bluuebunny/crossref_metadata_2025_split huggingface dataset:
EPIDEMIOLOGICAL FRAMEWORK OF MYOCARDITIS DURING SARS–COV–2 PANDEMIC AND VACCINATION CAMPAIGN
Authors: Bonini J , Dal Passo B , Vitagliano A , Bugani G , Pallotti M , Casella G 
Published: May 2024

Abstract

Rationale
Myocarditis is an inflammatory condition of cardiomyocytes whose clinical course can be heterogeneous. Etiologies include infections (mostly viral), drugs or toxic exposures or auto–immunity, while few cases have been reported in association with vaccines (following, mainly, attenuated smallpox vaccine). Estimated prevalence is 2–22 cases/100000 people/year, with greater frequency in males aged 30–40. Since SARS–CoV–2 outbreak and vaccination campaigns there is growing interest in their association with myo–pericardial inflammatory conditions, with incidence reports of 1–5/100.000 and 1–5/1.000.000 respectively among vaccinated and unvaccinated subjects (as part of COVID–19) and relatively higher incidence in males after second (mRNA) vaccine administration.

Study Design and Objective
We designed this observational registry and included patients with CMR–confirmed myocarditis diagnosis admitted to Maggiore Hospital in Bologna from March 2017 to April 2023. Primary goal was to conduct an epidemiological analysis on myocarditis incidence in the era of SARS–CoV–2 and respective vaccination.

Results
We enrolled 48 patients, among which 37 were diagnosed during SARS–CoV–2 pandemic. 86% were male, and mean age at diagnosis was 31 years old; the vast majority did not show major modifiable CV risk factors (apart from cigarette smoking: 42%) or previous/comorbid CV conditions. Median LVEF (by CMR) at diagnosis was 56%, with 3 patients (6%) with LVEF &lt; 47%. Median hsTnI and CRP peaks were respectively 7317 ng/L and 4,5 mg/dl. We reported 6 (12.5%) arrhythmic events during index hospitalization (1 patient had sustained VT and 5 had non–sustained VT). 8 out of 37 patients with myocarditis during SARS–CoV–2 outbreak reported previous COVID–19, with a median time of 130 days from infection, but only 1 had myocarditis as part of its clinical course. 16 patients had already received at least one SARS–CoV–2 vaccine dose (median: 2 doses) at diagnosis, with a median time of 117 days from dose administration (only two patients were diagnosed &lt; 30 days from last administration).

Conclusions
Myocarditis epidemiology of our cohort seems to reflect available incidence data; furthermore, myocarditis as part of COVID–19 course or occurring shortly after vaccination appears to be an uncommon event. Our cohort consisted only of low or intermediate risk presentations. Data about diagnosis in the “COVID era” suggest a relative “underdiagnosis” in the previous period.
OUT–OF–HOSPITAL FLUID INFUSION IN THE SHOCK PATIENT: A SYSTEMATIC REVIEW OF THE LITERATURE
Authors: Palmieri T , Boni D , Conte A 
Published: May 2024

Abstract
This paper considers nursing in the critical care area and more specifically as the main topic, the use of volemic replacement fluids in the broad pathology of shock, applicable by the EMS. Shock is an acute, life–threatening pathological condition of the patient leading to cell and tissue hypoxia resulting in cell death and dysfunction of vital organs. The mechanism leading to such suffering may be decreased intake, increased consumption, improper oxygen utilization, or a combination of these three circumstances. The main cause turns out to be circulatory failure, clinically better known as hypotension. The literature demonstrates how important and critical fluid infusion appears to be in this type of patient. The following review of the bibliography aims to identify and collect the various scientific evidences by evaluating the best solution to infuse, the right dosage, and the target pressor to achieve depending on the type of shock: hypovolemic, distributive, cardiogenic, obstructive. The identification of the best infusible solution is one of the key points of acting in these scenarios as well as the target pressor set (permissive hypotension); it has emerged from the consultations that in the out–of–hospital setting colloids are not recommended because of the consequences compared to crystalloids. In the last decade, special attention is paid to permissive hypotension, that is, the target pressor to be achieved depending on the type of shock, showing how inappropriate fluid administration, in terms of quantity and type of substance to be used, is counterproductive to outcome. The literature shows how an abundant infusion of fluids can alter coagulation or sometimes induce the patient to ARDS; there is also evidence of how in hypovolemic shock the infusion of saline is not recommended, preferring a balanced solution, while in myelic shock saline is preferred.
ISCHEMIA WITH NON–OBSTRUCTIVE CORONARY ARTERY DISEASE (INOCA): A SINGLE CENTRE EXPERIENCE
Authors: Monaco S , Di Serafino L , Ciaramella L , Carbone C , De Rosa M , Mitrano L , Esposito G 
Published: May 2024

Abstract

Background
Myocardial ischemia with non–obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced quality of life, myocardial infarction and heart failure. INOCA is usually under–diagnosed precisely. We report our experience for endotype characterization, tailored therapy and short term follow up.

Methods
Thirty–five patients presenting with clinical presentation of chronic ischemic heart disease requiring coronary angiography for diagnosis, who referred to our department between October 2022 and December 2023 were included. All patients with acute coronary syndrome (ACS), prior artery bypass grafting (CABG), presence of obstructive CAD (stenosis &gt; 70% or FFR &lt; 0.80), sever valvular heart disease and EF &lt; 40% were excluded. All patients were clinically evaluated and subjected to validated questionnaires to characterize angina and quality of life. Subsequently, functional coronary angiographic evaluation was carried out, through the bolus thermodilution method using adenosine, including a study of the fractional flow reserve (FFR), the determination of coronary flow reserve (CFR), and the index of microvascular resistance (IMR), specific for the microvascular district. Finally, acetylcholine test to evaluate the presence of any epicardial vasospasm. Based on the results of these evaluations, 4 endotypes can be identified: microvascular dysfunction (CMD), vasospastic angina (VSA), both CMD and VSA and non–cardiac chest pain.

Results
The majority of patients were female (63%), with hypertension (86%), hyperlipidemia (86%) and diabetes (23%). They presented with typical angina (87%) and half of them (60%) undergone provocative ischemia tests (76% tested positive). Following functional coronary angiographic evaluation, 57% patients had a diagnosis of INOCA, of these 30% microvascular dysfunction (CMD), 40% vasospastic angina (VSA), 30% both CMD and VSA. The acetylcholine test was performed in all patients, resulting positive in 14 out of 35 (40%). Each patient was prescribed a personalized therapy. Short term follow–up was performed with a general improvement in symptoms following optimized medical therapy.

Conclusion
INOCA is a heterogeneous nosological entity, underdiagnosed and often poorly treated. Invasive functional angiography is helpful to identify endotypes and appropriate therapy with a significant clinical benefit.
TWO YEARS–EXPERIENCE OF REFERENCE REGIONAL CENTER FOR SPORTS IN PEOPLE WITH HEART DISEASE: CARDIOMYOPATHIES CASE SERIES
Authors: Vessella T , Giorgiano F , Pegoraro C , Merlo L , Barra B , Meneguzzo G , Sarto P 
Published: May 2024

Abstract

Whether patients with cardiomyopathies can exercise or not and what is the right dose in terms of intensity and frequency has always been a debated topic in cardiology and even today there are few indications in this regard. There are many elements to take into account in order to formulate a correct exercise prescription. First of all, the patient: his/her awareness of pathology, years since diagnosis, sports he/she practiced, volume of training he/she carried out. Then the pathology: phenotype, genetic mutations, history of cardiac arrest, presence of an ICD, risk of arrhythmic events. At the end, sports/exercise: it is important to distinguish between competitive sport and physical exercise and to consider that there are different training modalities and different possible intensities whose determination often requires more parameters than just heart rate. All these aspects are integral part of our "Julian Ross‘ Second Half" program that includes medical and psychological assessment, two moments of counselling, a period of supervised training and, finally, the return to physical activity with modalities and intensities compatible with the pathology. Our current series includes 45 patients with cardiomyopathies (39 men and 7 women, 19 hypertrophic cardiomyopathies mean age 44 years ± 17, 22 arrhythmogenic cardiomyopathies mean age 35 years ± 18 and 4 dilated cardiomyopathies mean age 19 years ± 4). We offered these patients a personalized exercise prescription after performing a complete risk stratification and a cardiopulmonary exercise stress test. All patients were prescribed aerobic and resistance training with intensities depending on the pathology, the ventricles involved, evidence of exertional obstruction, exertional arrhythmic burden, specific mutations etc. Both during supervised training sessions at our gym and the average follow–up of 18 months, we didn‘t recorded any cardiovascular major events. None of the patient who followed our indications showed a worsening of the pathology in terms of arrhythmic burden and ventricular involvement, while there was an increase in VO2 max.

Conclusions
Our case series demonstrate, even though in a short follow–up period, that aerobic and resistance training prescribed in a personalized way does not lead to a worsening of the disease and to adverse outcomes in an average follow–up of 18 months.
"UNUSUAL" ATRIAL FLUTTER: A CASE REPORT
Authors: Diella N , Sacchetta D , Genovesi E , Lombardi E , D‘Alleva A , Cappelli C , Di Marco M , Paloscia L 
Published: May 2024

Abstract
A 64–years old male patient was admitted in the Emergency Department with signs of heart failure in a setting of dilated hypokinetic cardiomyopathy with severe depression of left ventricular ejection fraction and no severe coronary artery disease. In the previous medical history: systemic arterial hypertension, obesity, dysthyroidism due to amiodarone, history of atrial fibrillation treated by transcatheter ablation in the left atrium with pulmonary veins isolation (PVI) and the creation of an anterior line in 2010. The ECG documented an atrial flutter rhythm 2:1 probably typical (Fig. 1). An indication was therefore made for hospitalization in Cardiology. After the restoration of a good hemodynamic state, given the persistence of the atrial tachyarrhythmia, an indication for transcatheter ablation was formulated. The electrophysiological study highlighted an activation sequence suggestive of typical common flutter (cranial–caudal right atrial activation; proximal–distal left atrial activation). We then proceeded to ablate the cavo–tricuspid isthmus without interrupting the arrhythmia. Therefore, left and right atrial electroanatomical mapping was performed which confirmed the right isthmic block and documented the left origin of the flutter, showing conduction gaps in the ostia of the pulmonary veins and in the previous anterior ablation line between the mitral annulus and the right superior pulmonary vein (RSPV) (Fig 2,3). Ablation of these gaps effectively stopped the arrhythmia. At the end of the procedure, after stimulation via atrial bursts of up to 200 msec there was no induction of arrhythmias. One month after the procedure, there was an improvement in the contractile function of the left ventricle. Discussion: This clinical case offers us an example of how the analysis of the surface ECG alone is not sufficient to adequately describe the complexity of the arrhythmic substrate characterizing an arrhythmia such as atrial flutter or atrial fibrillation. The electrophysiological study through electroanatomical reconstruction of endocavitary activation proves indispensable for the correct identification and consequent treatment of these complex arrhythmias, with clear clinical benefits for the patient.
A THICKENED LEAFLET: INFECTION OR SOMETHING ELSE?
Authors: Corsi E , D’Aiello I 
Published: May 2024

Abstract

Background
Prosthetic valve thrombosis is a rare but serious complication of valve replacement; it occurs more often in mechanical valves, but it can also be observed in bioprosthesis. It is associated with significant morbidity and mortality, thus the necessity of a prompt diagnosis and adequate treatment.

Case Description
A 81–years–old woman presented to the ED for progressive worsening dyspnoea and abnormal heart beat. She had undergone mitral plasty some years before and, few months before the access, a new cardiac surgery had been performed with implantation of a mitral bioprosthetic valve, tricuspid annuloplasty and LAA closure. After discharge she had been hospitalized for genitourinary tract infection, and twice for heart failure and atrial flutter. During this period, the anticoagulant therapy had to be modified for difficult warfarin management, and, after an appropriate period, had been switched to NOAC. At the admission to our ICU, the patient presented pulmonary oedema and transthoracic echocardiogram showed mitral prosthetic valve dysfunction with thicked and ipomobile leaflets and increased transvalvular gradient. In the suspect of IE empiric antibiotic therapy was introduced; UFH and inotropic support was also administered. The patient promptly undergone to TOE, that confirmed the severe thickening of the bioprosthetic valve leaflets resulting in severe stenosis, rising thus the suspect of bioproshetic thrombosis, that was found to be extended to inferior and superior vena cava. Despite the ongoing therapy, the patient hemodynamic kept worsening, and in the end fibrinolytic therapy was administered with rapid improvement in clinical conditions and bioprosthetic transvalvular gradient fall. During the following hospitalization the patient clinical and hemodynamical status kept recovering, and a new TOE confirmed the almost complete resolution of the thrombosis. The patient was then shift again to warfarin and discharged; during the hospitalization IE was excluded. A TOE performed after one month of oral anticoagulation confirmed the regular function of the mitral bioprosthesis.

Conclusion
This case shows a subtle but life–threatening case of prosthetic valve thrombosis and underlines the importance of searching for this condition even in biological prosthetic valves. It also shows the role of TOE in the diagnosis and management, and lets some questions open about anticoagulation therapy.
AGENESIS OF THE LEFT PERICARDIUM: REPORT OF A CASE
Authors: Placci A , Palumbo A , Suma S , Tadonio J , Niccoli G 
Published: May 2024

Abstract
We report a case of left pericardial agenesis in a 61 year old man presenting palpitations, without syncope. Clinical picture was not specific on clinical field: atypical chest pain, systolic murmur 2/6 Levine on the second left interspace were found. ECG showed sinus rhythm, clockwise deviation of axis in the precordial leads and incomplete right bundle branch block. Frequent isolated polymorphic premature extrabeats. Holter ecg was perfomed: frequent polymorphic extrabeats (9834/24 ore) with some couplets and triplets, without sustained ventricular tachycardia episodes. Starting metoprololo 100 mg per day the arrhythmic burden decreases significantly. Chest X–ray showed marked levocardia and dilatation of pulmonary trunk. Levocardia increased with the patient on the left side. Levoposition of the heart, lung interposition between the diaphragm and the base of the heart and between the aorta and pulmonary artery Echocardiography showed a classic abnormal swinging motion of the heart in the chest, a paradoxical interventricular septal movement, apparent right–sided heart enlargement, with unusual bulging of the apex of the right ventricle. Magnetic resonance imaging (currently the gold standard for diagnosing) confirmed the absence of the left pericardium, and a left pericardial agenesia diagnosis was performed Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. We analyze the diagnostic problems and the prognostic doubts of this rare congenital anomaly.
A CHALLENGING CASE OF PERCUTANEOUS ATRIAL SEPTAL DEFECT CLOSURE
Authors: Carluccio R , Riegler L , Forni A , Molinari R , Parlati A , Quaranta G , Pastore F , Zambrano A , Santoro G , D‘Andrea A 
Published: May 2024

Abstract
ASDs account for 13% of all congenital heart diagnoses at birth but remain asymptomatic until adulthood, when atrial arrhythmias, paradoxical embolization or pulmonary hypertension can develop. A 46–year–old woman, without significant cardiovascular history, was admitted to Cardiology Department for dyspnea at exertion. TTE showed an ASD OS type with large left–to–right shunt (Qp/Qs &gt;1.5) and right heart volume overload, dilated right chambers (RVD0: 50 mm) with good longitudinal ventricular function (TAPSE: 29 mm), moderate tricuspid regurgitation with PAPs estimated of 45 mmHg (TAPSE/PAPs: 0.64). TEE confirmed the presence of a 2 cm circular defect (2.01 cm at 61°, 1.98 cm at 91°, 1.92 cm at 98°), posterior and with a small IVC rim (PS rim: 0.571 cm at 0°, PI rim: 0.670 cm at 59°, IVC rim: 0.466 cm at 112°) but eligible to percutaneous closure. ASD was intra–procedure measured in 3 different TEE planes (0°, 45° and 90°) estimating the device size by adding 30% to the largest measurement (2.53 cm considering an ASD of 1.95 cm). With sizing balloon ASD balloon–stretched diameter resulted 2.25 cm at fluoroscopy and 2.56 cm with stop–flow CDUS technique. The procedure was therefore performed with the implantation of a 2.6 cm device, with good angiographic and echocardiographic final result. At 1–month follow–up TTE, device resulted in proper position without trivial leak, right chambers were less dilated (RVD0: 42 mm) with good longitudinal ventricular function (TAPSE: 32 mm), residual mild tricuspid regurgitation with PAPs estimated of 42 mmHg (TRV: 3.06 m/s, TAPSE/PAPs: 0.76).
AUTOIMMUNE MYOCARDITIS IN MELANOMA IMMUNOTHERAPY–COMPLEX CLINICA PRESENTATION AND ADVERSE THERAPEUTIC RESPONSE
Authors: Di Marino M , Galanti K , Testa S , Ricci M , Magnano R , Pezzi L , D‘Alleva A , Genovesi E , Forlani D , Vitulli P , Paloscia L , Gallina S , Di Marco M 
Published: May 2024

Abstract
A 68–year–old Caucasian female presented to the ED with cardiac chest pain and dyspnea. The patient had a history of arterial hypertension and was equipped with a biventricular pacemaker due to atrial fibrillation with low ventricular response. She had recently been diagnosed with metastatic melanoma and initiated treatment with nivolumab and ipilimumab two weeks prior. Troponin levels were elevated (700 ng/ml), and no ST–segment elevation was observed on the electrocardiogram (ECG). In suspicion of NSTEMI–ACS, coronary angiography was performed, revealing an intact epicardial coronary circulation without stenotic lesions. The echocardiogram showed borderline left ventricular systolic function (EF 50%), and the right ventricle exhibited initial signs of reduced systolic function (TAPSE, 15 mm; S RV, 9.5 m/s). The following day, there was a deterioration in hemodynamics and respiratory exchange, with evidence of apical and mid–distal interventricular septum hypokinesia of the left ventricle (EF 40%) and dilated right ventricle (BD 4.8 cm; MD 4 cm) with severely reduced systolic function (TAPSE 10 mm, S RV 7 m/s, FAC, 20%), and severe tricuspid regurgitation. Urgent computed tomography pulmonary angiography (CTPA) excluded pulmonary embolism. Additionally, there was a new troponin increase (5000 ng/ml) and elevated hepatic biomarkers. The clinical picture raised suspicion of myocarditis related to immune checkpoint inhibitor therapy. Corticosteroid therapy was initiated with a daily administration of methylprednisolone 1000 mg. Diagnostic confirmation was sought through autoimmune panel and viral marker assessments, which yielded negative results. Endomyocardial biopsy (EMB) revealed CD4 and CD8–positive lymphocytic infiltration and myocardial necrosis. Despite initial clinical improvement, an arrhythmic storm developed. Despite treatment with a defibrillator, intravenous antiarrhythmic therapy (beta–blocker, amiodarone, and lidocaine), and sedation, the patient unfortunately succumbed. Immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of many solid tumors. However, the dysregulation of immune mechanisms can rarely (2%) lead to autoimmune events involving multiple organs. Myocarditis, despite optimal treatment, is characterized by a mortality rate exceeding 50%, representing a significant challenge in the Intensive Care Unit.
DILATED CARDIOMYOPATHY, GUIDELINES PERSONALIZATION OF CARE
Authors: Spinelli A , Macchiusi A , Marino G , Di Fusco S , Pignalberi C , Colivicchi F 
Published: May 2024

Abstract
The term Dilated cardiomyopathy (CMD) refers to a family of diseases characterized by complex interactions between environment and genetic predisposition. Diagnostic tools as cardiac magnetic resonance imaging (MRI) must be systematically implemented in clinical practice to define the etiological cause and undertake a specific therapeutic treatment. We present the case of a young man with CMD and severe left ventricular dysfunction (ejection fraction, EF: 14%; left ventricular end–diastolic volume (LVEDV): 251 ml/m2; left ventricular end–systolic volume (LVESV): 197 ml/m2. The patient has a family history of sudden cardiac death (SCD). He is affected by a psychiatric pathology (ADHD) and has a history of alcohol and drug addiction. Many diagnostic hypotheses have been considered for etiological research (viral myocarditis, genetic or alcoholic–induced cardiomyopathy, toxic substances such as narcotics and psychiatric drug–induced cardiomyopathy). MRI after 11 days in hospital confirmed FE 14%, LVEDV: 320 ml/m2, LVESV: 275 ml/m2; reduction of the wall thickness at the antero–septal wall to the middle tract; areas of altered signal, hyperintense in T2W sequences, at the left ventricular myocardial wall suspected of myocardial edema, associated with extended signal hyperintensity of periventricular tissue, which show marked enhancement immediately after intravenous contrast agent administration (Fig. 1). The underlying psychiatric pathology and the possibility of poor adherence to the maintenance of the wearable defibrillator did not facilitate the clinical follow–up which should have included the identification of the etiological cause and the appropriate treatment guaranteeing the temporary prevention of SCD. So, it was decided to make a personalized therapeutic choice, the patient underwent implantation of a subcutaneous defibrillator, pending a better diagnostic definition and the possible need of other therapies as cardiac transplantation/implantation of mechanical assistance device.