022

Introduction

Volume depletion can trigger atrial fibrillation through the alteration of the balance of autonomic tone. Hemodynamic response to crystalloid infusion has never been investigated in Paroxysmal AF patients. In this pilot study we have evaluated volume expansion response using Doppler echocardiogaphy in a group of patients coming to our Emergency Department because of symptomatic paroxysmal AF.

Methods

In a group of consecutive Paroxysmal AF patients we performed a comprehensive echocardiographic examination including Vena Cava diameters and inspiratory collapse rate (from bidimensional subxiphoid view) and including Left Ventricular Outflow time–velocity integral (as mean value of 10 consecutive cardiac cycles). Those with mitral, aortic or tricuspid regrgitation of grade higher than 2+/4+, mitral stenosis, prosthethic mitral valve, FE < 55%, estimated sPAP higher than 40 mmHg were excluded. Thus we selected 13 patients (mean age 67,25 years, range 34–83). Time–velocity integral of LVOT was re–evaluated after intravenous infusion of 500 cc of normal saline in 10 minutes. An increase of at least 10% of LVOT time–velocity integral from baseline was considered as positive response to volume challenge, as stated in previous studies (1,2).

Results

Fluid challenge showed positive response in 7/13 patients. From ROC curve analysis an inspiratory diameter of 9,5 mm or a respiratory collapse of 52% or more both had a 75% sensitivity for volume challenge responsiveness.

Conclusion

Accounting for small sample size this preliminary work suggests that non invasive bedside parameters easy to evaluate can guide Paroxysmal AF management with crysalloid infusion on top of standard therapy. 1. Preau S et al Crit Care Med 2016; 45: e290–7 2. Bortolotti P et al Ann Intensive Care 2018; 8: 79