bluuebunny/crossref_metadata_2025_split huggingface dataset:
CASEOUS CALCIFICATION OF THE MITRAL ANNULUS: TIME IS PRECIOUS. WASTE IT WISELY
Authors: Falagario A , Colucci C , Basile P , Memmola C , Caparrotti S , Ciccone M 
Published: May 2024

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

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

Abstract

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

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

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

Abstract

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

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

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

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

Abstract

Introduction
Sodium–glucose cotransporter 2 inhibitors (SGLT2–i) are a novel class of oral hypoglycaemic agents currently used among patients with type 2 diabetes mellitus (T2DM). The effects of SGLT2–i inhibitors on cardiac structure and function are not fully understood.
The aim of the present study is to evaluate the echocardiographic changing among patients with well–controlled TDM2 treated with SGLT2–i inhibitors in real–world setting.

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

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

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

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

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

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

Abstract

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

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

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

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