bluuebunny/crossref_metadata_2025 huggingface dataset:
THE “SANDWICH” TECHNIQUE IN MITRAL ANNULAR CALCIFICATION
Authors: Brega C , Di Carlo M , Fiaschini C , Pin M , Zucchetta F , Panzavolta M , Ceresa R , Costantino A , Fiorentino F , Mikus E , Longo M , Calvi S , Tripodi A , Savini C
Published: May 2024

Objective

To assess the feasibility and safety of the “Sandwich” technique in case of massive mitral annular calcification (MAC). MAC is a multifactorial chronic disease and a challenging clinical entity to the surgeon: both respecting and resecting techniques have been developed, in order to prevent eventual annular ruptures.

Methods

Twelve patients underwent mitral valve replacement (MVR) between January and September 2023, mainly because of steno–insufficiency of the mitral valve, in presence of MAC. Their mean age was 76 ± 4.5, their BMI was 27.2 ± 2.8 and their surgery was mostly elective, except for one urgent active endocarditis; their mean EUROscore II was 8.2 ± 2.9.

Results

We performed 12 MVR with biological valve, through full sternotomy approach. The cardiopulmonary bypass and aortic cross–clamp time were 195 ± 57 and 155 ± 42 minutes respectively. We perform a double line suture respectful of the annular calcium, in order to reinforce the mitral annulus, before fixing the prosthesis. Surgical stiches on the anterior annulus were ordinarily put; on the posterior annulus, which is usually the most calcified part, a teflon band underneath the calcium was fixed as first, through separate prolene 2–0 U–stitches. Then the usual 2–0 ticron stitches with pledget were put between the posterior annulus and the atrial wall. Both 2–0 prolene and ticron were passed through the prosthesis sewing ring: prolene was placed more externally than ticron. No leakages were found, both intraoperative and postoperative. There were no in–hospital deaths. No strokes, thromboembolic or coronary complications were observed.

Conclusions

The “Sandwich” technique is reproducible, feasible and safe and it does not imply a long surgical learning curve. It is not a disruptive approach, avoiding annulus failure and it is respectful of the cardiac structures.
EARLY SINGLE–CENTER EXPERIENCE IN AORTIC VALVE REPAIR WITH GEOMETRIC RING ANNULOPLASTY
Authors: Maraschioni G , Pocar M , Cura Stura E , Abbà P , Brenna D , Barbero C , Rinaldi M
Published: May 2024

Introduction

Degenerative valve disease is the most common cause of aortic regurgitation (AR) in Western country. These patients are good candidates to aortic valve repair (AVr), avoiding the long–term risks associated with prosthetic substitutes.

Methods

We analyzed retrospectively all AVr procedures with geometric ring annuloplasty at our Division between January 2022 and December 2023.

Results

During the study period, 44 patients underwent AVr at our Division. Mean age was 50.4 years and 37 were male. Mean Logistic EuroSCORE was 4.74%. Mean ejection fraction (EF) was 57% and mean left ventricle (LV) end–diastolic diameter (EDD) and volume (EDV) were 55.1 mm and 159.3 ml, respectively. All but one patient had moderate or severe AR (97.8%). The aortic valve was tricuspid in 24 patients (54.6%) and bicuspid in 20 (45.4%), respectively. The bicuspid cohort were younger (mean age 35.15 vs. 63.2 yo) with more dilated LV (mean EDV 173 vs. 144.5 ml) and annulus (28.3 vs. 25.3 mm). 3 patients had previous cardiac surgery procedures. All patients were operated electively. Cardiopulmonary bypass time was 147.4 min (± 35.7) and aortic cross–clamp time was 124.5 min (± 28.5). In all the patients, AVr was performed with the geometric ring annuloplasty, 24 tricuspid and 20 bicuspid rings. 40 (90.9%) patients needed cusps repair. 22 (50%) patients had concomitant cardiac procedures: 13 patients had ascending aortic replacement (29.5%), 8 mitral valve surgery (1 replacement and 7 repair), 1 tricuspid valve repair, 2 coronary bypass graft and 1 AFib ablation. In 2 patient aortic valve replacement was necessary at the time of AVr because of residual significant AR. Mean length–of–stay in ICU and in hospital were 1 and 6.5 (± 1.7) days. Only 1 patient, already listed for kidney transplantation before surgery, needed dialysis. No other complications were reported, nor intra–operative and in–hospital mortality. At 6–month echocardiographic follow up, the mean post–operative EF was 54.6%, with LV mean EDD and EDV of 49.3 mm and 133.1 ml, respectively. The mean aortic gradient was 12.6 mmHg (±3.5). Only 1 patient was found with severe AR and was successfully reoperated for valve replacement. Only 1 death occurred after discharge within 30 days of surgery, due to extracardiac pathology.

Conclusion

In selected centers, AVr for AR is safe and reproducible procedure alternative to replacement with good early results.
MITRAL VALVE REPLACEMENT OR REPAIR IN INFECTIVE ENDOCARDITIS: ROLE OF THE ISOLATED PATHOGENS ON MORTALITY AND EARLY OR LATE RELAPSE RATE
Authors: Fiorentino M , Mikus E , Costantino A , Pin M , Sangiorgi D , Tenti E , Tripodi A , Savini C
Published: May 2024

Background

Mitral valve repair (MVr) is unquestionably superior to mitral valve replacement (MVR) in non–infective settings. European Society of Cardiology (ESC) and American Association for Thoracic Surgery guidelines recommend repair oxver replacement where possible even for endocarditis. Despite these recommendations, mitral valve repair rates are still low in this population.

The aims of this study were to compare outcome of patients with infective endocarditis undergoing mitral valve repair compared to those undergoing mitral valve replacement and to investigate the impact of microbial etiology on patient outcomes.

Methods

The study retrospectively analyzed 215 patients undergoing valve replacement or repair for endocarditis from January 2010 to December 2022 in a large cardiosurgical center. The primary outcome was a composite outcome of early (30–days) all–cause mortality and/or endocarditis relapse, while the secondary outcome was medium/long term (1 year) all–cause mortality.

Results

A total of 215 patients with either active or healed mitral valve endocarditis were included in our study: 154 (71.6%) underwent mitral valve replacement and 61 (28.4%) underwent mitral valve repair. Patients with multi–valve disease were also included (97, 45.1%). 188 patients (87.4%) were operated in the active phase (80.9% as an urgent/ emergency). In–hospital mortality was observed in 5 patients (8.2%) in the repair group and 19 (12.3%) in the replacement group. Endocarditis relapse occurred in 6 patients (9.8%) in the repair group after a median time of 3.8 months and in 5 (3.3%) in the replacement group after 11.8 months. (p=0.356). Median follow up was 12.6 months. Early and medium survival rates in the propensity–adjusted cohort showed no difference between mitral valve repair and replacement, but resulted to be influenced by the microbial etiology with the worst prognosis for both Staphylococcus aureus and Coagulase–negative Staphylococci.

Conclusions

The choice of surgical treatment strategy in infective endocarditis had no effect on major postoperative complications, mortality, relapse or medium/long–term survival. Mitral valve repair seems to have a major incidence of relapse even though non statistically significant, probably due to the low number of events. Both Staphylococcus aureus and Coagulase–negative Staphylococci are a risk factor for early mortality and relapse rate. Mitral valve repair for endocarditis should be pursued, if feasible.
SPORT INDUCED QT PROLONGATION: DETECTION AND MANAGEMENT OF THIS NEW COMPLEX ENTITY
Authors: Roagna E , Visalli A , Tribuzio A , Saglietto A , Vairo A , Angelini F , Brach G , Deaglio S , Giustetto C , De Ferrari G , Dusi V
Published: May 2024

Introduction

Intense exercise training has been recently associated with QTc prolongation and morphologic repolarization abnormalities, whereas detraining, in asymptomatic genotype negative patients, was associated with ECG normalization. Data about this condition and its best management are scant.

Case

An asymptomatic, 16 years old, competitive basketball player (training load 11 hours/week, significantly increased in the previous 6 months), with negative family history was referred to our Center for the appearance of notched T waves in V2–V3 and of late T wave peak in the other leads, with mild QTc prolongation in DII (455 msec), severe in V2–V3. Holter ECG (12 leads) confirmed the presence of a 2nd dynamic component of ventricular repolarization leading to a markedly prolonged QT (QTc max> 550 ms), that was more evident after sudden heart rate (HR) increases. A genetic test was performed using in silico long QT panel by next–generation sequencing (NGS) and then multiplex–ligation dependent probe amplification (MLPA) to exclude deletions/duplications, and turned out negative. A complete 6–month detraining was recommended. At the reassessment, QTc and morphological abnormalities had both normalized at resting ECG (QTc in DII 401 msec) and for most of Holter ECG (QTc mostly between 375 and 400 msec). A 2nd dynamic component of ventricular repolarization with U wave characteristics could be detected only after sudden HR increases. Exercise stress test confirmed preserved QTc adaptation during exercise and recovery (with a 4th minute recovery QTc of 401 msec). Cardiac ultrasound in detraining showed preserved LVEF (62%) and global longitudinal strain (–23%), with a global electromechanical dispersion of 34 ms and an electromechanical window of –11 ms at 73 bpm. Return to play was granted with a reduced training load (6 hours/week) and mandatory complete cardiological assessment after 6 months (pending). Resting ECG after 3 months was within normal limits.

Conclusion

Our case confirms that intense exercise training can induce dynamic non physiological abnormalities in ventricular repolarization with QTc prolongation, in genotype negative patients. Detraining is therefore mandatory before definitive long QT diagnosis every time this condition is suspected and, if the level of suspicion of an expert Center is high, beta–blocker therapy initiation may be temporarily deferred. Return to play and best subsequent monitoring are still a matter of debate.
CARDIOINSIGHT: A NEW MAPPING SYSTEM
Authors: Bianco Dolino E , Manconi S , Gallone G
Published: May 2024

Cardioinsight is a non–invasive mapping system that collects chest ECG signals and combines them with CT scan data to produce and display simultaneous biatrial and biventricular three–dimensional cardiac maps. Cardioinsight is intended for the collection, analysis, visualization and storage of cardiac electrophysiology data and maps for subsequent medical analysis. It is therefore a device capable of identifying the point from which cardiac arrhythmias originate. Cardioinsight is an innovative system as until 2018 electrophysiological studies were used to study the electrical properties of the heart. The substantial difference between Cardioinsight and electrophysiological studies is that Cardioinsight is non–invasive and allows the point from which the arrhythmia arises to be identified without the need to resort to catheterization and therefore leading to zero risk of intra–procedural and post–procedural complications. The Cardioinsight consists of: the mapping vest and the Workstation. The mapping vest is a non–sterile, disposable device that includes: 3 panels: front right, front left and rear 252 electrodes Connectors that connect the mapping vest to the system The Cardioinsight Workstation consists of the monitor and the amplifier and is always used with the Cardioinsight mapping vest. Cardioinsight has 3 advantages: it is not invasive 3D simultaneous multi–camera mapping: Capable of capturing rhythms that span multiple cameras) a single heartbeat is enough to generate maps.

The use of Cardioinsight requires 3 phases: Prepare the patient and apply the vest Obtain a CT scan and record the signals Combine CT and signal data to create maps The doctor analyzes the maps and plans the next step of care for the patient Treatment can be catheter ablation or stereotactic ablation. The latter provides an alternative therapeutic strategy to traditional ablation as it is non–invasive and painless and consists in the administration of precise and targeted doses of radiation which produce tissue damage resulting in cell death. In our reality we have had the opportunity to use Cardioinsight twice and it has been established that it is a valid alternative to traditional mapping with advantages for the patient and for an optimal path in the search for the most appropriate therapeutic approach.
PERIPROCEDURAL ANTITHROMBOTIC THERAPY AND IN–HOSPITAL OUTCOMES IN OUT–OF–HOSPITAL CARDIAC ARREST PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION
Authors: Raone L , Bongiorno A , Bendotti S , Currao A , Primi R , Adamo M , Ghiraldin D , Marino M , Dossena C , Poli A , Affinito S , Maffeo D , Kajana V , Baldi E , Ferlini M , Savastano S
Published: May 2024

Background

Myocardial Infarction (MI) is the leading cause of Out–of–Hospital Cardiac Arrest (OHCA). The management of periprocedural antithrombotic therapy in this setting is still challenging due to limited data available and given the heightened thrombotic and hemorrhagic risks in this subset of patients. We aimed to investigate the application of antithrombotic therapy, in–hospital bleeding rate and mortality in OHCA patients undergoing percutaneous coronary intervention (PCI).

Methods

A multicentric, prospective, observational study was conducted, enrolling all consecutive OHCA patients from January 1st, 2015, to December 31st, 2022, undergoing PCI at 6 Northern Italy centers. Bleeding events were categorized using the BARC (Bleeding Academic Research Consortium) scale, defining major bleeding as BARC ≥ 3.

Results

A total of 623 patients were included; of these, 403 underwent coronary angiography and 249 underwent PCI. Patients’ median age was 64.0 years (54–73); femoral artery was the site of access for PCI in 131 (52.6%) patients. Ticagrelor was the most used oral P2Y12 inhibitor, with 164 patients (65.9%) receiving it, while cangrelor and a glycoprotein (GP) IIb/IIIa receptor inhibitor were used in 27 (10.8%) and 66 (25.3%) patients, respectively. Overall survival rate at hospital discharge was 69.5%. Minor and major bleeding events occurred during hospital stay in 12 (4.8%) and 19 (7.6%) patients, respectively. While the rate of major bleeding was similar among patient groups treated with different oral P2Y12 inhibitors, patients treated with cangrelor or GPIIb/IIIa inhibitors exhibited a higher prevalence of major bleeding events (cangrelor: 7/27 vs 12/219, χ² = 5.4248, p = 0.006; GPIIb/IIIa inhibitors: 9/63 vs 10/183, χ² = 14.0994, p = 0.002). Regardless of baseline bleeding risk, cangrelor was significantly associated with the risk of a bleeding event [OR 6.8 (CI 2.3 to 20.4); p–value < 0.001] and with an increase probability of survival at discharge [OR 3.7 (CI 1.2 to 12.8); p–value 0.037].

Conclusions

In patients with OHCA undergoing PCI, administration of cangrelor was associated with an increased risk of in–hospital bleeding events and, at the same time, with a better survival at discharge. Our results suggest a potential net clinical benefit that may outweigh the increased bleeding risk, possibly due to its protective effect against periprocedural thrombotic events. Specific and larger studies are needed to confirm this hypothesis.
ATRIAL FIBRILLATION IN A CIED POPULATION: RESULTS FROM A TELEMONITORING FOLLOW–UP
Authors: Toniolo S , Veneziano F , Cavedon S , Zimelli E , Mecenero A , Volpiana A , Fortuna G , Dalla Valle C , Dolci G , Battisti V , Loddo I , Verlato R , Bilato C
Published: May 2024

Background

Telemedicine has emerged as a crucial tool in managing patients with Cardiac Implantable Electronic Devices (CIED), addressing the common challenge of the Atrial Fibrillation (AF) in cardiology. The incidence of AF in CIED recipients varies widely (30–70%), influenced by implant indication, device type, and population characteristics. This study aims to evaluate AF in an unselected, real–world CIED population, considering patients’ characteristics and the remote follow–up.

Methods and Results

808 consecutive CIED recipients were evaluated between 2021 and 2023 in two Italian Division of Cardiology by collecting patients’ baseline characteristics and the scheduled remote follow–up data. Mean age was 75.6±12.6 years, 42% were females. 16.7% of the population was working actively and 73% of individuals were assisted by at least one caregiver, reflecting a diminished quality of life (EQ–5D score 8.9±4.3). Over a median follow–up of 20.6 months, 8.9% of patients died. 68.8% of the patients received a pacemaker, 19.3% an ICD and 11.9% a loop recorder. History of AF was present in 40.1% of the population, with a prevalence of permanent AF (46.6%). Ongoing anticoagulant therapy was documented in 303 patients (37.5%), 71% of whom were taking direct oral anticoagulants. Baseline CHA2DS2–VASC score was ≥3 in 79.7%, and the median HAS–BLED score was 1. During the observation period, scheduled remote transmissions revealed 719 AF episodes (15.7 episodes/patient/year), causing 21% of the overall remote alarms. Among patients without AF history, 69 (14.3%) experienced AF episodes (4.8 episodes/patient/year). Notably, 21.8% of the AF episodes lasted less than 10 minutes.

Conclusions

The wide spreading of heart rhythm monitoring technologies reveals the challenge of the subclinical AF in healthcare systems. This study, encompassing an unselected CIED population of elderly and frail patients with high AF prevalence, highlights AF as a primary cause of remote alerts and a substantial burden in telemonitoring controls. Telemedicine facilitated new AF diagnoses in 14.3% of individuals without a prior AF history and resulted a valuable tool considering the significant cardioembolic risk in these patients. However, the initiation of anticoagulation therapy remains debatable, especially for episodes of brief duration which in our experience exceeded 20% of the cases.
THE REBUS OF POCKET INFECTIONS
Authors: Ferrieri A , Dentico A , Pastore I , Benedetto L , Carretta D , D‘Agostino C
Published: May 2024

Introduction

The guidelines define pocket infection as an infection limited exclusively to the generator pocket. This is clinically associated with local signs of inflammation. However, the infection often also involves the electrocatheters which constitute a gateway to the infection at a cardiac and systemic level. Does the pocket infection constitute a big rebus for the type of approach to adopt, conservative or aggressive? Our study aims to identify significant predictive criteria to develop a score that identifies the patients most at risk of endocarditis and sepsis.

Methodology

66 patients who underwent extraction for pocket infection were enrolled. Before extraction, all patients underwent instrumental and laboratory investigations to look for vegetations or culture positivity.

Results

Of the 66 patients, 61 presented vegetations and/or positivity on culture examination of the catheters. The statistical analysis made it possible to assign a score to each sign and/or symptom with the creation of a score with a maximum cut-off of 5. The 61 positive patients had a score greater than/equal to 5. The score structured in this way demonstrated a predictability of 92.4%, resulting positive in 61 out of 66 patients.

Conclusions

In patients with pocket infection, the identification of a highly predictive score of endocarditis or sepsis on leads allows the clinician to easily identify the patients at highest risk to be quickly sent to third level centers for the most suitable treatment of the clinical situation without having to carry out particular tests, often difficult to perform (PET/CT), and allows the electrophysiologist, who will have to carry out the extraction procedure, to have a precise indication in class I. The study we have initiated is a preliminary study which has the limit on the number of patients enrolled. We intend to increase the number of patients thanks to collaboration with other centers that carry out extractions. However, this study, based on the data obtained so far, could be a guide to the management of patients with pocket infection who often create awkward decisions about the therapy to be adopted also due to the lack of clarity of the guidelines.
DILATED CARDIOMYOPATHY AND THERAPEUTIC FOLLOW–UP: EXPERIENCE OF A DEDICATED HEART FAILURE CLINIC
Authors: Dominici T , Percoco F , Schiavoni M , Dato I , Tung M , Pontiroli C , Verbena S , Evangelista F , Ciccaglioni L , Barbato A , Kol A
Published: May 2024

Dilated Cardiomyopathy (DCM)is associated with an increased risk of developing ventricular arrhythmias and sudden cardiac death (SCD), although to a lesser extent than ischemic heart disease (IHD).It is now well established that defibrillator implantation (ICD) reduces mortality in patients with reduced systolic function after a myocardial infarction, conversely, this effect is less evident in patients with DCM. The aim of this work is to report the experience of a dedicated outpatient clinic for heart failure patients and to underline the importance of a multiparametric assessment for a patient who is a candidate for ICD implantation. From December 2019 to December 2023, 38 patients (34 males and 4 females) (mean age 62.6 years) were referred to our hospital with a diagnosis of hypokinetic dilated heart disease of first detection, in 4 cases due to declared alcohol and/or substance abuse.Three patients had already undergone defibrillator implantation in primary prevention but did not have on board the 4 classes of drugs recommended by the latest guidelines, so they were subjected to the maximum tolerated dose and re–evaluated remotely with clinical improvement and echocardiographic values. The other 35 patients, whose disease began with de novo reduced ejection fraction heart failure (HFrEF), admitted to our ICU, all underwent coronary angiography with finding of a coronary tree free of critical alterations; 28 had performed a magnetic resonance imaging (MRI) that showed no edema, necrosis and/or fibrosis; only in two patients have been documented fibrosis with a low percentage of distribution, which does not account for low EF values. Of the other 7 patients, 4 did not undergo MRI 2 for claustrophobia and 3 for atrial fibrillation. Maximal drug therapy with the 4 pillars recommended by the guidelines was set up for all patients;the introduction of glyphozines in diabetic patients has been shared with diabetologist. All patients underwent echocardiographic check–ups at 3–6 months and one year, which over time documented a recovery associated with improvement in symptoms and quality of life. All patients also underwent ECG according to Holter for arrhythmic risk stratification: none of them required ICD implantation procedures. This preliminary analysis shows that a correct application of the guidelines allows to improve the prognosis of patients with dilated cardiomyopathy; of course, further larger studies are needed to substantiate these findings.
INCIDENCE AND DETERMINANTS OF SUB–OPTIMAL DRUG TREATMENT IN CHRONIC HEART FAILURE: A SINGLE CENTER PILOT SURVEY
Authors: Arcari L , Belmonte E , Manzo D , Camastra G , Cacciotti L
Published: May 2024

Background

The latest European Society of Cardiology guidelines on heart failure (HF) recommend a pharmacological treatment including 4 drugs (ARNI or ACE–inhibitor, beta–blocker, SGLT–2 inhibitor and MRA), with a class I indication in patients with HFrEF. However, the implementation of the 4 pillars approach is still largely insufficient in clinical practice. The aim of the present study was to investigate incidence and determinants of sub–optimal HF drug–treatment.

Methods

We conducted a 2–months survey in the heart failure outpatient clinic at our first–level community hospital. Physicians were asked to record the drug treatment patients were actually taking, and in the absence of one of the four pillars drug, to specify the underlying reason.

Results

100 patients were enrolled, mean age 72±10 years old, 32 females. There were 36 HFpEF and 64 HFrEF patients. Quadruple therapy was present in 67 (HFpEF 58%, HFrEF 72%). Prescription rates of the four pillars drugs were: ARNI/ACE–inhibitor 96% (HFpEF 92%, HFrEF 98%; p=0.097), beta–blockers 98% (HFpEF 97%, HFrEF 98%; p>0.99), SGLT–2 inhibitor 81% (HFpEF 72%, HFrEF 86%; p=0.093), MRA 82% (HFpEF 78%, HFrEF 84%; p=0.410). No significant associations between age and sex with pharmacological treatments were noted (all p>0.05). Considering left ventricular ejection fraction (LVEF) as a continuous variable, patients under ARNI and SGLT–2 inhibitor treatments had lower values (43±10% vs 36±9%, p=0.001 and 43±9% vs 38±10%, p=0.034 respectively). Main reasons absent treatment were presence of chronic kidney disease with or without hyperkalemia (ARNI: 7%; ACE–inhibitor: 1%; BB: 0%; SGLT–2 inhibitor: 3%; MRA: 8%) and LVEF value (ARNI: 7%; Ace–inhibitor: 0%; BB: 0%; SGLT–2 inhibitor: 3%; MRA: 2%). Beta–blocker was not prescribed in 2% of the patients due to bradycardia. Hypotension leading to treatment discontinuation was more common in the ARNI group (ARNI: 8%; ACE–inhibitor: 1%; others: 0%).

Conclusions

In our sample, more than two thirds of HF patients were prescribed the quadruple heart failure pharmacological treatment. Save for hypotension in the ARNI treated patients, a high drug tolerability was observed. Physician–guided lack of prescription was influenced by the presence of chronic kidney disease and absent drug reimbursement due to LVEF cut–off as per AIFA criteria at the time of prescription. Results of this survey highlights potential areas to improve adherence to guidelines–directed medical treatments.
EARLY USE OF SGLT–2 INHIBITORS FOLLOWING ACUTE DECOMPENSATED HEART FAILURE PATIENTS WITHOUT REDUCED EJECTION FRACTION: PRELIMINARY DATA FROM A SINGLE CENTRE
Authors: Alonzo A , Matteucci A , Castello L , Marino G , Spinelli A , Di Fusco S A , Colivicchi F
Published: May 2024

Introduction

Following the 2023 ESC Guidelines update for heart failure, SGLT2 inhibitors (dapagliflozin, empagliflozin) are strongly recommended for cardiovascular outcomes both in patients with heart failure with preserved ejection fraction (HFpEF) and with mildly reduced ejection fraction (HFmrEF). The EMPULSE study supports empagliflozin initiation in acute heart failure, regardless of ejection fraction, demonstrating tolerance and significant clinical benefits. Our study aims to establish the feasibility of early use of SGLT-2 inhibitors in acute decompensated heart failure (ADHF) without HFrEF, exploring prescription rates and reasons for underutilization.

Methods

We retrospectively collected data from 33 consecutive patients admitted from the Emergency Room to our Department with a diagnosis of HFpEF and HFmrEF from August to October 2023. We compared data of systolic arterial pressure, creatinine, glomerular filtration rate (GFR), kaliemia, and hemoglobin values at admission with those at discharge.

Results

Patients had a mean age of 80.7±6, and 55% were male. The mean ejection fraction was 50.8% ± 7.5. The mean BMI was 28.4±5 and 39% of the patients had diabetes. The mean hospital stay was 4.3 ± 2.6 days. The utilization of SGLT2 inhibitors at admission was 18% up to 64% at discharge (p <0.001). Both hemoglobin values and systolic arterial pressure significantly decreased during hospitalization, from 13.1±1.6 g/dl to 12.7±1.8 g/dl (p=0.030) and from 129±15 mmHg to 118±14 mmHg (p=0.003), respectively. Creatinine levels moved from 1.32±0.44 to 1.39±0.44 (p=0.006), while GFR reduced from 51±19 ml/min to 46±15 ml/min (p = 0.012), significantly. Kaliemia remained stable from 4.04±0.47 mEq/l to 4±0.42 mEq/l (p = 0.73). Among patients who didn’t receive SGLT2 inhibitors, only two patients (9%) had an absolute contraindication represented by a GFR < 25 ml/min.

Discussion

Our data confirm that the prescription rate of SGLT2 inhibitors in patients with HFpEF and HFmrEF is still low. Approximately 26% of patients lacked clear clinical reasons for not receiving the treatment. Despite mild reductions in hemoglobin, systolic arterial pressure, and GFR, consistent with the class profile, SGLT2 inhibitors demonstrate safety and tolerability without significant impact on key clinical and laboratory parameters. This underutilization is likely linked to therapeutic inertia, necessitating concerted efforts to bridge this gap.
DIFFERENT FATES AND ROUTES OF CHRONIC HEART FAILURE, AN ARTIFICIAL INTELLIGENT BASED ANALYSIS OF THE MECKI SCORE DATASET
Authors: Chiesa M , Salvioni E , Emdin M , Piepoli M , Sinagra G , Sanni M , Mapelli M , Limongelli G , Parati G , Agostoni P
Published: May 2024

Background

Individual prognostic assessment and disease evolution pathways in chronic heart failure (HF) are unmet needs. The application of unsupervised learning methodologies could help at: a) identification of HF patient phenotypes; b) identification of the evolution states and progression in each phenotype and c) assessment of risk of adverse event.

Methods

We retrospectively analyzed the MECKI registry including 7948 HF patients. After preliminary preprocessing, we selected 4876 patients with a minimum 2–year follow–up. We implemented a Topological Data Analysis (TDA), based on 43 variables derived from clinical, biochemical, cardiac ultrasound and exercise evaluations, to identify several patients’ clusters. Thereafter, we used the trajectory analysis to describe the evolution of HF states, which is able to identify bifurcation points, characterized by different follow–up paths, as well as stopping points, i.e. specific end–stages conditions of the disease. Finally, we conducted a survival analysis to generate 5–year time–to–event curves using as study endpoint the composite of cardiovascular death, LVAD or urgent heart transplant. Findings were validated on internal (n=527) and external (n=777) populations.

Results

Nineteen patient clusters were identified by TDA. Trajectory analysis revealed a path characterized by 3 bifurcation points with 2 different follow–up path each and 4 stopping points. Clusters survival rate varied from 44% to 100% at 2 years and from 20% to 100% at 5 years, respectively. Finally, we compared the event frequency at a 5–year follow–up for each study cohort cluster with those in the validation cohorts (R = 0.94 and R = 0.84, p < 0.001, for internal and external cohort, respectively).

Conclusions

Each HF phenotype has a specific disease progression and prognosis. The bifurcation points need attention since are followed by different disease routes as the 4 different disease end–stages which are characterized by different prognosis. These findings allow to individualize HF patient evolutions and to tailor assessment.
QUALITY OF CARE FOR PATIENTS WITH ACUTE MYOCARDIAL INFARCTION: RESULTS OF THE FIRST 3 MONTHS OF THE QUALITY IN CARDIOLOGY (QIC) PROJECT
Authors: Chiappa L , Avanzini F , Conti A , Anguilano M , Bova C , Centola M , Colombo G , Di Giulio P , Iacuitti G , Mollichelli N , Moro C , Paone M , Rigamonti A , Rogacka R , Saltafossi D , Santambrogio M , Spina M , Vinci F , Achilli F
Published: May 2024

Background

Assessing the quality of care is the first step for improve the management of patients with acute myocardial infarction (AMI). The European Society of Cardiology (ESC) and the Acute Cardiovascular Care Association (ACCA) recently defined a set of quality indicators (QI) of care for AMI.

Aim

To evaluate the quality of care of patients admitted to the Cardiology ward of our first level hospital for an AMI using the ESC ACCA QI.

Methods

QiC project is a prospective quality improvement study in real–world practice on all patients admitted to our ward for an AMI 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. Thirty–day mortality was assessed by telephone interviews. The ESC ACCA QI include 18 main and 8 secondary QI on centre organization, reperfusion and invasive strategy, risk assessment, antithrombotic treatment, secondary prevention discharge treatments, and patient experience. For each IQ was evaluated the percentage of QI assessable and attained.

Results

A total of 78 patients were admitted for AMI in our Cardiology Department in the first 3 months. No one patient denied consent, one died during hospitalization, 7 patients had to be transferred to another hospital, and 3 patients did not have their record form filled in. The median age of the 67 patients discharged alive was 66 (IQR 58–75) years, 45 (67.2%) were males, 35 (52.2%) had a ST–segment elevation myocardial infarction (STEMI) and 32 (47.8%) a non–ST–segment myocardial infarction (NSTEMI). The percentages of non–assessment, non–attainment and attainment for each QI are reported in the Figure: the degree of non–assessment of the 26 QI ranged from 0 to 22% and the degree of QI attainment from 25 to 100%.

Conclusions

Quality of care for acute myocardial infarction can be measured in the majority of patients admitted to our Cardiology Department using the ESC ACCA quality indicators. Although most quality indicators are met in our patients, a large room for improvement is present in the reperfusion and invasive strategy (mainly in timely reperfusion of STEMI patients) and in the patient’s satisfaction (discharge letter sent to patient).
IMPLEMENTATION OF TELEMEDICINE IN ASST BERGAMO EST: RESULTS ACHIEVED
Authors: Rocca P , Bighi M
Published: May 2024

The Healthcare Trust Bergamo Est (ASST–bergamo Est) started a telemedicine project in 2020, setting up a Telemedicine Team and a managment model called “TEELEMEBII strategy” (see dedicated abstract). Three years after their establishment, the four minimum Telemedicine services required by the legislation, are active: Televisit, Teleconsultation, Home monitoring, Teleassistance (Figure 1). Televisit has been active in the company in six Units: Rehabilitative Cardiology, Diabetology, Home Artificial Nutrition, Gynaecology, Addiction Service and Pain Therapy. Teleconsultation was developed in two healthcare contexts: Teleconsultation among General Practitioners and Specialists: the GPs can ask for a teleconsultation with the hospital physicians of ten specialties. Multidisciplinary teleconsultation for the discussion of complex clinical cases. The diagnostic–therapeutic process of patients with head–neck cancer is discussed in teleconsultation with the synchronous participation of Otolaryngologist, Oncologist and Radiation Oncologist and, if necessary, Radiologist, Anatomopathologist, Speech therapist, Nutritionist. Other multidisciplinary teams are activating this service. Telemonitoring allows transmission of clinical parameters through wearable sensors. The service, primarily provided by nursing staff, is active in Rehabilitative Cardiology for patient with chronic heart failure and in Electrophysiology Clinic for patients with implantable devices (PM, ICD, wearable defibrillator). A feasibility project is being activated in Gazzaniga Community House where nursing staff can remotely monitor vital parameters of fragile patients. Teleassistance provided by a nurse is based on the remote interaction between the professional and the patient. Nursing teleassistance is active, associated with telemonitoring, for patients with chronic heart failure, diabetes mellitus and fragile patients. Data express the positive impact of the implementation of the management model (Figure 2): Medical specialties involved in company telemedicine processes went from 7 in 2022 to 18 in the first half of 2023, with an increase of 157%; The number of operators with access to the company‘s telemedicine platform increased from 33 in 2022 to 107 in the first half of 2023, an increase of 224%; Televisits provided since the beginning of 2022 are approximately 800; in the first half of 2023 there were 293, 38.2% more than in the same period of the previous year.
ACUTE MYOCARDIAL INFARCTION WITH “ST” SEGMENT ELEVATION IN SOUTHERN MARCHE: INTRA AND POST–HOSPITAL PROCESS INDICATORS IN THE APPLICATION OF THE UNIFIED PDTA “RETE STEMI” AST OF ASCOLI PICENO AND FERMO. LONGITUDINAL OBSERVATIONAL CLINICAL STUDY
Authors: Parato V , Fratini T , Traini T , Lattanzio F , Principi T , Viviani G , Grossi P , Marcelli S
Published: May 2024

Background

SCAs (Acute Coronary Syndromes) are one of the most frequent cardiovascular diseases, among which STEMI is certainly the most relevant in terms of short and long–term prognosis. The latest ESC Guidelines about ACS–STEMI indicate some key elements in terms of diagnosis and treatment, from first contact to cardiological rehabilitation.

Objective

Detect the number of SCA–STEMIs managed in the AST of Ascoli Piceno, along with intra and post–hospital process indicators provided in the PDTA of the “RETE STEMI” issued by the Marche Region specifically in AST of Ascoli Piceno. MATERIALS & METHODS An observational, longitudinal, monocentric, not–for–profit clinical study without diagnostic–therapeutic interventions was designed. The data collection started on 01/11/2022 and ended on 30/06/2023, at “Madonna del Soccorso” Hospital of San Benedetto del Tronto and “Mazzoni” Hospital of Ascoli Piceno in Cardiological Intensive Care Units (UTIC). Useful data for this study were acquired every month, consulting the folders of each patient diagnosed with “SCA–STEMI”, and then, reported in an Excel sheet, they were processed with different mathematical and statistical functions, including frequency, percentage, arithmetic average and standard deviation, and later used to design tables and graphs. All the data have been aggregated in full compliance with current legislation on the protection of patient privacy.

Results

The most significant results are related to the time between the first medical contact and the’ starting of the PPCI procedure, with an average time detected of 110 minutes. Another very important result is the number of patients sent to a post–acute cardiological rehabilitation program (PCRP): from the present study it appears that only the 1% of the entire sample was sent to a PCRP. Finally, other indicators considered in relation to the PDTA appear to be in line with the current Guidelines.

Conclusions

The present study highlights the aspects of the STEMI PDTA of the Marche Region which could be improved, namely reducing FCM–Wire crossing time and sending patients to a cardiological rehabilitation program, also by implementing the figure of the nurse specialized in the critical and cardiological area.
ENDOCARDITIS TEAM? DESIGNING AN ORIGINAL AND TAILORED CLINICAL PATHWAY
Authors: Pavone N , Cammertoni F , Bruno P , Calabrese M , Lombardo A , D‘Acierno E , Conserva A , De Belvis A , Scoppettuolo G , Massetti M
Published: May 2024

Infective endocarditis (IE) remains a poorly understood disease that primarily affects either native or prosthetic heart valves. Its incidence has increased over the past two decades, now affecting 3 to 10 individuals per 100.000/year in the general population. Despite advances in early diagnosis and surgical intervention, IE continues to pose a significant challenge, often leading to severe complications and carrying a substantial burden of morbidity and mortality. Data from the EURO–Endo registry show a drastic change in IE and provide an accurate picture of IE disease today. In European countries, it tends to affect older patients with a remarkable 12% of cases occurring in those aged ≥ 80 years. The traditional care pathway is often fragmented into multiple and potentially dangerous steps, resulting in delayed diagnosis and treatment. Such a “patchy” approach may cause suboptimal patient management, especially in the subset of frail patients with important concomitant diseases and high surgical risk. Clinical pathways (CPs) are an evidence–based multidisciplinary care plans involving diagnosis, treatment and rehabilitation phases, through which to follow patients from hospital admission to discharge, in order to manage a specific health condition, aiming to optimize patient and hospital/team outcomes, while contributing to a better organized care processes. In 2018, a working group composed by healthcare managers, infectious disease specialists, cardiac surgeons, cardiologists, anesthesiologists, geriatricians and other professionals involved in the care of IE patients have engineered a dedicated CP for IE at our institution. The CP introduced significant changes in the management of patients with IE. As a result, the quality of care and services offered increased, a faster and more appropriate diagnosis and treatment were achieved, patient outcomes and safety improved and a better coordination and continuity of care between different settings was guaranteed. The growing burden of IE in western countries demands an evidence–based multidisciplinary care plan. The creation of a territorial network ensures continuity and appropriateness of care in conjunction with the referring physicians/hospital and rationalization of resources. Although some controversies still exist, we believe that CP will have a positive impact on quality in health care.
TAKOTSUBO SYNDROME PRECEDING THE INDEX EVENT: A DANGEROUS CLINICAL SETTING
Authors: Notarianni G , Pontillo D , Luciani M , Malavasi M , Zampi G , Sommariva L
Published: May 2024

We describe the case of a 68–year–old patient who presented to the Emergency Department following an unwitnessed syncopal episode with slow recovery of consciousness. On admission, the patient had dyspnoea together with physical signs of pulmonary congestion. Cardiac ultrasound showed severe left ventricular dysfunction with an ejection fraction of 30%, and apical and paraapical akinesis. The admission electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities, hs TnI was elevated and BNP vl blood gas analysis were unremarkable. During observation in the Emergency Department, the patient experienced epileptic seizure, promptly resolved by intravenous Midazolam. Contrast–enhanced chest CT ruled out aortic dissection disclosing a clinically irrelevant subsegmental pulmonary embolism. A non–contrast CT scan of the brain yielded negative results. In consideration of the atypical clinical presentation and scattered evidence of an acute coronary syndrome, the patient was admitted to our Cardiac Intensive Care Unit (CICU) for additional diagnostic workup delaying coronary angiography in the presence of stable TnI elevation. Three hours after admission the patient continued showing altered consciousness and a subsequent brain CT was performed, demonstrating an intraparenchymal hemorrhagic spreading. Repeat ECGs showed precordial T wave inversion and prolongation of the QT interval. These data, together with LV apical dysfunction, raised the suspicion of Takotsubo syndrome secondary to an acute cerebrovascular event. During the hospital stay, recovery of consciousness, spontaneous absorption of the cerebral hemorrhagic spread and complete recovery of left ventricular function at repeat cardiac ultrasound examinations were observed, confirming the almost unequivocal diagnosis of Takotsubo syndrome. The patient was discharged uneventfully and was scheduled for an outpatient coronary CT scan. This case underscores the crucial importance of a thorough clinical assessment in the management of complex patients in the presence of nonunivocal clinical signs and misleading blood test and imaging data. Moreover, Takotsubo syndrome is a protean clinical entity that can precede the index event as in our patient, i.e. cerebral hemorrhage. Misclassification of these patients as having an acute coronary syndrome could have led to the initiation of antithrombotic therapy, with potential fatal outcomes for the patient.
SCARY ECG IN TAKOTSUBO CARDIOMYOPATHY
Authors: Iezzi L , Cicchitti V , Gallina S
Published: May 2024

Takotsubo cardiomyopathy (TTC) is characterized by a transient ventricular wall motion abnormality and shares common features with acute coronary syndrome (ACS) with a wide spectrum of triggers, such as both emotional or physical, activating common toxic catecholamines–mediated pathways. TTC might be associated with severe clinical complications. We report a case of a 74–year female patient with circulatory shock with mixed phenotype, distributive due to sepsis and cardiogenic due to TTC. The patient presented to the emergency department with severe hypotension, pathological qSOFA score and clinical and laboratory findings consistent with severe sepsis. ECG showed diffuse lambda ST–segment elevation, also called “shark fin”(fig.1). According to hemodynamically unstable scenario and ECG pattern, emergency coronary angiography was performed, showing absence of coronary artery disease(fig. 2). Echocardiography revealed severe LV systolic disfunction (EF 20–25%) with apical ballooning and severe systolic anterior motion (SAM) of the anterior mitral leaflet eliciting dynamic LVOTO with peak gradient greater than 90 mmHg; fig. 3) and severe MR. Patient was treated with cautious fluid administration, hemotrasfusion and empiric large spectrum antibiotic therapy. According to TTC working diagnosis, even if septic state was thought to contribute to cardiogenic shock, norepinephrine was not administered due to concerns for LVOTO and SAM. After overcoming of dramatic first phase and after hemodynamic steadiness was achieved, beta blockade and ACEi were progressively administered. Seriate transthoracic echocardiogram revealed progressive improvement of LV systolic function, regression of apical ballooning, SAM and LVOTO. ECG monitoring showed regression of ischemic ST elevation. ST elevation has been described in about 56% of TTC cases, however with amplitude tipically lower than in STEMI. Lambda–wave ST elevation has been rarely reported. Vasospasm, local intermittent microvascular constriction, catecholamine–induced metabolic toxicity, transmural systolic wall tension and its the mechano–electric feedback can explain scaring ECG–pattern. Despite its rare prevalence in TTC “shark fin” pattern appears to relate to adverse outcome and it should be used as an early marker of potential further clinical deterioration, suggesting more intensive monitoring to avoid delays in possible therapy escalation.