[Multidistrict atherosclerotic disease: epidemiological and clinical framework]. / Malattia aterosclerotica polidistrettuale: inquadramento epidemiologico e clinico.

Atherosclerosis is a systemic disease that can involve different arterial districts. Traditionally, the focus of cardiologists has been on the diagnosis and treatment of atherosclerotic coronary artery disease (CAD). However, atherosclerosis localization in other districts is increasingly common and is associated with an increased risk of CAD and, more generally, of adverse cardiovascular events. Although the term peripheral arterial disease (PAD) commonly refers to the localization of atherosclerotic disease in the arterial districts of the lower limbs, in this document, in accordance with the European Society of Cardiology guidelines, the term PAD will be used for all the locations of atherosclerotic disease excluding coronary and aortic ones. The aim of this review is to report updated data on PAD epidemiology, with particular attention to the prevalence and its prognostic impact on patients with CAD. Furthermore, the key points for an appropriate diagnostic framework and a correct pharmacological therapeutic approach are summarized, while surgical/interventional treatment goes beyond the scope of this review.

The Key Role of a Psychoactive Substance Use History in Comprehensive Cardiovascular Risk Assessment, Diagnosis, Treatment, and Prevention.

BACKGROUND: Psychoactive substances have toxic effects resulting different cardiovascular and non-cardiovascular organ damage. Through a variety of mechanisms, they can trigger the onset of various forms of cardiovascular disease: acute or chronic, transient or permanent, subclinical or symptomatic. Hence, a thorough knowledge of the patient's drug habits is essential for a more complete clinical-etiopathogenetic diagnosis and consequent therapeutic, preventive, and rehabilitative management. SUMMARY: The prime reason for taking a psychoactive substance use history in the cardiovascular context is to identify those people who use substances (whether habitual or occasional users, symptomatic or not) and adequately assess their overall cardiovascular risk profile in terms of "user status" and type of substance(s) used. A psychoactive substance history could also alert the physician to suspect, and eventually diagnose, cardiovascular disease related to the intake of psychoactive substances, so optimizing the medical management of users. This anamnesis could finally assess the likelihood of patients persisting in the habit as a user or relapse, while maintaining high their cardiovascular risk profile. Taking such a history should be mandatory when a causal connection is suspected between intake of psychoactive substances and the observed symptoms or pathology, regardless of whether the individual is a declared user or not. KEY MESSAGES: The purpose of this article was to provide practical information on when, how, and why to perform a psychoactive substance use history.

[Cardiology units and organizational models of heart transplantation centers in Italy: a survey by the Italian Association of Hospital Cardiologists-Italian Society of Organ Transplantation (ANMCO-SITO)]. / Cardiologie e modelli organizzativi dei centri trapianto di cuore: indagine ANMCO-SITO.

BACKGROUND: The extent and quality of the involvement of cardiology units in health programs delivered by Italian centers for heart transplantation (HTx) have not been investigated previously. METHODS: The Italian Association of Hospital Cardiologists (ANMCO) and the Italian Society for Organ Transplantation (SITO) developed and delivered a nationwide survey to the Directors of the Italian centers for HTx to investigate the extent to which cardiology units contribute to HTx programs. The survey investigated: (i) the organization of the centers and institutional frame under which cardiology units contributed to HTx programs; (ii) the volumes of procedures and clinical services delivered by cardiology units to HTx centers for listing patients, following those waiting for HTx, managing acute heart failure, selecting and allocating organs to recipients, following and managing organ rejection after HTx. RESULTS: Of the 14 Italian centers involved, 13 provided full responses to the survey. Between 2017-2019, on average, 46% of the respondents performed up to 15 HTx/year, and additional 46% performed between 16 and 30 HTx/year. Of the respondents, 62% were included in a department of cardiac Surgery which did not include a cardiology unit; furthermore, 54% declared not to be included in a formal network for heart failure management. Cardiology units were the source for referrals of candidates to HTx in 85% cases. Of the respondents, 15% declared to be able to provide cardiological services thorough intra-center multidisciplinary team including cardiologists, whereas cardiological services were outsourced in 61% of the respondents. The clinical follow-up of patients waiting for HTx was performed directly by surgeons in 38% of the respondents. Worsening heart failure was managed directly by the HTx center in 33% of the cases using dedicated beds. Post-HTx follow-up, including endomyocardial biopsy, involved external cardiology units in less than 25% of the centers. CONCLUSIONS: The ANMCO-SITO survey shows that in Italy a very wide variability exists in terms of organization of HTx centers and their relationships with cardiology units for delivering specific cardiological services and procedures. In large majority, patient referral to HTx centers is mediated by cardiology units, whereas HTx was rarely included in a structured cardiological network for heart failure management.

Somatic-Affective, But Not Cognitive-Depressive Symptoms are Associated With Reduced Health-Related Quality of Life in Patients With Congestive Heart Failure.

BACKGROUND: Depression has been associated with poor health-related quality of life (HRQoL) in patients with congestive heart failure (CHF). However, to date, whether somatic-affective and cognitive-depressive symptoms differently contribute to poor HRQoL and behavioral functional capacity in patients with CHF has yet to be investigated. OBJECTIVE: To examine the differential influence of somatic-affective vs cognitive-depressive symptoms on HRQoL and behavioral functional capacity in CHF patients. METHOD: Overall, 55 patients with CHF completed a psychologic evaluation, including the Minnesota Living with Heart Failure Questionnaire, the Beck Depression Inventory-II, and the Beck Anxiety Inventory for HRQoL, depressive, and anxiety symptoms, respectively. The patients completed the Instrumental Activities of Daily Living Questionnaire and the 6-minute walk test for behavioral functional capacity. Hierarchical regression analyses were used to predict HRQoL and behavioral functional capacity from Beck Depression Inventory-II and Beck Anxiety Inventory scores. RESULTS: Somatic-affective depressive symptoms were associated with physical (ß = 0.37, p = 0.005) and emotional (ß = 0.39, p = 0.008) Minnesota Living with Heart Failure Questionnaire subscale scores. Likewise, somatic-affective depressive symptoms predicted Instrumental Activities of Daily Livings Scores (ß = 0.43, p = 0.004) and distance ambulated during the 6-minute walk test (ß = -0.36, p = 0.029). By contrast, cognitive-depressive symptoms and anxiety were unrelated to HRQoL and behavioral functional capacity (all p > 0.05). CONCLUSIONS: These findings showed that somatic-affective depressive symptoms, but not cognitive-depressive symptoms and anxiety, are associated with poor HRQoL and behavioral functional capacity independent of age, clinical functional status, and medical comorbidities. This study suggests that patients with CHF with somatic-affective rather than cognitive-depressive symptoms or anxiety may be at greater risk of poor HRQoL and behavioral functional capacity.

New onset right ventricular enlargement in recent dyspnea: Is echocardiography enough for a diagnosis of pulmonary thrombo-embolism?

Pulmonary embolism may be often promptly diagnosed just by bedside echocardiography, in the case of new onset severe right ventricular enlargement, increased pulmonary pressure and dyspnea. However, CT confirmation could be required in the presence of contrasting findings during diagnostic work up. We report the case of a 79-year old woman who presented with acute dyspnea, right ventricular enlargement and leftward septal shift. Despite first diagnosis of pulmonary embolism, an irregular mass was detected at CT scan in mid left lung, apparently infiltrating left pulmonary artery branches, without signs of evident pulmonary thrombo-embolism. Visceral pleural and lymphonodular infiltration suspected for malignancy was also present. We hypothesize that acutely increased pulmonary pressures and enlarged right ventricle were caused by the infiltrating pulmonary mass, presumably a lung tumor, partly involving left pulmonary artery branches and by tumor pulmonary embolism. A diagnosis of pulmonary thrombo-embolism exclusively based on echocardiography may be occasionally misleading without a careful diagnostic work-up.

Long-term results of ablation for isolated atrial fibrillation through a right minithoracotomy: toward a rational revision of treatment protocols.

OBJECTIVE: Despite continued technical improvements, results of transcatheter radiofrequency ablation of atrial fibrillation may be suboptimal in some patient subgroups. Short-term follow-up of minimally invasive epicardial ablation of isolated atrial fibrillation has been encouraging. METHODS: One hundred four patients with drug-refractory isolated atrial fibrillation underwent minimally invasive surgical ablation through right 3- to 4-cm minithoracotomy by isolation of pulmonary veins and were followed-up for an average of 17 months. Previous failed transcatheter ablation was not a criterion for this procedure. Antiarrhythmic drugs were continued until postoperative month 6, despite demonstration of stable sinus rhythm. RESULTS: The procedure was confirmed to be safe (1 case of procedure-related morbidity, no operative deaths) and effective (89% overall freedom from recurrent arrhythmia at follow-up, 96% freedom from paroxysmal atrial fibrillation, 80% freedom from persisting type atrial fibrillation). Results tended to improve with the expansion of the surgical experience. Cox hazard regression and Kaplan-Meier analysis identified persisting type atrial fibrillation and enlarged left atrium as the major predictors of recurrent atrial fibrillation at follow-up. Health-related quality of life was confirmed to be improved at the end of the follow-up relative to baseline in most Medical Outcomes Study 36-Item Short-Form Health Survey domains. CONCLUSIONS: Minimally invasive epicardial ablation of isolated atrial fibrillation yields stable, gradually improving results. Earlier surgical referral is justifiable after careful cardiologic work-up. To define the relative roles of minimally invasive ablation and transcatheter ablation, which may be considered in the future as alternative therapies, a randomized trial to compare these procedures is advisable.

One-year results after implantation of the CorCap for dilated cardiomyopathy and heart failure.

BACKGROUND: We conducted a prospective study of the clinical outcomes and health-related quality of life after implantation of the CorCap support device (Acorn Cardiovascular Inc, St Paul, MN) for dilated cardiomyopathy. METHODS: The criteria adopted for CorCap implantation were dilated cardiomyopathy (left ventricular [LV] end-diastolic diameter≥60 mm, LV ejection fraction≤0.30 and >0.10), and New York Heart Association functional class II or III despite maximal medical therapy. Echocardiographic follow-up and evaluation with the Short Form-36 questionnaire were performed. RESULTS: Included were 39 patients: 5 in New York Heart Association class II and 32 in class III. At 13.3±2.5 months of follow-up, a statistically significant improvement was evident in mean LV volume (LV end-systolic volume from 202±94 to 138±72 ml. p=0.005) and systolic function (LV ejection fraction from 0.26±0.05 to 0.36±0.05, p<0.001). The mean LV sphericity index was significantly increased at the end of the follow-up (p=0.009). Ischemic etiology, diabetes, advanced age, and LV ejection fraction of less than 0.15 predicted lesser reversal of the LV alterations. Operative mortality was 5.1%. Cumulative follow-up mortality was 10.2%. The average Physical Health domain scores (Physical Functioning, Role Physical, General Health) were improved. Average Mental Health domain scores were also increased. CONCLUSIONS: The cardiac support device obtains reverse remodelling of the LV and is useful to improve the quality of life of patients with dilated cardiomyopathy and New York Heart Association class III symptoms of heart failure. The integration of different and complementary strategies (cardiac support device and resynchronization therapy) may represent the key to success for more complex patients, although further studies are required.

A new extracorporeal vacuum-assisted device to optimize cardiopulmonary bypass. Comparison with the conventional system.

Miniaturized cardiopulmonary bypass (CPB) systems, though more biocompatible, are limited by not being adaptable to all cardiac surgical operations. We evaluate a versatile CPB system [extracorporeal vacuum-assisted device optimized (EVADO)] based on the elimination of roller pumps, separation of extracavitary suctioned blood and state-of-the-art technology for oxygenator systems and digital control. We randomized 165 patients to either EVADO or conventional CPB (cCPB). Surgery could be completed in all cases without conversion to cCPB. The use of EVADO significantly reduced the intraoperative haemolysis (lesser increase in free hemoglobin, P<0.001 vs. control, and lesser decrease in haptoglobin levels, P=0.001 vs. control). Among patients who were submitted to EVADO, postoperative bleeding (P=0.004), transfusions (P=0.046), rate of revision for bleeding (P=0.03), rate of postoperative atrial fibrillation (P=0.007), time to extubation (P=0.02) and ICU stay (P=0.04) were reduced. The clinical benefits associated with the EVADO may be due to better end-organ perfusion, lesser impairment of the coagulation and inflammatory reaction.

Minimally invasive epicardial ablation of lone atrial fibrillation in pediatric patient.

We describe a case of epicardial surgical ablation of drug refractory lone atrial fibrillation in a pediatric patient. Minimally invasive radiofrequency equipment was used off-pump through a right mini-thoracotomy. Electrical isolation of the pulmonary veins cuffs was obtained. The preoperative electrophysiological study identified a macro re-entrant circuit around the pulmonary veins orifices as the mechanism of arrhythmia triggering. At follow-up, the patient is in stable sinus rhythm and there is no evidence of pulmonary vein stenosis. The minimally invasive, off-pump ablation of lone atrial fibrillation is feasible and reliable, even in children who may pose incremental technical challenges. This technique may represent an additional tool for the current treatment algorithms to treat lone atrial fibrillation.