bluuebunny/crossref_metadata_2025 huggingface dataset:
P147 THE WINNING FORMULA IN COMPLEX ADULT CONGENITAL REDO INTERVENTIONS: MULTIDIMENSIONAL PERSPECTIVE IN A HYBRID SETTING
Authors: Gambardella R , Ferraro F , Olimpieri A , Nesta M , Calabrese M , Pavone N , Grandinetti M , Bruno P , Amodeo A , Massetti M
Published: May 2023

Introduction

Transposition of the great artery is one of the most common congenital heart anomalies [1]. One of the surgical techniques to correct this anomaly is the Rastelli procedure [2]. After surgical correction, right and left ventricular outflow obstruction are the most common late complications [3]. In grown–up congenital disease (GUCH) late surgery is a high risk procedure and, repeated sternotomy may be associated with adverse injuries to mediastinal structures.The aim of this work is to demonstrate how a preoperative planning may be helpful in identifying patients at risk of re–entry. Case presentationA 50–year–old woman, with primary diagnosis of transposition of the great arteries (TGA), ventricular septal defect (VSD) and pulmonary stenosis (PS) was referred to our Grown Up Congenital Heart (GUCH) center for progressive dyspnoea and reduced exercise tolerance. She underwent a Blalock–Taussig shunt palliation at the age of 3 and a Rastelli procedure after 2 years. Echocardiography revealed moderate–to–severe RV–PA conduit obstruction (122 mmHg) and a left Ventricle–Aorta (LV–Ao) tunnel obstruction (Mean gradient 32 mmHg, Max gradient 52 mmHg). Cardiac MRI and cardiac catheterization confirmed the echo findings and showed the proximity of the RV–PA conduit to the left anterior descending coronary artery, which was considered an exclusion criteria for trans–catheter therapy. A CT scan confirmed diagnosis and showed that mediastinal structures, in particular the aorta, were adherent to the sternum. (Fig 1). After careful examination of the clinical case, our Heart Team decided for high risk surgical treatment of the residual lesions.A percutaneous cannulation was performed, to minimize the re–entry injury risks. Two other percutaneous devices were used: the coronary sinus cannula and the percutaneous left heart venting catheter. The postoperative course was regular and one month after surgery a CT scan confirmed a good result of surgery (Fig 2).

Conclusions

This peculiar case is emblematic to understand how a multidimensional perspective is mandatory in redo GUCH interventions. Hybrid surgery room setting and a multidisciplinary team of surgeons, interventional cardiologists, anesthesiologists and radiologists are essential to reach the goal of successful outcomes for these kinds of complex procedures as a GUCH “big operation”.
P153 A DEEP–LEARNING APPROACH FOR SCAR DETECTION IN EARLY CONTRAST–ENHANCED CARDIAC COMPUTED TOMOGRAPHY IMAGES
Authors: Penso M , Babbaro M , Guglielmo M , Baggiano A , Moccia S , Pepi M , Fusini L , Carerj L , Andreini D , Caiani E , Pontone G
Published: May 2023

Diagnosis of myocardial fibrosis has a relevant prognostic and therapeutic role. Scar–tissue analysis is commonly performed with late gadolinium contrast–enhanced (CE) cardiac magnetic resonance (CMR). However, CMR might be contraindicated or unavailable. Coronary computed tomography (CCT), which is the technique of choice for many routine assessments, is emerging as an alternative to CMR. The objective of this study is to evaluate whether artificial intelligence (AI) could allow identification of myocardial fibrosis from routine early CE–CCT images. Fifty consecutive patients with left ventricular dysfunction (LVD), who underwent both CE–CMR and (early and late) CE–CCT were retrospectively selected. According to the late enhancement CMR patterns, patients were classified as with ischemic (n=15, 30%) or non–ischemic (n=25, 70%) LVD. Scar regions were manually traced on late CE–CCT using CE–CMR as ground–truth. On early CE–CCT images, the myocardial sectors were extracted according to AHA 16–segment model and labeled as with scar or not based on the late CE–CCT manual tracing. A deep–learning model was developed to classify each sector (Picture 1). Of the initial 44187 sectors computed out of the 8285 slices available from the early CE–CCT images, 4594 sectors (10%) presented scar. The CNN approach on the early CE–CCT images yielded a classification accuracy for all sectors of 71% (95% confidence interval (CI): 63%–79%) obtained through 5–fold cross validation. The mean sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the testing fold resulted in 73% (95% CI: 66%–79%), 56% (95% CI: 48%–65%) and 85% (95% CI: 82%– 88%), respectively. The mean AUC across the five folds was 76% (95% CI: 72%–81%). In a per–segment analysis of the 16–segment AHA model the bull’s eye segmental comparison of CE–CMR and respective early CE–CCT findings an 91% agreement was achieved (Picture 2). Artificial intelligence can detect both ischemic and non–ischemic myocardial fibrosis from routine noninvasive coronary scans, without additional contrast–agent administration or radiational dose, thus assisting diagnosis and management of patients with LV dysfunction and coronary artery disease.
P157 PROJECT PROXIMITY: APPLICATION OF TELEMEDICINE IN THE SECONDARY PREVENTION OF PATIENTS WITH ACUTE CORONARY SYNDROME
Authors: Biava L , Marchisio G , Colombo M , Noto L , Franzin S , Scacciatella P
Published: May 2023

Background

Cardiovascular disease is one of the leading causes of death in European countries despite advances in treatment. Lifestyle changes and medication adherence are crucial to prevent recurrences. Telemedicine initiatives represent an innovative tool to support clinicians.

Objective of the Work

Evaluation of the telemedicine project "Proximity" on the improvement of medication adherence, reduction of re–hospitalisation, improvement of lifestyle and health education after hospital discharge.

Materials and Methods

Patients discharged with a diagnosis of acute coronary syndrome from the Cardiology Department of the "U. Parini" Hospital in Aosta from August 2022 were consecutively enrolled, after obtaining informed consent. A Care Management Centre consisting of a social media manager and a nurse has been set up. Patients adhering to the project are provided electronically with information material on the disease, correct drug intake and lifestyle. Adherence and tolerance to therapy is investigated and assistance is offered in booking check–ups. In some cases, a telemonitoring kit is delivered to record and share vital parameters with the operators.

Results

A total of 24 patients were enrolled: 77% male, mean age 64 years and mean ejection fraction 52%. Patients were proposed to achieve an average of 3/5 goals including smoking cessation, weight loss, increased compliance with therapy, nutrition education and increased physical activity. On average, patients achieved 60% of the required goals. In 27% of the patients, early symptoms such as falling or rising blood pressure values, increased heart rate, creatinine value, changes in liver function, bleeding, dyspnoea at rest were identified. In 8% of the cases, the cardiologist or general practitioner had to be contacted to solve clinical problems. In 25% of the cases, the discharge therapy was changed. No patient abandoned the project. No patient was re–hospitalised.

Conclusions

The analysis of the preliminary results of the "Proximity" project supports the use of telemedicine initiatives in the follow–up of patients hospitalised for acute coronary syndrome.
P165 ARRHYTHMIC STORM IN SUBACUTE MYOCARDIAL INFARCTION: A CASE REPORT
Authors: Campana N , Gioi A , Casula M , Scotto R , Tola G , Donovan R , Orrù P , Semeraro L , Manca P , Manconi M , Falchi S , Atzeri V , Pisano L , Loi B , Corda M
Published: May 2023

Introduction

Ventricular arrhythmias (VA) represent a common complication of myocardial infarction (MI). Typically, they occur in two scenarios: during acute MI, related to ongoing ischemia, as ventricular tachycardia (VT) or ventricular fibrillation (VF), or in the context of a late phase of MI, related to the presence of a scar, as monomorphic VT (mVT). Despite the above, their occurrence may be atypical.

Clinical Case

55–year–old man affected by obesity, diabetes and hypertension, admitted to our department for subacute MI. Coronarography showed three–vessel disease with indication for surgical revascularization. Thirty hours after admission, in absence of symptoms, occurrence of cardiovascular arrest due to mVT, which degenerated into VF. After resuscitation, ECG and Echo findings did not change compared to those observed at admission, excluding the presence of current ischemia. A blood gas analysis excluded dysionias. Few minutes later, arrhythmic recurrence of mVT degenerated into VF. This was refractory to electrical and antiarrhythmic therapy and stopped only after percutaneous left stellate ganglion block (LSGB) and deep sedation. Then, emergency surgical revascularization was performed. In the early postoperative days, during weaning attempts from sedation and ECMO support, that had become necessary due to hemodynamic instability after surgery, numerous recurrences of mVT, regressed only after deepening of sedation, multiple external shocks, antiarrhythmic polytherapy, and LSGB. A new coronarography documented patency of coronary artery bypass grafts. On 6th postoperative day, discontinuation of deep sedation and weaning from circulatory support without recurrence of VA. The patient was discharged from the intensive care unit and started on a rehabilitation pathway.

Conclusions

mVTs are commonly related to the presence of a scar, formed late after MI, or to the context of ongoing ischemia in acute MI. However, it should be remembered that even during the subacute phase of MI, arrhythmic instability might still occur. The responsible mechanisms are not completely known but it can be assumed that, even in the absence of a new ischemic event, the process of scar maturation may have led to a transient proarrhythmic substrate, responsible for the arrhythmic storm. Further studies are needed to clarify the mechanisms of arrhythmogenesis in the subacute phase of MI.
P166 LEFT VENTRICULAR SUMMIT PVC–INDUCED CARDIOMYOPATHY: A CASE REPORT
Authors: Di Fraia F , Canciello M , Izzo G , Calvanese R
Published: May 2023

A 76 y.o. patient referred to our attention for syncopal and presyncopal episodes. His ECG showed several premature ventricular contractions (PVC) with the morphology of a right bundle branch block (RBBB)– positive concordance in precordial leads and transtion in V3 lead– and an inferior axis. Echocardiographic finding was a moderate reduced ejection fraction. Furthermore coronarography did not identify critical stenosis, excluding an ischemic etiology. Cardiac MRI was performed, confirming the reduce ejection fraction and excluding LGE. Because of high burden of 25000 PVCs on 24 h ECG registration and progressive deterioration of ejection fraction, despite antiarrhythmic drugs, catheter ablation was considered. An high density multielectrode mapping catheter was used and an initial right ventricular mapping was perfomed, recording local electrograms but without identification of a clear earliest site of activation. Therefore a retrograde transaortic left ventricular mapping was performed. Earliest site of activation was not significant (about 15 milliseconds), as well as percentage of correlation during pace–mapping. Epicardial mapping through coronary sinus into the anterior interventricular vein (AIV) showed a significant earliest activation site (greater than 30 ms) and a negative unipolar signal (QS) was detected. Pacing in this region highlighted a significant percentage of correlation with native PVC (92%), then catheter ablation was attempted. A first short duration application of radiofrequency was erogated on the endocardial side in front of the projection of the catheter in the AIV, because of possible risks of procedure, obtaining a temporary PVC suppression. Subsequently, after execution of a coronary angiogram proving a distance of the ablator in AIV and IVA/Cx vessels greater than > 1 cm, an endovenous approach was attempted with application of radiofrequency into the AIV, obtaing complete PVC suppression. At a 6 months follow–up ejection fraction improved (FE 50%) and PVC were not detected.

Discussion

Epicardial approach throught coronary sinus is an effective strategy to map and ablate arrhythmias of left ventricular summit. In addiction this stretegy allows a less invasive epicardial approach than other procedures, requiring a cardiosurgery standby.
P179 RISCONTRO ACCIDENTALE DI UN RARO CASO DI COR TRIATRIUM DESTRO ASSOCIATO A DIFETTO INTER–ATRIALE IN UN PAZIENTE ADULTO
Authors: Talarico M , Colangelo M , Cassadonte F , Ciconte V
Published: May 2023

Background

Il cor triatrium destro (CTD), anomalia congenita in cui l’atrio sinistro è settato da una membrana in due parti, è un rilievo estremamente raro: in centri ad alti volumi la prevalenza è inferiore allo 0.01% (1). Il cor triatriatum destro è spesso associato ad alter anomalie congenite quali anomalie della valvola polmonare, il ventricolo destro ipoplasico, l’anomalia di Ebstein, i difetti del setto inter–atriale (DIA) (2,3). Quando la settazione è incompleta può essere asintomatico e riscontrato accidentalmente all’esame ecocardiografico (4). Descrizione del caso: A dicembre 2022 un uomo di 55 anni, affetto da fibrillazione atriale parossistica e sintomatico per cardiopalmo e dispnea (EHRA II),si ricoverava per ablazione dell’aritmia. Non venivano rilevati segni di scompenso cardiaco e gli esami del sangue erano normali. All’esame obiettivo si auscultava un soffio sistolico continuo. All’esame ecocardiografico (TTE) si evidenziava un DIA ed una membrana che divideva in modo incompleto l’atrio destro in due parti. Si sospettava un CTD o una valvola di Eustachio prominente. All’ecocardiogramma trans esofageo 3D (TEE) si mostrava una membrana non ostruttiva che divideva l’atrio destro in una camera superiore ed una camera inferiore, compatibile con CTD (Figura 1 e 3). Si confermava la lieve dilatazione dell’atrio destro ed il DIA ostium secundum (Figura 2 e 3) con un flusso eccentrico di 0.7 cm2 di area, shunt sinistro – destro non significativo (Qp/Qs 0.9). Non si indicava la chiusura ma follow–up clinico ed ecocardiografico poichè la funzione e le dimensioni del ventricolo destro e le pressioni polmonari erano normali. Per il riscontro di una formazione trombotica nell’auricola sinistra, ridotte velocità di svuotamento e smock–effect, si indicava una strategia e l‘ablazione veniva posticipata.

Conclusion

i: Il presente caso clinic sottolinea la possibile coesistenza di CTD ed altre anomalie cardiache congenite, inclusi i DIA, come riscontrato nel nostro paziente. Mentre molti casi di CTD richiedono correzione chirurgica nell’infanzia, nell’adulto il CTD è spesso asintomatico e diagnosticato accidentalmente perché non coinvolti né le camere sinistre né l’arteria polmonare. Il presente caso clinico contribuisce ad aumentare la conoscenza di questa anomalia estremamente rara, inclusa la possibile associazione con uno stato pro–trombotico e con le aritmie sopra–ventricolari.
P189 WHEN A PACEMAKER CAN BE HARMFUL IN A PATIENT WITH COMPLETE AV BLOCK
Authors: Maffè S , Paffoni P , Bergamasco L , Prenna E , Facchini E , Franchetti Pardo N , Careri G , Ariotti S , Paino A , Dellavesa P
Published: May 2023

The occurrence of complete AV block in patients with aortic valve stenosis is a frequent event and the implantation of a dual–chamber pacemaker is the therapy of choice for these cases. We present the case of an 84–year–old hypertensive diabetic patient hospitalized with heart failure during a severe anemia caused by bleeding duodenal ulcer (Hb < 7g/dl). The patient was treated with blood transfusions, proton pump inhibitors, and endoscopic ulcer treatment with clinical stabilization. However, he presented a third–degree AV block, with a narrow QRS escape rhythm of about 45 bpm. The echocardiogram showed a calcified aortic valve with severe stenosis (transvalvular flow 4m/s, valvular area 0.9 cm2) ( fig1–2), with moderate mitral regurgitation and preserved systolic function (EF 60%). He was therefore subjected to a dual–chamber pacemaker implant. In the hours following the procedure, with heart rate increased to 90 bpm and correct AV synchronism, the patient presented an episode of acute pulmonary edema, treated with diuretics, oxygen and nitrogliceryn. with initial clinical improvement but subsequent new instabilization. The echocardiogram showed worsening of systolic function with septal dyssynergia secondary to electrostimulation and a severe mitral regurgitation (fig 3). The clinical status definitively stabilized only after changing the pacemaker programming to VVI 40 bpm (sentinel mode). The patient repeatedly refused the indications for aortic valve replacement surgery, and was therefore discharged with medical supportive care, third–degree AV block at electrocardiogram and a dual–chamber pacemaker programmed in sentinel VVI to obtain a minimal ventricular pacing. After 24–month follow–up, the patient remains in good clinical conditions, he was never hospitalized again, the third–degree AV block persists with PM stimulation percentages of 5%. This clinical case shows how electrostimulation and increased heart rate, in the presence of aortic outflow obstruction and significant mitral valve disease, can cause very insidious acute left ventricular systolic dysfunction, while restoring correct AV synchrony.
P192 POSTINFARCTION VENTRICULAR SEPTAL DEFECT: MANAGEMENT AND A NEW SURGICAL OPTION FOR CLOSURE
Authors: Torre M , Baldi C , Bottiglieri P , Vassallo M , Attisano T , Vigorito F , Bonadies D , Coscioni E
Published: May 2023

Postinfarction ventricular septal defect is a rare mechanical complication of myocardial infarction, with difficult management, debated closure timing and high mortality rates. Standard repair techniques – infarcectomy and infarct exclusion through a left ventriculotomy – are surgically challenging and have high risk of operative mortality and frequently suboptimal results. We report the case of a 66–year–old patient with a 1.4 cm septal rupture developed after a sub–acute STEMI. At the admission, he had chest pain and moderate dyspnoea, EKG showed inferior STEMI with increased myocardial necrosis markers. Echocardiography showed a preserved ejection fraction, akinesia of the inferior, posterolateral walls and of the posterobasal septum, with septal rupture at this level and 1.5 Qp/Qs ratio. A total occlusion of proximal right main coronary artery was found at coronary angiography. After the heart team meeting, we performed a new modified closure, in urgent setting, using two hand–made composite patches (Fig. 1) parachuted through a transversal aortotomy and a right atriotomy, without left ventriculotomy (Fig. 2). In the 7th postoperative day a second septal rupture was detected at the echocardiographic control. After two weeks follow–up in optimized medical therapy, we decided to complete the closure of the later developed septal rupture percutaneously using an Amplatzer device. Six months after the event, the patient is still asymptomatic and echocardiography documents a 50% ejection fraction, with trivial residual left–to–right shunt and normal valve function. Computed tomography scans confirmed optimal surgical result. Timing, management and surgical strategy are still on debate. Our technique is effective, simple, reproducible and provides good result (Fig. 3) and can be perfectly integrated in a hybrid approach.
P193 A MYXOMA IN THE LEFT ATRIUM ADHERENT TO THE INTERATRIAL SEPTUM
Authors: Cortese F , Costantino M , Matera A , Stabile E , Luzi G
Published: May 2023

A 73–year–old woman came to our observation to perform a routine echocardiographic examination. The patient had arterial hypertension, dyslipidemia, hypothyroidism, and paroxysmal atrial fibrillation. She underwent a bilateral mastectomy for breast cancer about 5 years ago, and she was undergoing chemotherapy and radiation therapy for a stage IV lung adenocarcinoma. The clinical evaluation was normal, as was the electrocardiogram. The transthoracic echocardiographic evaluation showed the presence of a rounded formation with variable echogenicity, with an irregular surface (4 x 3 cm), adherent to the interatrial septum at the level of the fossa ovalis, which did not hinder the excursion of the mitral valve. No other significant cardiac abnormalities were detected.Transesophageal echocardiography confirmed the presence of atrial mass adhered to the oval fossa (panels A, B). of coarsely rounded shape, and variable echogenicity, in the absence of interference with the movement of the valve leaflets and of anomalies of the interatrial septum (panel C). Coronary angiography showed right–dominant coronary circulation (panel D) and mild stenosis of the mid–left anterior descending artery. Abundant arterial perfusion of the atrial mass, with several vessels originating from the circumflex artery, was also evident at the coronary angiography (panels E, F). The patient underwent cardiac surgery; the surgical exeresis of the left atrial mass was performed through right mini–thoracotomy (panels I and L). Because the neo–formation was adherent not only to the atrial septum but also to the left atrial roof, to obtain a radical excision, a large portion of the atrial wall and the septum were removed and totally reconstructed with the pericardium. The main artery supplied the mass–related vascular network was ligated. The postoperative course was uneventful, and the patient was discharged at home on day six. The pre–discharge echocardiography and the cardiac magnetic resonance ( panels G, H) showed the absence of any residual mass in the left atrium that appears anatomically reshaped, no shunt at the level of the interatrial septum, and preserved ventricular function of both ventricles. Histological analysis confirmed the diagnosis of atrial myxoma. At the six–month follow–up the patient was asymptomatic and the echocardiography was superimposable to discharge.
P201 DRUG–COATED BALLOON AND DIABETES MELLITUS: A MATTER OF SURVIVAL
Authors: Zilio F , Verdoia M , Gioscia R , Viola O , Brancati M , Fanti D , Soldà P , Bonmassari R , Rognoni A , De Luca G
Published: May 2023

Background

Patients with diabetes mellitus (DM) are at higher risk of restenosis and stent thrombosis after percutaneous coronary intervention and drug eluting stent (DES) positioning. Limited although interesting data are available on prognosis after revascularization with drug–coated balloon (DCB) in this group of patients. The aim of this study is to evaluate the prognostic impact of DCB use in patients affected by DM.

Methods

Patients with DM enrolled in a retrospective multicenter registry were identified and matched to a control population of diabetic patients treated with DES enrolled in another retrospective registry, according to a propensity score calculated on the independent predictors of main adverse cardiac events (MACE). The primary study endpoint was the occurrence of MACE, a composite of death, myocardial infarction, and target vessel revascularization. Secondary endpoints were the independent components of the primary endpoint, or target lesion failure (TLF).

Results

150 patients were identified in the DCB group and matched with 150 DES–treated patients. However, patients treated with DCB displayed more often a previous cardiovascular history and received a more complete pharmacological therapy. Target vessel diameter and the percentage of stenosis were lower in DCB patients, whereas binary in–stent restenosis was more common. At a median follow–up of 545.5 days, MACE occurred in 54 (19.4%) of the patients, with no difference according to the PCI strategy. Although a trend toward higher TLF was found (p=0.06), overall death was significantly reduced in diabetic patients (3.6% vs 10.9%; adjusted HR[95%CI]= 0.27[0.08–0.91], p=0.03).

Conclusion

Although limited by some differences among the groups, the present propensity–matched study shows that, among patients with DM undergoing PCI for in–stent restenosis or de novo lesions, the use of DCB is associated to a similar rate of MACE and a possible increase in TLF, but a significantly improved survival as compared to use of DES.
P205 COMPASSIONATE DRUG USE FOR PATIENTS WITH TRANSTHYRETIN AMYLOID CARDIOMYOPATHY: THE FIRST EXPERIENCE IN ITALY
Authors: Ciliberti G , Torselletti L , Barbarossa A , Principi S , Coraducci F , Belleggia S , Coretti F , Bonci A , Stronati G , Casella M , Dello Russo A , Guerra F
Published: May 2023

Razionale. L’amiloidosi cardiaca da transtiretina (ATTR–CM), nella sua forma ereditaria o acquisita, è una cardiomiopatia a fenotipo ipertrofico–restrittivo che porta a un‘insufficienza cardiaca progressiva causata dalla deposizione extracellulare di transtiretina. Materiali e Metodi. Presso il nostro centro abbiamo avviato un ambulatorio dedicato alla gestione dei pazienti con amiloidosi cardiaca sin dal 2019. Poiché a quel tempo in Italia non erano disponibili terapie specifiche per questa condizione, decidemmo di creare un protocollo di uso compassionevole per il farmaco tafamidis in base ai risultati dello studio registrativo di fase 3. Risultati. Dopo l‘approvazione del nostro protocollo da parte dell’azienda produttrice e del comitato etico locale, a partire da ottobre 2019 e fino a novembre 2021, sono stati selezionati n=7 pazienti con ATTR–CM i quali erano idonei ricevere il farmaco (tabella 1).Dopo 22 mesi di follow–up, un paziente è deceduto per insufficienza cardiaca avanzata e un paziente ha manifestato insufficienza cardiaca che ha richiesto il ricovero in ospedale. Al termine del nostro protocollo di uso compassionevole non sono state osservate reazioni avverse al farmaco, tutti i pazienti sopravvissuti erano in classe NYHA II e hanno potuto effettuare con successo la transizione alla prescrizione ordinaria secondo i criteri del registro di monitoraggio AIFA (tabella 2).

Conclusion

i. Il presente rapporto descrive in dettaglio le caratteristiche della prima coorte di pazienti in Italia sottoposta a terapia farmacologica tramite uso compassionevole per il trattamento di ATTR–CM. L‘uso compassionevole è una modalità fattibile ed efficace per avviare la cura farmacologica in pazienti selezionati in attesa dell‘approvazione ufficiale da parte degli enti regolatori, il che può essere molto importante soprattutto nelle malattie ad andamento progressivo, in cui la somministrazione precoce della terapia è fondamentale per ottenere un beneficio clinico significativo.
P208 PREVALENCE OF TRANSTHYRETIN CARDIAC AMYLOIDOSIS IN PATIENTS HOSPITALIZED FOR HEART FAILURE
Authors: Lanati G , Aschieri D , Di Dio M , Calabrò D , Mori M , Piepoli M , Rusticali G
Published: May 2023

Background

Bone scintigraphy with labeled diphosphonates allows for the non–invasive diagnosis of transthyretin cardiac amyloidosis, in case of high cardiac uptake of the radiotracer and concomitant absence of serum monoclonal component (Gillmore algorithm).

Objective

The aim of this study was to establish the prevalence of transthyretin cardiac amyloidosis in a population of patients hospitalized for heart failure.

Methods

In this prospective observational study, patients hospitalized for heart failure at the Cardiology Unit of Castelsangiovanni Hospital were evaluated in the period from 1 January 2021 to 31 July 2022. Twenty–five of them, who presented with echocardiographic moderate to severe left ventricular hypertrophy (i.e. maximum end–diastolic thickness of the interventricular septum ≥ 15 mm), were included in the study. All patients underwent anamnesis, physical examination, 12–lead electrocardiogram and transthoracic echocardiogram. Patients were divided into 2 groups according to the presence or absence of the following clinical, electrocardiographic and echocardiographic diagnostic red flags: history of carpal tunnel syndrome and/or rupture of the long head of the brachial biceps, low voltage QRS, granular sparkling of the ventricular myocardium, apical sparing pattern of the global longitudinal strain.

Results

Fifteen patients with heart failure, left ventricular hypertrophy and at least one diagnostic red flag were screened for cardiac amyloidosis by: a) search for a serum monoclonal component; b) bone scintigraphy with labeled diphosphonates. In thirteen patients, an high cardiac uptake of the radiotracer was found on bone scintigraphy. One patient with high cardiac uptake also presented a serum monoclonal component and was referred for tissue biopsy. In the remaining twelve patients (85% of the cases studied) a non–invasive diagnosis of transthyretin cardiac amyloidosis was made. In six patients affected by transthyretin cardiac amyloidosis, a salivary genetic test was also performed to search for mutations in the transthyretin gene, which resulted negative in all cases examined.

Conclusions

In this study of patients hospitalized for decompensated heart failure, rigorous application of Gillmore‘s algorithm in suspected cases led to non–invasive diagnosis of cardiac transthyretin amyloidosis in 85% of cases, without wasting healthcare resources.
P212 EFFICACY AND SAFETY OF GENOTYPE–GUIDED AND PLATELET FUNCTION TEST–GUIDED ANTI–P2Y12 THERAPY IN PATIENTS UNDERGOING PCI: A META–ANALYSIS OF RCTS
Authors: Rocchetti M , Podda G , Birocchi S , Minardi A , Squizzato A , Cattaneo M
Published: May 2023

Clopidogrel is the most commonly used anti–P2Y12 drug in DAPT. Impaired pharmacological response and antithrombotic efficacy associated with cytochrome–P450 and/or ABCB1 gene mutations is observed in about 1/3 of treated patients. To circumvent this problem, guided therapy has been tested, based on either identification of predisposing gene mutations or results of platelet function tests (PFTs). Patients with with predisposing gene mutations or high platelet reactivity on clopidogrel (HPR) were treated with alternative, potentially more effective regimens: higher clopidogrel doses, prasugrel, ticagrelor, or additional cylostazol. In this meta–analysis, we tested the efficacy and safety of these two different strategies of guided therapy separately. We searched relevant articles published in English until October 1th 2022 on MEDLINE, Embase and Central. Articles included all RCTs comparing standard anti–P2Y12 therapy (ST) versus genotype–guided or PFTs–guided anti–P2Y12 therapy in patients with acute coronary syndromes (ACS) or chronic coronary artery disease (CCAD) undergoing PCI. Two reviewers independently assessed study eligibility and risk of bias, and extracted data. Hazard ratios with 95% CI were calculated based on fixed effects models. Efficacy outcomes comprised major adverse cardiovascular events (MACE) as defined in each study. Main safety outcome included major bleedings (MB) according to BARC. Different sub–analyses were also performed based on type of anti–P2Y12 drug in ST, type of alternative drug, type of PFT, patients’ ethnicity, prevalence of ACS. We retrieved 6 RCTs testing genotype–guided anti–P2Y12 therapy on 10443 patients and 14 RCTs testing PFTs–guided anti–P2Y12 therapy on 11596 patients. MACE were lower in genotype–guided therapy than in ST, RR 0.68 (95% CI, 0.49–0.94) while MB did not significantly differ between the two groups, RR 0.88 (95% CI, 0.63–1.23). MACE and MB did not significantly differ between PFTs–guided anti–P2Y12 therapy and ST: RR 0.83 (95% CI, 0.58–1.18) and 1.24 (95% CI, 1.00–1.53), respectively. Sub–analyses revealed that MACE were lower in PFTs–guided anti–P2Y12 therapy compared to ST in patients of Asian descent. In conclusion, gentotype–guided anti–P2Y12 therapy reduced the incidence of MACE without increasing MB, compared with ST, in patients with ACS or CCAD undergoing PCI; in contrast, PFTs–guided anti–P2Y12 therapy did not affect the incidence of MACE or MB in these patients.
P213 A COMPLICATED STEMI : POISED BETWEEN THROMBOSIS AND HEMORRHAGE
Authors: Di Fonzo R , Palumbo B , Cancro F , Loria F , Turino S , Galasso G , Vecchione C , Di Muro M , Soriente L
Published: May 2023

The introduction of more effective and powerful antithrombotic therapies has allowed the progressive reduction of ischemic events associated however with an increase in haemorrhagic events. What we are describing is an example of how iatrogenic and non–iatrogenic complications can add up, making routine therapeutic management difficult during and after hospital stay.We are talking about a 50–year–old male patient, a smoker and with a history of dyslipidemia under treatment, who arrived at our cath–lab with a diagnosis of anterior SCA–STEMI, after loading ticagrelor 180 mg from the spoke center where he had gone for chest pain. At coronary angiography, evidence of critical disease of the median anterior interventricular artery treated by primary angioplasty and for the high thrombotic load by thromboaspiration, DES and Tirofiban bolus and 18–hour continuous infusion. Approximately 15 hours after the event, the patient appeared confused and aphasic. A brain CT scan with and without contrast agent was performed which documented the presence of a hemorrhagic focus in the atypical left temporal site, in the absence of arteriovenous malformations not susceptible to surgical therapy (BARC–3). Therefore, in view of the high risk of bleeding, de–escalation therapy with cardioaspirin and clopidogrel was practiced. Five days after the event, the clinical picture was complicated again by the finding of apical thrombosis on the transthoracic ultrasound. For this reason, given the stability of the haemorrhagic lesion on CT scans and control MRIs, Enoxaparin sodium 4000 IU was introduced in therapy once, with resolution of the formation in the imaging control after one month. The patient was then discharged with indication for short–DAPT in consideration of the high PRECISE–DAPT score. The arduous task of managing this case led us to reflect on the importance of the pre– and post–PCI clinical picture of the patient in order to seek the appropriate antithrombotic treatment by dynamically balancing the ischemic and haemorrhagic risk during hospitalization through numerous standardized tools at our disposal.
P214 THE THERAPEUTIC IMPLICATIONS OF A FATAL COINCIDENCE
Authors: Fiorella A , D‘Alessandro G , Rodio G , Pollicino T , Abbracciavento L , Luzzi G
Published: May 2023

Background

Factor VII deficiency is a rare, inherited disorder secondary to a reduction or absence of factor VII (FVII) of the coagulation pathway presenting with autosomal recessive transmission and caused by different types of mutation of the F7 gene. The clinical manifestations of the syndrome are highly variable: depending on the case, it can remain asymptomatic, or it can present with episodes of bleeding secondary to trauma and surgery, or it can manifest with potentially fatal spontaneous hemorrhages. It can be treated by long–term replacement prophylaxis, which consists of periodic infusions of FVII concentrates.

Clinical case

A 75–year–old woman presented to the emergency room in a soporose state. On the electrocardiogram, ST–segment elevation in the antero–septal and in AVR and septal akinesia affecting the left ventricle was shown. On admission, she presented with syncope, marked hypotension, and tonic–clonic spasm. Blood tests showed sodium levels of 112 mEq/L, secondary to the administration of high doses of Escitalopram and associated with the genesis of epileptic seizures. During the emergency coronary angiography, severe stenosis of mid–proximal IVA was seenand subsequently treated with PTCA/DES. Right before the procedure, therapy with Acetylsalicylic acid (ASA) 250 mg, Ticagrelor 180 mg, and Heparin sodium was administered 5000 IU + 5000 IU. Immediately after, severe anemia (5.9 Hb) and INR lengthening were demonstrated, with widespread skin hematomas. In the complete study of the coagulative state, an almost complete factor VII deficiency was found, which required infusion of factor VII concentrate. The subsequent course was further complicated by pre–renal acute renal failure and paroxysmal atrial fibrillation. Following the initial suspension of antiplatelet and anticoagulant therapy (OAT), it was possible to reintroduce, without loading dose, ASA and clopidogrel, preserving OAT for later phases.

Discussion and Conclusions

FVII deficiency, a rare hemorrhagic disorder, may represent a fatal coincidence in the context of myocardial infarction, due to the therapeutic implications of the pathology, which may lead to inevitable uncontrolled bleeding. This occurrence is difficult to predict in some cases, including the present one. It would be interesting to identify indicators that could prompt, even in an emergency setting, the suspicion of such a dangerous association.
P217 SHORT–TERM EFFECTS OF DAPAGLIFLOZIN ON CARDIAC BIOMARKERS, FLUID RETENTION, RENAL AND PULMONARY FUNCTION IN HFREF PATIENTS: NOT AS GOOD AS EXPECTED
Authors: Mapelli M , Capovilla T , Marongiu A , Maranzano G , Salvioni E , Mattavelli I , Paganin C , Vignati C , Gugliandolo P , Mantegazza V , Garlaschè A , Sinagra G , Agostoni P
Published: May 2023

Background

Sodium–glucose co–transporter–2 inhibitors (SGLT2–i) are currently a standard therapy for patients with heart failure with reduced ejection fraction (HFrEF). Still, their potential benefits on biomarkers, respiratory function parameters and fluid retention have not been extensively studied. Bioimpedance vector analysis (BIVA) has emerged as a new tool capable of assessing congestion, providing an estimate of the total body water and hydration index (HI). BIVA is more accurate than NT–proBNP in detecting peripheral congestion in chronic heart failure and can be used to evaluate the effects of the treatment. This study aims to assess the short–term effects of Dapagliflozin on spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), cardiac biomarkers, and BIVA.

Methods

Stable HF patients (EF <40%, NYHA class II or III) eligible for SGLT2–I therapy according to guidelines underwent standard spirometry, DLCO, BIVA and venous blood sampling at baseline (V0) and after 2–4 weeks of therapy (V1).

Results

Patients characteristics (N=32) at baseline are shown in Table 1. None of the patients interrupted the treatment and/or experienced adverse events. After 26±6 days, we observed worsening of renal function (eGFR from 73.1±28.5 mL/min/1.73m2 to 67.4±27.0 mL/min/1.73m2, p<0.001) and potassium levels (4.36±0.36 mEq/l vs 4.58±0.57 mEq/l, p= 0.017). There were no significant changes in NT–proBNP levels (1378 [615–2542] ng/l vs 1034 [554–2552] ng/l, p= 0.538). HI, total body water, DLCO and spirometry values did not change. On the contrary, a mild reduction in hsTnI was observed (13.88 [9.24–26.8] ng/l vs 11.58 [7.7–24.2] ng/l).

Conclusions

Our study did not detect short–term effects of Dapagliflozin on spirometry values, DLCO, fluid retention and NT–proBNP. As revealed in DAPA–HF trial, a mild worsening of potassium and serum creatinine levels was observed. Taken together, these results suggest that the favourable effects of Dapagliflozin could unfold over a longer period of time. A more extended follow–up and a larger population are needed to confirm these preliminary data.
P219 EXTRINSIC COMPRESSION OF THE RIGHT VENTRICLE CAUSING ISOLATED RIGHT HEART FAILURE
Authors: Indennidate C , Massa L , Merlo M , Sinagra G
Published: May 2023

Isolated right heart failure (RHF) can be caused by right ventricular (RV) compression, mainly described in severe cases of pectus excavatum. Mediastinal masses can determine an extrinsic compression of the RV. A 62–year–old retired agricultural inspector from Sicily presented in our clinic with worsening signs of RHF. His medical history consisted of echinococcosis familiarity, surgically treated congenital subvalvular aortic stenosis, resulted in a residual moderate aortic insufficiency and permanent atrial fibrillation. Around January 2021 he developed isolated leg swelling. Aortic valvular dysfunction, heart failure and other cardiogenic explanations were excluded. A year later dyspnea (NYHA class II) appeared. High resolution CT demonstrated fluid collection with peripheric calcifications inside the anterior mediastinum. PET showed uptake in a limited zone of the anterior mediastinum. The patient slowly started developing ascites, hardly manageable with diuretics because of kidney failure. Transthoracic echocardiography (TTE) highlighted mild RV dysfunction (FAC 35%) and right ventricular free wall hypokinesia due to the mediastinal mass extrinsic compression. Transesophageal echocardiography showed a heterogeneous cystic aspect of the mediastinal mass, an oscillating intraventricular mass of the right aortic cuspid (6x4 mm) and a severe mitral annular calcification. In consideration of medical history, endocarditis was considered. Cardiac magnetic resonance recognized a mediastinal mass with echinococcosis features. Echinococcous serology and antibodies were negative but the Quantiferon tested positive. Laboratory tests showed an absolute eosinophilia and a high CD4/CD8 ratio. Because of the patient severely compromised hemodynamic balance the mass was surgically removed and identified as pseudocystic tuberculoma. After the excision, hemodynamic balance was improved and the TTE showed a restored RV function with persistent hypokinesia of the RV free wall and increased right atrium pressure. In this clinical case RHF was determined by an extracardiac mass which interfered with the hemodynamic balance and the function of the right heart in the absence of any signs of left heart failure. Because of the mass mechanical action on the reduction of RV ejected volumes, a surgical option was the only possible strategy to avoid a following worsening of the heart failure.
P220 PERIPARTUM CARDIOMYOPATHY: HOW TO RECOGNIZE AND TREAT IT
Authors: Terrinoni F , Liberatore I , Basso V , Imparato L , Sciarra L , Romano S
Published: May 2023

Introduction

Peripartum cardiomyopathy is characterized by LV systolic dysfunction in the absence of other existing cardiac disease. It presents with clinical signs of acute heart failure, with ventricular arrhythmias or cardiac arrest in the last stages of pregnancy up to 5–6 months after delivery. The LV may be non–dilated, but EF is usually <45%. Initial EF <30%, end–diastolic LV diameter ≥6 cm, and RV involvement are associated with adverse outcomes. Case report: 44–year–old female, denies CAD and home therapy. It occurs due to the appearance of peripheral edema, worsening dyspnea and forced orthopneic decubitus arising after cesarean delivery which occurred 3 days earlier. On auscultation: MV abolished at the right base with diffuse rales. In the laboratory increased BNP is evident. (1485 pg/mL). On ECG Sinus tachycardia, 126 bpm. New onset BBSs. PA 100/60. Respiratory acidosis at the EGA. On Echocardiogram (Fig.1) dilated LV with severe reduction of EF 25/30%, moderate–severe IM, RV within limits. Moderate IT with PAPs 40 mmHg. Vena cava dilated, hypo collapsible. Minimal pericardial detachment. At Wcm Pulmonary CT with picture of acute pulmonary edema and apical–basal right pleural effusion, cardiogenic involvement in the interstitial–alveolar phase (Fig. 2). It is treated with inotropics, high dose diuretics and CPAP ventilation with progressive improvement. She underwent Cardiac MR (Fig. 3), to exclude ischemia, myocarditis or heart disease, which described a picture of non–ischaemic dilated heart disease of the LV with severe systolic dysfunction, moderate RV dysfunction and modest MI. On discharge, therapy with B–blockers, loop diuretics, MRA, ARNI and subsequently SGLUT–2 inhibitor was introduced. In relation to age and EF she was referred for evaluation for transplant listing and CRT–D evaluation.

Conclusion

it is a rare disease: 50% of patients improve with standard medical treatment; 25% develop chronic heart failure and the rest die in the course of the disease. The onset is subtle with non–specific signs and symptoms often confused with "inconveniences" related to the pregnancy itself. To limit the diagnostic delay it is necessary to pay attention to the appearance of tachycardia, third heart sound, basal crackling rales and jugular venous turgor, since they are not physiologically present in pregnancy and to carry out a control echocardiogram especially if in old age.
P222 POSTINFARCT CARDIAC FREE WALL RUPTURE DETECTED BY CARDIAC CT
Authors: Berloni M , Tonet E , Campo G , Guardigli G
Published: May 2023

A 57–years–old man with a history of smoke and hypertension was transferred to our unit with chest pain and dyspnoea, lasting few days. Electrocardiography revealed the presence of ST elevation in the infero–lateral leads with Q waves and Transthoracic Echocardiographic Study revealed a normal dimension left ventricle with infero–postero–lateral akinesia, moderately reduced EF (40%) in the absence of significant valve disease and an organized pericardial effusion of about one centimetre. In the meantime, the first signs of hemodynamic instability and cardiogenic shock appeared and the ETT revealed the exacerbation of the pericardial effusion. So we did an emergency coronary angiography that revealed a calcified three–vessel disease with occlusion of the middle segment of Cx. Because of the worsening of the cardiogenic shock we used the aortic balloon pump to improve the hemodynamic instability. The concomitant presence of signs of late infarction, pericardial effusion and cardiogenic shock make us suspect a myocardial rupture so we did a cardiac computed tomography (CT ) scan that was suggestive for a cardiac wall rupture within the infarcted left ventricle. The patient was urgently transported to the cardiac surgery room where the patch of inferior wall was performed and then was transferred to the Intensive Care Unit. After the surgery, a residual of pericardial effusion persisted without hemodynamic significant and the revascularization was planned one month after discharge. Heart rupture represents a mechanical complication of MI that we have to suspect every time we find signs of myocardial infarction and pericardial effusion that degenerate into cardiogenic shock. Although it occurs in a very limited number of cases, the postinfarct cardiac free wall rupture is characterized by a poor prognosis and cardiac Computed Tomography provides primary information for the diagnosis.