bluuebunny/crossref_metadata_2025 huggingface dataset:
SHEATHLESS RADIAL APPROACH IN CONTEMPORARY CORONARY ROTATIONAL ATHERECTOMY: DATA FROM TWO HIGH VOLUME CENTERS
Authors: Dall‘Ara G , Alagna G , Spartà D , Compagnone M , Grotti S , Guerrieri G , Campanella F , Taverna G , Galvani M , Tarantino F , Andò G
Published: May 2024

Aim

To analyze the feasibility and procedural outcome of percutaneous coronary intervention (PCI) using rotational atherectomy (RA), performed via transradial sheathless guiding catheter as compared to a standard radial and femoral vascular approach.

Methods

All consecutive patients undergoing RA at two high–volume PCI centers from May 2011 to May 2023 were included. Comparisons were made between the two transradial approaches and between the three types of vascular access.

Results

Two hundred twenty–three patients were enrolled. Baseline characteristics were similar, with the exception of gender. We observed, in percentages, fewer cases of failure for sheathless than standard transradial attempts (7.5% vs. 11.5%, respectively), whereas all trans–femoral attempts were successful. Transfemoral procedures were longer and more frequently performed under mechanical circulatory support. There was no difference in procedural success between the three vascular approaches. A trend towards a higher rate of vascular and bleeding complications was found in the femoral group.

Conclusion

Sheathless transradial vascular access is a viable option when performing RA during complex PCI procedures, tending to result in fewer failures than the standard transradial approach and in reduced bleeding and vascular complications compared to the femoral method.
DISCOVERING PALPITATIONS
Authors: Vecchio C , Zuffada F , Bianchi M , Nassiacos D
Published: May 2024

NA is a 51 years old dyslipidemic man without previous cardiovascular history. It’s been for 2 years that occasionally transient palpitations appear but nothing has been made. He came to ED for palpitations after vomiting: the ECG showed sinus rhythm with transient NSVT then sinus rhythm again and SVT with ST alteration. Metoprolol 2.5mg ev and MRA ev were administered because of mild hypokalemia with benefit. Echocardiogram and chest X–ray were normal without drugs intake. During hospitalization we started bisoprolol 2.5mg po and anti–dyslipidemic therapy but we observed very frequently PVC and PSVC and symptomatic wide QRS complex sustained tachycardia paroxysms at 180 bpm without loss of consciousness, hypotension or electrolytic abnormalities and SVT 170 bpm unresponsive to BB and amiodarone. The stress test without BB evidenced early wide QRS complex sustained tachycardia at 220 bpm well hemodynamically tolerated: metoprolol 10mg ev administration showed a brief sinus rhythm and then a narrow QRS complex sustained tachycardia at 160 bpm with significantly ST underleveled so flecainide 150mg ev was given with cardioversion to sinus rhythm and slowly ST abnormality regression. Subsequent coronary angiography and cardiac magnetic resonance resulted normal. The electrophysiological study demonstrated AVRT with a left lateral pathway retroconduction with and without LBBB and subsequent short AF paroxysms: the left lateral pathway was ablated without complications but the high atrial electrical vulnerability with reproducible SVT and triggered AF paroxysms lead to ILR implantation. The patient was discharged without antiarrhythmic and anticoagulant therapy: during the follow up there’s no arrhythmic relapses evidence and the patient is asymptomatic. Never give up to looking for solutions about palpitations: accessory pathway happens when you least expect it.
PERMANENT JUNCTIONAL RECIPROCATING TACHYCARDIA: IT IS IMPORTANT TO KNOW HOW TO RECOGNIZE IT
Authors: Testa S , Gallina S , Renda G , Ricci F
Published: May 2024

Permanent junctional reciprocating tachycardia, also known as Coumel‘s tachycardia, is a rare form of supraventricular tachycardia that is usually incessant, characterised by retrograde conduction via an accessory pathway usually located in the posteroseptal region with slow and decremental conduction. Tachycardia is virtually incessant, at a rate ranging from 120 to 250 beats/minute. The electrocardiogram inscribes inverted P waves in leads II, III, AVF, as well as left lateral leads, along with a P–R interval shorter than the R–P interval during the tachycardia. The characteristic, but not diagnostic, electrocardiographic feature is a long R–P interval consistent with slow retrograde conduction. Spontaneous resolution of tachycardia is not un common. Electrocardiographically, it manifests as a narrow QRS tachycardia with long RP‘, with negative retrograde “p” waves in lower leads (D2, D3 and avF). The initiation and termination of the arrhythmia is not determined by a premature beat, but by critical changes in the RR cycle, that is, for values of the heart rate at which the activating front finds the retrograde decremental pathway outside refractoriness. Due to its incessant characteristic in some cases, patients may present tachycardiomyopathy, with myocardial dilation and ventricular dysfunction. We report the case of a 5–year–old girl who came in for onset of heart palpitation for several hours. On electrocardiogram finding of supraventricular tachycardia, narrow QRS, HR 170/min, negative p waves in DII–DIII–AVF. The electrocardiographic finding was compatible with a picture of permanent junctional reciprocating tachycardia. Following the administration of 50mg of phleicanide, there is a progressive reduction in heart rate until the clinical picture stabilizes. antiarrhythmic therapy was subsequently set with subsequent re–evaluation and discharge to the patient‘s home.
STELLATE GANGLION BLOCK: CLINICAL MONITORING AFTER INJECTION
Authors: Giuranna M , Freschini M , Notaristefano F , Barengo A , D‘Ammando M , Del Papa M , Zingarini G , Russo G
Published: May 2024

70–year–old man with chronic coronaric syndrome (CABG x 6 in 2006) and HFrEF. ICD implant in primary prevention in 2011. He was admitted for arrhythmic storms refractory to IV lidocaine therapy. Following sedation with midazolam, a left stellate ganglion block was performed using the ultrasound–guided lateral approach, injecting 200 mg of Lidocaine and 200 mg of Mepivacaine. After a few minutes, there was the appearance of anisocoria, different thermotouch in the upper limbs, ptosis, dysphonia, as an effect of local anesthetics on the sympathetic nervous system fibers and on the recurrent laryngeal nerve, near the stellate ganglion. At the same time, the arrhythmias did not recur. Among the rare complications described in the literature (usually transient) arising after stellate ganglion block for the treatment of various chronic pain syndromes or refractory ventricular arrhythmias, we find: hoarseness, stridor, confusion, cough, severe hypertension, subdural/intrathecal block with respiratory arrest, loss of consciousness and paralysis of the four limbs, epileptic seizures, transient locked–in syndrome, headache, visual hallucinations, myoclonus, Horner‘s syndrome, diaphragmatic palsy (phrenic nerve injury), allergic reactions, bleeding and hematoma formation, dural puncture, pneumothorax, local infections. Serious adverse effects described include cases of death or tetraplegia following epidural abscess. For this reason, it is of utmost importance monitoring after the procedure and the availability of the equipment necessary for a possible resuscitation to avoid long–term of sequelae.

Conclusion

In cases of arrhythmic storm refractory to antiarrhythmic therapy, percutaneous stellate ganglion block is an effective and safe procedure and serious complications are rare.
THE CONUNDRUM OF DRUG INTERACTIONS AND HOLTER MONITORING: LAMIN GENE MUTATION DISCOVERED BY A TORSADE DE POINTES EPISODE FOLLOWED BY OUT–OF–THE–HOSPITAL RESUSCITATION
Authors: Malavasi M , Notarianni G , Pontillo D , Luciani M , Petrungaro M , Zampi G , Sommariva L
Published: May 2024

The prolongation of the QTc interval on the electrocardiogram is known to be associated with an increased risk of developing life–threatening ventricular arrhythmias such as torsades de pointes (TdP). QTc values exceeding 500 ms can double or even triple the risk of TdP. Many drugs, including amiodarone and some SSRI antidepressants like paroxetine, can prolong the QTc interval. A 57–year–old patient experienced cardiac arrest during an overnight Holter recording prescribed to exclude brady–tachy syndrome in the presence of persistent atrial fibrillation. ECG ambulatory monitoring revealed significant bradycardia with the onset of idioventricular rhythm, followed by TdP triggered by premature ventricular contractions, subsequently degenerating into ventricular fibrillation. The patient was resuscitated by family members and later by emergency medical personnel using 3 DC shocks, leading to the restoration of spontaneous circulation. The patient was transferred to the cardiology intensive care unit where a coronary angiography showed normal results. Blood tests indicated low potassium levels (3.3 mEq/L), with a moderately reduced left ventricular ejection fraction at 45%. The patient was discharged after ICD implantation and during the diagnostic follow–up the genetic testings for long QT syndrome were negative, but showed a mutation of the LMNA lamin A/C gene. During the two months previous to hospital admission, the patient had complained of fatigue in the presence of atrial fibrillation with a low ventricular response. Nonetheless, she had been prescribed oral amiodarone to optimize the chances of successful electrical cardioversion, in combination with paroxetine that the patient was already taking at home. The combination of these two drugs and the patient‘s idiopathic bradycardia contributed to a marked prolongation of the QT interval, leading to TdP degenerated into ventricular fibrillation. This case, notable for the prolonged recording of ventricular fibrillation and subsequent resuscitation chest compressions during a Holter monitoring, suggests caution in the use of antiarrhythmic drugs unless strongly indicated in the presence of potentially ominous drug interactions. It is encouraging to note how the widespread adoption of cardiopulmonary resuscitation culture has enabled individuals who might not have otherwise received medical attention to be effectively resuscitated.
BIOCLINICAL, PSYCHO–SOCIAL–RELATIONAL AND NURSING–SENSITIVE OUTCOMES (NSOS) IN CARING FOR PATIENTS WITH ACUTE CORONARY SYNDROME
Authors: Danesi S , Simonetti M , Candelori L
Published: May 2024

Patients with ACS represent a highly complex situation that requires management using a multidisciplinary approach. Nursing plays a crucial role in the evaluation, monitoring, intervention planning and educational process to achieve optimal results for the pre–established objectives. One important aspect is analysing and measuring care performance, i.e. outcome indicators that reflect the quality of care. The objective of this study was to monitor nursing–sensitive outcomes (NSOs) to enable critical areas to be identified, care improvement to be implemented, and patient health needs to be adequately met. The study was organised as a retrospective observational review of data extracted from electronic medical records (eMRs) on total admissions to the Hospital‘ s Coronary Intensive Care Unit (CICU) in 2023. A validated checklist was used to study the following elements: bioclinical aspects, pain scale, fall risk, pressure ulcer risk, degree of autonomy, and tromboembolic and haemorrhagic index. The following psyco–social–relational variables were collected: level of education, loneliness index, and counselling and health education activities. Total admissions were 652, with 7 beds, an average stay of 2.79 cases, a bed turnover rate of 88.86, cardiac markers at 100%, NPRS assessed at 96%, Conley scale at 91%, Braden scale at 90%, Barthel index at 93%, CHA2DS2–VASc score of 95%, and Killip classification and GRACE score of 92%. The level of education was 45%, and the loneliness index was found to be 12% in patients aged >85 years. Counselling was recorded in 50% of cases, and the educational aspect involved 62%. The clinical audit enabled assessment of the appropriateness of the care processes, the identification of critical issues and missed nursing care, as well as aspects which need to be improved through clinical governance with structured briefings.
LONG–TERM OUTCOME OF MITRAL VALVE REPAIR WITH TAILOR–MADE POSTERIOR FLEXIBLE BAND
Authors: Olivieri G , De Chiara B , Settepani F , Abrami G , Biolcati M , Grieco M , Moreo A , Russo C
Published: May 2024

Background and Aim

Mitral valve repair commonly involves the fixation of the annulus to restore optimal diameters. In specific features (normal LV and annulus dimensions), the implementation of posterior rings reduce recurrent MR, avoiding possible systolic anterior motion development. Aim of our study was to evaluate the long–term outcome of patients undergoing mitral repair with a tailor–made posterior band.

Methods

Retrospective and prospective single centre analysis. Inclusion criteria: age > 18 years; mitral valve repair with posterior leaflet resection and implantation of posterior flexible band; surgery from 2003 to 2021. End–points: freedom from mitral valve re–operation, freedom from recurrence of mitral regurgitation grade > II and overall survival at follow–up. Data obtained from regional database, clinical outpatient assessments and phone calls. Institutional ethical committee board approval.

Results

289 patients, 109 females (37.7%), were included. Median age was 64 years (IQR 56–71). Sternotomy was the preferred surgical approach (225 pts, 77.8%) while 64 patients underwent mini–thoracotomy (22.1%). 74 (25.6%) patients required combined procedures: CABG, PFO closure and LAA exclusion were the most popular with 21, 20, and 18 cases respectively (6.3, 6 and 5.4%). In–hospital mortality was 0.01% (3 patients). Major post–operative complications (AKI, prolonged ventilation, major injection, severe bleeding, stroke) occurred in less than 5% of the patients. Median follow–up is 11.1 years (IQR 4.7–15.2). Freedom from re–operation is 98.6±0.7%, 97.3.±1.2% and 77.7±8.5% after 1, 10 and 18 years, respectively. Freedom from recurrence of MR grade > II is 98.5.±0.7%, 95.7.±1.5% and 83.8±4.6% at 1, 10 and 18 years, respectively. Overall survival at follow–up is 97.5±0.9%, 83.1.±2.7% and 55.6±8.7% at 1, 10 and 18 years, respectively.

Conclusion

In our experience mitral valve repair with tailor–made posterior flexible band is a safe and reproducible surgical technique, both isolated or as a combined procedure. Outcomes are positive and encouraging with a satisfactory low rate of re–operation and recurrent mitral regurgitation grade II or more at long–term follow–up. Data of a larger population are required to confirm the positive results of our single centre study.
EXPLORING THE 12 LEAD ECG CHARACTERISTIC OF PAEDIATRIC AND YOUNG ADULT CARRIERS OF DESMOPLAKIN GENE VARIANTS
Authors: Montuoro S , Imperatore G , Moscatelli S , Field E , Kaski J
Published: May 2024

Background and Aim

The DSP gene (locus. 6p24.3) encodes desmoplakin, a quintessential desmosomal protein for cellular adhesion, particularly within cardiac tissues. DSP gene variants can cause dilated cardiomyopathy, non–dilated left ventricular cardiomyopathy (NDLVC) and arrhythmogenic righ ventricular cardiomyopathy (ARVC), cardiac conditions known to trigger malignant ventricular arrhythmias and cause sudden cardiac death in young individuals. Nevertheless, the electrocardiographic (ECG) patterns in children carrying DSP variants are underexplored.

Methods

A retrospective analysis was conducted involving paediatric DSP gene variant carriers (</=18 years), followed at Great Ormond Street Hospital from 2006 to 2023. Their 12–lead ECGs were characterised and compared with those of an age and gender–matched healthy control group (χ2, p–value<0.05).

Results

25 DSP carriers (64% females; 12.6±4 years) were identified [including 4 (16%) with an overt cardiomyopathy phenotype] and compared to 25 healthy matched controls (12.7±4.3years). Compared to the control group, DSP carriers exhibited a higher prevalence of low QRS voltages (72% vs 44%, p= 0.041), QRS notching (72% vs 26%, p= 0,014) and flattened T waves (72% vs 52%, p= 0,026). All 4 patients with an overt cardiomyopathy phenotype had widespread low QRS voltages and QRS fractionation, as well as flattened/inverted T waves, particularly in the inferior and lateral leads.

Conclusion

Predominant ECG features observed in paediatric patients with DSP gene variants included low QRS voltages, QRS notching, and flat or inverted T waves. Our findings suggest that ECG features may precede the development of an overt cardiomyopathy phenotype in children with DSP variants, but further studies with larger cohorts are needed to confirm this and to determine their prognostic significance.
BRUGADA SYNDROME: NEWEST DATA ON RISK STRATIFICATION
Authors: Massara M , Casella M , Dello Russo A
Published: May 2024

Background

Brugada Syndrome (BrS) is a rare genetically based channelopathy responsible for malignant arrhythmias and sudden cardiac death (SCD) in young adults.

Objectives

The aims was to evaluate prognostic indicators useful for accurate arrhythmic risk stratification in BrS by studying genetic, clinical, anamnestic, instrumental parameters, and those derived from electrophysiological study (EPS) and intracavitary mapping.

Materials and Methods

209 patients with Brugada type 1 were recruited between 01/01/2018 and 01/10/2023.

Results

In the first study, predictive factors related to high arrhythmic risk from the data obtained for the total population of 209 Brugada patients enrolled in our case series include a positive history of cardiogenic syncope (p value 0.000041), having had a resuscitated cardiac arrest (p value 0.00025), presenting positive EPS for inducibility of ventricular tachycardia (p value 0.00032), having a family history of sudden cardiac death (p value < 0.00001), and presenting positive cardiac mapping and MRI for pathological alterations (both with p value > 0.00001). From the data obtained for the subset of 80 Brugada patients with ICD in our case series, predictive factors related to high arrhythmic risk are different from the previously analyzed population: presenting spontaneous type 1 ECG (p value 0.0015), having had a resuscitated cardiac arrest (p value 0.014028), having a family history of sudden cardiac death (p value < 0.00001), and presenting positive mapping, genetics, and cardiac MRI for pathological alterations. Positive EPS and syncope in this subset do not appear to be risk factors, unlike the population of all 209 enrolled patients.

Conclusions

Multiparametric scores, including the mentioned markers, have been introduced in clinical practice for a better approach in selection. However, new markers are needed to improve risk stratification in BrS patients, especially those in the so–called "gray zone" with intermediate risk. In the future, it will be evaluated through experimental models and genotype–phenotype integration whether such electrical heterogeneity is also associated with specific genetic or structural abnormalities and may represent a new therapeutic target for etiological treatment in BrS patients. In conclusion, there is an urgent need to develop new methods for risk stratification in Brugada syndrome that are sufficiently sensitive, specific, reproducible, and easy to apply.
MYOCARDIAL AND PERICARDIAL DISEASES INCIDENCE IN COVID
Authors: Fazio G
Published: May 2024

Severe acute respiratory syndrome coronavirus 2 (SARS–CoV–2), also referred to as COVID–19, was declared a pandemic by the World Health Organization in March 2020. The manifestations of COVID–19 are widely variable and range from asymptomatic infection to multi–organ failure and death. Like other viral illnesses, acute myocarditis and/or pericarditis has been reported to be associated with COVID–19 infection. The guidelines for the diagnosis of COVID–19 introduced the echocardiogram for diagnosis of carditis in these patients.

Purpose

In our study we investigated the incidences of myocarditis and/or pericarditis in a consecutive series of 1540 Athletes undergo to agonostic certification that performed echocardiogram, and subdivided the incidence of carditis depend on the period and the possible subtype of the covid (alpha, beta, gamma, delta, epsilon).

Methods

From March 2020 to October 2022 we enrolled in this epidemiological evaluation 1540 patients that was affected by COVID. Every patients was admitted to ambulatory of sport medicine of 2 Italian centres on the major islands to perform a return to play agonist certificate. Overall, 69% males and 31%. females were enrolled with a mean age of 24.3 years (12–67 years). None presented a risk factor of a cardiac disease.

Results

The incidence of Echocardiographic abnormality was 3,2% in our population The kind and the incidence of alteration was showed in table 1, and consist in dilated cardiomiopathy (0,4%), regional cinetic dysfunction (0,4%), pericardial effusion (1,9%), aspecific alterations (0,2%). Based on the period we evaluated the incidence of the echocardiographic alterations during the seasons and in corralation of variant of COVID . The results was showed in figure 1.

Conclusions

Based on our evalution the incidence of echocardiographic findings in COVID was 3,2% in all period, with a progressive reduction long the time, from alpha variant to epsilon variant.
EFFECTIVENESS AND SAFETY OF HALF–DOSE THROMBOLYSIS IN INTERMEDIATE–HIGH RISK PULMONARY EMBOLISM: A RETROSPECTIVE, SINGLE CENTER EXPERIENCE
Authors: Zagarese G , Santori V , Giatti S , Marcantoni L , Maddalozzo A , Pastore G , Valenza S , Bertola S , Ribichini F , Zanon F , Picariello C
Published: May 2024

Background

Current guidelines recommend full–dose systemic thrombolysis for acute pulmonary embolism (PE) in high–risk or hemodynamically unstable intermediate–high risk (IHR– PE) patients. Recent trials suggest that a low, half dose (50 mg) of tissue plasminogen activator (HDrtPA) could be a safe, effective alternative with low bleeding risk. We aimed to evaluate whether HDrtPA in IHR–PE could improve right heart function echocardiographic parameters and NT–proBNP levels at discharge, in comparison to unfractionated heparin (UFH) alone.

Methods

We retrospectively analyzed ninety IHR–PE consecutively admitted to our Intensive Cardiac Care Unit between January 2016 and May 2023. HDrtPA patients (Group A, n=28) received low–dose thrombolytic therapy (0,6 mg/kg, max. 50 mg in 1 hour) plus UFH. Group B included patients were treated with UFH alone. Primary endpoint was an improvement between admission and discharge of tricuspid annular plane systolic excursion (TAPSE), tricuspid velocity (TV), RV– arterial coupling (TAPSE/PASP or pulmonary artery systolic pressure), basal right ventricle diameter (RVD), and NT–proBNP levels. Secondary endpoint involved assessing the occurrence of mortality and bleeding events. Linear regression models were used with Inverse Probability Weighting propensity scores. Due to the low occurrence of death events, this endpoint was investigated only through descriptive statistics.

Results

Mean age was 73.48 ± 12.49 (mean ± Sd) and n=43 (47.8%) were males (table 1). Group A had improvement of TAPSE/PASP (+0.16, p=0.006, CI 95%: 0.06; 0.27), RVD (–6 mm, p=0.001, CI 95%: –8.61; –3.58), TAPSE (+2.6 mm, p=0.003, CI 95%: 0.77; 4.49) and TV values (–0.46 m/s, p=0.018, CI 95%: –0.8; 0.09), while the decrease in NT–proBNP values (–2048 pg/ml) did not achieve statistical significance (p=0.382, CI 95%: –7101.17; 2413.45). No significant increase in major bleedings was observed between groups (Group A: 3.5%, Group B: 0%) with an acceptable number of minor bleedings (Group A: 25%, Group B: 1.6%). Death occurred in 3 patients in group A (10%) and 1 patient in group B (1.6% – table 2).

Conclusions

In selected IHR–PE patients, administration of HDrtPA seems to improve right ventricular function, dimensions and RV–arterial coupling in comparison to UFH alone, with an acceptable bleeding and mortality risk. These results should be confirmed in randomized, prospective trials to allow HDrtPA to be fully included in future guidelines.
CARDIOVASCULAR CONSIDERATIONS IN ANTIDEPRESSANT THERAPY: SINUS ARREST DUE TO SERTRALINE
Authors: Scollo C , Rossi D , D‘Andria R , Magnano R , Pezzi L , D‘Alleva A , Genovesi E , Verrengia E , Duronio G , Forlani D , Vitulli P , Gallina S , Paloscia L , Di Marco M
Published: May 2024

A 39–year–old Caucasian woman with a silent cardiac anamnesis and no family history of cardiovascular diseases, and a history of mood disorder treated with Sertraline for about 1 month, went to the Emergency Department reporting several syncopal episode, all with rapid and complete recovery of consciousness. In the Emergency Department, another syncopal episode occurred in the supine position, characterized by sinus bradycardia evolving into a brief asystole, with spontaneous restoration of normal sinus rhythm. Admitted to the Cardiovascular Intensive Care Unit, the patient showed no abnormalities in laboratory testsas well as in echocardiography results. The patient received appropriate hydration, and home medication was discontinued. A non–contrast head CT scan showed no acute lesions. Cardiac MR revealed normal morpho–functional findings, with no evidence of myocardial edema or pericardial effusion and no pathological late gadolinium enhancement areas. Brain MRI demonstrated normal anatomical and functional findings, with no signal abnormalities. Considering the patient‘s young age and the suspicion of an iatrogenic origin of the rhythm disorder, the decision to postpone pacemaker implantation was made, and cardiac electrical activity was monitored using a loop recorder. At the one–month follow–up, the patient, who had been off Sertraline since admission, was in good health, reporting no further syncopal or pre–syncopal episodes. Loop recorder monitoring revealed no significant arrhythmias. The only relevant anamnestic data was the use of Sertraline, and the application of the Adverse Drug Reaction Probability Scale suggests that the iatrogenic origin of this event as a pharmacological adverse effect is at least probable (score: 7). Limited literature connects Sertraline directly to documented cases of asystole, but reports indicate that drugs in the same pharmacological class may induce cardiac rhythm disturbances, including tachyarrhythmias and bradyarrhythmias. This case draws attention to sinus arrest during sertraline therapy and how an appropriate pharmacological washout led to the resolution of the pathology.
A CASE REPORT OF HEART FAILURE WITH IMPAIRED EJECTION FRACTION DUE TO DILATED CARDIOMYOPATHY IN A YOUNG PATIENT
Authors: Minichiello S , Bianchino G , Botticella F , Di Gianni A , Dragonetti C , Foffa A , Gualdiero P , Lo Conte C , Manganelli G , Pellecchia V , Ambrosini V
Published: May 2024

A 30–year–old female, with no prior history of heart disease sought medical treatment for increasing shortness of breath, oedema in the lower limbs, abdominal enlargement from seven days. She had was adopted, was a smoker, no use of illicit drugs. Her heart rate was 90 per minute, she had bilateral pitting oedema to mid–shin, her blood pressure was 100/70mm Hg, there were no signs of jugular venous hypertension, the pulmonary and cardiac auscultations were normal. She had ascites and her liver was palpable 3cm below the right costal margin. Her ECG had shown sinus rhythm, heart rate of 92bm, PR interval of 160ms, left bundle branch block (QRS duration of 130ms). Her echocardiogram showed severe global left ventricular dysfunction with left ventricular (LV) ejection fraction (EF) 18% using the apical biplane Simpson’s rule, GLS WAS –4.3%, her right ventricle was dilated and impaired (TAPSE 1,6cm). Her BNP was 2393,90pg/ml. To exclude coronary artery disease, especially congenital coronary artery disease a coronary CT angiography (CTA) was performed. The coronary CTA scan showed normal findings. Cardiac MRI showed severe impairment of both left and right ventricular systolic function with a pattern of gadolinium enhancement negative for necrosis or fibrosis. The patient, after being initially treated with large doses of diuretics and levosimendan, was promptly treated with sacubitril valsartan, empaglifozin, bisoprolol, spironolactone plus vericiguat with rapid titration to maximal tolerated dose. About 1 week later her symptoms began to subside and the patient was discharged in a stable condition. She was referred for consideration of cardiac transplantation and cardiac resynchronisation therapy defibrillator; blood samples for genetic pathology research were taken. A program of serial echocardiograms was introduced, every 30 days, and was observed after 2 months. At follow up our patient had an impressive improvement in terms of improved quality of life, NYHA functional class (from III to I), and performance capacity. A new echocardiographic assessment had shown an LVEF of42% with GLS of–12%. Conclusions: Four pillars of heart failure therapy and vericiguat addiction with rapid titration represents a safe and effective strategy for the treatment of cardiac decompensation with reduced FE. Basal / 60 day EF % 18 /42 GLS % –4.3/ –12.0 E/A 5 /2,1 BNP pg/ml 2393.90 / 889.90 TAPSE cm/s 1.6 / 2.1
USE OF SGLT2-i IN ELDERLY PATIENTS WITH HFrEF- REAL WORD DATA
Authors: Verga F , Orso F , Salucci C , Corti G , Graziani M , Alfano F , Poletti E , Cagnoni C , Ungar A , Baldasseroni S
Published: May 2024

Introduction

SGLT2-i have been shown to improve prognosis in patients with reduced ejection fraction heart failure (HFrEF) in randomized clinical trials (RCTs). However, we have little data on the use of these drugs in clinical practice, both in terms of safety and efficacy profile, especially in elderly patients.

Objectives

To describe the characteristics of HFrEF outpatients who started SGLT2-I and evaluate tolerability and effect of therapy.

Results

We evaluated 42 patients, 32 M and 10 F, with a mean age of 78±8.2 years (62.1% over 75). At baseline, the mean EF was 34.5%± 6.0 and the patients' renal function calculated with CKD-EPI was 56.3±18.6 ml/min/m2.

We followed at 6 months 36 patients. After 6 months of SGLT2i therapy, there was a significant reduction in NYHA class (NYHA I 30.6% vs 9.8%, NYHA III 13.9% vs 31.7%), a slight recovery in EF (38% vs 33% p-value = 0.039) and a decrease in diuretic dose (34 mg/day vs 64 mg/day, p-value 0.033). Despite a slight initial reduction in eGFR, like RCTs, there was recovery of renal function at 6 months. At 6 months, only 2 patients discontinued SGLT2i therapy due to urinary infection.

Conclusions

In our analysis after 6 months of SGLT2-i therapy in elderly patients, there was clinical improvement as evidenced by improvement in NYHA class and reduction in diuretic therapy. SGLT2-i have been shown to be relatively safe, with no adverse effects occurring and no significant worsening of renal function.
QUALITY OF CARE FOR PATIENTS WITH ACUTE HEART FAILURE: RESULTS OF THE FIRST 3 MONTHS OF THE QUALITY IN CARDIOLOGY (QIC) PROJECT
Authors: Corticelli A , Avanzini F , Conti A , Anguilano M , Bersano C , Bertocchi P , Bova C , Carbone S , Di Giulio P , Loffreno A , Paone M , Rigamonti A , Russo G , Santambrogio M , Scifo C , Serpato E , Spinelli M , Achilli F
Published: May 2024

Background

Assessing the quality of care is the first step for improve the management of patients with acute heart failure (AHF). The European Society of Cardiology (ESC) recently defined a set of quality indicators (QI) of care for AHF. Aim: To evaluate the quality of care of patients admitted to the Cardiology ward of our first level hospital for an AHF using the ESC QI.

Methods

QiC project is a prospective quality improvement study in real–world practice on all patients admitted in our ward for an AHF from 1.5.2023 to 30.4.25 with six–monthly audit activities. Case record forms were filled in by doctors during admission and were attached to the patient’s discharge letter. The ESC QI include 12 main and 4 secondary QI on structural framework, patient assessment, initial treatment, and assessment of patient health–related quality of life. For each QI was evaluated the percentage of QI assessable and attained.

Results

A total of 39 patients were admitted for AHF in our Cardiology Department in the first 3 months. One patient denied consent, one died during hospitalization, 5 patients had to be transferred to another hospital, and 7 did not have their record form filled in. The median age of the 25 patients discharged alive was 76 (IQR 64–83) years, 17 (68.0%) were males, 3 (12.0%) had a preserved, 1 (4.0%) mildly reduced, and 21 (84.0%) reduced ejection fraction. The percentages of non–assessment, non–attainment and attainment for each QI are reported in the Figure: the degree of non–assessment of the 16 QI ranged from 0 to 16% and the degree of QI attainment from 12 to 100%.

Conclusions

The quality of care for acute heart failure can be measured in the majority of patients admitted to our Cardiology Department using the ESC quality indicators. Although the majority of quality indicators are met in our patients, a large room for improvement is present in the domain of the patient assessment (mainly in completeness of blood tests and cardiac rehabilitation programme), of the initial treatment (SGLT2 inhibitor prescription), and of the assessment of patient health–related quality of life.
HEART FAILURE PATIENTS WITH IMPROVED EJECTION FRACTION: INSIGHTS FROM THE MECKI SCORE DATABASE
Authors: Mapelli M
Published: May 2024

Aims

Improvement of left ventricular ejection fraction is a major goal of heart failure (HF) treatment. However, data on clinical characteristics, exercise performance and prognosis in HF patients who improved ejection fraction (HFimpEF) are scarce. The study aimed to determine whether HFimpEF patients have a distinct clinical phenotype, biology and prognosis than HF patients with persistently reduced ejection fraction (pHFrEF).

Methods

7948 patients enrolled in the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score database were evaluated (median follow–up of 1490 days). We analyzed clinical, laboratory, ECG, echocardiographic, exercise, and survival data from HFimpEF (n=1504) and pHFrEF (n=6017) patients. The primary endpoint of the study was the composite of cardiovascular death, left ventricular assist device implantation, and urgent heart transplantation.

Results

Main results are shown in Figure 1. HFimpEF patients had lower HF severity: LVEF 44.0[41.0–47.0] vs. 29.7[24.1–34.5]%, BNP 122[65–296] vs. 373[152–888] pg/mL, hemoglobin 13.5[12.2–14.6] vs. 13.7[12.5–14.7] g/dL, renal function by MDRD 72.0[56.7– 89.3] vs. 70.4[54.5–85.3] mL/min, peakVO2 62.2[50.7–74.1] vs. 52.6[41.8–64.3]%pred, VE/VCO2 slope 30.0[26.9–34.4] vs. 32.1[28.0–38.0] in HFimpEF and pHFrEF, respectively (p<0.001 for all). Cardiovascular mortality rates were 26.6 and 46.9 per 1000 person–years for HFimpEF and pHFrEF, respectively (p<0.001). Kaplan–Meier analysis (Fig.2) showed that HFimpEF had better a long–term prognosis compared with pHFrEF patients. After adjustment for variables differentiating HFimpEF from pHFrEF, except echocardiographic parameters, the Kaplan–Meier curves showed the same prognosis.

Conclusions

HFimpEF represents a peculiar group of HF patients whose clinical, laboratory, ECG, echocardiographic, and exercise characteristics parallel the recovery of systolic function. Nonetheless, these patients remain at risk for adverse outcome.
CHRONIC THROMBOEMBOLIC PULMONARY DISEASE: ASSOCIATION WITH EXERCISE–INDUCED PULMONARY HYPERTENSION AND RIGHT VENTRICLE ADAPTATION OVER TIME
Authors: Alberti M , Madonna R , Biondi F , Morganti R , Badagliacca R , Vizza C , De Caterina R
Published: May 2024

Background and Aim

Chronic thromboembolic pulmonary disease (CTEPD) is a progressive condition caused by fibrotic thrombi and vascular remodeling in the pulmonary circulation despite prolonged anticoagulation. We evaluated clinical factors associated with CTEPD, as well as its impact on functional capacity, pulmonary haemodynamics at rest and after exercise, and right ventricle (RV) morphology and function.

Methods

We compared 33 consecutive patients with a history of acute pulmonary embolism and either normal pulmonary vascular imaging (negative Q–scan, group 1, n = 16) or persistent defects on lung perfusion scan (positive Q–scan) despite oral anticoagulation at 4 months (group 2, n = 17). Investigations included thrombotic load, the Pulmonary Embolism Severity Index (PESI) score, functional class, N–terminal prohormone of brain natriuretic peptide (NT–proBNP), cardiopulmonary exercise test (CPET) and echocardiographic parameters at rest and after exercise (ESE), at 4 and at 24 months.

Results

Compared with group 1, group 2 featured a higher PESI score (p = 0.02) and a higher thrombotic load (p = 0.004) at hospital admission. At 4 months, group 2 developed exercise–induced pulmonary hypertension (Ex–PH) at CPET (p < 0.001) and ESE (p < 0.001). At 24 months group 2 showed higher NT–proBNP (p < 0.001), WHO–FC (p < 0.001), systolic (p<0.001) and diastolic (p = 0.037) RV dysfunction and worse RV–arterial coupling (p < 0.001) despite maintaining a low or intermediate echocardiographic probability of PH.

Conclusions

This is the first "proof of concept" study showing that patients with a positive Q–scan frequently develop Ex–PH and RV functional deterioration as well as reduced functional capacity, generating the hypothesis that Ex–PH could help detect the progression to CTEPD.
IS IT REALLY A CASE OF TAKOTSUBO? SOMETIMES APPEARENCES CAN BE DECEPTIVE
Authors: De Donno F , Gidiucci R , Tosi C , Verde A , Masciocco G , Garascia A
Published: May 2024

We report the case of a 22–year–old female with a history of David procedure and mechanical valve replacement (ATS 22 mm) due to bicuspid aortic valve and severe AR with ascending aorta aneurysm in 2015. Regular annual clinical follow–up (EKG and ultrasound) was always normal. Since 2022 the patient suffered from episodes of dyspnea, chest pain and sadness diagnosed as Panic Disorder. Home–therapy: Warfarin, estroprogestinic pill. At the latest outpatient visit she was asymptomatic and in good overall condition, but her EKG showed novel alterations (T wave inversion in antero–lateral leads and QT prolongation). She was then sent to the ED. LAB: troponin levels were normal (6.8 ng/ml) with an elevated Nt–proBNP (425 ng/ml) and a low INR (1.53). Questioned about recent events she reported a road trauma which occurred two weeks prior. She was then admitted to Cardiology clinic. Ultrasound: apical akinesia with reduced wall thickness, EF 48%, E/E‘ 10, and normal right ventricular function. The aortic valve prosthesis was functional without pathological regurgitation, and other echocardiographic parameters were within normal limits. EKG and ultrasound abnormalities along with a recent history of trauma supported Takotsubo Syndrome diagnosis (InterTAK score = 79.8% – 67pt), even though troponin levels were normal. Throughout hospitalization there were no changes in the EKG or pathological increases in troponin, and the patient remained asymptomatic. The patient was treated with LMWH to achieve adequate INR levels and initiated on B–blocker, ACEi, and SGLT2i for HFmrEF. Cardiac MRI revealed apical segment akinesia with dilation and reduced wall thickness (EDV 97 ml/m²), EF 41%, transmural ischemic LGE in the apical region and a ventricular thrombus (16x4 mm). The patient underwent coronary angiography which showed normal epicardial coronary arteries. Upon careful history–taking, the patient admitted irregular intake of VKA in the previous months. Given this information, the MRI and angiographic findings the diagnosis of unrecognized prior acute coronary syndrome, likely due to coronary thromboembolism in a patient with PHV and suboptimal compliance with VKA, was established. The patient was discharged home upon achieving a persistently therapeutic INR, with instructions to discontinue contraceptive therapy. Conclusion: coronary thromboembolism is a rare complication of PHV with inadequate anticoagulation leading, in this case, to an unrecognized MI.
ACUTE PULMONARY EMBOLISM: NEW HORIZONS IN CAT LAB
Authors: Valenti G , Monello A , Rusticali G , Losi L , Bolognesi G , Aschieri D
Published: May 2024

Pulmonary embolism (PE) has an incidence of 30–100 cases per 100,000 inhabitants per year and is one of the main causes of cardiovascular mortality.The 2019 ESC guidelines suggest treating patients at intermediate–high risk with heparin, discouraging thrombolysis and leaving embolectomy to the clinician‘s judgment in case of impending hemodynamic instability. The case involves a patient with intermediate–high risk PE,and how the cardiologist‘s intuition was supported by the multidisciplinary team‘s work to ensure timely treatment.

Clinical Case

A 75–year–old female with systemic hypertension, recently discharged with a pneumonia diagnosis,presented to the Emergency Department complaining of dyspnea. The CT angiogram showed PE with a saddle thrombus occupying a significant portion of the main pulmonary arterial branches, severe right ventricular dilation (baseline diameter 50 mm, 44 mm RVOT average, TAPSE 16 mm),dilated vena cava; stable hemodynamics (BP 120/90 mmHg), slightly elevated troponin I (73.4 ng/L, normal range <12 ng/L), placing the patient in the intermediate–high–risk category, for which intravenous heparin was administered according to European guidelines. A follow–up CT angiogram on the fourth day showed no improvement in the radiological picture. With stable hemodynamics, indicating no systemic thrombolysis, and hypoxemia with peripheral desaturation (pO2 60 mmHg, SaO2 <90%), the possibility of using pulmonary thromboaspiration was requested. On the fifth day, a pulmonary embolectomy procedure was performed via transfemoral vein (Flowtriever device).Thrombus aspiration (6 cm in length) immediately improved the baseline hemodynamic profile: PAPs pre–procedure 67 mmHg, post–procedure 43 mmHg.The follow–up CT angiogram no longer showed thrombus in the main arterial branches (remaining thrombi in segmental and subsegmental pulmonary arteries). In the pre–discharge echocardiogram, estimated PAPs was 30 mmHg, TAPSE 19 mm.

Conclusions

Acute pulmonary embolism still represents a clinical reality for which effective therapeutic strategies are not universally available, both for acute treatment and preventing chronic thromboembolic pulmonary hypertension.The Flowtriever device we used proved to be easy and safe to use, with immediate therapeutic results, both clinically and instrumentally.Further studies are needed to consolidate the role of percutaneous pulmonary thrombectomy in the routine treatment of patients with pulmonary embolism.
REMOTE CARDIAC DEVICE MANAGEMENT: REAL–WORLD INSIGHTS AND CHALLENGES
Authors: Veneziano F , Toniolo S , Cavedon S , Zimelli E , Mecenero A , Volpiana A , Fortuna G , Dalla Valle C , Battisti V , Dolci G , Tenaglia R , Loddo I , Verlato R , Bilato C
Published: May 2024

Background

telemedicine plays a crucial role in managing patients with Cardiac Implantable Electronic Devices (CIEDs), offering unique technical and clinical benefits. This study explores the characteristics of a real–world population of CIED recipients undergoing entirely remote follow–up.

Methods and Results

in a prospective evaluation of 808 consecutive CIED patients from two Italian Cardiology Centers (2021–2023), initial on–site assessments were followed by remote evaluations, either scheduled or alert–triggered. The majority received pacemakers (68.8%), with others having Implantable Defibrillators (19.3%) or Implantable Loop Recorders (11.9%). The average age was 75.6±12.6 years, and 42% were female. Most of the patients were retired (83.3%), and 73% required at least one caregiver. The EQ–5D score indicated a lower quality of life (8.9±4.3) compared to the Italian general population. During the observation period (20.6 months), 34.9% of patients were admitted to the hospital, with 50% of cases being cardiovascular–related. Heart failure was the most common cause (13.2%). Device–related issues prompted outpatients’ cardiology clinic Department evaluations in 13.4% of cases. The telemedicine program produced 2780 remote transmissions, with 23% being automatic alerts. In–clinic evaluations were 1313, with a mean duration of 19.2 minutes. Atrial fibrillation (AF) history was prevalent (40.2%), and 719 AF episodes occurred during the observation period.

Conclusions

Managing CIED patients via telemedicine is feasible but requires structured organization considering patient characteristics and possible outcomes. AF management is crucial, given its high prevalence. Older age and compromised quality of life are significant factors, partly mitigated by the widespread presence of caregivers. Despite remote follow–up, many patients access healthcare structures for cardiovascular reasons, emphasizing the need for distinct pathways for device–related and general care necessities.
HYPERTENSIVE EMERGENCIES AND URGENCIES: ADHERENCE TO GUIDELINES AND RELATIONSHIP BETWEEN BLOOD PRESSURE MANAGEMENT AND IN–HOSPITAL MORTALITY
Authors: Maloberti A , Valobra T , Giani V , Garofani I , De Censi L , Galasso M , Colombo V , Menna A , Giacalone A , Ferretti C , Sultana A , Gheda S , Capsoni N , Galbiati F , Bombelli M , Giannattasio C
Published: May 2024

Introduction

Data regarding prevalence and clinical management of hypertensive emergencies and urgencies are lacking and heterogeneous. Our goal is to characterize patients with hypertensive emergencies and urgencies admitted to the Emergency Department (ED) of Niguarda hospital and Pio XI Hospital of Desio. In this population we also want to evaluate factors associated with organ damage, adherence to guidelines and the impact of Blood Pressure (BP) management on in–hospital mortality.

Method

We performed a multi–centre retrospective study collecting data about all adult patients with systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg admitted to our hospitals‘ ED during 2017 and 2019.

Results

Admission to ED for BP elevation were 1838 (0.95% of total admission to ED), of whom 38% were hypertensive emergencies and 62% were hypertensive urgencies. Patients with hypertensive emergencies were older, mainly male, with more comorbidities and more symptomatic at ED admission. In the emergencies group, we observe a SBP mean reduction of 39.50 mmHg (±26.35) and a DBP mean lowering of 16.28 mmHg (±17.57); the most used drugs were furosemide, nitroglycerin and parenteral labetalol. In the urgencies group, the mean reduction was 39.09 mmHg (±22.46) for SBP and 15.34 mmHg (±16.07) for DBP. The most used drug was short–acting nifedipine benzodiazepine and amlodipine in this group. Age, sex, clinical history of heart failure and chronic obstructive pulmonary disease, symptoms at ED admission ad eGFR have been recognised as factors associated with organ damage. Instead, BP at ED admission and its management didn’t appear to have a significant impact on outcomes.

Conclusions

Our study demonstrated better adherence to guidelines in the treatment of hypertensive emergency than of hypertensive urgencies. Furthermore, no significant association were found between the BP management in the ED and in–hospital mortality.