bluuebunny/crossref_metadata_2025 huggingface dataset:
LASER CORONARY ATHERECTOMY AND POLYMERIC CORONARY WIRES IN UNCROSSABLE LESIONS – A WORD OF CAUTION
Authors: Marengo G , Amat Santos I , De Benedictis M , Barbero U , Doronzo M , Moncalvo C
Published: May 2024

Background

Excimer laser coronary atherectomy (ELCA) represents one of the last available options in case of balloon uncrossable lesions but no bench testing or clinical experience has been reported with polymeric wires. We aimed to assess whether ECLA use can disrupt or melt the cover and coating of coronary wires.

Methods

A total of 22 wires (10 polymer–jacketed and 12 hydrophilic non polymeric) were tested in an uncrossable lesion model. Two ELCA tests were performed over each wire at 8 and 4 cms from the tip with low and high settings, respectively. Microscopic analysis was performed at baseline images and after each test. Wire disruption was classified as Grade 1 (superficial scratches), Grade 2 (coil damage or solution of continuity of the polymeric cover) and Grade 3 (wire rupture/core disruption or de–coiling).

Results

After 44 ELCA simulations, wire disruption occurred in 16 cases (36.3%). Overall, events were more common for polymer–jacketed than for hydrophilic wires (12 vs 4, p=0.004). No grade 3 events occurred. Grade 2 events occurred in 9 cases (20.5%) and were more frequent with polymer–jacketed wires (8 vs 1, p=0.006). With low ELCA settings only polymer–jacketed wires suffered disruption (5 vs 0, p=0.009). With higher settings 11 events occurred (7 of Grade 2 and 4 of Grade 1) and incidence of grade 2 events was higher for polymer–jacketed wires (6 vs 1, p=0.02).

Conclusions

ELCA might be a safe option for coronary uncrossable lesions but its use with high settings over polymer–jacketed wires is discouraged.
MULTIFOCAL ATRIAL TACHYCARDIA AND HYPERTROPHIC CARDIOMYOPATHY IN THREE PATIENTS WITH COSTELLO SYNDROME
Authors: Catucci S , Lombardi M , Massari E , Maiorano A , Meliota G , Pirolo T
Published: May 2024

Introduction

Costello syndrome is a rare disease, caused by mutation of the HRAS gene, associated with intellectual disability, growth retardation, facial dimorphisms. Cardiac abnormalities, mainly cardiac hypertrophy and multifocal atrial tachycardia, are present in 1/3 of patients.

Clinical Cases

From 2019 to 2023, 3 newborns with Costello syndrome came under our observation. M.M. showed respiratory distress, hypotonia and dysmorphic notes; genetic analysis highlighted the pathogenic variant c.64C>A (p.Gln22Lys). On the echocardiogram, septal hypertrophic cardiomyopathy was found with left outflow obstruction and mitral insufficiency. Therapy with propranolol was undertaken. Holter ECG never revealed arrhythmias. At the last check–up, SIV hypertrophy, continent mitral valve, free left ventricular outflow. The second patient, O.L., arrived at 10 days of age following a run of supraventricular tachycardia. He had bilateral clubfoot and facial dimorphisms. The echocardiogram was normal. On Holter ECG atrial tachycardia interrupted by rare sinus beats. Therapy with flecainide was undertaken, without benefit. Subsequently, was undertaken amiodarone, then associated with digitalis. She was discharged with satisfactory control of the average ventricular rate, but later due to the appearance of chaotic atrial arrhythmia, propranolol was added; on the Holter ECG in triple therapy, periods of sinus rhythm alternating with short episodes of atrial tachycardia were observed. Genetic analysis revealed the pathogenic variant c.34G>A, p.(Gly12Ser) of the HRAS gene. The third patient, F.A., presented atrial tachycardia. Flecainide therapy had transient benefit. Subsequently propranolol was added, without benefit. Therapy with amiodarone was initiated. Transesophageal electrophysiological study demonstrated multifocal atrial tachycardia, unresponsive to overdrive pacing. Partial control of the average ventricular rate was achieved in triple therapy. On the echocardiogram, mild concentric hypertrophy and dysplastic pulmonary valve. Genetic testing detected the c.35G>C, p(Gly12Ala) variant of the HRAS gene.

Conclusions

Costello syndrome requires cardiac monitoring for the possible presence of multifocal atrial tachycardia and hypertrophic cardiomyopathy. Arrhythmia, which can also occur independently of hypertrophy, can be self–limited in the first months of life with aggressive pharmacological treatment but can persist or worsen in ¼ of patients.
THE CLINICAL IMPACT OF IMPLANTABLE LOOP RECORDER IN CHANGING MEDICAL DECISION: A SINGLE CENTER EXPERIENCE
Authors: Zaccaria C , Bernardini A , Paoletti Perini A , Padeletti M , Ciliberti D , Giomi A , Milli M
Published: May 2024

Background

Implantable Loop Recorder (ILR) has various indications for monitoring patients in different clinical settings. Most studies focus on a single indication without comprehensively evaluating the clinical impact of ILR. This study aims to retrospectively review a single experience regarding the actual role of ILR.

Methods

Patients were enrolled from March 2015 to April 2023 due to: syncope of unknown etiology, embolic stroke of undetermined source (ESUS), palpitation, monitoring of arrhythmias in Brugada syndrome (BrS), and following a pulmonary vein isolation (PVI). A change in the clinical course (cardiac implantable electrical devices (CIEDs) implantation, start of anticoagulation therapy, execution of an electrophysiologic study, ablation for tachyarrhythmias or PVI ablation) due to an ILR finding was considered as the primary endpoint. An unexpected result was defined as a different clinical finding from the expected for the cause of ILR implantation (ex. the finding of an atrioventricular block in a patient implanted for ESUS).

Results

130 patients of which 58 (44%) were females with a mean age of 58 ± 6 years were enrolled. The indication for implant resulted to be ESUS (25/130, 19%), syncope (38/130, 29%), palpitation (18/130 14%), BrS (24/130 28%), or after PVI follow–up (25/130 20%). A change in clinical course was reached in 44 (33%) patients after 12 ± 8 months of follow–up. Ten (8%) patients had a double event. The change of the clinical course was more frequent in female sex than in males (26/58 [45%] vs. 18/72 [25%] patients, p =0.025). In patients with syncope, a CIED was implanted in 7 (24 %) patients but interestingly 7 tachyarrhythmias events (5 AF and 2 SVT) were incidentally detected. In the stroke group, 6 (24%) started anticoagulation therapy after AF detection, and 3 (12%) CIEDs were implanted due to bradyarrhythmia. ILR allowed the diagnosis of tachyarrhythmia in 4 (22%) patients implanted for palpitation. In the syncope and ESUS group, no difference between expected diagnosis and unexpected events was found (syncope 7/38 [18%] vs. 9/38 [24%], p= 0.32; ESUS 3/25 [12%] vs. 6/25 [24%], p = 0.55).

Conclusions

ILR impacted on clinical pathway in 33% of patients during 12 ± 8 months of follow–up. Despite the reason for its implantation, it remains a useful tool for diagnosing other arrhythmias and the consequent changing of therapeutical approach. ILR had more impact in changing the clinical course in females than in males.
A CATASTROPHIC COMPLICATION OF A CHEST TRAUMA: A CASE REPORT
Authors: Bianco S , Piscione M , Polito D , Crispino S , Pugliese M , Ussia G , Grigioni F , Gabrielli D
Published: May 2024

A 43 year old patient came to the Emergency Department of our hospital for a cardiology visit. The EKG revealed polymorfic ventricular tachycardia with a heart rate of 160 bpm so that he was admitted to the Intensive Care Unit. In 2005, he had a post traumatic myocardial infarction after a car accident treated with the implantation of one drug eluted stent on the descending artery. Three years later, a single–chamber ICD was placed. On admission in Intensive Care Unit, cardiac auscultation revealed normal heart sounds without murmurs. No lower extremity edema was observed. A transthoracic echocardiogram showed general hypokinesis with reduced global left ventricle systolic function and no pericardial effusion (EF=20%). The patient was haemodynamically stable, the blood pressure was of 130/80 mmHg. The device was also interrogated and it showed six ineffective attempts of antitachycardia pacing. After that, the patient was given an effective intracavitary shock. Moreover, the patient underwent coronary angiography which showed no disease progression and patency of the stent previously implanted on the proximal descending artery. The electrophysiological study was performed and subsequently 3 ventricular ectopic focuses were effectively ablated. Multiple DC shocks were delivered during the procedure and the atrioventricular bundle was damaged. In consideration of the clinical features and the left ventricular reduced ejection fraction, an indication to the implantation of CRT–D was given.

Conclusions

This case report describes a rare complication of a blunt chest trauma. A young patient with no significant past medical history suffered a dissection of the coronary descending artery resulting in ST–elevation myocardial infarction. The mechanism of coronary occlusion following blunt chest injury may be due to: shear force applied to the coronary arteries leading to intraluminal thrombosis; vascular rupture; embolism to the coronary arteries; fissuring of an atherosclerotic plaque with dislodgment of plaque material; vascular spasm at the site of the injury. Anyway, severe left ventricular dysfunction caused the developing of polymorfic ventricular tachycardia which was unresponsive to medical treatment and was treated with ablation.
ACQUIRED LQTS WITH VENTRICULAR ARRHYTMIAS IN METHADONE AND CARDIOMYOPATHY AT ONSET
Authors: Roagna E , Angelini F , Gallone G , Vairo A , Bellettini M , Bocchino P , Saglietto A , Anselmino M , Giustetto C , De Ferrari G , Dusi V
Published: May 2024

Introduction

Methadone is associated with QT interval prolongation and increased risk of ventricular arrhythmias such as torsade de pointes (TdP), particularly if associated with other contributing factors. The management is complex, considering that in the majority of cases methadone suspension is impossible.

Clinical Case

Man, 39y, history of past cocaine and heroin abuse, in chronic methadone therapy, cames in ED for palpitation and recurrent syncope, after increasing methadone dose from 50 to 130 mg/die. At The ECG sinus rhythm, 83 bpm, wide monomorfic ventricular extrasystolia bigemina, of epicardical origin from the inferior–lateral wall (morphology like BBDx, positive concordance in the precordial leads, negative in DIII and aVF); QTc likely markedly prolonged. During observation recurrent episodes of TdP with external defibrillation; administred ev potassium (K 3.1), MgSO4 and β blocker ev. During hospitalization started nadolol, titrated until 1 mg/kg, and gradually reduced methadone up to 50 mg/die. Executed Holter ECG and ergometric test with evidence of flat and notched T waves with QTc markedly prolonged (> 550 ms) and poor adjustment to chronotropic variations. The echocardiogram shows LVFE 50%, GLS –13% (more reduce at inferior and infero–lateral walls); strongly negative electromechanical window (EMW –232 ms) and pronounced mechanical dispersion (+73 ms). The CMR evidenced late gadolinium enhancement (LGE) of non ischemic pattern, in the same segments with alterated kinesis. Mexiletine oral load test (6 mg/kg) was performed with contemporary ECG and Echo, without significant QTc, EMM or mechanical dispertion variation, suggesting unusefulness of chronic administration. After collective discussion, and considering patient choise, a bicameral ICD was implanted. A wide spectrum genetic test for channellopathies and cardiomyopathies was performed, (NGS and MLPA tecnique), resulted negative. At 1 year follow up (methadone 40 mg/die) persist prolonged QTc (580 ms), without arrhythmic episodes.

Conclusions

Our clinical case illustrates methadone proarrhytmic effect, associated with hypokalaemia and cardiomyopathy at onset, in a subset of prolonged QTc, with elevated electro–mechanical dispersion. Permanent ventricular bigeminism, rare in other acquired or congenital LQTS, is decribed linked with methadone use and its molecular effect of IKr and IK1 block; in our patient there’s correlation between site of origin and site of fibrosis (LGE).
OUTCOME OF OUT OF HOSPITAL CARDIAC ARREST: ARE THERE GENDER DIFFERENCES?
Authors: Bolognesi M , Rossi L , Pelizzoni V , Seghini P , Biagi A , Bricoli S , Ferraro S , Pisati M , Aschieri D
Published: May 2024

Background

Despite advance in resuscitation science, out of hospital cardiac arrest (OHCA) has an average survival rate of only 10 %. Ventricular fibrillation (FV) is amenable to defibrillation, but deteriorates to non shockable rhythms over time. It’Known that immediate cardiopulmonary resuscitation and eraly defibrillation increase survival after OHCA. It remains unclear whether there is an association between gender and survival. It seems that women OHCA patients are older, are less likely to have a witness arrest and they had fewer arrest in pubblic location than men . However these data are controversial.

Methods

We considered consecutively 6995 OHCA survivors resuscitated from emergency medical System (EMS) or bystander (BS) In Piacenza between june 1999 to decembre 2022 and we evaluated the outcome, considering sex and gender disparities

Results

Out of 6995 suffered from OHCA, 2983 (43%) were females with average age 81 ±13 years and 4012 (57%) males with average age of 73 ±15 years (p<0,00001).We observed with advanced age an incresead rate of woman that suffered from OHCA in comparison to man (< 44 years 177 m vs 63 w; 45–60 y 594 m vs 152 w, 61–75 y 1261m vs 530w; > 75 y 1980 m vs 2239 w).The survival of our population was 270 patients At EMS arrival 6150 patients (88%), 2779 (45%) female and 3371 (55%) male presented a non schockable rhythms (NSR):asystole or pulseless electrical activity (PEA) whilst 845 patients(12%), 170(75%) males and 56 (25%) females, presented FV .In the group with FV as initial rhythm, the survival was 26% (56/206 f 27% vs 107/647 m 26% p= 0,06). Also in this group women were slightly older (73 years f vs 67 m, p<0,00001). In all population survival decreased in females vs males (66/2984 w 2% vs 200/4012 5%f vp<0,00001).Females appeared with more non schockable rhythms (93 % f vs 84 % m, p< 0,00001)Women suffered from OHCA were found more frequently at home (2785 w 93% vs 3379 84%m p < 0,0001).Furthermore 97% males and 98% female were treated by EMS and 3 % males and 1,3% females by BS(survival males 3,6% EMS vs 51% BS and females 2 EMS%vs 26%BS).

Conclusions

In our OHCA population, the survival was 4% with better results in man Female were older and they had less survival, because initial rhythm registered were non shockable rhythms. They were found at home,with a delay in the first aid. This can be due to a gender disparities with advanced age.
LYME AND DENGUE FEVER: FROM BANGLADESH TO ITALY
Authors: Massara M , Zappelli L , Lanari A , Pergolini M , Giovagnoli A , Refi G , Di Noto G
Published: May 2024

Background

Dengue fever (Flavivirus) and Lyme disease (Borrelia burgdorferi) are rare tropical infectious diseases transmitted by hematophagous vectors (Aedes mosquitoes and ticks, respectively), and they are extremely uncommon in Italy. In European countries, both represent a public health concern as they manifest as imported diseases.

Case Report

A 54–year–old man from Bangladesh was admitted with symptoms of fever, dyspnea, and pericarditic chest pain. Laboratory and imaging examinations revealed severe acute respiratory failure secondary to left lower lobe pneumonia and pleuropericardial effusion. Broad–spectrum antibiotic therapy and anti–inflammatory treatment were initiated, suspecting para–pneumonic pleuropericarditis. During hospitalization, there was a gradual improvement with a reduction in inflammatory indices and resolution of lung consolidation. The patient was discharged after 14 days with anti–inflammatory therapy (ibuprofen and colchicine). Approximately 7 days later, the patient returned to the emergency department complaining of a recurrence of symptoms and fatigue. The EKG showed phases of 2:1 AV block, EAS and EPS, complete de novo left bundle branch block (LBBB), alternating with an escape atrial rhythm, not evident in previous EKG. During hospitalization, complete AV block emerged with prolonged asystolic phases, requiring urgent placement of a temporary pacemaker. Concurrently, blood tests revealed anemia and increased levels of inflammatory markers, troponin, creatinine, transaminases, cholestatic indices, LDH, and lipase, indicative of multiple organ failure (MOF). Acute pathologies or active bleeding were ruled out by total body CT with contrast. Blood cultures and serological tests were performed to exclude infections by Trichinella, Mycoplasma, Borrelia, Dengue, and other rare infectious diseases. Due to progressive deterioration, the patient was transferred to a tertiary care hospital. In the following days, laboratory results showed positive IgG and IgM for Dengue (without serological evidence of viral RNA) and positive IgG and IgM antibodies for Borrelia burgdorferi.

Conclusion

In Italy, the incidence of these diseases is low, and their coexistence in the same host is even rarer (if not anecdotal). However, coinfection cannot be excluded in patients from areas where these diseases are endemic, such as Bangladesh.
AN UNCOMMON CASE OF SUPERIOR VENA CAVA SYNDROME FOLLOWING CARDIAC SURGERY
Authors: Michele C , Asta A , Maio E , Giovanella E , Vera Mondazzi L , Trunfio D , Abbas Ahmed M , Rocchi D , Portella G , Masini F
Published: May 2024

Superior vena cava (SVC) syndrome (SVCS) is due to the obstruction of the SVC leading to swelling of the upper body and to low cardiac output. Non tumoral causes, mainly thrombosis of endovascular devices, account for 30% of cases. We report a case of acute iatrogenic SVCS. A 7 years old 16 kg boy underwent mitral valve surgery in severe rheumatic mitral regurgitation. After induction a 15 cm 5.5 Fr 3 lumens central venous catheter (CVC) was inserted in the right internal jugular vein (IJV) under ultrasound guidance without issues. After achieving proper anticoagulation ascending aorta (18 Fr) and bicaval cannulation were performed (20 Fr single stage cannula with right–angled metal tip in the SVC and 26 Fr single stage cannula in the inferior vena cava). Cardiopulmonary bypass (CPB) was performed with pediatric circuit and the mitral valve was repaired. Despite apparently good result of the repair and uneventful weaning from CPB a more accurate transesophageal echo (TEE) showed moderate iatrogenic mitral stenosis. Cannulation was re–performed with same size cannulas and mitral valve replacement (St.Jude 25 mm) was provided. After weaning from CPB with mild cardiovascular support (adrenaline 0.03 mcg/kg/min and noradrenaline 0.05 mcg/kg/min) the TEE showed no abnormalities and the patient was transferred to the ICU in stable conditions. The central venous pressure (CVP) never raised over 10 mmHg. In the ICU the patient developed sinus tachicardia and hypotension, unresponsive to fluids and vasopressors, and swelling of the face with no increase in CVP. The chest Xray showed enlargement of the right upper mediastinum with TEE evidence of accellerated flow in the SVC around the CVC (fig.1). The patient was taken to the operating room and a too tigh pursue string suture was found on the SVC. After optimization of the suture the flow through the SVC was restored with immediate clinical improvement and de–escalation of the cardiovascular support. The face oedema quickly decreased allowing extubation on the day after surgery. The following course was uneventful. SVCS is a life threatening complication of cardiac surgery. A too tight pledgetted pursue–string suture is an uncommon cause compared to clot compression. The CVP measured by a IJV CVC is generally elevated in SVCS, but in our case the tip of the CVC was downstream to the stenosis so showing normal values. Multimodal monitoring is mandatory to lead to emergency surgical treatment in case of need.
EARLY RESULTS OF MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING
Authors: Squiccimarro E , Margari V , Kounakis G , Visicchio G , Pascarella C , Carbone C , Paparella D
Published: May 2024

Coronary artery bypass grafting (CABG) is the benchmark in elective revascularization for Coronary Artery Disease (CAD), particularly for complex or multivessel CAD, left main coronary involvement, diabetes, or impaired heart function. Traditional CABG, via median sternotomy using cardiopulmonary bypass (CPB), has limitations like CPB–related morbidity and sternal complications. Alternatives like Minimally Invasive Cardiac Surgery (MICS CABG) and Hybrid Revascularization (HR) aim to address these drawbacks. We present a series of 215 consecutive patients (mean age 67±9 years, 27.9% females, EuroSCORE II 1.5±1.3%) between 2017–2023 who underwent elective minimally invasive surgical revascularization. Among the cohort, 164 (76.3%) had Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) via anterolateral left mini–thoracotomy (ALMT) at the fifth intercostal space (IS), with 140 (85.4%) receiving a single left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and 24 (14.6%) an additional distal anastomosis. Thirty–four (20.7%) had HR via percutaneous coronary intervention (PCI) on the right coronary artery (RCA). Of the total cohort, 35/215 patients (16.3%) underwent multivessel MICS CABG via ALMT, with mean 2.3±0.5 distal anastomoses using LITA, right ITA, radial artery, or saphenous vein. Heart manipulation was via a subxiphoid device. Four MICS CABG patients (11.4%) had HR. More than half of MICS CABG cases were performed with planned peripheral CPB, without cross–clamping the Aorta. Of the total cohort, 16/215 patients (7.4%) received MICS CABG in an endoscopic fashion, using 3D thoracoscopy for LITA and RITA harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior MT. Distal anastomoses were performed via left anterior MT, with easy subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. Conversion to sternotomy was needed in 3 cases, all were MIDCAB. Thirty–day mortality was 1.4%, median ventilation was 4 [2–5] hours, and Intensive Care Unit–stay was 1 [1–2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow–up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) requiring follow–up PCI. MICS CABG is a promising future technique for heart revascularization by dedicated teams.
IATROGENIC ACUTE MITRAL INSUFFICIENCY FOLLOWING IMPELLA–ASSISTED INTERVENTIONAL PROCEDURE
Authors: Totaro P , Pelenghi S
Published: May 2024

Background

Short–term left ventricle mechanical assistance device could be useful in assist interventional cardiologist during high–risk procedures. Abiomed Impella is one of the most frequently used device in this respect due to the high flow available with a low rate of reported complications. Here we report a rare but potentially catastrophic complication related to the Impella device.

Case Description

A 78 years old patient was referred to our Division by a peripheral hospital for a severe, symptomatic (NYHA III) mitral regurgitation (MR) due to posterior mitral leaflet prolapse (with focal eversion of P3) and chordal rupture (Fig 1a). Medical history included a previous admission in the some hospital due to a scheduled Impella–assisted PTCA (left main/left anterior descending artery) . Pre–procedural trans–thoracic ECHO (TTE) did not show significant MR (Fig 1b). Results Patient underwent urgent surgical procedure. At operation postero–medial mitral commissure was seen to be completely everted with multiple rupture of P3 and A3 chordae. Surgical procedure (Fig 1c) included: P3 plication + posterior–medial commissure edge–to–edge plasty + complete mitral semi–rigid ring (Simulus) n.30. Left atrial appendage was also closed using an external Atriclip. Postoperative course was without significant complications except a superficial wound dehiscence which delayed hospital discharge till 20th postoperative day.

Conclusion

Despite being a feasible and attractive option for short–term mechanical circulation assistance during high–risk interventional procedure, Impella device insertion could cause significant mitral valve damage leading to clinical deterioration. Such potentially catastrophic complication should be, therefore, mandatory excluded before patient discharge following interventional procedure.
CASEOUS CALCIFICATION OF THE MITRAL ANNULUS: TIME IS PRECIOUS. WASTE IT WISELY
Authors: Falagario A , Colucci C , Basile P , Memmola C , Caparrotti S , Ciccone M
Published: May 2024

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification, affecting most commonly elderly women with hypertension and end–stage renal disease. It is frequently misdiagnosed as an abscess, tumor, or infective vegetation. Although CCMA is generally a benign and asymptomatic condition, it can manifest with conduction abnormalities or with systemic embolization of caseous material. Case report: a 64 years old woman with long–standing hypertension, diabetes mellitus, hypercholesterolemia, solitary kidney and previous tuberculosis infection was referred to our hospital. She experienced painless monocular vision loss associated with nausea and epigastric pain. She denied flu–like symptoms and syncope. Both neurological and ophthalmological physical examinations were negative. Laboratory test showed Hs–cTnI elevation, while ECG was normal. The initial transthoracic echocardiography revealed a roundish echo–dense mass involving the posterior portion of the mitral annulus with a preserved left ventricular ejection fraction. A transesophageal echocardiogram and chest–CT were performed for further evaluation. They confirmed the presence of a large round mass with a heterogeneous aspect measuring 27 x 23 mm in the posterior annulus and the posterior leaflet of the mitral valve, suggestive of CCMA. The color Doppler images showed severe mitral regurgitation with an eccentric jet direction in absence of flow in the central zone of the mass. After a Heart Team discussion, the patient underwent cardiac surgery: a biologic mitral valve was implanted after debridement and obliteration of the cavity that appeared filled with necrotic debris. Pathologic examination revealed necrotic eosinophilic material and diffuse calcification with a surrounding mixed inflammatory infiltrate composed of histiocytes and lymphocytes. Gram stain demonstrated no organisms. The patient had an uneventful postoperative recovery and was discharged at home. Discussion: there is no consensus on the optimal management of CCMA patients. Most patients are treated conservatively; otherwise, surgery should be indicated for severe symptomatic mitral valve dysfunction or systemic embolization of caseous debris. Multimodality imaging assessment and Heart Team discussion play a key role in the optimization of the decision–making process and the prevention of cardio–embolic events. Time is precious. Waste it wisely.
THE BROAD PHENOTYPIC SPECTRUM OF ARRHYTHMOGENIC CARDIOMYOPATHY
Authors: Mistrulli R , Salerno L , Tiberi P , Francia P , Luca P , Autore C , Rubattu S , Barbato E , Pagannone E
Published: May 2024

Arrhythmogenic cardiomyopathy (ACM) is a rare inherited cardiomyopathy (CMP) characterized by progressive fibro–adipose replacement of the myocardium. It is mainly caused by variants in desmosomal genes with autosomal dominant transmission and incomplete penetrance. Originally, ACM was considered a CMP with main if not exclusive involvement of the right ventricle (RV) and more rarely both ventricles. To date, recent data have also highlighted the possibility of isolated left ventricular (LV) involvement, which often results in a disease with peculiar and distinct features. The case we propose is that of a 70–year–old man with no cardiology history but a family history of cardiomyopathy (brother has unspecified cardiomyopathy and is an ICD carrier). In 2015 due to occasional finding of ventricular extrasystole, the patient underwent CVG which was negative and cardiac MRI which documented an area of late–Gadolinium Enhancement (LGE) of the mid–basal portion of the inferior and lateral wall, with greater involvement of the subepicardial versant of the LV of possible post–myocarditis involvement. In September 2023, he was admitted to our cardiology department following a syncopal episode not preceded by prodromes. The ECG showed poor R–wave progression, low voltages and diffuse repolarization changes. The echocardiogram showed dilated LV with reduced EF(35%). Both CVG and cardiac MRI was repeated. The first was still negative and cardiac MRI showed a considerable progression of LGE areas at the mesomyocardial and subendocardial levels, with an almost ubiquitous distribution in the LV. Additional areas of LGE were also appreciated at the atrioventricular valves, the interatrial septum, and in the RV, but the latter was not dysfunctional. These findings appeared compatible with LV ACM with initial biventricular extension. It was decided to implant ICD in primary prevention and to request genetic analysis, which is still ongoing. Beyond the unusual appearance in extent and locations of areas of LGE on cardiac MRI, our clinical case highlights the close correlation that is often present between left ACM and acute myocarditis. It is not well known whether the inflammation associated with acute myocarditis is a primary injury that results in fibroadipose replacement or whether it is the degeneration of the cardiomyocytes themselves that results in these inflammatory phases (hot–phases) with myocarditis–like expression.
A WELL KNOWN CARDIOMYOPATHY BEHIND A FAMILY DRAMA: A CASE REPORT
Authors: Piscione M , Polito D , Re F , Ussi G , Grigioni F , Gabrielli D
Published: May 2024

We report a case of a 55–year–old woman who came to our regional reference center for cardiomyopathies. Her cardiovascular risk factors were systemic arterial hypertension, dyslipidemia, family history of sudden cardiac death. Her first son –20 years old– had died of sudden cardiac death during a football match, at the peak of the exertion, one year before. The autopsy had showed biventricular, diffuse fibro–fatty replacement areas diagnostic for arrhythmogenic cardiomyopathy. DNA extraction in tissue was evaluated for genetic testing. According to 2022 ESC Guidelines, familial evaluation of descendents of patients died of sudden cardiac death should include: genetic testing, gathering of medical history and performing physical examination, standard and high precordial leads ECG, echocardiography and exercise testing, CMR and ambulatory cardiac rhythm monitoring. All of these were normal, except for cardio RM which revealed: aneurysmatic bulging of the right ventricular wall, most prominent at the apex and free wall with normal contractility. Absence of both left and right ventricular dilatation. Left ventricular and right ventricular ejection fraction measured 58% and 55% respectively. According to Padua’s criteria the woman had borderline arrhythmogenic cardiomyopathy. Instead, her 18 years old little son used to practice sports and used anabolics. His cardio–RMN demonstrated: reduced function of the right ventricle with mild dilation and biventricular bulging areas. The patient met the criteria for definite Arrhythmogenic Cardiomyopathy since he had two major criteria. In the meantime of the results of genetic testing, suspension of the smoking habit and reduction of strenuous physical activity were advised.

Conclusions

Arrhythmogenic displasia of right ventricle is characterized histopathologically by the extensive replacement of right ventricular myocardium with fibro–fatty tissue (dysplasia triangle). Involvement of the left ventricle has been documented on a lesser frequency and has a higher mortality. Different from other conditions, in arrhythmogenic cardiomyopathy, sports practice not only conveys arrhythmic risk to that specific moment (as it happens to the little patient) but also accelerates disease progression.
IMPLANTABLE LOOP RECORDER IN BRUGADA SYNDROME: INSIGHTS FROM A SINGLE–CENTER EXPERIENCE
Authors: Arabia G , Cerini M , Calvi E , Falco R , Bellicini M , Cersosimo A , Curnis A
Published: May 2024

Brugada syndrome (BrS) is characterized by a “coved” ST segment elevation of ≥2 mm in the right precordial electrocardiographic (ECG) leads, either spontaneously or drug–induced. Risk stratification in individuals with BrS remains challenging. Currently, miniaturized and remotely monitored implantable loop recorders (ILRs) are available, providing physicians with a diagnostic tool that can help guide intervention or therapy decisions for these patients. The objective of this study was to investigate the characteristics and outcomes of patients diagnosed with BrS who underwent ICM insertion during routine clinical activity. This is a retrospective single center cohort study. We screened 147 consecutive patients who were diagnosed with BrS based on the presence of spontaneous or drug–induced type 1 ECG pattern between January 2009 and May 2023. Once this comprehensive diagnostic pathway was completed, we engaged in detailed counseling with patients to discuss the potential need for ICD implantation or ILR insertion, if deemed indicated. Compared to patients who did not receive a device, those who received an ILR had a higher prevalence of suspected arrhythmic syncope (43% vs. 22%, p=0.012) and tended to be younger (median age 38 years, IQR 30–52, vs. 43 years, IQR 35–55, p=0.044) and with a higher presence of SCN5A gene mutations (17% vs. 6%). On the other hand, compared to patients who received an ICD, those with an ICM underwent programmed ventricular stimulation less frequently (40% vs. 85%, p=0.010) and, as a result, had a lower frequency of positive result of this test (0% vs. 91%, p< 0.001). During a median follow–up period of 14.7 months (IQR, 4.7–44.8), no deaths occurred among the patients with ILR. Eight individuals (19%) were diagnosed with arrhythmic findings through continuous ILR monitoring. Among these findings, three patients experienced AF (including one case of new–onset AF), two patients exhibited symptomatic asystolic pauses lasting 16 seconds and 3.6 seconds respectively, two patients had non–sustained ventricular tachycardia, and one patient had episodes of paroxysmal supraventricular tachycardia. Except for a history of AF, no significant differences were observed between patients with arrhythmic findings and those without any events. In the ICD group, the median follow–up period was 32.2 months (IQR, 23.2–95.0). During this period, no deaths occurred and no appropriate or inappropriate ICD therapies were delivered.
FALSE POSITIVE STRESS TESTING IN A PATIENT WITH INTERMITTENT WOLFF–PARKINSON–WHITE SYNDROME IN ABSENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE: A CASE REPORT
Authors: Cariello F , Ventura G , Bencardino G
Published: May 2024

Introduction

Wolff–Parkinson–White (WPW) is a congenital cardiac preexcitation syndrome characterized by abnormal cardiac conduction through an accessory pathway, with the presence of a short PR interval and prolonged QRS complex on the ECG (Delta wave), which can lead to symptomatic arrhythmias. Low–risk patients are characterized by the sudden and complete normalization of the PR interval and the disappearance of the Delta wave during exercise or after procainamide, propafenone, or disopyramide administration.

Case Report

Asymptomatic 54–year–old male with intermittent WPW (anteroseptal accessory pathway), affected by arterial hypertension and dyslipidemia. No previous arrhythmic episodes. The stress test is characterized by significant ST–segment depression in the precordial leads with persistent ventricular pre–excitation. The coronary angiography does not show significant stenosis.

Discussion

The ST–segment depression during the stress test, typical of ischemia, manifests in half of the patients with Wolff–Parkinson–White (WPW) syndrome. However, the ST–segment depression takes on a different meaning based on the presence or absence of pre–excitation. ST–segment depression during the stress test in the presence of pre–excitation should be considered a false positive, In fact, exercise–induced ST–segment depression in patients with pre–excitation is believed to result from repolarization changes attributed to abnormal myocardial depolarization through the accessory pathway.

Conclusion

The stress test cannot be used for the diagnosis of coronary artery disease (CAD) in patients with Wolff–Parkinson–White (WPW) syndrome and manifest pre–excitation, as it often leads to false positive results.
IMPROVEMENT OF GLOBAL LONGITUDINAL STRAIN AND MYOCARDIAL WORK IN TYPE 2 DIABETES PATIENTS ON SODIUM–GLUCOSE COTRANSPORTER 2 INHIBITORS THERAPY
Authors: Del Giudice C , Fabiani D , Malvezzi M , Pezzullo E , Scognamiglio G , Liccardo B , D‘Andrea A , Golino P , Russo V
Published: May 2024

Introduction

Sodium–glucose cotransporter 2 inhibitors (SGLT2–i) are a novel class of oral hypoglycaemic agents currently used among patients with type 2 diabetes mellitus (T2DM). The effects of SGLT2–i inhibitors on cardiac structure and function are not fully understood.

The aim of the present study is to evaluate the echocardiographic changing among patients with well–controlled TDM2 treated with SGLT2–i inhibitors in real–world setting.

Materials and Methods

35 well–controlled T2DM patients (65± 9 years, 43.7% male) with preserved left ventricular ejection fraction and 35 age and sex–matched controls were included. T2DM patients underwent clinical and laboratory evaluation; 12–lead surface electrocardiogram (ECG); 2–dimensional color Doppler echocardiography at enrolment, before SGLT2–i administration, and at six months follow–up after an uninterrupted 10 mg once daily of Empagliflozin (n: 21) or Dapagliflozin (n: 14). Standard echocardiographic measurements, LV global longitudinal strain (LV–GLS), global wasted work (GWW) and global work efficiency (GWE) were calculated.

Results

T2DM patients showed higher EE’ ratio (8.3± 2.5 vs. 6.3± 0.9; p< 0.0001) and lower LV– GLS (15.8 ± 8.1 vs. 22.1± 1.4%; P<0.0001) and global myocardial work efficiency (91± 4 vs 94± 3%; P: 0.0007) compared to age and sex–matched controls. At six–months follow–up, T2DM patients showed a significant increase in LVEF (58.9± 3.2 vs 62± 3.2; p<0.0001), LV–GLS (16.2± 2.8 vs 18.7± 2.4%; p=0.003) and GWE (90.3± 3.5 vs 93.3± 3.2%; P= 0.0004) values; conversely, GWW values (161.2± 33.6 vs 112.72± 37.3 mmHg%; P<0.0001) significantly decreased.

Conclusions

SGLT2–I therapy showed a significant anti–remodelling effectiveness, improving the LV–GLS and MWE, among well–controlled diabetic patients with preserved left ventricular ejection fraction.
HALF–DOSE THROMBOLYSIS IN HIGH–RISK PULMONARY EMBOLISM
Authors: Tinazzi A , Pirondini M , Ornaghi M , Sabbatini G , Pierini S
Published: May 2024

An 87–year–old woman was admitted to our Emergency Department because of two syncopal episodes with head trauma. BP was 100/60 mmHg and HR was 150 bpm in atrial fibrillation. Lab tests showed elevation of NT–proBNP(9000 pg/mL)and serum lactate(4 mmol/L). Echocardiography revealed a large floating thrombus in the right atrium, as well as severe right ventricle enlargement and dysfunction. Chest CT angiography showed massive bilateral PE. After having performed a brain CT scan to exclude bleeding due to trauma, half–dose thrombolytic therapy(rt–PA 50 mg) was administered without complications. There was complete dissolution of the thrombus within the first 24h, with clinical and echocardiographic improvement. A 60–year–old man with history of DVT, transiently treated with anticoagulant therapy,and kidney stones complicated by recurrent infections, underwent lithosurgery and placement of DJ stent. At the induction of anesthesia, severe hypotension and desaturation occurred needing amine support; echofast revealed dilation and severe dysfunction of the RV and chest CT angiography documented bilateral massive PE. After a collegial discussion (Resuscitator, Cardiologist, Urologist) the risk/benefit ratio was judged favorable and the patient underwent thrombolysis with a reduced dose of rt–PA(50 mg) with rapid hemodynamic improvement and weaning from amine support. Doppler was negative for deep vein thrombosis. On pre–discharge echocardiogram the size and systolic function of the RV were normalized,with no pulmonary hypertension. Acute PE, defined as occlusion of the pulmonary arterial tree by thrombus, represents a life–threatening emergency. Patients diagnosed with PE should be stratified based on the risk of short term mortality, in order to decide the best therapeutic strategy. According to the latest ESC 2019 guidelines,high–risk patients(with hemodynamic instability at presentation) should undergo thrombolytic therapy if there are no absolute contraindications (active bleeding, cerebrovascular events and trauma/surgery within the previous 3 weeks). Even in these circumstances, in carefully selected cases, the use of a halved dose of thrombolytic (rt–PA 50 mg instead of 100 mg) could be taken into consideration in order to reduce bleeding risk, especially if it represents a rapidly life–saving strategy or if there is not the possibility of performing percutaneous catheter–directed treatment or surgical embolectomy.
SEMAGLUTIDE EXERTS POSITIVE INOTROPIC EFFECTS IN THE HUMAN ATRIUM
Authors: Joachim N , Britt H , Ulrich G
Published: May 2024

Semaglutide is currently an approved drug to treat diabetes II and obesity. It can increase release of insulin and inhibit release of glucagon in the pancreas. It is unknown whether it exerts positive inotropic effects in the human heart. Therefore, we studied in isolated electrically stimulated 1 Hz right atrial preparations from patients that underwent open heart surgery, force of contraction under isometric conditions in buffer solution. We noted the semaglutide and liraglutide increased force of contraction starting at 10 nM and maximally at 100 nM by about 85 % (the highest concentration studied, n=8, p<0.05). These effects semaglutide were accompanied by a reduction in the time of relaxation. The positive inotropic effects of semaglutide were antagonized by 1 µM exenadin, an antagonist at glucagon–like peptide–1 receptors (GLP–1R) and were less than induced by 10 µM isoprenaline which maximally stimulated β–adrenoceptors. The positive inotropic effect were potentiated (starting at 3 nM) by pre–incubation with 1 µM cilostamide, a phosphodiesterase IV inhibitor. Under the same experimental conditions glucagon increased force of contraction but via glucagon receptors. Our data suggest that at therapeutic concentrations semaglutide can stimulate force of contraction via a cAMP dependent pathway starting with the GLP–1R. Clinically, our results suggest that semaglutide via increases in cAMP content in the atrium might induce atrial fibrillation.
ATRIAL FIBRILLATION AND CARDIOTOXICITY: IS TRANSCATHETER ABLATION AN EFFECTIVE STRATEGY?
Authors: Spera F , Vannini F , Tiberi P , Mistrulli R , Falcetti R , Barbato E
Published: May 2024

Atrial fibrillation (AF) is the most commonly cardiac arrhythmia in clinical practice with an incidence of about 1.5–2% in the general population, rising to 20% in cancer patients. The use of antiarrhythmics in patients undergoing chemotherapy, besides being less effective in maintaining sinus rhythm, leads to an increase in side effects of both drug classes. Therefore, in patients with cancer, transcatheter ablation (CA) of arrhythmia may be the effective strategy for symptom control, reduction of heart failure flare–ups and improvement of quality of life. Our clinical case concerns a 57–year–old patient suffering from dilated cardiomyopathy with severe left ventricular dysfunction (FE 25%) induced by chemotherapy treatment with anthracyclines for previous breast cancer. The patient developed persistent AF of long duration and underwent multiple ineffective attempts at pharmacological and electrical cardioversion. Despite optimised therapy, the patient has been hospitalised over the past year due to multiple episodes of heart failure flare–ups during AF with high mean ventricular response (RVM). On the occasion of the last admission, it was decided to proceed with CA. After transseptal puncture, bipolar mapping of the left atrium was performed, which showed a large area of low voltage at the level of the left pulmonary veins (PV), anterior wall of the retro–aortic portion and at the level of the inferior septum. Isolation of the VPs bilaterally and subsequent isolation of the posterior wall by means of line on the roof and floor of the left atrium and anterior mitral line was performed. A cavotricuspid line was also performed at the level of the right atrium. At the end of the procedure, effective electrical cardioversion was performed with stable RS restoration. The echocardiogram, performed at pre–discharge, showed an improvement in EF to 35%. Since then, the patient has not shown any relapses of decompensation on the basis of AF. Although to date there is a lack of studies concerning the outcome and the type of ablative strategy most suitable in this context, this clinical case reinforces the idea that CA may be a viable first–line alternative to antiarrhythmic therapy.
PREDICTIVE MACHINE LEARNING MODEL FOR MECHANICAL DILATATION IN TRANSVENOUS LEAD EXTRACTION PROCEDURES
Authors: De Lucia R , Micheli A , Parlato A , Podda M , Pedrelli L , Parollo M , Segreti L , Di Cori A , Canu A , Grifoni G , Barletta V , Viani S , Aliprandi F , Zucchelli G
Published: May 2024

Background

Transvenous lead extraction (TLE) remains a procedure that requires a high level of expertise, with a doubled risk of death and clinical failure when performed in low–volume centers compared to high–volume ones. PURPOSE The aim of this study was to create a machine learning (ML)–based risk stratification system for predicting the need for mechanical dilatation in patients undergoing TLE due to infection.

Methods

We designed a ML–based risk stratification system trained with data from our registry to predict the need for mechanical dilatation in patients undergoing TLE for infection. An extensive evaluation of 5 different ML models (k–nearest neighbors, support vector machine, decision tree, and decision tree ensembles, such as random forest and gradient boosting machine) was conducted to identify a classifier with the highest potential to correctly predict previously unseen patients.

Results

Data to train the model was extracted from our 25–year registry of patients undergoing TLE (June 1998 – March 2023), for a total of 491 patients (77.8% male; age 69.7 ± 12.8 years) and 938 leads (ICD 21.2%; pacing 78.8%; indwelling time 61 ± 60 months) removed with success in 100% of cases. Each patient was represented by a set of 21 attributes (14 clinical, 7 device–related). Manual traction (MT) was used in 27.5% of cases, and mechanical dilatation (MD) was employed in the remaining 72.5% of cases. 5–fold nested cross validation was used to estimate performances: in turn, 393 patients were used for training and model selection, and 98 patients were used for independent testing. According to the evaluation, Gradient Boosting Machine performed best, achieving test accuracy of 89% (+/– 2% std. dev.), test sensitivity of 95% (+/– 3% std. dev.), test specificity of 73% (+/– 8% std. dev.), test AUROC of 92% (+/– 1% std. dev.). A further interpretability analysis on the best performing decision tree was conducted, showing remarkable adherence between the internal decisions taken by the model to make predictions and the current clinical practice for TLE.

Conclusion

ML models have enhanced the prediction of MD requirements in TLE procedures. This data may support the referral of patients to specialized and high–volume centers, thereby improving preoperative risk assessment.