bluuebunny/crossref_metadata_2025 huggingface dataset:
MINIMALLY INVASIVE SURGERY FOR ISOLATED MITRAL VALVE DISEASE: A SINGLE CENTER 5–YEAR EXPERIENCE
Authors: Borrelli E , Faragasso E , Caprili L , Fahim N , Fedeli C , Adornini G , Fiorani V
Published: May 2024

Introduction

Minimally invasive surgery (MIS) has become the standard of care in our department to address mitral valve diseases (MVD). We nowadays use the mini–thoracotomy approach independently of the MVD etiology and for both complex and simple lesions (posterior leaflet prolapse).

The aim of this study was to analyze the efficacy of the approach by observing also post–operative results.

Methods

We retrospectively analyzed 484 patients who consecutively underwent mitral valve surgery with a minimal invasive approach from January 1st 2018 to December 31st 2022. The patients included in the study were addressed to surgery for a mainly mitral valve pathology (regurgitation, stenosis, prosthesis disfunction). All of the interventions were executed by the same surgeon. We performed a minithoracotomy at the III or IV intercostal space, depending on the anatomy of the patient, always assisted by an endoscopic camera. When necessary, we used periareolar thoracotomy or axillary approach. In the latter without assistance of the camera. The patients had a 3–month follow up visit at least and the longest follow–up monitoring was at five years.

Results

Overall repair rate was 90% (±3%) which increased to 96% (±1%) when we analyzed the repair rate for degenerative mitral valve pathology as unique etiology. 48% of the mitral valve insufficiency was related to posterior leaflet prolapse and among them 63% had an isolated lesion of of P2 scallop. Hospital stay was 10 days that turned to 6 days when we excluded patients with transitory complications.

Conclusions

MIS for isolated mitral valve disease provided a good repair rate even in complex anatomy. We also observed good results for mitral valve replacement, deemed necessary in non–degenerative etiologies. A good exposure of the valve, then, permits to address the great majority of the MVD avoiding the longer hospital stay needed after median sternotomy and guarantees a faster return to work without rib fracture implying excellent pain control.
A PARTICULAR CASE OF CARDIAC ARREST
Authors: Sanna S , Lampus M
Published: May 2024

88–year–old man with arterial hypertension, cognitive impairment, carrier of dual–chamber PM due to sinus node disease. Diagnosis of congenital long QT syndrome (LQT1) approximately 20 years ago during family screening (syncopal episodes in his son positive for LQT1), no history of syncope or major arrhythmias. In home therapy with mirtazapine and norvasc. He arrived in our cardiac intensive care unit for ACC on torsade de pointes trated with two cycles of CPR and 1 DC shock at 200 Joules with ROSC. On arrival ECG evidence of electrically induced ventricular rhythm, QTc 850 msec. On echocardiogram akinesia of the mid–basal segments of all the LV walls (takotsubo–like) with EF 25–30%. On coronary angiography non critical multivessel coronary disease. At laboratory tests increase of WBC, PCR and PCT, slight plateau movement of troponin, normal electrolytes. The patient underwent a chest CT scan with evidence of an inflammatory focus for which antibiotic therapy was started. Congenital long QT syndrome (LQTS) is an inherited condition characterized by prolongation of the QT interval (more than 450 ms in men and 460 ms in women), associated with repolarization abnormalities. There are three main forms transmitted via AD: LQT1, LQT2 and LQT3. The most common variant is LQT1 caused by a loss of function mutation in the KCNQ1 gene which causes a reduction in the outgoing potassium current during phase 3 of the action potential. In these patients, episodes of syncope caused by torsade de pointes, major arrhythmias and sudden cardiac death are frequent. Patients with LQTS should avoid taking drugs that can prolong the QT interval such as some antipsychotics, antidepressants (like mirtazapina that can cause QT prolongation, torsade de pointes, ventricular tachycardia and sudden cardiac death if administered at high doses or in patients with predisposing factors), antibiotics. Furthermore, there are various factors that can influence the QT prolongation: electrolyte alterations, physical stress, cerebrovascular events. The use of mirtazapine for a long period in association with takotsubo syndrome (probably triggered by underlying pneumonia) in a patient with LQTS, may have resulted in massive lengthening of the QT interval causing torsade de pointes and therefore ACC. During the hospitalization, mirtazapine was suspended and nadolol was introduced with a progressive reduction of the QT segment. No new arrhythmic events were recorded.
ADVANCED CARDIAC IMAGING IN LIVER TRANSPLANTATION ECHOCARDIOGRAPHIC VENTRICULAR STRAIN AS PROGNOSTIC TOOLS
Authors: Cartoni D , Giannelli V , Sperduti N , Scirpa R , Buffa V , Guglielmo N , Pellicelli A , Petrolati S
Published: May 2024

While cardiac involvement in the end–stage liver disease (ESLD) is a known condition, the characteristics of cardiac function in cirrhotic cardiomyopathy and their effects on candidates to liver transplant (LT) are still vague. The evaluation of right ventricular failure (RVF) in liver transplant candidates has been revolutionized by advanced cardiac imaging techniques, particularly echocardiography with global longitudinal strain (GLS) analysis. Aim of the present study is to evaluate RV function indexes in ESLD patients candidate to LT and the potential relationship with the liver disease status and cardiovascular major events on early post–LT phase Forty ESDL adult patients (age 46.8 ± 10 yrs, M/F 33/7) candidate to LT (19 for hepatic failure, 18 for hepatocarcinoma and 3 for other causes) were evaluate. All were submitted to transthoracic echocardiography and coronary CT angiography or coronary angiography. The Model for End–stage Liver Disease (MELD) score in the study population was 19±6.8. The higher values of the MELD score (i.e. the worst liver function condition) were directly correlated with the lower RV–GLS (p<0.02). Cardiac function indexes were LV–EF 62.8±4.5%, RV–GLS –22.9±4.5%, LV–GLS –19.5±4.6% and PAPs 31.8±6.6 mmHg. On 21 day follow–up, 4 patients died (2 with acute RV failure, 1 with Tako–Tsubo syndrome). On CT–angiography the value of calcium score was significantly different between the group of fatal events and the rest (0 vs 567±900), revealing that none of the died patient suffered from coronary atheromatic disease. Our findings identified that specific RV–GLS patterns on echocardiography, indicative of subclinical myocardial dysfunction, were strongly correlated with worst clinical hepatic conditions and reduced survival rates post–transplant. The study highlights the importance of advanced cardiac imaging in identifying liver transplant candidates at higher risk of post–transplant mortality due to RHF.
AN ACUTE EVENT AS SIGN OF A CHRONIC PROCESS
Authors: Carluccio R , Ippolito D , Rumolo M , Parlati A , Giallauria F , Santoro C , De Luca N
Published: May 2024

A 66–year–old woman was admitted to the Emergency Department with dyspnea at rest. 11 days earlier she had undergone surgery because of femoral fracture. The Computed Tomographic Pulmonary Angiogram (CT Angiogram) confirmed the diagnosis of Pulmonary Embolism (PE). Patient was transferred to Cardiac Intensive Care Unit were Echocardiogram showed signs of right ventricle overload and Echo–Vascular showed trombotic occlusion of the right popliteal vein. Infusional heparin sodium and NIV were started. After 6 days of treatment, patient was asymptomatic, heparin was switched to DOAC and she was transferred to Rehabilitative Cardiology for thrombofilia and oncological screening: oncological markers resulted negative but for the evaluation of hypercalcemia, high value of PTH and low value of Vitamin D, she was transferred to Endocrinology Department with suspicious of primary hyperparathyroidism, possible cause of bone fracture in a young woman.
A CASE OF PARADOXICAL PULMONARY EMBOLISM AS CAUSE OF RENAL INFARCTION: IT’S TIME FOR USAT
Authors: Falagario A , Camassa N , Pansini M , Ostuni V , Mannarini A , D‘Agostino C
Published: May 2024

Case Report

A 67 years old Angolan woman was referred to our hospital for worsen dyspnea, palpitation and left flank pain while walking. She had no relevant medical history and her only cardiovascular (CV) risk factor was hypertension. For high suspicion of pulmonary embolism (PE), an abdominal–thoracic CT was performed, demonstrating the presence of bilateral PE with greater thrombotic burden of the right branch, right ventricle (RV) enlargement and left renal infarction. She was stratified in an intermediate–high risk class. The patient was hemodynamically stable (BP: 120/65 mmHg, HR: 115 bpm) with a calculated PESI class of III and elevated Hs–cTnI. Transthoracic echocardiography (TTE) showed RV dilation, McConnell sign, flattened intra–ventricle septum, mild pulmonary and severe tricuspid valve regurgitations. Therefore, we decided to start anticoagulation and to perform ultrasound–assisted thrombolysis (USAT) without procedural complications. A venous echo–doppler demonstrated the presence of thrombosis of the left popliteus veins. Moreover, screening for thrombophilia syndromes and neoplastic markers were negative. The day after, a partially–restored flow was noticed on renal artery US. The bubble test during transesophageal echocardiography revealed a patent foramen ovale (PFO) with a moderate right–to–left shunt. From these findings, a paradoxical embolism (PDE) through amoderate PFO was confirmed as the cause of her renal infarction. After 7 days of hospitalization, the patient was discharged on anticoagulant (apixaban) in good health status and with reduced serum creatinine levels.

Discussion

PE is the 3rd leading cause of CV mortality. A rare scenario in PE is PDE, manifesting in this case with acute kidney injury, with no other organ involvement. PDE occurs when a thrombus crosses an intracardiac defect into systemic circulation and it usually follows PE because elevated right–side pressure enhances right–to–left shunting. For patients with intermediate–risk PE, there is no clear consensus on 1st–line therapy. In our case, USAT has been effective in reversing RV dysfunction with early decrease of right–side pressures by TTE assessments. Compared with anticoagulation alone, USAT may quicker protect from PDE recurrence and potentially reduce the incidence of chronic thromboembolic pulmonary hypertension, a rare but serious long–term complication. Moreover, as we observed, thrombolytic local release can dissolve systemic clots when PDE occurs.
A REAL–WORLD PROTOCOL OF EARLY USE OF TRIPLE LIPID LOWERING THERAPY WITH I–PCSK9
Authors: Demichelis B , Giammaria M , Annibali G , De Rosa C , Muccioli S , Fasano R , Sillano D , Civera S , Bongioanni S , Coda L , Zappia L , Radano I , Musumeci G , Delnevo F
Published: May 2024

Aim

We evaluated the feasibility of an early triple lipid lowering therapy (LLT) with PCSK9 inhibitors in patients with acute coronary syndromes (ACS).

Methods

In this multicenter experience, we consecutively enrolled ACS patients from July to November 2023. The prescribed LLT was evaluated at discharge. Triple therapy with a high–intensity statin plus ezetimibe and PCSK9i was recommended in the following cases: patients already on statin or statin/ezetimibe therapy with LDL–C values > 70 mg/dl; patients not on LLT at admission with LDL–C values > 70 mg/dl and at least one of diabetes mellitus (DM), multivessel coronary artery disease (MV) or peripheral arterial disease (PAD); patients not on LLT at the time of admission and LDL–C values > 140 mg/dl even in the absence of DM, MV or PAD. A six–month follow–up was planned to determine LDL–C target attainment, compliance, side e!ects, and cardiovascular events.

Results

We consecutively enrolled 264 patients, 95% of whom were discharged with high–intensity statin plus ezetimibe and 29% discharged with in–hospital addition of PCSK9i (triple therapy). Of the 77 patients discharged in triple LLT, the median age was 71.4 years, 71% were male, 42% were current smokers, DM was present in 19%, and 48% had history of hypertension. The diagnosis at admission was ST–Elevation Myocardial Infarction in 66.2%, Non–ST–Elevation Myocardial Infarction in 29.5%, and unstable angina in 4.3% of cases; 63% of patients had history of coronary artery disease and 6.8% had history of peripheral artery disease (PAD); 19.6% were already on at least one statin therapy and the median LDL–C value at admission was 128 mg/dl.

Conclusions

In conclusion, the use of an early and strong lipid lowering approach in very high risk patients with in–hospital or at discharge PCSK9i administration is feasible and safe. The complete results of six–months follow–up and LDL–C values will be available for the congress.
NON–RESPONSE TO INCLISIRAN THERAPY IN THREE PATIENTS WITH STATIN INTOLERANCE: A CASE SERIES
Authors: Pozzi A , Bonfanti P , Bartesaghi G , Refugjati T , Marini A , Corrado G
Published: May 2024

Background

Inclisiran is the first silencing–RNA therapy used to reduce LDL–C. It is also recommended in patients with statin intolerance. We describe a case series of three no–responder patients to inclisiran.

Case Series

64–year–old man with medical history of type II diabetes mellitus, obesity, hypertension, chronic kidney disease (eGFR 38 ml/min/1.73 m^2), dyslipidemia and statin intolerance. In 2022 the coronary angiography showed diffuse atherosclerosis without significant stenosis. His LDL–c was 115 mg/dl. Rosuvatatin 10 mg was prescribed however it was withdrawn due myalgia. Inclisiran and ezetimibe were prescribed, however one, three and four months later his LDL–C was 96 mg/dl, 114 mg/dl, and 115 mg/dl respectively (Fig 1). Due to the lack of effect, lovastatin 20 mg was added after the third dose of inclisiran, reaching LDL–C levels of 100 mg/dl one month after the initiation of lovastatin. Inclisiran was withdraw (as well as statin due to myalgia) and evolocumab 140 mg was administrated three months later the last dose of inclisiran. Ten days after evolocumab, LDL value was 66 mg/dl. 60–year–old man with hypertension, obesity, and dyslipidemia (LDL 152 mg/dl) with a moderate cardiovascular risk (target LDL–C <70 mg/dl). Patient refused statin therapy because he was scared about myalgia. In October 2021 (first Italian patient out of clinical trial) inclisiran was administrated. However, LDL–C did not change one month after the first and the second dose (147 mg/dl and 134 mg/dl respectively, Fig1). Due to the inefficacy, inclisiran was withdraw and the combination rosuvastatin and ezetimibe 10/10 mg was started with a reduction in LDL–cholesterol levels (51 mg/dl) four months later. However, this treatment was withdrawn due to myalgia in favor of bempedoic acid. One month later LDL–C level was 79 mg/dl. 79–year–old woman with history of coronary revascularization. She was statin and ezetimibe–intolerant, so she was treated with alirocumab 150 mg (LDL–C 89 mg/dl). Since the treatment was ineffective to reach the LDL target values, alirocumab was stopped in favor to inclisiran. However, LDL values increased over the time reaching 103 mg/dl one month after the first dose and 120 mg/dl two months later the second dose (Fig1).

Conclusion

some patients may be no–responder to inclisiran. A polymorphism of the asialoglycoprotein receptors might be a possible reason. Statin intolerance may also affect inclisiran efficacy.
ANTIBIOTIC THERAPY IN POST-EXTRACT PATIENTS
Authors: Ferrieri A , Pastore I , Carretta D , D‘Agostino C , Benedetto L
Published: May 2024

Introduction

With the increase in complications associated with the implantation of pacemakers and defibrillators, the number of patients who undergo transvenous extraction of leads following infection has increased. Often, in pacemaker-dependent patients there is the problem of having to carry out an early reimplantation after extraction. This study aims to evaluate the incidence of reinfection in post-extracted patients treated with antibiotic therapy and reimplanted with a second device.

Methodology

To demonstrate the reduction in infection recurrences, a follow-up was carried out on all patients extracted in our center, differentiating between patients reimplanted with a second device who underwent targeted antibiotic therapy before and after surgery and patients reimplanted without targeted pre-extraction antibiotic coverage due to the failure to identify a specific germ.

Results

184 device extraction procedures performed due to infection in our center were considered. In 100 patients the need arose to reimplant a second device at the same time as the extraction procedure. Among these patients, 33, in whom the germ of the infection was known, were treated with pre- and post-procedure antibiotic therapy, while in 24 patients no pre-extraction antibiotic therapy was carried out as they did not have a targeted antibiotic and in waiting for a positive blood culture. 4 patients, however, were treated with empirical therapy, which was then updated post-extraction following the results of the analysis of the extracted material. Subsequently, a follow-up was carried out to evaluate any recurrence of infections and it emerged that: a recurrence of infection occurred in 6% of patients treated with targeted antibiotics pre- and post-extraction and in 4% of patients treated with antibiotics only post-extraction -extraction. Among the 4 patients treated with empiric antibiotic therapy, 1 had a recurrent infection.

Conclusions

From this study it was possible to demonstrate that targeted antibiotic therapy also made it possible to limit infections in the short and long term even in patients who, not having positive blood cultures before the extraction procedure, underwent the therapy only following the results obtained by the extracted material, without the use of empirical antibiotic therapy.
EFFECT OF SGLT2 INHIBITORS ON THE ARRHYTHMIC BURDEN IN HEART FAILURE
Authors: Vecchi A , Saccinto G , Bisceglia F , De Ponti R , Campana C
Published: May 2024

Background

Sodium–glucose co–transporter 2 inhibitors (SGLT2–i) have shown significant cardiovascular benefits in patients with and without type 2 diabetes mellitus, however, their potential beneficial effect on arrhythmic burden has been poorly investigated.

Objective

This observational study explores the potential arrhythmic burden reduction in a cohort of heart failure (HF) patients treated with SGLT2 inhibitors, regardless of ejection fraction.

Methods

29 consecutive HF patients, who underwent cardioverter defibrillator (ICD) implantation for at least 6 months before the enrollment, were followed up 6 months later SGLT2–i initiation. Every single event was analyzed by Cardiologists experienced in home monitoring systems and has been categorized as follow: atrial high–rate episodes (AHRE), SVT (Sustained Ventricular Tachycardia), non–sustained Ventricular Tachycardia (NSVT), Premature Ventricular Beat burden (PVC), anti tachycardia pacing (ATP), proper and inappropriate shocks. All data were collected in an arbitrary observational time of 6 months before and after SGLT2–i therapy has been initiated.

Results

In the 6 months before SGLT2–i introduction the following data were observed: 211 AHRE in 6 patients (21% of patients who experienced at least an event), 1 SVT (3%), 8 NSVT in 5 patients (17%), 2 ATP in 1 patient (3%), 1 inappropriate ICD shock. Considering the limited sample size which affected statistical power, after SGLT2–I initiation a trend of arrhythmic burden reduction was observed: 554 AHRE in 3 patients (10%), 1 SVT (3.4%), 7 NSVT in 3 patients (10%), 2 ATP in 1 patient, 1 appropriate shock. Despite an absolute increase in total AHRE episodes, patients who experienced at least an event halved (from 21% to 10%). Moreover, a remarkable NSVT reduction was observed both as patients who experienced the event (17% to 10%) along with absolute number of events.

Conclusions

SGLT2–is have been showing strong improvements on cardiovascular events, especially HF hospitalization and CV death. Besides, the burden of cardiac arrhythmias is still a matter of debate, especially in the field of ventricular burden. Our study delineates a positive effect of SGLT2i, showing a trend in reduction of the arrhythmic event, both in AHRE and NSVT. Expanding sample size of this study is mandatory to support the benefit of SGLT2i on arrhythmic burden, suggesting a charming pharmacodynamic model of these still unknown, extraordinary drugs.
HEART FAILURE AND PALLIATIVE CARE, ITALIAN VALIDATION OF THE "NEED ASSESSMENT TOOL: PROGRESSIVE DISEASE – HEART FAILURE" (NAT: PD–HF)
Authors: Mancuso G , Moggia F , Rizzello F
Published: May 2024

Palliative Care in Heart Failure cardiology setting is still a demanding topic and lacking of clear indications regarding which patients should be referred to palliative care is an actual issue, as confirmed by a systematic review of international literature. Assessment tools facilitate the identification of patient needs and guide the actions of healthcare professionals to address them. Some existing tools described in literature were used with non–cardiological patients, but they cannot be applied to Heart Failure as they are incomplete and investigate non–specific aspects of the disease. Two recent systematic reviews indicate that the most comprehensive and specific tool for Heart Failure patients is the "NAT: PD–HF." The "NAT: PD–HF" has already been translated and validated from English to Dutch and German, but an Italian validation is still missing in literature. It is a quick and easy–to–use tool consisting of four sections that assess the patient’s well–being and quality of life, the caregiver‘s ability to provide assistance and support, both patient’s and caregiver’s needs and requests and any critical element that, if present, would justify a specialist palliative evaluation. Therefore, with prior authorization from the original authors, we proceeded with the translation and transcultural validation of the tool. The study protocol was approved by the Bioethics Committee of Bologna in April 2023. We are currently at the final phase of the protocol, namely testing the tool on the target population by the professionals involved in the care process. The purpose of transcultural validation is to provide the Italian scientific community with the "NAT: PD–HF" tool: throw its incorporation into the medical records of Heart Failure Patients receiving care in the territorial setting, we aim to increase the use of palliative cares and, consequently, the quality of life of patients and caregivers, as demonstrated in the original study.
TAKING A WALK ON THE HEART FAILURE SIDE: COMPARISON OF METABOLIC VARIABLES DURING WALKING AND MAXIMAL EXERTION
Authors: Mapelli M , Salvioni E , Bonomi A , Paneroni M , Raimondo R , Gugliandolo P , Mattavelli I , Bidoglio J , Mirza K , La Rovere M , Gustafsson F , Campodonico J , Pezzuto B , Vignati C , Agostoni P
Published: May 2024

Background

Although cardiopulmonary exercise testing (CPET) is the gold standard to assess exercise capacity, simpler tests (i.e. 6–minute walk test, 6MWT) are also commonly used. Aim of this study was to evaluate the relationship between cardiorespiratory parameters during CPET and 6MWT in a large, multicenter, heterogeneous population.

Methods

We included athletes, healthy subjects, and heart failure (HF) patients of different severity, including left ventricular assist device (LVAD) carriers, who underwent both CPET and 6MWT with oxygen consumption measurement.

Results

We enrolled 186 subjects (16 athletes, 40 healthy, 115 non–LVAD HF patients, and 15 LVAD carriers). CPET–peakV̇O2 was 41.0 [35.0–45.8], 26.2 [23.1–31.0], 12.8 [11.1–15.3], and 15.2 [13.6–15.6] ml/Kg/min in athletes, healthy, HF patients, and LVAD carriers, respectively (p<0.001). During 6MWT they used 63.5 [56.3–76.8], 72.0 [57.8– 81.0], 95.5 [80.3–109], and 95.0 [92.0–99.0] % of their peakV̇O2, respectively. None of the athletes, 1 healthy (2.5%), 30 HF patients (26.1%), and 1 LVAD carrier (6.7%), reached a 6MWT–V̇O2 higher than their CPET–peakV̇O2. Both 6MWT–V̇O2 and walked distance were significantly associated with CPET–peakV̇O2 in the whole population (R2=0.637 and R2=0.533, p=<0.001) but not in the sub–groups. This was confirmed after adjustment for groups.

Conclusion

The 6MWT can be a maximal effort especially in most severe HF patients and suggest that, in absence of prognostic studies related to 6MWT metabolic values, CPET should remain the first method of choice in the functional assessment of patients with HF as well as in sport medicine
IMPACT OF NEW MULTIPARAMETER ALGORITHM FOR THE MANAGEMENT OF HEART FAILURE PATIENTS WITH AN ICD IN TERMS OF REDUCED HOSPITALIZATION AND ROLE OF THE CARDIOLOGY TECHNICIAN IN TELECARDIOLOGY RELATED TO SPECIFIC HEART FAILURE SERVICE – OUR EXPERIENCE
Authors: Scapinelli M , Guerra A , Caputi A , Merighi S , Sacchetti G , Boccedi M , Bonfiglioli N , Bagni E
Published: May 2024

Introduction

Heart failure represents an important cause of hospitalization and is associated with an increased cardiovascular risk for the patient as well as an increase in healthcare spending. In recent years, algorithms for detecting pre–heart failure subclinical changes have been developed for implantable defibrillator (ICD) users so as to be able to act early and avoid hospitalization. In our reality we have created a teamwork dedicated to the evaluation of alerts which includes the electrophysiologist, the heart failure cardiologist and the cardiology technician.

Material and Methods

Thirteen patients implanted with Boston Scientific ICDs and CRT–Ds in the period between November 2019 and December 2022 were considered, 9 males and 4 females with an average age of 69.7 years. The object of the study were the Heart–Logic algorithm with a total of 41 alerts received which were followed by telephone contact in an average time of 2.6 days evaluating any ongoing symptoms, adherence to the prescribed therapy and whether there had been any changes to the same, blood pressure trend and any recent laboratory tests. On the basis of this, an outpatient visit was scheduled in 13 cases (31.7%) and the diuretic was increased in 19 cases (46.3%) and the beta–blocker in 6 cases (14.6%); in 4 cases (9.7%) has been modified the SGLT2 dose. In 12 cases (29.2%) no action was taken following telephone contact and among these only 2 hospitalizations occurred. The most represented component of alert activation was the variation in heart tones followed by thoracic impedance and nocturnal heart rate. The average time on alert was 3.4 weeks.

Conclusions

The multiparametric algorithm has shown, also in our experience, good sensitivity but the share of false positives is not negligible, for which we believe as very important the clinical–therapeutic evaluation following receipt of the alert, which must be analyzed in its activation components before therapy adjustments or other decisions. In our organization the Cardiology Technician plays a fundamental role as he receives the alert, quickly calls the patient collecting the information described above and interfaces with the doctor to decide the actions to take. As part of the specific heart failure service for patients with CIEDs, the Technician supports the cardiologist in the management of the patient, providing a fundamental contribution in the evaluation and interpretation of remote transmissions.
PULMONARY VENO–OCCLUSIVE DISEASE ASSOCIATED WITH METHAMPHETAMINE ABUSE: A FIRST CASE DESCRIPTION
Authors: Baratto C , Gagliardi M , Liberatore M , Dipierro P , Boniolo F , Perego G , Parati G , Caravita S
Published: May 2024

Background

Recreational methamphetamine is widely used worldwide (about 35 million people), mainly as 3,4–Methylenedioxymethamphetamine (MDMA). A definite association has been established between methamphetamine and pulmonary arterial hypertension (PAH). This drug–associated form of PAH shares histological, clinical and hemodynamic characteristics, prognosis and treatment strategies with idiopathic PAH. However, the association between MDMA and a rarer and devasting form of PAH with concomitant venous involvement (pulmonary veno–occlusive disease, PVOD), has never been reported. Notably, initiation of PAH–specific treatment in PVOD may lead to catastrophic consequences.

Case Description

A 32–year–old man was fast–track referred to our PH Centre in December 2023, due to high echocardiographic probability of pulmonary hypertension (PH). After interrogation, he admitted the regular use of MDMA. No other risk factor for PAH was found. Right heart catheterization showed a pre–capillary PH (mean pulmonary artery pressure 35 mmHg; wedge pressure 12 mmHg; pulmonary vascular resistance 5.9 WU) with low cardiac output (2.2 L/min/m2) and no acute response to vasoreactivity testing. Exercise capacity was severely reduced (oxygen consumption 19.6 mL/Kg/min, 50% of predicted) due to absent stroke volume reserve, accompanied by augmented exercise hyperventilation (VE/VCO2 slope 60) and exercise–induced desaturation (SaO2 94 à 77%), this latter not explained by a right–to–left shunt. Diffusion capacity of the lung was severely reduced (DLCO 28%). Chest CT and perfusion scan excluded both thromboembolic etiology and parenchymal lung disease. A diagnosis of PVOD was made, based on the presence of pre–capillary PH, oxygen desaturation, extreme exercise hyperventilation and very low DLCO, even in the absence of pathognomonic CT features. Counselling for stopping MDMA abuse was offered. Cautious monotherapy with macitentan was started and was well tolerated. A genetic testing for EIF2AK4 is ongoing. Contact with transplant center has been performed. A follow–up RHC has been planned before careful therapy up–titration.

Conclusions

This is the first case reported of the potential association between methamphetamines and PVOD. Due to the large worldwide use of MDMA, this link should be considered because of its prognostic and therapeutic implications. The diagnosis of PVOD is a clinical one, needing a high index of suspicion especially in the absence of chest CT findings.
AN UNUSUAL CASE OF PULMONARY ARTERIAL HYPERTENSION FOLLOWING SURGICAL TREATMENT OF A LUNG ABSCESS IN A PATIENT WITH LATENT SYSTEMIC SCLEROSIS
Authors: Damele A , Pittaluga M , Somaschini A , Buscemi M , Cordone S , Toma M , Bellone P , Ameri P
Published: May 2024

Background

Pulmonary arterial hypertension(PAH) is frequently associated with systemic sclerosis(SS). Nevertheless, little is known about the triggers that may exacerbate PAH in these patients.

Case Report

A 71–year–old woman, previously diagnosed with Raynaud‘s Syndrome and without any other significant medical history, was admitted to our Emergency Room due to dyspnea and fever. She was diagnosed with pulmonary infection complicated by empyema(Figure1) and underwent surgical toilet and decortication of the lower lobe with full recovery. Echocardiography during the hospital stay was normal. Few months after discharge she developed dyspnea WHO–FC III and fatigue and eventually she was hospitalized with a diagnosis of acute heart failure. The ECG showed right bundle branch block and signs of right ventricle strain(Figure2). The echocardiogram(Figure3) was characterized by normal left ventricular systolic function, enlarged right ventricle with D shape and moderate impairment of systolic radial function; pulmonary hypertension(PH) with an estimated pulmonary artery pressure of 60mmHg was also detected. Pulmonary CT angiography excluded pulmonary embolism. Aiming to better characterize PH, a right heart catheterization was performed with the following findings: mean pulmonary artery pressures 34mmHg(55 mmHg systolic–22mmHg diastolic), wedge pressure 5mmHg, right atrium pressure 2mmHg, pulmonary vascular resistance 8WU; the cardiac output and cardiac index were only mildly reduced. Elevated levels of NT–proBNP and troponin I were also found(1926pg/m [n.v.<125] and 65.9ng/L [n.v.<19] respectively), whereas blood count, liver and renal function, rheumatoid factor, and C–reactive protein levels were normal. Based on the above findings, a diagnosis of pulmonary arterial hypertension(PAH) in intermediate–high risk class was made. Therefore, dual specific therapy for PAH with sildenafil and macitentan was initiated. The rheumatologic screening findings(CENP A/B positive, typical pathological findings at capillaroscopy) associated with the patient’s history PAH, Raynaud Syndrome) were consistent with a diagnosis of SS. After three months the patient showed a good response to dual therapy and progressed to a low–risk class(WHO–FC II, 6MWD=420m, normal NT–proBNP values).

In conclusion

lung abscess and its surgical treatment may have played a role in our patient. Close follow–up of SS patients should be ensured when they face interventions and/or acute stresses.
INDIPENDENT PROGNOSTIC VALUE OF SOLUBLE–SUPRESSION OF TUMORIGENICITY (S–ST2) IN PATIENTS AFFECTED BY PULMONARY HYPERTENSION
Authors: Novielli M , De Tommasi E , Camassa N , De Michele L , Mannarini A , Cascella S , Andreani S , Mazzilli D , Lucente F , Discipio O , Di Serio F , D‘Agostino C
Published: May 2024

Introduction

According to ESC 2022 guidelines, pulmonary hypertension (PH) is a hemodynamic condition characterized by mean pulmonary arterial pressure>20 mmHg. Pulmonary arterial hypertension (PAH) represents 5% of the PH, with an unfavorable prognosis primarily because of late diagnosis and treatment. In PAH, it is important to evaluate the individual patient mortality risk through a multiparametric approach: a three–layer model at diagnosis and a four–layer model based on WHO–FC, 6MWD and NT–proBNP at follow up, which allows better discrimination within the intermediate risk group helping therapeutic decision making. The only biomarker included in risk stratification is NT–proBNP; however, in previous studies soluble–Supression of Tumorigenicity 2(s–ST2), a marker of myocardial stress, resulted a strong predictor of death in heart failure and acute coronary syndromes.

Aim

The aim of this study is to analyze the prognostic value of s–ST2 in patients with pulmonary hypertension.

Methods

This is a prospective study conducted on 45 PH patients (75% PAH), which were followed for survival. They underwent echocardiography, venous sampling to measure s–ST2 levels, right heart catheterization. All the patients were followed for survival.

Results

During an average 18–month follow–up, 17 patients died, 76% of whom had pulmonary arterial hypertension (PAH). They showed significantly higher values of s–ST2. sST2>78 ng/ml represents a numerical value with the highest association with mortality in our study population: at 6–12 months the patients with sST2>78 ng/ml showed statistically significant early higher mortality in comparison with sST2 <78 ng/ml patients (Fig. 1). At multivariate analysis s–ST2>78 ng/ml is confirmed to be a statistically significant predictor of mortality, regardless of WHO functional class III–IV, PAPs and NT–proBNP. Furthermore, s–ST2 appears a better early mortality predictor than NT–proBNP, at the limit of statistical significance (Fig. 2).

Conclusions

In a population of patients with pulmonary hypertension (predominantly PAH) we define a numerical value of sST2>78 ng/ml, which is a prognostic discriminator, independent and incremental to NT–proBNP at short–term follow–up. It allows the clinician the appropriate planning of therapeutic strategies in a condition in which the earliness of therapy affects prognosis.
PULMONARY HYPERTENSION AND CONGENITAL HEART DISEASE: THE CLINIC BEYOND THE EVIDENCE
Authors: Ferrara A , Di Fonzo R , Vigorito F , Galasso G , Vecchione C , Soriente L
Published: May 2024

Eisenmenger syndrome (ES), first described by Victor Eisenmenger, was defined by Paul Wood in pathophysiologic terms as “pulmonary hypertension (PH) at systemic level, caused by a high pulmonary vascular resistance (PVR), with reversed or bidirectional shunt at aorto–pulmonary, ventricular, or atrial level.” It represents the most severe hemodynamic phenotype of pulmonary arterial hypertension (PAH) in association with congenital heart disease (CHD) and develops in the presence of large, unrepaired atrial or ventricular septal defects, arterial shunts, or complex forms of CHD. Although therapeutic management has rapidly advanced in recent years, these patients were not included in randomized controlled trials for specific pulmonary arterial hypertension drugs, except for bosentan. However, in clinical practice we apply treatment strategies combining drugs targeting multiple pathobiological pathways. The clinical case we describe is that of a 44–year–old patient, suffering from Down syndrome, with ES due to subaortic VSD and a a patency of Botallo duct, followed in our PH clinic of the "Ruggi D‘Aragona" University Hospital for about 9 years. The patient, on dual therapy with Macitentan 10 mg and Sildenafil 60 mg, was in the intermediate–high risk class, stationary. During the last two checks, there was a progressive worsening of the hemodynamic parameters, walking distance of only 100 meters, with SpO2 at baseline 90% and desaturation during the 6mwt. On cardiac color Doppler ultrasound evidence of TAPSE 18 mm, PAPS 100 mmHg, RAA 20 cm²; TAPSE/PAPS 0.18. The patient presented in WHO class 3. The only RCTs currently available concern the use of bosentan, but in clinical practice, initial monotherapy with an endothelin receptor antagonist or a phosphodiesterase type 5 inhibitor for symptomatic patients is proposed. Reassess and consider escalation to a double combination therapy in case of clinical worsening or inadequate clinical response. Consider uptitration with the addition of prostanoids when inadequate response and timely assess the eligibility for transplantation. For our patient therefore, in consideration of the impossibility of surgery, although there is little evidence on prospective observational studies based on cohorts of a few patients, we added selexipag 200 ug x 2/day to titrate therapy.This case opens the door to still unclear scenarios in which unfortunately the only weapon available remains the clinician‘s judgment and experience.
OUT–OF–HOSPITAL MANAGEMENT INDICATORS IN THE APPLICATION OF THE UNIFIED PDTA "STEMI NETWORK" FOR THE AST OF ASCOLI PICENO AND FERMO: FROM DIAGNOSIS TO PCI WIRE–CROSSING. LONGITUDINAL OBSERVATIONAL CLINICAL STUDY
Authors: Paolone L , Parato V , Traini T
Published: May 2024

Introduction

The incidence of STEMI in European countries varies between 40 and 140/100 000/year, which equates to more than 500 000 patients with STEMI hospitalized each year. STEMI is defined by chest pain or equivalent symptoms and ST segment elevation or left bundle branch block on diagnostic ECG and subsequent confirmation of diagnosis by cardiac troponin elevation. The cornerstone of STEMI treatment is acute reperfusion therapy preferably with primary percutaneous coronary intervention (PPCI).Objective The general objective of the study proposes to detect the process and outcome indicators contained in the unified PDTA "STEMI Network" of the AST of Ascoli Piceno and the AST of Fermo. The specific objective of the study is to aggregate in percentage form, the Items included in the data collection of patients diagnosed with ACS STEMI taken from the territory by emergency vehicles or arrived in the Emergency Room of the plants mentioned above with their own vehicle, in the 8 extra–hospital indicators provided for by the PDTA through.

Materials and Methods

All medical records diagnosed with SCA STEMI made available by U.T.I.C. have been selected of the HUB Hospital of Ascoli Piceno. All services provided for diagnosis of ACS N–STEMI have been excluded. The analysis period includes the last two months of 2022 and the first six months of 2023. A limitation emerged in identifying whether the rescue vehicle needed remote telephone consultation if the diagnosis had been doubtful in cases where the nursing staff did not use the intervention card provided by PDTA.

Results and Conclusions

Indicators: patients transferred to the HUB center and PCI 120‘ N 45 (85%) Ntot 53; Patients in Spoke and PCI 90‘ N6 (30%) Ntot 20; DIDO <30‘ N9 (45%) Ntot 20; ECG in Triage within 10‘ N29 (41%) Ntot 41; Pre–PCI drug treatment N89 (100%); Arrival PCI Hub 60‘ N13 (62%) Ntot 21; remote consultation N12 (23%) Ntot 53; favorable transmission ECG N31 (58%) Ntot 53. Other timing: FMC/WC ratio N89, average 110’. To reduce the timing target, increase the performance of the indicators according to the standards recommended, the only solution is the training of health personnel who works within the network and information to citizens for an early recognition of symptoms with a consequent first medical contact and the decision to subject the patient to a PCI–W.C. in the shortest possible time for a better long–term outcome term.
APPLICATION OF AN ORGANIZATIONAL MODEL FOR PATIENT CARE: PRIMARY NURSING IN A REHABILITATION CARDIOLOGY CENTER
Authors: Zanuzzi B , Longobardo E , Ferrante G , Vecchi S , Vaccaro M
Published: May 2024

The issue of chronicity and frailty is shaped in the current health care environment as an increase in the complexity of pz–users referred to Rehabilitation Cardiology. Advances in medical care and improvements in general living conditions have led to an explosion of chronic diseases and the spread of a new figure of the caregiver, in which several diseases coexist. For this reason, over the past 20 years, the need for care, in the R.C. has increased significantly precisely bc of the increase in multiple comorbidities of pz hospitalized for cardiologic events. This need translates into increased care complexity, which therefore requires the need to experiment with new organizational models capable of ensuring a systemic approach to taking care of the person. In this scenario, the PN of care is developed, an innovative method capable of going beyond the therapeutic project, centering the process from operator–centered to pz–centered. The essential aspect of this organizational model is the practitioner‘s full acceptance of his or her responsibilities from admission to discharge of the pz. From August 2023 to November 2023, 228 consecutive pz were admitted to the RC. The PN organizational model was applied to all in pz admitted during the period under observation. During admission to the ward, the charge nurse, in full sharing with the pz, carried out data collection and planned care activities; in order to create guidance for colleagues who collaborated with the charge nurse in the care plan, the nurse implemented the drafting of the care process. Finally, in order to provide assurance of continuity of care and to ensure a safer and smoother return home or transfer to another facility for the pz and family members, the nurse, thanks to the PN, also planned the discharge, having personally followed the patient throughout the entire hospitalization. In order to assess the quality of care provided, a satisfaction questionnaire was administered to all in pz admitted during the period under observation. The mean age of the observed pz is 68.7 aa, 79% of pz observed had previous hospitalizations in other hospitals,no pz had any experience with PN, 98% of observed pz noted improved care with referral nurse intake,2% of pz did not complete the questionnaire.In our brief experience, the PN organizational proved to be an effective and comprehensive method, contributed to improving the quality of care provided in our OU and improved the satisfaction of staff.
CONNECT HF/CKD A MULTI–DISCIPLINARY TELEMONITORING PROJECT FOR HOSPITAL RE–ADMISSIONS REDUCTION AND THERAPEUTIC OPTIMIZATION IN HEART FAILURE IN THE ERA OF DIGITAL DEVICES
Authors: Grossi F , Fatucchi S , Innocenti L , Bertini A , Bartolini S , Taborchi G , Minneci C , Zoppi P , Alti E , Rosati A , Milli M
Published: May 2024

Introduction

Management of patients affected both from heart failure (HF) and Chronic Kidney Disease (CKD) is a well–known issue. The latest ESC 2023 Heart Failure Guidelines recommend the use of four classes of drugs to reduce mortality and hospital admissions due to HF. CKD represents one of the most frequently reported factors underlying the failure to prescribe or to titrate recommended treatments. New telemonitoring techniques can be useful in the detection of signs of decompensation and achievement of therapeutic targets.

Methods

Our project aims at optimizing the management, treatment and follow–up of patients with HF, thanks to multidisciplinary management and an accurate and easy–to–use home telemonitoring equipment provided to patients. Patients will be divided into two groups based on a high (group A) or medium/low risk (group B) profile. Remote monitoring will last 3 weeks, before the first clinical control in out–patient HF clinic. Once the inclusion and exclusion criteria have been assessed, the patient will be enrolled in one of the two groups. The home telemonitoring equipment allows the detection of different clinical parameters (oximetry, blood pressure, heart rate, 6–lead EKG, body weight) and the visualization of blood test reports. Data are recorded on a tablet connected to a cloud server. A questionnaire is provided to the patient aimed at understanding his/her symptoms and quality of life. Data are sent daily to all the healthcare professionals involved in the project. Group A: High risk patients. The patient will be trained on the operation of the remote monitoring equipment. Daily self–measurement of parameters for 3 weeks after discharge. GROUP B: Low–medium risk patients. Weekly measurement of the parameters by the community nurse for 3 weeks after discharge. In case of signs of congestion and clinical HF decompensation patients from both groups could be treated with diuretic infusion at home or in community out–patient clinics (Case di Comunità).

Expected Results

Reducing mortality and re–hospitalization for decompensated HF, achievement of the pharmacological treatment targets recommended by the ESC guidelines, reducing renal disease progression, building a multi–professional HF support–team, testing a community telemonitoring programme based on the cloud. Preliminary data: preliminary data will be available on May 2024.