bluuebunny/crossref_metadata_2025_split huggingface dataset:
P138 ST–SEGMENT ELEVATION, QTC PROLONGATION AND BRUGADA LIKE PATTERN IN THE EMERGENCY DEPARTMENT: A NEW ENTITY FOR US TO KNOW? CASE 1
Authors: Carmina M , Bellavia D , Pieri D , Donzelli M , Vaccaro P , Panzarella G , Bonomo V , Polizzi V , Geraci G 
Published: May 2023

Abstract

Introduction
ST elevation (STE) usually means acute transmural ischemia by epicardial coronary artery occlusion by a blood clot,so Guidelines recommend rapid reperfusion therapy, possibly within the first hour. Nevertheless,STE due to non–ischemic etiologies has been reported in up to 15% of the general population.We report a case of ‘likely STEMI’ presenting with marked STE,QTc prolongation and Brugada like pattern on ECG but no significant coronary obstruction on angiography.Case 1A 74y woman presented in the ER with syncope and chest pain.History of pulmonary emphysema and Crohn‘s disease previously operated on. On admission:apyretic,BP 80/40, HR130 bpm, SO2 98% on mask O2 12 l/min.WBC 20,000, 84% neut, high D–Dimer 36091 and HS–TnI 99. On transthoracic echo (TTE) akinesis in apical, apical lateral, anteroseptal, and anterior wall and EF 25%.On Chest CT bilateral emphysema,no pulmonary embolism.On ECG sinus tachycardia,frequent PVCs,diffuse deep negative waves and prolonged QTc.While in ER,a new she syncope occurred,and tachycardia with large complex,with spontaneous resolution,was observed.On ICU admission ECG diffuse STE with coved pattern in V1 and prolonged QTc 641 ms;treated with magnesium sulfate,calcium gluconate,metoprolol,ASA,heparin;on urgent coronary angiography subcritical stenosis of left anterior descending artery without blood clot:PCI with drug–eluting stent was performed. Nevertheless,ECG did not change while multiple ventricular fibrillations occurred later, requiring electric shock.Later on, after prolonged treatment with magnesium sulfate, Calcium gluconate, antibiotic, electrolytes correction,QTc,ECG and EF progressively normalized.

Discussion
The patient reported was labelled as a “TakoTsubo syndrome“ diagnosis,but in fact we think the ECGs (persistent STE, prolonged QTc and Brugada pattern), the TTEs and clinical features can be explained by different nosological entity due to the dysregulated INa, and in particular by increased late sodium current INa late : it leads to impaired cardiac energetics and contractile dysfunction as well as cardiac arrhythmias; acidosis and hypoxia can also increases IN late.As for our patient, unlike Takotsubo syndrome, she had no emotional trigger, no characteristic apical balloon on TTE, while severe physical trigger like hypoxia and acidosis stand out.Patients presenting with these ECG features should not be treated with thrombolysis but referred to a HUB center for coronary angiography.
P141 ACUTE MYOCARDIAL INFARCTION OR SOMETHING MORE? CASE REPORT AND CHALLENGES ASSESSMENT OF GIANT CORONARY ANEURYSM MANAGEMENT
Authors: Pala B , Tifi P , Bruno N , Tocci G , Gabrielli D 
Published: May 2023

Abstract

Background
Coronary Artery Aneurysms (CAA) are defined as localized coronary artery dilations more than 1.5 times the diameter of the adjacent segments. Giant CAA (GCAAs) are rare coronary diseases and the presence of multiple CAAs, located in more than one coronary artery, is even more uncommon. The pathophysiology is unknown but the majority are due to atherosclerosis. There is currently no consensus concerning the management. Case presentation: We report the case of a 72–year–old man, referred to our emergency department due to chest pain. The patient’s electrocardiogram was consistent with myocardial infarction with inferior leads ST–segment elevation. Two-dimensional echocardiography showed hypertrophic Left Ventricle (LV) with akinesia of the infero–postero-lateral LV wall and hypokinesia of the remaining LV segments (LVEF = 40%). Coronary angiography and computed tomography revealed multiple CAAs, some of them giant, associated with significant coronary artery disease: two CAAs on the right coronary artery, including a giant one (Dmax 11 mm and Dmax 32 mm); one large aneurism on the circumflex artery (D max 20.5 mm) and one on the left main descendent artery (D max 8 mm). The patient had a previous history of hypertension, dyslipidemia and abdominal aortic aneurysm. He had no history of percutaneous coronary intervention or cardiac surgical procedures. Serological studies for vasculitis or connective tissue disease were all negative. The patient underwent surgical exclusion of the giant right CAA with ligation of the proximal and distal ends of the aneurysm and double bypass surgery to the obtuse marginal and right posterior descending coronary arteries.

Conclusions
CAAs’ treatment options include medical treatment, interventional or surgical management. No clear evidence about the better option exists, but it seems that surgical option should be favored in cases of bigger, more tortuous and more calcified CAAs. Based on these evidences and the anatomic lesions of our patient, we opted for surgery and he successfully underwent CAAs resection with coronary bypasses. We reported our experience and we examined the current knowledge on CAA/GCAA. Overall, management is hampered by lack of evidence. We need prospective studies and registries to further our knowledge in the management of this disorder and prognosis. From our attitude, surgical treatment should be performed for multiple GCAA to prevent fatal complications.
P142 EARLY MANAGEMENT OF STEMI PATIENTS DURING COVID–19 PANDEMIC: THE ROLE OF AN EMERGENCY DEPARTMENT–BASED CARDIOLOGY UNIT IN SAN RAFFAELE SCIENTIFIC INSTITUTE
Authors: Morciano D , Barki M , Mager R , Morosato M , Ricchetti G , Assanelli A , Agricola E , Margonato A , Slavich M 
Published: May 2023

Abstract
During COVID–19 pandemic, a critical issue for cardiologists was to provide early access to the standard of care for patients with time–dependent diseases such as ST–segment elevation myocardial infarction (STEMI), while making efforts to prevent their exposure to SARS CoV–2. Aims: The aim of our research project was to evaluate the role of an Emergency Department–based operative unit directly managed by the Cardiology Department in providing a prompt cardiological evaluation to STEMI patients at first medical contact, which we assumed might positively impact on the reperfusion strategy and timing and thus on the extent of myocardial salvage.

Methods
We retrospectively included a group of STEMI patients admitted by our ED with a definitive diagnosis of STEMI from March 2020 to November 2021 and a control group admitted from January 2019 to February 2020. The groups were compared in terms of critical time intervals, rate of PCI or initial non–invasive conservative management, pre–discharge characteristics and in–hospital clinical outcomes, including all cause mortality and complications.

Results
Throughout the study period, a total of 211 patients were admitted to our institution with a diagnosis of STEMI. The number of patients presenting late (at least twelve hours since symptoms onset) was significantly higher and time from symptoms onset to hospital admission was significantly longer during the first COVID–19 pandemic peak, compared with the previous year. Almost all patients in both cohorts underwent invasive coronary angiography with subsequent primary PCI. Remarkably, despite the time–consuming hygiene practices and policies necessary to prevent patients’ exposure to SARS CoV–2 virus, door–to–balloon time was comparable between the two cohorts. No statistically significant differences were found regarding the occurrence of STEMI–related complications. The in–hospital mortality was comparable between the two cohorts, as was predischarge LVEF. The high–sensitivity Troponin–T peak was significantly lower after the introduction of the ED–based cardiology unit. Total in–hospital stay was shorter after the introduction of the ED cardiology unit.

Conclusions
Our experience has shed light on the potential advantages of an ED–based unit directly managed by the Cardiology Department: despite the confirmation of a longer time from symptoms onset to hospital admission, no significant differences were found in terms of hard outcomes between the groups.
P144 USE OF SACUBITRIL/VALSARTAN IN A GUCH PATIENT POPULATION. PRELIMINARY STUDY
Authors: Sanfilippo M , Morreale P , Scardino G , Comparato C 
Published: May 2023

Abstract
Sacubitril/Valsartan (S/V) is used with optimal results in the therapy of heart failure (HF); reduces mortality and hospitalizations by 20% compared to ACE inhibitor therapy. There is a little data on the use of S/V in adult patients with congenital or acquired pediatric heart disease (GUCH). In these patients, HF is a real challenge for the cardiologist. HF in GUCH often has a different pathophysiology than usual, and interesting univentricular hearts in Fontan circulation, systemic right ventricle and patients undergoing multiple cardiac surgical procedures. The literature is poor in information and the guidelines do not give clear indications. We report our experience on a GUCH population. Starting from November 2019 we started S/V therapy in 13 GUCH patients with severe ventricular dysfunction, all in NYHA class III and already in optimal therapy for HF. Median age was 42.7 years (27–79 years); 8 males and 5 females. Basic heart disease: 4 patients with Fontan circulation, 3 patients with systemic right ventricle (TGA, operated according to Mustard), n. 2 complete CAV operated, n. 1 Ebstein‘s disease, n.1 Patent ductus arteriosus, n. 2 pediatric onset dilated cardiomyopathy. Median duration of follow–up 11.6 months (2–26 months). In n. 1 patient it was necessary to suspend the S/V due to skin itching, which resolved on diuscontinuation. The dosage was reduced in tree patients due to symptomatic hypotension (1 of these was taking Sildenafil). In n. In 1 patient there was a reduction in the glomerular filtration rate, which did not require discontinuation of the drug. After treatment: 6 patients are in NYHA class I, n. 3 pts in NYHA II class and 4 pts remained in NYHA III class. In the year preceding the start of S/V therapy, all patients cumulatively had n. 15 hospitalizations; in the year following the first six months of treatment, the number of hospitalizations decreased to no. 5 (4 for HF and 1 for severe anemia) The ejection fraction, evaluated by Simpson‘s method, remained stable. However, the limitations of the echocardiographic method in patients with such complex anatomy must be considered

Conclusions
The use of S/V is safe and effective in GUCH patients. However, larger studies and longer follow–up are needed.
P145 IVABRADINE IN TETRALOGY OF FALLOT AND POSTOPERATIVE JUNCTIONAL ECTOPIC TACHYCARDIA
Authors: Catucci S , Lombardi M , Maiorano A , Pirolo T , Meliota G , Massari E , Vairo U 
Published: May 2023

Abstract

Introduction
Ivabradine is a selective inhibitor of sodium’s If current; it acts at the level of the sinus node causing a bradycardizing effect without effect on inotropism and atrioventricular conduction. In fact, the If channel, located in pacemaker cells, is activated in hyperpolarization and allows the membrane potential to become gradually more positive until the threshold potential is reached. Previous studies have actually shown the usefulness of ivabradine not only for slowing sinus rate but also in case of atrial tachycardia and ectopic junctional tachycardia. Case report: Our patient, suffering tetralogy of Fallot, undergoes transannular patch correction surgery at the age of 6 months. During the stay in postoperative intensive care presents numerous episodes of junctional tachycardia. Therapy with amiodarone ev is undertaken, with a discrete response; on the ECG, frequent isolated and repetitive supraventricular extrasystoles (pairs and triplets) are observed. After the infusion ev is undertaken, oral therapy with amiodarone and beta–blocker is associated, but not obtaining a good rhythm control. In addition, the presence of numerous and sustained episodes of high frequency arrhythmia affects the hemodynamic parameters of the child. For the persistence of arrhythmic episodes, ivabradine therapy is undertaken at a dose of 0.05 mg/kg orally twice a day. Stable sinus rhythm is observed, so amiodarone therapy is subsequently discontinued and ivabradine therapy continued. No arrhythmias are observed either during hospitalization or in the subsequent follow–up after discharge, carried out with seriated Holter ECGs. After about 3 months, therapy is discontinued, in the absence of supraventricular and ventricular arrhythmias.

Conclusions
Ivabradine is a selective inhibitor of the sodium channel at the level of pacemaker cells; born as a bradycardizing drug for its action on the sinus node, its usefulness has also been demonstrated in the treatment of supraventricular arrhythmias due to enhanced automatism and atrial reentry. It is, therefore, conceivable the presence of If channels also in ectopic foci, which would allow its use as a real antiarrhythmic drug, exploiting its peculiar action not interfering with inotropism and atrium and intraventricular conduction.
P147 THE WINNING FORMULA IN COMPLEX ADULT CONGENITAL REDO INTERVENTIONS: MULTIDIMENSIONAL PERSPECTIVE IN A HYBRID SETTING
Authors: Gambardella R , Ferraro F , Olimpieri A , Nesta M , Calabrese M , Pavone N , Grandinetti M , Bruno P , Amodeo A , Massetti M 
Published: May 2023

Abstract

Introduction
Transposition of the great artery is one of the most common congenital heart anomalies [1]. One of the surgical techniques to correct this anomaly is the Rastelli procedure [2]. After surgical correction, right and left ventricular outflow obstruction are the most common late complications [3]. In grown–up congenital disease (GUCH) late surgery is a high risk procedure and, repeated sternotomy may be associated with adverse injuries to mediastinal structures.The aim of this work is to demonstrate how a preoperative planning may be helpful in identifying patients at risk of re–entry. Case presentationA 50–year–old woman, with primary diagnosis of transposition of the great arteries (TGA), ventricular septal defect (VSD) and pulmonary stenosis (PS) was referred to our Grown Up Congenital Heart (GUCH) center for progressive dyspnoea and reduced exercise tolerance. She underwent a Blalock–Taussig shunt palliation at the age of 3 and a Rastelli procedure after 2 years. Echocardiography revealed moderate–to–severe RV–PA conduit obstruction (122 mmHg) and a left Ventricle–Aorta (LV–Ao) tunnel obstruction (Mean gradient 32 mmHg, Max gradient 52 mmHg). Cardiac MRI and cardiac catheterization confirmed the echo findings and showed the proximity of the RV–PA conduit to the left anterior descending coronary artery, which was considered an exclusion criteria for trans–catheter therapy. A CT scan confirmed diagnosis and showed that mediastinal structures, in particular the aorta, were adherent to the sternum. (Fig 1). After careful examination of the clinical case, our Heart Team decided for high risk surgical treatment of the residual lesions.A percutaneous cannulation was performed, to minimize the re–entry injury risks. Two other percutaneous devices were used: the coronary sinus cannula and the percutaneous left heart venting catheter. The postoperative course was regular and one month after surgery a CT scan confirmed a good result of surgery (Fig 2).

Conclusions
This peculiar case is emblematic to understand how a multidimensional perspective is mandatory in redo GUCH interventions. Hybrid surgery room setting and a multidisciplinary team of surgeons, interventional cardiologists, anesthesiologists and radiologists are essential to reach the goal of successful outcomes for these kinds of complex procedures as a GUCH “big operation”.
P153 A DEEP–LEARNING APPROACH FOR SCAR DETECTION IN EARLY CONTRAST–ENHANCED CARDIAC COMPUTED TOMOGRAPHY IMAGES
Authors: Penso M , Babbaro M , Guglielmo M , Baggiano A , Moccia S , Pepi M , Fusini L , Carerj L , Andreini D , Caiani E , Pontone G 
Published: May 2023

Abstract
Diagnosis of myocardial fibrosis has a relevant prognostic and therapeutic role. Scar–tissue analysis is commonly performed with late gadolinium contrast–enhanced (CE) cardiac magnetic resonance (CMR). However, CMR might be contraindicated or unavailable. Coronary computed tomography (CCT), which is the technique of choice for many routine assessments, is emerging as an alternative to CMR. The objective of this study is to evaluate whether artificial intelligence (AI) could allow identification of myocardial fibrosis from routine early CE–CCT images. Fifty consecutive patients with left ventricular dysfunction (LVD), who underwent both CE–CMR and (early and late) CE–CCT were retrospectively selected. According to the late enhancement CMR patterns, patients were classified as with ischemic (n=15, 30%) or non–ischemic (n=25, 70%) LVD. Scar regions were manually traced on late CE–CCT using CE–CMR as ground–truth. On early CE–CCT images, the myocardial sectors were extracted according to AHA 16–segment model and labeled as with scar or not based on the late CE–CCT manual tracing. A deep–learning model was developed to classify each sector (Picture 1). Of the initial 44187 sectors computed out of the 8285 slices available from the early CE–CCT images, 4594 sectors (10%) presented scar. The CNN approach on the early CE–CCT images yielded a classification accuracy for all sectors of 71% (95% confidence interval (CI): 63%–79%) obtained through 5–fold cross validation. The mean sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the testing fold resulted in 73% (95% CI: 66%–79%), 56% (95% CI: 48%–65%) and 85% (95% CI: 82%– 88%), respectively. The mean AUC across the five folds was 76% (95% CI: 72%–81%). In a per–segment analysis of the 16–segment AHA model the bull’s eye segmental comparison of CE–CMR and respective early CE–CCT findings an 91% agreement was achieved (Picture 2). Artificial intelligence can detect both ischemic and non–ischemic myocardial fibrosis from routine noninvasive coronary scans, without additional contrast–agent administration or radiational dose, thus assisting diagnosis and management of patients with LV dysfunction and coronary artery disease.
P157 PROJECT PROXIMITY: APPLICATION OF TELEMEDICINE IN THE SECONDARY PREVENTION OF PATIENTS WITH ACUTE CORONARY SYNDROME
Authors: Biava L , Marchisio G , Colombo M , Noto L , Franzin S , Scacciatella P 
Published: May 2023

Abstract

Background
Cardiovascular disease is one of the leading causes of death in European countries despite advances in treatment. Lifestyle changes and medication adherence are crucial to prevent recurrences. Telemedicine initiatives represent an innovative tool to support clinicians.

Objective of the Work
Evaluation of the telemedicine project "Proximity" on the improvement of medication adherence, reduction of re–hospitalisation, improvement of lifestyle and health education after hospital discharge.

Materials and Methods
Patients discharged with a diagnosis of acute coronary syndrome from the Cardiology Department of the "U. Parini" Hospital in Aosta from August 2022 were consecutively enrolled, after obtaining informed consent. A Care Management Centre consisting of a social media manager and a nurse has been set up. Patients adhering to the project are provided electronically with information material on the disease, correct drug intake and lifestyle. Adherence and tolerance to therapy is investigated and assistance is offered in booking check–ups. In some cases, a telemonitoring kit is delivered to record and share vital parameters with the operators.

Results
A total of 24 patients were enrolled: 77% male, mean age 64 years and mean ejection fraction 52%. Patients were proposed to achieve an average of 3/5 goals including smoking cessation, weight loss, increased compliance with therapy, nutrition education and increased physical activity. On average, patients achieved 60% of the required goals. In 27% of the patients, early symptoms such as falling or rising blood pressure values, increased heart rate, creatinine value, changes in liver function, bleeding, dyspnoea at rest were identified. In 8% of the cases, the cardiologist or general practitioner had to be contacted to solve clinical problems. In 25% of the cases, the discharge therapy was changed. No patient abandoned the project. No patient was re–hospitalised.

Conclusions
The analysis of the preliminary results of the "Proximity" project supports the use of telemedicine initiatives in the follow–up of patients hospitalised for acute coronary syndrome.
P165 ARRHYTHMIC STORM IN SUBACUTE MYOCARDIAL INFARCTION: A CASE REPORT
Authors: Campana N , Gioi A , Casula M , Scotto R , Tola G , Donovan R , Orrù P , Semeraro L , Manca P , Manconi M , Falchi S , Atzeri V , Pisano L , Loi B , Corda M 
Published: May 2023

Abstract

Introduction
Ventricular arrhythmias (VA) represent a common complication of myocardial infarction (MI). Typically, they occur in two scenarios: during acute MI, related to ongoing ischemia, as ventricular tachycardia (VT) or ventricular fibrillation (VF), or in the context of a late phase of MI, related to the presence of a scar, as monomorphic VT (mVT). Despite the above, their occurrence may be atypical.

Clinical Case
55–year–old man affected by obesity, diabetes and hypertension, admitted to our department for subacute MI. Coronarography showed three–vessel disease with indication for surgical revascularization. Thirty hours after admission, in absence of symptoms, occurrence of cardiovascular arrest due to mVT, which degenerated into VF. After resuscitation, ECG and Echo findings did not change compared to those observed at admission, excluding the presence of current ischemia. A blood gas analysis excluded dysionias. Few minutes later, arrhythmic recurrence of mVT degenerated into VF. This was refractory to electrical and antiarrhythmic therapy and stopped only after percutaneous left stellate ganglion block (LSGB) and deep sedation. Then, emergency surgical revascularization was performed. In the early postoperative days, during weaning attempts from sedation and ECMO support, that had become necessary due to hemodynamic instability after surgery, numerous recurrences of mVT, regressed only after deepening of sedation, multiple external shocks, antiarrhythmic polytherapy, and LSGB. A new coronarography documented patency of coronary artery bypass grafts. On 6th postoperative day, discontinuation of deep sedation and weaning from circulatory support without recurrence of VA. The patient was discharged from the intensive care unit and started on a rehabilitation pathway.

Conclusions
mVTs are commonly related to the presence of a scar, formed late after MI, or to the context of ongoing ischemia in acute MI. However, it should be remembered that even during the subacute phase of MI, arrhythmic instability might still occur. The responsible mechanisms are not completely known but it can be assumed that, even in the absence of a new ischemic event, the process of scar maturation may have led to a transient proarrhythmic substrate, responsible for the arrhythmic storm. Further studies are needed to clarify the mechanisms of arrhythmogenesis in the subacute phase of MI.