bluuebunny/crossref_metadata_2025 huggingface dataset:
P178 OCCASIONAL ECHOCARDIOGRAPHIC DIAGNOSIS OF BRONCHOGENIC CYST
Authors: Rossini D , Giordano P
Published: May 2023

Bronchogenic cysts (BCs) are abnormal rounded formations associated with the tracheobronchial tree, that can cause recurrent infections or obstructive respiratory symptoms. They are often asymptomatic and can be discovered on occasional cardiac imaging. The treatment of bronchogenic cyst is controversial; some clinicians recommend surgical resection or transbronchial needle aspiration, others prefer a conservative attitude, reserving treatment for the possible appearance of symptoms or complications. We describe the case of a 54–year–old male patient which came to our observation in 2005, for the onset of intermittent angina pectoris. The first tests showed: no ECG alterations, mild hypokinesia of the inferolateral wall of the left ventricle with preserved systolic function on the echocardiogram, a modest increase in myocardial enzymes: total CK 731 U/L, CK–MB 40 U/L, CK–MB/CK ratio 5,4. The next day, the patient underwent coronary angiography and ramus intermedius PCI. However, the echocardiogram showed a rounded, anecogenic formation, 52 x 49 mm, behind the left atrium (Fig.1–2), which CT and MRI of the chest (Fig.3) diagnosed as BC in mediastinal location. Excluding the presence of neoplastic cells in the bronchoalveolar lavage fluid, a conservative strategy was agreed with the pulmonologists, choosing echocardiogram for follow–up. In the 17–year observation period, BC remained clinically silent, with no increase in size. Bronchogenic cysts are caused by an abnormal branching of the respiratory airways, that leads to the formation of segments separated from the tracheobronchial tree. About 80% of BCs are localized in the mediastinum, the remainder in the lung parenchyma. Unlike lung BCs, mediastinal BCs rarely communicate with the tracheobronchial tree and therefore usually do not undergo infectious processes. Mediastinal BCs localized near the carina of the trachea can cause compression symptoms (cough, dysphagia, dyspnoea). The other mediastinal BCs usually do not cause disorders. Knowledge of this rare congenital pulmonary disease is useful for echocardiographic differential diagnosis. Sometimes the cardiologist can play a role in the follow–up of this pathology.
P180 EXTREMELY WIDE QRS TACHYCARDIA IN SEVERE HYPERKALEMIA: THE IMPORTANCE OF MONITORING MRA THERAPY
Authors: Ciampi C , Baroni M , Maloberti A , Ghidini S , Mazzone P , Giannattasio C
Published: May 2023

Although uncommon in the general population, hyperkalemia can affect up to 50% of patients with heart failure who are receiving MRA and/or are affected by CKD . Since potassium is the most abundant intracellular cation, hyperkaliemia causes a profound change in action potential, which manifests as expected electrocardiographic changes (lower voltage P wave, AV block, wide QRS, high voltage T wave) and arrhythmias. Clinic case. A 77–year–old woman was admitted to ED for dyspnea. She had a medical history of stage 3 CKD and a HFrEF with a recent admission in medical department for worsening congestion, from which was dimitted with a supratherapeutic dose of MRA (canrenone 300 mg/die). Physical examination at the admission excluded signs of central or peripheral congestion . An EKG was performed and revealed an heart rate of 95 beats per minute and extremely wide QRS (280 ms). Contextually, a blood gas analysis showed high potassium level (K 9 mmol/l) and metabolic acidosis. Due to the inability to demonstrate the presence of P wave and a regular A–V conduction, a differential diagnosis between a VT and a SVT with a wide QRS was required. The presence of a fusion beat, a negative concordance of QRS in the precordials derivation, and an extreme right axis deviation led to a diagnosis of slow VT. Cuncurrently with the onset of hyperkalemia therapy, an ECV with sinus rhythm restoration was done. The following EKGs showed expected electrical changes based on the measured potassium level. After ECV with K 8 mmol/l: QRS remained wide (180ms) with an heart rate of 65 beats per minute in the presence of possible junctional rhythm or sino–ventricular rhythm, which is sometimes described in hyperkalemia as an expression of atrial inectability with the exception of the conduction fibers. After 1 hour with K 6.3 mmol/l: QRS of normal duration with an HR of 60 bpm and a sinus rhythm but with low voltage P wave and concomitant AV block of I grade that was gradually restored with the normalization of potassium levels after canrenone suspension. Because the numerous side effects of hyperkaliemia careful monitoring of MRA therapy and potassium level plays a critical role in the prevention and diagnosis of arrhythmias and EKG changes in patients with HFrEF.
P182 A STRANGE ELECTROCARDIOGRAM RECORDED AFTER A FALL TO THE GROUND
Authors: Clò S , Bertini M , Sirugo P , Orazio G , Capanni A , Guardigli G , Malagù M
Published: May 2023

An 84–year–old man was found unconscious on the ground by his daughter. The patient had a medical history of arterial hypertension, dyslipidemia and type II diabetes mellitus complicated by peripheral neuropathy and has been experiencing frequent falls. The emergency services were alerted, and the man was taken to the emergency room. In the ER, an abnormal electrocardiogram was recorded, and an urgent cardiological consultation was requested. Upon reading the ECG, the cardiologist ordered the patient‘s body temperature to be measured, which was found to be 29.7°C. The recorded ECG showed signs of severe hypothermia, including an advanced atrioventricular block (in this case, III–degree AV block), a widening of the QRS complex with the appearance of the Osborn wave, and a prolonged QT interval. The Osborn wave is a positive deflection visible at the J point and it is an uncommon electrocardiographic finding that immediately suggests hypothermia, although it is not pathognomonic (it can also be found in acute myocardial ischemia, hypercalcemia, sepsis, and other non–hypothermic conditions). The electrophysiological basis of the Osborn wave lies in the Ito current, a transient current caused by the release of potassium ions from the ventricular myocardiocyte, which is responsible for a brief partial repolarization during phase 1 of the action potential. Hypothermia increases the amplitude and width of the action potential notch due to the Ito current in the epicardium much more than in the endocardium, creating a transmural voltage gradient that manifests on the surface ECG as the Osborn wave. The Osborn wave is initially more evident in the inferolateral leads; as the body temperature decreases, the wave gradually becomes visible in all 12 leads and, when the body temperature returns to normal, the wave progressively disappears. This potential difference also correlates with possible proarrhythmic effects and, when linked to acute myocardial ischemia, the Osborn wave is an adverse prognostic factor as it is associated with a higher risk of ventricular fibrillation. In this case, the patient had fallen during the night and remained on the ground for hours. He was hospitalized for short intensive observation, warmed up, and hydrated, with a rapid and complete resolution of the clinical and electrocardiographic abnormalities
P185 FOLLOW–UP OF PATIENTS UNDERGOING POST–EXTRACTION LEADLESS PACEMAKER IMPLANTATION
Authors: Ferrieri A , Dentico A , Altieri T , Carretta F , D‘Agostino C , Carretta D
Published: May 2023

Introduction

The implantation of traditional stimulation devices involves numerous complications, in the short and long term, among which one of the most important is represented by infections. Most patients who experience this complication undergo a lead extraction procedure. In pacemaker–dependent patients, there is often the problem of having to perform an early reimplantation after extraction. This study aims to evaluate the outcome of Micra implantation in patients previously undergoing TLE, comparing them with patients who have a Micra as their first implant. Study materials and methods. From January 2017 to November 2022, 190 leadless pacemaker implant procedures were performed in our center. Of these patients 24 underwent an extraction procedure. To evaluate the technical performance of leadless pacemakers in post–extracted patients, a comparison was made between these and the "de novo" implanted leadless, so as to evaluate the effectiveness of the technical specifications. In particular, all the basic characteristics of the various patients, the data of the extraction and the implantation procedure were considered. Subsequently, the values ​​of the sensing, threshold, impedance and percentage of stimulation parameters collected in the follow–ups performed by the two groups of patients at 1 month after implantation, 6 months and every year were compared. Study results. An initial analysis of the follow–up of the aforementioned classes of patients from 2017 to today already provides us with some important data: in the patients who have implanted a leadless pacemaker following extraction, in no case has there been a recurrence of infection; the success of the Micra implant was 100%. Furthermore, the analysis of the electrical parameters statistics demonstrated the absolute effectiveness of the leadless device in both classes of patients compared, without highlighting major differences.

Conclusions

Leadless pacemaker implantation in post–extracted patients has proven to be an effective choice as an alternative to the implantation of a traditional pacemaker, to allow the reduction of the risk of infectious complications, while still guaranteeing optimal performance
P186 LEADLESS PACEMAKER VERSUS TRANSVENOUS PACEMAKER: THE BEST ALTERNATIVE FOR THE POST–EXTRACTION PATIENT
Authors: Dentico A , Ferrieri A , Altieri T , Carretta F , D‘Agostino C , Carretta D
Published: May 2023

Introduction

As complications associated with pacemakers or defibrillators implant increase, the number of patients undergoing transvenous lead extraction following infection has increased. This study aims to compare follow–up and to evaluate the incidence of reinfection between post–extracted patients re–implanted with leadless pacemakers and post–extracted patients re–implanted with transvenous device. Materials and

Methods

From December 2016 to October 2022, 163 patients underwent transvenous lead extraction in our center. Of these patients, 24 were subsequently reimplanted with a leadless pacemaker, while 52 with a traditional device. Instead, 11 were reimplanted with S–ICD, 3 with a loop recorder; 73 are patients who, after cardiological re–evaluation, either didn’t reimplant a new device or were redirected to the first implant center. For each patient has been evaluated the efficacy of the reimplanted device, the appearance of any minor or major complications, the recurrence of infection.

Results

About the 24 post–extracted patients who were reimplanted with a leadless pacemaker, in no case there was a recurrence of infection and/or complications associated with the device. In the 52 post–extracted patients reimplanted with a traditional device, only 1 case experienced a recurrence of infection (0.02% rate). If we analyze this last class better, we see how in the past some of these had already undergone a pocket overhaul or an extraction of first implant device. Many are also patients with leads abandoned by another center and with new device’s infection.

Conclusions

Leadless PM implantation in post–extracted patients, when we have patients eligible for this device, proved to be an effective choice in reducing re–infection recurrences compared to the population of patients reimplanted with a transvenous device. However, if we consider the low rate of reinfection in patients re–implanted with transvenous device, we can say that when the patient is well prepared and the implant prophylaxis is correct, the recurrence of infection is low even if one decides to re–implant a traditional device.
P190 TWIDDLER’S SYNDROME IN A 96–YEAR–OLD PATIENT TREATED BY REPOSITIONING THE VENTRICULAR LEAD
Authors: Massacesi C , Core A , Di Eusanio M , Di Francesco G , Di Saverio M , Marini L , Rolando M , Gregori G
Published: May 2023

A 96–years–old woman was admitted to our cardiological intensive care unit in December 2022 with atrioventricular dissociation, with a junctional ventricular escape rhythm at a rate of 38 beats per minute, and an atrial rhythm dissociated from the ventricular rhythm, at a rate of 80 beats per minute (Figure 1). The patient had a history of third–degree atrioventricular block, effectively treated with single–chamber pacemaker implantation (Assurity MRI SR, Abbott), operation performed approximately 10 months before access, in February 2022. The patient underwent a chest X–ray, which showed "coiling" of the ventricular catheter in the pacemaker pocket area (left subclavicular), with macroscopic dislocation of the ventricular electrode, which had its distal tip in the right atrium (Figure 2). Therefore, the clinical case was typical of Twiddler‘s syndrome. The patient would therefore have undergone revision surgery. An attempt was made to reposition the original lead, with passive fixation (Isoflex 1948/58, Abbott), by inserting a "straight" stylet, a procedure which was done effectively. The ventricular lead was repositioned in the right ventricular apex. The detected parameters were optimal (sensing 7 mV, ventricular barrier threshold 0.5 mV/0.4 ms, impedance 797 Ohm). The result was considered acceptable. The remainder of the hospital stay was without complications. The patient was discharged on the fifth day in good general condition. Twiddler syndrome is defined as a dislocation of one or more catheters, resulting in the catheters "coiling" in the pocket of the device. It is usually related to the manipulation of the generator by the patient itself. It usually occurs within a year of implantation and is usually more common in females, the elderly, the obese, pediatric patients, or patients with psychiatric disorders. The identification of patients at risk for this pathology, the adequate education of the patient and family regarding the management of the device, the use of catheters with active fixation, as well as the fixation of the generator device to the pectoral muscle, through non–absorbable sutures. In the case described, the patient denied manipulation of the device, which however could not be excluded, given the age of the patient.
P191 MITRAL VALVE REPAIR FOR INFECTIVE ENDOCARDITIS LONG TERM RESULTS
Authors: Malvindi P , Bifulco O , Zingale A , Berretta P , Alfonsi J , Pierri M , Suvitesh L , Ohri S , Di Eusanio M
Published: May 2023

Background and aim

The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis remain not clearly established. We aim to review the clinical experience in mitral valve surgery for infective endocarditis looking at mid–term survival.

Methods

Prospectively collected data of patients who underwent cardiac surgery for infective endocarditis between 2001 and 2021 at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest–neighbour propensity score matching, including twelve preoperative variables, was performed to account for differences in patients’ profile between the repair and replacement subgroups.

Results

Propensity matching provided 87 well–matched pairs. Mean age was 60±15 years, 76% of the patients were male. Twenty–two patients (12%) had a recent cerebral event. CABG and aortic valve replacement were associated in 10% and in 38% of the cases, respectively. Patients who underwent mitral valve replacement had a higher rate of annular, commissures and bileaflet lesions. Overall in–hospital mortality was 7% with no difference between the repair and the replacement cohorts (p=0.77). Survival probabilities at 1, 5– and 10–years were 89%, 70% and 67%, respectively after mitral repair, and 88%, 76% and 62%, respectively after mitral replacement; log–rank p=0.94. Freedom from mitral intervention by any cause at 10–years was 3.3% and 8.7%, respectively after mitral repair and mitral replacement; Gray’s p=0.37.

Conclusions

Mitral valve repair was associated with acceptable in–hospital mortality and survival in a high–risk and comorbid cohort of patients with mitral valve infection. We found no difference in early, mid–term survival and mitral reoperation risk between patients who underwent repair or replacement of the mitral valve in the setting of infective endocarditis.
P195 INFECTIVE ENDOCARDITIS OF COMPOSITE AORTIC VALVE GRAFTS
Authors: Olevano C , Fiorani B
Published: May 2023

Background

The Infection of aortic valve graft conduit is a relatively rare complication still burdened by notable morbidity and mortality. Medical and surgical strategies play a crucial role in patient outcome and vary depending on infection extends into adjacent cardiac structures, systemic spread and identify microbes.

Methods

In this retrospective and observational study, we report two centre experience in the management of thirty patients consecutively admitted to our centre with composite aortic valve graft infection during the period 2008–2020. Our end–points were: infection control, early mortality and long–term survivor.

Results

Twenty patients underwent redo surgery with an early mortality of 10% and a survival of 83% at 7–year follow–up. Ten patients were treated medically and experienced an early mortality of 30% and a mid–term survival of 33%. Patients with stable haemodynamic in the absence of local and systemic complications had an acceptable survival after lone antibiotic therapy.
P196 ENDOCARDITIS MASQUERADING AS STILL‘S DISEASE: WHEN AN ECHOCARDIOGRAM SAVES YOUR LIFE
Authors: Giovannico L , D‘Errico Ramirez A , Fischetti G , Parigino D , Santeramo V , Savino L , Silva A , Vitale N , Bavaro D , Di Bari N , Bottio T , Milano A
Published: May 2023

A 44–year–old man in apparent good health thus far presented with weight loss and fever preceded by shivers, profuse sweating, and arthralgias. Blood tests documented normal white blood count with slightly altered CRP and ESR. Chest X–rays did not find pleuro– parenchymal lesions with normal cardiac silhouette. Abdomen ultrasounds was regular. Due to the persistence of the symptoms, he was referred to a rheumatologist who diagnosed Adult Still’s disease (AOSD) and recommended therapy with prednisone and sulfasalazine, interleukin–1 inhibitor, with the resolution of the fever. After three months, because of the recrudescence of the fever, he was admitted to the emergency room a total–body CT–scan documented inflammatory–abscess lesions in the brain and hypodense areas in the spleen. ECG showed type 1 second–degree atrioventricular (AV) block. The patient was therefore transferred to the Cardiology Department; echocardiograms documented an endocardic mass on the aortic valve and suspected periannular abscess also infiltrating the interventricular septum. The patient underwent urgent surgery with excision of the aortic valve, opening and draining of the abscessual cavities, reconstruction of the aortic annulus with bovine pericardium patch and aortic valve replacement with bioprosthesis. The patient did not present further febrile episodes after surgery but a pacemaker implantation was necessary due to persistent AV block. Biological material sent for culture was positive for S. gallolyticus. AOSD is one of the most common conditions responsible for fevers of unknown origin. It is characterized by fever, arthritis, evanescent rash, leukocytosis, and multiorgan involvement. Yamaguchi criteria required for the diagnosis of AOSD are as follows: main criteria: Fever >39°C, lasting 1 week or more, Arthralgia or arthritis, lasting 2 weeks or more, Typical rash, Leukocytosis >10,000/mm3; Minor criteria: Sore throat, Recent development of significant lymphadenopathy, Hepatomegaly or splenomegaly, Negative tests for antinuclear antibodies and rheumatoid factor; Exclusion criteria: Infections, Malignancies, Other rheumatic diseases.
P209 HUGE AND OCCLUDING LAA THROMBUS DISSOLUTION IN A CASE OF SEVERE TACHI–CARDIOMYOPATHY
Authors: Maurizi K , Ianni U , D'Agostino S , Gizzi G , Molisana M , Parato V
Published: May 2023

A 62–year–old man was admitted to our emergency department for worsening nocturnal dyspnea and orthopnea for 15 days. Finding of Acute Pulmonary Edema in a setting of non datable high ventricular response atrial fibrillation (AF) associated with severe LV dysfunction. NT–proBNP 8.252 pg/ml. ECG: atrial fibrillation with high ventricular response (120/bpm). TTE: Severe left ventricular systolic disfunction (EF 20%). TOE/3D TOE: evidence of voluminous oval–shaped thrombotic formation (10 x 17 mm) protruding in LA and completely occluding the left atrial appendage (LAA). LA thrombosis in patients with AF is relatively rare and represents a contraindication to rhythm control strategies. Once an LAA thrombus is identified, effective anticoagulation is recommended for at least three weeks or until LAA thrombus resolution is detected. Available evidence on left atrial thrombus dissolution largely refers to the use of vitamin K antagonist oral anticoagulant (VKAs), but their effectiveness may be influenced by variability in the level of anticoagulant activity obtained, wich may be suboptimal. In a recent prospective observational study has been evaluated the effectiveness of Edoxaban for the resolution of LA thrombosis in 25 patients with AF: it has been demonstrated a complete thrombus resolution in 56% of patients at 4 weeks, similar to studies using VKAs and the other NOACs. Use of NOACs in this setting represents a great field of interest for the near future. In our experience, indeed, after confirmed diagnosis of LAA thrombus, we started anticoagulant therapy with warfarin (currently the first choice), however due to poor INR control, we switched to continuous infusion of unfractionated heparin (UFH), wich represents, in a hospital setting, a safe and effective method for thrombus dissolution, allowing continuous monitoring of efficacy and a rapid cessation of effect in case of major bleeding. In this way we obtained complete thrombus dissolution in about 3 weeks. At the meantime we initiate a rate control therapy, an optimized treatment for HFrEF and intravenous diuretics. Our experience highlights the need of great ductility in the choice of anticoagulant therapy in patients with evidence of voluminous LAA thrombus, monitoring treatment’s efficacy parameters and being ready to change strategy if necessary and it reminds that auricular thrombosis is often inserted in a wider picture of heart disease wich requires multiple other specifics treatments.
P224 THE SHARK–FIN THAT EMERGES AND IMMERGES: A CASE REPORT OF TRANSIENT AND REPETITIVE TRIANGULAR QRS–ST–T
Authors: Valcher S , Villaschi A , Bertoldi L , Briani M , Corrada E , Chiarito M , Condorelli G
Published: May 2023

Introduction

Shark fin sign, also known as triangular QRS–ST–T waveform (TW), is characterized by a giant R wave (amplitude ≥ 1 mV) resulting from the fusion of the QRS complex, the ST–segment and the T wave and showing triangular morphology. TW pattern is quite uncommon and reveals a life–threatening condition that needs aggressive management. Case presentation: A 45–year–old black man with history of arterial hypertension and without known comorbidities arrived at our emergency department (ED) with out–of–hospital cardiac arrest (OHCA). Return of spontaneous circulation occurred after 11 minutes and 2 direct current shocks. At arrival in the ED, he was hemodynamically stable, electrocardiogram showed atrial fibrillation without repolarization abnormalities, and echocardiogram revealed left ventricular hypertrophy and hypokinesia of the mid–basal inferior wall. Plasma level of electrolytes and high–sensitivity troponin were in range. Sedation in the ED was needed due to psychomotor agitation. He was transferred to the cardiac intensive care unit; no arrhythmias were noted. During the night, electrocardiogram monitoring revealed a progressive ST segment elevation in inferior leads up to a triangular QRS–ST–T giant waveform (“Shark fin sign”), confirmed at 12–lead electrocardiogram. After 3 minutes the electrocardiogram showed a progressive and complete resolution of ST–elevation. Akinesia of the inferior wall was confirmed at echocardiogram. The episode repeated 5 more times in the following 40 minutes, while waiting for the arrival of the Cath lab personnel. Coronary angiography revealed a sub–occlusive mid right coronary artery (RCA) stenosis. Percutaneous coronary intervention with the implantation of one drug eluting stent was performed. After the procedure the patient was hemodynamically stable, and the ECG did not show any other abnormality and no episodes of recurrent ST–elevation occurred.

Conclusion

The shark fin sign refers to the abrupt total deprivation of blood flow in large areas of myocardium that are seen during coronary thrombotic occlusion or vasospasm. In our case we assisted to transient but repetitive inferior triangular ST–elevation, probably the expression of RCA plaque coronary vasospasm that cause the ECG shark fin sign and OHCA. This sign correlates with high risk of cardiogenic shock, electrical instability, and cardiac arrest, thus requiring prompt and aggressive management.
P232 CORONARY DISSECTION FROM AMMONIA INTOXICATION
Authors: Ossola P , Gualini E , Ciampi C , Gallone G , Santolamazza C , Pedrotti P , Quattrocchi G , Soriano F , Giannattasio C , Pirola R
Published: May 2023

Spontaneous coronary artery dissection is one of the possible causes of MINOCA defined by a separation of the intima or adventitia from the arterial wall and frequently related to a nontraumatic, noniatrogenic etiology. Coronary artery dissection often involves a single vessel most often represented by the anterior interventricular artery. Case report. An 82–year–old patient with a silent cardiology history presented to the emergency department after accidental ammonia inhalation reporting cough, epiphora, and chest pain. On admission ECG we show a normofrequent sinus rhythm with an EAS and a high lateral Q wave with a negative T wave. In view of the TnT values of 425 mg/dL, an indication for admission with a diagnosis of NSTEMI was posited. On echoscopy, a hypo–akinesis of the mid–distal portion of the anterolateral wall, posterior wall, and interventricular septum (SIV) with inspective left ventricular ejection fraction (FEVS) 35% was evident. In the face of persistence of modest angor, as well as further elevation of troponin values (1400 ng/L) and a significant change in electrocardiogram with development of right bundle branch block, the patient underwent urgent coronarography. Coronary angiography documented by IVUS analysis a spontaneous coronary artery dissection of the anterior descending artery (VAT) with the presence of a non–occlusive wall hematoma at the middle tract. In view of the patient‘s achieved asymptomaticity, hemodynamic stability, and ubiquitous TIMI 3 flow, a conservative approach was opted for, setting medical therapy with ASA + Clopidogrel "off–label" by virtue of the woman‘s low bleeding risk and high ischemic risk. Follow–up echocardiogram performed three days after the patient‘s arrival on the ward showed a fair recovery of biventricular systolic function with an FEVS of 50% with alterations in regional hypokinetic Chinese. Diagnosis was completed by cardiac MRI, which confirmed the ultrasound findings inherent in the kinesis and showed areas of edema at the anterior wall, anterior septum, and anterolateral wall in the absence of late ischemic myocardial enhancement. These findings were found to be suggestive of an associated TakoTsubo syndrome picture.
P234 IT IS TIME THAT ITALIAN AMI NETWORKS ARE BASED ON DIAGNOSTIC–THERAPEUTIC PATHWAYS INCLUDING BOTH TYPES OF ACS (STEMI AND NSTEMI)
Authors: Parato V , Berrettini U , Luzi M , Paci M , Grossi P , Principi T , Zamponi E , Ciucani A , Petrelli G , Curto R , Gabrielli D
Published: May 2023

Background

Nowadays AMI management represents one of the most challenging clinical scenarios. On 8 july 2022 ANMCO held a special event about the last 20 years of AMI networks in Italy. During this event it was highlighted how these networks – supported by ANMCO – led to mortality reduction in the last 20 years (till –57%). By the way, the networks are usually based on diagnostic–therapeutic (D–T) pathways that not include NSTEMI–ACS. At contrary, the prevalence of NSTEMI–ACS is increasing and it significantly contributes to whole mortality due to coronary heart disease in the world. Materials and

Methods

The Functional Cardiology Department of Marche Region (Italy) covers the territory of three provinces. This department provided a new diagnostic–therapeutic pathway for AMI–network on July 2022. Globally, the department provides heart diseases management to 500.000 subjects living in that area. Working group who proposed the new D–T pathway included: 1) all Cardiology Units Directors; 2) all Emergency System Directors; 3) all Emergency Rooms Directors. The diagnostic–therapeutic pathway was based on 1) latest ESC guidelines and whole medical licterature on the topic; 2) geographic area features; 3) logistic local criticisms; 4) multiple sharing meetings results.

Results

The D–T pathway was divided in two chapters: 1) STEMI–ACS; 2) NSTEMI–ACS. STEMI–ACS chapter included 7 steps: 1) Symptoms onset and Emergency System Alert; 2) out of hospital intervention; 3) emergency room (ER) intervention; 4) primary PCI; 5) in–hospital complications; 6) whole in–hospital management and back transfer to the spoke; 7) cardiac rehabilitation and secondary prevention programs. The novelties were represented by: 1) ECG trasmission to the ICUs; 2) detailed establishment of which HUB every town/city of the area is assigned to; 3) inclusion of cardiac rehabilitation and secondary prevention programs in the pathway; 4) inclusion of NSTEMI–ACS with the two revascularization arms cited by the ESC guidelines.

Conclusions

The reported D–T pathway appears very innovative in order to including both two types of ACSs (STEMI and NSTEMI). Considering the latest guidelines, it could be appropriate that new D–T pathways, promoted by AMI networks in Italy, include a specific chapter dedicated to NSTEMI–ACS, given that also this type of ACS may require a time–dependent revascularization therapy and the correct approach may affect mortality and the whole prognosis.
P235 THE ROLE OF BIOELECTRICAL PHASE ANGLE IN PATIENTS WITH HEART FAILURE
Authors: Scicchitano P , Potenza A , Basile M , Sasanelli P , Massari A , Landriscina R , Cannito A , Abruzzese S , Tangorra M , Caldarola P , Massari F
Published: May 2023

The most challenging feature of heart failure (HF) still remains the evaluation of congestion. Residual congestion at discharge and the difficulties in perfectly dosing therapies in order to balance the hydration status of the patient are the most worrisome issues when dealing with HF. The use of bioimpedance vector analysis (BIVA) might promote a different approach in the general management of patients with HF. BIVA is a reliable, fast, bedside tool able to assess the congestion status. It proved to be helpful to physicians for diagnosing congestive status, managing therapies, and providing prognostic information in the setting of HF. Bioelectrical Phase Angle (PhA) – as derived from equations related to the parameters of BIVA – recently surged as a possible biomarker for patients with HF. Studies provided data about the application of PhA in the clinical management and in the overall risk stratification of HF patients. Basically, the use of PhA might be considered as a holistic evaluation of patients with HF which includes the need for a multiparametric approach able to effectively depict the clinical status of patients. There is no definite biomarker able to comprehensively describe and identify all the features of HF patient, but scores based on molecules/techniques able to explore the different pathogenetic mechanisms of HF are desirable. The aim of this review was to provide a comprehensive evaluation of literature related to PhA role in HF and the impact of this biomarker on clinical management and risk stratification of HF patients.
P237 WORSENING OF RENAL FUNCTION AND INCREASE IN RENAL RESISTANCE INDEX AFTER CARDIAC SURGERY
Authors: Barone R , Goffredo G , Di Terlizzi V , Squiccimarro E , Margari V , Di Biase M , Brunetti N , Iacoviello M , Paparella D
Published: May 2023

Worsening of renal function (WRF) is frequently observed after cardiac surgery and it is associated with both short– and long–term worse outcome. Among the pathophysiological conditions favoring the occurrence of WRF, the abnormalities in renal blood flow could play a key role. The aim of this study was to evaluate the changes in renal resistance index (RRI), a parameter reflecting renal parenchymal and hemodynamic parameters, after cardiac surgery.

Methods

Thirty–one patients were enrolled (age 65±12 years, 29% males, mean left ventricular ejection fraction 55±5%, mean creatinine serum levels 0.89±0.18 mg/dl, mean eGFR 89±28 ml/min*1.73 m2). All patients underwent cardiac surgery. Before cardiac surgery, after 3 days and before discharge, RRI was evaluated according to Peurcelot’s formula by renal interlobular arteries pulsed Doppler. Worsening of renal function was defined as an increase in serum creatinine of > 0.3 mg/dl associated with a change > 25% or the need of renal replacement therapy due to severe acute kidney injury.

Results

As shown in the table 1, after cardiac surgery a significant increase in RRI was observed at 3 days after cardiac surgery but not before discharge. The significant increase in RRI was observed both in patients with and without WRF. However, in patients with WRF significant higher values of RRI were observed before as well as after cardiac surgery.

Conclusions

Among patients undergoing cardiac surgery a significant increase in RRI values is observed after surgery. Among patients with WRF a significant greater values of RRI are observed before as well as cardiac surgery thus suggesting that a critical increase in renal resistance could play a role in the cardiorenal syndrome worsening.
P238 THE HEART LOGIC EXPERIENCE IN OUR CENTER “SANTA MARIA DELLA MISERICORDIA” HOSPITAL, UDINE
Authors: Favaretto V , Fumarola F , Tioni C , Facchin D , Driussi M , Imazio M , Sinagra G
Published: May 2023

Background

Outpatient monitoring of patients with chronic heart failure (HF) may result in HF exacerbation and subsequent hospitalizations that may be avoided with an early recognition. The HeartLogic (HL) algorithm automatically calculates a daily HF index based on values including heart sounds, markers of ventilation, thoracic impedance, activity and heart rate and recognize an active alert state relative to a configurable threshold.

Methods

We included 35 patients with HF in optimized medical therapy; the investigational chronic ambulatory data collection was performed via implanted Boston pace–maker, defibrillator or cardiac resynchronization therapy and we analyzed these data since February 2021, ongoing. We established a cut off of HL index of 16 due to the confirmatory trial and we contacted the patients 2 weeks after the threshold exceeding to evaluate their clinical state.

Results

Preliminary data (until December 2021) showed us 24 alarms in total, of whom 7 were truly heart failure related alarms. These are independent from the values of the HL index reached and the best parameter resulted to be the chest impedance. Measurement of third heart sound was another sensitive but not very specific parameter. The main confounding factor was given by infections, especially related to Covid–19. The therapeutic strategy was predominantly increasing the doses of diuretics. There were no heart failure events in patients without the warning HL index.

Discussion

The preliminary data showed us how high is the negative predictor factor of the HL index based on our center parameters. We aim to analyze further data to be more accurate and to find the best way to detect heart failure.
P242 CARDIOGENIC SHOCK WITH ISCHEMIC PHENOTYPE SECONDARY TO INCESSANT VENTRICULAR TACHYCARDIA: A CALL FOR IMPLEMENTATION OF HUB–AND–SPOKE MODEL
Authors: Corticelli A , Centola M , Spina M , Spinelli M , De Carlini C , Moro C , Loffreno A , Ruggiero D , Provenzale G , Aurino L , Russo G , Achilli F
Published: May 2023

A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation >2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.
P245 IMPLICATIONS IN PHARMACOLOGICAL AND ELECTRICAL OPTIMIZATION IN HEART FAILURE: A EMBLEMATIC CASE
Authors: Placci A , Notarangelo F , Crocamo A , Gonzi G , Bearzot L , Serra W
Published: May 2023

We describe the case of an 82–year–old man with permanent atrial fibrillation in oral anticoagulation therapy. Former smoker. Diabetes mellitus. In 2009, subacute MI with PTCA/DES of anterior descending artery and obtuse marginal branch, critical stenosis of circumflex artery, right coronary artery occluded. Infrarenal aorta occlusion. Echocardiography TT mild–moderate mitral regurgitation. Ejection fraction (EF) preserved. Inferior wall akinesia. In 2019 hospitalization for heart failure due to severe bradyarrhythmia in atrial fibrillation. In therapy with bisoprolol 10 mg/day Echocardiography FE 35%, moderate–severe functional mitral regurgitation, PAPs 55 mmHg. Arterial pressure 100/85 Sat 2O 90% Treatment at discharge: furosemide 75 mg/day, bisoprolol 7,5 mg/day, Metformina 500 mg/day, potassium canrenoate 50 mg/day atorvastatin 40 mgday and warfarin,Ramipril 2.5 mg/day, allopurinol 150 mg/day. In 2020 new hospitalization for heart failure. NYHA III–IV; BNP 1890 pg/ml. Beta–blocker therapy reduced to bisoprolol 3.75 day for pulmonary hypertension and bradycardia, furosemide increased to 100 mg/day, possibly further titratable on the basis of renal function, blood electrolytes and clinical response, maintaining restriction of daily liquids at about 1000 cc. Initiated Sacubitril/Valsartan 24/26 mgx 2 /day. Coronary angiography was not possible due to occlusion of the abdominal aorta and right radial artery (1,2,3). CT CORO performed with relief of the interventricular branch occluded in the middle section; patent obtuse marginal branch stent; right coronary artery occluded. Abdominal aorta occluded at the level of the renal arteries. The patient was submitted to CRT–D implant for bradycardia and wide QRS like left bundle branch block. Glyphozine associated with Metformin. Echocardiography TT LVEF 40%, moderate functional MR, PAPS 35 mmHg. NYHA II. Edema resolution No hospitalizations for decompensation. titrated ARNI at 49/51 mg x 2/day, and the beta blocker Cardicor 5mg/day. At remote monitoring decreased ventricular catheter impedance. What does the case tell us? The combination of Sacubitril/Valsartan and Glifozine determined an inverse remodeling of the heart. The combination of Sacubitril/Valsartan and Glifozine improved cardiac compensation and clinically stabilized the patient.
P249 INTRAMYOCARDIAL HAEMATOMA AS A COMPLICATION OF ACUTE MYOCARDIAL INFARCTION
Authors: Pennacchi M , Mistrulli R , Natale E , Scirpa R , De Luca L , De Felice F , Gabrielli D
Published: May 2023

A 72–year–old overweight man, with known hypertension and dyslipidaemia, had an episode of high intensity chest pain, which appeared at rest and lasted for several hours. A few days later, he underwent a cardiological examination and the electrocardiogram showed normofrequent sinus rhythm, ST elevation of 3 mm and Q waves formed in the anterior and lateral wall leads. The patient was diagnosed with late ST elevation myocardial infarction and was transported to our emergency department. On blood test, troponin levels were significantly elevated. He was treated with dual antiplatelet therapy (DAPT, aspirin and ticagrelor) and then underwent percutaneous coronary intervention (PCI). The mid segment of the LAD was suboccluded and two drug eluting stent (DES) were implanted. The right coronary artery also had a critical stenosis at the second segment treated with implantation of a DES. Final angiographic result was good (TIMI 3). The patient was admitted to our coronary unit where he continued to receive DAPT. During hospitalization a routine transthoracic echocardiogram (TTE) was performed which showed dilated left ventricle with a–dyskinesis of the apex and middle segment of the septum and the anterior wall and reduced ejection fraction (FE 35%). Within the apical segment of the septum and inferior wall, was noted an area of 40x14 mm with different echogenicity, probably referable to intramyocardial haematoma (IH) of the ventricular wall or a stratified thrombus. Both Colour Doppler and echo–contrast, using Sonovue, did not show a continuity between the suspected IH and one of the ventricular cavities. On cardiac MRI, this finding was considered of uncertain interpretation (whether IH or non–protundant mural thrombus). Late transmural enhancement was also observed at the same echocardiographic sites with subendocardial hypointensity bands consistent with areas of no–reflow. As the patient was clinically stable and TTE monitoring showed no progression of IH, a joint decision was made by cardiologists and cardiac surgeon to continue conservative management with DAPT without initiating anticoagulant therapy. At 1 month follow–up, TTE showed a reduction of the IH and an improvement of the EF to 45%. IH is a rare complication of myocardial infarction and revascularization treatments. The incidence is not well documented and the finding is usually occasional by TTE. Appropriate management is still controversial and a personalised approach is recommended.
P252 THE TREATMENT WITH BETA–BLOCKERS AFTER MYOCARDIAL INFARCTION WITHOUT REDUCED EJECTION FRACTION (REBOOT) TRIAL, 2023 UPDATES
Authors: Bianco M , Lazzero M , Agnelli N , Staszewsky L , Pellizzoni V , Vasami‘ A , Ferraro S , Latini R , Chinaglia A
Published: May 2023

Introduction

The role of beta blockers (BB) post–myocardial infarction (MI) in patients without reduced ejection fraction in the era of invasive management is controversial results from observational studies have led to opposite results.

Methods

REBOOT is an independent multinational pragmatic, controlled, randomized, open–label, with blinded endpoint adjudication clinical trial. The study is testing the benefits of BB maintenance therapy in post–MI patients (either with or without ST segment elevation) discharged with LVEF >40%. Patients ≥18 years old undergoing invasive management during admission and without history of heart failure (HF) are eligible to participate. At discharge, they are 1:1 randomized to either receive BB (agent and dose chosen by the treating physician) or no BB therapy. The primary endpoint is a composite of all–cause death, nonfatal re–MI, or heart failure hospitalization over a minimum follow–up period of 2.75 years (minimum 2 years, maximum 3 years). Events are adjudicated by a blinded committee. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) is the sponsor of the trial and the coordinator of Spanish Centers while Istituto di Ricerche Farmacologiche Mario Negri IRCCS coordinates the Italian participating network. Hospital admission for COVID–19 were also recorded since June 2020.

Results

The study is currently ongoing and 29 Italian centers are still actively recruiting. A sample size of 8468 pts (728 events) was estimated to provide a power of 85% to detect a RRR of 20% (incidence of primary endpoint in control 10%) and assuming 5% withdrawals. More than 75 Spanish and 35 Italian centers recruited patients. The first patients have been included in Spain in October 2018, in Italy in January 2019. On December 31st 2022, the number of enrolled patients by Italian centers was 1685. The top three Italian enrollers at the moment are: Ospedale G. da Saliceto –Piacenza (483 pts), Ospedale S. Luigi Gonzaga – Orbassano (183 pts) and A.O San’Anna and San Sebastiano – Caserta (170 pts). The patient enrollment rate was almost stable during all the study periods with a slight decrease during COVID pandemic outbreaks. The Italian REBOOT Network goal is to include 1800 patients by April 2023. The first results will become available by the end of 2025.

Conclusion

The REBOOT, with other ongoing trials, will provide robust evidence to guide the prescription of BB to patients discharged after MI without reduced LVEF.