ANMCO position paper: 2022 focused update of appropriate use criteria for multimodality imaging: aortic valve disease.

This document addresses the evaluation of the Appropriate Use Criteria (AUC) of multimodality imaging in the diagnosis and management of aortic valve disease. The goal of this AUC document is to provide a comprehensive resource for multimodality imaging in the context of aortic valve disease, encompassing multiple imaging modalities. Clinical scenarios are developed in a simple way to illustrate patient presentations encountered in everyday practice.

[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies]. / Follow-up dei pazienti sottoposti ad intervento per dissezione aortica acuta di tipo A: evidenze e controversie.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

[Cardiovascular prevention in the elderly: limitations and opportunities]. / Prevenzione cardiovascolare negli anziani: limiti e opportunità.

The world's population is ageing; however, the prolonged life expectancy is barely associated with an increase of healthy aging, and an important part of this demographic shift is a rising susceptibility to development and progressive accumulation of multiple chronic illness, challenging healthcare systems. Aging, therefore, represents the major risk factor for multimorbidity, a milestone for progressive loss of resilience and age-related multisystem homeostatic dysregulation. Cardiovascular risk factors, time and comorbidities play a vicious role in the development of heart disease. Among the other comorbidities, age itself is one of the most important risk factors for the development of cardiovascular disease and the prevalence and incidence of cardiovascular disease in the elderly are significantly increased. Elderly subjects, particularly when frail and with comorbidities, however, are scarcely represented in primary and secondary prevention trial aimed to treat hypercholesterolemia, diabetes mellitus and arterial hypertension. In particular, concerns exist about whether treatment should more or less intensive according to tolerability and risk of interactions; as well as there is uncertainty about therapeutic targets at different ages.This article reviews the relationship between ageing and cardiovascular disease, focusing on several issues regarding cardiovascular prevention in the elderly.

[ANMCO/SICI-GISE/SIC/SIECVI/SIRM Consensus document: Appropriateness of multimodality imaging in cardiovascular disease]. / Documento di consenso ANMCO/SICI-GISE/SIC/SIECVI/SIRM: Appropriatezza dell'imaging multimodale nelle patologie cardiovascolari.

The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.

[Role of multimodality imaging in the clinical evaluation of hypertrophic cardiomyopathy]. / Valutazione clinica della cardiomiopatia ipertrofica: ruolo dell'imaging multimodale.

Sarcomeric hypertrophic cardiomyopathy is the most common cardiovascular genetic disease. Clinical evaluation and comprehensive echocardiography are crucial for the diagnosis and early evaluation of the hypertrophic phenotype, but multimodality imaging approach is often required to better define diagnosis and differential diagnosis from phenocopies. This review aims to assess the role of multimodality imaging and, in particular, advanced echocardiography and cardiac magnetic resonance in relation to differential diagnosis and preclinical diagnosis, identification of different phenotypes, and assessment of disease progression and risk of sudden cardiac death. A multimodality imaging approach is also crucial for the selection of patients amenable to surgical or percutaneous septal myectomy and for guiding both procedures.

[ANMCO/GISE/SICCH Inter-Society Consensus Document: Antithrombotic therapy after surgery or structural interventional procedures for valvular heart diseases: how to treat postoperative complications]. / Documento di consenso intersocietario ANMCO/GISE/SICCH: Terapia antitrombotica nei pazienti sottoposti a chirurgia e/o interventistica cardiaca valvolare: come trattare le complicanze.

Continuous improvement of technologies, devices and drugs needs a renewal and update of current recommendations and guidelines on antithrombotic strategies, especially in those fields where literature lacks of established scientific evidences. Accordingly, the aim of this consensus statement is to provide support for antithrombotic therapy based on current guidelines and the most recent scientific evidences.After an overview on the currently available devices, the appropriate therapy according to type of procedure and implanted device is discussed. The occurrence of postoperative thromboembolic and/or hemorrhagic complications is analyzed, along with the appropriate diagnostic tools and therapeutic approach. A section is dedicated to counseling to pregnancy in women with heart valve prosthesis. Finally, the role of novel oral anticoagulants is discussed, and indications are provided for the management of patients undergoing surgery or interventional procedures on oral anticoagulation therapy.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement.

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

Transesophageal Echocardiography and Radiation-induced Damages.

The long-term sequelae of mantle therapy include, especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus). We presented the case of 66-year-old female admitted for congestive heart failure in radiation-induced heart disease. The patient had undergone to massive radiotherapy 42 years ago for Hodgkin's disease (type 1A). Transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls. Our case is an extraordinary report of radiotherapy's latency effect as a result of dramatic changes in the structure of mediastinum, in particular in the esophagus, causing unavailability of a transesophageal echocardiogram.

[ANMCO/SIC/SICI-GISE/SICCH Consensus document: Risk stratification in elderly patients undergoing cardiac surgery and transcatheter aortic valve implantation]. / Documento di consenso ANMCO/SIC/SICI-GISE/SICCH: Stratificazione del rischio in chirurgia cardiaca e per l'impianto transcatetere di valvola aortica specifico per il paziente anziano.

Aortic stenosis is one the most frequent valvular diseases in developed countries, and its impact on public healthcare resources and assistance is increasing. A substantial proportion of elderly patients with severe aortic stenosis is frequently not eligible for surgery because of advanced age, frailty and multiple comorbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant proportion of patients die or do not achieve an improvement of quality of life in the short to medium-term follow-up. It is important to determine: 1) whether and how much patient frailty influences the procedural risk; 2) whether quality of life and the individual patient survival are influenced by aortic valve disease alone or by other associated factors; 3) whether a geriatric specialist intervention to evaluate and correct other diseases with their potential or already evident disabilities can improve the results of TAVI, in particular patient quality of life. Consequently, in addition to risk stratification with conventional tools, a number of factors including multimorbidity, disability, frailty and cognitive function should be considered in order to assess the expected benefit of TAVI. Preoperative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, renal) that can potentially worsen the reduced physiological reserves characteristic of frailty. The systematic implementation into clinical practice of multidimensional assessment instruments of frailty and cognitive function for screening and exercise, and the adoption of specific care pathways should facilitate this task.

Combined venoarterial extracorporeal membrane oxygenation and transcatheter aortic valve implantation for the treatment of acute aortic prosthesis dysfunction in a high-risk patient.

We describe the case of a patient with acute bioprosthesis dysfunction in cardiogenic shock, in whom hemodynamic support was provided by venoarterial extracorporeal membrane oxygenation, and successfully treated by transcatheter aortic valve implantation.

The Strange Case of the Infarcted Myxoma.

In the setting of an acute coronary syndrome, the differential diagnosis between a thrombus and a myxoma may be cumbersome. We describe the case of a patient presenting with an acute coronary syndrome associated with an aneurysmatic apical left ventricular myxoma.

Noncompaction and embolic myocardial infarction: the importance of oral anticoagulation.

Left ventricular noncompaction (LVNC) is characterized by left ventricular (LV) hypertrabeculations and is associated with heart failure, arrhythmias and embolism. We report the case of a 67-year-old LVNC patient, under oral anticoagulation (OAC) therapy for apical thrombosis. After she discontinued OAC, the thrombus involved almost the whole of the left ventricle; in a few months her condition worsened, requiring hospitalization, and despite heparin infusion she experienced myocardial infarction (MI), caused by embolic occlusion of the left anterior descending artery. Although infrequent as a complication of LVNC, and usually attributable to microvascular dysfunction, in this case MI seems due to coronary thromboembolism from dislodged thrombotic material in the left ventricle.

Thrombotic aortic restenosis after transapical SAPIEN valve implantation.

We describe a patient previously implanted with a SAPIEN Edwards valve by the transapical approach, who subsequently experienced a valve thrombosis. The literature on this subject is reviewed.