bluuebunny/crossref_metadata_2025 huggingface dataset:
C19 A STATISTICAL MODEL TO IMPROVE HEART SCORE IN STRATIFYING THE RISK OF MAJOR ADVERSE CARDIAC EVENTS IN PATIENTS WITH CHEST PAIN
Authors: Bonora A , Turcato G , Bampa B , Lunardi A , Conte S , Tonelli M , Zaboli A , Pratticò F , Pfeiffer N , Maccagnani A
Published: May 2023

Background

Heart Score is a simple and reliable post–test score to predict chest pain patients at higher risk of major adverse cardiac events (MACE), but fails in 1.5 to 2.5% of cases. Aim of this study was to evaluate the effectiveness of the nomogram in improving Heart Score performance.

Methods

In this multicenter retrospective study we considered all the patients consecutively observed for chest pain from January to June 2021 in the Emergency Departments of three Northern Italian hospitals. Main outcome was the onset of MACE within a 3 months–follow–up. All data were carefully recorded and included in univariate analysis. The variables associated with outcome (significance level p<0.1) were subsequently evaluated in multivariate analysis by a Logistic Regression model and, when significant (accuracy level at least 0.5%), included in the final model, the nomogram. The statistical weight of each variable was numerically quantified and the total score corresponded to a risk probability. We further validate the model by internal bootstrap on 5000 patients re–sample. Validation and discrimination were assessed by the area under receiver operating characteristics curve (AUC).

Results

Overall 9837 patients (5863 males, 3974 females, mean age 63 ys) were eligible for the study. In the follow–up period 1671 patients (16.9%) developed a MACE (MACE+). Significant variables (p<0.001) after univariate analysis were: risk factors (median MACE+ 3 vs MACE– 1); Chest Pain Score (median 7 vs 4); lenght of chest pain (median 1 vs 4 hours), electrocardiogram findings and troponin levels (median 70 vs 5). All those were confirmed in the multivariate analysis (p<0.001): risk factors (OR 2.66); Chest Pain Score (OR 1.24); pain duration (OR 1.47); electrocardiogram findings (OR 1.51); troponin levels (OR 2.01). The Logistic Regression model reached a good likelihood level (R=0.685). The individual score of variables in the nomogram contributed to final score from 0 to 220, corresponding to a 3–months MACE risk rate (range 0.1–0.9). Discrimination level of nomogram (AUC 0.954) was higher than Heart Score (AUC 0.935) (p<0.005). In our series 1.6% of MACE+ were “low–risk patients” according to Heart Score, but those reported as low risk (risk rate < 0.2) in the nomogram were only the 0.2% (sensibility 99%, negative predictive value 99%).

Conclusions

In patients observed for chest pain nomogram achieved a more accurate stratification of low–risk ones than Heart Score.
C26 SIDE EFFECTS OF SGLT–2 INHIBITORS IN PATIENTS WITH HEART FAILURE: A META–ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
Authors: Pozzi A , Cirelli C , Merlo A , Scangiuzzi C , Rea F , Tavano E , Iorio A , Giovanni C , Senni M
Published: May 2023

Background

sodium–glucose cotransoporter–2 inhibitors (SGLT–2Is) improve prognosis in heart failure patients both with reduced (HFrEF) and preserved ejection fraction (HFpEF). However, these drugs can have some side effects. Purpose: estimate the relative risk of side effects in HF patients treated with SGLT–2Is irrespectively from left ventricular EF and setting (acute and chronic HF).

Methods

4 randomized controlled trials (RCTs) enrolling patients with HFrEF 3 RCTs enrolling acute HF and 3 RCTs enrolling HFpEF were included. Among side effects, urinary infection, genital infection, acute kidney injury diabetic ketoacidosis, hypotension, hypoglycemia, hyperkalemia, hypokalemia, bone fractures and amputations were considered in the analysis.

Results

overall 22687 patients were included in the analysis: 8830 (39%) patients with HFrEF, 12563 (55%) with HFpEF and 1295 (6%) with acute HF. There weren’t differences between SGLT–2Is and placebo in the risk to develop diabetic ketoacidosis, hypoglycemia, hyperkalemia, hypokalemia, bone fractures and amputations. HFrEF patients treated with SGLT–2is had a significative reduction of acute kidney injury [RR 0.54; 95% CI 0.33–0.87) p= 0.011], whereas no differences have been reported in the HFpEF [RR 0.94 (95% CI 083–1.07) p=0.348] and acute setting [RR 0.97; 95% CI 0.58–1.64) p= 0.915] (Fig 1A). A higher risk to develop genital infection [overall 2.82; 95% CI 1.96–4.05) p <0.001] was found irrespectively from EF [HFrEF 2.38 (95%CI 1.34–4.24) p= 0.003; HFpEF RR 3.04 (95%CI 1.88–4.90) p <0.001] (Fig 1B). The risk to develop urinary infections and hypotension was increased in the overall HF population with a RR of 1.15 (95%CI 1.02–1.30) p= 0.028 and RR 1.15; 95%CI 1.02–1.29) p= 0.017, respectively (Fig 2 A–B). This risk was mainly driven by HFpEF patients [RR urinary infections 1.19 (95%CI 1.02–1.38) p= 0.029; RR hypotension 1.23 (95% CI 1.05–1.43) p= 0.011], whereas no differences have been reported in HFrEF [RR urinary infection 1.04 (95%CI 0.80–1.35) p= 0.774; RR hypotension 1.04 (95%CI 0.87–1.24) p= 0.687] and in the acute setting [RR urinary infections 1.19 (95%CI 0.81–1.74) p= 0.375; RR hypotension 1.23 (95%CI 0.78–1.96) p= 0.371].

Conclusions

SGLT–2is increase the risk of genital infections in HF patients. In HFpEF patients SGLT–2Is increase the risk of urinary infections and hypotension compared to placebo, whereas reduce the risk of acute kidney disease in patients with HfrEF.
C30 24–HOUR PULMONARY ARTERY ELASTANCE IS THE STRONGEST HEMODYNAMIC PREDICTOR OF IN–HOSPITAL MORTALITY IN ACUTE DECOMPENSATED HEART FAILURE–RELATED CARDIOGENIC SHOCK
Authors: Baldetti L , Den Uil C , Fiore G , Gallone G , Romagnolo D , De Ferrari T , Peveri B , Cianfanelli L , Calvo F , Gramegna M , Pazzanese V , Sacchi S , Frias A , Ajello S , Scandroglio A
Published: May 2023

Aim

The initial bundle of cares strongly affects hemodynamics in acute decompensated heart failure cardiogenic shock (ADHF–CS). We sought to characterize whether 24–hour hemodynamic profiling provides superior prognostic information as compared to admission assessment, and which hemodynamic parameters best predict in–hospital death.

Methods and results

We included 99 patients (62±14 years, 24.2% females) with ADHF–CS and available admission and 24–hour invasive hemodynamic assessment from two academic institutions. Overall, in–hospital mortality was 28.3%. In the admission multivariable model, age (OR=1.08; 95%CI 1.03–1.13; padj=0.002) and CPIRAP (OR=0.62; 95%CI 0.39–0.90; padj=0.022) were significantly associated with in–hospital death. Among several 24–hour hemodynamic univariate predictors of in–hospital death, pulmonary artery elastance (PaE) was the strongest (AUC 0.73; 95%CI 0.66–0.86). At 24–hours, PaE (OR=5.86; 95%CI 1.87–18.50; padj=0.003), PAPi (OR=0.75; 95%CI 0.55–0.92; padj=0.023) and age (OR=1.08; 95%CI 0.1.03–0.1.14; padj=0.005) were independently associated with in–hospital death. This 24–hour model outperformed admission model (AUC 0.85 [0.76–0.93] vs AUC 0.77 [0.67–0.88]; Figure 1). Patients were then grouped according to the optimal cutpoints of PaE 1.11 mmHg/mL and PAPi 2.12. Patients with high 24–hour PaE exhibited the highest in–hospital mortality at either low and high PAPi. The “high PAPi–low PaE” group had best parameter of (bi)ventricular function and lowest right and left filling pressures; the “low PAPi–low PaE” group exhibited parameters of poor RV function and high RAP (prevalent RV dysfunction); the “high PAPi–high PaE” group had signs of LV dysfunction coupled with parameters of relatively preserved RV function (compensated RV afterload mismatch); finally, the “low PAPi–high PaE” group exhibited worse parameters of LV and RV functions, coupled with high degree of pulmonary circulation overload and high biventricular filling pressures (decompensated RV afterload mismatch). We observed a different mortality in the cohorts identified by this classification (13.5 vs 25.0 vs 50.0 vs 43.8%; p=0.016, Figure 2).

Conclusion

PaE was the most powerful 24–hour hemodynamic predictor of in–hospital death in ADHF–CS. This index, coupled with PAPi, may identify patients with RV afterload mismatch and was independently associated with hospital mortality event after adjustment for multiple clinically relevant variables.
C38 EARLY AND MID-TERM RESULTS FROM THE RESILIA AORTIC TISSUE VALVE ITALIAN REGISTRY (RES-ITA)
Authors: D'Ascoli R , Prestipino F , Luzi G
Published: May 2023

Objective

The objective of our study is to evaluate safety, hemodynamic performance and durability of the new generation aortic bioprosthesis with Resilia Tissue.

Methods

RES-ITA Registry is the Italian multicenter registry created in 2017, enrolling patients who underwent isolated or combined AVR with Resilia tissue valve. The Registry was recently recognized by SICCH as the official national registry of Resilia tissue valve implantations, with Potenza’s Cardiac Surgery Unit as its coordinating center. Isolated AVR (50%) was performed predominantly through an upper J mini-sternotomy or a right anterior mini-thoracotomy, while combined procedures (50%) were performed in full sternotomy and included associated CABG, ascending aorta surgery, mitral valve repair or replacement, aortic annulus enlargement. For all patients, clinical and echocardiographic assessment were evaluated at discharge, 30 days, 6 months and every year after surgery.

Results

Between June 2017 and March 2022, about 1000 patients were included, coming from 13 Italian cardiac surgery centers. During last year, 6 more Italian centers have asked to join the Registry. Mean age was 57±11 years. Mean Euroscore II was 2.24±3.01%. Redo surgery was performed in 11%. Most frequently implanted valve sizes were 23 mm (30%), 25 mm (27.7%) and 27 mm (19%). Two-year freedom from all-cause mortality for isolated AVR and for all patients was 97.4±1.3% and 95.7±1.1%, respectively. Two-year freedom from major paravalvular leaks (≥2+/4) was 98.4±0.8; freedom from prosthesis thrombosis was 96.7±2 and freedom from prosthesis dysfunction (according to VARC-2 criteria) was 96.7±1.7. Mean gradient was 13.3±8.3 mmHg and maximum gradient was 23.2±16.2 mmHg at 2-year follow-up.

Conclusions

The new generation aortic prosthesis with RESILIA tissue demonstrates versatility of use, safety, good early and mid-term outcomes and hemodynamic performance. Further investigations and longer follow-up are needed to evaluate long-term durability.
C40 SYSTEMATIC TOTAL ARCH REPLACEMENT WITH THORAFLEX HYBRID GRAFT IN ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE
Authors: Chivasso P , Mastrogiovanni G , Miele M , Colombino M , Triggiani D , Cafarelli F , Leone R , Masiello P , Iesu S
Published: May 2023

Introduction

The traditional surgical management for acute Type A aortic dissection focuses on handling emergencies in the aortic root and ascending aorta. The remaining untreated distal portion of the aorta has a potential risk of rupture or causing malperfusion syndrome. Therefore, an aggressive repair approach using total aortic arch replacement combined with the frozen elephant trunk (FET) implantation has been advocated. We describe the early and midterm clinical outcomes of the Thoraflex Hybrid graft for the treatment of emergency type A aortic dissection.

Methods

Between December 2017 and January 2022, 69 consecutive patients were admitted with acute type A aortic dissection; of those, 66 patients (62.9 ± 10.2 years of age, 81.8% men) underwent emergency hybrid aortic arch and frozen elephant trunk repair with the multibranched Thoraflex hybrid graft and were enrolled in the study. Primary end point were 30 days– and in–hospital mortality. To better clarify the impact of age on surgical outcomes, we have divided the study population into two groups: group A for patients < 70 years of age (47 patients), group B for patients ≥ 70 years (19 patients).

Results

All 66 device implants were technically successful. Mean follow–up was 19.7 ±17.4 months. 30–days– and in–hospital mortality were 10.6 and 13.6%, respectively. Stroke occurred in 3 (4.5%) patients. Two (3.0%) patients experienced spinal cord ischemia. Renal failure requiring CVVH and respiratory failure requiring tracheostomy were 30.3% and 28.8%, respectively. Overall survival for the entire cohort at 3 months, 6 months, 12 months and 24 months was 85%, 80.3%, 76.5%, 74.4% respectively. We did not find any statistically significant difference among the two groups in terms of main post–operative outcomes. The multivariable Cox proportional hazard model showed left ventricular ejection fraction (HR: 0.83, 95% CI: 0.79–0.92, p <0.01), peripheral vascular disease (HR: 15.8, 95% CI: 3.9–62.9, p < 0.01), coronary malperfusion (HR: 0.10, 95% CI: 0.01–0.77, p =0.03), lower limbs malperfusion (HR: 5.1, 95% CI: 1.10–23.4, p = 0.04) and cardiopulmonary bypass time (HR: 1.02, 95% CI: 1 – 1.04, p = 0.01) as independent predictors of long term mortality.

Conclusions

Hybrid aortic arch and frozen elephant trunk repair with the Thoraflex Hybrid graft to treat emergency type A aortic dissection appears to be associated with good early and mid–term clinical outcomes even in the elderly.
C47 ADAPTATION OF THE PULMONARY CIRCULATION AND OF THE RIGHT HEART IN INTRACARDIAC INVETERATE SHUNTS: UNDER PRESSURE OR LET IT FLOW?
Authors: Pugliesi G , Baratto C , Badano L , Sganzerla P , Perego G , Muscogiuri G , Parati G , Caravita S
Published: May 2023

Congenital heart disease can be associated with pulmonary hypertension (PH) development and heart right remodelling. Nevertheless, the adaptation of the pulmonary circulation and of the right heart can be extremely heterogeneous, so that an accurate diagnostic work up may be advisable when an intracardiac shunt is suspected.

Case Presentation

A 53 years old woman, with no relevant clinical history and asymptomatic, was incidentally found to have clinical, ECG and echocardiographic signs of PH, and was referred to our Center.

Diagnostic and Therapeutic Work Up

Echocardiography showed: normal left ventricle (LV 3D volumes 88/35 ml), mild left atrial dilatation (39 ml/m2); severe right chambers dilatation (RV 3D 347/124 ml, EF 3D 62%, AD 116 ml/m2), moderate tricuspid regurgitation with a regurgitant jet velocity of 2.9 m/s. Right heart catheterization showed normal pulmonary pressures at rest (mPAP 20, PAWP 5 mmHg), extremely high pulmonary blood flow (Qp 29 L/min, calculated with the direct Fick method), with normal pulmonary vascular resistance (PVR 0.5 WU). During the oxymetric run, a step up in hemoglobin saturation between superior vena cava and right atrium (from 74 to 97%) was found, with a Qp/Qs ratio of 5.5. During exercise, Qp reserve was normal, suggesting a normal contractile reserve function of RV despite the extreme dilatation. Additionally, the patient did not develop exercise PH and exercise capacity was normal, based on a measured oxygen consumption (VO2) at peak of 24 ml/kg/min (104% of predicted). Angio–CT of the chest was performed, confirming the presence of a sinus venosus atrial septal defect. The patient was then referred for surgical correction.

Conclusion

Echocardiography signs are useful to direct correctly diagnostic work up. A severe RV dilatation with normal systolic function in an asymptomatic middle age woman should raise the possibility of an intracardiac shunt. Despite a large intracardiac shunt with a high Qp/Qs ratio for decades, PVR was normal, confirming that individual predisposition may play a role in the development of PH in pre–tricuspid shunts. Exercise test showed an optimal RV reserve, suggesting a low cardiac surgery risk.
C49 NO CONTRAST TAVI
Authors: Paparoni F , De Remigis F , Tomassoni G , Marrangoni A , Marrone G , Fragassi G , Lezzi A , Fabiani D
Published: May 2023

Background

Chronic renal failure is a common comorbidity in patients undergoing TAVI. Large amounts of contrast media are generally needed to safely perform TAVI with potential deleterious effects on renal function and long term life quality.

Objectives

Every step of the procedure can be safely replaced by no contrast techniques: ultrasound guided vascular puncture and final check, alignement of 3 guides in Valsalva sinuses to check coplanarity or cusp overlap, coupling of hemodynamics and transthoracic echocardiography to check the results and need of postdilatation, measure of gradient across the arterial puncture to rule out iatrogenic stenosis.

Matherials and Methods

3 patients with severe renal failure (GFR < 30 ml/min/ 1.73 m2) and 1 patient with moderate renal failure and previous double renal transplantation underwent TAVI with protocol without contrast in our center in the last year. All cases were performed with local anesthesia and conscious sedation. 3 cases were performed with balloon expandable bioprosthesis and 1 with self expandable bioprosthesis.

Results

We were able to perform TAVI procedure without contrast in all 4 patients in which the technique was attempted without complications. Hemodynamics was excellent in all cases with no residual gradient or significant leaks. No vascular complication occured. Procedural time was generally 20% longer than average procedure but X rays dose exposure was reduced because less cine acquisitions were needed.

Conclusions

TAVI with no use of contrast media is feasible and safe by extensive use of vascular ultrasound, hemodynamics, transthoracic echocardiography and multiple guides to depict coronary sinuses and assure correct prothesis implantation.
C52 GENDER DIFFERENCES IN AMPLITUDE SPECTRAL AREA (AMSA) OF VENTRICULAR FIBRILLATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST
Authors: Vicini Scajola L , Quilico F , Gentile F , Compagnoni S , Baldi E , Aramendi E , Isasi I , Lopiano C , Primi R , Bendotti S , Currao A , Contri E , Palo A , Savastano S
Published: May 2023

Introduction

Ventricular fibrillation (VF) Amplitude Spectral Area (AMSA) is a well–established predictor of successful defibrillation and return of spontaneous circulation (ROSC). Attending to the limited evidence on the topic, gender seems to affect AMSA, and higher values have been reported in females. The aim of this work was to investigate the effect of gender in AMSA values for patients suffering out–of–hospital cardiac arrest (OHCA).

Methods

We enrolled 4619 consecutive OHCA patients from January 2015 to December 2020 in the LombardiaCare Registry. We considered only those subjects with attempted cardio–pulmonary resuscitation (697 patients) and at least one shock delivered. A total of 250 patients were considered (40 F/ 210 M) with 830 shocks (100 F/ 730 M). AMSA values were computed for the ventricular fibrillation in the 2–s pre–shock interval of the ECG recorded by the Corpuls3 defibrillator (Corpuls, Kaufering, Germany).

Results

Female patients were older than male [median(IQR) 70.5 (62–72) vs 67 (55–75) years, p=0.01], with cardiac arrest more frequently at home (84% vs 76%, p=0.003), fewer shocks [2 (1–4) vs 4 (2–7), p=0.004] and higher percentage of success (53% vs 40%, p= 0.009). On the contrary, cardiac arrest duration [ 58.7 (31–69) vs 57.6 (41.4–77.3) min, p=0.366] and the rate of ROSC (32% vs 33%, p=0.88) were similar in both groups. Higher AMSA values were found in female patients [10.3 Hz–mV (6.6–13.5) vs 7.9 Hz–mV (5.2–12.1), p= 0.0007]. At a multivariable analysis, after correction for witnessed status, bystanders CPR, amiodarone administration, age and call–to shock time, male sex was found to be independently associated with the probability of having low values of AMSA, below the median value of 8.3 Hz–mV [OR 2.15 (95%CI1.35–3.43), p=0.001]. Despite gender stratification ROC curve analysis confirmed AMSA as a predictor of shock success [AUC–F: 0.75 (95%CI 0.65–0.83), p<0.001; AUC–M: 0.78 (95%CI 0.74–0.81)] and ROSC [AUC–F: 0.69 (95%CI 0.59–0.68), p=0.008; AUCM: 0.84 (95%CI 0.81–0.87)].

Conclusion

Female sex is related to higher AMSA values. As AMSA reflects the energetical status and the ATP levels in the myocardial cells during cardiac arrest, this difference may be due to lower incidence and lower severity of cardiac ischemic disease in women. AMSA remains a valid predictor of both shock success and ROSC for female and male patients. Further investigations are needed to support and comprehend these conclusions.
C57 ASSOCIATION OF CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY AND STRESS–ECHOCARDIOGRAPHY WITH LONG–TERM CARDIAC OUTCOME: A COMPARISON STUDY
Authors: Tuttolomondo D , Gaibazzi N
Published: May 2023

Aims

The study aims to assess which variables on coronary computed tomography angiography (CTA) and vasodilator stress–echocardiography (SE) are best associated with long–term cardiac outcome in patients presenting for suspected chronic coronary syndrome (CCS) who performed both tests.

Methods

We identified 397 patients with suspected CCS who, between 2007 and 2019, underwent both SE and CTA within 30 days. Coronary artery calcium score (CACS) and the number of coronary arteries with diameter stenosis >50% were assessed on CTA. The presence of reversible regional wall motion abnormalities (RWMA) and reduced Doppler coronary flow velocity reserve in the left anterior descending coronary artery (CFVR) were assessed on SE. The association of SE and CTA variables with cardiac outcome (cardiac death or myocardial infarction) was assessed using Fine and Gray competing risk models.

Results

During a median follow–up of 10 years, 38 (9.6%) patients experienced a non–fatal myocardial infarction and 19 (4.8%) died from a cardiac cause. RWMA (HR 7.189, p<0.001) and a lower CFVR (HR 0.034, p<0.001) on SE, CACS (HR 1.004, p<0.001) and the number of >50% stenosed coronary vessels (HR 1.975, p<0.001) on CTA were each associated with cardiac events. After adjusting for covariates, only CACS and CFVR remained associated (both p<0.001) with cardiac outcome.

Conclusion

Our data suggest that only CFVR on SE and CACS on CTA are independently and strongly associated with long–term cardiac outcome, unlike RWMA or the number of stenosed coronary arteries, usually considered the hallmarks of coronary artery disease on each test.
C58 A NEW MAGNETIC RESONANCE IMAGING TECHNIQUE TO ASSESS PROGNOSIS IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY AND LOW–INTERMEDIATE 5–YEAR RISK OF SUDDEN DEATH
Authors: Bracco A , Sinagra G , Carerj S , Todiere G , Grigoratos C , Di Bella G , Aquaro G
Published: May 2023

Background

Late gadolinium enhancement (LGE) is an important prognostic marker in hypertrophic cardiomyopathy and an extent >15% it is associated with high risk of sudden cardiac death. We proposed a novel method, the LGE–dispersion mapping, to assess heterogeneity of scar, and evaluated its prognostic role in patients with hypertrophic cardiomyopathy.

Methods

One hundred eighty–three patients with hypertrophic cardiomyopathy and a low– or intermediate 5–year risk of sudden cardiac death underwent cardiac magnetic resonance imaging. A parametric map was generated from each LGE image. A score from 0 to 8 was assigned at every pixel of these maps, indicating the number of the surrounding pixels having different quality (nonenhancement, mild–enhancement, or hyperenhancement) from the central pixel. The Global Dispersion Score (GDS) was calculated as the average score of all the pixels of the images.

Results

During a median follow–up time of 6 (25th–75th, 4–10) years, 22 patients had hard cardiac events (sudden cardiac death, appropriate implantable cardioverter–defibrillator therapy, resuscitated cardiac arrest, and sustained ventricular tachycardia). Kaplan–Meier analysis showed that patients with GDS>0.86 had worse prognosis than those with lower GDS (P<0.0001). GDS>0.86 was the only independent predictor of cardiac events (hazard ratio, 9.9 [95% CI, 2.9–34.6], P=0.0003). When compared with LGE extent >15%, GDS improved the classification of risk in these patients (net reclassification improvement, 0.39 [95% CI, 0.11–0.72], P<0.019).

Conclusions

LGE–dispersion mapping is a marker of scar heterogeneity and provides a better risk stratification than LGE presence and its extent in patients with hypertrophic cardiomyopathy and a low intermediate 5–year risk of sudden cardiac death.
C59 CLINICAL AND ECHOCARDIOGRAPHIC FOLLOW–UP IN PATIENTS WITH SUTURELESS AORTIC PERCEVAL BIOPROSTHESIS: SINGLE CENTER ANALYSIS IN ELEVEN–YEARS EXPERIENCE
Authors: Concistrè G , Margaryan R , Bianchi G , Chiaramonti F , Kallushi E , Gasbarri T , Murzi M , Varone E , Simeoni S , Leone A , Pierandrea F , Solinas M
Published: May 2023

Aims

We describe long–term clinical and echocardiographic follow–up in the largest single center cohort of patients underwent aortic valve replacement (AVR) with sutureless Perceval (CorCym, Italy) bioprosthesis.

Methods

Between March 2011 and September 2022, 1237 patients underwent AVR with Perceval bioprosthesis implantation. Mean age was 78 ± 4 years and mean EuroSCORE II was 6.9 ± 2.8%. Concomitant procedures were performed in 272 patients (22%).

Results

Thirty–day mortality was 1.37% (17/1237). 890 of 951 (93.5%) isolated AVR underwent minimally invasive surgery with a ministernotomy (n = 221) or right minithoracotomy (n = 669) approach. Cardiopulmonary bypass and aortic cross–clamp times were 80.6 ± 21.5 and 50.1 ± 10.5 minutes for isolated AVR and 145.8 ± 33.6 and 95.8 ± 20.7 minutes for combined procedures. At mean follow–up of 55.09 ± 6.7 months (range: 1–138.5 months), survival was 95.4% and mean transvalvular pressure gradient was 13.3 ± 4.2 mmHg. LV mass decreased from 153.5 g/m2 to 114.6 g/m2 (p< 0.001) and moderate paravalvular leakage occurred in 3 patients without hemolysis not requiring any treatment. Freedom from reoperation was 97.4%. Nine patients required surgical reintervention and 21 patients transcatheter valve–in–valve procedure for structural prosthesis degeneration at mean of 6.3 years after first operation (range: 2–10 years).

Conclusion

AVR with Perceval bioprosthesis is associated with good clinical results and excellent hemodynamic performance in our eleven–years experience. Structural degeneration rate of Perceval is comparable with others bioprosthetic aortic valve. Sutureless technology may reduce operative time especially in combined procedures and enable minimally invasive AVR.
C61 RAREFACTION OF MYOCARDIAL LYMPHATIC VESSELS IN PATIENTS WITH CARDIAC AMYLOIDOSIS
Authors: Aimo A , Martinelli G , Bonino L , Musetti V , Castiglione V , Emdin M , Vergaro G , Pucci A
Published: May 2023

Introduction

In cardiac amyloidosis (CA), amyloid fibers accumulate in the extracellular spaces of the heart, causing a compression and obliteration of lymphatic vessels, and possibly their disappearance. As lympathic drainage removes proteins from the interstitial spaces, including amyloid precursors, an impairment of lympathic vessels could exacerbate amyloid accumulation, triggering a vicious circle.

Methods

Lymphatic vessels were visualized by immunohistochemistry using a monoclonal antibody against podoplanin (D2–40, a marker of lymphatic endothelial cells) and the immunopreroxidase technique. We investigated 3 groups of cases: 1) as a reference standard, endomyocardial specimens from the left ventricular (LV) endomyocardium of 10 heart valve donors, deceased for trauma and/or cerebral hemorrhage, with no evidence of cardiac disease on gross and microscopic examination; 2) 15 consecutive LV endomyocardial biopsies (EMBs) from patients with CA, where cardiac amyloid was detected and typed by Congo red staining, immunohistochemistry and proteomics, and 3) 13 surgical endomyocardial biopsies from patients with septal LV hypertrophy, undergoing aortic valve surgery and with CA excluded by histology.

Results

In donor hearts (n=10), lymphatic vessels were mostly distributed in the subendocardial and subepicardial layers, with some intra–myocardial lymphatic vessels near larger blood vessels. We then examined 15 patients with CA (amyloid transthyretin [ATTR]–CA, n=10; amyloid light–chain [AL]–CA, n=5; 50% men, median age 75 years [interquartile range 71–78]), and 13 patients with CA excluded (55% men, median age 68 years [59–71]). The density of lymphatic vessels in patients with CA was 0.52 vessels/mm2 (0–3.32), vs. 10.90 vessels/mm2 (3.10–26.25) in those without CA (p=0.001). No significant differences were found in LV mass index (p=0.170) or LV ejection fraction (p=0.262). Three patients with ATTR–CA and 2 patients with AL–CA showed no lymphatic vessels on EMB. The density of lymphatic vessels did not differ significantly in patients with ATTR– or AL–CA.

Conclusions

Patients with CA have significantly decreased endo–myocardial lymphatic vessels as compared to patients without CA, despite no significant difference in the degree of LV wall thickening or LV ejection fraction. These results support the hypothesis that the lymphatic drainage is deranged in patients with CA, possibly promoting further amyloid deposition.
C71 EFFICACY AND SAFETY OF PERCUTANEOUS LEFT STELLATE GANGLION BLOCK IN PATIENTS WITH REFRACTORY ELECTRICAL STORM
Authors: Compagnoni S , Gentile F , Baldi E , Sanzo A , Rordorf R , Savastano S
Published: May 2023

Background

Neuromodulation by percutaneous stellate ganglion block (PSGB) with local anaesthetic has proved its antiarrhythmic effect suitable for an emergency setting.

Purpose

To assess the efficacy and safety of PSGB performed with an anterior anatomical approach in patients with refractory electrical storm refractory.

Methods

Patients with electrical storm at the Policlinico S.Matteo of Pavia were enrolled from November 2017 to January 2022. Left PSGB (PLSGB) was performed after failure of at least one intravenous antiarrhythmic drug. Its repetition or a continuous infusion of the local anaesthetic were considered in selected cases. Clinical data, characteristics of the block and complications were collected. The efficacy was evaluated by comparing the number of arrhythmias treated with ATP or DC–shocks by external or internal defibrillator 1 hour before the block with 1 hour after the block. Per–patient efficacy was assessed by comparing the number of ATP/shocks in the 12 hours before the first procedure with that in the 12 hours after the last one.

Results

37 patients were enrolled: 76% male, mean age 65 years; 11 with dilated cardiomyopathy, 18 with chronic ischemic heart disease, 11 with STEMI, 3 with NSTEMI, 1 with ARVC and 1 with drug intoxication. A total of 62 PLSGBs were performed: 19 for VT, 26 for VF and 17 for both VT and VF episodes; 15 on intubated patients, 4 in extracorporeal circulation, 7 in cardiogenic/septic shock, 28 on patients on single antiplatelet therapy, 11 on dual antiplatelet therapy, 33 on anticoagulant therapy. PLSGBs were performed during intravenous infusion of antiarrhythmics (amiodarone in 30, lidocaine in 37 procedures). The local anaesthetic used was lidocaine in 27/62 PLSGB, bupivacaine in 6/62 and both in 29/62. The per–procedure analysis showed a significant reduction of the number of ATP/shocks in the hour after PLSGB compared with the hour before [0 (0–0) vs 5 (1–8) p<0.001]. Similarly, in the per–patient analysis, the number of ATP/shocks significantly decreased in the 12 hours after the PLSGB compared with that in the 12 hours before [0 (0–1.3) vs 7 (4.8–12.5) p<0.001]. No complications occurred.

Conclusions

This is the case series with the highest number of PLSGB for antiarrhythmic purposes in literature and it confirms its efficacy and safety in refractory electrical storm. The exiguity of the equipment required makes the anatomical approach suitable to be easily performed by cardiologists.
C75 INTRAVENOUS CANGRELOR INFUSION IN ELDERLY PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: A SUBANALYSIS OF THE ICARUS REGISTRY
Authors: Scalamera R , Benenati S , Gragnano F , Schettino M , Bertero E , Capolongo A , De Sio V , Musumeci G , Annibali G , Campagnuolo S , Galasso G , Silverio A , Bellino M , Centore M , Menozzi A , Caretta G , Rezzaghi M , De Luca L , Veneziano F , De Nardo D , Cirillo P , De Rosa G , Calabrò P , Porto I
Published: May 2023

Aims

To assess the clinical characteristics and compare in–hospital outcomes of elderly and non–elderly patients receiving cangrelor in the peri–percutaneous coronary intervention (PCI) phase.

Methods

Consecutive patients treated with cangrelor in 7 Italian institutions were retrospectively enrolled in the ICARUS (“Intravenous CAngrelor in high–bleeding Risk patients Undergoing percutaneouS coronary intervention”, NCT05505591) registry. Elderly patients were defined if age was ≥75 years at the time of PCI. The primary endpoint was net adverse clinical events (NACE), defined as a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis and Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding, at 48 hours. Secondary endpoints were assessed at 48 hours and throughout the hospital stay. Independent predictors of the primary endpoint were also assessed.

Results

Out of 551 patients undergoing PCI with cangrelor between January 2019 and August 2022, 174 (32%) were elderly. Mean age was 81±5 vs. 61±8 years in elderly vs. non–elderly patients (p<0.001). Female sex (32% vs. 21%, p=0.006), atrial fibrillation (20% vs. 5%, p<0.001), chronic kidney disease (30% vs. 6%, p<0.001) and heart failure (14% vs. 8%, p=0.041) were more frequent in the elderly group, whereas presentation with acute coronary syndrome (ACS) was less frequent (69% vs. 83%, p=0.001). Elderly patients received shorter cangrelor infusion (122±25 vs. 134±43 minutes, p=0.001) and were more frequently administered with clopidogrel after PCI (50% vs. 19%, p<0.001). At 48 hours, elderly patients had higher rates of NACE (13% vs. 6%, p=0.006) and BARC 2, 3 or 5 bleeding (11% vs. 5%, p=0.013), whereas the rates of other 48–hour and in–hospital clinical endpoints did not differ. At multivariable analysis, age ≥75 years (odds ratio [OR] 1.07, 95% CI 1.02–1.12, p=0.004), major anemia (OR 1.10, 95% CI 1.005–1.22, p=0.038), ACS at presentation (OR 1.08, 95% CI 1.03–1.14), femoral access (OR 1.13, 95% CI 1.06–1.22) and cardiogenic shock (OR 1.35, 95% CI 1.21–1.50) independently predicted the occurrence of 48–hour NACE.

Conclusions

Advanced age is a distinctive risk feature among patients receiving intravenous cangrelor in the peri–PCI phase. Elderly patients had higher rates of adverse events at 48 hours, with advanced age (≥75 years) being an independent predictor of NACE.
C83 BEHIND MYOCARDITIS DIAGNOSIS
Authors: Andreoli F , Tolone S , Cifarelli A , Pennacchi M , Cesario V , Pulignano G , Tinti M , Gabrielli D
Published: May 2023

Background

Myocarditis is an inflammatory disease of myocardium, with a wide range of clinical presentation. Myocarditis may mimic acute coronary syndrome (ACS), but it is also possible an overlap between these two different syndromes, as we considered the close relationship between wide inflammatory systemic condition and coronary atherosclerotic plaque instability Case report: We report the case of 29 years old man admitted to emergency department for burning chest pain changed with breathing and in different positions of the body, associated to dyspnea on mild–moderate exertion. Symptoms had begun to arise a week earlier, with flu–like symptoms, and got worse in the last 48 hours. In his clinical history the patient reports: previous myocarditis, dyslipidemia, hyperhomocysteinemia, overweight, family history of cardiovascular disease and a previous COVID infection. Blood tests found a rise of Troponin I HS. Electrocardiogram showed diphasic T wave in antero–lateral leads. An echocardiogram showed left ventricle with normal cavitary dimensions and preserved global systolic function, apical segment of interventricular septum and inferior wall hypokinetic; minimal pericardial detachment with leaflet hyperecogenicity. The patient was admitted to Cardiology ward, and he was given a medical therapy with colchicina 0.5 mg 1 cp x 2/die and AcetylSalicilic Acid 1000 mg x 3 /die. Cardiac Magnetic Resonance showed epi–mesocardial LGE in inferior and lateral distal segments, compatible with myocarditis. CT coronary angiography exhibited a calcified plaque determining partial caliber reduction in anterior descending coronary proximal segment, the coronary in its apical portion appeared ectatic, hypodense and poorly dulled likely for steno–occlusion. Therefore, it was performed a coronary angiography that revealed an anterior descending coronary artery occluded at the apical tract, the OCT showed plaque erosion with thrombotic apposition at the mid–proximal tract of the vessel. Finally, considered results of instrumental exams, a second antiplatelet agent, a hypolipidemic drug were added

Discussion

According to the cardiac MRI findings and the coronary angiography, it was hypothesized a picture of acute coronary syndrome triggered by erosion of the unstable coronary plaque, induced by the massive myocardial inflammation related to the myocarditis. The relationship between acute infections and myocardial infarction has been already established in COVID–19 patients
P1 NEW TREATMENT STRATEGIES IN PATIENTS WITH SENILE CARDIAC AMYLOIDOSIS
Authors: Chiorazzo L , Valerii F , Bencivenga S , Acitelli A , Antonini L , Romano S , Sciarra L
Published: May 2023

We present the case of a 75 year–old man, diabetic, dyslipidemic, hypertensive, previous ischemic heart disease, AF, previous hospitalizations for heart failure, who underwent cardiology evaluation for worsening dyspnea (NYHA class II–III), swallen ankles and elevated BNP levels (900 pg/ml). The patient suffered from sensory–motor polyneuropathy diagnosed with EMG and ENG. Echocardiographic evaluation: severe concentric hypertrophy of the left ventricle (SIV 18 mm, PP 17 mm), granular sparkling and EF 50%, left atrium dilatation, light–moderate mitral regurgitation, moderate tricuspid regurgitation with PAPS 40–45 mmHg. Circumferential pericardial effusion (12 mm). Moreover, we noticed a decreased longitudinal contractive function of the left ventricle (TDI e‘, a’, e s’ <5 cm/s e absolute GLS < 15%), speckle–tracking ‘cherry on the top‘ and restrictive diastolic pattern. •ECG: low QRS voltage and increased wall thickness (>12 mm). •Laboratory: (SPIE and UPIE) no monoclonal protein present. •Bone scintigraphy: grade 3 cardiac uptake. •Cardiac MRI: asymmetric hypertrophy of the left ventricle with moderate biventricular systolic dysfunction. Subendocardial late gadolinium enhancement. •Genetic testing: no sarcomeric or TTS gene mutations. All findings were suggestive for senile cardiac amyloidosis (ATTR wt), the patient was discharged from the hospital with optimized medical therapy for heart failure and follow up was prescribed. After 3 months from the first diagnosis we added Tafamidis to the therapy (ESC indications class IB). ATTR–ACT, published on ‘New England Journal of Medicine’ showed that Tafamis is superior to placebo in reducing the combination of all–cause mortality and cardiovascular–related hospitalizations. Tafamidis was also associated with a significant reduction in the decline in functional capacity (as measured by the 6–minute walk test) and the decline in quality of life (as measured by the KCCQ–OS) at month 30, with differences first observed at 6 months. Tafamidis was well–tolerated, with a safety profile comparable to placebo. Follow–up: 6 months later the introduction of Tafamidis, the patient has not needed other hospitalizations for heart failure, well tolerates the drug with a subjective symptom reduction and remarkable improvement in quality of life.
P2 A RARE CASE OF MUTANT TRANSTHYRETIN CARDIAC AMYLOIDOSIS
Authors: Del Torto A , Agostoni P , Assanelli E
Published: May 2023

A 65–year–old man with a history of multiple hospitalizations in the past 12 months for heart failure with preserved left ventricular ejection fraction (HFpEF) attended the emergency department for exertional dyspnea, peripheral edema, abdominal bloating, and weight gain. An ECG showed sinus bradycardia with first degree AV block, RBBB, and inferior pseudo–q. Blood tests showed NT–proBNP 8985 pg/ml, troponin hs–cTnI 106 ng/L. An echocardiogram demonstrated severe left ventricular hypertrophy, EF 50%, GLS –11% with apical sparing, and restrictive transmitral pattern, raising suspicion of infiltrative disease (Figure 1). A cardiac MRI corroborated the suspicion, showing altered gadolinium kinetics, diffuse subendocardial LGE, and increased native T1 and extracellular volume (Figure 2). A search for monoclonal components on serum and urine was negative. A bone tracer scintigraphy showed cardiac uptake (Perugini grade 2). A genetic test showed the presence of p.Ile88Leu (Ile68Leu) mutation in heterozygosity, so a non–biopsy diagnosis of mutant transthyretin cardiac amyloidosis (ATTRv) was posed. A thorough neurological evaluation did not document signs of amyloid neuropathy. The patient was then started on tafamidis therapy. Transthyretin cardiac amyloidosis (ATTR) is still an underdiagnosed but increasingly recognized condition, causing up to 13% of HFpEF cases. ATTR is caused by extracellular accumulation of amyloid substance resulting from transthyretin misfolding. In Italy ATTRv is rare and Ile68Leu is among the most frequent mutations, especially in the Tuscan–Emilian Apennines. Ile68Leu is usually associated with an almost exclusively cardiac phenotype, clinically indistinguishable from ATTR wild type, except for an earlier age of onset. Because effective treatments are available for ATTRv with cardiac and/or neurological involvement, it is important to suspect the diagnosis of ATTR in patients with HFpEF and to proceed with genetic testing to identify individuals with ATTRv.
P13 THE PHANTOM OF TRICUSPID PROSTHESIS: CASE REPORT OF A PECULIAR TRANSCATHETER TRICUSPID VALVE–IN–VALVE IMPLANTATION
Authors: Colucci E , Mattei C , Scavelli F , Sclafani R , Notaristefano S , Santucci A , Aimi A , Bordoni E , Cavallini C
Published: May 2023

Background

Transcatheter tricuspid valve–in–valve replacement for patients with degenerative tricuspid surgical bioprosthesis disease has emerged in recent years as a new treatment possibility in patients that required tricuspid valve replacement at young age and in circumstances where redo tricuspid valve replacement is not feasible because of the remarkable morbidity and mortality. Case presentation. A 76 year–old Caucasian male was referred to our center for worsening dyspnoea and fatigue. He had a pacemaker implanted for third degree atrio–ventricular block in 1996. After massive endocarditis affecting the tricuspid valve and the pacemaker right ventricular lead, the patient underwent surgical tricuspid valve replacement with a 32 mm Liotta BioImplant L.P.B., right ventricular lead extraction and concomitant epicardial pacemaker reimplantation. Transthoracic echocardiogram at hospital admission denoted a degenerative stenosis of the tricuspid prosthesis with a trans–valvular mean gradient of 8 mmHg associated with right atrial and inferior vena cava dilatation. Given the high surgical risk due to comorbidities (systemic arterial hypertension, paroxysmal atrial fibrillation in DOAC, grade II obesity, smoking history and chronic lymphoproliferative leukemia) the patient was deemed not suitable for a re–do surgical tricuspid valve replacement and was offered a percutaneous replacement. Preprocedural planning with computed tomography allowed accurate reconstruction of the tricuspidal prosthetic annulus and correct sizing of Edwards SAPIEN valve, the most used in valve–in–valve procedures. The degenerated prosthesis was not visible at fluoroscopy meaning no fluoroscopic landmarks available to provide an anatomic view for valve deployment. Therefore, a combination of balloon valvuloplasty and right atrium angiographies before the valve–in–valve deployment were critical to provide the correct valve position and yield the procedure effective and safe. Hemodynamic gradient post–TVIV was absent and no paravalvular leaks were observed. Clinical and echocardiographic improvement were confirmed after the procedure and at 1 year–follow up.

Conclusion

Tricuspid valve–in–valve replacement can be technically feasible and a safer alternative to re–do surgical valve replacement, also in radiolucent bioprosthesis. In our case the successful procedural outcome not only relied on meticulous planning before the procedure, but also on specific intra–procedural adjustments.
P15 EFFICACY AND SAFETY OF LEFT ATRIAL APPENDAGE CLOSURE COMPARED WITH ORAL ANTICOAGULATION IN ATRIAL FIBRILLATION: A META–ANALYSIS OF RANDOMIZED CONTROLLED TRIALS AND PROPENSITY–MATCHED STUDIES
Authors: Piroli F , Franchin L , Demola P , Navazio A
Published: May 2023

Backgrounds

In the recent years, two randomized controlled trials (RCTs), the PROTECT–AF trial and the PREVAIL trial demonstrated that in atrial fibrillation (AF) patients, left atrial appendage closure (LAAC) compared with oral anticoagulants (OAC), showed a non–inferiority in the prevention of stroke and even a reduction in mortality. Nevertheless, this net clinical benefit was not confirmed in the most recent RCT comparing LAAC vs OAC, the PRAGUE–17 trial. The aim of the present meta–analysis was to evaluate the efficacy and safety of LAAC compared to OAC among available high–quality studies.

Methods

A systematic search of electronic databases (Medline, Scopus, Embase and the Cochrane Library) was performed to identify eligible RCTs and observational studies with propensity score matching (PSM) analysis. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Outcomes of interest were the occurrence of cardiovascular death (CVD), all cause death, all–type stroke, and major bleedings.

Results

A total of 3 RCTs and 6 PMS studies involving 6924 patients were identified. After a median follow–up of 2.7 years (IQR 2–4.5), patients who received LAAC had a lower risk of CVD (OR=0.58; 95%CI 0.48–0.71, I2=0%), all cause death (0.59; 95% CI 0.45–0.76, I2 67%) and major bleedings (OR=0.58; 95%CI 0.43–78 I2=52%) compared with patients on OAC. No difference was found between the two groups regarding strokes incidence (OR=0.94; 95% CI 0.76–1.16, I2=0%).

Conclusions

According to this meta–analysis, LAAC presents a comparable efficacy in the prevention of stroke compared to OAC with a reduced risk of major bleedings, all cause death and CVD that may stand out with longer follow–up.
P16 ELIGIBILITY COAPT TRIAL IN DAILY PRACTICE: A REAL WORLD EXPERIENCE
Authors: Zancanaro E , Buzzatti N , Denti P , Maisano F
Published: May 2023

Background

The COAPT Trial was the first ever to demonstrate a survival benefit in treating functional mitral regurgitation (FMR). That was achieved through transcatheter mitral repair in selected patient. The exact proportion of patients fulfilling COAPT selection criteria in the real–world is unknown.

Objectives

To assess the of COAPT in real–world .

Methods

We assessed the clinical data and follow–up results of all consecutive patients admitted for FMR at our Department between January 2016 and May 2021 according to COAPT eligibility and received. COAPT eligibility was retrospectively assessed by a cardiac surgeon and a cardiologist

Results

Among 394 patients, 56 (14%) were COAPT eligible. The most frequent reasons for exclusion were MR<=2 (22%), LVEF <20% or >50% (19%) and non–optimized GDMT (21,3%). The 4–year survival between non–COAPT (MC–NC) patients vs Medical Therapy (MC–NC) group was 91,5% (CI: [0.864, 0.96] vs 71,8 % (CI = [0.509, 0.926]) respectively, p=0.027,Figure 1. Concerning the 4–year recurrent MR>=3+ in MitraClip patients was 17,2% (CI: [0.101, 0.238]), while in Medical therapy group was 40% (CI = [0.248, 0.522]), p 0.0019, Figure 2.

Conclusions

Only a minority (14%) of real–world patients with FMR referred to a tertiary hospital fulfilled the COAPT selection criteria. Patients treated with MitraClip beyond the restrictive COAPT.