bluuebunny/crossref_metadata_2025 huggingface dataset:
FULMINANT EOSINOPHILIC MYOCARDITIS TREATED WITH STEROIDS AND INTRA–AORTIC BALLOON PUMP
Authors: Pazzanese V , Barone G , Galdieri C , Yacoub M , Baldetti L , Sacchi S , Ajello S , Scandroglio A
Published: May 2024

Background

Hypereosinophilic syndrome (HES) is a hematological disorders characterized by a chronic, unexplained hypereosinophilia (HE) with tissue damage. Cardiac involvement occurs in ∼20% of patients with HES and it carries a poor prognosis.Early detection and treatment of myocardial involvement improves prognosis. Immunosuppressive therapy represents the core treatment in the majority of patients with Eosinophilic Myocarditis.

Case Summary

50–year–old man with history of intrinsic asthma and HE was admitted for cardiogenic shock B stage according SCAI classification (heart rate was 130 bpm, systolic blood pressure was 90 mmHg and lactate <2). EKG showed sinus tachycardia and diffuse ST segment depression. Echocardiography revealed severe left ventricular systolic dysfunction and mild pericardial effusion. Blood test showed leukocytosis (33x10^9/L) with HE (47%), mild hepato–renal damage, high TroponinT 3874 pg/mL and NT–proBNP 11060 ng/L. Coronary angiography was unremarkable. Pulmonary artery catheter was placed: IC 1,78 l/min/mq, CPO 0,63, WP 21, SVO2 60%, SVR 17 WU, RAP/WP 0.74. We reclassified patients as SCAI C with “mixed shock” due to inflammatory component and latent right ventricular dysfunction. Intra–aortic balloon pump (IABP) was placed and we performed endomyocardial biopsy (EMB). High dose of intra venous corticosteroids was started obtaining progressive improvement of hemodynamic parameters and reduction of inflammation parameters (Fig.1). EMB confirmed the diagnosis of myocarditis with initial transition into ‘’Loffler’s cardiomyopathy’’. Polymerase chain reaction (PCR) analysis did not detect cardiotropic viruses. After improvement of clinical status we performed cardiac MRI that revealed diffuse biventricular myocardial edema and the presence of subepicardial and mid–wall enhancement with non ischemic pattern,endocardial fibrosis and multiple left ventricular thrombi (Fig. 2). β–blockers and angiotensin–converting enzyme inhibitors were started and the patient was discharged at home with a complete myocardial recovery and immunosuppressive therapy based on corticosteroids and azathioprine.

Discussion

This case demonstrates the usefulness of myocardial biopsy in fulminant myocarditis. Treatment with corticosteroids resulted in rapid improvement. Early invasive monitoring allowed more precise hemodynamic characterization and mechanical circulatory support with IABP proved feasible and might have helped by unloading the left ventricle.
PLATYPNEA–ORTHODEOXIA SYNDROME SECONDARY TO TRAUMATIC TRICUSPID VALVE RUPTURE: A CASE REPORT
Authors: Della Torre M , Freschini M , Del Pinto M
Published: May 2024

Introduction

Platypnea–Orthodeoxia Syndrome (POS) is a rare clinical condition characterized by dyspnea and arterial desaturation exacerbated in an upright position and alleviated in the supine position. The main pathophysiological mechanism involves an intra– or extracardiac right–to–left (R–L) shunt. We report an acute POS presentation secondary to traumatic tricuspid valve rupture.

Clinical Case

A 42–years–old man presented to the ED with new–onset worsening dyspnea. A week prior, he was involved in a car crash with airbag deployment and blunt chest trauma, confining him to bed. In medical history: double surgical aortic valve replacement for endocarditis caused by intravenous drug use. At presentation: BP was 100/65 mmHg, sO2 was 94% on room air. Transthoracic echocardiography revealed a LVEF of 40% with akinesis of the apex and the distal segments. Coronary angiography ruled out LAD artery traumatic injuries. After thorough clinical evaluation, an abnormal drop in sO2 (<80% on room air) was observed in the seated position. A microbubble test demonstrated a massive R–L shunt through the interatrial sept (IAS). Transesophageal echocardiography revealed atrial septal aneurysm, patent foramen ovale (PFO) with R–L shunt, severe tricuspid regurgitation (TR) with the jet directed to the IAS due to a chordae tendineae rupture and posterior leaflet flail. Heart Team discussion: high surgical risk, only the percutaneous closure of the PFO was recommended. The procedure was performed with the deployment of Amplatzer device and resulted free of complications. In the subsequent days, the patient was cautiously mobilized. A 6MWT showed no evidence of desaturation and good effort tolerance. Due to the high surgical risk, a conservative strategy with close clinical and echocardiographic follow–up was adopted regarding the TR. The patient was discharged in clinical compensation and in good general condition.

Conclusion

This case of POS is categorized among those secondary to intracardiac shunting without an increase in pressures in the right heart. The direction of flows within the right cardiac chambers, determined by the TR jet in this instance, dictates the shunt. This report expands our knowledge of potential POS causes, highlighting the importance of considering rarer etiologies based on the patient‘s medical history and presentation. Furthermore, this case emphasizes the necessity for a multidisciplinary approach to assess optimal treatment options.
A RARE MANIFESTATION OF Q FEVER
Authors: Rossi D , Scollo C , D‘Andria R , Magnano R , Pezzi L , D‘Alleva A , Corazzini A , Primavera M , Fulgenzi F , Forlani D , Vitulli P , Paloscia L , Gallina S , Genovesi E , Di Marco M
Published: May 2024

A 19–year–old male with no significant medical history presented to the Emergency Department with persistent chest pain and worsening fever over five days. The 12–lead electrocardiogram (ECG) showed sinus rhythm, elevation of the ST segment in the inferior leads, and slight depression in V1–V2. Laboratory tests revealed elevated cardiac enzymes (hs–TnI 11698 pg/ml) and a mild increase in inflammatory markers. Echocardiography demonstrated normal morpho–functional parameters and a mild pericardial effusion. The patient was admitted to the Cardiovascular Intensive Care Unite with a diagnosis of myopericarditis. Treatment with ibuprofen and colchicine led to a gradual improvement in cardiac enzymes and inflammatory markers. Microbiological exams showed IgM positivity for Coxiella burnetii, suggesting a possible zoonotic origin. Cardiac Magnetic Resonance Imaging (MRI) revealed signs of myocardial edema and non–ischemic late gadolinium enhancement (LGE). As the myopericarditis was uncomplicated, no immunosuppressive/modulatory treatments were administered. Coronary CT confirmed the integrity of the epicardial coronary circulation. One month later, the patient was asymptomatic with no recurrence of fever or chest pain. Pericardial effusion resolved, and laboratory and instrumental findings were normal. The cause of myopericarditis was attributed to Coxiella burnetii, an intracellular bacterium with reservoirs in domestic animals. Transmission occurs through contact with urine, feces, unpasteurized milk, or infected animal placentas. Clinical presentation varies from asymptomatic to flu–like symptoms or organ involvement. The heart can be affected in both endocarditic and, rarely, myocarditic forms. In conclusion, this case represents an infectious myocarditis caused by Coxiella burnetii, confirmed by antibody positivity and a favorable response to anti–inflammatory and antibiotic therapy. In the literature, few cases of myocarditis due to Coxiella burnetii are reported, and it is a rare complication of Q fever. However, it is an entity that exists and should be considered in the appropriate clinical–anamnestic context.
HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFPEF) IN A PATIENT WITH RECENT TAVI AND NUMEROUS CORONARY FISTULAS OF THE LEFT CORONARY ARTERY DRAINING INTO THE VENTRICULAR CAVITY
Authors: Maffei S , Tarsi G , Paolini F
Published: May 2024

Coronary fistula is a rare form of congenital heart disease and is defined as an abnormal connection between a coronary branch and a cardiac chamber or a large intrathoracic vessel without the interposition of the capillary circulation. The right coronary artery is the most common site of origin for coronary fistula. Other sites include the left anterior descending artery and left circumflex artery. The clinical presentation and the natural history can be extremely variable depending on the patient‘s age, fistula size, and anatomy. Small to medium–sized coronary fistulas may be asymptomatic. Large fistulas can manifest with angina pectoris due to myocardial ischemia secondary to the coronary steal phenomenon. Shunting through large fistulas can have hemodynamic consequences secondary to volume overload in the pulmonary or systemic circulation, leading to symptoms and signs of heart failure. We describe the case of an 83–year–old woman recently undergoing TAVI and suffering from primary myelofibrosis requiring periodic transfusions. Pre–TAVI coronary angiography showed coronary vessels free from significant hemodynamic lesions and multiple coronary–ventricular fistulas draining into the left ventricle. Total body aortic CT angiography did not reveal other abnormal vascular connections. One month after the aortic valve correction procedure, the patient presented with heart failure (HfpEF). At a recent follow–up visit, diuretic therapy was discontinued due to the successful correction of aortic valve disease and normal ejection fraction. Due to further anemization from the underlying hematologic condition, the patient underwent blood transfusion with worsening of dyspnea despite correction of hemoglobin levels. Discontinuation of diuretic therapy and transfusion of red blood cell units resulted in volume overload with worsening clinical condition. The presence of multiple coronary fistulas precluded an interventional approach, but therapeutic optimization and reintroduction of diuretic therapy restored the patient‘s hemodynamic compensation. Usually fistulas drain into the low–pressure venous circulation like right ventricle and right atrium. This case represents a rare instance of multiple left coronary fistulas draining into the left ventricle (only 3% of cases). Aortic valve correction may have further reduced left ventricular telediastolic pressures, worsening the shunt of coronary fistulas resulting in heart failure due to volume overload.
HCM AT THE CROSSROAD
Authors: Bosso A
Published: May 2024

Introduction

Treatment of oHCM frequently requires difficult choices, especially when it is superimposed on other urgent clinical conditions,such as AMI or mechanical complications.

Clinical Case

A 52–year–old man with known oHCM, who spontaneously quickly discontinued recommended therapy, presents to theED with a sudden episode of dyspnea and presyncope. A firstECG was essentially normal for pathology. After 1h, the patient experiences a sudden episode of chest pain with rapid hemodynamic deterioration and cardiogenic shock(CS). The ECG shows changes compatible with inferolateral MI. The TTE shows severe LVOTO, SAM, severe MR and a suspicious oval image attached to the anterior mitral leaflet. The patient underwent orotracheal intubation, coronary angiography and TEE. Coronary angiography shows a thrombotic occlusion of the proximal circumflex artery, treated with pPCI. TEE confirms a partial rupture of the papillary muscle head. Treatment:The patient‘s CS can be caused by 2different conditions that require treatments with opposing pathophysiological principles. SevereMR due to papillary muscle rupture, as mechanical complication of MI, requires afterload reduction, hemodynamic stabilization with IABP and emergency transfer to a cardiac surgery center. In contrast, the treatment of the underlying pathology(severe LVOTO and severe rMR due to SAM)requires pharmacological stabilization with depression of cardiac contractility and increase in afterload. In the context of cardiogenic shock a rapid choice was required. To help us make the right choice, an Esmolol test was performed. After iv administration of 2mg Esmolol, heart rate was reduced without reduction in BP. The patient was then treated with esmolol in continuous infusion and norepinephrine. In oHCM the ventriculo–arterial coupling is reduced, less than 1. This treatment favored better V–A coupling, ensuring an increase in afterload and a reduction in myocardial contractility. The patient‘s clinical condition rapidly improved, allowing extubation at48h and early mobilization at96h. Myectomy and mitral repair surgery was scheduled 1 month afterPCI.

Conclusions

Through the use of a short–lived drug such as Esmolol, it was possible to trace the prevailing mechanism of the patient‘s CS. Differently from other cases of CS, to rebalance the V–Acoupling, it was crucial to reduce myocardial contractility and increase afterload. A pathophysiological pharmacological approach ensured a good outcome.
AN UNUSUAL CASE OF VENTRICULAR DYSFUNCTION
Authors: Minopoli T , Petrone A , Di Mario C
Published: May 2024

Sarcoidosis is a multisystemic inflammatory disorder characterized by non–caseating granulomas and rarely involves the heart. While frequently presenting without symptoms, cardiac sarcoidosis can lead to arrhythmias, heart failure, and sudden death, with symptoms mimicking other cardiac conditions. We present a case of a 61–year–old woman admitted to our emergency department in February 2021 with resting dyspnea and atypical chest pain. Elevated hs–troponin and NT–proBNP levels, a new–onset left bundle branch block on ECG, and signs of pulmonary congestion on chest X–ray prompted further investigation. Echocardiography revealed diffuse hypokinesis with akinesia of the mid–apical inferior wall and a significant ventricular dysfunction (LVEF 30%). Coronary angiography excluded lesions, diagnosing MINOCA. Cardiac MRI showed transmural fibrosis without a typical cardiomyopathic pattern. An FDG–PET scan indicated uptake in the heart and lymph nodes. A biopsy of a left supraclavicular lymph node confirmed non–necrotizing granulomas, consolidating the diagnosis of cardiac sarcoidosis. Treatment with Prednisone 25 mg was initiated and gradually tapered to 6.5 mg, leading to a progressive normalization of systolic function (LVEF 56% at 12–month follow–up) and resolution of lymphadenopathies. Unexplained isolated ventricular dysfunction presents a wide range of potential causes. Despite its rarity, sarcoidosis should be considered as a possible etiology. While characteristic patterns may emerge in cardiac MRI, atypical presentations underscore the need for a comprehensive diagnostic approach. Timely diagnosis and effective treatment can significantly enhance prognosis, emphasizing the importance of prompt intervention for optimal outcomes.
ACUTE PERICARDITIS IN A PATIENT WITH PRIMARY HEART LYMPHOMA
Authors: Lanati G , Di Spigno F , Caraffini A , Sabatino M , Covini D , Turchio P , Rusticali G , Febo O , Aschieri D
Published: May 2024

A 51–year–old male patient was admitted to the emergency room for stabbing chest pain associated with dyspnea on mild exertion. Past medical history: obesity, previous HCV infection, previous intravenous substance abuse. Physical examination: no audible cardiac murmurs or rubs, no wet lung sounds, mild edema of the face and upper limbs. ECG: sinus rhythm, no repolarization alterations. Lab tests: elevation of troponin I (93 ng/l) and CRP (2 mg/dl). Echocardiogram (poor visualization): non–dilated and normokinetic left ventricle (EF 0.55), no significant valvular disease, mild pericardial effusion. Coronary angiography: no obstructive coronary disease. A diagnosis of acute pericarditis was made, and anti–inflammatory therapy with ibuprofen and colchicine was started. Cardiac MRI showed a large right atrial mass, which infiltrates the interatrial septum and causes obstruction of the superior vena cava; the mass showed hypointensity on T1, clear hyperintensity on T2 and modest and non–homogeneous late gadolinium enhancement; mediastinal lymphadenopathy was also detected; overall, the exam raised the suspicion of malignant primary cardiac tumor (cardiac lymphoma versus angiosarcoma). The patient was referred to a tertiary center for endomyocardial biopsy, which showed the presence of large B–cell lymphoma, and the patient was started on chemotherapy. Discussion Cardiac masses are rare and usually benign. Malignant tumors are more frequently secondary, while primary ones are very rare. Lymphomas represent 1–2% of all cardiac tumors, are more frequent in male adults and are associated with immunodeficiency conditions. 70% are diffuse large B–cell lymphomas. Transthoracic echocardiogram is the main first–level test but has poor sensitivity, especially in cases with high acoustic impedance. Cardiac MRI is the main test for accurate anatomical definition and tissue characterization. In this specific case, the hyperintensity in the T2 sequences, the presence of inhomogeneous LGE and the mediastinal lymphadenopathy suggested the possible lymphoproliferative nature of the mass. Angiosarcoma appears more heterogeneous on T2 sequences and presents a ring of peripheral enhancement with central hypopointesity in post–contrast sequences. Endomyocardial biopsy allows for a definitive diagnosis, but is performed only when the benefits outweigh the risks. In this case, it proved to be essential for the histological characterization and the subsequent therapeutic approach.
USE OF SGLT2–INHIBITORS IN THE TREATMENT OF ANTHRACICLINE CARDIOTOXICITY
Authors: Pezzi L , Magnano R , D‘Alleva A , Vitulli P , Forlani D , Primavera M , Verrengia E , Corazzini A , Duronio G , Genovesi E , Paloscia L , Di Marco M
Published: May 2024

The survival rate of cancer patients has significantly increased in the last 25 years thanks to the extraordinary advances in anti-tumor therapies. However, many chemotherapeutic agents are potentially cardiotoxic. In particular, anthracycline-induced cardiotoxicity is a clinical condition caused by chemotherapy drugs that lead to morpho-functional alterations and cell death of cardiomyocytes; the most typical clinical manifestation of this cardiotoxicity is the development of left ventricular dysfunction, which over time can evolve towards full-blown heart failure. It is therefore characterized by a reversible asymptomatic stage that progresses to an irreversible stage, often difficult to treat. For an early individualization of this toxicity, a dedicated clinic has been established in our center for the monitoring of patients undergoing treatment with cardiotoxic chemotherapy. We describe the case of a 53-year-old patient with preserved biventricular systolic function undergoing neoadjuvant treatment for breast cancer, who at the end of the second infusion of anthracyclines presented with mild exertional dyspnoea associated with radiological signs of pulmonary congestion and an increase in the indices of myocardionecrosis and BNP. The echocardiogram revealed a sudden worsening of the left ventricular systolic function which was 48%. It was therefore decided to hospitalize the patient and initiate infusional diuretic therapy with a rapid clinical and instrumental response. An SGLT2 inhibitor with indication for the treatment of heart failure with moderately reduced ejection fraction was also added to the therapy. At the one-month check-up, there was an almost complete recovery of left ventricular function and a clear symptomatic benefit with associated normalization of laboratory markers of myocardial damage and heart failure, with the possibility for the patient to undergo surgery to remove the left ventricle. tumor mass. This clinical case could represent a starting point to start considering therapy with SGLT2 inhibitors for the prevention and early treatment of cardiac toxicities from some chemotherapeutics, in order to avoid the process of irreversibility of myocardial damage with subsequent poor response to anti-inflammatory therapies. – conventional compensation.
A CASE REPORT OF MICROVASCULAR ANGINA WITH ATYPICAL ECG FINDINGS
Authors: Todisco S , Federico D , Cappannoli L , Buffon A , Fracassi F , Burzotta F , Crea F
Published: May 2024

Coronary microvascular dysfunction (CMD) relates to a broad range of clinical settings in which cardiac microcirculation is morphologically and/or functionally affected, leading to myocardial ischemia and causing anginal symptoms (microvascular angina). Based on the pathogenetic mechanism, there are two possible endotypes of CMD: 1) coronary microvascular spasm and 2) reduced coronary flow reserve (CFR). The gold standard for CMD diagnosis is represented by the coronary angiography with functional tests: 1) the acetylcholine provocative test for the diagnosis of microvascular spasm (endothelium–dependent dysfunction); 2) the determination of CFR and of the index of microvascular resistance (IMR) thorough a flow guidewire after endothelium–independent vasodilation (usually obtained with intracoronary adenosine injection). We report an emblematic case of CMD due to microvascular spasm in a young woman with episodes of typical angina at rest, especially during the night, associated with tachycardia episodes. The patient was admitted to the cardiology unit and underwent coronary angiography, which revealed mild coronary atherosclerosis without any significant stenosis. Due to the very suggestive clinical presentation, provocative test by intracoronary acetylcholine infusion at increasing doses (20–50–100 micrograms) was also performed: from the beginning of the second dose (50 micrograms) the patient started suffering from her typical angor (symptomatology similar to that reported at home), and diffuse ST–T alterations (ST depression and T waves inversion in precordial leads) occurred. At the beginning of the third dose (100 micrograms) a lateral ST–segment elevation (mostly in aVL) was surprisingly observed. The ST–T modifications (including the elevation) were interestingly associated with only diffuse moderate vasoconstriction of the left anterior descending artery, not fulfilling the Covadis criteria for epicardial vasospasm, thus suggesting the presence of a vasospasm of the coronary microcirculation. Symptoms and ECG changes both regressed after intracoronary nitrates administration. As a consequence of the diagnosis of microvascular angina with microvascular vasospasm, medical therapy with calcium antagonists was administered (withdrawing beta–blockers).
CORONARY ARTERY ANEURYSM IN IGG4–RELATED DISEASE
Authors: Mingoia G , Astuti G , Orlando E , Comparato F , Farina C , D’Angelo F , Leggio G , Evola S , Novo G , Corrado E , Puccio D
Published: May 2024

Introduction

Coronary artery ectasia is a rare disease defined as a local or diffuse dilatation of the coronary artery more than 1.5 times the diameter of the adiacent normal segment. The etiology is diverse and can be rarely associated with immunoglobulin G4 (IgG4)–related disease. The high levels of serum IgG4 may promote the development of low–density plaques, intimal thickening due to pericoronitis and subsequent coronary ectasia.

Case Report

We present the case of a 72–year–old male patient with arterial hypertension, dyslipidemia, chronic renal insufficiency, and a family history of cardiovascular diseases. In the previous year, he suffered a cerebral hemorrhage attributed to an unspecified cerebral vascular malformation, which was managed with an endovascular approach. The patient was admitted for Non–ST–segment Elevation Myocardial Infarction (NSTEMI). Coronary angiography revealed widespread ectasia of the coronary vessels, a chronically occluded marginal branch, and an aneurysmatic proximal right coronary artery with the presence of a thrombus on the aneurysmal segment, dissolved following administration of intracoronaric heparin. Furthermore a critical stenosis at the crux involving the posterior interventricular branch was detected and angioplasty with drug–eluting stent implantation was performed on the affected vessel. Given the coronary artery ectasia, aortic ectasia revealed by echocardiography, renal insufficiency and persistently elevated amylase and lipase levels, further diagnostic investigation was conducted suspecting IgG4–related disease. Hematological tests revealed elevated IgG and IgG4 subclass levels (882 mg/dL and 1438 mg/L, respectively), C3 117 mg/dL, C4 30 mg/dL, and total IgE 130 KU/L. The diagnosis of IgG4–related disease was confirmed and the patient was advised to continue cardiological and rheumatological follow–up.

Conclusion

When the coronary arteries are involved in the IgG4–related disease, risk of acute events such as heart attack may increase and the prognosis is poor. Coronary thickening and ectasia, typical imaging features, other aortic involvement and inflammation indicators, like elevated serum IgG4, should be considered as red flags for an early investigation and subsequent early intervention.
LEFT ATRIAL COMPRESSION BY HIATAL HERNIA IN A PATIENT WITH INTESTINAL OCCLUSION
Authors: Cangemi S , Bartolotta T , Geraci G
Published: May 2024

Introduction

A 93–year–old woman was admitted to the emergency department due to undifferentiated shock, she was unconscious and hypotensive. A 12–leads EKG was unremarkable except for sinus tachycardia. The patient was reanimated using volume filling. The objective examination showed cold and sweaty skin, the thoracic auscultation was normal and the abdomen was bloated without tenderness. The cardiologist consultant was called to perform a complete echocardiography Investigation Following volemic filling, the patient became conscious. She reported to have difficulty evacuating for the past three days. The echocardiogram evidenced:” Left ventricle of small dimension hyperkinetic. Left atrium was very small and compressed by a massive external mass. Due to a displacement of mitral leaflet and severe hypovolemia, there was systolic anterior movement of anterior mitral leaflet with moderate mitral regurgitation and significant aortic gradient“. Considering the possibility that the mediastinal mass was the dilated gastric fundus of a hiatal hernia, we placed a nasogastric tube with aspiration of fecal material. After stabilizing, we took the patient for a complete total body CT scan, which confirmed the picture of intestinal obstruction with the presence of a massive hiatal hernia in the mediastinum.

Management

After volume refilling and aspiration of the gastric contents using a nasogastric tube, the patient reported a significant clinical improvement. The patient underwent intestinal resection and repair of the crural hernia. The patient was discharged home and a control echocardiogram showed good biventricular kinetics without significant valvular disease.

Discussion

A hiatal hernia is a condition in which the upper part of the stomach or other internal organ bulges through the hiatus of the diaphragm often causing gastroesophageal reflux disease. In our clinical case the hiatal hernia modified the clinical expression of the intestinal occlusion, i.e. not only a hypovolemic shock but the dilation of the gastric fundus present in the mediastinum determined the compression of the atrium with consequent reduction in cardiac output. The timely identification of these causes via echocardiogram allowed correct treatment.

Conclusion

We present a clinical case of initial undifferentiated shock where the use of echocardiography helped to understand a rare mechanism of shock: hypovolemia plus cardiogenic shock due to left atrial compression by a massive hiatal hernia.
RENAL INFARCTION: AN ACUTE COMPLICATION OF APICAL THROMBOSIS IN A PATIENT WITH STEMI
Authors: Pedio E , Tauro S , Perfetti S , Zaccaro S , Greco G , Mandunzio D , Caldarola P
Published: May 2024

Introduction

Left ventricular thrombosis (LVT) is a complication that can be found in up to 12% patients with anterior ST–elevation myocardial infarction (STEMI).

Discussion

We reported a case of a 50–years–old male referred to our department for chest pain and ischemic ECG abnormalities. At admission he was hemodynamically stable, complaining of angina. ECG showed sinus rhythm and ST–segment elevation in V1–V4 and Q waves in the anterior leads. Thus diagnosis of anterior STEMI was made and urgent coronary angiography was performed: left descending artery occlusion was treated with primary angioplasty. Laboratory tests pointed out high troponin levels (13124 ng/L, normal <14 ng/L). Transthoracic echocardiogram (TTE) showed severe LV dysfunction (ejection fraction 30%); akinesia of apex, septum, anterior and mid inferior segments and spontaneous echo contrast in LV. TTE performed 6 days later revealed two mobile thrombi (1.2 x 0.5 cm and 2,1 x 0,7 cm) in LV lateral and septal apex. Anticoagulant therapy with Warfarin was started and low–molecular weight heparin was administered until International Normalized Ratio (INR) value reached a therapeutic range. Moreover de–escalation of P2Y12 receptor inhibitor therapy (switch from ticagrelor to clopidogrel) was carried out. Few days later, because of flank pain and vomiting, an abdominal CT was performed. It showed two right renal infarcts. The following TTE revealed just the presence of the thrombus located in LV septal apex. After one week LVT was no longer detected at TTE and the patient was discharged to cardiac rehabilitation, continuing therapy with Vitamin K antagonists (VKA).

Conclusions

LVT may lead to systemic embolism and consequently, in some cases, to renal infarction. This case report proves the importance of serially evaluating, with TTE, STEMI patients, in particular when apex akinesia is known. Treatment of LVT is anticoagulant therapy, extended for 3–6 months, usually with VKA, with an target INR of 2,5. New ESC guidelines for acute coronary syndromes pave the way to the use of new oral anti–coagulants (NOAC), after results of a meta–analysis and studies conducted on Rivaroxaban. In our case, administration of NOAC was not taken into account due to Chronic Kidney Disease. In conclusion, the treatment of LVT is nowadays a challenge for cardiologists, given the lack of data and the unstable balance between the hemorrhagic and thrombotic risk related to STEMI patients.
CARDIAC REMODELING AND OUTCOME AFTER SURGICAL INTERVENTION FOR ATRIAL FUNCTIONAL MITRAL REGURGITATION
Authors: Cortese F , Costantino M , Luisiana S , Serena D , Luzi G
Published: May 2024

The atrial functional mitral regurgitation refers to a newly recognized disease entity in which mitral regurgitation occurs secondary to left atrial disease, without left ventricular dilatation and intrinsic mitral valve disease. To better define this new entity and understand the benefits of surgery in patients with severe regurgitation, we conducted an observational analysis on 28 subjects with atrial functional mitral regurgitation who underwent surgical treatment between February 2020 and December 2022, at the Cardio Surgery Department of the “San Carlo” Hospital in Potenza. Twenty–eight subjects (11 males, 39.3%), mean age ± standard deviation 72.7 ± 8.4 years, who underwent surgical correction (mitral annuloplasty and tricuspid ring annuloplasty when needed) for significant atrial functional mitral regurgitation, sometimes associated with significant tricuspid insufficiency, were evaluated. No surgical treatment of atrial fibrillation has been performed. Subjects were assessed at enrollment and at one–year follow–up. We evaluated clinical and echocardiographic parameters. There was no in–hospital mortality. Mitral valve repair determined a reverse remodeling of the left ventricle and left atrium, with a significant reduction of the end–diastolic volume of the left ventricle [110 ml (95–148 ml)] vs. (55 ml (48–59 ml), z: –0,7, p<0.001]) and of left atrial volume [83.5 ml (63.2–96.5 ml) vs. 63 ml (45.5–78.7 ml), z: –3.2, p: <0.01]. We also observed a significant reduction of the estimated pressure in the pulmonary artery, an expression of reduced pressures in the left ventricle that affect the pulmonary circulation [35 mmHg (30–43) vs. 25 (22–32.7), z: –3.9, p< 0.001]. Results were not altered by the presence or absence of atrial fibrillation. The overall 1–year survival rates were 100% and all the patients recovered to NYHA functional class I/II at the follow up (z: –6, p < 0.001). Our results suggest that mitral valve repair for atrial functional mitral regurgitation is safe and effective. It improves heart failure symptoms and results in reverse–remodeling of both the left atrium and left ventricle. The presence of atrial fibrillation did not alter the outcome.
CHRONIC INFECTION AND SEVERE MITRAL REGURGITATION: A TRICKY CASE REPORT
Authors: Pozzi A , Bartesaghi G , Refugjati T , Bonfanti P , Berlinghieri N , Foglia Manzillo G , Esposito G , Corrado G
Published: May 2024

Background

Techniques of mitral valve repair has improved in the last decades. Percutaneous approach is now a reliable and safe therapy in those patients with high surgical risk. Of note, the presence of implanted prothesis may increase the risk of endocarditis, especially in those patients experiencing recurrent infection.

Case Summary

We describe a case of a 75–year–old with medical history of chronic lymphedema. It was characterized by periodical episode (yearly) of cellulitis, with a rapid onset of fever (38.5–39° C), lasting for a few days after paracetamol therapy. Patients had severe mitral valve regurgitation due to prolapse of the posterior leaflet (P2). In December 2022, he had percutaneous edge–to–edge mitral valve. Three months later the patient was admitted to the emergency department of our hospital due to fever without any specific symptoms. The patient was well compensated, normal blood pressure, heart rate and oxygen saturation. He had emocolture which revealed the presence of Staphilococcus lugdunensis. Transesophageal echocardiogram confirmed the presence endocarditis, showing a huge (10x12 mm) vegetation at the level of mitral device (Fig 1 and 2). Patients was then referred to cardiac surgery for urgent mitral valve replacement with mitral bioprothesis (Fig 3). He was treated with ev antibiotic for six weeks after cardiac surgery. Additionally, chronic treatment with amoxicillin 500 mg/day was also prescribed at discharge. After six months follow–up, patients had no signs of endocarditis.

Conclusion

The management and treatment of chronic infection is of paramount importance to reduce the risk of prothesis infection procedure in patients needing a prothesis implantation. The last European Society of Cardiology guidelines on endocarditis do not provide any recommendation regarding a long–term treatment of patients with high risk of infection (i.e. due to chronic infection) and with an implanted cardiac device/prothesis. We believe this represents an important unmeet need.
RIGHT VENTRICULAR TO PULMONARY ARTERY COUPLING AND IN–HOSPITAL OUTCOMES IN PATIENTS WITH SEVERE PRIMARY MITRAL REGURGITATION UNDERGOING CARDIAC SURGERY
Authors: Grieco M , Bonelli A , Guasti S , Di Simone V , De Sanctis G , De Chiara B , Cerrito L , Russo C , Giannattasio C , Moreo A
Published: May 2024

Background

Recent data suggests that right ventricular to pulmonary artery (RV–PA) uncoupling negatively influences prognosis in several clinical conditions. Little is known about the role of RV–PA coupling in patients with mitral regurgitation (MR).

Objectives

Our study aimed to investigate the role of RV–PA coupling in a cohort of patients with chronic severe primary MR (PMR) undergoing cardiac surgery.

Methods

We retrospectively assessed patients with severe PMR undergoing surgical repair or replacement from January 2018 to December 2021. Patients underwent preoperative transthoracic echocardiography and speckle tracking analysis. RV–PA coupling was assessed by the ratio of RV global longitudinal strain (RVGLS) and pulmonary artery systolic pressure (PASP). Patients were divided into tertiles according to RVGLS/PASP values. We studied the association between RV–PA coupling and the length of stay in the intensive care unit (ICU), the length of hospitalization and NYHA class at discharge.

Results

A total of 120 patients (mean age 65.2 ± 11.9 y) were included in the study. 84 (70%) patients underwent surgical valve repair while 36 (30%) underwent surgical valve replacement. Patients with lower RVGLS/PASP values had lower left ventricular ejection fraction (LVEF: 58.1±10.5% vs 62.0±7.4% vs 62.9±5.3%, p=0.018), more dilated left atrial volume (LAV: 71.0±21.9ml/m2 vs 62.3±21.2ml/m2 vs 55.9±23.9ml/m2, p=0.012) and lower peak atrial longitudinal strain values (PALS: 21.1 ± 10.1% vs 29.7 ± 11.0% vs 34.1 ± 9.4%, p<0.001). Patients with lower RVGLS/PASP ratio had longer hospital stay (11.5 ± 3.9 vs 10.4 ± 3.4 vs 8.5 ± 2.2 days, p<0.001) and stay in ICU (3.7 ± 2.0 vs 2.8 ± 2.4 vs 1.9 ± 1.3 days, p< 0.001). There was a significant inverse association between RVGLS/PASP and hospital stay and length of stay in ICU [for each 0.1%/mmHg increase: respectively β=–0.59 (–0.89; –0.29), p< 0.001 (Figure 1) and β=–0.35 (–0.53;–0.17), p<0.001 (Figure 2)]. Moreover, RVGLS/PASP was also associated with the probability of having a NYHA class ≥ 2 at discharge [OR 0.69(0.54; 0.89), p= 0.004 (Figure 3)]. These relationships were confirmed after adjustment for other variables.

Conclusions

Our study suggests that in patients with PMR undergoing cardiac surgery RV–PA coupling may identify a more compromised group of patients and that it is related to clinical outcomes in the very short–term after surgery.
Diverse Gene Regulatory Mechanisms Alter Rattlesnake Venom Gene Expression at Fine Evolutionary Scales
Authors: Gopalan Siddharth S , Perry Blair W , Francioli Yannick Z , Schield Drew R , Guss Hannah D , Bernstein Justin M , Ballard Kaas , Smith Cara F , Saviola Anthony J , Adams Richard H , Mackessy Stephen P , Castoe Todd A
Published: May 2024

Understanding and predicting the relationships between genotype and phenotype is often challenging, largely due to the complex nature of eukaryotic gene regulation. A step towards this goal is to map how phenotypic diversity evolves through genomic changes that modify gene regulatory interactions. Using the Prairie Rattlesnake (Crotalus viridis) and related species, we integrate mRNA-seq, proteomic, ATAC-seq and whole-genome resequencing data to understand how specific evolutionary modifications to gene regulatory network components produce differences in venom gene expression. Through comparisons within and between species, we find a remarkably high degree of gene expression and regulatory network variation across even a shallow level of evolutionary divergence. We use these data to test hypotheses about the roles of specific trans-factors and cis-regulatory elements, how these roles may vary across venom genes and gene families, and how variation in regulatory systems drive diversity in venom phenotypes. Our results illustrate that differences in chromatin and genotype at regulatory elements play major roles in modulating expression. However, we also find that enhancer deletions, differences in transcription factor expression, and variation in activity of the insulator protein CTCF also likely impact venom phenotypes. Our findings provide insight into the diversity and gene-specificity of gene regulatory features and highlight the value of comparative studies to link gene regulatory network variation to phenotypic variation.
Copyright in the Artificial Intelligence Act – A Primer
Authors: Peukert Alexander
Published: May 2024

The European Union’s AI Act as adopted by the European Parliament on 13 March 2024 contains two provisions of particular relevance for copyright. According to Art. 53(1)(c) and (d), providers of general-purpose AI models shall (1) put in place a policy to comply with Union copyright law, and in particular to identify and comply with, including through state of the art technologies, a reservation of rights expressed pursuant to Art. 4(3) of Directive (EU) 2019/790, and (2) draw up and make publicly available a sufficiently detailed summary about the content used for training of the general-purpose AI model. This article summarizes the history of these provisions, explains that the EU legislature has merged two different types of laws, identifies the addressees of the copyright-related obligations, and gives an overview of their legal nature, content and enforcement.
Ensemble machine learning for managing the required thermal energy from the architectural characteristics of residential buildings
Authors: Gan HuiHui , Gao Wei
Published: May 2024

Forecasting the amount of required energy is a primary task for sustainable building design. In recent decades, machine learning (ML) has provided effective solutions to this problem, particularly thermal energy forecasting. This study aims to develop new ML paradigms for predicting annual thermal energy demand (EDAT) based on the building’s architecture. A valid dataset is obtained from the previous literature to feed the ML models. It is then synthesized with four of the most recent optimization algorithms, namely gazelle optimization algorithm (GOA), incomprehensible but intelligible-in-time logics (ILA), osprey optimization algorithm (OOA) and sooty tern optimization algorithm (STOA), which are responsible for training the ML. The quality of training and validation of the ensembles used are checked using relative and absolute accuracy quantifiers. According to the results, all four ensembles of ML-GOA, ML-ILA, ML-OOA and ML-STOA are trained and validated with excellent accuracy, and therefore, they can be recommended for the practical forecast of the EDAT. A comparison, however, disclosed the superiority of the GOA-based model. This model has also been successfully validated against several hybrid algorithms used in earlier efforts. In short, the introduced models can directly contribute to the energy–construction sectors by assisting decision-makers in effectively designing residential buildings and their energy systems.
Wombat burrows are hotspots for small vertebrates in a landscape subject to gigafire
Authors: Linley Grant D , Geary William L , Jolly Chris J , Spencer Emma E , Ashman Kita R , Michael Damian R , Westaway Dylan M , Nimmo Dale G
Published: May 2024

Ecosystem engineers modify their environment and influence the availability of resources for other organisms. Burrowing species, a subset of allogenic engineers, are gaining recognition as ecological facilitators. Burrows created by these species provide habitat for a diverse array of other organisms. Following disturbances, burrows could also serve as ecological refuges, thereby enhancing ecological resistance to disturbance events. We explored the ecological role of Common Wombat (Vombatus ursinus) burrows using camera traps in forests of southeastern Australia. We compared animal activity at paired sites with and without burrows, from the same fire severity class and habitat. We examined how animal activity at Common Wombat burrows was affected by the 2019–20 Black Summer bushfires in Australia. We predicted that burrows would serve as hotspots for animal activity and as refuges in burned areas. The activity of several species including Bush Rat (Rattus fuscipes), Agile Antechinus (Antechinus agilis), Lace Monitor (Varanus varius), Painted Button-quail (Turnix varius), and Grey Shrike-thrush (Colluricincla harmonica) increased at sites where Common Wombat burrows were present, while other species avoided burrows. Species that were more active at burrows tended to be smaller mammal and bird species that are vulnerable to predation, whereas species that avoided burrows tended to be larger mammals that might compete with Common Wombat for resources. Species composition differed between sites with and without burrows, and burrow sites had higher native mammal species richness. The association of several species with burrows persisted or strengthened in areas that burned during the 2019–20 Black Summer bushfires, suggesting that Common Wombat burrows may act as ecological refuges for animals following severe wildfire. Our findings have relevance for understanding how animals survive, persist, and recover following extreme wildfire events.
Shepherd’s Accounts of Space and Time
Authors: Landy David
Published: May 2024

There is an apparent tension in Shepherd’s accounts of space and time. Firstly, Shepherd explicitly claims that we know that the space and time of the unperceived world exist because they cause our phenomenal experience of them. Secondly, Shepherd emphasizes that empty space and time do not have the power to effect any change in the world. My proposal is that for Shepherd time has exactly one causal power: to provide for the continued existence of self-same or changing objects. Because Shepherd takes causation to be a relation whereby two objects combine to form a third, their effect, whenever we perceive a continually existing object, since time is a proper part of such objects, our perception of time is caused by time itself. Likewise, space’s causal power is to provide for the possibility of the motion or rest of objects, and so when we perceive objects with space as a proper part, we come into causal contact with space.
Beyond Hasidism: Tracing the Cultural Legacies of Israel Ba’al Shem Tov
Authors: Moseson Elly
Published: May 2024

While Israel Ba’al Shem Tov (the Besht) is traditionally considered the founder of Hasidism, modern scholarship has shown that the Hasidic movement emerged only in the decades following his death. This image of the Besht as the founder of Hasidism poses significant challenges in assessing his impact both during his lifetime and independently of the movement. This study seeks to extricate him from the Hasidic context that has historically defined him by analyzing four distinct types of traditions that preserve his cultural legacy—mystical pietistic teachings, kabbalistic intentional formulae (kavvanot), medico-magical recipes, and biographical narratives—and tracing their oral and written transmission histories. It argues that the initial dissemination of traditions attributed to the Besht both preceded and exceeded the Hasidic movement and that recognizing this fact allows for a better appreciation of his contributions to Jewish culture on their own terms, as well as a more accurate assessment of their subsequent influence on the Hasidic movement.
(Successful) Democracies Breed Their Own Support
Authors: Acemoglu Daron , Ajzenman Nicolás , Aksoy Cevat Giray , Fiszbein Martin , Molina Carlos
Published: May 2024

Using large-scale survey data covering more than 110 countries and exploiting within-country variation across cohorts and surveys, we show that individuals with longer exposure to democracy display stronger support for democratic institutions, and that this effect is almost entirely driven by exposure to democracies with successful performance in terms of economic growth, control of corruption, peace and political stability, and public goods provision. Across a variety of specifications, estimation methods, and samples, the results are robust, and the timing and nature of the effects are consistent with our interpretation. We also present suggestive evidence that democratic institutions that receive support from their citizens perform better in the face of negative shocks.