bluuebunny/crossref_metadata_2025 huggingface dataset:
CHOLESTEROL–LOWERING THERAPIES IN ACUTE CORONARY SYNDROME: A SINGLE–CENTER OBSERVATIONAL STUDY
Authors: Marino G , Spinelli A , Macchiusi A , Altamura V , Di Fusco S , Aquilani S , Aiello A , Colivicchi F
Published: May 2024

Background

LDL–cholesterol (LDL–C) is a key target of atherosclerotic cardiovascular disease secondary prevention. We report a cohort study aimed at assessing lipid–lowering drug use in patients hospitalized for acute coronary syndrome (ACS).

Methods and Results

In this single–center observational study we enrolled 81 patients hospitalized from September to October 2023 at the Clinical and Rehabilitation Cardiology of the San Filippo Neri Hospital with diagnosis of ACS treated with angioplasty. Thirteen (16.05%) of these patients had no history of ASCVD, 68 (83.95%) patients had a history of ASCVD. Among the latter, 12 (17.65%) experienced a second vascular event within two years. At enrolment, LDL–C mean values in the total population were 86,31 mg/dl. LDL–C levels were higher in the group without a history of ASCVD than in the group with a history of ASCVD (109,30 mg/dl vs 82,31 mg/dl). In the subgroup of patients with a history of ASCVD and two cardiovascular events in the last two years, the mean level of LDL–C was 93.60 mg/dl. According to the most recent 2019 ESC/EAS guidelines, for patients with ASCVD (very high risk) the recommended therapeutic LDL–C goal is <55 mg/dl and for patients with ASCVD who experience a second vascular event within two years, an LDL–C goal of <40 mg/dl may be considered. In our study only 16,17% of patients with a history of ASCVD achieved such goals. At admission about half of patients included in this study (49,38%) were not prescribed any therapy, 16,05% received monotherapy (statins or ezetimibe or nutraceuticals), 28,40% were taking combination therapy (statin + ezetimibe) and 6,17% other combinations of statins, ezetimibe, nutraceuticals, and Proprotein Convertase Subtilisin/Kexin–type 9 inhibitors (PCSK9i) (Figure 1). At discharge 80,25% of all patients received combination therapy (statin + ezetimibe), 13,58% received other combinations (statin + ezetimibe + PCSK9i; statin + ezetimibe + bempedoic acid; statin + ezetimibe + inclisiran; statin + ezetimibe + omega–3 fatty acids; ezetimibe + inclisiran), 6,17% received monotherapy (PCSK9i or statin) (Figure 2).

Conclusion

Before hospitalization the use of cholesterol–lowering therapies was not optimal and the majority of patients had LDL–C level higher than recommended targets. Hospitalization allowed us to optimize and personalize the therapy and to prescribe some of the newest cholesterol–lowering drugs.
ROLE OF THE MACHINE LEARNING–DERIVED HYPOTENSION INDEX (HPI) TO CONTAIN INTRAOPERATIVE HYPOTENSION DURING TRANSCATHETER EDGE TO EDGE REPAIR PROCEDURES
Authors: Lombardi F , Lucarelli K , Frassanito L , Casamassima V , Troisi F , Bellomo V , Argentiero A , Mancini G , Casamassima F , Lanza G , Burzotta F , Grimaldi M
Published: May 2024

Introduction

Percutaneous endovascular valvular interventions can result in profound hemodynamic instability, elevated burden of intraoperative hypotension (IOH) and related postoperative complications: ischemic stroke, acute kidney injury and increased mortality. Machine learning(ML),a branch of Artificial intelligence (AI), can analyze large volumes of data, find associations and allowing predictive rather than reactive interventions. The Hypotension Prediction Index (HPI)a ML derived algorithm,provides a unitless number from 0 to 100, that increases accordingly to the risk of developing a hypotensive event (mean arterial pressure – MAP – < 65 mmHg for more than 1 minute) in the following minutes. The aim of this study is to describe IOH in patients undergoing percutaneous valve repair under general anesthesia treated according to an HPI–based hemodynamic guidance (fig.1).

Methods

Eligible adult patients undergoing transcatheter valve repair procedures (MitraclipTM, TriclipTM)were included in the study. When HPI value exceeded 85,a proactive individualized treatment protocol to prevent hypotension was provided according to the following modalities (fig. 2). Primary outcome measure was TWA–MAP (time weighted average mean arterial pressure)under the threshold of 65 mmHg. Secondary outcomes were number of patients with at least one hypotensive event, number of events per patient,depth and duration of hypotensive events and area under MAP threshold of 65 mmHg (AUT–MAP < 65).

Results

Twenty–five consecutive patients were prospectively enrolled and treated. During an average monitoring time per patient of 187 ± 31 minutes, the global burden of hypotension, measured as TWA–MAP < 65 mmHg, was 0.12 [0.02, 0.8] mmHg. Two thirds of the patients(16/25) experienced hypotensive events, with a median number of hypotensive events of 1 [0, 3.25] per patient and about 11% of the time spent < 65 mmHg. Each event lasted 4 [1.7, 8.6] minutes with a MAP of 59 [56, 62] mmHg, leading to a total AUT–MAP < 65 mmHg of 20.3 [3.5, 142.2] mmHg x minutes. The majority of hypotensive events occurred after induction of general anesthesia, while hypotension was rare during the procedure (fig. 3).

Conclusions

HPI algorithm provides accurate and continuous prediction of impending IOH before its occurrence. Machine learning models,as in the case of HPI, could facilitate the physicians to treat IOH which is a potentially modifiable risk factor for major postoperative complications.
NURSING COUNSELING FOR THE OPTIMIZATION OF THE REMOTE MANAGEMENT OF PATIENTS WITH ILR AFTER CRYPTOGENIC STROKE
Authors: Bruno R , De Marco G , Affuso N , Chiarello O , De Fazio D , Mazzei E , Fortuna C , Tomaselli C , Talarico A , Quirino G
Published: May 2024

Background

ILR is a device used to diagnose and document cardiac rhythm disorders in various clinical contexts including syncope and CS. The ILRs can be remotely monitored through a dedicated system consisting of a fully automatic home monitor or, in the latest generation devices, throughan APP that can be downloaded by the patient on his mobile phone. ILR remote monitoring can be performed by the nurse after acquiring the necessary skills on system functioning and knowledge about heart rhythm disorders.

Methods

Since 2017, a collaboration between Cardiologists and Neurologists has been established at our hospital providing a shared protocol for the management of patients with CS implanted with an ILR to detect asymptomatic AF. All CS patients referred for ILR implantation at our center received a MEDTRONIC ILR and were equipped with a remote monitoring system. ILR management protocol includes a first phase after the implant, where the nurse carries out patient training and counseling; enters all data in the Medtronic Carelink website, provides the patient with the home monitor, clearly explaining its use at home and, finally, obtains patient informed. Second phase of the protocol includes patient FU management, where the nurse reviews all remote transmissions, identifies any arrhythmic events and contacts by phone the patient to evaluate symptoms and, in case,establish the date for FU.

Results

Since 2017, 70 pz with CS (mean age:65±9 years,67.24% with CHADS2–VASc Score >=4) underwent ILR implantation.ILR remote monitoring allowed the diagnosis of AF in 27% pz (asymptomatic in 72%), of bradyarrhythmia in 4% and VT in 2%. Patients with arrhythmic diagnoses were contacted for FU in H to set up appropriate intervention. In described care pathway, the training and counselling carried out by nurses after the implant was crucial to establish the relationship of trust between patient and nurse, which significantly improved patient compliance.

Conclusions

The use of ILR has allowed to detect arrhythmias, even when asymptomatic, in patients affected by CS. In our experience, remote monitoring managed by trained nurses was crucial for the early diagnosis of AF. However, since technology is rapidly evolving, training updates to nurse staff regarding remote monitoring systems are essential to improve the counselling. Teamwork and constant cardiologist–nurse communication proved to be fundamental in offering the best care to these patients.
WHAT IS THE EXPERIENCE OF CARDIAC SURGERY PATIENTS REGARDING THE NURSING CARE THEY RECEIVE? SCOPING REVIEW
Authors: Ulisse A , Moro A , Magon G , Cislaghi A , Stella M , Bonino E , Caccamo D , Dimito M , Adamini L
Published: May 2024

Introduction

The patient experience is recognized as a key indicator of the quality of healthcare. Patients‘ expectations and experiences significantly influence health outcomes, including the effects of treatments in specialized settings, such as cardiac surgery. Cardiovascular disease is one of the world‘s major public health problems, and people who survive a heart attack become ‘chronically ill‘, resulting in economic costs to society.

Aim

The aim of this scoping review is to investigate and highlight the experiences of patients undergoing cardiac surgery, identifying which factors are considered significant and which have led to patient discomfort, in order to improve nursing care.

Methods

A scoping review was conducted in June and July 2023 and the scoping followed the guidelines outlined by Joanna Briggs Institute. The drafted review protocol is aligned with the PRISMA guidelines. The search for relevant articles was conducted using 6 databases (PubMed, Cinahl, Web of Science, PsycInfo, Scopus, Embase), and articles extracted from secondary bibliographies were also considered. All paper with a qualitative approach, as this is the methodology that provides the best understanding of the patient experiences about nursing care, written in Italian or in English, in the field of cardiac surgery and referring to the review question were included.

Results

The analysis of the qualitative data extracted from the 43 articles identified 4 themes – communication, perceived professionalism, nurse–patient relationship, patient needs, and criticality – and 43 subthemes, which were differentiated into 16 "positive" and 27 "negative" subthemes, depending on the meaning reported by patients. For each subtheme, the frequency of recurrence was calculated since they do not all have the same weight and recurrence.

Conclusions

This review has extrapolated from the patient experience which areas of nursing care are considered significant by patients and which need improvement and more attention. In order to increase personalized and patient–centered nursing care, it is now necessary to consider the experiences, and emotions of patients undergoing cardiac surgery to nip worries and anxieties in the bud, promote rapid recovery in the postoperative period, and foster improvement in the quality of nursing care.
MYOCARDIAL INFARCTION DUE TO LEFT CIRCUMFLEX ARTERY OCCLUSION: A SUBTLE TROJAN HORSE
Authors: Ottaviani A , Foglietta M , Ricci F , Zimarino M , Renda G , Gallina S
Published: May 2024

A 47–year–old man presented to the emergency department complaining of recurrent chest pain (CP) since the previous day. His medical history included active smoking and dyslipidemia. The ECG revealed sinus bradycardia (56 bpm) with widespread ST elevation, consistent with benign early repolarization, and hyperacute and broad–based T waves in V2–V3 (Fig. A). The echocardiography showed normal left and right ventricular systolic function and no valvular abnormalities. A low but abnormal initial high–sensitivity cardiac troponin I value (40 pg/mL, normal range: 1.7– 34,2 pg/mL) and a slightly and early increase after two hours (52 pg/ml) were seen. Therefore, the patient was admitted to our intensive cardiac care unit (ICCU) with a working diagnosis of non–ST–segment elevation myocardial infarction (NSTEMI). No sign or symptoms of heart failure on physical examination were recorded. GraceScore 2.0 was calculated as 68 points and coronary angiography was organized within 24h. Two hours after admission to the ICCU, the patient experienced a new episode of CP. Consequently, ECG and echo were repeated. Compared to the previous results, ECG showed dynamic changes in V2–V3, with the resolution of hyperacute T waves (Fig B); bedside echo remained unchanged. Considering the unresponsiveness to nitrate therapy, the cath lab was activated for a time–dependent coronary angiography. The exam showed an acute total thrombotic occlusion of the mid–segment of the circumflex branch (LCx) in the setting left–sided dominant circulation. A drug eluting stent was deployed into the culprit lesion (Fig. C), and the coronary flow was restored completely (TIMI Flow 3). The subsequent hospital stay proceeded without complications. The peak troponin level was 60’000 pg/ml. The patient was discharged on the fifth day, asymptomatic and hemodynamically stable, with instructions to continue dual antiplatelet therapy. The case report focuses on the electrocardiographic and angiographic expression of LCx total occlusion. Despite acute myocardial infarction (AMI) size was large, as confirmed by the abnormal troponin I values and the angiographic total occlusion, the first and the repeated ECGs showed only vague repolarization changes without clear ST–segment modifications. LCx occlusion is often characterized by the absence of significant ST–elevation, therefore categorized as NSTEMI. Greater awareness of the presentation of LCx–related AMI can be crucial to avoid delays in reperfusion.
HOSPITAL READMISSION PREVENTION IN PEOPLE WITH HEART FAILURE: NURSING EDUCATIONAL INTERVENTION USING GORDON‘S FUNCTIONAL HEALTH PATTERNS
Authors: Feletto E , Mazzariol E , Moschetta S
Published: May 2024

Background

Heart failure (HF) is a complex clinical syndrome that combines common characteristics that manifest differently in each patient. A personalized educational intervention is essential at the time of discharge to the home to identify the educational needs and resources of the person. It is, therefore, necessary to start from an organized and precise collection of data to adapt the intervention to the needs of the patients, guarantee a good quality of life, and prevent the relapses of chronic pathology.

Objective

The research aims to describe the best educational nursing strategies relating to Gordon‘s Functional Health Patterns for patients with HF upon discharge to prevent readmission.

Methods

A narrative review of the literature was conducted by consulting the MEDLINE (via Pubmed) and Cumulative Index of Nursing and Allied Health Literature (CINHAL) databases, inserting free and MeSH terms. Twenty–eight articles were included in the literature.

Results

The results obtained from the analysis of the materials were divided into two macro areas: the first concerns aspects relating to nursing education according to Gordon‘s Functional Health Patterns; the second concerns the effects of education on hospital readmissions. Compared to Functional Health Patterns, the literature pays little attention to the educational aspects of Sexuality and Reproduction and Values and Beliefs. Although other health problems can be considered a priority, these two elements can be regarded as relevant for the patient to live with the pathology and maintain psychological and relational well–being during treatment and rehabilitation. Furthermore, the literature has underlined how a personalized educational process at discharge helps prevent hospital readmissions due to disease exacerbation within 30 days.

Conclusions

According to Gordon‘s Functional Health Patterns, the organization of nursing data can help the professional plan an effective educational intervention. Furthermore, this last moment of care is crucial in preventing hospital readmissions and guaranteeing the person‘s well–being at home.
CARDIAC CONTRACTILITY MODULATION: AN OPTION FOR CHRONIC HEART FAILURE; A CASE REPORT
Authors: Lamaida N , Cerciello A
Published: May 2024

Introduction

Cardiac resynchronization therapy (CRT) reduces hospitalizations and mortality in patients with advanced heart failure and prolonged QRS duration. In patients with a narrow QRS complex, CRT has failed to reduce the rate of death or hospitalization. Thus, there is an alternative device–based treatment for patients with persistent symptoms despite best medical therapy (BMT). Cardiac Contractility Modulation (CCM) is a relatively new electrical device–based technique proposed for enhancing ventricular contractile strength of the failing myocardium independent of the synchrony of myocardial contraction. In this work, we show the use of CCM therapy in an older patient with non–ischemic dilated cardiomyopathy without indication to CRT, demonstrating the clinical benefit of this novel HF device–based therapy.

Case Report

We present a 72–year–old patient successfully implanted with a cardiac contractility modulation (CCM) system. The patient had arterial hypertension, and a history of chronic heart failure (HF) due to non–ischaemic cardiomyopathy with severe systolic dysfunction (left ventricular ejection fraction [LVEF] 30 %). Due to persistent severe HF symptoms (NYHA class III/IV) despite BMT (bisoprolol 5 mg/die, sacubitril/valsartan 49/51 mg bis in die, SLGT2 inhibitors and eplerenone 25 mg/die), the NT–proBNP value was 1300 pg/mL, and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was 80 points. The patient was referred for implantation of a CCM system as a first–line cardiac device treatment. The patient did not fit the criteria for cardiac resynchronization therapy (CRT) due to narrow QRS. At 3–month follow–up, the patient already experienced significant improvements in terms of quality of life with an MLWHFQ score of 20 and a decrease in BNP to 600 pg/mL In addition, no HF–related hospitalizations was observed. At 12–month follow–up, no HF–rehospitalizations occurred and the patient had stable NYHA class II, an LVEF of 40% (an increase in systolic function of the left ventricle using the Simpson biplane method) an MLWHFQ score of 6, an NT–proBNP value of 300 pg/m and stable renal function.

Conclusions

in this report, CCM proves to be an useful and safe HF device therapy for HFrEF not eligible for CRT implantation, led to improved quality of life and a reduction in HF–related hospitalizations in an older patient with HFrEF due to non–ischemic dilated cardiomyopathy.
PERCUTANEOUS MITRAL PLICATION FOR WEANING BY VA–ECMO IN PATIENT WITH OBSTRUCTIVE SAM ASSOCIATED WITH PRECLINICAL PHENOTYPE OF HYPERTROPHIC CARDIOMYOPATHY AND STEMI COMPLICATED BY CARDIOGENIC SHOCK
Authors: Rende G , De Rosa M , Perfetti M , Di Fulvio M , Giuliani L , Rossi S , Aquilani R , Di Pace G , Ricci F , Gallina S , Zimarino M , Appignani M
Published: May 2024

A 53–year–old man with a history of hypertrophic obstructive cardiomyopathy with a preclinical phenotype, classified at low risk of sudden cardiac death (HCM–SCD risk score 2.98%), and cardiac arrest (OHCA) in the absence of a shockable rhythm. The patient underwent cardiopulmonary resuscitation for more than 30 minutes before the diagnosis of complete atrioventricular block, masked by concomitant atrial stand–still, resolved after transcutaneous pacing. After temporary trans–venous cardiac pacing was obtained, the electrocardiogram revealed signs of an extensive anterolateral occlusive infarction (OMI), treated with primary angioplasty during percutaneous ventricular support (Impella CP). The ICU course was characterized by several ineffective attempts to wean from mechanical assistance to the circulation finally made possible by correction of outflow obstruction from mitral SAM, achieved by percutaneous mitral plication with MitraClip system. This case, in addition to suggesting an alternative strategy of weaning from mechanical assistance to the circulation in patients with a similar hemodynamic profile (SCAI D stage cardiogenic shock by dual mechanism: pump dysfunction and outflow obstruction), offers important insights into the management of OCHA in the absence of a shockable rhythm.
ECG SCREENING, HEART RATE VARIABILITY AND SUDDEN CARDIAC DEATH PREVENTION IN ENDURANCE ATHLETES
Authors: Crispino E , Ricciardi D , Liporace P , Sanasi L , Loiacono G , Italiano E , D‘Amore M , Sposito E , Marchi F , Picarelli F , Gioia F , Calabrese V , Ussia G , Grigioni F
Published: May 2024

Introduction

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. Identifying non–invasive and repeatable risk markers during annual athletes screening remains a goal for the scientific community for the prevention of SCD. The Heart Rate Variability (HRV) has been shown to be an independent predictor of mortality in populations with CVD, but its relationship with SCD has been little explored in those at low risk, including athletes. This study aims to use a 5 minute ECG screening in athletes practicing endurance sports and evaluate its clinical role. The aim of the study is to assess whether morphological and spectral ECG analysis in endurance athletes by the 5–minute ECG screening can add information to periodic screening for the prevention of SCD.

Methods

The study population were selected from Endurance Marathon athletes. A control group was also collected for comparison. The 5 minutes ECG was recorded at rest with the Kardia Mobile 6L. HRV indices were obtained using the Kubios software. A morphological analysis was performed and the HRV parameters were analyzed in the time and frequency domains.

Results

A total of 554 subjects (220 athletes and 334 controls, 325 male and 229 women) were analyzed. A higher incidence of arrhythmic and morphological abnormalities in athletes compared to controls was observed (p<0.05). Athletes had a significantly shorter QTc than the control group, a finding suggestive of greater protection from episodes of malignant ventricular arrhythmias. Th PNS and SNS indices were respectively higher and lower in the athlete group than in the controls, suggestive for higher vagal tone. Given the absence of a normality range of standard HRV parameters in the athlete population, values in the normal range of the 5th to 95th percentile were extrapolated in the whole population for the main HRV parameters. The project, therefore, is to evaluate patients with HRV values higher or lower than 5–95 percentile to identify those deserving further clinical investigations and closer follow–up for suspected increased risk of CVD and SCD.

Conclusions

The 5–minute ECG screening allows a greater number of static and dynamic alterations to be detected; moreover, the analysis of HRV could provide more information, such that it could be considered as a complementary tool during the athlete‘s follow–up. Further long–term prospective studies are needed to correlate alterations in HRV and clinical events.
VAI OF MARSHALL ETHANOL INFUSIONE: SOMETIMES, LESS CAN BE MORE. A CASE REPORT OF SAFETY WITHOUT DECEASING EFFICACY
Authors: Magnano M , Oriente D , Abdirashid M , Rametta F
Published: May 2024

Vein of Marshall ethanol infusion (VoM–EI) is a new therapeutic option effective for decreasing the likelihood of atrial tachyarrhythmias in patients with persistent atrial fibrillation (PAF). Complications related to retrograde EI described in the literature are rare but can have grave consequences for the patient. Our clinical case shows how a careful evaluation of the anatomy of the left atrium venous circulation can significantly reduce the risk of serious adverse events (SAEs). A 64–year–old man underwent a second ablation for symptomatic PAF with VoM–EI. Selective angiography (Fig.1) showed a particular anatomical variant: the VoM (antero–lateral) and a vein of the interatrial septum (postero–medial direction) originated from a posterior and proximal common trunk (CT). A limited perforation of the CT with the wire occurred as shown by the iodine extravasation into the pericardial space: this condition significantly increases the risk of delayed tamponade (DT), the most frequent SAEs related to this procedure. Furthermore, a rare SAEs observed in the literature is the appearance of complete atrioventricular block and has been correlated to the presence of septal collateral branches of VoM with particularly proximal origin (like that of our patient). Then, we decided to exclude the septal branch and VoM perforation from the EI area: an over–the–wire balloon was used to a selective EI in the antero–lateral branch of the CT distal to the perforation (Fig.3). As desired, only the VoM area was involved in the ethanol–related endocardial scarring, but its ventricular aspect was excluded (Fig.2): endocardial and within the coronary sinus RF delivery was therefore necessary to achieve complete conduction block at the mitral isthmus. No conduction disturbances appeared after EI. The patient was discharged 48 hours after the procedure and a weekly echocardiographic control in the month following discharge excluded DT. In conclusion, careful analysis of the anatomy in selected cases must guide the choice of the site of VoM–EI: excluding its most proximal portion can limit the extension of the scar, but can also significantly reduce the risk of severe complications.
BETWEEN SCYLLA AND CHARYBDIS: MULTIPLE LEFT ATRIAL THROMBI DESPITE ORAL ANTICOAGULATION AND ANTIPLATELET THERAPY IN A PATIENT CANDIDATE FOR LEFT ATRIAL APPENDAGE OCCLUSION
Authors: De Marchi A , Raccis M , Sanna G , Decandia F , Navarese E , Casu G
Published: May 2024

Introduction

Left atrial (LA) thrombosis usually occurs in patients affected by atrial fibrillation (AF), generally involving the left atrial appendage (LAA). We present the unexpected echocardiographic finding of multiple LA thrombi despite an adequate antithrombotic strategy.

Case Presentation

A 76–year–old lady underwent transesophageal echocardiographic examination (TOE) to assess eligibility for percutaneous LAA occlusion (LAAO) procedure due to high bleeding risk. Her medical history included AF and a recent percutaneous coronary revascularization; therefore, her antithrombotic therapy included apixaban 2.5 mg bid and clopidogrel 75 mg od. The TOE showed LA structural and functional remodeling with spontaneous echo contrast and multiple thrombi involving the LAA (one [12 x 9 mm] overflowing the orifice and attached to the Coumadin Ridge and the second [12 x 7 mm] attached and arising from the tunnel of patent foramen ovale). Mitral valve stenosis was excluded (Fig.1). Due to TOE findings, the patient was not considered eligible for percutaneous LAAO. Due to the concomitant very high thromboembolic risk, despite the previous intracranial bleeding, we decided to stop apixaban and to start parenteral anticoagulation for 3 weeks with low–molecular weight heparin (100 UI/kg bid) followed by the switch to a vitamin k antagonist (VKA). We also prescribed a hematological evaluation to exclude a hypercoagulability disorder. Our patient’s daughter was a carrier of a mutation in both the methylenetetrahydrofolatereductase and Thrombin genes. A TOE after 30 days showed the persistence of LA thrombi, although with significantly reduced size and mobility (Fig.2). The follow–up was clinically uneventful. We suggested to continue anticoagulation therapy with VKA, and we planned a new TOE after 4 weeks.

Discussion

Although proper anticoagulation decreases cardioembolic risk in patients with AF, atrial thrombosis may occur due to LA remodeling, high CHA2DS2–VASc score and other factors, including hypercoagulability disorders. The presence of multiple LA thrombi represents a challenge for clinicians, especially in case of concomitant high thromboembolic and bleeding risk. However, the best treatment strategies for these extreme conditions are not defined, so far. Therefore, the therapeutic choice is often tailored to the single patient and based on the clinical judgment, bearing in mind that avoiding Charybdis means passing to close to Scylla and vice versa.
A CASE OF A HUGE AORTIC PSEUDO–ANEURYSM FOLLOWING AORTIC BIO PROSTHETIC ENDOCARDITIS: KEY ROLE OF 3D ECHOCARDIOGRAPHY
Authors: Sordelli C , Fele N , Weisz S , Verde R , Guarino A , Mazzella F , Claudia S , Severino S
Published: May 2024

Complications of infective endocarditis (IE) are associated with increased mortality and morbidity and therefore guidelines recommend early surgery [. Although two–dimensional echocardiography (2D) is the first line investigation, three–dimensional (3D) imaging provides incremental diagnostic information by allowing visualisation of structures in multiple planes. We present a cases which demonstrate how 3D imaging provides better morphological assessment of valve leaflets and associated structures, allows greater accuracy in identifying complications of IE. A 47 year old male with previous meccanic prosthetic aortic valve replacement was admitted to our department for evaluation of pyrexia. Lab–work was notable for leukocytosis with a white blood cell count of 13.000/mm3 and a hemoglobin level of 10.8 gr/dl. Blood cultures grew Staphylococcus Epidermidis. A transesophageal echocardiogram was performed showing a pulsatile perivalvular echo free–space with colour Doppler flow inside suggestive of an aortic pseudoaneurysm . 3D–TEE imaging provides better morphological assessment of aortic pseudoaneurysm. 3D TEE clearly demarcates an irregularly shaped of perivalvular cavity and through multiplanar reconstruction allowed a correct evaluation of the area and circumference. Conclusione: Decision making in IE is complex. The most common indications for early surgery are development of heart failure, uncontrolled infection or risk of embolism. In particular uncontrolled infection is commonly due to perivalvular abscess formation. 3D–TOE allows rapid, accurate, unique assessment of IE complication through unlimited multiplanar reconstructions, volume–rendered real–time imaging and colour full–volume regurgitation assessment which may not always possible on 2D–TTE or 2D–TOE. This case demonstrate how traditional 2D TEE may provide incomplete anatomical information. 3D imaging improved identification and characterisation of the complications of IE. The complementary data provided aids in decision making with regard to both requirements for timing and planning of surgery.
A RARE CASE OF LOEYS–DIETZ SYNDROME: THE IMPORTANCE OF DIAGNOSIS IN PATIENTS UNDERGOING CARDIOVASCULAR SURGERY
Authors: Mandi O , Agusto S , Contiello C , D‘Ambrosio G , Baldasseroni S , Orso F , Silverii M , Burgisser C , Fattirolli F , Ungar A
Published: May 2024

Background

Loeys–Dietz syndrome (LDS) is a rare autosomal dominant genetic disorder of connective tissue, characterised by a broad spectrum of craniofacial, vascular (arterial tortuosity and aneurysms) and skeletal clinical signs. Four subtypes have been described, related to mutations in genes encoding for components of the transforming growth factor beta signalling pathway (TGFBR1, TGFBR2, SMAD2, SMAD3, TGFB2 and TGFB3). Diagnosis is based on the evaluation of clinical manifestations and family history. Therefore, many radiologists remain unfamiliar with the imaging and clinical findings in LDS.

The Case

75–year–old woman, history of surgery for ruptured gastric a. aneurysm and ectasia of visceral arterial vessels. One year onset of worsening dyspnoea and asthenia, at echocardiography (ECOCG) severe aortic insufficiency has been detected and patient underwent aortic valve replacement with bioprosthesis. Cardiac surgery was complicated by aortic dissection (Stanford A; DeBakey I type) treated with replacement of ascending aorta and anterior hemiarch with tubular prosthesis. On that occasion a family diagnosis of SMAD3 gene mutation was made (both sister and nephew typed), compatible with Loeys–Dietz syndrome type 3. At the control angioTC evidence of proximal and distal anastomosis in order, in the absence of signs of periprosthetic leak. At ECOCG (FE 55%), thickened septum with marked postcardiac dyskinesia. No abnormality detected on ECG. Due to persistence of dyspnoea on mild exertion (NYHA class III) and reduced tolerance to orthostatism, cardiac rehabilitation program was undertaken on an outpatient basis for three months, providing an improvement in exertion tolerance (NYHA II) and a benefit on functional autonomy. LDS is a multisystem connective tissue disorder that is associated with a high burden of complications, a correct diagnosis will allow clinicians to appropriately establish the best therapeutic strategy, especially in cardiac surgery, taking into account the intraoperative and perioperative potential risks.
MULTIDRUG RESISTANT DYSLIPIDEMIA: A CASE REPORT
Authors: Daus F , Maloberti A , Pavanello C , Toscani G , Riccio A , Fabbri S , Ciampi C , Caccia A , Tognola C , Algeri M , Intravaia R , Merlini P , Mosca L , Cavallari U , Giannattasio C
Published: May 2024

Introduction

Recently introduced lipid–lowering agents (PCSK9–i, bempedoic acid) can efficiently treat statin–intolerant patients, who couldn‘t reach LDL target before. Nonetheless, there are still cases where the pharmacological management may have strong limitations.

Case Report

A 71 year–old woman, with multiple cardiovascular risk factors (diabetes, hypertension and familial dylipidemia, LDL–C 276) underwent heart transplantation for a hypertrophic cardiomyopathy with an evolution towards a dilated phenotype in 2005. Before the transplant, she was on low–dose statin treatment (pravastatin 10 mg/die) that was suspended years later owing to hyper–CKemia (600 U/L), despite her being totally asymptomatic. A second attempt with simvastatin/ezetimibe 40/10 mg resulted again in elevation of CK levels, associated with significant muscular pain. Thus, just ezetimibe was continued. In 2020, 15 years after the transplant, the patient underwent a coronary angiography showing a moderate coronary allograft vasculopathy (ISHLT CAV2). Specifically, a sub occlusive ostial left main coronary artery lesion was treated by percutaneous angioplasty and stent implantation. Since a lower LDL target was needed (LDL–C 55 mg/dL), Alirocumab was introduced. However, 6 months later, no significant LDL levels reduction had been observed. The shift to evolocumab led to the same result, although the patient reported full therapeutic compliance. In the suspicion of anti–drug antibodies development, we opted for Inclisiran without achieving a significant decrease in LDL–C levels. In parallel with the search for genetic mutations in the PCSK9 gene and other genes involved in cholesterol metabolism (including LDLR, APOB, and LDLRAP1 and resulting positive only for common variants in LDLR receptor), therapy with bempedoic acid was initiated, again without substantial benefit (LDL–C 118 mg/dL).

Conclusion

Despite cholesterol management has been simplified by the introduction of new drugs, it may still be complex in patients requiring very low LDL–C levels in some specific cases. Drugs with a LDL receptor–independent mechanism of action (e.g., evinacumab) may allow the achievement of therapeutic goals suggested by clinical guidelines.
EARLY DIAGNOSIS OF A RARE PULMONARY VASCULAR CONDITION: THE NEED FOR A HIGH INDEX OF SUSPICION, A GOOD NETWORK, AND THE RIGHT TOOLS
Authors: Gagliardi M , Di Marco F , Bandera F , Perego G , Badano L , Parati G , Baratto C , Caravita S
Published: May 2024

Pulmonary veno–occlusive disease (PVOD) is a rare and deadly form of pulmonary arterial hypertension (PAH), characterized by preferential venular involvement/obliteration. This leads to reduced diffusion capacity of the lung (DLCO), oxygen desaturation, and pathognomonic alterations at chest computed tomography (CT): mediastinal lymph node enlargement, centrilobular ground–glass opacities, smooth thickening of the interlobular septa. PVOD is generally a late diagnosis that may benefit of lung transplantation only: acute pulmonary edema may occur after initiation of PAH–specific treatment. We report the case of a middle–age man in whom PVOD diagnosis was obtained only within 6 months from onset of symptoms and despite the absence of obvious CT findings. Treatment with PAH–specific drugs resulted in clinical and hemodynamic benefit. A 57–year–old male triathlete started complaining exertional dyspnea since December 2022. In February 2023, acute and chronic pulmonary embolism, as well as intracardiac and intrapulmonary shunt were excluded. Chest CT did not reveal relevant significant abnormality. Lung volumes were normal but DLCO was severely reduced (40%). Echocardiography suggested a low probability of PH, and BNP was normal. Right ventricular dimensions and function were within normal limits (RVEDV 90 mL/m2, RVEF 53%). Cardiopulmonary exercise test showed a moderate reduction of exercise capacity, an exercise–induced oxygen desaturation and a marked exercise–induced hyperventilation. He was thus referred to our center to undergo right heart catheterization (RHC) and invasive CPET (table). Genetic testing excluded EIF2AK4 gene mutation. A presumptive diagnosis of sporadic PVOD was made. Treatment with macitentan 10 mg was started, and well–tolerated. Three months later, both hemodynamics and exercise capacity were nearly normalized (table). Further treatment escalation adding tadalafil 40 mg was discussed and started. After that, the patient reported additional symptomatic benefit with improved exercise tolerance. This case raises several considerations: i) we need a high index of suspicion and a network approach to obtain early diagnoses of rare pulmonary vascular diseases; ii) CPET can enhance the diagnostic suspicion; iii) a low threshold for RHC in patients with unexplained dyspnea might be considered; iv) an early diagnosis and treatment of PVOD with PAH–specific drugs in our case was associated with clinical improvement, despite their intrinsic risk.
ONE STEP BEFORE EOSINOPHILIC CARDIOMYOPATHY
Authors: Mastroberardino S , Segreti A , Piccirillo F , Grigioni F , Ussia G
Published: May 2024

A 57–year–old woman was admitted to our Emergency Department (ED) for chest pain, cough, and fever that appeared a few days before. She was affected by bronchial asthma since childhood. The EKG showed a new–onset right bundle block, and the blood samples increased myocardionecrosis markers. A coronary angiography was performed showing coronary arteries free from lesions. Therefore, a transthoracic echocardiogram demonstrated a significant diastolic dysfunction with reduced global longitudinal strain (GLS). A cardiac magnetic resonance (CMR) showed mildly reduced left ventricle ejection fraction (LVEF) with hyper–intensity of the anterolateral wall. The high–resolution chest tomography (HRCT) showed: diffuse parenchymal thickenings, partly with a ribbon–like morphology and a ground–glass appearance. A high eosinophil count was observed in peripheral blood and bronchoalveolar lavage (BAL) during hospitalization. To conclude, even a healthy person with an atopic pre–disposition may experience a hypersensitivity reaction to an inhaled antigen and develop a lung or cardiac affection. Our patient’s symptoms improved with high–dose steroids, as well as the chest computed tomography and the transthoracic echocardiogram showed a general improvement. This may be justified with a possible immune–related origin of the pathology so that eosinophilic pneumonia may be thought to represent the stage before Loeffler endocarditis.
MULTIDISCIPLINARY APPROACH TO A DIFFICULT CASE OF ACUTE HEART FAILURE DUE TO POSSIBILE ISOLATED CARDIAC SARCOIDOSIS
Authors: Mapelli M , Grilli G , Campodonico J , Vignati C , Baggiano A , Majocchi B , Bianchini L , Ianniruberto M , Doni F , Fazzari F , Tassetti L , Pontone G , Agostoni P
Published: May 2024

Background

Cardiac sarcoidosis (CS) is a rare, infiltrative cardiomyopathy that results from granulomatous inflammation affecting the heart with high morbidity and mortality. It is usually associated with a systemic (i.e. pulmonary) involvement, but lone heart involvement has been described. Even with extensive multidisciplinary evaluation making a firm diagnosis is difficult, especially in case of isolated CS where the endomyocardial biopsy (EBM) diagnostic yield is low (20–30%).

Case Description

A 71–year–old patient, heavy smoker with no previously known diseases, was admitted with a 3–month history of dyspnea. On admission he showed typical features of heart failure with reduced ejection fraction (HFrEF). A coronary angiography excluded coronary artery disease, while echocardiography (TTE), cardiac magnetic resonance (CMR), and positron emission tomography (FDG–PET) showed a pattern consistent with a non–ischemic dilated cardiomyopathy with reduction in systolic function, and signs of active inflammation (highly suspected CS). Two electroanatomic mapping driven EBM were made but no clear histological signs of CS (i.e., granulomatous inflammation) were detected. The patient was treated with corticosteroids and HFrEF optimal medical therapy (sacubitril/valsartan, mineralocorticoid receptor antagonists, beta–blockers, dapagliflozin) and a temporary wearable defibrillator (LifeVest) was applied. At 2–month follow–up, despite a moderate improvement in the systolic function and HF symptoms, after a multidisciplinary discussion, considering the extensive left ventricle scar, inflammatory involvement, and the presence of multiple non–sustained ventricular tachycardia, a permanent cardioverter–defibrillator (ICD) was implanted.

Conclusion

This case highlights how, even with (repeated) extensive multidisciplinary evaluation (TTE, CRM, FGD–PET, EBM), a definitive diagnosis of isolated CS often remains presumptive. The presence of an experienced cardiomyopathy team (HF specialists, cardiac imager, electrophysiologists, internal medicine doctor) can help in the diagnostic–therapeutic management of these patients with inflammatory heart disease.
A RARE CASE OF IPILIMUMAB/NIVOLUMAB–INDUCED MYOCARDITIS COMPLICATED BY HIGH GRADE ATRIOVENTRICULAR BLOCK IN A PATIENT WITH METASTATIC RENAL CELL CANCER
Authors: Logiacco A , Basile P , Mandunzio D , Gentile M , Carella M , Memeo R , Santobuono V , Forleo C , Ciccone M , Guaricci A
Published: May 2024

Background

Immune checkpoint inhibitors (ICIs) such as Ipilimumab and Nivolumab have revolutionized the field of cancer therapy. These monoclonal antibodies help to reinforce antitumor immunity, resulting in robust activation of the immune system which promotes tumor cell death. T–cell–targeted immunomodulators are now widely used in the treatment of about 50 cancer types, including metastatic Renal Cell Carcinoma (RCC). However, immune responses by ICIs, especially when used in combination, may lead to systemic immune–related adverse events (irAEs), such as inflammatory and non–inflammatory cardiotoxicity.

Case Presentation

A 70–years old woman without previous cardiovascular events, affected by RCC metastasized to lungs, was admitted to our intensive care unit for the onset of worsening fatigue and dyspnea after a second cycle of ICI–based combination therapy (Ipilimumab plus Nivolumab). The 12–lead ECG showed a third–degree atrioventricular block (AVB) with junctional escape rhythm and negative T–waves in inferior and lateral leads. The laboratory examinations revealed increased values of troponine I, myoglobin, C–reactive–protein and NT–pro–BNP. The transthoracic echocardiography was within the normal range. A temporary cardiac pacing was provided and an acute coronary syndrome was rule out by coronary angiography. High doses of intravenous methylprednisolone were initiated for the suspicion of ICIs–related myocarditis. Moreover, due to the persistence of the conduction disorders in the following days, a leadless atrio–ventricular pacemaker (PM) was implanted. During the in–hospital follow up no complications occurred, and the patients was discharged at home in good clinical condition. The therapy with ICIs was not resumed during the follow up.

Discussion

ICIs have improved the clinical outcome for several malignancies, although they may cause a wide spectrum of severe irAEs. ICI–related myocarditis is a rare but potentially life–threatening event with a high mortality without an early recognition. A strict monitoring involving cardiologists and oncologists should be advisable in patients treated with these innovative drugs, for a prompt identification and treatment of irAEs. In presence of these serious adverse events, the discontinuation of the immunotherapy with or without the administration of glucocorticoids should be considered. The development of persistent conduction alterations is infrequent and may require the implantation of a permanent PM.
A CASE OF STEMI COMPLICATED BY CARDIOGENIC SHOCK TREATED USING A MINIMAL APPROACH
Authors: Cangemi S , Inglese F , Vinci D , Barone G , Ferrarello S , Geraci G
Published: May 2024

Introduction

An 88–year–old woman was admitted to our hospital for a posterior STEMI. The medical history was significant only for arterial hypertension. The echocardiography showed a mild left ventricular global dysfunction (EF 48%) with hyperkinesia of the posterior wall. After administration of loading doses of acetylsalicylic acid, clopidogrel and heparin, the patient underwent coronary angiography.

Investigation

The coronary angiography showed an occlusion of a dominant left circumflex (LCx) in the proximal tract and an irregular plaque, determining a critical stenosis of the ostial left anterior descending (LAD) artery. After the diagnostic examination, the patient becomes very hypotensive (65/45 mmHg arterial blood pressure) and sleepy. Management Considering the impossibility of using the impella and the IABP because they were already used for other patients, we decided for a minimal approach guided by intracoronary imaging. We used an XB 3.0 6F guide catheter, crossed the LCx with a BMW wire, and performed an inflation with a Semi–compliant 2.0x20 mm balloon, obtaining TIMI 3 flow. The “culprit lesion” was in the proximal tract of a trifurcation with three vessels of equal size. We decide to implant a 2.75x8 mm stent covering the lesion without protruding inside the left main. Because the patient was still hypotensive and started to have frequent ectopic ventricular beats often organized in run we decided to treat also LAD ostium stenosis avoiding to cover left main in the acute phase. So we implanted a 3.0x15 mm on LAD “nailing” ostium using only angiographic projection. Without the need to administer X, the patient achieved normal blood pressure and became alert. After stabilization of the patient we checked the stent on the LAD and the left main with IVUS. The stent had no significant underexpansion, and the trunk was free of significant plaque or dissection. After primary PTCA in the UTIC, the patient had no complications at 12 months follow up.

Conclusions

Our clinical case is an example of how in primary angioplasty, often based on the coronary anatomy, a minimal approach with the aim of guaranteeing a stable TIMI 3 coronary flow and avoiding prolonged dilation on the common trunk can guarantee the patient‘s survival. The stenting technique must be personalized based on the patient‘s clinical conditions and the resources available.