Provision of Italian diagnostic reference levels for diagnostic and interventional radiology.

OBJECTIVES: The diagnostic reference level (DRL) is a useful tool for the optimisation of medical exposures. Thus, a Working Party coordinated by the Italian National Institute of Health and the National Workers Compensation Authority has been formed to provide Italian DRLs, for both diagnostic and interventional procedures, to be used as appropriate for the implementation of the 2013/59 European Directive into the national regulation. MATERIALS AND METHODS: The multidisciplinary Working Party was formed by professionals involved in diagnostic and interventional radiology medical exposures and started from a critical revision of both the literature and the results of previous Italian surveys. The procedures were divided into five sections for adult (projection radiography, mammography, diagnostic fluoroscopy, CT and interventional radiology) and two sections for paediatric patients (projection radiography and CT). The provided DRL values have been identified for "normal" adult patients and for age-classes of paediatric patients. RESULTS: Some of the DRL values provided by the Working Party are reported in this study as an example, divided by adult/paediatric patients, radiological technique and examination: specifically, DRLs for new radiological practices and new dose quantities as DRLs metric were introduced. The median value (rather than the mean) for each procedure, derived from a sample of patients, has to be compared with the corresponding DRL value, and dosimetric data related to a minimum number of patients should be collected for each examination. CONCLUSIONS: The approach to the definition and use of DRLs through guidelines of national Authorities in collaboration with scientific Associations should simplify the periodical updating and could be useful for keeping the optimisation of medical exposures faithful to the development of radiological practice.

Clinical management of fusion in primary mandibular incisors: a systematic literature review.

Objective: Dental anomalies occurring in deciduous teeth can affect the eruption of the permanent dentition and the occlusion stability. The occurrence of dental anomalies such as double teeth during the primary dentition in the daily practice might be frequent. The study aimed to qualitatively summarize the therapeutic management of double teeth in primary incisors.Material and Methods: A systematic review regarding the therapy of primary fused incisors in the mandible was performed and the obtained data were assessed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following electronic databases were screened from 1st January, 1996 until 30th July, 2019: PubMed, Scopus, EBSCO and the archives of paediatric dental journals. The search terms were grouped in anatomic entity: (tooth OR teeth OR incisor), pathological condition: (fused OR fusion OR geminated OR double), intervention: (treatment OR intervention OR therapy OR prevention OR control OR management OR restoration), observed parameters: (primary dentition OR primary tooth OR primary teeth).Results: Ten articles met all inclusion criteria. The data disclosed the occurrence of double teeth in mandibular incisors. The main management of this clinical condition is either preventive or surgical involving the extraction of fused teeth, based on the deciduous nature of the teeth, the degree of caries and malocclusion development risk.Conclusion: An early diagnosis of dental anomalies is fundamental for the application of proper preventive strategies to avoid a potential malocclusion in permanent dentition and to maintain these teeth sound and caries-free until the eruption of the permanent dentition.

[SICI-GISE Position paper: Enhancing radiation safety in the catheterization laboratory]. / Position paper SICI-GISE: Miglioramento della radioprotezione nel laboratorio di Emodinamica.

The radiation dose received by interventional cardiologists during their activity in the catheterization laboratory is a matter of concern in terms of possible deterministic and stochastic risk. At the same time, very often, the knowledge of the effect and consequences of radiation exposure in the interventional cardiology community is limited. This document endorsed by the Italian Society of Interventional Cardiology (SICI-GISE) provides recommendations for cardiologists' radiation protection. Radiation safety considerations dedicated to women and other staff personnel working in the catheterization laboratory are also discussed.

Impact of ambulatory cardiac rehabilitation on cardiovascular outcomes: a long-term follow-up study.

AIMS: To evaluate the long-term clinical impact of the application of cardiac rehabilitation (CR) early after discharge in a real-world population. METHODS AND RESULTS: We analysed the 5-year incidence of cardiovascular mortality and hospitalization for cardiovascular causes in two populations, attenders vs. non-attenders to an ambulatory CR program which were consecutively discharged from two tertiary hospitals, after ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, coronary artery bypass graft, or planned percutaneous coronary intervention. A primary analysis using multivariable regression model and a secondary analysis using the propensity score approach were performed. Between 1 January 2009 and 31 December 2010, 839 patients attended a CR program planned at discharged, while 441 patients were discharged from Cardiovascular Department without any program of CR. During follow-up, the incidence of cardiovascular mortality was 6% in both groups (P = 0.62). The composite outcome of hospitalizations for cardiovascular causes and cardiovascular mortality were lower in CR group compared to no-CR group (18% vs. 30%, P < 0.001) and was driven by lower hospitalizations for cardiovascular causes (15 vs. 27%, P < 0.001). At multivariable Cox proportional hazard analysis, CR program was independent predictor of lower occurrence of the composite outcome (hazard ratio 0.58, 95% confidence interval 0.43-0.77; P < 0.001), while in the propensity-matched analysis CR group experienced also a lower total mortality (10% vs. 19%, P = 0.002) and cardiovascular mortality (2% vs. 7%, P = 0.008) compared to no-CR group. CONCLUSION: This study showed, in a real-world population, the positive effects of ambulatory CR program in improving clinical outcomes and highlights the importance of a spread use of CR in order to reduce cardiovascular hospitalizations and cardiovascular mortality during a long-term follow-up.

Heterogeneity of clinical presentation in Tako-Tsubo syndromes: the prevalence of normal segmental wall motion and normal ECG pattern.

AIM: The aim of this study is to report the heterogeneity of clinical presentation in Tako-Tsubo syndrome (TTS), including a significant prevalence of normal ECG and echocardiographic patterns in a series of consecutive patients from a single center. METHODS AND RESULTS: From our database we selected a total of 168 cases of TTS. A total of 140 of these (Group A); 14 men (10%), mean age 60.3 years, range 39-87; 126 women (90%), mean age 66.1 years, range 43-93; matched the following reported criteria: typical stenocardic pain immediately following an emotional acute stress, or acute medical or surgical event within the preceding 12 h; acute rise and fall of troponin release; absence of significant coronary disease at coronary angiography. ECG findings at presentation ranged from T wave abnormalities (41 cases, 29.3%) to ST elevation (52 cases, 37.1%) and ST depression (11 cases, 7.9%), whereas in 36 cases (25.7%) the ECG was normal. Echocardiography at presentation showed akinesia of the total apical or medium-apical segments in 74 patients (53%), whereas it showed akinesia of left ventricular wall segments in other locations in 30 patients (21%) and even normal regional wall motion and thickening in 36 patients (26%). We described also a series of 13 female patients (mean age 70.2 years; age range 45-85 years) (Group B) who did not complain of chest pain at presentation, but showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography. Finally we selected 15 female patients (mean age 69.3 years; age range 49-89 years) (Group C) who formally did not report acute stress immediately preceding their presentation to the hospital for chest pain. They showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography and only one case of normal ECG pattern at presentation. CONCLUSION: In this series of acute TTS, a wide variability of ECG and echocardiographic patterns are observed, ranging from ST elevation with coexisting segmental wall motion abnormalities of the typical TTS to a clinical presentation characterized by normal ECG and normal segmental wall motion pattern.

Management of untreatable ventricular arrhythmias during pharmacologic challenges with sodium channel blockers for suspected Brugada syndrome.

Pharmacologic challenge with sodium channel blockers is part of the diagnostic workout in patients with suspected Brugada syndrome. The test is overall considered safe but both ajmaline and flecainide detain well known pro-arrhythmic properties. Moreover, the treatment of patients with life-threatening arrhythmias during these diagnostic procedures is not well defined. Current consensus guidelines suggest to adopt cautious protocols interrupting the sodium channel blockers as soon as any ECG alteration appears. Nevertheless, the risk of life-threatening arrhythmias persists, even adopting a safe and cautious protocol and in absence of major arrhythmic risk factors. The authors revise the main published case studies of sodium channel blockers challenge in adults and in children, and summarize three cases of untreatable ventricular arrhythmias discussing their management. In particular, the role of advanced cardiopulmonary resuscitation with extra-corporeal membrane oxygenation is stressed as it can reveal to be the only reliable lifesaving facility in prolonged cardiac arrest.

The combined use of Drug-eluting balloon and Excimer laser for coronary artery Restenosis In-Stent Treatment: The DERIST study.

AIM: Stents reduce angiographic restenosis in comparison with balloon angioplasty. The rate of in-stent restenosis (ISR), although less frequent than post-angioplasty restenosis, is becoming increasingly prevalent due to the recent exponential increase in the use of intracoronary stents. The aim of this study is to evaluate angiographic and clinical outcomes of PTCA in combination with the use of excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) in treatment of in-stent restenosis (ISR). METHODS AND RESULTS: This multi-centric case-control study evaluated angiographic and clinical outcomes of PTCA with excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) in 80 patients with in-stent restenosis (ISR). All patients underwent nine months of clinical and a coronary angiography follow-up. This study showed clinical and angiographic long-term success in the 91% of the patients. The incidence of myocardial infarctions and deaths was lower than the rate after plain balloon angioplasty within the stent. CONCLUSIONS: This study showed that excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) may be an alternative treatment for in-stent restenosis (ISR).

Early outcome of high energy Laser (Excimer) facilitated coronary angioplasty ON hARD and complex calcified and balloOn-resistant coronary lesions: LEONARDO Study.

AIM: An innovative xenon-chlorine (excimer) pulsed laser catheter (ELCA X80) has been recently used for the treatment of complex coronary lesions, as calcified stenosis, chronic total occlusions and non-compliant plaques. Such complex lesions are difficult to adequately treat with balloon angioplasty and/or intracoronary stenting. The aim of this study was to examine the acute outcome of this approach on a cohort of patients with coronary lesions. METHODS AND RESULTS: Eighty patients with 100 lesions were enrolled through four centers, and excimer laser coronary angioplasty was performed on 96 lesions (96%). Safety and effectiveness data were compared between patients treated with standard laser therapy and those treated with increased laser therapy. Laser success was obtained in 90 lesions (93.7%), procedural success was reached in 88 lesions (91.7%), and clinical success in was obtained in 87 lesions (90.6%). There was no perforation, major side branch occlusion, spasm, no-reflow phenomenon, dissection nor acute vessel closure. Increased laser parameters were used successfully for 49 resistant lesions without complications. CONCLUSIONS: This study suggests that laser-facilitated coronary angioplasty is a simple, safe and effective device for the management of complex coronary lesions. Furthermore, higher laser energy levels delivered by this catheter improved the device performance without increasing complications.

Transcatheter aortic valve implantation for degenerative aortic valve regurgitation long after heart transplantation.

Transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option for the management of high-risk patients with severe degenerative aortic stenosis. Recently it has been extended to high-risk patients with severe aortic regurgitation. Degenerative aortic valve disease is generally uncommon in heart transplant recipients. We report the case of a 75-year-old man in whom severe degenerative aortic regurgitation developed 14 years after heart transplantation (HTx). Because of multiple comorbidities and high surgical risk, TAVI was preferred. A 29-mm CoreValve prosthesis (Medtronic Inc, Minneapolis, MN) was successfully implanted using a transfemoral approach.

Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest.

AIMS: Acute coronary lesions are known to be the most common trigger of out of hospital cardiac arrest (OHCA). Aim of the present study was to assess the predictive value of ST-segment changes in diagnosing the presence of acute coronary lesions among OHCA patients METHODS: Findings of coronary angiography (CA) performed in patients resuscitated from OCHA were retrospectively reviewed and related to ST-segment changes on post-ROSC electrocardiogram (ECG) RESULTS: Ninety-one patients underwent CA after OHCA; 44% of patients had ST-segment elevation and 56% of patients had other ECG patterns on post-ROSC ECG. Significant coronary artery disease (CAD) was found in 86% of patients; CAD was observed in 98% of patients with ST-segment elevation and in 77% of patients with other ECG patterns on post-ROSC ECG (p=0.004). Acute or presumed recent coronary artery lesions were diagnosed in 56% of patients, respectively in 85% of patients with ST-segment elevation and in 33% of patients with other ECG patterns (p<0.001). ST-segment analysis on post-ROSC ECG has a good positive predictive value but a low negative predictive value in diagnosing the presence of acute or presumed recent coronary artery lesions (85% and 67%, respectively) CONCLUSIONS: Electrocardiographic findings after OHCA should not be considered as strict selection criteria for performing emergent CA in patients resuscitated from OHCA without obvious extra-cardiac cause; even in the absence of ST-segment elevation on post-ROSC ECG, acute culprit coronary lesions may be present and considered the trigger of cardiac arrest.

Impact of emergency coronary angiography on in-hospital outcome of unconscious survivors after out-of-hospital cardiac arrest.

Acute coronary thrombotic occlusion is the most common trigger of cardiac arrest. The aim of the present study was to assess the impact of an invasive strategy characterized by emergency coronary angiography and subsequent percutaneous coronary intervention (PCI), if indicated, on in-hospital survival of resuscitated patients with out-of-hospital cardiac arrest (OHCA) and no obvious extracardiac cause who do not regain consciousness soon after recovery of spontaneous circulation. Ninety-three consecutive patients (67 ± 12 years old, 76% men) were included in the study. Clinical characteristics and coronary angiographic and in-hospital outcome data were retrospectively collected. Multivariate Cox proportional-hazards analysis was performed to identify independent determinants of in-hospital survival. Coronary angiography was performed in 66 patients (71%). Forty-eight patients underwent emergency coronary angiography; in the remaining 18 patients, mean time from OHCA to coronary angiography was 13 ± 10 days. In patients referred to emergency coronary angiography, successful emergency PCI of a culprit coronary lesion was performed in 25 patients (52%). In-hospital survival rate was 54%. At multivariate analysis, emergency coronary angiography (hazard ratio 2.32, 95% confidence interval 1.23 to 4.38, p = 0.009) and successful emergency PCI (hazard ratio 2.54, 95% confidence interval 1.35 to 4.8, p = 0.004) were independently related to in-hospital survival in the overall study population; delay in performing coronary angiography (hazard ratio 0.95, 95% confidence interval 0.92 to 0.99, p = 0.013) was independently related to in-hospital mortality in patients referred to coronary angiography. In conclusion, an invasive strategy characterized by emergency coronary angiography and subsequent PCI, if indicated, seems to improve in-hospital outcome of resuscitated but unconscious patients with OHCA without obvious extracardiac cause.

Long-term outcome after drug-eluting stent implantation in unselected population: ROME and UDINE experience (the RUDI registry).

OBJECTIVES: The aim of our study is to evaluate the safety and efficacy of DES implantation in an unselected, "real world," high-risk population. BACKGROUND: Several clinical trials showed that drug-eluting stents (DESs) implantation is safe and effective in selected population. In spite of these encouraging results, there are some concerns about "real world" utilization of these stents. METHODS: One thousand four hundred and fifty-five off-label patients have been included in our registry. Primary end-points were: long-term clinical incidence of major adverse cardiac and cerebrovascular events (MACCE) and thrombosis (ST). We detected the difference between uniDES vs. multiDES implantation in terms of MACCE, death, nonfatal-MI, the composite of death/nonfatal-MI and target lesion revascularization (TLR) and the difference between DES type in term of MACCE. RESULTS: At 36 months follow-up we found: cardiac death occurred in 20 patients (1.6%); 33 patients (2.6%) had a nonfatal MI and 81 patients (6.3%) had a TLR. We observed one (0.1%) acute, 9 subacute (0.6%), 6 late (0.6%), and 1 (0.5%) very late definite ST. No difference were found in terms of overall MACCE, MI, death and composite of death/nonfatal-MI between uni- and multiDES implantation but multiDES group had a higher incidence of TLR. No difference between DES type in term of MACCE was detected. CONCLUSIONS: DES utilization shows their safety and efficacy in off-label patients with complex clinical and angiographic profile in terms of long-term incidence of MACCE. MultiDES implantation is associated with a higher risk of long-term TLR. No difference between DES type was found.

The acute myocardial infarction with ST segment elevation Udine registry (Come-to-Udine): predictors of 3 years mortality.

BACKGROUND: Percutaneous coronary intervention (PCI) is considered the best treatment for acute myocardial infarction with ST segment elevation (STEMI), but it is difficult to deliver. OBJECTIVES: To report on long-term mortality predictors in a registry based on a 'hub and spoke' model, according to the initial strategy: thrombolysis followed or not by PCI, invasive strategy followed or not by primary PCI and no reperfusion. METHODS AND RESULTS: From May 2001 to June 2003, 514 patients (mean age 67 +/- 12) with STEMI onset less than 12 h (<24 h if pain ongoing) were enrolled, 34% transferred from spoke centers. Patients were stratified according to thrombolysis in myocardial infarction risk score (TRS) and to local high-risk criteria (LHRC, one of the following: contraindication to thrombolysis, cardiogenic shock, anterior or right ventricular location, ST segment elevation in > or =6 leads, Killip class >1 and previous STEMI). Mean TRS score was 4.0 and 53% of patients met LHRC. Thrombolysis was undertaken in 49% of patients, invasive strategy in 29% and no reperfusion in 22%. The latter had higher TRS (4.9) but only 40% met LHRC. Reperfusion time was significantly longer in patients who underwent PCI as compared with those who underwent thrombolysis (223 vs. 120 min, P < 0.0001). Patients in the thrombolysis group had better risk profiles and underwent emergency or elective revascularization within 30 days in 66% of cases. Overall, long-term mortality rate (36 months) was 23.3%. Both TRS and LHRC identified patients with higher mortality (43 and 32%, respectively). Multivariate analysis showed age, left ventricular ejection fraction and Killip class more than 1 to be significant predictors of mortality (P < 0.0001/P < 0.0001/P = 0.0103), whereas reperfusion strategy and time to treatment were not. CONCLUSION: An initial strategy of thrombolysis followed by emergency or elective PCI as appropriate is still an option in a setting in which limited resources are available. Decision-making based on risk scores and time from symptom onset lead to proper patient selection and even to foregoing reperfusion without affecting mortality.

Radionuclide evidence for reversible ischemia after percutaneous treatment of anomalous right coronary artery with dynamic compression by great vessels.

Anomalous origin of the right coronary artery from the left sinus is a rare congenital anomaly, possibly related to myocardial ischemia by dynamic compression. We present a case of percutaneous treatment of this coronary anomaly resulting in regression of inducible ischemia, as demonstrated by radionuclide scintigraphy.

Transient left ventricular apical ballooning syndrome: a 4-year experience.

BACKGROUND: Transient left ventricular apical ballooning syndrome, primarily described in Japanese patients, has been recently recognized outside Japan also. Aim of this study is to elucidate incidence and clinical features of left ventricular apical ballooning syndrome in a tertiary-care hospital in northeastern Italy. METHODS AND RESULTS: From January 2002 to August 2006, 29 patients admitted for suspected acute coronary syndrome (25 women, mean age 64+/-12 years) fulfilled the Mayo Clinic Criteria of left ventricular apical ballooning syndrome. Twenty patients (69%) had an episode of emotional or physiologic stress preceding left ventricular apical ballooning syndrome. Fourteen patients (48%) had at least one risk factor for coronary artery disease. Chest pain was present at admission in 24 patients (83%). Twenty-five patients (86%) had ST-T segment abnormalities at ECG on admission. Four patients were treated with fibrinolytic therapy and one with glycoprotein IIb/IIIa inhibitors. At coronary angiography, 23 patients (79%) had no coronary lesions, 2 (7%) had small vessel occlusion and 4 (14%) had nonsignificant coronary stenosis. ECG changes and echocardiographic wall motion abnormalities completely regressed in all patients within 10 weeks. Neither death nor major complications occurred during in-hospital stay and after discharge. Two patients (7%) experienced a recurrence during follow-up. CONCLUSION: Left ventricular apical ballooning syndrome is a novel syndrome with a nonnegligible incidence, a clinical presentation mimicking acute myocardial infarction and a favorable outcome. The present data confirm a higher prevalence in women and the frequent association with emotional stress. The differential diagnosis with acute myocardial infarction at presentation is still puzzling, and only ECG findings in conjunction with echocardiography and coronary angiography are so far diagnostics.

Impact of acute renal failure following percutaneous coronary intervention on long-term mortality.

BACKGROUND: Acute renal failure (ARF) following percutaneous coronary intervention (PCI) has been shown to be associated with a worse outcome. Whether this event should be considered as a marker of disease severity or an independent contributor to mortality is still unclear. METHODS: In a multicenter, prospective cohort study we investigated the predictive variables and the impact of postprocedural ARF on 2-year all-cause mortality in 2860 consecutive patients (50% with stable angina and 50% with non-ST-elevation acute coronary syndromes) undergoing PCI. Serum creatinine determinations were made immediately before and 24 h after PCI. ARF was defined as an increase in serum creatinine of > or =0.5 mg/dl over baseline. RESULTS: One hundred and six patients (3.7%) experienced ARF. At logistic regression analysis, ARF was associated with pre-existing low values of estimated glomerular filtration rate, reduced left ventricular ejection fraction, hypertension, and prior coronary bypass surgery. Mortality data at 2 years were available for all patients: 119 patients (4.16%) had died, 3.9% of those without and 11.3% of those with ARF (univariate hazard ratio 3.16; 95% confidence interval 1.68-5.94; P = 0.0004). At Cox regression analysis, the significant predictors of mortality were age, ejection fraction, preprocedural estimated glomerular filtration rate, PCI failure, atrial fibrillation, diabetes mellitus, and fluoroscopy time. In this comprehensive mortality model, ARF maintained a borderline statistical significance (hazard ratio 1.83, 95% confidence interval 0.98-3.44; P = 0.06). CONCLUSIONS: ARF following PCI occurs almost exclusively in patients with chronic kidney disease or left ventricular dysfunction. These risk factors are also among the most powerful predictors of long-term mortality and are likely to explain most of the association between postprocedural ARF and long-term mortality. After correction for clinical determinants, however, postprocedural ARF maintains a clinically significant impact on mortality that must be taken into account for benefit vs. risk evaluation of PCI in individual patients.

The effect of fellows' training in invasive cardiology on radiological exposure of patients.

The aim of this work was to evaluate and quantify the impact of an invasive training of cardiology fellows on some exposure parameters. From 1 January 2000 to 31 December 2002, three staff members performed 2.582 diagnostic procedures (Group 1) that were compared with 819 performed by, or with the participation of five cardiology fellows (Group 2). Exposure parameters were as follows (Group 1/Group 2): fluoroscopy time 3.8 +/- 4.5/5.5 +/- 5.9 min (+38%), mean number of frames 589 +/- 282/642 +/- 260 (+9%), Kerma-area product (KAP) during fluoroscopy 10.6 +/- 14/15.5 +/- 16 Gycm2 (+45%), KAP during cine-angiography 20.8 +/- 14/22.5 +/- 12 (+8%), total KAP 31.5 +/- 28/38.1 +/- 28 (+21%). Differences were all significant (P