bluuebunny/crossref_metadata_2025 huggingface dataset:
764 CARDIONEUROABLATION OF VAGALLY MEDIATED BRADYARRHYTHMIA: A SINGLE-CENTER EXPERIENCE
Authors: Valeriano Chiara , Fabbricatore Davide , Buytaert Dimitri , De Potter Tom
Published: December 2022

Background

Cardioneuroablation (CNA) is a novel catheter-ablation technique for the treatment of vagally-mediated bradyarrhythmia including vaso-vagal syncope (VVS), functional atrioventricular block (AVB) and sinus node dysfunction (SND). CNA aims to blunt the cardioinhibitory reflex by eliminating postganglionic parasympathetic neurons in the atrial wall and ganglionated plexi (GPs). Early-phase studies have shown promising results, but clinical evidence remains limited.

Purpose

We present our single-center experience with CNA in the setting of VVS, symptomatic functional AVB, and SND.

Methods

Baseline and procedural characteristics, procedure-related complications, and clinical outcomes were collected in patients who underwent CNA from December 2018 to July 2022. The procedural workflow included an electroanatomic mapping-guided ablation strategy, which combines the bi-atrial 3D mapping with endocardial atrial bipolar electrograms (EGM), specifically targeting high-amplitude fractionated EGM.

Results

A total of 14 CNA procedures were performed in our center. Ablation indication was mainly VVS (57%), followed by AVB (29%) and SND (14%). Syncope was the most common symptom in our cohort (71%, burden of 7 per person-lifetime). Patients were young (43±16 years) and without structural heart disease (LVEF 58±4 ml, LAD 31±7 mm). Procedures were performed under general anesthesia, mean procedure time was 102±42 min, with minimal fluoroscopy dose (2.7±1.8 Gy/cm2). We observed 1 instance of post-ablation pericarditis and 2 sinus tachycardia which required medical treatment; no major adverse events occurred. Heart rate increased after ablation in all the patients, with a mean RR interval shortening of 28% and no further increase after atropine administration. Two patients had a recurrence at a median follow-up of 251 days (IQR: 118-536), both cases were syncopal events without documentation at loop-recorder of sinus bradycardia or atrial bradyarrhythmia.

Conclusions

CNA may be an alternative to pacemaker implantation in young, highly symptomatic patients, refractory to conventional therapies and without structural heart disease. Ablation is reasonably safe in experts’ hands, especially if compared with the long-life risk of device-related complications. Further large-scale randomized studies are needed to support these findings.
205 SGLT-2 INHIBITOR DAPAGLIFLOZIN REDUCES ANTHRACYCLINE-MEDIATED CARDIOMYOPATHY IN PRECLINICAL MODELS THROUGH REDUCTION OF MYOCARDIAL NF-KB, MYD-88 AND NLRP3 EXPRESSION: A BIOCHEMICAL AND HISTOLOGICAL STUDY
Authors: Quagliariello Vincenzo , Buccolo Simona , Caronna Antonietta , Maurea Carlo , Paccone Andrea , Saviano Claudia , Bonelli Annamaria , Conforti Gabriele , Maurea Nicola
Published: December 2022

Background

Doxorubicin-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in breast cancer patients. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have recently been shown to be of therapeutic value in patients with type 2 diabetes, chronic kidney disease, and heart failure with reduced ejection fraction (HFrEF), conditions that commonly coexist and are interrelated pathophysiologically.

Purpose

We hypothesized that Dapagliflozin (an SGLT2i), administered during doxorubicin, could improve cardiac function in preclinical models

Methods

Female C57Bl/6 mice were untreated (Sham, n=6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n=6), DAPA at 12 mg/kg (DAPA, n=6) or doxorubicin combined to DAPA (DOXO-DAPA, n=6). Ejection fraction, radial and longitudinal strain were analyzed through transthoracic echocardiography (Vevo 2100). Cardiac tissue expression of NLRP3 inflammasome, Myd88, DAMPs (galectine 3 and calgranulinS100), pAMPK, NF-kB, and 13 chemokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified through ELISA and western blot methods.

Results

DAPA improved significantly the EF and prevented the reduction of radial and longitudinal strain after 10 days of treatment with doxorubicin. A reduced expression of NLRP3, MyD88, DAMPs and NF-kB in cardiac tissues was seen in DOXO-DAPA group compared to DOXO mice (p<0.001). Cardiac expression of IL-1β, IL-6, TNF-α, G-CSF and GM-CSF were significantly reduced after treatment with DAPA indicating anti-inflammatory properties. Expression of pAMPK was strongly enhanced in DAPA-DOXO compared to DOXO group. Levels of Calgranulin S100 and galectine-3 were strongly enhanced in DOXO group; on the other hand their expression were reduced by 47.7 and 52.3% in DAPA-DOXO group vs DOXO (p<0.005). Hystology evaluation indicate reduction NF-kB expression in myocardial and renal tissue in DOXO-DAPA vs DOXO.

Conclusion

In this preclinical study, DAPA is able to improve cardiac function and reduce biomarkers involved in heart failure and fibrosis. The overall picture of the study pushes the use of DAPA in prevention of cardiomyopathies induced by anthracyclines in cancer patients.
206 LOW DOSES OF ADVANCED GLYCATION END PRODUCTS AND FRUCTOSILATION PRODUCTS PROMOTES PREMATURE CELL DEATH OF HUMAN CARDIAC CELLS AND INCREASES DRUG RESISTANCE OF HUMAN BREAST CANCER CELLS EXPOSED TO DOXORUBICIN THROUGH NLRP-3 AND MYD-88
Authors: Quagliariello Vincenzo , Maurea Fabrizio , Buccolo Simona , Caronna Antonietta , Paccone Andrea , Bonelli Annamaria , Conforti Gabriele , Saviano Claudia , D´aiuto Giuseppe , Maurea Nicola
Published: December 2022

Introduction

Advanced glycosylation end-products (AGEs) are non-enzyme, protein glycosylation products caused by glucose-induced metabolic disorder, and play an important role in aging, cancer, metabolic syndrome and cardiovascular diseases.

Purpose

We aimed to assess whether AGEs and fructosilation products, such as methylglyoxal (MG) and N-carboxymethyllysine (N-CML) could increase susceptibility to cell damages induced by doxorubicin

Methods

Human cardiomyocytes were pre-exposed for 24h with low doses (50 mmol/L) of methylglyoxal (MG) or N-carboxymethyllysine (N-CML). After, cells were exposed to subclinical concentration of doxorubicin (at 100 and 200 nM) for 48 and 72h. After the incubation period, we performed the following tests: determination of cell viability, through analysis of mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4-hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro-inflammatory studied were also performed (activation of NLRP3 inflammasome; expression of peroxisome proliferator-activated receptor-α; mTORC1 Fox01/3a; transcriptional activation of p65/NF-κB and secretion of cytokines involved in cardiotoxicity (Interleukins 1β, 8, 6). Expression of p53 was also performed through western blot method

Results

Pre-exposure to methylglyoxal (MG) but especially to N-carboxymethyllysine (N-CML) increase cell mortality to doxorubicin of 48-53% compared to control. Pre-exposure to N-CML promotes premature death of cardiomyocytes to doxorubicin through NLRP3-driven pathways. Notably, MG and N-CML increased significantly the cardiotoxicity through NLRP3 inflammasome, Myd88 myddosome and cytochrome C-mediated apoptosis. Pre-exposure to N-CML and MG increase the secretion of interleukin-6 that increase cell apoptosis through a paracrine and autocrine mechanism. Induction of IL-6 reduces the expression of p53 resulting in the induction of the apoptotic process.

Conclusion

These observations suggest that AGEs and fructosilation producs promotes premature cardiotoxicity of human cardiac cells exposed to doxorubicin by activation of NLRP3, Myd88-related pathways and downregulation of p53.
551 RAPID RELATIVE EFFECTIVENESS OF A NOVEL NUTRACEUTICAL FOR THE MANAGEMENT OF HYPERCHOLESTEROLEMIA: A MULTICENTER PRIMARY CARE EXPERIENCE IN A LARGE POPULATION OF PATIENTS AT LOW TO MODERATE CARDIOVASCULAR RISK
Authors: Natale Francesco , Molinari Riccardo , Covino Simona , Alfieri Roberta , Altobelli Ippolita , Cimmino Giovanni
Published: December 2022

Backgroud

In the last few years increasing evidence have reinforced the benefits of low-density lipoprotrein (LDL-C) levels reduction on cardiovascular outcome. Different targets have been suggested based on the cardiovascular risk (CVR). A goal of LDL-C less of 115mg/dL is desiderable for patients at low to moderate CVR according the current european guidelines. However, an high percentage of patients at low to moderate CVR are far from this target. Nutraceuticals are “food supplements” that may help to achieve this goal in this population. The aim of this retrospective analysis was to evaluate the effects of dietary supplementation with a novel nutraceutical formulation on plasma lipid levels in subjects with low to moderate hypercholesterolemia who are not on treatment with conventional drug and/or with other dietary supplements.

Methods

Adult patients with hypercholesterolemia were retrospectively selected from the database of participant family practitioners. All patients had a baseline evaluation already recorded, including family and medical history, physical examination, and blood test that included total cholesterol (TC), LDL-C, high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), C-reactive protein (CRP), and transaminases (AST and ALT) and have started a dietary supplementation with nutraceuticals. After this selection, a total of 504 patients under this novel nutraceutical (given 1 tablet daily at dinner) with blood test at 30-days already performed, were identified. Similarly, 108 subjects with comparable clinical features but not treated with any supplements were also selected.

Results

At 30-day of follow-up, the use of this novel dietary supplement was associated with significant reduction of LDL-C 124 ± 16 vs. 100 ± 13 mg/dL, p-value <0.001) and TC levels (210 ± 56 vs. 187 ± 60, p-value < 0.0001), in absence of a significant changes of transaminase levels (AST: 30 ± 6 vs. 30 ± 6 U/L, p-value 0.198; ALT: AST: 30 ± 6 vs. 30 ± 6 U/L, p-value 0.325) and in CRP (3.9 ± 1.5 vs. 3.9 ± 1.4 mg/dL, p-value 0.889). No side effects were reported in the database along to the observation period.

Conclusion

This novel nutraceutical formulation is an effective dietary supplement in obtaining a significant and early reduction of LDL-C in patients with hypercholesterolemia at low to moderate cardiovascular risk.
792 FULL EVALUATION OF LEFT ATRIAL FUNCTION AFTER MITRACLIP IMPLANTATION
Authors: Ielapi Jessica , Malizia Biagio , Neri Giuseppe , Carbone Andrea , Serratore Serena , Costanzo Assunta Di , Messina Chiara , Polimeni Alberto , Mascaro Giuseppina , Mongiardo Annalisa , Spaccarotella Carmen , Indolfi Ciro , Aquila Iolanda
Published: December 2022

Objective

interventional edge-to-edge repair by MitraClip ™ is widely demonstrated to be able to reduce the degree of MR in patients with high surgical risk. The left atrial (LA) dysfunction in patients with severe MR is associated with poor prognosis and its changes after MV repair is reported in several studies. While, little is known about the full evaluation of the LA function by Two-dimensional speckle echocardiography tracking (2D STE)

Materials and methods

from March 2015 to December 2021, clinical and echocardiographic data of 67 patients with MR who underwent Mitraclip™ implantation in our division were evaluated for LA function. Strain Reservoir (S_R), Conduit Strain (S_Cd), Contractile Strain (S_Ct), LA emptying Fraction (LAEF_4CH), LAESV (Left atrial end-systolic volume), LAEDV (Left atrial end-diastolic volume) at baseline, at 1 month, at 6 months and 1 year of follow up were assessed. The variation of continuous variables was evaluated using a student T test for paired data. The categorical variables between baseline, at 1 month, at 6 months and 1 year of follow up were evaluated using the ANOVA test. The Multiple Bonferroni test comparison was conducted as a post hoc analysis P values <0.05 were considered significant.

Results

the etiology of the MR was primary in 29,2% and secondary in 70,8% of the included patients. The MR degree was 3+ in 16,9% of patients and 4+ in 81,5%. When compared to baseline at 6 months and 1 year a statistically significant improvement was observed for LAEF_4CH (p 0.006 and <0.001) and at 1 year for S_R (p 0.013) and S_Cd (p 0.033). When compared at 1 month the S-R improvement was observed at 6 months and 1 year (shown in Table 1). Finally, no significant changes were observed in S_Ct at different time point analyzed.

Conclusions

the MR improvement after MitraClip™ procedure allows hemodynamic changes with LA remodeling which can be detected by 2D STE through an improvement in LA function. These data emphasize the hypothesis that these echocardiographic parameters represent an advanced method to evaluate the response to device implantation.
180 LONG TERM FOLLOW UP OF A NON-PROGRESSIVE LEFT MAIN CORONARY ARTERY FISTULA TO RIGHT ATRIUM
Authors: Pezzato Andrea , Fabris Enrico , Korcova Renata , Belgrano Manuel , Sinagra Gianfranco
Published: December 2022

A 63 years old man, with multiple cardiovascular risk factor, presented at the emergency department with a transient ischemic attack during an hypertensive crisis. Electrocardiogram revealed a sinus rhythm and no sign of ischemia. No critical stenosis were detected at ultrasonography of the supra-aortic trunks. Brain CT showed an arachnoid cyst in right posterior cerebellar site. Transthoracic echocardiographic showed normal wall motion with a left ventricular ejection fraction of 66%. The transesophageal echocardiography, performed for searching possible emboligenic heart disease, revealed a fistulous aneurysmal formation arising from the left main coronary artery. Angio-CT confirmed a CAF between distal left main coronary artery and right atrium, with a retro-aortic serpiginous course and an ectasic vascular structure (above 8.35 mm), this pathological vessel also had an aneurismatic formation of maximum diameter of 1 cm. CT scan detected also a 50% soft eccentric plaque in mid circumflex coronary artery and a less than 50% soft eccentric plaque in the right coronary artery.

An elective hospitalization was performed in order to better assess the CAF. Coronary angiography revealed no significant coronary atherosclerotic disease and confirmed the CAF with its convoluted course. No left to right shunt was found either in cardiac magnetic resonance (Qp/Qs close to 1) or in right heart catheterization. Maximal stress test with cycloergometer was negative for clinical and electrocardiographic inducible ischemia (120W).

CAF is a rare vascular abnormality, occurring in only 0.002% of the general population. The majority of CAFs have a congenital origin, but occasionally they may be acquired after cardiac surgery or repeated myocardial biopsies in cardiac transplantation. The CAFs may increase in size over time, although this does not occur invariably, and complications include: myocardial ischemia (due to myocardial ‘steal’), thrombosis and embolism, heart failure, atrial fibrillation, rupture, endocarditis/endarteritis, arrhythmias and also spontaneous rupture of the CAF causing hemopericardium. Current treatment options for CAF include surgery or transcatheter closure.

Considered the age of the patient, the absence of clinical symptoms and the absence of left to right shunt, a conservative strategy was chosen. The patient had strict follow up, with clinical and echocardiographic assessment every 6 months, and with annually CT scan and stress test. During these 9 years of follow up the CAF remained stable, and the patients clinically asymptomatic.
332 RIGHT VENTRICULAR STRAIN IN FABRY CARDIOMYOPATHY: PROGNOSTIC IMPLICATIONS
Authors: Meucci Maria Chiara , Lillo Rosa , Lombardo Antonella , Lanza Gaetano A , Parisi Valentina , Grandinetti Maria , Massetti Massimo , Marsan Nina Ajmone , Crea Filippo , Graziani Francesca
Published: December 2022

Left ventricular (LV) hypertrophy is the main feature of Fabry cardiomyopathy (FC), but the right ventricle (RV) is also frequently affected. Previous studies failed to demonstrate an independent association between RV hypertrophy or conventional parameters of RV function and the occurrence of adverse outcomes in patients with FC. Nevertheless, if RV free wall strain (RV-FWS), assessed by 2D speckle tracking analysis, may provide a better prognostication is currently unexplored.

We retrospectively evaluated the association between RV-FWS and the occurrence of cardiovascular events in a cohort of 28 patients with FC. The study endpoint comprises the occurrence of cardiovascular mortality, severe heart failure symptoms, new-onset atrial fibrillation, bradyarrhythmias requiring pacemaker implantation and sustained ventricular tachyarrhythmias.

The median value of RV-FWS was 21.4% (interquartile range:17.1-23.9%) and a total of 18 (64%) patients showed reduced RV-FWS (<23%). During a median follow-up of 49 (IQR: 37-51) months, 17 (61%) patients met the study endpoint. A ROC-curve analysis confirmed the previously defined threshold of reduced RV-FWS (23%) as the best cut-off for predicting cardiovascular outcomes at 4 years (area under curve: 0.76; p-value=0.018), but with a lower predictive value in comparison to left-sided parameters (Panel A). Kaplan-Meier survival curves showed significantly lower event-free survival at 4 years in patients with impaired RV-FWS as compared to patients with preserved RV-FWS (log rank p=0.013) (Panel B). On univariable Cox regression analysis, RV-FWS expressed as continuous variable was significantly associated with the study endpoint (Hazard ratio [HR]: 0.85, 95% CI: 0.75-0.96, p=0.009). RV-FWS retained an independent association with outcomes after alternative adjustment for age (p=0.048) or indexed LV mass (p=0.036). Conversely, RV-FWS was not significantly associated with cardiovascular events, after correcting for LV global longitudinal strain or indexed left atrial volume (p=0.401 and p=0.208; respectively).

In Conclusion, impaired RV-FWS was not independently associated with the occurrence of cardiovascular events in FC, confirming previous observations that prognosis is mainly driven by the severity of LV cardiomyopathy.
937 INCIDENTAL DIAGNOSIS OF ANOMALOUS ORIGIN AF A CORONARY ARTERY: BETTER LATE THAN NEVER.
Authors: D´elia Roberta , Vincenza Polito Maria , D´auria Federica , Lambiase Catello , Malinconico Marisa , Ciccarelli Michele , Vecchione Carmine , Galasso Gennaro
Published: December 2022

Background

Anomalous origin of the left circumflex coronary artery (LCx) from the right sinus of Valsalva (RSV) is the most frequent among anomalous aortic origin of the coronary arteries (AAOCA). The estimated prevalence is low (about 0.4%) and in most cases asymptomatic. Angina, shortness of breath, myocardial infarction has been described in some patients, although diagnostic and therapeutic management is controversial, particularly in elderly patients.

Case presentation

A 76-year-old female patient was admitted to our outpatient clinic for dyspnea and chest discomfort. In clinical history hypertension, dyslipidemia and diabetes were documented. Hemodynamic parameters, clinical examination and ECG were normal.

Transthoracic echocardiography showed preserved global systolic function without abnormalities of regional kinesis and valvular diseases were excluded. Interestingly, in five chambers apical view, a binary structure in the atrioventricular groove above the mitral valve plane that seemed to cross the aorta perpendicularly (RAC sign) was detected. Furthermore, in parasternal short axis view, we visualized the origins of the left and right coronaries and a blood vessel behind the aortic root, as well as a small circle below the non-coronary aortic cusp in mitroaortic angle in the parasternal long axis view (Bleb sign) was identified. We hypothesized an anomalous origin of LCx from the RSV with a retroaortic anomalous course and this was confirmed by coronary computed tomography (coroCT), that excluded an intramural course and critical stenosis of coronary arteries. Finally, we decided to perform an exercise stress echocardiography which excluded inducible myocardial ischemia. Pharmacological therapy was optimized and clinical follow-up was unremarkable.

Conclusions

AAOCA may be incidentally diagnosed also in advanced age. Specific echocardiographic signs should suggest more advanced imaging techniques to confirm the diagnostic suspect. Non-invasive multimodality imaging is crucial, in order to exclude inducible myocardial ischemia and to avoid more invasive and harmful diagnostic tests.
1062 DIAGNOSTIC AND PROGNOSTIC VALUE OF STRESS CMR IMAGING TO EVALUATE STABLE CHEST PAIN: A TWENTY-YEAR META-ANALYSIS
Authors: Ricci Fabrizio , Khanji Mohammed Yunus , Bisaccia Giandomenico , Cipriani Alberto , Cesare Annamaria Di , Ceriello Laura , Mantini Cesare , Zimarino Marco , Fedorowski Artur , Gallina Sabina , Petersen Steffen , Bucciarelli-ducci Chiara
Published: December 2022

Background

Assessment of inducible ischemia with stress cardiovascular magnetic resonance (CMR) is recommended in patients with chest pain and intermediate or high pre-test probability of coronary artery disease (CAD). We aimed to provide a contemporary quantitative data synthesis on diagnostic accuracy and prognostic value of stress CMR in patients with stable chest pain syndromes.

Methods

We performed a systematic review and meta-analysis of studies published over the last twenty years on the diagnostic and prognostic value of stress CMR (PROSPERO: CRD42022299275). We measured pooled diagnostic indicators, including diagnostic odds ratio (DOR), sensitivity, specificity, area under the curve (AUC), and summary effect size indicators, including odds ratios (ORs) and cumulative annualized event rates (AERs) for all-cause death, cardiovascular death and major adverse cardiac events (MACE).

Results

We identified 33 diagnostic studies pooling 7,815 individuals (mean age, 62 years, 62% males) and 31 prognostic studies pooling 67,080 patients (mean age, 62 years; 57% males; mean follow-up 3.5 years for a total of 381,357 person-years). Stress CMR yielded a pooled DOR of 26.4 (95%CI:10.6-65.9), a sensitivity of 81% (95%CI:68-89%), a specificity of 86% (95%CI:75-93%), and an AUC of 0.84 (95%CI:0.77-0.89) for the detection of functionally obstructive CAD with fractional flow reserve as the reference test. In subgroup analysis, 3 Tesla imaging yielded higher diagnostic accuracy achieving a DOR of 33.2. Presence of stress-inducible ischemia was associated with higher all-cause mortality (OR:2.0; 95%CI:1.7-2.3), cardiovascular mortality (OR:6.4; 95%CI:4.5-9.1), and increased risk of MACE (OR:5.3; 95%CI:4.0-7.0). AERs for cardiovascular death and MACE were <1% in patients without stress-inducible ischemia.

Conclusions

Stress CMR yields high diagnostic accuracy and delivers robust prognostication in patients with stable chest pain and known or suspected CAD, particularly with 3 Tesla imaging. While inducible ischemia portends excess mortality and increased risk of MACE, a negative stress CMR indicates a very low risk of future cardiovascular events, with a warranty period of at least 3.5 years.
38 PERIPHERAL ENDOTHELIAL FUNCTION AND CARDIOPULMONARY FUNCTION IN PATIENTS AFFECTED BY PULMONRY HYPERTENSION
Authors: Tricarico Lucia , Casiere Vivian , Alfieri Simona , Croella Francesca , Nunno Nicola Di , Amatruda Marco , D´alessandro Damiano , Granatiero Michele , Correale Michele , Iacoviello Massimo , Di Biase Matteo , Brunetti Natale D
Published: December 2022

Background

Pulmonary arterial hypertension (PAH) is a progressive and severe rare disease. It is a pulmonary vasculature obstructive disease that leads to right heart failure and death. Pulmonary circulation dysfunction endotelial is characterized by vasoconstriction and proliferation.

Aim of study

to search possible correlations between peripheral endothelian function and cardiopulmonary function in patients with suspect PAH.

Materials

Between February 2021 and May 2022, consecutive patients with suspect PAH underwent to assessment of peripheral endotelial function by FMD before of right heart catheterization and cardiopulmonary exercise testing.

Results

46 patients (22 male, 67,9 ± 10,4 years old) with pulmonary hypertension were enrolled in the study. The following correlations were found between stress-resting absolute difference and % difference radial diameter: ramp (r: 0,69; p: 0,003 and r: 0,54; p: 0,028, respectively), Watt_AT (r: 0,63; p: 0,01 and r: 0,54; p: 0,03, respectively) and WATT_peak (r: 0,64, p: 0,009).

Conclusions

peripheral endothelial function may be related to funtional capacity in patients affected by pulmonary hypertension.
117 PROGNOSTIC VALUE OF ELECTROCARDIOGRAPHIC PARAMETERS IN PATIENTS WITH IDIOPATHIC/HERITABLE/DRUG-INDUCED PULMONARY ARTERIAL HYPERTENSION
Authors: Dardi Fabio , Bertozzi Riccardo , Guarino Daniele , Magnani Ilenia , Rotunno Mariangela , Ballerini Alberto , Donato Federico , Martini Giulia , Manes Alessandra , Palazzini Massimiliano , Galiè Nazzareno
Published: December 2022

Background

despite therapeutic improvement, pulmonary arterial hypertension (PAH) is still a chronic, incurable, high mortality disease. Several clinical, laboratory, hemodynamic and instrumental prognostic factors have been already established in PAH patients. However, no electrocardiographic prognostic factors have been identified so far in a systematic multivariate analysis together with clinical, exercise and haemodynamic parameters.

Methods

patients with idiopathic/heritable/drug-induced PAH (I/H/D-PAH) referred to a single centre were included from 1993 to 2021. All patients underwent baseline clinical, 12-lead ECG, hemodynamic with vasoreactivity test, 6 minutes walking distance (6MWD), brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), WHO functional class evaluation and risk stratification (according to a recently validated simplified version of 2015 ESC/ERS guidelines’ risk table). All cause mortality has been considered to identify the predictors of mortality using univariate and multivariate Cox regression analysis.

Results

570 PAH patients were included: 448 idiopathic (79%), 105 heritable (18%) and 17 drug-induced (3.0%). 20 patients were on atrial flutter/fibrillation at baseline. Considering only electrocardiographic parameters the variables independently associated with prognosis are shown in the table below:

Taking into account also the risk stratification the independent prognostic variables are:

Considering also clinical, exercise and haemodynamic variables the independent prognostic variables are:

Conclusions

in patients with I/H/D-PAH heart rate is a prognostic factor independently from other electrocardiographic, clinical, exercise and haemodynamic parameters as reflects the attempt to preserve the cardiac output in patients with an increased right ventricular afterload causing a reduced stroke volume; both PR interval prolongation, marker of right atrial overload, and QTc prolongation, marker of right ventricle's electrical remodeling, are prognostic variables independently from baseline patient's risk level; right bundle branch block, expression of right ventricular electrical remodeling, has proved to be an independent predictor of mortality merely if we consider only the electrocardiographic parameters.
498 PERSISTENT FIFTH AORTIC ARCH IN A PATIENT WITH CHARGE SYNDROME: A CASE REPORT AND SYSTEMATIC REVIEW OF LITERATURE
Authors: Ferraioli Mario , Nocilla Alessandra , Vincenza Polito Maria , Malinconico Marisa , Coppola Guido , Ferrara Francesco , Ciccarelli Michele , Vecchione Carmine , Galasso Gennaro
Published: December 2022

Background

CHARGE syndrome (CS) is a rare genetic disease characterized by a constellation of clinical findings including Coloboma, Heart defects, choanal Atresia, Retardation of growth and/or development, Genitourinary malformation and Ear abnormalities. We present a case of persistent fifth aortic arch (PFAA), an extremely rare congenital anomaly of aortic arch (AA), in a child with genetically confirmed CS and perform a systematic review of published studied, in an effort to examinate the distribution of congenital heart diseases (CHDs) and their impact in CHARGE patients.

Case presentations and results

A 12 years-old child was referred to our echocardiography laboratory for atypical chest pain. He had bilateral ocular coloboma, left hypoacusis, scoliosis, mild motor impairments, nocturnal enuresis, micropenis and facial dysmorphisms. Molecular diagnostic testing identified a de novo mutation (variant c.5290_5300+10del) in the CHD7 gene and CS was diagnosed. Echocardiography showed a single posterolateral papillary muscle and a cleft of anterior mitral leaflet. Interestingly, AA had a double-lumen appearance without Doppler signs of coarctation. A PFFA was hypothesized and then confirmed at angioCT. A systematic review of the literature was performed according to PRISMA guidelines. All published articles reporting the association CS and CHDs were chosen. A total of 975 records were identified. After the screening of title and abstract, assessed for eligibility were 219 papers. Finally, inclusion and full-text analysis was made in 60 studies, of which 37 case reports and 23 case series. We found that ventricular septal defects emerged as the most prevalent heart defect (32%), followed by atrial septal defects reported in 23% of cases. Complex CHDs were also described. Interestingly, AA abnormalities were reported in a high percentage (27%) of patients, right AA in 20% in association or not with aberrant subclavian artery and vascular ring, interrupted AA in 5% of cases, as well as aortic coarctation in 10%. Of note, almost half of the cases (49%) required cardiac surgery, mostly performed within 1 year from birth and, although outcome was available in a minority of patients, the death was reported in almost 30%.

Conclusions

Our case is the first that reports PFFA in CS and may be mistaken for AA dissection. In comparison with other syndromic diseases, a high prevalence of AA abnormalities was found in patients with mutations in the CHD7 gene.
740 TREATMENT STRATEGY IN CASE OF REPAIRED TRUNCUS ARTERIOSUS AND AORTIC COARCTATION
Authors: Leonardi Denis , Iseppi Manuela , Ciuffreda Matteo , Cristofaletti Alessandra , Prioli Maria Antonia , Rossetti Lucia , Sandrini Camilla , Luciano Ribichini Flavio
Published: December 2022

Background

Common Truncus arteriosus (TA) is a rare congenital, cyanotic heart disease with a single vessel coming out from both ventricles and related low interventricular defect, right-left shunt, low pulmonary flow and right ventricle (RV) hypertension. TA is associated with aortic coarctation (CoA) in 10-20% of cases.

Case

A 15-year-old male affected by type 2 TA and CoA undergoing first post-natal cardiac surgery with pulmonary valved conduit (PVC) implantation and CoA repair, subsequently multiple percutaneous (PC) interventions due to right pulmonary artery (RPA) stenosis and re-CoA.

He was referred to our Centre for dyspnoea on mild efforts. Echocardiography revealed RV hypertension (75% of systemic pressure) and mild disfunction. Angio-CT showed RPA re-stenosis due to peeling of previous stents, a degenerative PVC and mild residual CoA.

Results

Cardiac catheterization confirmed imaging findings, revealing the following systolic/diastolic blood pressures [mmHg]: 100/15 in RV, 33/10 in left pulmonary artery (LPA), 13/7 in RPA, 132/65 in ascending and 125/60 in descending aorta. First, extensive balloon-interrogation of stented RPA and RV outflow tract (RVOT) with semi-compliant balloon was performed followed by PC intra-stenting transluminal angioplasty of RPA with modified undersized non-compliant balloon. As RPA was very closed to CoA with risk of aortic rupture, and mostly the main pulmonary OT accounted for increased pressure gradient, RPA enlargement with re-stenting was avoided. Then, a long semi-opened-cell stent was arranged on the prosthetic RVOT and Melody valve was implanted as Valve-in-Valve (ViV), both with balloon post-dilatation. Dilated LPA with only moderate focal stenosis and mild residual CoA were excluded from intervention. Post-interventional right heart pressures were reduced: 45/4 in RVOT and 42/13 mmHg in the main PA. At 1 month dyspnoea disappeared with good effort tolerance, echocardiographic ViV mean gradient was 12 mmHg with improved RV systolic function and pressure (50% of systemic).

Conclusions

Repaired complex TA of type described may develop multiple re-stenosis of RPA. RPA optimization was not the goal of the procedure because at high risk of vessels’ injury due to the very closed anatomy with otherwise prosthetic CoA. RV pressures and dysfunction could depend on degenerative obstructive PVC. Thus, interventional approach mostly focused on the main PA aimed at working PVC could be the best effective treatment.
1033 A STRANGE CASE OF PULMONARY EMBOLISM IN A YOUNG PATIENT WITH CARDIAC RESYNCHRONIZATION THERAPY
Authors: Restelli Davide , Poleggi Cristina , Carlo Alessandro Di , Pelaggi Giuseppe , Di Bella Gianluca , Micari Antonio , Bonanno Marco , Trifirò Maria Paola , Paleologo Giuseppe , Carerj Scipione
Published: December 2022

Introduction

Clinically relevant pulmonary embolism (PE) related to pacemaker leads is reported in up to 3.5% of cases of implantations. We reported a particular case of acute massive PE in a patient bearer of a Cardiac Resynchronization Therapy-Defibrillator (CRT-D).

Case presentation

A 49-year-old man presented to our ER reporting dyspnea and localized pain to the left hemithorax. Past medical history included HFrEF due to idiopathic dilated cardiomyopathy complicated by apical thrombosis, CRT-D, Charcot-Marie-Tooth syndrome, dyslipidemia, and a hepatic nodule undergoing diagnosis. Recently, he reported COVID-19 and successive pleuropneumonia requiring hospitalization. At home, he was taking Acenocoumarin, Sacubitril/Valsartan 97/103mg bid, Carvedilol 6.25mg bid, Digoxin 0.0625mg, and Canrenon 50mg with questionable adherence. On physical examination, he was pyretic, mildly hypotensive and hypoxemic. An ECG showed atrio-guided biventricular stimulation at 110 bpm. A transthoracic echocardiogram (TTE) revealed biventricular disfunction and dilation, mitral and tricuspid regurgitation, PAPs 60 mmHg, and a thrombotic formation in the left ventricle apex. Blood tests found elevated D-Dimer and infection markers, INR 1.1. A CT angiography confirmed a bilateral acute massive PE associated with lung consolidations and left pleural effusion. We excluded deep vein thrombosis in the lower limbs. Patient was admitted to CCU and treated with intravenous heparin, antibiotics, and support therapy. After one week, we performed a transesophageal echocardiogram that confirmed the previous TTE except for a minor PAPs and unknown thrombotic formations on the atrial side of the tricuspid valve, adhering to CRT-D leads, pedunculated, highly mobile, the largest with an area of 1.9cm2. Cardiac surgery wasn't indicated; we excluded thrombophilia and thoracic cancer. Patient is still hospitalized, asymptomatic and with a precarious cardiovascular status.

Discussion

The incidence of asymptomatic clot adhering to cardiac device's leads found by echocardiography is 1.4%, and thromboembolic complications are even rarer, especially after years from the implant. In our patient, the right atrium thrombosis is probably the cause of PE, and possible precipitating factors were pneumonia or unknown hepatic neoplasm. In the diagnostic workup, TTE probably wasn't sensitive enough to detect those thrombi.

Conclusions

We presented a particular case of PE in a relatively young patient affected with HFrEF. Even if thrombosis related to pacemaker leads is rare, it should be considered as a possible cause of PE in a patient bearer of a cardiac stimulating device.
723 PREDICTORS OF PERCUTANEOUS CORONARY INTERVENTION DERIVED FROM CORONARY CT ANGIOGRAPHY IN PATIENTS WITH CHRONIC CORONARY SYNDROME
Authors: Belmonte Marta , Paolisso Pasquale , Bertolone Dario Tino , Gallinoro Emanuele , Caglioni Serena , Leone Attilio , Colle Cristina De , Bermpeis Konstantinos , Storozhenko Tatyana , Sonck Jeroen , Wyffels Eric , Penicka Martin , Collet Carlos , De Bruyne Bernard , Barbato Emanuele , Andreini Daniele
Published: December 2022

Aims

To assess whether quantitative and qualitative plaque features derived from coronary CT angiography (CCTA) could predict subsequent coronary revascularization by percutaneous coronary intervention (PCI) in patients with suspected chronic coronary syndrome (CCS).

Methods

From April 2019 to October 2020, all consecutive patients with suspected CCS undergoing CCTA and computation of Fractional Flow Reserve derived from CCTA (FFRCT), with consequent referral to coronary angiography and invasive physiological assessment, were included. The FFRCT 3D-model was used to calculate i) FFRCT value, in distal coronary segments where invasive FFR was measured, ii) trans-lesion gradient, defined as the difference in FFRCT units across the lesion derived from CTA, iii) vessel gradient, i.e., the difference in FFRCT units along the vessel. Quantitative and qualitative plaque analysis at CCTA was performed by experienced operators as recommended by current guidelines.

Results

Overall, 108 patients (143 vessels) were included. The mean age was 65±8.6 years, and 11% were diabetics. At baseline, 87 (80%) patients had chest pain. Left ventricular ejection fraction was 59±4.6%. Sixty (55.5%) patients underwent PCI, 8 (7.5%) were treated with coronary artery bypass graft (CABG), and 40 (37%) were referred to medical therapy (MT). At CCTA, the lesions undergoing PCI were significantly longer (38.85±17mm, p<0.001), with more severe diameter stenosis (45.43±16.69, p=0.002), lower minimal lumen area (MLA) (2.30± 1.33mm, p=0.013), higher plaque volume (292.31±158.32mm3, p<0.001), greater fibrous-fatty and necrotic core volume (18.87±20.7 and 14.78±27.42, p<0.001), greater maximum calcium arc in the lesion (108.63±65.9, p<0.001) and lower calcium arc the MLA (88.5±10 p=0.037) than the others referred to CABG/MT. In the PCI group, FFRCT was significantly lower (0.69± 0.11, p<0.001), while trans-lesion and vessel gradients were higher (0.09±0.04 and 0.27±0.10 respectively, p<0.001) than the other groups. On multivariate regression model, corrected for all confounding factors, longer lesions (OR 1.11, CI 1,01-1,21, p=0.022), higher maximum calcium arc (OR 1.02, CI 1.01-1.04, p= 0.007) and lower calcium arc at the MLA (OR 0.99, CI 0.98-0.99, p=0.031) were shown to be independent predictors of referral for PCI.

Conclusion

Lesion length and calcium arc derived from CCTA predict subsequent revascularization by PCI in patients suspected of CAD.
459 PREOPERATIVE ANGIOGRAPHY-DERIVED FRACTIONAL FLOW RESERVE MAY PREDICT BYPASS GRAFT OCCLUSION AND DISEASE PROGRESSION AT MID-TERM FOLLOW-UP
Authors: Mushtaq Saima , Gigante Carlo , Conte Edoardo , Capovilla Teresa Maria , Sonck Jeroen , Tanzilli Alessandra , Barbato Emanuele , Pontone Gianluca , Bartorelli Antonio Luca , Collet Carlos , Andreini Daniele
Published: December 2022

Background

Coronary artery bypass grafting (CABG) is the most common revascularization mode for patients with multivessel coronary artery disease (CAD). Despite substantial improvements in the outcome of patients undergoing CABG surgery, graft occlusion remains a weakness of this procedure and has been associated with competitive flow of native coronary arteries. Our study aims to assess graft occlusion and the progression of CAD in native vessels after CABG surgery at follow-up with coronary CT angiography (CCTA), and their relationship with angiography-derived vessel-fractional flow reserve (vFFR) performed before surgery.

Methods

We retrospectively selected patients from two European institutions, treated with CABG between January 2006 and December 2018, who underwent follow-up with CCTA. All patients had a preoperative angiogram performed before CABG.

Results

In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 non-grafted vessels. Table 1 shows clinical and main procedural characteristics. Preoperative vFFR was assessed in 131 left anterior descending arteries (LAD), 132 left circumflex arteries (LCX) and 94 right coronary arteries (RCA) and was <0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared to patent grafts (0.75 vs. 0.60, p<0.001) (Figure 1) and was associated with graft type. The best vFFR cut-off to predict graft occlusion was 0.67. The functional CAD progression was higher in grafted compared to non-grafted vessels (89.6% vs 47.5% p < 0.001) and pre-CABG vFFR predicted disease progression of grafted native vessels (AUC=0.83) (Figure 2).

Conclusions

Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.
784 IMPACT OF ELECTIVE, UNCOMPLICATED TARGET LESION REVASCULARIZATION ON CARDIAC MORTALITY AFTER ELECTIVE PERCUTANEOUS CORONARY INTERVENTION OF UNPROTECTED LEFT MAIN CORONARY ARTERY DISEASE
Authors: Celeski Mihail , Compagnone Miriam , Taglieri Nevio , Ghetti Gabriele , Marrozzini Cinzia , Orzalkiewicz Mateusz , Bruno Antonio Giulio , Galiè Nazzareno , Saia Francesco , Palmerini Tullio
Published: December 2022

Background

Percutaneous coronary intervention (PCI) appears a reasonable alternative to coronary artery bypass graft in selected groups of patients with unprotected left main coronary artery (ULMCA) disease. Despite technological progression, improved operator skills and introduction of drug-eluting stents (DES), in-stent restenosis still remains a major limitation after PCI of ULMCA disease. The prognostic relevance of target lesion revascularization (TLR) after PCI of ULMCA disease is unknown.

Objectives

This study sought to evaluate the impact of elective, uncomplicated target lesion revascularization on long-term cardiac mortality after PCI of ULMCA disease.

Methods

Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in one interventional center in Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. The secondary endpoints of the study were all-cause death, MI, stroke as individual endpoints, or the composite of cardiac death, MI or stroke defined as major adverse cardiac events (MACE).

Results

Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HR] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72).

Conclusion

Elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.
604 PERCUTANEOUS TRANSCATHETER CLOSURE OF SYMPTOMATIC PATENT FORAMEN OVALE IN PATIENT WITH INFERIOR VENA CAVA INTERRUPTION
Authors: De Filippis Aurelio , Ricottini Elisabetta , Gallo Paolo , Cammalleri Valeria , Nobile Edoardo , Nusca Annunziata , Circhetta Simone , Mangiacapra Fabio , Rinaldi Raffaele , Cocco Nino , Melfi Rosetta , Grigioni Francesco , Paolo Ussia Gian
Published: December 2022

Percutaneous closure of a patent forame ovale (PFO) is indicated in selected patients with a confirmed cryptogenic stroke, transient ischemic attack (TIA), or systemic embolism and an estimated high probability of a casual role of the PFO as assessed by clinical, anatomical and imaging features. This procedure is usually undertaken from the femoral vein. In this case, the patient was affected by vena cava agenesis with a compensatory enlargement of azygos vein.

We performed the percutaneous closure of the PFO using a 9F jugular vein access. We advanced a straight guide trough the foramen with a Multipurpose 6F catheter supported by a Destino Oscor 8F. Then we changed the straight guide with an Amplatz Super-Stiff 0.035" guide in the left ventricle, on which a Mullins 9F trans-septal catheter was advanced. Finally we delivered an Amplatzer Multifenestrated Septal Occluder "Cribriform" 25/25 mm.

In our case, it was impossible to perform the PFO closure procedure using the classic femoral vein access due to the inferior vena cava agenesis. Performing PFO closure using the right internal jugular venous approach was technically challenging but safe and it is possible using standard equipment normally present in the Catheterization Laboratory.

In rare cases of an indication for PFO closure and lack of access through the femoral veins, alternative techniques using on the shelf materials help in overcoming the challenging anatomies. The use of steerable catheter is critical for engaging the foramen ovale with unfavourable angulation. The procedure with nitinol double disk devices is safe and effective.
680 SINGLE-CENTER EXPERIENCE IN TRANSCATHETER MITRAL VALVE REPLACEMENT WITH THE TENDYNE MITRAL VALVE SYSTEM
Authors: Parlato Alessandro , Carapellucci Eliana , Mazzola Matteo , Vitale Carlo , Gentile Francesco , Spontoni Paolo , Giannini Cristina , Colli Andrea , De Carlo Marco , Petronio Anna Sonia
Published: December 2022

Background

Transcatheter mitral valve replacement (TMVR) with the Tendyne System is a therapeutic option for selected patients with severe symptomatic mitral regurgitation (MR) not eligible for either surgical intervention or transcatheter repair. To date, only a few studies have evaluated the short-term and mid-term outcomes of these patients in a real-life scenario.

Objectives

To describe the baseline features, and the short- and mid-term outcomes of patients undergoing TMVR with the Tendyne System at our Center.

Methods

Consecutive patients undergoing TMVR with the Tendyne System at our Center from November 2018 and August 2022 were enrolled. The baseline features of the study cohort were collected during the index hospitalization and patients were followed-up for the endpoints of all-cause death, residual MR, and prothesis dysfunction.

Results

Twenty-two patients (aged 75±6 years, 36% men) with moderate-to-severe or severe MR undergoing TMVR with the Tendyne System were recruited. Many patients were highly symptomatic (45% New York Heart Association [NYHA] functional class III or IV) and the etiology of MR was secondary or mixed in 18 (82%) cases. Prostheses were successfully implanted in all patients, with no peri-procedural residual MR (only two patients had a mild paravalvular leak). One patient died of sepsis during the index hospitalization. Out of 19 patients evaluated at a 30-day follow-up, 18 (95%) had no residual MR, 16 (84%) had an improved functional status (of at least one NYHA grade). Mid-term (>6 months) follow-up was available for 15 patients, 4 of whom were dead (2 died of heart failure, one of sepsis, and one of intestinal ischemia). Among the 10 patients undergoing a mid-term follow-up echocardiography, 8 had no residual MR and 2 had only mild MR. Two valve-related adverse events (i.e., endocarditis) were registered during the follow-up.

Conclusions

TMVR with the Tendyne System appears to be a safe and promising technique for symptomatic patients affected by signficant MR and not suitable for other procedures. Since experience is still limited, more data including a longer follow-up is warranted to optimize patient selection and outcomes.