[Management of patent foramen ovale in non-cardiac surgery]. / Gestione della pervietà del forame ovale nella chirurgia non cardiaca.

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis.

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Ischemia With No Obstructive Coronary Artery Disease: Are Misdiagnosis and Undertreatment Always Behind the Corner?

Ischemia with no obstructive coronary artery disease (INOCA) is not an uncommon diagnosis in patients presenting with chest pain who undergo clinically indicated coronary angiography. However, the symptoms reported by patients with INOCA may be heterogeneous, leading to misdiagnosis and undertreatment. Herein we report 3 clinical cases of INOCA misdiagnosis and describe how the cases were reinvestigated following the appropriate diagnostic pathway. (Level of Difficulty: Advanced.).

New Onset Atrial Fibrillation in STEMI Patients: Main Prognostic Factors and Clinical Outcome.

The indications for the treatment of patients with known atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) are clear, while less is available about the management of new-onset AF (NOAF) during ST-segment elevation myocardial infarction (STEMI). The aim of this study is to evaluate mortality and clinical outcome of this high-risk subgroup of patients. We analyzed 1455 consecutive patients undergoing PCI for STEMI. NOAF was detected in 102 subjects, 62.7% males, with a mean age of 74.8 ± 10.6 years. The mean ejection fraction (EF) was 43.5 ± 12.1% and the mean atrial volume was increased (58 ± 20.9 mL). NOAF occurred mainly in the peri-acute phase and had a very variable duration (8.1 ± 12.5 min). During hospitalization, all the patients were treated with enoxaparin, but only 21.6% of them were discharged with long term oral anticoagulation. The majority of patients had a CHA2DS2-VASc score >2 and a HAS-BLED score of 2 or 3. The in-hospital mortality was 14.2%, while the 1-year mortality was 17.2% and long-term mortality 32.1% (median follow-up 1820 days). We identified age as an independent predictor of mortality both at short- and long-term follow-ups, while EF was the only independent predictor for in-hospital mortality and arrhythmia duration for 1-year mortality. At the 1-year follow-up, we recorded three ischemic strokes and no bleeding complications.

Age-Related Mortality in STEMI Patients: Insight from One Year of HUB Centre Experience during the Pandemic.

Background: Old patients have a poor prognosis when affected by ST elevation myocardial infarction (STEMI). The aim of our study was to evaluate the impact of age on acute and mid-term mortality in STEMI patients over one year in the pandemic period. Methods: we collected data on 283 STEMI patients divided into three groups according to age (not old, "Not-O", ≤74 y/o; old, "O", 75−84 y/o; very old, "Very-O", ≥85 y/o). Results: the three groups did not differ in their clinical or procedural characteristics. The Very-O patients had a significantly increased incidence of in-hospital MACE (35%), mortality (30.0%), and percentage of cardiac death (25.0%). The only two independent predictors of in-hospital mortality were the ejection fraction (EF) [OR:0.902 (95% CI) 0.868−0.938; p < 0.0001] and COVID-19 infection [OR:3.177 (95% CI) 1.212−8.331; p = 0.019]. At follow-up (430 +/− days), the survival rates were decreased significatively among the age groups (Not-O 2.9% vs. O 14.8% vs. Very-O 28.6%; p < 0.0001), and the only two independent predictors of the follow-up mortality were the EF [OR:0.935 (95% CI) 0.891−0.982; p = 0.007] and age [OR:1.06 (95% CI) 1.018−1.110; p = 0.019]. Conclusions: in very old patients, all the accessory procedures that may be performed should be accurately and independently weighed up in terms of the risk−benefit balance and the real impact on the quality of life because of the poor mid-term prognosis.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature.

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Intravascular imaging for left main stem assessment: An update on the most recent clinical data.

Left main (LM) stem has different structural and anatomical characteristics compared to all of the other segments of the coronary tree, thus its management through percutaneous coronary intervention (PCI) is a challenge and is associated with worse clinical outcome and higher need for revascularization as compared to other lesion settings. Intravascular imaging, by means of intravascular ultrasound (IVUS) or optical coherence tomography (OCT), is an important tool for LM PCI guidance, aiming at improving the immediate performance and the long term outcome of this procedure. Following current guidelines and recent scientific findings, IVUS becomes important to firstly assess, and finally evaluate the result of LM stenting, according to the experience and preferences of the operator. The role of OCT still remains to be defined, but recent data is shedding light also on this imaging technique. The aim of this review is to highlight the latest scientific advancements regarding intravascular imaging in LM coronary artery disease.

Optical Coherence Tomography and Coronary Dissection: Precious Tool or Useless Surplus?

Spontaneous coronary artery dissection (SCAD) is a rare clinical condition, but frequently manifested as acute myocardial infarction. In this particular setting, in recent years, optical coherence tomography (OCT) has been established as a possible diagnostic method due to the high spatial resolution (10-20 µm), which can visualize the different layers of coronary vessels. OCT can better analyze the "binary" or double lumen morphology, typical of this entity. Furthermore, it can identify the entrance breach and the circumferential and longitudinal extension of the lesion. However, we have to emphasize that this technique is not free from complications. OCT could further aggravate a dissection or exacerbate a new intimal tear. Therefore, the use of OCT in the evaluation of SCAD should be defined by balancing the diagnostic benefits versus procedural risks. Moreover, we underline that as SCAD is a rare condition and OCT is a recently introduced technique in clinical practice, limited data is available in literature.

Access-site hematoma in distal and conventional transradial access: a randomized trial.

BACKGROUND: Distal transradial access (dTRA) has been recently proposed as an innovative access for coronary procedures and a valuable alternative to conventional transradial access (cTRA). The aim of this study was to assess the safety of dTRA versus cTRA in patients undergoing percutaneous coronary angiography and intervention. METHODS: In this single-center randomized trial, consecutive patients admitted for stable cardiac condition or acute coronary syndrome (ACS) were assigned to dTRA or cTRA. The primary endpoint was an early discharge after transradial stenting of coronary arteries (EASY) grade ≥II access-site hematoma (ASH). Vascular access failure, radial artery occlusion (RAO) at hospital discharge, 30-day rates of death, myocardial infarction, stroke and bleeding not related to coronary artery bypass grafting were considered as secondary endpoints. RESULTS: A total of 204 patients were included and randomized to dTRA (N.=100) or cTRA (N.=104). The two populations were similar, except for a higher percentage of ACS in the dTRA than in the cTRA group (38% versus 24%, P=0.022). The rate of EASY grade ≥II ASH was lower in dTRA than in cTRA patients, but the difference was not statistically significant (4% versus 8.4%, respectively, P=0.25). Vascular access failure was more frequent in dTRA patients than in cTRA patients (34% versus 8.7%, P<0.0001). We detected no case of RAO at hospital discharge and similar rates of 30-day adverse events in both groups. CONCLUSIONS: DTRA is safe and feasible. When compared to cTRA, dTRA is technically more demanding and limited by more frequent crossover to an alternative vascular access.

Echocardiographic Advances in Dilated Cardiomyopathy.

Although the overall survival of patients with dilated cardiomyopathy (DCM) has improved significantly in the last decades, a non-negligible proportion of DCM patients still shows an unfavorable prognosis. DCM patients not only need imaging techniques that are effective in diagnosis, but also suitable for long-term follow-up with frequent re-evaluations. The exponential growth of echocardiography's technology and performance in recent years has resulted in improved diagnostic accuracy, stratification, management and follow-up of patients with DCM. This review summarizes some new developments in echocardiography and their promising applications in DCM. Although nowadays cardiac magnetic resonance (CMR) remains the gold standard technique in DCM, the echocardiographic advances and novelties proposed in the manuscript, if properly integrated into clinical practice, could bring echocardiography closer to CMR in terms of accuracy and may certify ultrasound as the technique of choice in the follow-up of DCM patients. The application in DCM patients of novel echocardiographic techniques represents an interesting emergent research area for scholars in the near future.

Incremental Value of Renal Dysfunction Addition to the CHA2DS2-Vasc Score for Mortality Prediction in Patients with Acute Coronary Syndrome.

INTRODUCTION: This study analyzes the usefulness of the CHA2DS2-VASc score for mortality prediction in patients with acute coronary syndromes (ACSs) and evaluates if the addition of renal functional status could improve its predictive accuracy. METHODS: CHA2DS2-VASc score was calculated by using both the original scoring system and adding renal functional status using 3 alternative renal dysfunction definitions (CHA2DS2-VASc-R1: eGFR <60 mL/min/1.73 mq = 1 point; CHA2DS2-VASc-R2: eGFR <60 mL/min/1.73 mq = 2 points; and CHA2DS2-VASc-R3: eGFR <60 mL/min/1.73 mq = 1 point, <30 mL/min/1.73 mq = 2 points). Inhospital mortality (IHM) and post-discharge mortality (PDM) were recorded, and discrimination of the various risk models was evaluated. Finally, the net reclassification index (NRI) was calculated to compare the mortality risk classification of the modified risk models with that of the original score. RESULTS: Nine hundred and eight ACS patients (median age 68 years, 30% female, 51% ST-elevation) composed the study population. Of the 871 patients discharged, 865 (99%) completed a 12-month follow-up. The IHM rate was 4.1%. The CHA2DS2-VASc score demonstrated a good discriminative performance for IHM (C-statistic 0.75). Although all the eGFR-modified risk models showed higher C-statistics than the original model, a statistically significant difference was observed only for CHA2DS2-VASc-R3. The PDM rate was 4.5%. The CHA2DS2-VASc C-statistic for PDM was 0.75, and all the modified risk models showed significantly higher C-statistics values than the original model. The NRI analysis showed similar results. CONCLUSIONS: CHA2DS2-VASc score demonstrated a good predictive accuracy for IHM and PDM in ACS patients. The addition of renal dysfunction to the original score has the potential to improve identification of patients at the risk of death.

Impact of RAAS Inhibitors on Clinical Outcome and Mortality in Patients With STEMI During the COVID-19 Era: A Multicenter Observational Study.

Conflicting results are available regarding the influence of ACEi/ARBs on the risk of COVID-19 infection, while less is known about their impact on the clinical outcome of patients with STEMI diagnosed with COVID-19. Our aim was to evaluate the impact of ACEi/ARBs therapy on in-hospital mortality and clinical outcomes of patients with STEMI during the COVID-19 pandemic. We retrospectively analyzed consecutive patients with STEMI hospitalized from February 20 to May 10, 2020 in four Hospitals in Lombardy. SARS-COV-2 diagnosis was performed by nasopharyngeal swab test. Procedural outcome, respiratory complications, and in-hospital mortality were reported. Univariate and multivariate analyses were performed by logistic regressions. Our population was represented by 182 patients with STEMI, 76.9% of which were males, and mean age was 67 ± 12.5. Hypertension was reported in 53.3%, and 29.1% was treated with ACEi/ARBs. COVID-19 diagnosis was confirmed in 17.1% of the patients. In-hospital mortality (13.2%) was significantly higher in patients with COVID-19 (31 vs. 10%, p = 0.003), even if ejection fraction [OR 0.93 (95% CI) 0.87-0.99; p = 0.03] and respiratory complications [OR 9.39 (95% CI) 1.91-45.9; p = 0.006] were the only two independent predictors. The incidence of COVID-19 infection was not influenced by ACEi/ARBs (16.5 in naïve vs. 18.8%) whose presence on admission did not correlate with respiratory complications or mortality both in the case of discontinuation and maintenance. In conclusion, in a high-risk population, such as that of patients with STEMI, the potential benefit of ACEi/ARB discontinuation in patients with COVID-19 is overcome by its detrimental effect. Intensive care, additional preventive respiratory investigations, regardless of swab test result, should be suggested for all patients admitted for STEMI during the pandemic.

Arrhythmic event prediction in patients with heart failure and reduced ejection fraction.

AIMS: Implantable cardioverter defibrillator (ICD) is an effective treatment to reduce mortality in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) 35% or less. LVEF presents a low sensitivity for predicting arrhythmic events. Aim of this study was to identify predictors of sustained ventricular arrhythmias (SVAs), overall and according to the cause of heart failure. METHODS: Single-center, retrospective, cohort study of 193 patients (51 nonischemic and 142 ischemic) with chronic heart failure and LVEF less than 35% who had received ICD for primary prevention of sudden cardiac death. We collected clinical data, echocardiographic parameters and SVAs detected by the ICD. RESULTS: During a median follow-up of 1440 days, 32 (16.2%) patients had SVAs. SVAs incidence was similar in patients with nonischemic (15.6%) and ischemic cause of heart failure (16.9%). Hypertension, diabetes, chronic renal failure, atrial fibrillation, chronic obstructive pulmonary disease, New York Heart Association class at least III were predictors at univariate analysis of SVAs. A clinical score, assigning one point to each of these variables, was associated with a significantly increased risk of SVAs [odds ratio for each point increase = 1.92, 95% confidence interval 1.40-2.65, P < 0.0001, area under the curve (AUC) 0.73], with 72% sensitivity and 60% specificity for a cutoff at least three and remained significant in nonischemic (AUC 0.84) and ischemic (AUC 0.68) patients. CONCLUSION: Our study shows the benefit of ICD implantation in primary prevention and its independency of cause. A simple clinical score, based on comorbidities, identifies patients with more benefits from ICD implantation.

Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

On March 11th 2020 the World Health Organization declared the pandemic infection of SARS-CoV-2 (COVID-19) and Italy was one of the most affected country. The regional Emergency Medical System (EMS) founded itself facing an exponential increase in hospitalizations with a consequent organizational system crisis. Experts from Cina, UK and US suggested to reconsider thrombolysis as the best treatment in term of balance between time consumption and operators safety for ST-segment elevation myocardial infarction (STEMI) patients respect to primary PCI (pPCI). The system reorganization consisted in a centralization of all the emergency nets: from 55 hospitals with cardiac catheterization laboratories distributed within our region offering a 24/7 service we passed to 13 Hub and 42 Spoke centres. Dedicated in-hospital paths for patients COVID positive or suspected (pCOV+) and COVID negative (pCOV-) were instituted. We analysed all consecutive patients undergoing emergency coronary angiogram from March 14 to April 14, 2020 at San Carlo Hospital in Milan comparing the two different in-hospital paths. We collected 30 STEMI patients. Eighteen patients (60%) were treated in pCOV-, while twelve patients (40%) in pCOV+. No significant differences were found among the two groups regarding key time points of STEMI care and interestingly we didn't find any treatment delay in pCOV+. In conclusion, a focused overhaul of the EMS may allow to maintain pPCI as the treatment of choice for patients and operators.