bluuebunny/crossref_metadata_2025_split huggingface dataset:
SEVERE HEART DYSFUNCTION AND INTRA–CARDIAC THROMBOSIS: WHAT ELSE?
Authors: Mastroberardino S , Segreti A , Frau L , D‘Antonio L , Appetecchia A , Ricciardi D , Grigioni F , Ussia G 
Published: May 2024

Abstract

Introduction
Eosinophilic granulomatosis with polyangiitis (EGPA), formerly Churg–Strauss syndrome, is a rare vasculitis of small–medium blood vessels. We report a case of a young woman with severe cardiovascular, neurological and respiratory problems caused by the syndrome.

Case Report
A 45–year–old woman, affected by bronchial asthma and nasal polyposis, experiencing dyspnea and paresthesia on the left lower limb, underwent a total body PET–CT which demonstrated left segmental pulmonary thromboembolism, lung pseudo–nodular infiltration, and pericardial and pleural effusions. Thus, she entered Emergency Department. Hepatomegaly, left lower limb hot and edematous were observed. The ECG revealed low QRS voltages in the peripheral leads and poor r–wave progression in the precordial leads. The trans–thoracic echocardiography showed dilatated and hypokinetic right (RV) and left ventricle (LV) with severe reduction of global systolic function (LV ejection fraction, LVEF = 20%), bi–atrial dilation, circumferential pericardial effusion and thrombotic stratification at the apex. Blood test examination displayed severe eosinophilia, raised NT–Pro BNP and troponin I levels. A heart/coronary CT was performed, documenting epicardial coronaries free from significant atheromatous pathology. In addition, a cardiac MRI showed late gadolinium enhancement in the sub–endocardial area with diffuse involvement of the mid–apical ventricular segments and intraventricular septum, as in fibrotic outcomes. The subsequent total body CT scan confirmed the known thromboembolism, pulmonary lesions and pleuro–pericardial effusion; cardiogenic liver cirrhosis, and thrombosis of the right uterine vein and left gonadal vein were also reported. The auto–antibodies blood testing showed negativity for ANCA. In the presence of bronchial asthma, nasal polyposis, motoneuritis and hypereosinophilia, we diagnosed ANCA–negative eosinophilic vasculitis with cardiac involvement. Genetic testing was negative for FIP1L1–PDGFRA, excluding treatment with imatinib. Thus, we started immunosuppression therapy. However, albeit optimal medical treatment for ventricular dysfunction, the implantation of a subcutaneous cardiac defibrillator was required.

Conclusion
The possible cardiac manifestations in the context of EGPA may be several. Therefore, a prompt diagnosis results in a better prognosis for the patients.
MYOCARDITIS, CORONARY ARTERY DISSECTION OR BOTH: A JUVENILE ENIGMA
Authors: Sala E , Cereda A , Di Giovine G , Conconi B , Lucreziotti S 
Published: May 2024

Abstract

A 26–year–old man was admitted to the Coronary Care Unit for severe, non–irradiated, oppressive anterothoracic pain. He had no relevant pathological history, but reported an episode of gastroenteritis the week before. EKG showed sinus rhythm and accelerated idioventricular rhythm phases. Blood pressure and 2D echo were normal. Inflammation indeces were negative, hsTnT reached a peak of 2026 ng/L. Despite the absence of inflammation signs, our first guess was myocarditis. Cardiac magnetic resonance (CMR) was performed: T2w–STIR images showed edema of the middle inferior wall and of the mid–basal anterior and anterolateral wall, while T1–weighted post gadolinium images showed transmural enhancement of the mid–basal anterior, antero lateral and inferior walls with a dubious origin from the sub endocardium in the anterior and anterolateral segments; LVEF was 55%. Invasive coronary angiography (ICA) was performed to rule out ischemic etiology: LAD showed a very thin lumen in its periphery and two obtuse marginal branches had an amputated appearance: it made us think of healing dissections. Then it turned out that the patient have been working out with heavy weights the day before: we therefore considered spontaneous coronary artery dissection. Such hypothesis was consistent with the absence of inflammations indices, but didn’t explain the basal and middle inferior involvement that CMR had shown. On the other hand, the angiographic finding may be consistent with peripheral vascular suffering linked to myocarditis induced inflammation. To date, we haven’t found univocal interpretation. Anti–remodeling therapy with IACE and beta blockers was administered, in addition to acetylsalicylic acid. CMR will be performed in two months and may provide further results once the edema will be reabsorbed. ICA will be repeated to make sure that distal coronary blood flow is improved.

Take Home Messages
Myocarditis can also occur with no signs of inflammation. In myocarditis it has been demonstrated that slower distal coronary blood flow may occur, due to the increase in peripheral vascular resistance linked to the presence of edema. In the acute phase, especially if CMR is performed very early, the large amount of edema can make the enhancement transmural, masking the site of origin of the damage.
GIANT RIGHT ATRIAL MYXOMA CAUSING HEART FAILURE SYMPTOMS
Authors: Maffè S , Paffoni P , Bergamasco L , Facchini E , Ariotti S , Prenna E , Ticozzi S , Paino A , Dellavesa P 
Published: May 2024

Abstract

Background
Cardiac myxoma is the most common benign tumor of the heart. About 75% of myxomas occur in the left atrial cavity, but they can also appear in the right atrium (18%) as unusual location. It presents with a variety of clinical signs and symptomatology making diagnosis frequently quite a challenge.

Objective
The aim of this article is to present a case report of giant right atrial myxoma with symptoms of heart failure in adult patient.

Case Report
We present a case of large right atrial myxoma, discovered incidentally in a female patient 88–year–old who came to our attention for worsening dyspnea, asthenia, peripheral edema,dizziness and palpitations. The transthoracic and transesophageal echocardiogram show a voluminous hyperechogenic formation in the right atrium, measuring 82 x 42mm (Figure 1) which almost entirely occupies the atrium and was found to prolapse through the tricuspid valve into the right ventricle, causing obstruction during diastole. The right cardiac chambers appear dilated, with increased pressures causing compression on the left cardiac chambers, with D–shape of the interventricular septum and fixed left convexity of the interatrial septum. The patient presents paroxism of atrial fibrillation, and a massive left pleural effusion requiring drainage. Cardiac magnetic resonance imaging confirms the mass and the tissue characterization (isointensity of the T1 signal, increased intensity in T2, absence of contrast uptake in the perfusion sequences and presence of heterogeneous late enhancement) support the diagnosis of atrial myxoma (Figure 2). The patient underwent surgery with removal of the mass (Figure 3), subsequent regular clinical course with normalization of the right chambers and of hemodynamic compensation. The histological diagnosis of myxoma was confirmed. Cardiac myxomas can produce three types of clinical manifestations: constitutional symptoms, embolization and intracardiac obstruction. Most of the myxomas are asymptomatic; the right atrial myxomas present with obstructive features like dyspnoea, syncope, right side heart failure; rarely it can cause left ventricular overload and biventricular heart failure, as in our case. Transesophageal echocardiography is superior for precise evaluation of cardiac tumors, but our case demonstrates how cardiac MRI has become the gold standard exam, allowing a perfect morphological evaluation and overall a tissue characterization of cardiac masses before histology.
WELLENS SYNDROME: TIMELY RECOGNITION AND SUCCESSFUL REVASCULARIZATION
Authors: Liberatore I , Terrinoni F , Commisso C , Patrizi R , Cittadini E , Palermo M , Granatelli A 
Published: May 2024

Abstract
Wellens syndrome is a condition characterized by clinical and instrumental signs suggestive of a critical proximal left anterior descending (LAD) coronary artery stenosis and requires early revascularization. Diagnostic criteria include T–wave changes in ECG during asymptomatic periods in patients with a history of chest pain, absence of significant cardiac enzyme movement, no ST–segment elevation, preserved R–wave, and no pathological Q waves. Early recognition of this syndrome is crucial, due to its 10–15% prevalence, allowing proper management and myocardial function recovery, avoiding potentially catastrophic outcomes. A 64–year–old male, with hypertension, undiagnosed diabetes, and family history of CAD, presented to our ER with sudden, brief chest pain radiating to the left upper limb. Similar episodes had occurred in the past week. The patient denied previous cardiovascular events and home therapy. ECG conducted by the attending cardiologist, during free chest pain period, showed biphasic T–wave in V1–V3 (a). Admission ECG resembled the ambulatory one. Lab results: Hb 14.7 g/dl, Troponin I 0.059 ng/ml (cut–off 0.034). Echocardiogram indicated distal septum akinesia. Urgent coronary angiography was performed, detecting subocclusive stenosis in the proximal–mid LAD. Successful revascularization was achieved by PTCA and implantation of 1 DES. (b) Subsequently, the patient was admitted to the Cardiac Intensive Care Unit for multiparametric monitoring. The ECG showed deeply negative T waves from V1 to V6. (c) No complications during hospitalization. Discharge ECG showed repolarization anomalies improvement. Echocardiography revealed preserved systolic function, without global or segmental anomalies in wall motion. Wellens syndrome is a manifestation of acute coronary syndrome that precedes an anterior wall MI. This condition can be identified by its characteristic T–wave patterns on ECG. Patients with this syndrome have severe LAD occlusion and require early coronary intervention. In chest pain episodes, the ECG appears normal, and troponin levels often remain within the normal range, which can potentially provide false reassurance. Wellens syndrome is a cardiac emergency requiring immediate attention; it is crucial for the physician to promptly identify the typical ECG signs of Wellens Syndrome, facilitating early coronary revascularization to prevent adverse patient outcomes.
TRANSIENT GLOBAL AMNESIA AND CONCOMITANT TAKOTSUBO CARDIOMYOPATHY: A CASE SERIES
Authors: Borsi L , Di Spigno F , Biagi A , Rusticali G , Turchio P , Tedeschi A , Aschieri D 
Published: May 2024

Abstract
Transient global amnesia (TGA) is a clinical syndrome characterized by the sudden onset of anterograde amnesia, accompanied by repetitive questioning lasting up to 24 hours with whole restoration and without compromise of other neurologic function. Case reports suggest that cardiac dysfunctions may also occur in patients TGA although until now, no study has systematically assessed this phenomenon. Several pathophysiologic mechanisms have been proposed, with particular emphasis on the role of the central and autonomic nervous systems and an increased sympathetic hyperactivity, likewise to Takotsubo Syndrome (TTS). A case series of two cases (one man and one woman) of TGA as a precocious display of concomitant Takotsubo cardiomyopathy was described.
ISCHEMIC MITRAL REGURGITATION: MV-TEER AS AN ALTERNATIVE TO SURGERY IN HEMODINAMICALLY UNSTABLE PATIENT
Authors: Leuzzi F , Esposito L , Cancro F , Attisano T , Pierri A , Maione A , Di Muro M , Ravera A , Citro R , Vigorito F , Galasso G , Baldi C 
Published: May 2024

Abstract

Background
Severe ischemic mitral regurgitation is a complication that develops in approximately 7% of patients with STEMI. It can be caused by the rupture of a papillary muscle or, more frequently, by unfavorable regional remodeling of the left ventricle, and is burdened by a mortality up to 50%. The optimal treatment is controversial, because of the high surgical risk of these patients; at the same time, conservative management is not able to manage the most compromised cases and is associated with an unfavorable prognosis. In these patients, percutaneous mitral valve repair with edge-to-edge technique (MV-TEER) can be considered a reasonable alternative.

Clinical History
A 62-year-old woman was admitted to the emergency room with a diagnosis of lateral STEMI; she was immediately transferred to the catheterization laboratory where a primary PCI on the circumflex branch, in a left-dominant coronary circulation, was performed. Despite a normal epicardial coronary flow, probably due to a no-reflow phenomenon, echocardiography revealed severe left ventricular dysfunction secondary to an inferior and posterolateral wall akinesia, which at the same time was responsible for a newly severe secondary mitral regurgitation (SMR). In the following day the patient developed the signs of cardiogenic shock associated with pulmonary edema unresponsive to conventional therapy. Given the patient’s worsening symptoms, the inefficacy of the medical therapy, the severe SMR and the high operative risk, the clinical case was evaluated in the heart team and the final decision was to proceed to MV-TEER with the MitraClip system. 7 days after the MI, the patient underwent successful TEER with the implantation of 2 G4 NTW® clips in A2/P2 position. The patient was discharged 11 days after TEER. At 6,12 and 18-months follow-up, the patient showed a mild residual SMR and reported a significant improvement of symptoms (NYHA Class I). The patient has never been hospitalized for decompensated heart failure and returned to a good quality of life.

Discussion
Acute ischemic SMR complicated by hemodynamic instability is associated with a high risk of in-hospital mortality. The critical condition of these patients often represents a contraindication to cardiac surgery. In this specific setting, TEER is a valuable therapeutic option, as it might effectively reduce SMR, improving the hemodynamic condition and ultimately resulting in a better short- and mid-term survival compared to surgery.
DEVELOPMENT OF A HUB–SPOKE NETWORK FOR TRANSCATHTER AORTIC VALVE IMPLANTATION: THE INTERVENTIONAL CARDIOLOGY UNIT OF IRCCS SAN RAFFAELE HOSPITAL (OSR HUB–SPOKE)
Authors: Federico F , Zanda G , Ferri L , Martino G , Harris R , Ancona M , Vella C , Russo F , Bellini B , Ghizzoni G , Gentile D , Dallavalle F , Gentilini C , Bonfanti P , Corrado G , Chieffo A , Montorfano M 
Published: May 2024

Abstract

Background
The growing prevalence of aortic stenosis determined in recent years an increase in candidates for percutaneous aortic valve replacement (TAVI), bringing out a difficult access to this procedure. In order to reduce waiting lists and to guarantee the training of the Interventional Cardiologists of Centers not equipped with on–site cardiac surgery, we implemented a TAVI protocol with one Hub center, the Interventional Cardiology Unit of IRCCS San Raffaele Scientific Institute, Milan, and two participating Spoke Centers: the ASST–Franciacorta Chiari Center and Valduce Hospital, Como.The aim of this study is to report in hospital outcomes of patients treated using this model of Hub–Spoke Network.

Methods
Patients included in this model were selected in the Spoke center where baseline clinical evaluation with echocardiography and CT scan were performed (inclusion and exclusion criteria attached). The cases were then discussed with a multidisciplinary team on–line and the procedure planned (access, valve type size). Once the procedure was scheduled, the patients underwent a single day transport to the Hub Center where they underwent TAVI and a same day return to the Spoke Center. A bailout hospitalization in the Hub Center was available in case of major complication. All Spoke Centers patients who underwent TAVI procedures in our Center according to our protocol were included in this analysis. The primary study objective was in hospital major adverse cardiac events (all cause or cardiovascular mortality, stroke, myocardial infarction); secondary study objectives were technical success, prolonged recovery in Hub Center and major vascular complications.

Results
Since 2019, a total of 69 patients underwent TAVI with the Hub and Spoke model. Mean age was 83 years ± 6 and mean ejection fraction was 59% ± 7%. Two patients (2.9%) had a prolonged hospitalization in the Hub center for a major vascular complication and an intra–procedural cardiac arrest, successfully resuscitated. Technical success was reached in 97.1% of patients. One patient experimented an ischemic stroke after the return in the spoke center: in hospital MACE was than 1.4%.

Conclusion
Considering the growing prevalence of aortic stenosis, The Hub Spoke Model for TAVI guarantees reduction in waiting lists, "access to care" for patients referred to Spoke centers, involvement and improvement of skills of their Interventional Cardiologists, keeping a high level of safety and efficacy.
COMPLEX LEFT ATRIAL APPENDAGE CLOSURE USING 3D PRINTING SYSTEM IN A PATIENT WITH RECURRENT EMBOLISM AND PREVIOUS MITRAL PROSTHETIC VALVE IMPLANTATION
Authors: Tarantini R , Pignalosa L , Marconi S , Sanzo A , Vicini Scajola L , Quilico F , Magrini G , Savastano S , Baldi E , Petracci B , Vicentini A , Rordorf R 
Published: May 2024

Abstract

Background
To prevent stroke in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is often prescribed especially for those with high risk (CHADS2–VASC score ≥ 2), however some patients present contraindications to OAC or they have persistent thrombosis. Left atrial appendage (LAA) closure (LAAc) has emerged as a safe and effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF).

Case Description
A 61–year–old woman was referred to our cardiology department for left atrial appendage (LAA) closure (LAAc). She had history of previous mitral valve surgery and replacement with mechanical prothesis (On–X 25/33 mm) and permanent atrial fibrillation (AF) with CHADS2–VASC score 4 and HAS–BLED score 2. The patient presented after a third episode of cardioembolic stroke and transesophageal echocardiography (TEE) revealed a thrombus within the LAA despite anticoagulation treatment. Due to multiple episodes of embolic stroke despite adequate oral anticoagulation, the patient was candidate for LAAc. In preparation for the procedure, TEE and computed tomography (CT) scan were performed to evaluate the anatomy, the size and the potential interference of the prosteshis ring with the LAA. Spontaneous echocontrast was present, the morphology was cauliflower with the ostium close to the mitral prosthesis ring. The anomalous anatomy of the patient increased the technical complexity of the intervention: thus, the procedure’s simulation on a 3D printed model resulted of great help in the choice of the most suitable device. The model was printed in deformable material mimicking the atrial wall mechanical behaviour. After written informed consent, the procedure was performed using a standard transvenous approach. Transseptal puncture was performed postero–inferiorly under TEE guidance and Watchman FLX 35 mm was successfully implanted without residual leak. No complications occurred during the procedure. At 1–month follow–up visit, imaging demonstrated complete LAA occlusion and correct placement of the device with an adequate compression and no residual leak.

Conclusion
This is a clinical case that describes complex LAAc in a patient with mechanical prosthetic mitral valve. Simulating the patient’s anatomy with a 3D–printed model can be useful in complex LAAc procedures to guide prosthesis selection and device sizing reducing procedure time and the risk of failure.
MITRACLIP TREATMENT FOR CARDIOGENIC SHOCK DUE TO ACUTE MITRAL REGURGITATION IN A PATIENT WITH POSTINFARCTION PAPILLARY MUSCLE RUPTURE
Authors: Capodaglio I , Tofoni P , Lofiego C , Vagnarelli F , Patani F , Brugiatelli L , Maurizi K , Pietrucci F , Perna G , Marco M , Piva T , Dello Russo A , Di Eusanio M 
Published: May 2024

Abstract

A 85–year–old woman presented to ED with worsening dyspnea for 24 hours; no other related symptom. Her medical history included hypertension, dyslipidemia, type 2 DM and surgical coronary revascularization 13 years before for multiple critical coronary artery disease (LIMA to LAD and sequential SVG to PDA and OM branch). The ECG promptly revealed a subacute infero–lateral STEMI. Transthoracic echocardiography (TTE) showed inferior and postero–lateral wall akinesia with severely reduced left ventricle ejection fraction (LVEF), mildly reduced right ventricle systolic function and severe mitral regurgitation (MR) due to posterior papillary muscle (PM) rupture (Fig.1). Clinical scenario was complicated by pulmonary edema and cardiogenic shock treated with diuretics and sodium nitroprusside infusion, non–invasive ventilation and IABP insertion. Urgent coronary angiography revealed a thrombotic occlusion of the venous graft for OM branch. Surgical correction was excluded due to hemodynamic instability. Graft occlusion was treated with manual thromboaspiration, balloon dilatations and abciximab infusion. After an initial stabilization, transesophageal echocardiography (TEE) was performed confirming severe MR resulting from rupture of one head of a bifid posterior PM (red arrows, Fig.1) and prolapse of the anterior leaflet combined with restrictive systolic movement of the posterior leaflet due to wall motion abnormalities. 3 days later a transcatheter mitral valve edge–to–edge repair (MTEER) was performed using a MitraClip device (1 XTR clip and 1 NTR clip, Fig.2). TEE with 3D and TrueVue vision confirmed the correct placement of clips (Fig.3), a mild–to–moderate residual MR, absence of significant transmitral gradient and a mildly reduced LVEF. No clinical events were reported during recovery; patient was discharged after 2 weeks.

Conclusion
MTEER is an established therapy for reducing degenerative and functional MR. Little data is available on its use in the setting of PM rupture. This rare complication of AMI carries a mortality rate of 80% during the first week without surgical correction but more than half of patients are excluded because of prohibitive operative risk. TEER may be an alternative for these patients. In this case report we described the utility of MTEER in the setting of cardiogenic shock secondary to acute ischemic MR with papillary muscle partial rupture. This procedure can be useful with acceptable safety and procedural success.