Tako-Tsubo syndrome in patients with COVID-19: a single centre retrospective case series.

Growing evidence shows that COVID-19 is associated with an increase in Tako-Tsubo syndrome (TTS) incidence. We collected data from patients hospitalized in our multidisciplinary COVID-19 department who had a diagnosis of TTS during the second and third wave of the pandemic in Italy. We reported four cases of TTS associated with COVID-19. No patient had any classical trigger for TTS except for COVID-19. Mean age was 72 years (67-81) and all patients had a SARS-CoV-2-related interstitial pneumonia confirmed by computed tomography. Typical apical ballooning and transitory reduction in left ventricle (LV) systolic function with a complete recovery before discharge were observed in all patients. The mean LV ejection fraction (LVEF) at TTS onset was 42% (40-48%). ECG showed ST-segment elevation in two cases, while an evolution with negative T waves and QTc prolongation was observed in all patients. Three patients underwent coronary angiography. Two patients had Alzheimer's disease. The time interval from hospital admission to TTS onset was 4 (2-6) days, and the time interval from COVID-19 symptom onset to TTS diagnosis was 10 (8-12) days.  COVID-19 may be a trigger for TTS, though TTS pathophysiology in COVID-19 patients remains unclear, likely due to its multifactorial nature.

In-hospital outcomes of Portico transcatheter aortic valve replacement with the FlexNav as compared to the first-generation delivery system.

Introduction: Technological advancements in transcatheter heart valve platforms are essential in order to achieve high standards of efficacy and safety in transcatheter aortic valve replacement (TAVR). Aim: To evaluate the performance of the new version of the Portico valve delivery system (FlexNav) as compared to the first-generation device. Material and methods: In this single-center, observational study consecutive patients undergoing Portico valve implantation with the new FlexNav delivery system (DS) were compared with patients treated with the first-generation delivery system (1st gen DS). In-hospital outcomes were self-adjudicated according to the Valve Academic Research Consortium-3 definition. Results: Fifty patients were included in this study; 22 were treated with the FlexNav DS and the remaining patients with the 1st gen DS. Clinical characteristics were similar between groups, except for older age (82.6 ±3.6 vs. 80.7 ±3.8; p = 0.07) and higher prevalence of female gender (68.2% vs. 39.3%; p = 0.04) in the FlexNav DS group as compared to the 1st gen DS group, respectively. We observed similar rates of procedural success but higher rate of moderate-to-severe paravalvular leak in the 1st gen DS as compared to FlexNav DS group (28.6% vs. 4.6%; p = 0.03); major vascular complications were reduced, although not significantly, in the FlexNav DS as compared to the 1st gen DS group (4.5% vs. 10.7%; p = 0.64). Conclusions: Our data suggest that the FlexNav DS, thanks to its lower profile and enhanced stability during valve deployment, might be associated with reduced rates of vascular complications and moderate to severe paravalvular leak, thus improving procedural results.

[ANMCO statement: Uric acid and cardiovascular disease: evidence and therapeutic approach]. / Statement ANMCO: Acido urico e malattie cardiovascolari: evidenze e approccio terapeutico.

Pathophysiologic processes promoted by uric acid, including inflammation and oxidative stress, play a key role in the pathogenesis of several cardiovascular diseases. Furthermore, a number of epidemiological studies have shown an association between uric acid plasma levels and multiple cardiovascular risk factors. This ANMCO statement provides an update on available evidence regarding the association between elevated plasma uric acid levels and cardiovascular disease risk and the safety and efficacy of uric acid lowering agents (allopurinol and febuxostat) used in patients with urate crystal deposits. In addition, it summarizes practical indications for the use of these drugs in at-risk patients or in patients with cardiovascular disease.

Do Pathophysiologic Mechanisms Linking Unhealthy Lifestyle to Cardiovascular Disease and Cancer Imply Shared Preventive Measures?　- A Critical Narrative Review.

Growing evidence has shown a bidirectional link between the cardiologic and oncologic fields. Several investigations support the role of unhealthy behaviors as pathogenic factors of both cardiovascular disease and cancer. We report epidemiological and research findings on the pathophysiological mechanisms linking unhealthy lifestyle to cardiovascular disease and cancer. For each unhealthy behavior, we also discuss the role of preventive measures able to affect both cardiovascular disease and cancer occurrence and progression.

Takotsubo syndrome: hyperthyroidism, pheochromocytoma, or both? A case report.

BACKGROUND: Takotsubo syndrome (TTS) is a transient left ventricular dysfunction usually with apical akinesia (classical pattern). Other less frequent variants have been described: the mid-ventricular pattern is characterized by hypokinesia of the mid-left ventricle and hypercontractile apical and basal segments; the inverted or basal pattern is characterized by basal and mid-ventricular segment hypokinesia or akinesia with preserved contractility or hypercontractility of apical segments and finally the focal pattern. There are also biventricular variants and forms with exclusive involvement of the right ventricle. There is a correlation between endocrine disorders and TTS, the one most frequently described is with pheochromocytoma. Catecholamine-mediated myocarditis, focal and diffuse myocardial fibrosis, and myocardial dysfunction are described in pheochromocytoma. CASE SUMMARY: We describe a case of a 69-year-old patient with a recent diagnosis of hypertension and Graves' disease, hospitalized for persistent chest pain, hypertensive crisis, tachycardia, dyspnoea, and diaphoresis. Thyroid hormones, antibodies to TSH receptors, and hs-troponin I were increased. Electrocardiogram showed sinus tachycardia at 130 b.p.m., first-degree atrioventricular block, signs of left ventricular hypertrophy with inverted T wave in V4-V6. Echocardiogram demonstrated left ventricular apical and para-apical akinesia. Coronary angiography ruled out an obstructive coronary artery disease. Computed tomography angiogram aortic dissection ruled out aortic dissection but incidentally revealed a left adrenal mass compatible with a pheochromocytoma. Plasma and urinary metanephrines were increased. A TTS secondary to pheochromocytoma and hyperthyroidism was diagnosed. Pharmacological treatment included nitrates, urapidil and esmolol IV and methimazole at high doses. Type 2 multiple endocrine neoplasia has been excluded. After a complete haemodynamic stability on 20th day of hospitalization, the patient underwent an adrenalectomy. DISCUSSION: High levels of catecholamines in pheochromocytoma can lead to myocardial dysfunction. Similarly, an excess of thyroid hormones with up-regulation of adrenergic system can lead to myocardial dysfunction. These two conditions, if both present, define a high haemodynamic risk profile. How do catecholamines interact with the thyroid gland? The clinical case is of interest as a relationship has been hypothesized between the incretion of plasma catecholamines and Graves' disease. We suppose an imbalance of the immune system with a predominance of the T helper-type 2 (Th2)-mediated response. Predominance of Th2-mediated immune response may induce humoral immunity causing Graves' disease. In addition Th2 cytokines are strong inducers of M2 macrophages (alternatively activated) that are involved in autoimmune diseases, myocarditis, and myocardial fibrosis. Knowing the interaction between the cardiovascular system, immune response, and endocrine glands can help define the patient's risk class, possible complications, and follow-up.

[Marked increase in high-sensitivity troponin I without evidence of acute coronary syndrome]. / Marcato incremento della troponina I ad alta sensibilità in assenza di evidenza di sindrome coronarica acuta.

Troponins measured by high-sensitivity methods (hs-cTn) are the current reference biomarkers to diagnose acute myocardial infarction. Conditions other than obstructive coronary heart disease may present an increase in hs-cTn. Heterophilic antibodies can interfere with the hs-cTn dosage. We report the case of a patient affected by rheumatoid arthritis, hospitalized for syncope and atypical chest pain. Serial blood samples documented high values of high-sensitivity troponin I and normal values of creatine kinase-MB and myoglobin. Echocardiogram, coronary angiography and electrophysiological study were normal. The use of heterophilic antibody blockers defined these values as false positive results. Therefore, to diagnose acute myocardial infarction, laboratory data should be integrated with clinical information and instrumental examinations. Marker release kinetics is crucial. Finally, there may be some possible causes of heterophilic antibodies (rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, mixed cryoglobulinemia, hepatitis C, infections, cancer, sarcoidosis) that could interfere with biomarker dosage.

Vascular Aging and Central Aortic Blood Pressure: From Pathophysiology to Treatment.

Large conductive arteries undergo to structural modifications by aging, eventually leading to increased vascular stiffness. As consequence, cardiovascular hemodynamic changes by increasing central blood pressure which may be also associated to the remodelling of peripheral resistance arteries that contribute to increase further the central vascular stiffness and blood pressure. These modifications resemble the ones that has been shown in essential hypertension, thus a condition of "early vascular aging" has been described in hypertensive patients. Since hypertension related target organs, particularly the heart, face aortic blood pressure rather than brachial blood pressure, it has been recently suggested that central blood pressure and other parameters of large arteries' stiffness, including pulse wave velocity (PWV), may better correlate with subclinical organ damage and might be useful to assess the cardiovascular risk of patients beyond the traditional risk factors. Different devices have been validated to measure central blood pressure and PWV, and are currently available for clinical use. The increasing application of these tools in clinical practice could improve the management of hypertensive patients by better defining the cardiovascular risk and address the antihypertensive therapy.

Esthetic restoration in progressive hemifacial atrophy (Romberg disease): structural fat grafting versus local/free flaps.

BACKGROUND: Progressive hemifacial atrophy, also called Parry-Romberg disease, is a craniofacial disorder that typically involves the subcutaneous layer of 1 side of the face. Autologous reconstruction is achieved through various techniques, including autologous grafting of fatty tissue, the use of pedicled flaps, and free tissue transfer based on microvascular anastomoses. Thus far, a systematic literature review devoted to compare different surgical techniques has not been published. METHODS: The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database, Current Contents, PubMed, Google, and Google Scholar. RESULTS: The initial search resulted in 871 articles through online access on July 2013. Sixty-six articles were included and fully reviewed for data extraction of the surgical procedures and divided into the following 4 groups: pedicled flaps, free flaps, structural fat grafting, and conjoint treatment (free flaps plus lipofilling). CONCLUSIONS: The therapeutic management of progressive hemifacial atrophy is based on the severity of the disease. Except for minor degrees of atrophy, for which lipofilling can satisfy the requirements, vascularized fatty tissue is essential for long-term contour correction. Microsurgical transfer of buried flaps can be considered the most effective surgical treatment of middle and severe Romberg disease in long-term correction, complication rate, and reoperative rate.

Wet and dry techniques for structural fat graft harvesting: histomorphometric and cell viability assessments of lipoaspirated samples.

BACKGROUND: Autologous fat transplantation is among the surgical procedures performed most commonly by plastic surgeons for cosmetic and/or reconstructive purposes. In the procedure, autologous fat is harvested and infiltrated during the same operation, and the success of this procedure relies on harvesting and transferring viable adipocytes. This study was designed to assess the histomorphometric characteristics and viability of the lipoaspirated cells that were harvested through different techniques. METHODS: This study enrolled 65 patients undergoing lipofilling for reconstructive purposes. Subcutaneous fat samples were collected manually through the wet and dry techniques using a two-hole Coleman blunt cannula attached to a 10-cc Luer-Lok syringe. Fat tissue preservation was assessed through conventional histomorphometry and a cell viability assessment, evaluating the mitochondrial function through the MTS CellTiter 96 Aqueous One Solution Assay (Promega Corp., Madison, Wis.). RESULTS: No differences were observed between adipocyte samples harvested with or without tumescent solution. The morphometric analysis and adipocyte viability assessment confirmed the visual findings: the mean surface area and shape (circularity index) of the adipocytes were not significantly different in the lipoaspirate collected through the different techniques. CONCLUSION: The results from the present study provide the first histologic evidence and cell viability assessment to demonstrate that there are no substantial differences in the adipose tissue specimens harvested with the wet and dry techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

[A case of intravesical migration of an intrauterine device detected 14 years later]. / Un caso di un dispositivo intrauterino migrato in sede intravescicale quattordici anni dopo.

We report the case of a patient arrived because of urological symptoms characterized by terminal hematuria, strangury and dysuria due to migration into the bladder of an intrauterine contraceptive device (IUD) placed 14 years before and penetrated into the bladder with formation of lithiasis. These cases have already been described in literature, but the particular feature of this case is that the patient had been pregnant and had a eutocic delivery, she never voluntarily removed the IUD and nor was it found during a gynecologic laparoscopy. The patient underwent the surgical removal of the IUD and of the bladder stone, without detecting adjacent connective routes between uterus and bladder.

[Wunderlich syndrome. Clinical and therapeutic aspects of a long-term experience]. / Sindrome di Wunderlich. Aspetti clinici e terapeutici di una esperienza pluriennale.

INTRODUCTION: Wunderlich's syndrome is defined as a clinical manifestation secondary to sudden spontaneous rupture of renal parenchyma in the absence of injury, resulting in hemoretroperitoneum. This syndrome may occur in patients with benign or malignant neoplasm of the kidney, arterial venous fistulae, immunovasculitis and other phlogosis of the kidney. MATERIALS AND METHODS: We present 19 cases of acute spontaneous hemoretroperitoneum or Wunderlich's syndrome diagnosed from 1996 to 2009, related to the following conditions: 7 renal carcinomas, 4 angiomyolipomas, 2 adrenal hemorrhages, 1 bleeding polycystic kidney, 2 hemorrhagic renal cysts and three cases of immunovasculitis. Overall, 6 patients were treated with acetylsalicylic acid and 4 with dicumarolics for cardiovascular disease, while 13 patients were suffering from hypertension? RESULTS: In 19 cases there was no mortality and the following treatment was performed: 11 nephrectomy, 4 partial nephrectomy, 2 adrenalectomy, 2 selective embolization of intrarenal branches as single treatment, while in three other cases, the embolization was carried out from a surgical procedure, conservative (partial nephrectomy) in one case, ablative (nephrectomy) in two other cases. CONCLUSIONS: The spontaneous hemoretroperitoneum is a rare syndrome associated with acute kidney disease often unknown to the patient and only in selected cases with small hematoma; it is possible to perform arteriography with selective embolization of branches avoiding renal access surgery. So far, it is unknown to which extent anti-platelet and anticoagulant drug treatment contributes to this syndrome but, in our experience, they have increased the morbidity of the clinical condition.

Contrast-enhanced ultrasound: a filter role in AJCC stage I/II melanoma patients.

One of the most significant advances in melanoma staging is sentinel lymph node biopsy (SLNB). It is a surgical technique to detect occult nonpalpable micrometastases in regional lymph nodes. Recently, contrast-enhanced ultrasound (CEUS) was introduced as a noninvasive procedure, in spite of SLNB, for the detection of SLNs in patients with cutaneous melanoma. The main purpose of this study was to evaluate the diagnostic accuracy of CEUS in the diagnostic workup of patients with melanoma in comparison with the final histology of SLNs detected through preoperative lymphoscintigraphy. Fifteen patients with cutaneous melanoma underwent prompt excisional biopsy with narrow margins in order to avoid impairment of the melanoma lymphatic basin and were referred for SLNB according to routine indications between January and February 2009. In our study CEUS showed, albeit based on a small patient sample, a negative predictive value of 100%, that means that all negative results were confirmed by negative SLN histopathological examination; all ultrasonographically negative lymph nodes corresponded to nonmetastatic sentinel nodes.

Intraoperative localisation and management of renal calculi during nephrolithotomy by real-time ultrasonography.

OBJECTIVE: To evaluate the role of ultrasound as a sole procedure for intraoperative localisation and management of complex renal calculi. MATERIAL AND METHODS: Between September 1997 and November 2001, 16 patients underwent complex surgery for multiple, large or recurrent renal stones using the ultrasound image as a the sole intraoperative diagnostic procedure. A 8.5 MHz sector transducer with a pulse Doppler signal was used to identify the avascular area, the shortest distance between the renal surface and the stone. RESULTS: Complete stone removal was achieved in all patients without complications. CONCLUSION: Intraoperative sonography for localisation of the intrarenal arteries combined with B scan sonography for intraoperative localisation of stones allows complete removal via radial nephrotomies without peduncle clamping and cooling procedure. The advantage is the exact and quick localisation of stones avoiding X-ray.