bluuebunny/crossref_metadata_2025_split huggingface dataset:
PERCUTANEOUS TREATMENT OF ABDOMINAL AORTIC ANEURYSM AND AORTIC VALVE STENOSIS WITH ‘STAGED’ EVAR & TAVR
Authors: Casilli F , Medda M , Briguglia D , D‘Alessandro V , Donatelli F 
Published: May 2024

Abstract
Symptomatic AS and AAA are critical clinical conditions, increasingly more prevalent with aging of the population. TAVR is a treatment of choice in high risk and inoperable patients with symptomatic severe AS, who are often elderly. A continuous increase in the number of TAVR procedures–per–year is expected due to the increasingly robust evidence that TAVR is advantageous in the population with non–increased surgical risk. Our ‘tailored’ interventional approach has planned an endovascular correction of the AAA as the first step, followed by a ‘staged’ TAVR. The AAA was treated first because was it considered strategically better in the presence of severe AS in stable clinical conditions. Moreover the potential elevation of the systolic arterial pressure after TAVR might provoke enhanced strain at the AAA wall increasing the risk of rupture. During the EVAR procedure all the material needed to proceed to an ‘urgent’ aortic valvuloplasty or TAVR if necessary was available and ready. The proposed treatment was effective in all treated patients, offering the resolution of both problems through totally percutaneous treatment in patients with a significant high risk for both mortality and vascular complications. The risk of acute kidney injury is reduced compared to simultaneous procedures because the total amount of contrast agents used overall is spread among two different procedures after an adequate time of recovery. The main clinical, technical and procedural considerations of TAVR procedure in this case series were: Transfemoral access into the bifurcated endoprosthesis was feasible in 100% of patients The use of highly supportive stiffer guides (or buddy wire technique) to overcome the tortuosity of the iliac–femoral approaches should be considered; The introducer advancement under fluoroscopic guidance and through–and–through wire technique is strongly recommended in the presence of tortuosity; The strategy to protect the main vascular access must be personalized choosing between the ipsilateral femoral approach or the radial (or omeral) approach; The total amount of contrast medium administered to patients should be carefully monitored; The procedures should always be conducted with as much ‘contrast zero‘ methods as possible. Define a delay time between EVAR and TAVR according to the clinical status, the age and the co–morbidities of patients even in the presence of clinical stability, is highly debated.
A VERY COMPLEX CASE OF DORV TYPE FALLOT: A CASE REPORT
Authors: Testa S , Ricci M , Sabina G , Renda G , Ricci F 
Published: May 2024

Abstract
Double outlet right ventricle (DORV) is a rare CHD characterized by ventriculoarterial connection in which both great arteries arise entirely or predominantly from the right ventricle. Its prevalence is 0.9% of all CHDs. Several chromosomal abnormalities have been associated with DORV, including trisomy 13, trisomy 18, and chromosome 22q11 deletion. Hearts with DORV are an extremely heterogeneous group showing various morphological features, connections, and relationships at each level of the cardiac segments and intersegmental junctions. As a consequence, the clinical manifestations and required surgical procedures for patients with DORV are variable. The anatomical spectrum is higly variable: it can be associated with ventricular septal defect, transposition of the great arteries (TGA) and functional single ventricle. We report the case of an infant with prenatal diagnosis of CHD and finding partial duplication of the short arm of the X chromosome. Pregnant woman at 22 weeks comes to the outpatient clinic to perform follow–up ultrasound. At that site finding of CHD which was later confirmed at birth and therefore prostaglandin therapy was started. Echocardiogram showed a wide DIV from malalignment with antero–cephalic deviation of the conal septum with significant aortic destroposition configuring picture of double outlet right ventricle. It also presents a complex right efflux obstruction already at subvalvular pulmonary departure. The pulmonary valve presented dysplastic, with en dome motion, hypoplastic. Pulmonary perfusion appears to be provided predominantly by the Botallo‘s duct originating from the isthmic region of the aorta and leading with a long and tortuous course to the pulmonary confluence near the left pulmnary artery with high velocity flow. The remaining findings are normal. Therefore, in view of the clinical picture, he was subjected to palliative surgery of right systemic–pulmonary shunt between the brachiocephalic trunk and right pulmonary artery (modified Blalock–Taussing surgery) in 3.5mm PTFE and ligation of Botallo‘s duct. At subsequent follow–up, the systemic–pulmonary shunt appeared pervious with regular flow. Wide DIV from anterior malalignment with aorta cavalier to DIV. Severe stenosis at complex pulmonary outflow with max gradient up to 124mmHg with dynamic and valvular component. For the subsequent course of treatment, the patient will be discussed collegially.
A RARE GUCH AND PULMONARY HYPERTENSION: A SHORT STORY
Authors: Saraullo S , Palermi A , Ricci F , Renda G , Gallina S 
Published: May 2024

Abstract
A 44–year–old woman presented to emergency department with dyspnea and anasarca. No past history of cardiologic diseases. Physical exam was notable for jugular turgor, hepatomegaly, rales and tachy–arrhythmic tones. Laboratory tests showed severe anemia (Hb 3.2 g/dl) and a severe mixed acidosis. ECG showed atrial fibrillation, 150/min. On echocardiogram left ventricle had normal size and systolic function while right chambers were dilated, hypokinetic (TAPSE 14 mm, RVFAC 30%), systo–diastolic D–shape, severe tricuspid regurgitation; high probability of pulmonary hypertension (VRT 3.2 m/s, and accessory signs). Angio–CT chest was performed, ruling out pulmonary embolism. She was admitted with a working diagnosis of right heart failure complicated by respiratory failure, intercurrent undated AF and severe pulmonary hypertension. On a routinal echo aorto–pulmonary shunt and ASD and coronary venous sinus dilatation were reavaled. A cardiac–CT was performed, for suspected congenital heart disease, and showed ASD sinus venosus (Fig.1), patency of Botallo‘s duct (PDA), aortic coarctation (Fig.2) and persistence of left superior vena cava (PLSVC, type III) draining into coronary sinus (Fig. 3). The patient‘s clinical condition deteriorated progressively until she died from cardiac arrest on the fifth day from the admission, preventing further investigations. Our patient was a so called GUCH with ASD and PDA resulting in group I (WHO) pulmonary hypertension due to a prevalent left – right shunt (Simonneau et al). The clinical presentation, on the other hand, could be due to the onset of atrial fibrillation leading to hemodynamic instability and thus reversal to right–to–left shunt (Eisenmerger‘s Syndrome) with multiple organ involvment facilitated by anemia. In our case, it is unclear, as well as in the literature, whether PLSVC play a role in the development of pulmonary hypertension; further investigation (MRI, autopsy) would have allowed a better anatomo–functional characterisation excluding a possible unroofed coronaric sinus with left atrial drainage. In our opinion, it is important to recognize PLSVC not only for its implications during interventional procedures but as markers of associated congenital heart disease.
NEW ONSET OF PULMONARY HYPERTENSION IN A PATIENT AFFECTED BY RECURRENT LUNG CANCER
Authors: Pezzullo E , Del Giudice C , Cappelli M , Natale F , Cimmino G , Ciaramella F , Golino P , Loffredo F 
Published: May 2024

Abstract
39 years old non–smoker female patient came to our observation in July 2023 complaining dyspnea on mild exertion. She had a history of lung adenocarcinoma with epidermal growth factor receptor (EGFR) positive for exon 19 deletion treated with left pneumonectomy and ipsilateral hilar mediastinal lymphadenectomy 5 years earlier, and contralateral disease progression currently treated with chemotherapy. Transthoracic echocardiogram showed circumferential prepericardial effusion requiring pericardiocentesis with transient clinical benefit. Indeed, after a month, she presented with worsening dyspnea and echocardiographic evidence of dilated and hypokinetic right ventricle and severe pulmonary hypertension associated with distal right pulmonary artery stenosis secondary to extrinsic compression by the neoplastic mass as shown by the chest CT scan (fig 1). A right heart catheterization confirmed this finding (minimum diameter of right pulmonary artery of 6 mm, maximum systolic pulmonary blood pressure of 99 mmHg) and a palliative stenting of the distal portion of the right pulmonary artery was performed with resolution of the stenosis, reduction of the pulmonary gradient (fig 2 and 3) and resolution of the dyspnea.
PROMINENT CRISTA TERMINALIS AND ATRIAL FLUTTER: CASE REPORT
Authors: Cariello F , Bencardino G , Ventura G 
Published: May 2024

Abstract

Introduction
Crista terminalis is a fibromuscular ridge at the posterolateral region of the right atrium (RA). Prominent crista terminalis can mimic pathologic RA mass on transthoracic echocardiograms. Transesophageal echocardiography can be used to differentiate non pathologic structures from pathologic ones.

Case Report
A 51–year–old men was referred to our clinic with typical atrial flutter. Transthoracic echocardiogram (TTE) revealed a RA mass. It was round, 15 mm in diameter, immobile, not calcified, and located at the posterior region of RA. Transesophageal echocardiography (TEE) showed prominent crista terminalis superiorly located beneath superior vena cava in the RA at 91 degrees midesophageal position. The patient undergoes catheter ablation for typical atrial flutter.

Discussion
Several congenital structures and normal variants such as Chiari’s network, eustachian and thebesian valves, and atrial septal aneurysms may simulate pathologic RA masses such as RA thrombus or myxomas. However, in this case, an anatomical variant is associated with an arrhythmia that requires treatment.

Conclusion
In this case we want to emphasize that prominent crista terminalis can mimic RA mass and may lead to atrial arrhythmias. TEE can be used to differentiate normal structures from pathologic.
CAN A “BROKEN HEART” SUCCESSFULLY BE TRANSPLANTED? A CASE REPORT
Authors: Mazzone F , Giovannico L , Fischetti G , Parigino D , Savino L , Silva A , Di Bari N , Bottio T 
Published: May 2024

Abstract
In January 2023 a 59–year–old woman with dilated ischemic cardiomyopathy, was admitted to our Cardiac Surgery Center for a heart transplant eligibility study. She presented symptoms of dyspnea and in the last 6 months was admitted four times to the hospital for heart failure. An echocardiogram showed a severely biventricular hypocontractility (LVEF: 22%; TAPSE 11 mm). After one month, the patient was urgently admitted to our Intensive Care Unit for cardiogenic shock. ECMO VA was implanted percutaneously. Therefore, the patient was placed on the national emergency waitlist for transplantation. A potential donation was identified ten days later. The donor was a 58–year–old woman with no cardiovascular risk factors, had died of a rupture of a cerebral aneurysm. During hospitalization, echocardiography showed LVEF of 30% with akinesia of the middle and apical wall and hyperkinesia of the basal with a mild improvement in contractility (LVEF: 40%) two days later. Coronary angiography was normal. The patient‘s condition resembled Takotsubo syndrome. Virtual and subsequently cytotoxic crossmatch was negative. We proceeded with orthotopic heart transplant. No noteworthy complications occurred during the operation. She received anti–thymocyte immunoglobulin for immunosuppression induction and prednisone, tacrolimus and mycophenolate mofetil for maintenance therapy. The echocardiogram, performed few days later, revealed preserved contractile function in both ventricles (LVEF: 58%). The patient was discharged after the first four endomyocardial biopsies displaying no signs of rejection (ISHLT’04 0R). At ten–month follow–up, the patient is in good clinical condition with no substantial changes during the follow–up echocardiogram. Brain injuries, including subarachnoid haemorrhage, traumatic brain injury and stroke, have been extensively documented in the literature to cause a surge in catecholamines, with a direct effect on the heart, resulting in a transient myocardial dysfunction commonly referred to as ‘Takotsubo cardiomyopathy‘ or ‘broken heart syndrome‘. Studies have shown that dysfunctional hearts at the start of transplant screening have normal contractile function at the time of organ retrieval have similar outcomes to those without dysfunction. This knowledge may help to increase the pool of potential donor hearts and improve the availability of hearts for transplantation, which is crucial given the shortage of suitable donor organs.
“OPS… I DID IT AGAIN”: ANOTHER CASE OF COEXISTENCE OF CORONARY ARTERY DISEASE AND CORONARY ARTERY BRIDGING IN A PATIENT WITH EXERCISE–INDUCED ISCHEMIA. WHEN A SINGLE TEST MIGHT NOT BE ENOUGH
Authors: Campana N , Mapelli M , Nava A , Pezzuto B , Vignati C , Campodonico J , Teruzzi G , Giulia S , Mani N , Montisci R , Cadeddu Dessalvi C , Agostoni P 
Published: May 2024

Abstract

Introduction
To investigate the presence of significant coronary artery disease (sCAD), the clinician may resort to the use of anatomical or functional tests. When multiple factors contribute to the genesis of ischemia, a single test may not be enough, and an integrated approach is essential.

Clinical Case
74–year–old man, athlete, has been complaining dyspnoea after intense exertion for 3 months. Rest ECG and echocardiogram were unremarkable. A cardiopulmonary exercise test (CPET) showed excellent functional capacity (peakVO2 24 ml/Kg/min, 113% of predicted value) without signs of ischemia; however, the test was stopped early due to high blood pressure (250/120 mmHg) and therefore submaximal (peak RQ 0.95). Antihypertensive therapy was set. A coronary CT showed sCAD. The coronary angiography revealed significant stenosis of the middle circumflex artery and significant stenosis of the distal right coronary artery; both lesions were treated with angioplasty and stent implantation. Due to symptoms persistence, we performed a new CPET. The test was maximal (peak RQ 1.13), confirming an even better functional capacity, but highlighting the presence of inducible ischemia (O2–pulse downsloping and VO2/W flattening). A new coronarography showed good angiographic result. The results prompted our team to revise the anatomic tests, leading to the finding of intramyocardial course of anterior interventricular artery. Verapamil 80mg t.d.s. was set. Before discharge, a CPET was repeated: the test was maximal (RQ 1.1) and showed attenuation of signs of ischemia at high load. Following discharge, the patient reported well–being during regular follow–up.

Conclusions
our case highlights how the integration of anatomic and functional diagnostic tests (performed during a proper physical exercise), plays a key role in the management of suspected myocardial ischemia. The clinical case also shows how CPET is a valuable tool for the detection of myocardial ischemia only if performed reaching the maximality criteria.
STRESS ANGINA IN A PATIENT WITH ANOMALOUS ORIGIN OF THE LEFT CORONARY ARTERY AND INTRAMYOCARDIAL COURSE: A RARE DANGER
Authors: Fiorella A , Burattini O , Ganimede M , D‘Alessandro G , Rodio G , Luzzi G 
Published: May 2024

Abstract

Background
The anomalous origin of coronary artery (AOC) still represents one of the most intriguing conundrumsin cardiology. It is generally diagnosed during coronary angiography performed for other reasons and 85% of the cases are benign. Nonetheless, they can sometimes cause angina, coronary syndrome, and sudden cardiac death.

Clinical Case
We describe a rare case of a 50–year–old dyslipidemic man, overweight, with arterial hypertension (AH) reporting episodes of stable angina when performing physical activities for several months. On the EKG a negative T wave in the lateral site was noticed, therefore an echocardiogram was ordered, which showed heart disease with moderate left ventricular hypertrophy, without obstruction of the left ventricular outflow tract. Notably, the patient already underwent cardiac magnetic resonance imaging (CMR) in another center, in the suspicion of initial hypertrophic cardiomyopathy. However, to us, the hypertrophy seemed to be rather related to the previously unknown AH, which probably remained undiagnosed for years. Coronary angiography showed an anomalous origin of the left coronary artery from the right sinus of Valsalva. On CT coronary angiogram the anterior descending artery (ADA), after its anomalous origin, described an interventricular, subpulmonary course, becoming intramyocardial for a stretch of approximately 39 mm, consequently undergoing a severe narrowing of caliber. Hence, stress CMR was performed with dobutamine and resulted positive for inducible ischemia. We proceed with interseptal cardiac surgical correction, cautiously releasing the ADA from the endocardium and overlying myocardium (coronary debridging).

Discussion and Conclusions
In clinical practice, it is difficult to establish a causal relationship between symptoms and AOC, as this represents a rare finding. In our case, an intramyocardial course was also identifiedand was responsible for both systolic and diastolic compression by the hypertrophic myocardium. The symptoms had begun to appear when myocardial hypertrophy due to untreated AH had become significant. Following the European guidelines, the treatment of AOC with evidence of ischemia should be surgical. We believe it is of fundamental importance in the presence of AOC to always suspect and exclude the presence of any coronary compressions, responsible for ischemia and arrhythmic events.
NOT JUST A SIMPLE BIRTH: SPONTANEOUS CORONARY ARTERY DISSECTION IN A YOUNG MOTHER
Authors: Caprio M , Ottaviani A , Ricci F , Renda G , Gallina S 
Published: May 2024

Abstract
A 33–year–old Caucasian woman with no cardiovascular history was admitted to the gynecology department due to a threat of preterm birth. During hospitalization, the patient experienced chest pain complicated by ventricular fibrillation. Resuscitation maneuvers were performed, followed by an emergency cesarean section with fetal extraction and DC shock, resulting in return of spontaneous circulation. Coronary angiography revealed spontaneous dissection of the first marginal branch, treated with conservative strategy. After 3 days, another episode of chest pain occurred with evidence of inferolateral STEMI. Emergency coronary angiography showed severe stenosis in the proximal segment of the circumflex branch and the mid–segment of the anterior descending branch; OCT confirmed spontaneous coronary dissection (SCAD) in these vessels. A conservative strategy was adopted, with medical therapy including DAPT for a year, ACE inhibitor and beta–blocker. After 1 month, a follow–up OCT of the coronary arteries showed almost complete resolution of the previously observed dissections. 7 years later, the patient presented to the emergency room with chest pain similar to the previous episode. A diagnosis of NSTEMI was made and the patient was admitted to the cardiac intensive care unit. Coronary angiography revealed spontaneous dissection of the right coronary artery causing occlusion in the mid–segment. Coronary angioplasty guided by IVUS was performed with a drug–coated balloon achieving TIMI 3 flow. Given the patient‘s medical history and suspicion of fibromuscular dysplasia, further diagnostic evaluation was conducted with CT angiography of the intracranial circulation, revealing double focal dissections in the both carotid arteries asymptomatic and without flow obstruction. The patient was discharged, prescribed SAPT and scheduled for follow–up with coronary and intracranial circulation CT angiography. SCAD is defined as an epicardial coronary artery dissection that is not associated with atherosclerosis. It commonly occurs in patients with few traditional cardiovascular risk factors. Its cause is hypothesized to be multifactorial with contributions from underlying arteriopathies, hormonal influences or systemic inflammatory diseases, often compounded by environmental precipitants or stressors. The abstract emphasizes the challenges of diagnosis, limited understanding of pathophysiology and the absence of well–defined guidelines regarding the treatment of SCAD.
MACARONI SIGN AND TAKAYASU ARTERITIS IN A PATIENT WITH TUBERCOLOSIS: AN EASY TOOL FOR DIAGNOSIS
Authors: Mazzella F , Weisz S , Guarino A , Verde R , Sorbelli C , Fele N , Severino S 
Published: May 2024

Abstract
Takayasu arteritis (TKA) is a chronic systemic autoimmune disease characterised by inflammation of the aorta and major branch vessels. Carotid Artery (CA) lesions in TKA, known as the ‘macaroni sign’, are characterised by global thickening of the common CA wall and lumen narrowing. There has been speculation that there is a link between TKA and tuberculosis (TB). Both illnesses cause arterial wall changes. We describe a TKA case diagnosed based on the presence of the ‘macaroni sign’ on CU in a young Asian women 30 years old with a diagnosis of latent TB. She has not previous histiry of disease and visited the hospital with complaints dyspnoea and carotidynia. At admission, body temperature, blood pressure and heart rate were 36.8°C, 112/60mm Hg on her right arm (left, 84/60 mmHg) and 76 beats/min, respectively. The pulse in her left radial artery was not palpable. Physical examination revealed spontaneous pain and tenderness on both sides of the patient’s neck. Blood test results demonstrated an elevated inflammatory response C–reactive protein, 8.0 mg/dL (normal range: less than 0.5 mg/L); erythrocyte sedimentation rate (ESR), 120 mm/hour. ANA, ENA and ASMA profile were negative. Quantiferon TB gold was positive. We suspected TKA and performed a CU, which revealed marked thickening of the intima/media of the bilateral common CAs and a positive macaroni sign (figure 1, Panel A and B). After a detailed evaluation of the systemic vessels the patient was diagnosed with TKA Type I limited to Branches from the aortic arch. The FDG–PET/CT demonstrated an increase in the glucose uptake in thoracic aorta, subclavian and right CA (SUV 4.5). The patient was treated with oral steroids at a dose of 0.8mg/kg and Isoniazid. After 6 months she showed a disappearance of carotidynia and dyspnoea, with a reduction in C–reactive protein, 1.5 mg/ dL and ESR=39 mm/hour. The FDG–PET/CT demonstrated a reduction in the glucose uptake in thoracic aorta, subclavian and right CA (SUV 3.5). Although MRI is usually recommended for the definitive diagnosis, the ‘macaroni sign’ identified by CU is a low–cost, simple and non–invasive method that can be easily performed during initial hospital visits. In addition, a clear correlation between MRI and CT angiography findings and disease activity or progression has not been found for TKA yet. Therefore, methods using ultrasound in combination with ESR should be considered easy and useful for diagnosis and clinical follow–up.