bluuebunny/crossref_metadata_2025_split huggingface dataset:
P176 MITRAL FISTULA IN PATIENT WITH OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT
Authors: Gioia M , Rinaldi A , Milo M , De Castro A , Ignone G 
Published: May 2022

Abstract
Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.
P179 DYSFUNCTION OF A MITRAL VALVE BIOPROTESIS FROM FLAIL OF A LEAFLET
Authors: Gizzi G , D‘Agostino S , Parato V 
Published: May 2022

Abstract

Introduction
The degeneration of biological valve prostheses is an irreversible process determined by intrinsic factors (calcification, thickening, fibrosis of the leaflets) or extrinsic (prosthesis–patient mismatch, malapposition, prosthetic detachment, thrombosis, endocarditis) that determine hemodynamic dysfunction with frequent need for surgical re–intervention . The average life span of a valve bioprosthesis is around ten years but in some cases premature dysfunction can occur.

Clinical Case
In September 2021, an 83–year–old woman who was symptomatic of progressively worsening dyspnea entered the emergency care unit of our hospital. In medical history: mitral valve replacement surgery using bioprosthesis in 2016, hypothyroidism in medical therapy. At the entrance, the patient appeared alert, attentive and oriented. Tachypnoic and dyspnoic at rest. Objectively ss 3/6 was appreciated on mitral focus, ss 2/6 on tricuspid focus. Signs of pulmonary congestion. PA 120/80 mmHg. HR 100 bpm, SpO2 88%. Laboratory tests showed increased NTproBNP values. On the ECG: sinus rhythm, HR 96 / min, atrioventricular conduction within limits, narrow QRS, widespread alterations in repolarization as from overload. The echocardiogram performed during the cardiological consultation showed normal biventricular size and contractility. The mitral biological prosthesis appeared in place with an increased transprosthetic gradient (mean Gp 7mmHg) and evidence of severe intraprosthetic regurgitation. There was also moderate to severe tricuspid insufficiency with PAPs estimated at 38 mmHg; the VCI was dilated and non–collapsing. Admitted to cardiac intensive care unit, trans–esophageal echocardiogram was performed which confirmed the finding of bioprosthesis dysfunction caused by severe mitral valve insufficiency in relation to eversion of the posterior leaflet. The patient remained in conditions of haemodynamic instability despite medical therapy with respiratory failure therefore after consulting cardiac surgery she was intubated and transferred for trans–catheter intervention of valve–in valve in emergency.

Conclusions
Transesophageal echocardiography represents the reference method in the evaluation of valve bioprostheses: in this case it allowed to highlight an unusual mechanism of mitral bioprosthesis dysfunction due to complete eversion of a leaflet.
P181 CARDIAC PROTECTION BY PIRFENIDONE AFTER MYOCARDIAL INFARCTION: A BIOINFORMATIC ANALYSIS
Authors: Aimo A , Iborra–Egea O , Martini N , Galvez–monton C , Burchielli S , Panichella G , Passino C , Emdin M , Bayes–Genis A 
Published: May 2022

Abstract

Purpose
Left ventricular (LV) remodeling after myocardial infarction (MI) is promoted by an intense fibrotic response, which could be targeted by an anti–fibrotic drug such as pirfenidone.

Methods
We explored the relationship between protein modulation by pirfenidone and post–MI remodeling, based on publicly available molecular information and transcriptomic data from a swine model of MI. We also compared the effects of pirfenidone and angiotensin–converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), mineralocorticoid receptor blockers (MRA) and beta–blockers.

Results
We identified 6 causative motives of post–MI remodeling (cardiomyocyte cell death, impaired myocyte contractility, extracellular matrix remodeling and fibrosis, hypertrophy, renin–angiotensin–aldosterone system activation, and inflammation), 4 pirfenidone targets and 21 bioflags (indirect effectors). When considering both targets and bioflags, pirfenidone showed a broad relationship encompassing all 6 motives. p38γ–MAPK12 blockade inhibits cardiomyocyte apoptosis, cardiomyocyte hypertrophy and inflammation. Furthermore, pirfenidone can modulate extracellular matrix remodeling and cardiac fibrosis by targeting the TGFβ1–SMAD2/3 pathway and other effector proteins such as matrix metalloproteases 2 and 14, PDGFA/B, and IGF1, which promote myocardial fibrosis, cardiomyocyte hypertrophy and impaired contractility. All the gold standard drugs were found to be important for specific clinical motives, but pirfenidone had a more widespread action on the molecular pathways active in the post–MI setting.

Conclusion
A bioinformatic approach allowed to identify several possible mechanisms of action of pirfenidone with beneficial effects in the post–MI LV remodeling, and suggests additional effects over guideline–recommended therapies. These findings support clinical studies evaluating the beneficial effects of pirfenidone in patients with MI.
P184 DIASTOLIC FUNCTION IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION TREATED BY SACUBITRIL/VALSARTAN
Authors: Lamaida N , Cerciello A 
Published: May 2022

Abstract

Background
After the remarkable success of the PARADIGM.HF trial, SAC/VAL was approved by European Society of Cardiology (ESC2016) and the American Heart Association (AHA2017), for the treatment of adults with chronic heart failure with reduced ejection fraction (HFrEF) (NYHA class II–IV), to reduce the risk of cardiovascular death and hospitalization. CurrentlySAC/VAL is recommended in patients with a left ventricular ejection fraction (LVEF) &lt;35% as a replacement for an ACEI or ARB to further reduce the risk of HF hospitalization and death in ambulatory patients who remain symptomatic despite optimal treatment with an ACE–I, a beta–blocker and an MRA. However, the real world HF population differ from patients in randomized controlled trials in many clinical aspects. AIM: The aim of our work was to evaluate the reversibility of diastolic dysfunction before and after sacubitril/valsartan administration in patients with HF REF.

Methods
A total of 30 patients in NYHA class II–III and treated by ACE inhibitor or AAR2, were prospectively commenced on SAC/VAL (one tablet 24/26 mg twice daily). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. From multiparametric approach, Patients were subsequently categorized as diastolic dysfunction grade 1, 2 or 3.

Results
Mean age was 64.5±15 yo and 74 % patients were males. Ejection fraction averaged 35.5±7.0. Overall, after 12±3.0 months of treatment with sacubitril/valsartan, E/A ratio decreased from 1.9±1.5 to 1.04±0.72 (P &lt; 0.05), the E/Ea ratio decreased from 14±6.0 vs. 09.5±5.0 (P &lt; 0.05), tricuspid regurgitation peak velocity decreased from 3.0±0.7 to 2.4 m/s (P = 0.03) and left atrial volume decreased from 51.3±27.5 to 40.4±13.7ml/m2 (P &lt; 0.05). Subsequently, both left–ventricular diastolic function and filling pressure improved significantly (P &lt; 0.05, ).

Conclusions
In patients with HFrEF, administration of sacubitril/valsartan was associated with improvement of diastolic dysfunction and filling pressure, as shown in many studies.
P188 MANAGEMENT OF ANTICOAGULANT AND ANTIPLATELET THERAPY IN THE GREAT ELDERLY: A REAL LIFE CLINICAL CASE
Authors: Prenna E , Maffè S , Facchini E , Bergamasco L , Paffoni P , Careri G , Franchetti Pardo N , Paino A , Dellavesa P 
Published: May 2022

Abstract
In daily clinical practice we have often to manage great elderly people with multiple comorbidities. In these cases it is not always easy to apply the guidelines, which must sometimes be adapted to the patient we are treating. We present the case of a 99–year–old hypertensive patient in therapy with oncocarbide and acetylsalicylic acid for polycythemia vera. No cardiological history. It came to our attention for NSTEMI during an episode of persistent atrial fibrillation (AF) with a high ventricular rate. Subsequent spontaneous restoration of sinus rhythm. Significant increase in troponin on blood tests. On the echocardiogram, normal biventricular kinetics and systolic function, no significant valvulopathies. Given the age and hemodynamic stability, a conservative approach was chosen. Therefore, antiplatelet therapy was started with acetylsalicylic acid (ASA) and anticoagulant therapy, initially with low molecular weight heparin and then with oral anticoagulant (NOAC); being the patient over 75 we chose Apixaban 2.5 mg bid, in accordance with weight and renal function (Consensus ESC 2016). At 1 month follow up the patient month was stable in good compensation, the 24h–Holter ECG showed stable sinus rhythm. At this point the question was how to proceed with the therapy: maintain the NOAC, as indicated in the NSTEMI guidelines, or continue with ASA alone, also considering that the risk scores usually used in patients with AF to determine the bleeding and cardioembolic risk (HASBLED and CHADS–VASC) are not validated in such elderly patients. We also hypothesized that the short AF paroxysm was related to ongoing myocardial ischemia (and not vice versa); in the literature, however, the indication for anticoagulant therapy does not take these extreme situations into account. Polycythemia vera also contributes to complicating the situation, exposing the patient to an increased risk of thrombotic events in the absence of antiplatelet therapy. After discussing the case with the haematologist, we decided to suspend the NOAC, also considering the absence of new arrhythmic episodes, and to continue with ASA alone. For now, with a follow–up of 6 months, we have not registered thrombotic / haemorrhagic problems or arrhythmic recurrences. The management of the elderly is always complex and will frequently lead us to adapt and customize the treatments on every single patient.
P191 CONTEMPORARY CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH NON–ST ELEVATION MYOCARDIAL INFARCTION ACCORDING TO MANAGEMENT STRATEGIES
Authors: Orso F , Casolo G , Szasz C , Forni S , D‘Arienzo S , Gemmi F 
Published: May 2022

Abstract

Purpose
The aim of the present study was to analyze, in a large administrative database, the clinical characteristics and prognosis of a contemporary population of patients with Non–ST elevation myocardial infarction (NSTEMI) according to the treatment strategy.

Methods
This retrospective observational study included patients residing in the Tuscany region, aged 18+ years, discharged from a regional hospital with a diagnosis of NSTEMI (main diagnosis ICD–9–CM codes 410.7 or 411.1 in HDA) between 2016 and 2018. Patients were classified into two main groups: a conservative strategy (CON) group and an invasive strategy (INV) group that was further classified into three subgroups: a PCI group, a CABG group, and a group where patients were managed invasively but not revascularized.

Results
The study population consisted of 15,208 patients. The median age was 76 ± 9 years, females were 38.5%. Groups composition according to management strategies is shown in Figure 1. Compared to INV patients, patients in the CON group were older (mean age 85 vs 72 years, p &lt; 0.0001), more frequently female (54% vs 33%, p &lt; 0.0001), had a higher cardiovascular and non–cardiovascular comorbidity burden. All–cause mortality rates in hospital and 1–year MACCE (Figure 2 and 3) were 3% and 24.1%, resulting significantly higher in the CON strategic management group than in the INV strategic group: 8.9% vs 1.1; 34.0 vs 21.1%; p = 0.0001. Between the three INV subgroups we found no differences in hospital mortality, while at 1 year there was a significant difference in MACCE with a higher rate in the CABG group compared to the PCI subgroups and in that of invasively managed but not revascularized patients: CABG: 42.8% vs 19.3% vs 18.2% respectively, p = 0.0001

Conclusions
Real–world data show that patients with NSTEMI have significantly different characteristics and prognosis according to treatment strategy. Patients managed non–invasively have more complex characteristics and worse prognosis both in the hospital and after discharge. Patients who have been managed invasively but treated with medical therapy represent an interesting subgroup worthy of further study.
P193 MECHANICAL COMPRESSION DEVICE (LUCAS®) IN THE CATHETERIZATION LABORATORY: RETROSPECTIVE ANALYSIS OF A SINGLE CENTER
Authors: Dal Passo B , Cardelli L , Capecchi A , Nobile G , Canovi L , Frascaro F , Zanarelli L , Piscitelli L , Casella G 
Published: May 2022

Abstract

Background
The survival of IHCA and OHCA depends on the timeliness and the quality of cardiopulmonary resuscitation (CPR). During transport, in the Cath Lab or when resuscitation is extended, the availability of chest compression systems increases the quality of CPR and it is recommended in these specific situations by the AHA 2020 Guidelines.

Methods
Retrospective analysis of patients who encountered cardiocirculatory arrest (CCA) in the Cath Lab or in ICU of the Maggiore Hospital managed with CPR and application of a chest compression device (LUCAS® 3) from 2020 to 2021.

Results
The study population consisted of 21 patients, all undergoing invasive procedure (coronary angiography, angioplasty or aortic valvuloplasty) in peri–arrest: 17 patients (81%) with CCA during STEMI, 3 (14%) during NSTEMI and one patient during acute pulmonary edema caused by severe aortic stenosis. In 6 cases (29%) the onset rhythm of CCA was shockable, the others were pulseless electrical activities. Considering patients admitted with STEMI, 4 (24%) have OHCA and LUCAS® had been applied by 118 operators before entering the Cath Lab. In the other cases LUCAS® was placed in the Cath Lab, before or during the procedure; in all but two cases, the procedure was concluded. The resuscitation maneuvers involved, in addition to LUCAS®, the use of an external defibrillator, orotracheal intubation, administration of inotropes and, in 2 cases (10%) the intra–aortic balloon pump (IABP). The average time between CCA and application of LUCAS® was 14 minutes – the device was always positioned after at least 2 manual ECM cycles without restoring the circulation – and the average CPR duration was 73 minutes. Any complications related to the implantation of the device were observed. The survival at the end of the procedure in the Cath Lab was 24% and on discharge 14%.

Conclusion
The use of chest compression devices during CCA allows a better management by medical personnel during long–term CPR and a completion of invasive procedure. Unfortunately, it doesn’t substantially changes the survival of patients as reported by the literature.
P195 A CASE REPORT OF TYPE TWO KOUNIS SYNDROME
Authors: Napoli F , Giannattasio C , Sganzerla P 
Published: May 2022

Abstract

A 81–years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre–existing LBBB. HS–T–Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn’t show any new ischemic abnormalities in the setting of pre–existing LBBB. The peak CK–MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK–MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre–existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm.

Take Home Message
We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.
P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS
Authors: Caggiari L , Pittau R , Marchetti M , Tuveri F , Maiani S , Perra F , Utzeri E , Fazzini L , Contini F , Montisci R 
Published: May 2022

Abstract
A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.
P206 IMPACT OF AGE, GENDER AND HEART FAILURE ON MORTALITY TRENDS AFTER ACUTE MYOCARDIAL INFARCTION IN ITALY
Authors: De Luca L , Cicala S , D’Errigo P , Cerza F , Mureddu G , Rosato S , Badoni G , Seccareccia F , Baglio G 
Published: May 2022

Abstract

Background
The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

Methods
This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In–hospital mortality rate (I–MR) and 1–year post–discharge mortality rate (1–Y–MR) were assessed.

Results
Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization (Figure 1). Both I–MR and 1–Y–MR significantly decreased over time (from 8.87% to 6.72%; mean annual change − 0.23%; confidence intervals (CI): − 0.26% to − 0.20% and from 12.24% to 10.59%; mean annual change − 0.18%; CI: − 0.24% to − 0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes (Figure 2). In AMI patients complicated by HF, both I–MR and 1–Y–MR were markedly high, regardless of age and gender.

Conclusions
This contemporary, nationwide study suggests that I–MR and 1–Y–MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.