bluuebunny/crossref_metadata_2025 huggingface dataset:
CHARACTERISATION OF THE 12–LEAD ECG IN PAEDIATRIC CARRIERS OF PLAKOPHILLIN–2 GENE VARIANTS
Authors: Imperatore G , Montuoro S , Moscatelli S , Field E , Kaski J
Published: May 2024

Background and Aim

The PKP2 gene encodes the desmosomal protein Plakophilin–2, vital for cellular adhesion between cardiomyocytes. It is associated with classical Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), a cardiac disorder that can cause malignant ventricular arrhythmias and sudden cardiac death in the young. The 12–lead electrocardiogram (ECG) is an important tool for diagnosis of ARVC but ECG patterns in paediatric carriers of PKP2 variants have not been previously systematically assessed.

Methods

The retrospective study enrolled paediatric (<18 years) PKP2 gene carriers referred to Great Ormond Street Hospital between 2005 and 2023. Their ECGs were analysed and compared with an age and gender–matched healthy population using paired two–tailed χ2–test.

Results

28 PKP2 variant carriers (54% females) were identified, of which 2 (7%) were diagnosed with ARVC at the time of the ECG, with a mean age of 13.6 +∕– 4.8 years. These were compared to 28 healthy controls (mean age of 12.7 +/– 4.4 years). 17 carriers (60%) had low QRS voltages in the lateral leads, compared to 4 controls (16%). Fractioned QRS complexes were seen in the lateral leads in 19 (67%) and in the septal leads in 20 (71%), compared to 1 and 2 controls (3.5% and 7%, respectively). Abnormal T wave inversion (TWI) for age was found in 54% of the patients (29% in lateral leads) and flat T waves in 22 patients (78%); but these were not statistically–significantly different to controls.

Conclusions

Paediatric carriers of PKP2 gene variants are more likely to have low QRS voltages and QRS fractionation in the lateral and anterior leads than normal controls, but the presence of abnormally inverted or flat T waves did not discriminate between gene carriers and controls. Our findings suggest that paediatric–specific ECG features may represent early phenotypic expression of PKP2 gene variants.
MAGNETIC RESONANCE AND CARDIAC IMPLANTABLE DEVICES: A SAFE COMBINATION
Authors: Saporito D , Fabbri F , Spighi L , Trevisi N , Ottani F
Published: May 2024

Despite guidelines the presence of a cardiac implantable device (CIED) in a magnetic resonance (MR) ambient raises fears and perplexities and generates the often inappropriate request for support from the electrophysiologist. From January 2019 to November 2023 all patients with a cardiac implantable device (CIED) undergoing magnetic resonance (MR) were evaluated. All CIEDS were classified into three subgroups: MR–conditional, MR–unsafe and "non MR–conditional" (catheters and generators MR–conditional but of different manufacturers). No implantable loop recorders were enrolled. We performed a device control immediately before and after the RM procedure. We analyzed the percentage variations of each parameter (sensing, impedance and pacing threshold) pre– and post–MR and the variation versus the latest or the subsequent ambulatory control. 151 patients were proposed to undergo MR. 16 patients underwent multiple exams. The districts explored from RM were head (47%), column (21%), breast (1%), heart (3%), abdomen (20%), prostate (2%) and arms (16%). The median age was 70 years old, and 102 patients were males. CIEDS were pacemaker in 67% (3 leadless and 1 CRT–P), 33% defibrillators (5 S–ICD and 10 CRT–D). 85% of the systems were classified as MR–conditional, 3% as MR–unsafe and 12% as "non MR–conditional". The percentage median variation of atrial and ventricular sensing, impedance and threshold during the exam was 0%. MR did not significantly modify the parameters considered. No adverse events arise at the end of MR or in the days after. In our experience, there is no need for the presence of the electrophysiologist during the procedure due to safety even in "non MRI–conditional" or MR–unsafe patients.
CONTRAST STRESS ECHOCARDIOGRAPHY FINDINGS IN MYOCARDIAL BRIDGING COMPARED TO NORMAL CORONARY COURSE, WITH AND WITHOUT CORONARY ARTERY DISEASE
Authors: Tuttolomondo D , Gaibazzi N , Guerra E , Bergamaschi L , Pizzi C
Published: May 2024

Background

Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD).

Methods

We evaluated all consecutive patients who underwent contrast stress echocardiography and coronary computed tomography angiography (CCTA) due to suspected symptoms of CAD within 3 months in Parma Hospital. Coronary computed tomography angiography served as the reference standard for detecting MB and obstructive CAD. The patients were divided into 3 groups: (1) MB and no evidence of obstructive CAD (MB group, N = 64), (2) no evidence of obstructive CAD or MB (NoCAD group, N = 135), (3) obstructive CAD without MB (CAD group, N = 68).

Results

The coronary flow velocity reserve in the LAD (CFVR–LAD) was reduced in the MB and CAD groups, measuring 1.91 ± 0.21 and 1.82 ± 0.28, respectively, whereas it was 2.27 ± 0.34 in the NoCAD group (P < .001). The MB and CAD groups exhibited a higher prevalence of reversible myocardial perfusion defects (rMPDs) compared to the NoCAD group (57.8% vs 64.7% vs 3.7%, P < .001). Reversible wall motion abnormalities were frequently observed in the CAD group and rarely found in the MB and NoCAD groups (47.1% vs 18.8% vs 4.4%, P < .001). In multivariable analyses, the presence of MB was independently associated with reduced CFVR–LAD (odds ratio = 14.55; 95% CI, 6.84–30.93; P < .001) and the presence of rMPD (odds ratio = 37.96; 95% CI, 13.49–106.84; P < .001). Patients with deep MB (>2 mm depth) and very deep MB (≥5 mm depth) exhibited significantly greater CFVR–LAD reduction and rMPD than those with superficial MB.

Conclusions

Myocardial bridging is capable of inducing rMPD and reducing CFVR–LAD similar to obstructive CAD. The depth of the MB correlates with the abnormalities found in the stress echo evaluation. Contrast stress echo may serve as a valuable noninvasive tool for evaluating patients with MB.
CHANGES IN LEFT ATRIAL VOLUME DURING ECHOSTRESS IN PATIENTS UNDERGOING MITRAL VALVE PLASTIC CARDIAC SURGERY
Authors: Tassone E , Morabito G , Carullo G , Nardella S , Maselli D
Published: May 2024

Mitral Regurgitation (MR) is characterized by a high morbidity and mortality that often finds a solution only in the reparative surgical treatment, in particular in presence of myxomatous degeneration that cause the prolapse of one or both leaflets. This results in an increase in diastolic pressure that leads to a progressive dilation of the left atrium. The increase in Left Atrium Volume Index (LAVI) during stress test represents a negative prognostic factor in the clinical evolution of many pathologies, such as ischemic heart disease, hypertrophic cardiomyopathy, heart failure. An increase in peak/rest LAVI >6.8 ml/m2 correlates with a higher incidence of heart failure decompensation, reduced left ventricular contractile reserve (LVCR), pulmonary congestion.

We evaluate the effect of MR reparative surgery on the changes of LAVI during stress–echo. We enrolled 19 patients, 11 females and 8 males, affected by MR candidate to cardiac surgery. We performed a physical stress–echo test by using the ABCDE protocol suggested by the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI), before and after 12 weeks from surgery. During each test, the changes in LAVI (ΔLAVI) expressed as peak/rest difference in ml/m2 was measured. In addition, the prognostic score deriving from the sum of the ABCDE criteria was calculated, such as the LVCR (C parameter of the score) that represents a parameter of the force deriving from the hemodynamic changes during the test. In all patients we observed a significant reduction in ΔLAVI (8.4+0.5 mL/m2 vs 9.7+0.7 mL/m2; p<0.0001). In addition, there was a significant reduction in the ABCDE prognostic score (from 4.19+0.43 to 3.48+0.37; p=0.002), secondary to the increase in the LVCR observed approximately 3 months after surgery (from 1.77 mmHg/ml to 2.44 mmHg/ml, p<0.0001), as well as a significant reduction in pulmonary congestion during stress (B parameter). There were no significant changes in ejection fraction, wall motion score index–WMSI (A parameter), coronary reserve (D parameter) and heart rate reserve (E parameter).

These data demonstrate for the first time that mitral valve plastic surgery is able to reduce the ΔLAVI during stress echocardiography in patients with severe MR. The surgical procedure also resulted in both an improvement in the LVCR and a reduction in the degree of pulmonary congestion, that ultimately led to an improvement in the ABCDE prognostic score.
COMPLETE VS CULPRIT–LESION–ONLY MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST: INSIGHTS FROM THE MULTICENTRIC LOMBARDIA CARE REGISTRY
Authors: Raone L , Bongiorno A , Bendotti S , Currao A , Primi R , Adamo M , Ghiraldin D , Marino M , Dossena C , Poli A , Affinito S , Maffeo D , Kajana V , Baldi E , Ferlini M , Savastano S
Published: May 2024

Background

Out–of–hospital Cardiac Arrest (OHCA) is an uncommon yet potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit–lesion–only revascularization, was associated with an improved 1–year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort.

Methods

This is a multicentric, prospective, observational study. We considered all consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy.

Results

A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no history of ischemic heart disease. Median ejection fraction (EF) was 40%. MVD was present in 186 patients and was subsequently treated with either complete (32%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1–year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit–lesion–only revascularization group (p–value < 0.001). After correction for EF, hypercholesterolemia, mechanical or pharmacological support, cardiac arrest time and first shockable rhythm, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007].

Conclusions

in patients resuscitated from OHCA, complete revascularization strategy was confirmed to be associated with an improvement of 1–year survival and with a good neurological outcome. These results highlight the independent impact on survival of a complete percutaneous coronary intervention strategy in patients with OHCA plus MVD.
LONG–TERM ISCHEMIC STROKE AFTER ACUTE CORONARY SYNDROME IN SELECTED URBAN AND RURAL AREAS. THE ABC STUDY ON HEART DISEASE
Authors: Mahmoud H , Cordiano R , Palmieri R , Cavuto F , Bagato F , Dariod M , Merotto D , Menegon F , Petucco S , Berton G
Published: May 2024

Background

Little is known about the long–term risk of stroke among acute coronary syndrome (ACS) survivors.

Methods

In this prospective study, we enrolled 535 ACS patients admitted to hospitals in three provinces in the Veneto region of Italy, discharged and followed for 24 years or death. The patient‘s residency was classified into three urban and rural areas.

Results

All patients completed the follow–up (6142 Perso–years). 85 (16%) patients suffered an acute stroke. Patients median age was 67 years, 70% were male, and 318 patients were residing in rural areas. Patients who had a stroke and those who had not shared most of the demographic and clinical characteristics. The incidence rate of overall stroke was 14/1000 person–year. Cox analyses showed older age (HR 3.13;95%CI 2.31–4.26), male gender (HR 1.88;95%CI 1.20–2.95), baseline diabetes (HR 2.25 95%CI 1.37–3.69), heart failure (HR 2.69;95%CI 1.71–4.24), and higher albumin/creatinine ratio (HR 1.75;95%CI 1.33–2.30) were all associated with an increased risk of stroke. while higher baseline eGFR, reperfusion, statin and beta–blockers treatment during follow–up were associated with a decreased risk; HR (0.55 (95%CI 0.42–0.72), 0.45(95%CI 0.29–0.71), 0.21(95%CI 0.13–0.34), and 0.37(95%CI 0.23–0.57), respectively). In the multivariate analysis, only older age (HR1.55;95%CI 1.08–2.21; p=0.02) was an independent predictor of stroke while statin treatment was independently associated with a lower risk (HR 0.35;95% CI 0.21–0.58; p<0.0001). However, all these variables did not predict the risk of stroke in competing risk regression analysis where death was treated as the competing event. A sub–analysis of the 43 patients who had a fatal stroke (FS) revealed 7/1000 person–year FS IR. The Cox regression and competing risk analyses of predictors of FS showed similar results. Interestingly, we observed an association between geographic areas of residence and the long–term FS risk as the risk increased going from rural to urban (HR 2.08;95%CI 1.14–3.80; p=0.02) areas and from north to middle and south provinces (HR 1.47;95%CI 1.00–2.15; p=0.04) in the univariate Cox regression analysis.

Results

kept true using multivariate Cox and Competing risk regression models.

Conclusion

This analysis reveals the significant urban–rural difference in the long–term risk of fatal stroke among unselected ACS patients which highlights the importance of implementing a preventive policy based on area–specific knowledge.
ROLE OF THE MOLECULAR TESTS FOR PATIENTS WITH INFECTIVE ENDOCARDITIS UNDERGOING CARDIAC SURGERY: AN EXPANDING HORIZON
Authors: Cammertoni F , Pavone N , Calabrese M , Scoppettuolo G , Bruno P , Massetti M
Published: May 2024

Background

Molecular tests have been proven to be a highly sensible tool to identify the pathogen of infective endocarditis (IE). However, their usefulness in the management of both blood culture positive and valve culture negative IE remains unclear.

Methods

We prospectively enrolled 100 consecutive patients with IE who underwent cardiac surgery between April 2020 and June 2023. Molecular testing (broad–range PCR 16S rRNA) was systematically performed and results were collected together with those of preoperative blood culture, valve culture and histopathological analysis of the specimen.

Results

Blood culture, valve culture and molecular testing were positive in 83%, 47% and 76% of patients, respectively. Both the sensitivity of valve culture and 16S rRNA PCR decreased significantly with increasing duration of preoperative antibiotic therapy. In 7% of cases, molecular test was the only positive test, allowing an etiological diagnosis. In 33% of cases, valve culture was negative but molecular test was positive. In the majority of these patients, histopathological analysis documented acute inflammation. Finally, molecular test clarified discrepancies between the results of blood cultures and those of valve cultures in 12.5% of patients.

Conclusions

The molecular tests showed high sensitivity. Although it decreased as the duration of preoperative antibiotic therapy increased, it was still higher than that of valve culture 28 days after the start of treatment. In addition to patients without an etiological diagnosis, the molecular test proved useful in other circumstances: 1) when the valve culture was negative because, together to the results of the histopathological analysis, it allowed to identify those patients who could benefit from a prolongation of antibiotic treatment; 2) in cases of discordance between the results of blood cultures and those of valve cultures, because it allowed the type of antibiotic treatment to be directed. Figure 1: Usefulness of molecular tests (PCR) according to the results of blood and valve cultures. Figure 2: Valve cultures are of paramount importance in the management of antibiotic therapy (ABT). However, their sensibility is low and the risk of under–treatment exists. Molecular tests may help targeting the duration of ABT but they could be persistently positive leading to an over–treatment. Figure 3: Flow–chart showing the possible role of molecular test in the management of patients with infective endocarditis.
HOW TO MANAGE MITRAL VALVE POSTERIOR LEAFLET HYPOPLASIA
Authors: Fiorentino M , Mikus E , Antonino C , Savini C
Published: May 2024

Background

Mitral valve posterior leaflet hypoplasia is a relatively rare and often congenital anatomical malformation. In this condition, achieving a good and durable mitral valve repair still represents a challenge for surgeons.

Methods

We present the case of a 43 years old man presenting with exertional dyspnoea due to severe mitral regurgitation. Transthoracic and transesophageal echocardiograms revealed a severe hypoplasia of the posterior mitral leaflet with an significant prolapse of the anterior leaflet (particularly A2–A3), which determined massive regurgitation. The anteroposterior annular diameter was 38 mm with a 4 mm mitro–anular disjunction, left ventricular telediastolic diameter was 59 mm and ejection fraction 68%. No other cardiac malformations were evident; in particular tricuspid valve was normal.

Results

Surgery was performed through a right mini–thoracotomy with femoral cannulation, using three–dimensional video–assisted technology. The mitral valve was approached from the left atrium, behind the interatrial groove. Surgical inspection revealed a severely hypoplasic posterior leaflet and a wide anterior leaflet prolapsing near the postero–medial commissure (A2–A3) (Figure 1). Based on our previous experience, we decided to repair the valve performing a posterior para–commissural edge–to–edge (A3–P3) followed by an atypical annuloplasty using a bovine pericardium band, shaped on a 40 mm ring sizer, only in the postero–medial portion of the mitral annulus (Figure 2). On the hydrostatic test, the valve showed a satisfactory continence, that was confirmed on the intraoperative TEE. Postoperative course was uneventful and the patient was discharged home on postoperative day 7. Transthoracic echocardiography at discharge showed a good result of the mitral valve repair with no residual regurgitation a medium gradient across the mitral valve of 3 mmHg.

Conclusions

In our experience, reductive annuloplasty isn’t the optimal treatment for hypoplasic mitral valve posterior leaflet because it lowers the already small posterior leaflet, thus reducing the coaptation surface. To avoid this, we introduced this technique that improved our surgical outcomes.
INAPPROPRIATE S–ICD SHOCK RELATED TO ATRIO–VENTRICULAR BLOCK: WHEN THE TRUE CULPRIT IS NOT OVERT
Authors: Cesarano E , Casula M , Tola G , Perra F , Schintu B , Setzu A , Corda M
Published: May 2024

Subcutaneous implantable cardiac defibrillator (S–ICD) is a well–established alternative to transvenous defibrillator in patients with an indication for an ICD without the concomitant need of pacing. Despite the overall excellent performance of S–ICD, oversensing of cardiac and non–cardiac signals is still the main cause of inappropriate shocks (IS). We present a case of IS due to F–wave oversensing and QRS morphological variability related to compete atrio–ventricular (AV) block.

A 77–year–old man was admitted to the Emergency Room reporting two episodes of defibrillator shock, identified by remote monitoring as IS due to F–wave oversensing during paroxysmal atrial flutter (Figure 1). His past medical history included paroxysmal atrial fibrillation and post–ischemic left ventricular (LV) dysfunction with left bundle branch block, treated in 2012 with cardiac resynchronization therapy and implantable defibrillator (CRT–D) with subsequent normalization of LV ejection fraction (EF). The LV stimulation was later deactivated due to phrenic capture unavoidable with device reprogramming; afterwards, the occurrence of aortic valve and lead endocarditis resulted in CRT–D system extraction. At that time, considering the persistence of normal LVEF even without LV stimulation, an S–ICD was then implanted in primary prevention. The ECG at the time of admission presented with a complete AV block (Figure 2A), not clearly evident at the remote monitoring report. Few hours later a new episode of atrial flutter occurred, reveling a variable QRS morphologies of ventricular rhythm (Figure 2B). A more careful analysis of device memory reveals a previous episode of AV block with variable QRS morphologies leading to SMART Pass filter disabling (Figure 3). A transvenous ICD with left bundle branch area stimulation was then successfully implanted and the patient was discharged at home after two days.

To the best of our knowledge, this is the first described case of inappropriate S–ICD shock related to AV block. The unpredictable QRS morphology of an escape rhythm and the inability of S–ICD to store diagnostic data regarding bradyarrhythmia may limit our knowledge on the behavior of S–ICD in case of AV block. The occurrence of an IS should always prompt careful analysis of all available S–ECGs. Previous events of QRS morphology change and/or disabling of the SMART Pass filter should be regarded with suspicion, even if an AV bock is not overt evident.
UNPREDICTABLE IDENTIFICATION OF A TITIN MUTATION IN A YOUNG PATIENT PRESENTING WITH INFLAMMATORY CARDIOMYOPATHY
Authors: Marchionni G , Alfarano M , Bottillo I , Grammatico P , Vizza C , Chimenti C
Published: May 2024

Case Presentation

A 23 years old patient, affected by type 1 diabetes, presented with fever, dyspnea and bilateral peripheral edemas. In the last week he received antibiotic treatment for a persistent dry cough and sore throat, and became symptomatic for exertional dyspnea from three days. His mother died at the age of 40 for sudden cardiac death. Blood pressure and oxygen saturation were normal: the ECG showed sinus tachycardia with symmetric negative T waves in all precordial leads. High sensitivity troponin T was 0.01 mcg/L (normal value < 0.014 mcg/L). All remaining blood tests were normal, except for CRP that was slightly elevated. His echocardiogram revealed left ventricular (LV) remodelling and dilation, severely reduced LV ejection fraction (LVEF 20%) with global hypokinesia, more pronounced at the level of the anterior wall, interventricular septum and apex and a dilated right ventricle (RV) with reduced systolic function. Cardiac magnetic resonance (CMR) confirmed severe biventricular disfunction (LVEF 19%; RVEF 23%) and showed a small area of subepicardial inferior junctional late gadolinium enhancement (LGE). The patient underwent an endomyocardial biopsy that showed a lymphocytic virus–negative myocarditis. Given his known type 1 diabetes, steroid treatment was not considered and anakinra was started. The patient was discharged after two weeks with a slight amelioration of the LV function (LVEF 27%), on optimal heart failure therapy and anakinra. At six months he was in NYHA class II and CMR showed slight reduction in LV dimensions and improvement of the LV and RV function (LVEF 39%; RVEF 45%), with no changes in the LGE pattern. A genetic test was performed and revealed two titin gene mutations, both categorized as likely pathogenic (TTN c.[11831T>A]; c.[72510_72517delGACAAATG]), responsible for a genetic form of dilated cardiomyopathy.

Conclusion

The present case suggests that in young patients presenting with clinical or histological diagnosis of myocarditis, genetic testing for cardiomyopathies should be considered especially in presence of a positive family history for sudden death or an incomplete recovery of the LV function at follow–up. Identification of a gene mutation in these patients allows a more tailored risk stratification of the index case and a proper management of the entire family.
OUTCOMES OF OUT HOSPITAL CARDIAC ARREST: SEX DISPARITIES IN OUR REGION
Authors: Bolognesi M , Carinci V , Bricoli S , Cardelli L , Pelizzoni V , Gamberini L , Rossi L , Barbato G , Biagi A , Casella G , Aschieri D
Published: May 2024

Background

The incidence of out of hospital cardiac arrest (OHCA) differs consistently between women and men.Besides sex related factors, OHCA risk may relate to gender related factors.Although previous studies regarding sex difference outcomes after OHCA yielded conflicting results, from some researches it seems that women have less shockable initial rhythm than men and they have worse survival.

Methods

We considered 5524 consecutively OHCA survivors resuscitated from emergency medical System (EMS) or bystander In two city of Emilia Romagna: Piacenza (3452 ) and Bologna (2072) from January 2009 to December 2019 and we evaluated the outcomes, considering sex and gender disparities.

Results

Out of 5524 patients, who experienced OHCA, 3340 (60%) were males with average age 70,6 ±14 years and 2184 (40%) females with average age of 78,9 ±13 years (p<0,001).Overall survival rate was 8% .In our population we observed as initial rhythm of cardiac arrest : 3057 (57%) asystole, 1070 (22%) ventricular fibrillation (VF) and 998 (21%) pulseless electrical activity (PEA) with sex disparities.In fact we have found : 1695 asystole (51%), 840 FV (25%), 583 pea (17%) in men and 1362 asistolia (62%), 230 fv (11%), 415 pea (19%)in women. Asystole was more frequently in females (62 f vs 51m %, p<0.001), whilst VF in males (25 vs 11%, p<0.001).Furthermore considering sex disparities, survival was better in males 299 (9%) than in females 115 (5%), p<0.001.

Conclusions

In our population OHCA was more frequent in males in line with previous published data. However, females affected by OHCA are older, tend to present more frequently with non–shockable rhythms and show worse outcome. It’s unknown if these data are related to sex biological differences or gender disparities . Further data will be necessary to explain this challenge.
THE ROLE OF THE NURSING FIGURE IN THE MANAGEMENT OF INJECTABLE LOOP RECORDERS: THE IMPACT OF ARTIFICIAL INTELLIGENCE IN THE CLINICAL PRACTICE OF OUR CENTER
Authors: Affuso N , Bruno R , De Fazio D , Mazzei E , Chiarello O , Tomaselli C , Talarico A , Quirino G
Published: May 2024

Background

Injectable loop recorders (ILRs) are integral devices in managing cardiac disorders, with recent advancements in miniaturization enhancing installation and management processes. The Reveal LINQTM, introduced in 2014 by Medtronic, marked a breakthrough with significantly smaller dimensions than standard ILRs. The introduction of a tablet–based SmartSync Device manager programmer, coupled with the Linq Mobile Manager (LMM) application, further streamlined installation, ensuring direct data integration into the Medtronic CareLink Network. Nursing responsibilities involve triaging remotely transmitted data for clinical actions.

Materials and Methods

Over three years, 97 Linq II loop recorder implants were performed, mainly for syncope or cryptogenic stroke, utilizing the SmartSync programmer and LMM application. Eighty–two patients were enrolled in the Medtronic CareLink Network. Episodes recorded by Linq II™, classified by device algorithms, were sent to the Carelink platform via a monitor or patient‘s mobile app. Nurses review data to distinguish real episodes from false positives. The AccuRhythm™ AI platform, introduced in June 2022, applies AI to filter recorded episodes before reaching Carelink, reducing data and nursing staff time significantly.

Results

Results indicate a drastic reduction in false positives with AccuRhythm™, boasting high sensitivity (about 99.3%) and positive predictive value. In clinical practice, this led to a 100% reduction in pause alerts and a 21% reduction in atrial fibrillation alerts, saving 145 hours.

Conclusion

underscores the AccuRhythm™ AI Platform‘s cloud–based application of AI algorithms to LINQ II™ data, achieving time savings without compromising diagnostic yield. LINQ II‘s sensitivity on Atrial Fibrillation and High Pause is maintained, allowing efficient diagnosis and reallocating saved time to other essential patient–focused activities.
PREDICTION OF ACUTE AORTIC SYNDROMES IN PATIENTS WITH DILATATION OF ASCENDING AORTA: IS IT THE HOLY GRAIL OF CONTEMPORARY CARDIAC SURGERY?
Authors: Totaro P , Amoroso F , Kushta E , Musto M , Pelenghi S
Published: May 2024

Objective

Acute aortic syndromes (AAS) represent the most frequent emergency situation in cardiac surgery. Despite improvements in surgical outcomes in recent decades, postoperative mortality in these situations is still significant (5–20%). The study of potential markers able of identifying patients at high–risk for AAS has been widely evaluated for many years. Although many potential markers have been identified, current guidelines are based, in the absence of morphological signs, on two keys: maximum dilation and its evolution over time. In this work we have reviewed our twenty–year experience to better elucidate the clinical history that led to AAS in the current era. We also evaluated the real role of monitoring a known dilatation of the ascending aorta over time in the prevention of AAS.

Materials and Methods

Data from 267 patients undergoing emergency surgery for AAS (acute dissection, intraparietal hematoma, ulcerated plaque rupture) were examined. For each patients, the past medical history was reviewed including the diagnostic / instrumental evaluations carried out before the acute event.

Results

As Summarized in Figure 1A, despite history of hypertension was common, only a minority of patients had underwent adequate diagnostic evaluation of the thoracic aorta before AAS. Furthermore, out of 267 patients, only 3 patients had a known AAA > 50mm and all had previously refused surgery. The remaining patients (Fig 1B) presented dilatation without surgical indication according current international guidelines. In 1 patient a CT Scan was performed 1 week before AAS and maximum dilatation was 43mm (Fig 1C) with no sign of increased risk of dissection. At the time of dissection dilatation reached 52 mm (Fig 1D).

Conclusion

Our analysis, based on twenty years of experience, has clearly shown that only a minimal part of patients experiencing an AAS have a clear history of progressive aortic dilatation, amenable to analysis and risk weighting. In our series, the minority of patients with previous history of aortic dilatation, however, did not have aortic dilations at high risk of AAS according to international guidelines. The "real life" in contemporary cardiac surgery, therefore, seems to confirm the substantial unpredictability of an acute aortic event in the absence of systematic surveillance protocols to be adopted on the entire population at risk.
IMPROVED EARLY OUTCOMES IN WOMEN UNDERGOING AORTIC VALVE INTERVENTIONS
Authors: Bifulco O , Malvindi P , Berretta P , Alfonsi J , Cefarelli M , Zingaro C , Capestro F , D‘Alfonso A , Di Eusanio M
Published: May 2024

Surgical aortic valve replacement (SAVR) in female patients has been associated with higher mortality (up to 3.3–8.9%) and postoperative complication rates when compared with their male counterparts. In recent years, TAVI has been shown to provide a greater benefit than SAVR in women. We sought to assess the early outcomes of the contemporary aortic valve intervention practice (surgical and transcatheter) in patients referred to our cardiac surgery unit. The data of consecutive patients who underwent isolated aortic valve intervention for aortic valve stenosis during the 2018–2022 period were retrieved from our internal database. Several preoperative, intraoperative, and postoperative variables were analyzed, including the predicted risk of a prosthesis–patient mismatch. Nine hundred and fifty–five consecutive patients—514 women and 441 men—were included. Among them, 480 patients—276 female and 204 male—received a transcatheter procedure, and 475—238 women and 237 men—had conventional SAVR. The women were older and had higher EuroSCORE II, while the male patients presented a higher incidence of cardiovascular comorbidities. There was no difference in mortality or major postoperative complication rates after either the surgical or transcatheter procedures between the female and male populations. The availability and targeted use of different techniques and technologies have enabled the safe and effective treatment of female patients treated for severe symptomatic aortic valve stenosis with similar results when compared with their male counterparts.
A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION
Authors: Pallotta R , Saccocci M , Denti P , Buzzatti N , Agricola E , Maisano F
Published: May 2024

Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.
AN INCIDENTAL DIAGNOSIS OF ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA
Authors: Mistrulli R , Dei L , Halasz G , Gebrielli D , Re F
Published: May 2024

72–year–old patient with paroxysmal atrial fibrillation and hypertension. Mother died suddenly at the age of 40 from an unknown cause. The patient worked at a high physical and emotional intensity (firefighter) and denies syncopal episodes. During an hospitalisation for pneumonia, an echocardiogram was performed that showed dilatation of the outflow tract and basal portion of the right ventricle (RV), apical bulging and right ventricular (RV) free wall dyskinesia. Absence of signs of pulmonary hypertension. The left ventricle was of normal size with preserved ejection fraction (EF 60%). the electrocardiogram showed inversion of the T wave from V1 to V4 and in the lower leads. He underwent a coronary CT scan, which was negative. In view of the clinical findings, cardiac MRI was requested, which showed severe dilatation of the free wall of RV, which was dyskinetic and hypertrabeculated and reduced RV EF (38%). At T1 sequences, diffuse and trasmural late gadolinium enahcement of the RV free wall. The Holter ECG recorded 773 monomorphic ventricular extrasystoles. The patient underwent genetic analysis, which is still in progress. This is an established case of arrhythmogenic right ventricular dysplasia that was accidentally diagnosed at an advanced age. This finding is unexpected as such a benign prognosis has rarely been described in the literature and in the natural history of this cardiomyopathy. In this particular situation, it is also very difficult to choose the best management strategy even in light of the recently published new guidelines.
CLASS 1C AGENTS ARE EFFECTIVE AND SAFE IN TERMINATING RECENT–ONSET ATRIAL FIBRILLATION IN ELDER PATIENTS TOO
Authors: Bonora A , Turcato G , Piccoli A , Bampa B , Gabbiani D , Tonelli M , Beltrame F , Maccagnani A
Published: May 2024

Background

Amiodarone is still widely used in recent–onset atrial fibrillation (AF), mainly in elder people, for its presumed safety. Nevertheless the growing experience with class 1c agents could encourage their use in order to improve the management of AF in elderly too. Aim: To assess whether class 1c agents could be considered effective and safe in elder people, as well in younger, in terminating recent–onset AF.

Methods

We retrospectively evaluated a three–years experience in over 75 patients treated in the Emergency Department of University Hospital of Verona for recent–onset AF (< 48 h). We excluded patients submitted to electrical cardioversion and those in whom the choice of treatment was forced by clinical conditions or coronary and structural heart disease. Then we compared the results in terms of effectiveness and safety between the two groups of treatment, class 1c agents vs amiodarone. Statistical analysis was performed using Chi–square test, with significance level set at p<0.05.

Results

We attempted at restoration of sinus rhythm in 264 patients older than 75 years observed for recent–onset AF from January 2018 to December 2020. According to exclusion criteria, the study population was restricted to 147 patients (53 males, 94 females; mean age 80 years, range 75–95) where the treatment depended on the physician‘s choice only. Most of these patients (61.2%) was treated with amiodarone, while in 38.8% class 1c agents were administered. Mean age was not significantly different between the groups (81 vs 78.5). After treatment, stable restoration of sinus rhythm was reported in 43 patients (47.7%) in amiodarone and in 47 (82.4%) in class 1c group (p<0.01). Median time of conversion was 240 minutes (range 30–680) in amiodarone while 60 (range 15–530) in class 1c group (p<0.01), as shown in fig. 1. Surprisingly, even the narrow sample did not allow any significance, the incidence of adverse events was notably superior in amiodarone patients, both in number (5 cases) and seriousness (2 cases). Whereas in class 1c group we reported only one mild adverse event. At the end of observation, 43 patients (75.4%) in class 1c but only 38 (42.2%) in amiodarone group were discharged with stable sinus rhythm (p<0.02).

Conclusions

Class 1c agents appear to be more effective and as safe as amiodarone in terminating recent–onset AF even in selected elder people. However these preliminary results need to be confirmed in a larger and prospective study.
CLINICAL AND GENETIC FEATURES OF JUVENILE ONSET LONE ATRIAL FIBRILLATION
Authors: Bertello E , Berruquier P , Dusi V , Saglietto A , Vallino C , Tallone L , Solano A , Giannino G , Vairo A , Angelini F , Del Prever G Brach , Pidello S , Raineri C , Giustetto C , Matta M , Castagno D , Ferraris F , Deaglio S , De Ferrari G , Anselmino M
Published: May 2024

Background

Juvenile–onset lone atrial fibrillation (LAF) may be the initial manifestation of an othrewise concealed channelopathy or cardiomyopathy (CMP). Clinical characteristics, genetic background and proper management are still largely unknown.

Purpose

Describe the clinical and genetic characteristics of patients with juvenile–onset LAF.

Methods

We enrolled patients referred to our center for ablation between 1/2018 and 11/2023 with a first diagnosis of LAF below 60 years, absence of CMP, ischemic, valvular, congenital heart disease, and no overt channelopathy. A concealed Brugada syndrome was systematically excluded. Genetic testing was performed using Next Genome Sequencing and a dedicated gene panel.

Results

89 patients were included (84% male, LAF onset 43 ± 8 years, BMI 25 ± 7 kg/m2): 32% had a first–degree family history of AF (including 15% below 60 years), 18% of sudden death, 8% of cardiac conduction disorders and 2% of CMP. Arterial hypertension was present in 24%, smoking in 47% and obstructive sleep apnea in 4%; 20% were competitive athletes. Most patients (89%) presented with symptomatic paroxysmal AF (palpitations); LVEF was 61 5% and LAVI 35 14 ml/m2. Median follow–up time after the first AF was 6 years (IQR 4–10). Most patients (81, 91%) underwent ≥1 ablation after failed anti–arrhythmic drug (AAD) therapy (mostly IC). The first procedure (73% radiofrequency, 27% cryoablation) included pulmonary veins isolation (PVI) in all and additional lesions in 5%; the second (n=18, 22% of the ablation group) included PV re–isolation in all and additional lesions in 17%; the third (n=8, 10% of the ablation group) included PV re–isolation in 25% and additional lesions in 75%. The remaining 8 patients were treated with AAD only (mostly IC). By the last follow–up, 7% of patients in the ablation group and 25% in the AAD group had documented recurrences (even though 50% of those who received ablation were still on AAD). Among the 35 patients subjected to genetic investigation, 10 have available results: 30% tested positive for C4–C5 variants (2 for KCNQ1, 1 for TTN), 50% for C3 variants (RYR2, ABCC9, LMNA, KCNH2 and RMB20) and 20% were negative.

Conclusions

In the present cohort of patients with juvenile–onset LAF, a positive family history was found in almost one third of patients. Despite prompt diagnosis and treatment, recurrences rate is not trivial. The yield of genetic test so far is high, supporting its use in this population.
A COMPLEX CASE OF EARLY ONSET ATRIAL FIBRILLATION IN AN ENDURANCE ATHLETE: THE IMPORTANCE OF FAMILY HISTORY
Authors: Solano A , Tallone L , Bertello E , Berruquier P , Saglietto A , Brach G , Angelini F , Vairo A , D‘ Ascenzo F , Giustetto C , Raineri C , Deaglio S , Anselmino M , De Ferrari G , Dusi V
Published: May 2024

Introduction

Early onset atrial fibrillation (AF) in an endurance athlete represents a challenge for the cardiologist, especially in apparent absence of an overt structural heart disease. Different genetic variants have been associated with early onset AF but indications to genetic testing are still under definition.

Case

A 54–year–old man (BMI 19 kg/sqm), previous competitive athlete (Nordic running and walking) presented to the Emergency Department with sudden onset palpitations and dyspnea due to high penetrance AF (145 bpm). Family history (FH) was positive for cerebrovascular accidents in both parents and for early onset (<60 years) AF in the father. The man had a recent history of borderline hypertension, of effort related syncope of and of infundibular, isolated, premature ventricular complexes during a maximal exercise stress test (otherwise negative for ischemia) which ultimately led to the denial of competitive sport eligibility. Sinus rhythm (SR) was acutely restored with flecainide and the patient was discharged with low dose nadolol. Cardiac US showed normal left ventricular (LV) dimensions and thicknesses (10 mm), with regular LVEF (60%) and global longitudinal strain (–18%), mildly dilated left atrium (LAVI 36 ml/sqm) and bi–leaflet mitral valve prolapse without significant mitral regurgitation, mitro–anular disjunction nor Pickelhaube sign; 24h Holter ECG showed SR with rare supraventricular (SV) ectopic beats and a 4 beats SV run. Due to the recurrence of short episodes of palpitations, rhythm control with flecainide and antithrombotic prophylaxis were started and AF ablation was planned. Genetic testing for early onset AF identified a nonsense variant (c.84665delG; p.Gly28222fs*2) in TTN gene, classified as likely pathogenic (C4), so far not reported in scientific literature. Also, despite a moderate–low cardiovascular risk as assessed by SCORE2, mostly due to the FH and the desire to engage in high intensity exercise, coronary CT was prescribed, which showed a critical coronary disease leading to stenting on left anterior descending artery and intermediate branch. Cardiac MRI was planned.

Conclusions

Early onset AF in endurance athletes should not be underrated and a thorough examination including a detailed family history should be performed. TTN is the single gene most frequently associated with early onset AF in absence of an overt structural heart disease, but the subsequent clinical evolution is still largely unknown.
ASSOCIATION BETWEEN HEALTH LITERACY AND NURSING DEPENDENCY IN HEART FAILURE PATIENTS: A RETROSPECTIVE STUDY
Authors: Cesare M , Cristofori E , Magliozzi E , Damiani G , Cocchieri A
Published: May 2024

Background

Approximately 6.7 million Americans over 20 years of age have heart failure (HF) and 33% of the US adult population without known symptomatic HF is at–risk for HF. To understand self–care protocols, patients should understand and use health information and literature suggests a positive relation between health literacy (HL) and self–care. Health literacy (HL) is a potential risk factor for health outcomes and can be defined as “personal knowledge and competencies obtained through daily activities, social interactions and across generations”. However, even though HL has gained international relevance, it remains underestimated in most world countries. Moreover, HL is poorly measured in hospitalized HF patients and its relationship with nursing dependency is still poorly studied. We aimed to describe HL levels by analyzing the relationship between HL and nursing dependency.

Methods

A retrospective design was used by selecting 608 adult patients with HF consecutively admitted in cardiovascular and internal medicine units of an Italian university hospital across 1 year. Single Item Literacy Screener (SILS) was used to measure HL and was systematically reported on electronic health records; nursing diagnoses were collected from the clinical nursing information system to measure nursing dependency.

Results

The mean age of the sample was 75.50 ± 13.06. HL levels were low (SILS >2) in approximately 26% of the hospitalized patients (n=159; 26.2%). A mean of 4.1 ± 3.4 nursing diagnosis per patient was identified. A significant difference was observed between patients with adequate HL (n=449) and low HL (n=159) in terms of nursing diagnoses (mean 2.76 ± 20.3 VS mean 8.69 ± 2.79; p< .001, respectively). A statistically significant linear association (Spearman’s correlation coefficient) was observed between the HL score and the number of NDs.

Conclusion

HL was associated with the number of NDs in HF patients. Understanding the relationship between HL and nursing dependency can allow the planning of targeted interventions to improve the patient’s health outcomes, representing a key element for public health.