A Coronavirus Outbreak Linked to a Funeral Among a Romani Community in Central Italy.

Background: The epidemic dynamics of COVID-19 in the Molise region, central Italy, has dramatically changed from the beginning of May 2020, which was when infections were reported amongst Romani people. The aims of this study were to describe the characteristics of an outbreak that occurred in the Romani community and the interventions implemented for control. Methods: A retrospective analysis of outbreak data was performed to describe the SARS-CoV-2 transmission dynamics. Results: A young Romani woman was the first case reported and epidemiological investigation established a possible link with the funeral of a deceased member of this community. In total, 150 close contacts within 34 family groups in two cities were traced, and 109 (72.7%) Romani individuals were found to be infected by COVID-19. The patient's median age was 31 years, 58% were female, and the highest (20.2%) incidence occurred in the 0-9 years age group. A total of 26 (23.8%) patients developed typical SARS-CoV-2 symptoms, 15 (57.8%) were hospitalized, and 21 (22.1%) had comorbidities [most commonly hypertension (28.6%) and/or coronary heart diseases (23.8%)]. The outbreak was effectively controlled through compulsory quarantine and enhanced active surveillance. Conclusions: This is the first study providing insight into COVID-19 transmission dynamics among a Romani population living in Italy. These findings support general conclusions about the role of crowded social gatherings in SARS-CoV-2 spread, the high communicability among close contacts and household settings, and the impact of asymptomatic carriers. These features are of relevance to certain Romani customs where family gatherings are a fundamental pillar of their lives. Although difficulties emerged in interacting with Romani people related to cultural drivers, beliefs, and lifestyle, the outbreak management was effective and should be considered as a valuable model applicable to similar incidents occurring in minority populations.

[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.

Recovery of distal coronary flow reserve in LAD and LCx after Y-Graft intervention assessed by transthoracic echocardiography.

BACKGROUND: Y- graft (Y-G) is a graft formed by the Left Internal Mammary Artery (LIMA) connected to the Left Anterior Descending Artery (LAD) and by a free Right Internal Mammary Artery (RIMA) connected to LIMA and to a Marginal artery of Left Circumflex Artery (LCx). Aim of the work was to study the flow of this graft during a six months follow-up to assess whether the graft was able to meet the request of all the left coronary circulation, and to assess whether it could be done by evaluation of coronary flow reserve (CFR). METHODS: In 13 consecutive patients submitted to Y-G (13 men), CFR was measured in distal LAD and in distal LCx from 1 week after , every two months, up to six months after operation (a total of 8 tests for each patient) by means of transthoracic echocardiography (TTE) and Adenosine infusion (140 mcg/kg/min for 3-6 min). A Sequoia 256, Acuson-Siemens, was used. Contrast was used when necessary (Levovist 300 mg/ml solution at a rate of 0,5-1 ml/min). Max coronary flow diastolic velocity post-/pre-test > or =2 was considered normal CFR. RESULTS: Coronary arteriography revealed patency of both branches of Y-G after six months. Accuracy of TTE was 100% for LAD and 85% for LCx. Feasibility was 100% for LAD and 85% for LCx. CFR improved from baseline in LAD (2.21 +/- 0.5 to 2.6 +/- 0.5, p = 0.03) and in LCx (1.7 +/- 1 to 2.12 +/- 1, p = 0.05). CFR was under normal at baseline in 30% of patients vs 8% after six months in LAD (p = 0.027), and in 69% of patients vs 30% after six months in LCx (p = 0.066). CONCLUSION: CFR in Y-G is sometimes reduced in both left territories postoperatively but it improves at six months follow-up. A follow-up can be done non-invasively by TTE and CFR evaluation.

C-reactive protein and left atrial appendage velocity are independent determinants of the risk of thrombogenesis in patients with atrial fibrillation.

BACKGROUND: The association between inflammatory status and thrombosis in patients with atrial fibrillation (AF) is unclear. We studied the correlation between inflammation and the risk of thrombogenesis in patients with AF and the relationship of inflammation with other factors associated with thrombotic risk. METHODS: We studied 150 consecutive patients (69 men, age 65+/-12 years) with persistent non-valvular AF who had transesophageal echocardiography prior to cardioversion. Patients underwent also measurements of high-sensitivity C-reactive protein, fibrinogen, D-dimer, and hematocrit levels. RESULTS: Patients were divided into two groups according to the presence (n=52) or absence (n=98) of dense spontaneous echo contrast (SEC) in left atrium or left atrial appendage. The two groups were similar for age, sex, and major clinical risk factors. Patients with dense SEC had significantly larger left atrium diameter (p=0.007), lower left atrial appendage mean velocity (p<0.0001), and higher levels of C-reactive protein (p=0.003), D-dimer (p=0.008), and fibrinogen (p=0.006). At multivariate analysis, only left atrial appendage velocity (odds ratio: 19.11; 95% confidence interval 4.2-80.9) and C-reactive protein (odds ratio: 3.41; 95% confidence interval 1.2-9.8) were significantly associated with thrombus and/or dense SEC. However, there was no relationship between C-reactive protein levels and left atrial appendage velocity (p=0.24, r=-0.09). CONCLUSIONS: Our results show that left atrial appendage velocity and C-reactive protein are independently associated with the risk of thromboembolism in AF. Thus, blood stasis and inflammation appear to constitute two major distinct components of thrombogenesis.

Strain rate analysis and levosimendan improve detection of myocardial viability by dobutamine echocardiography in patients with post-infarction left ventricular dysfunction: a pilot study.

BACKGROUND: The assessment of myocardial viability by wall motion (WM) analysis on dobutamine echocardiography is subjective and provides suboptimal results. The aim of this study was to test the hypothesis that the prediction of functional recovery after revascularization can be improved by combining strain rate (SR) imaging, an objective method to quantify regional function, and levosimendan, a positive inotropic and vasodilator agent with no adrenergic effects. METHODS: Thirty postinfarction patients (mean age, 65 +/- 13 years) underwent, off drug, dobutamine (5-40 mug/kg/min) and then levosimendan (24 mug/kg in 10 minutes) echocardiography before percutaneous coronary intervention. WM score, peak systolic SR (SRs), end-systolic strain (Ses), and postsystolic strain (Sps) were assessed in all segments. Regional left ventricular functional recovery was identified by >/=1-point improvement in WM as assessed using the standard 16-segment model. RESULTS: Of 215 segments with abnormal resting function, 102 (47%) showed improvement in WM 8 months after revascularization. Functional recovery was predicted in 60 segments with dobutamine and in 76 segments with levosimendan (sensitivity, 59% vs 75%; P = .026), while failure to recover was identified in 93 segments with dobutamine and 90 segments with levosimendan (specificity, 82% vs 80%, P = NS). Overall there was significant agreement between the 2 tests (kappa = 0.73; P < .0001). Peak SRs in segments with functional recovery improved significantly (P = .001) with both dobutamine and levosimendan (from -1.36 +/- 0.41 to -1.87 +/- 0.59 and -1.99 +/- 0.49, respectively) but did not change in regions with unchanged WM at follow-up. There were no significant differences in Ses and Sps between rest and pharmacologic tests, with either dobutamine or levosimendan. Of note, an increment in peak SRs > -0.29 s(-1) after levosimendan had the highest specificity (93%) for predicting segmental functional recovery at follow-up (P = .001). CONCLUSION: The combination of a newer quantitative echocardiographic technique (SR analysis) and a newer pharmacologic agent (levosimendan) improves the sensitivity of viability assessment compared with conventional dobutamine echocardiography.

Levosimendan allows detection of contractile reserve in patients with chronic ischaemic left ventricular dysfunction and non-diagnostic dobutamine echocardiography.

BACKGROUND: Dobutamine echocardiography is commonly used to detect contractile reserve in ischaemic left ventricular (LV) systolic dysfunction, although its sensitivity and specificity are not optimal. We tested the hypothesis that echocardiography with levosimendan could identify contractile reserve in patients with a non-diagnostic dobutamine test. METHODS: Twenty-two patients with LV ejection fraction <40% and non-diagnostic dobutamine echocardiography underwent levosimendan challenge (24 microg/kg in 10 min) prior to coronary angioplasty or surgery. RESULTS: Contractile reserve was identified by levosimendan in 10 patients (Gr. A) but was not seen in 12 patients (Gr. B). With levosimendan, LV ejection fraction increased and wall motion score index decreased significantly in Gr. A, but only slightly in Gr. B. Similarly, mean mitral annular plane excursion and peak systolic mitral annular motion velocity increased significantly in Gr. A only. Six months after revascularisation, contractile reserve was seen in 8/10 Gr. A patients but in only 2/12 Gr. B patients (80% vs 17%, p=0.011). LV ejection fraction, wall motion score index, mean mitral annular plane excursion and peak systolic mitral annular motion velocity were significantly higher in Gr. A than in Gr. B. CONCLUSION: Levosimendan echocardiography can identify contractile reserve in a sizeable proportion of patients with chronic ischaemic LV dysfunction and a non-diagnostic dobutamine test.

Distal left circumflex coronary artery flow reserve recorded by transthoracic Doppler echocardiography: a comparison with Doppler-wire.

BACKGROUND: Coronary flow reserve (CFR) recording by means of transthoracic echocardiography (TTDE) in all the main distal coronary arteries is a challenge for advanced echocardiography. Validation studies of TTDE versus Doppler-wire (DW) recordings are available for Left Anterior Descending artery (LAD) and the Posterior Descending coronary artery (PD), but lacking for the more technically challenging Left Circumflex coronary artery (LCx). AIM: To evaluate the reliability of TTDE in assessing CFR in LCx when compared to the intracoronary Doppler flow-wire gold standard. METHODS: we evaluated 5 patients (age = 60 +/- 9 years, 5 males) on LCx by TTDE and invasive CFR assessment. TTDE recording was performed using a low-frequency probe, with a four-chamber as a guiding 2D view. The 2 tests were performed on different days and in random order within 48 hours in a blind fashion. Vasodilator stimulus was adenosine, intravenously (140 gamma/kg/min x 3-6 min) for TTDE and intracoronary (40 gamma bolus) for DW recordings. RESULTS: CFR values on LCx ranged from 1.9 to 2.8 for DW, and from 2.0 to 3.0 for TTDE, with an overall correlation of R = 0,85 (p = 0,06); normal (CFR > 2.5) or abnormal (CFR < 2.5) value was concordantly identified by the 2 techniques in 4 out 5 cases (80%). CONCLUSION: CFR of LCx artery can be obtained noninvasively with TTDE.

Ambulatory blood pressure monitoring early after acute myocardial infarction: development of a new prognostic index.

OBJECTIVES: The aim of our study was to assess the possible role of a prognostic index based on ambulatory blood pressure monitoring in a large cohort of patients with recent myocardial infarction. METHODS: The study population included 1335 consecutive patients admitted for ST elevation myocardial infarction and discharged alive from 48 Italian hospitals participating in the multicentric IMPRESSIVE (Infarto Miocardico, Pressione arteriosa e frequenza cardiaca. Studio Italiano di Valutazione Epidemiologica) study. Ambulatory blood pressure monitoring was performed 3 weeks after discharge, with a clinical follow-up of 12 months. End-points included cardiac death and new admission for heart failure. A prognostic index was obtained from the ambulatory blood pressure monitoring variables according to the formula: (220-age)-mean 24 h heart rate (m24hHR)+mean 24 h diastolic blood pressure (m24hDBP). RESULTS: Among many potential predictors only left-ventricular ejection fraction, creatinine levels, Killip class and the prognostic index were independently associated with events during the follow-up. In particular, higher values of the prognostic index were associated with a lower incidence of events, with an odds ratio of 0.958 (95% confidence intervals 0.943-0.974) and a 4% reduction in risk for each point of the prognostic index. Overall incidence of cardiac events was 6-fold higher in patients within the lowest quartile of the prognostic index (< or =148) compared with the other three quartiles (12 vs. 2, 1.4 and 2% respectively in the other three quartiles; P<0.0001). CONCLUSIONS: A simple prognostic index based on ambulatory blood pressure monitoring and age may be a useful tool in predicting cardiac death and heart failure in patients with recent myocardial infarction.

Giant vegetation of the mitral valve simulating primary cardiac tumor.

A case of a giant vegetation of the mitral valve causing sudden death of the patient is reported. The case underlines that urgent removal of a big mass must always be considered because of the risk of sudden death or catastrophic embolism. Echocardiographic differential diagnosis of a mass is discussed and is crucial for the choice of the strategy.

Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score.

AIMS: Aim of the present study was the development and the subsequent validation of a simple risk classification system for patients presenting with syncope to the emergency departments. METHODS AND RESULTS: A group of 270 consecutive patients (145 females, mean age 59.5 years) presenting with syncope to the emergency departments of six community hospitals of the Lazio region of Italy was used as a derivation cohort for the development of the risk classification system. Data from the baseline clinical history, physical examination and electrocardiogram were used to identify independent predictors of total mortality within the first 12 months after the initial evaluation. Multivariate analysis allowed the recognition of the following predictors of mortality: (1) age >65 years; (2) cardiovascular disease in clinical history; (3) syncope without prodromes; and (4) abnormal electrocardiogram. The OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) score was calculated by the simple arithmetic sum of the number of predictors present in every single patient. Mortality increased significantly as the score increased in the derivation cohort (0% for a score of 0, 0.8% for 1 point; 19.6% for 2 points; 34.7% for 3 points; 57.1% for 4 points; p<0,0001 for trend). A similar pattern of increasing mortality with increasing score was prospectively confirmed in a second validation cohort of 328 consecutive patients (178 females; mean age, 57.5 years). CONCLUSIONS: Clinical and electrocardiographic data available at presentation to the emergency department can be used for the risk stratification of patients with syncope. The OESIL risk score may represent a simple prognostication tool that could be usefully employed for the triage and management of patients with syncope in emergency departments.