bluuebunny/crossref_metadata_2025_split huggingface dataset:
SAFETY AND EFFICACY OF TRANSCATHETER AORTIC VALVE REPLACEMENT FOR NATIVE PURE AORTIC VALVE REGURGITATION: SINGLE–CENTER EXPERIENCE
Authors: Cavalli G , Vallabini A , Spatuzza P , Braccio M , Alemanni R , Russo E , Siena P , Palladino M , Gallo N , Greco F , Di Marco L , Pacini D , Cassese M 
Published: May 2024

Abstract

Background
TAVR has become the standard of care for high–risk patients with aortic stenosis. Considering unique procedural challenges posed by native pure aortic regurgitation (NPAR), our aim was to evaluate early and mid–term results of off–label treatment with new generation devices.

Materials and Methods
We retrospectively enrolled 61 consecutive patients, who underwent TAVR for NPAR between 2017 and 2023, because deemed ineligible for surgery. Mean logistic and Euroscore II were 17,07±11 and 5,62±5,9, though they did not accurately reflect surgical ineligibility: 7 patients (11,5%) had active cancer and 5 (8,2%) end–stage liver failure. Patients with valve calcifications or stenosis were excluded. A CT scan was obtained to choose device model and size, and access site. A percutaneous VA ECMO support was used in patients at higher risk for hemodynamic instability and procedural failure. Local anesthesia was preferred whenever feasible. Primary endpoints were technical and device success. Secondary endpoint was clinical efficacy at 1 year.

Results
Mean age was 75,69±9,01. Considering the high–risk population, we adopted local anesthesia in 56 patients (91,8%), reducing ICU admission and stay (27,9% and 1,98±6,51days). Mean aortic annulus diameter, perimeter and area were 25,5±2,16mm, 82,2±5,84mm and 520,04±74,32mm2. Consequently, the most frequently implanted prostheses were Evolut R/Pro 34 (41%), Sapien 3/Ultra 29 (26,2%) and Accurate neo M (9,8%). Approximately half of the population (54,1%) was shortly supported (24,46±24,7 minutes) with fem–fem VA ECMO, reducing hemodynamic instability due to rapid pacing. However, no increase in vascular complication was observed (p=0,58). One intraprocedural death was recorded (1,6%). Although 30–day mortality was 8,2%, primary outcomes were significantly better in the second half of the population (p=0,044 and p=0,036), reflecting the role of a standardized approach and surgeons’ higher expertise. Only 4 paravalvular leaks (6,6%) were detected at 1–month follow–up, 3 mild and 1 moderate (1,6%). Mean follow–up was 18,54±18,48 months. Clinical efficacy at 1 year was 76,3%, available for 38 patients.

Conclusions
TAVR is still considered an off–label approach for NPAR because of increased stroke volume and absence of annular and leaflet calcification. Nonetheless a standardized approach, with the aid of brief VA ECMO support for complex cases, should be considered a safe and valid option for inoperable patients.
CASE REPORT OF SNARING–ASSISTED TAVR UNDER CEREBRAL EMBOLIC PROTECTION: THE "CHAPERONE” WITH “TOP HAT" TECHNIQUE
Authors: Casilli F , Medda M , Montonati C , Cerutti C , Donatelli F 
Published: May 2024

Abstract
A 84–year–old woman was admitted for effort dyspnea (NYHA class II–III) in severe aortic stenosis (peak/mean gradient 107/61 mm Hg, aortic valve area 0.5 cm2) with high surgical risk (STS PROM 8%). Pre–operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, ‘gothic’ aortic arch (AA) and multiple calcific stenosis of both iliac–femoral vessels, severely tortuous. We planned a transfemoral implantation of a 29–mm self–expandable Evolut R valve (Medtronic) under complete cerebral protection (CP) with TriGuard™ system and delivery advancement ‘snaring–assisted’. The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino–tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp). The snaring procedure of self–expanding transcatheter heart valve (THV) has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the ‘gotic’ and calcific AA. The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses. In order to guide the advancement of the THV through the AA we preventively inserted a 20–mm AndraSnare catheter from the contra–lateral femoral artery. The THV was advanced on the snared guidewire, and the tip of the THV was ensnared and then pulled in order to be detached from the calcified wall of the ascending aorta, allowing the valve to be steered (“Chaperoned”) through them moreover without any interference with the CP system (“Top Hat”). At the macroscopic analysis of CP device there were also present small debris of calcium. Finally no complications related to the vascular accesses occurred. On the basis of our experience the risk–benefit balance of implementing CP with device (and specifically with TriGuard™ system) needs to be deeply evaluated because it requires a great care: a) to avoid uncontrolled movement of the device once opened, b) to avoid aggressive contacts with the aortic wall during complex maneuvers, c) the CP system requires a dedicated vascular femoral access (8F). To our knowledge, this is the first case of snaring–assisted TAVR under complete cerebral embolic protection with TriGuard™ system.
GENDER DIFFERENCES IN MORTALITY RISK AFTER TAVI: UNRAVELING THE ENIGMA THROUGH BODY COMPOSITION ANALYSIS
Authors: Casirati A , Somaschini A , Cornara S , Olivotti L , Giachello V , Astuti M , Botta M , Ghione M , Buscemi M , Cereda E , Caccialanza R , Bellone P , Cordone S 
Published: May 2024

Abstract

Introduction
In the context of Transcatheter Aortic Valve Implantation(TAVI), females often present with higher Society of Thoracic Surgeons(STS) mortality score values. Paradoxically, however, they tend to exhibit greater survival post–TAVI compared to males. Previous literature has shown that body composition(BC) may affect prognosis in cardiometabolic diseases. Specifically, increased visceral adipose tissue(VAT) and decreased skeletal muscle(SM) have been associated with worse outcomes, whereas subcutaneous adipose tissue(SAT) has shown a protective role. Nevertheless, whether these factors specifically interact with outcomes in relation to gender in patients treated with TAVI is still unknow.

Methods
Data of patients who underwent TAVI in 2010–2022 were collected. The areas of SM, VAT and SAT were measured from scans at the third lumbar vertebra of preoperative CT exams. Variables are expressed as median[25p–75p] or absolute number(%) and were compared by Mann–Whitney and Chi–square test as appropriate. Mortality analyses were performed through Kaplan–Meier curves with log rank test and Cox regression models.

Results
We enrolled 168 consecutive patients, including 89(53.3%) females. The median age was 84[81–86] years. In comparison to males, females exhibited higher values of STS mortality score (4.2[3.1–6.3] vs. 3.5[2.4–5.4], p=0.021) and SAT (189[111–242] vs. 135[92–170] cm2, p=0.001), along with lower values of SM (92[81–106] vs. 129[115–144] cm2, p&lt;0.0001) and VAT (116[48–197] vs. 210[118–266] cm2, p&lt;0.0001). Additional differences are detailed in Table 1. The overall 1–year mortality was 15.6%, with females exhibiting lower mortality rates compared to males (10.1% vs. 21.8%, OR=4.5, p=0.033), as illustrated in Figure 1. In the multivariate analysis, female sex emerged as an independent predictor of better survival after adjusting for the STS mortality score (HR=0.4, 95% CI 0.2–0.9, p=0.028).

Conclusions
In our cohort, female patients experienced lower 1–year mortality after TAVI compared to males. As females showed less SM and VAT and more SAT, we hypothesize that the interplay between muscle and adipose tissue, along with hormonal, inflammatory, and metabolic mechanisms, may create a more favorable cardiovascular environment, counteracting the higher pre–procedural STS mortality score. A distinct pattern of BC appears to be protective in female patients undergoing TAVI, and its evaluation could help optimize gender–specific risk stratification.
ATRIAL VOLTAGE ANALYSIS FOLLOWING VEIN OF MARSHALL ETHANOL INFUSION PREDICTS MITRAL LINE BLOCK
Authors: Taddeucci S , Garibaldi S , Nesti M , Landra F , Startari U , Panchetti L , Mirizzi G , Lionetti V , Piacenti M , Marchese P , Rossi A 
Published: May 2024

Abstract

Background
The vein of Marshall (VoM) is a promising target for atrial fibrillation (AF) treatment, matching with the ‘Coumel triangle‘ by housing triggers, autonomic connections, and serving as a substrate for perimitral flutters. Lateral mitral line (ML) represents a fundamental part for AF treatment, but achieving bidirectional block through endocardial ablations is challenging. VoM ethanol infusion (VOM–EI) facilitates ML block, with the newly–formed bipolar lesion serving as an effectiveness index. Voltage analysis assessment after VOM–EI in predicting ML block is poorly investigated.

Purpose
To compare unipolar and bipolar low–voltage areas (LVAs) along VOM trajectory after VOM–EI, and their role in predicting ML block.

Methods
We enrolled 59 patients undergoing catheter ablation of persistent AF or ML–dependent atrial flutter. High–density voltage mapping of left atrium was followed by VOM–EI and LA remapping. The area width difference was obtained and defined as ΔLVA. Normal bipolar voltage cutoffs were 0.50 mV in sinus rhythm or 0.29 mV in AF. Unipolar cutoffs were 2.7 mV and 1.1 mV, respectively. After VOM–EI, anatomical lesions included PVI, linear lesion for dome and ML isthmus. Systematic lines block validation was performed, defining ML block after coronary sinus (CS) electrograms sequence inversion (septal–to–lateral) during left atrial appendage pacing. Radiofrequency (RF) applications into the CS–great cardiac vein targeted epicardial gaps if present. Ablation time for ML block (AblTime) was obtained.

Results
In our cohort, 94.5% achieved ML block. Bipolar and unipolar low voltage areas after VOM–EI were 9,9 ± 6,9 cm2 and 12,2 ± 5,9 cm2 respectively. Bipolar ΔLVAs were significantly lower than unipolar ΔLVA (8.2 ± 6.5 cm2 vs. 9.4 ± 6.0 cm2; p=0.03) (Fig 1). A strong linear correlation between AblTime and bipolar ΔLVA (R: 0.76), and a significant correlation between AblTime and unipolar ΔLVA (R: 0.6) were found (Fig 2). Patients requiring RF applications into the CS for ML block (13/59, 22%) showed lower ΔLVAs in logistic regression for both bipolar (p&lt;0.01) and unipolar (p=0.03) analyses.

Conclusions
VOM–EI induces unipolar LVAs wider than bipolar along the mitral isthmus trajectory. Unipolar and bipolar voltage analysis predicts a short time ML block achievement. Moreover, wider unipolar and bipolar LVAs following VOM–EI correlates with higher likelihood to avoid the targeting of epicardial gaps via the CS musculature.
AN ODD CASE OF GIANT INTRAPERICARDIAL MASS
Authors: Maurizi K , Vagnarelli F , Lofiego C , Capodaglio I , Patani F , Tofoni P , Brugiatelli L , Pietrucci F , Dottori M , Pupita G , Schicchi N , Fogante M , Esposto Pirani P , Dello Russo A , Perna G 
Published: May 2024

Abstract
A 70–year–old man was admitted to our emergency department (ED) for chest pain during the previous 3 days variable with breathing and chest movements. Clinical history included chronic coronary syndrome (2018: transient ST–segment elevation treated with PTCA + DES on proximal LAD), chronic kidney disease (CKD), chronic myeloid leukemia, chronic hepatitis B and C. At the ED an ECG showed atrial fibrillation (AF) with medium ventricular response (100 bpm). Transthoracic echocardiogram (TTE, Fig.1a, 1b, 1d) and transesophageal echocardiogram (TEE, Fig.1c) revealed a voluminous roundish iso–ipoechoic mass (“red star”) with regular and hyperechoic margin, apparently intrapericardial and close to the lateral wall of the left atrium, measuring 8 x 5.5 x 2 cm, without infiltrating the wall and without obstructing pulmonary veins return. Minimal pericardial effusion was present. On contrast TTE (Sonovue) there was no uptake of contrast agent (Fig.2a). The MRI (Fig.2b) showed a heterogeneous formation with slight late contrast enhancement consistent with intrapericardial hematoma. We submitted the case to cardiac surgeons who recommended close echocardiographic follow–up, given the absent hemodynamic impact of the mass. Management of pericardial hematoma in this clinical setting is controversial, it has limited available evidence, and thus there is significant variability in clinical practice. Due to AF, anticoagulant therapy with warfarin (imbricating with heparin) was initiated; anti–inflammatory treatment with ibuprofen and colchicine was prescribed. The patient was discharged in good general conditions. One month later we scheduled a follow–up visit with echo: a clear volumetric reduction of the intrapericardial hematoma was documented (Fig.3) and the patient reported a complete disappearance of the symptoms. We chose this case to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac/pericardial masses; among others, MRI certainly represents the gold standard in this field but also Sonovue contrast echocardiography is definitely useful. Furthermore, a multidisciplinary approach involving clinical cardiologists, radiologists and cardiac surgeons is essential.
NOSOCOMIAL ENDOCARDITIS ON AORTIC BIOPROSTHESIS, A CASE OF ACCELERATED ATHEROSCLEROSIS
Authors: Di Marino M , Genovesi E , D‘ Alleva A , Magnano R , Pezzi L , Gallina S , Vitulli P , Forlani D , Corazzini A , Di Marco M , Paloscia L 
Published: May 2024

Abstract
Male, 79 years old, presented to the ED with chest pain and hemodynamically instability. Approximately one month prior, he underwent aortic bioprosthesis implantation for severe aortic stenosis. Pre–intervention coronary angiography revealed diffuse atheromatous plaques, none of which were stenotic. Additionally, the patient‘s medical history included paroxysmal atrial fibrillation on NOAC, hypertension and COPD. Upon admission: NIBP 80/50 mmHg, HR 150 bpm, and oxygen saturation was 85%. ECG showed atrial fibrillation with ST–segment elevation from V1 to V5. Arterial blood gas analysis revealed pH 7.25 and lactate 6 mmol/L. He received inotropic and vasopressor support, and prompt coronary angiography was performed, revealing 99% stenosis of the mid left anterior descending artery at the bifurcation with the diagonal branch, which was treated with angioplasty and coronary stent placement (Fig.1). Transthoracic echocardiography demonstrated the presence of the aortic bioprosthesis with diffusely thickened leaflets consistent with multiple vegetations. Transesophageal echocardiography confirmed a nosocomial infectious endocarditis, with mild–to–moderate stenosis, and evidence of peri–prosthetic echogenic material directed towards the left atrium, suggestive of abscess. The patient reported low–grade fever and asthenia in the weeks prior. The systemic and local inflammatory state of the endocarditis contributed to an accelerated atherosclerotic process, destabilizing the plaque and resulting in its rupture. Blood cultures identified multidrug–resistant Staphylococcus hemolyticus, for which specific antibiotic therapy was started. The patient and his family declined cardiac surgery due to high operative risk. Follow–up TEE, after approximately six weeks of intravenous antibiotic therapy, showed reduced vegetations on the bioprosthetic valve leaflets, with evolution of the previously noted large echolucent cavity, along with two similar peri–prosthetic lesions. These findings were confirmed on contrast–enhanced CT. The patient, achieving hemodynamic stability, was discharged home, continuing intravenous antibiotic therapy (OPAT protocol). At the one–month post–discharge follow–up, the patient was asymptomatic and hemodynamically stable. A repeat TEE showed normally mobile bioprosthetic valve leaflets without vegetations, and the previously noted large cavity with internal flow, consistent with cleansed abscess (Fig.2–3).
CARDIAC IMPLANTABLE ELECTRONIC DEVICES IN DIFFERENT ANATOMICAL TYPES OF PERSISTENT LEFT SUPERIOR VENA CAVA: A CASE OF INNOVATIVE SOLUTION OF PACING
Authors: Valecce R , Montemurro M , Incampo G , Moramarco M , Bonfantino M 
Published: May 2024

Abstract
A male patient(pt)76y old hypertensive,smoker underwent a right vocal cord biopsy.At the end of that procedure he presented lightheadedness and fatigue,with junctional escapement rhythm at the mean ventricular rate of 45 bpm and marked sinus bradycardia unresponsive to therapy.He was transferred to the cardiology intensive care unit(ICU).ECG:no atrial activity with ventricular escapement rhythm at 40 bpm.Color Doppler CDE (CDE):mild uniform left ventricular hypertrophy,normal ventricular functionality with 60% LVEF,coronary sinus(CS) dilatation as persistence of left superior vena cava (PLSVC).Isoprenaline infusion was started.Evidence ECG monitoring of sporadic and symptomatic sinus pauses lasting up to 4600 msec.A pacemaker(PM)implant was indicated under ESC 2021 guidelines(GL).Phlebography was done in the cathlab which confirmed PLSVC draining into the CS and no anonymous vein connecting the right and left superior vena cava (LSVC) and right subclavian draining into the PLSVC was documented through right phlebography.In accordance with ESC GL,we implanted a leadless VVI PM.PLSVC is a congenital anomaly due to an abnormal CS development during early fetal life with an incidence ranging from 0.3% in the general population to 4.3%.In 8% of cases,it drains into the left atrium causing hemodynamic changes as a left–right shunt.In the vast majority of cases it drains into the CS and remains asymptomatic.The unexpected presence of a PLSVC can complicate PM implantation,increasing the procedure time or forcing the operator to reinitiate the procedure on the right if a right SVC is present.In our case,both venous accesses were abnormal.The pt was a candidate for PM implantation via PLSVC as already demonstrated in the literature but this approach would have used the only upper venous access available,impacting the feasibility of future upgrading procedures.An epicardial PM implantation could have been an alternative but this approach was considered anachronistic.We opted for the implantation of a leadless VVI PM.This is recommended by ESC GL in class IIB.Essential information that contributed to our decision was knowing that the pt was a caregiver of a bedridden relative and needed to carry heavy weights as soon as possible after discharge.This choice ensured our pt a minimally invasive implant with the same length of stay as a transvenous PM,low infection risk,and preserved only venous access,albeit abnormal,for potential future procedures.
HYPOCALCEMIC CARDIOMYOPATHY PRESENTING AS HEART FAILURE EXACERBATION DUE TO UNTREATED PRIMARY HYPOPARATHYROIDISM: A CASE REPORT
Authors: Mapelli M , Nepitella A , Ferdico S , Formenti A , Baggiano A , Campodonico J , Ranieri M , Vettor G , Sambenedetto M , Basso C , Agostoni P 
Published: May 2024

Abstract

Introduction
Hypocalcemic cardiomyopathy (HC) is a rare and potentially reversible cause of heart failure (HF). Primary hypoparathyroidism, due to accidental damage to the parathyroid glands during thyroid surgery, is one of the most common causes of hypocalcemia. Identifying this etiology is crucial.

Case Report
A 54 y.o. patient affected by arterial hypertension and hypothyroidism, presented to our hospital with HF. He underwent total thyroidectomy 20 years earlier. An echocardiogram revealed a dilated cardiomyopathy with systolic dysfunction (LVEF 22%), reduced right ventricular function and elevation in pulmonary artery pressure. ECG showed sinus rhythm, QTc 470 msec. BNP was increased (1888 pg/ml) and troponin value normal. Blood calcium and phosphorus values were not performed on admission. Intravenous diuretic therapy led to good clinical response and disease–modifying therapy (bisoprolol, sacubitril/valsartan, eplerenone) was started and uptitrated. Coronary CT excluded significant coronary lesions. Cardiac MRI showed increased native T1–T2 values and an intramyocardial "patchy" distribution of late gadolinium enhancement involving the interventricular septum. Endomyocardial biopsy excluded the presence of viral DNA/RNA and signs of active inflammation. After few days an episode of dysarthria, spatial/temporal disorientation and muscle spasms was reported. Urgent brain CT was performed, which excluded acute ischemic or hemorrhagic events, but diffuse basal ganglia calcification. Blood tests revealed severe hypocalcemia in the setting of primary hypoparathyroidism (total calcium 1.57 mmol/L, ionized calcium 0.61 mmol/L, PTH 8,8 pg/ml). Trousseau‘s sign ("obstetrician’s hand”) was positive, suggesting the presence of latent tetany. Hypocalcemia was corrected with calcium carbonate and calcitriol administration. On ECG QTc was 522 msec with subsequent normalization. In the following days, progressive neurological improvement was reported. After a week he was discharged in good status. At follow–up we observed a progressive improvement in biventricular systolic function with complete normalization of LVEF and ventricular volumes at 9 months.

Conclusion
HC must be suspected when a patient presents with myocardial dysfunction, neuro–muscular signs and QT prolongation on ECG. Diuretics administration may aggravate hypocalcemia by increasing urinary calcium excretion. Normalization of calcium concentration could lead to complete recovery.
ALL THE ROADS LEAD TO THE MYSTERIOUS DISEASE
Authors: Polito D , Piscione M , Nafisio V , Ussai G , Grogioni F 
Published: May 2024

Abstract
A 58–year–old man with familiarity for sudden cardiac death was accepted to the hospital for dyspnea. Two years before he underwent cardiac angiography which showed a significative lesion of the descending artery which was treated with the placement of a drug eluting stent. For the appearance of an atrio–ventricular block 2:1, a permanent pacemaker was implanted. A transthoracic echocardiogram demonstrated: mildly dilated left ventricle with a reduced global systolic function (calculated ejection fraction was of 25%). Computed tomography with intravenous contrast of the chest showed upper, mid and lower multifocal nodularity with irregular margins with predominantly peri –bronchial distribution. The patient underwent bronchoscopy with endotracheal ultrasound and multiple transbronchial biopsies. Bronchoalveolar lavage (BAL) was negative for fungi infections, bacteria (including Mycobacterium Complex), and malignant cells. Endobronchial biopsies revealed non–necrotizing, well–formed granulomas embedded in dense hyaline sclerosis. Also the ratio of CD4+/CD8+ cells was within limits. FDG PET–TC scan showed: multiple enhancing areas in the lungs and lymph nodes probably of an inflammatory nature and therefore compatible with pulmonary sarcoidosis. A high dosage cortisone therapy was started, the patient was transferred to undergo endomyocardial biopsy, subsequently tested positive for multisystemic disease. Sarcoidosis is a rare disease with extremely heterogeneous clinical presentations. Actually, it is characterized by non–necrotizing granulomas, aggregates of epithelial cells, macrophages, multinucleated giant cells and CD4+ T lymphocytes, which infiltrate different tissues. When symptomatic, cardiac sarcoidosis includes conduction abnormalities, arrhythmias and ventricle dilation with hearth failure. Rhythm disorders, which rang from first to third degree, are the most common manifestation together with atrial fibrillation and ventricular tachyarrhythmias which can be explained with reentrant mechanisms from the granulomatous scar. Both atria–ventricular blocks and history of ventricular tachycardia elevate the risk for sudden cardiac death, which may be the first and unique manifestation of the disease. If myocardial involvement is extensive, cardiac sarcoidosis can present with hearth failure.