Adding the value of the Charlson Comorbidity Index to the GRACE score for mortality prediction in acute coronary syndromes.

BACKGROUND: Scarce and conflicting data still exist about the role of the Charlson Comorbidity Index (CCI) when added to the traditional Global Registry of Acute Coronary Events (GRACE) risk score for outcome prediction in patients with acute coronary syndrome (ACS). METHODS: All consecutive admissions due to ACS, from 1 January 2018 to 31 December 2020 were retrospectively reviewed from an internal database of a tertiary cardiac center in Salerno (Italy). Logistic and Cox proportional regression analyses were performed in order to assess the contribution of the CCI on 30-day and long-term mortality. The CCI adding value to the GRACE score was analyzed with several measures of improvement in discrimination: increase in the area under the receiver-operating characteristic curve (AUC), the integrated discrimination improvement (IDI), and the categorical and continuous net reclassification improvement (cNRI) more than 0. Robustness of the results was assessed through an internal validation procedure with bootstrapping. RESULTS: One thousand three hundred and ten patients were identified. The median age was 68 (58-78) years. One hundred and twenty (9.2%) and 113 (9.5%) deaths occurred, respectively, during the first 30 days from admission and during long-term follow-up (median follow-up time: 13 months; interquartile range: 9-24). After multivariate regression analysis, the CCI was not associated with short-term mortality, while it was significantly and independently associated with long-term mortality along with the GRACE score (hazard ratio: 1.34, 95% confidence interval: 1.22-1.47; P  < 0.001). An additive effect of CCI with the GRACE risk score was observed in predicting long-term mortality: AUC from 0.768 to 0.819 ( P  = 0.003), category-based NRI: 0.215, cNRI>0: 0.669 ( P  < 0.001), IDI: 0.066 ( P  < 0.001). CONCLUSION: The CCI is a predictor of long-term mortality and improves risk stratification of patients with ACS over the GRACE risk score.

Bioprosthetic Valve Fracture After TAVR Complicated by Balloon Rupture: Bail-Out TAVR in TAVR in SAVR.

Transcatheter aortic valve replacement in surgical aortic valve is a safe and effective procedure to treat patients with failed bioprosthetic surgical valves at high risk for reoperation. Performing bioprosthetic valve fracture has been shown to improve postprocedural hemodynamics of TAVR in surgical aortic valve replacement. However, specific complications related to valve fracture are becoming more common. (Level of Difficulty: Advanced.).

Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia.

OBJECTIVES: The aim of this study was to describe the prevalence of coronary artery ectasia (CAE) in patients with ST-elevation myocardial infarction (STEMI) and to compare the long-term outcome of subjects with and without CAE undergoing emergent coronary angiography. BACKGROUND: The prognostic impact of CAE in STEMI patients has been poorly investigated. METHODS: This retrospective, single-center, study included consecutive patients with STEMI undergoing emergent coronary angiography from January 2012 to December 2017. The primary endpoint was the assessment of recurrent myocardial infarction (MI) in patients with versus those without CAE at the longest available follow-up. The propensity score weighting technique was employed to account for potential selection bias between groups. RESULTS: From 1,674 patients with STEMI, 154 (9.2%) had an angiographic evidence of CAE; 380 patients were included in the no CAE group. CAE patients were more often males and smokers, and showed a lower prevalence of diabetes than no CAE patients. After percutaneous coronary intervention, the corrected thrombolysis in MI frame count (p < .001) and the myocardial blush grade (p < .001) were significantly lower in CAE than in no CAE patients. The mean follow-up was 1,218.3 ± 574.8 days. The adjusted risk for the primary outcome resulted significantly higher in patients with CAE compared to those without (adjusted HR: 1.84; p = .017). No differences in terms of all-cause and cardiac death were found between groups. CONCLUSIONS: In this study, STEMI patients with CAE had a distinct clinical and angiographic profile, and showed a significantly higher risk of recurrent MI than those without CAE.

Predictors of complications in initially haemodynamically stable patients admitted in a modern coronary care unit.

AIMS: Resource optimization in the intensive cardiac care unit (ICCU) is, nowadays, of great importance because of the increasing number of acute cardiovascular patients requiring high-intensity level-of-care. Because of natural limits in ICCU bed availability, understanding, which patients will really benefit from in a such a critical care setting, is of paramount importance. In our study, we analysed a heterogeneous ICCU population with initially stable haemodynamic conditions, in order to find potential predictors of severe complications. METHODS: Nine hundred and fifty patients admitted to our ICCU during the year 2019 were screened in order to detect those with a stable haemodynamic condition at admission. Data were extrapolated from an internal database. Comorbidity burden was expressed by the Charlson Comorbidity Index (CCI). Our primary end point was defined by a combination of severe complications requiring critical care, and in-hospital death. RESULTS: Ninety-eight patients (14.1% of 695 stable patients identified) developed severe complications. After a multivariable logistic regression analysis, four predictors were identified: signs of congestive heart failure [OR: 9.25, 95% confidence interval (CI): 5.61-15.25; P < 0.001], SBP 120 mmHg or less (OR: 2.10, 95% CI: 1.27-3.47; P = 0.004), haemoglobin level 13 g/dl or less (OR: 1.75, 95% CI: 1.03-2.95; P = 0.037), and the CCI above 3 (OR: 2.27, 95% CI: 1.13-4.56; P = 0.022). CONCLUSION: In our study, 73% of patients showed a stable haemodynamic condition on admission. Severe complications occurred in 14.1% of these patients, and signs of heart failure were the main determinants of the outcome. SBP, haemoglobin level, and the CCI concurred in the prediction of severe complications during the hospital stay.

A Rare Complication of Transcatheter Aortic Valve Replacement: Aortic Root-Left Atrium Fistulization.

The authors report the case of an 87-year-old man undergoing transcatheter aortic valve replacement via transfemoral approach who developed a life-threatening complication, i.e., fistulization between the aortic root and the left atrium, which was successfully treated by surgery. At 6-month follow-up, the clinical course was uneventful. (Level of Difficulty: Beginner.).

Safety and feasibility of balloon aortic valvuloplasty in non-TAVI centers: The "BAV for life" experience.

OBJECTIVES: To evaluate the safety and the feasibility of balloon aortic valvuloplasty (BAV) procedure made by trained operators in centers not performing transcatheter aortic valve implantation (TAVI). BACKGROUND: BAV is a valuable therapeutic tool for patients with symptomatic severe aortic valve stenosis (AS) at prohibitive risk for TAVI or surgery. METHODS: Consecutive high-risk AS patients underwent BAV in five non-TAVI centers, where BAV operators had completed a 6-month training period in high-volume TAVI centers (Group A). All clinical, echocardiographic, and procedural data were prospectively collected and compared with data of patients treated in TAVI center (Group B). RESULTS: Between June 2016 and June 2017, 55 patients (83.9 ± 7.0 years) were enrolled: 25 in Group A and 30 in Group B. After BAV, a substantial reduction of the peak-to-peak aortic valve gradient was obtained in both groups (-35.3 ± 15.2 vs -28.8 ± 13.9 mmHg, P =0.25). No major bleeding or vascular complications occurred. In-hospital death was observed in three patients of Group A and two patients of Group B (P =0.493). The mean follow-up time was 303 ± 188 days; no patients were lost. The 1-year survival free from overall death (Group A 75.8% vs Group B 68.8%; P =0.682) and heart failure rehospitalization (Group A 73.0% vs Group B 66.8%; P =0.687) was similar in the two groups. At multivariable analysis, low left ventricular (LV) ejection fraction (HR: 0.943; P = 0.011) and cardiogenic shock (HR: 5.128; P = 0.002) at admission were independent predictors of mortality. CONCLUSIONS: BAV is a safe and effective procedure that can be performed by trained operators in centers not performing TAVI.

[SICI-GISE commuNity CAmpania survey doNna TAVI (INCANTA): perioperative and short-term outcome of transcatheter aortic valve implantation in women]. / SICI-GISE commuNity CAmpania survey doNna TAVI (INCANTA): outcome perioperatorio e a breve termine della procedura di impianto transcatetere di valvola aortica nelle donne.

BACKGROUND: Nowadays the prognostic role of gender as a relevant factor after transcatheter aortic valve implantation (TAVI) is still unfair, since available data in the literature are few and uneven. The aim of this survey was to collect acute and 30-day safety and efficacy clinical data in high- and intermediate-risk women, who underwent TAVI with new-generation devices, in the Campania Region. METHODS: All medium and high-volume TAVI centers in Campania have been invited to fulfill an online, ad-hoc questionnaire, collecting pre-, peri- and post-procedural data concerning female patients, treated between January and December 2016. RESULTS: 331 women (representing the 61% of the overall population treated; mean age 83 ± 7 years) underwent TAVI in the participating Campania centers. Age >80 years (72%), high surgical risk score (63%) and frailty (55%) were found to be the top three reasons for the TAVI choice. Overall, 95% of the procedures were performed by transfemoral approach with local anesthesia; the remaining 5% (16 cases) were conducted via transapical (14, 4%) and transaortic (2, 1%) accesses, under general anesthesia. Edwards Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) and Medtronic Evolut R (Medtronic Inc., Minneapolis, MN, USA) were the most frequently implanted valves (146, 44% and 132, 43%, respectively). The questioned Centers reported a mean length of hospital stay of 5.5 ± 1.1 days, 1.6 ± 0.37 of which in a cardiac care unit. The most prevalent in-hospital complication was pacemaker implantation (15%), followed by life-threatening vascular complications (3%). The 30-day VARC-2 composite endpoint occurred in 7% of cases, all-cause death in 4%, and stroke in 1%. CONCLUSIONS: This survey, the first representative of women undergoing TAVI in Campania, appears to confirm the good safety and efficacy profile of this procedure, also in the high- and intermediate-risk settings, probably favored by a prevalent use of new-generation devices and a low rate prevalence of significant patient comorbidities.

Prognostic value of clinical, echocardiographic and angiographic indicators in patients with large anterior ST-segment elevation myocardial infarction as a first acute coronary event.

BACKGROUND: The risk of death in patients affected by ST-elevation segment myocardial infarction (STEMI) is well known, but more data are required to define the in-hospital mortality in special subsets. We sought to assess the prognostic value of indicators in patients with large anterior STEMI as a first acute coronary event, undergoing percutaneous coronary intervention (PCI) and intra-aortic balloon pump (IABP). METHODS AND RESULTS: We evaluated 48 consecutive large anterior STEMI patients admitted as first acute coronary event, undergoing in acute phase both PCI and IABP. Patient demographics, clinical, noninvasive and invasive findings, together with in-hospital complications, were collected. Moreover, findings obtained after a 24-month follow-up were reported. The primary endpoint was in-hospital mortality, whereas the secondary endpoints were out of hospital mortality, rehospitalization for heart failure or reinfarction, and New York Heart Association (NYHA) class at least 2 at follow-up visit. The univariate analysis showed a significant association with symptom to balloon, left anterior descending coronary artery, myocardial blush grade, and wall motion score index. Results of the multivariable analysis revealed the strongest predictive power for in-hospital mortality of proximal left anterior descending coronary artery (odds ratio: 6.9; 95% confidence interval: 1.1-67.7) and of myocardial blush grade 0-1 (odds ratio: 5.5; 95% confidence interval: 1.0-38.8). In-hospital death occurred in 13 patients (27% of total cases), whereas, at follow-up, the mean of survival was 66.7 ±â€Š7.0%. CONCLUSION: The patients with large anterior STEMI as a first acute coronary event, undergoing PCI and IABP, had a very high in-hospital mortality, whereas the mortality rate over the follow-up period was lower. The involvement of a large territory at risk and the ineffective treatment in terms of myocardial reperfusion were the main predictors of in-hospital mortality.

Advantages of a workbench reshaped AR1 mod catheter for right coronary angiography by right radial approach.

Transradial approach in cardiac catheterization is increasing. In daily practice, coronary angiography via radial artery is usually performed by using catheters designed for femoral approach. The aim of this study was to evaluate advantages in the use of a workbench reshaped AR1 mod catheter, in terms of procedural duration time, number of catheters per procedure, fluoroscopy time, contrast agent administered volume, images quality and costs. Two hundred patients, submitted to coronary angiography via right radial artery in our institution, have been retrospectively reviewed. Patients have been divided in two groups, depending on whether a workbench reshaped Cordis Amplatz AR1 mod catheter (rAR1 mod), or catheters in their original shape (OC) have been employed. In the rAR1 mod group (100 patients) a lower number of catheters per procedure (1.07 ± 0.25 vs. 1.47 ± 1.65; p < 0.001), a more frequent right coronary selective engagement (76.76% vs. 53.12%; p < 0.001), a smaller amount of contrast agent (63.02 ± 27.77 vs. 80.85 ± 29.22 ml, p < 0.001), a reduced fluoroscopy and global procedural time (4.19 ± 2.91 vs. 5.69 ± 3.85 min, p = 0.004; and 34.58 ± 17.05 vs. 42.58 ± 17.26 min, p = 0.001, respectively) were observed. According to our experience, when right coronary angiography via right radial approach is performed, the utilization of rAR1 mod catheter correlates with multiple advantages in terms of procedural parameters.

Coronary vasomotion dysfunction after everolimus-eluting stent implantation.

First generation drug-eluting stent can cause a paradoxical "in-segment" coronary vasoconstriction. This phenomenon was seen with sirolimus, paclitaxel, and, more recently, also with zotarolimus-eluting stent. For the first time, we describe a case of coronary-induced vasoconstriction by everolimus-eluting stents (EES).

Does the beta-blocker nebivolol increase coronary flow reserve?

INTRODUCTION: Nebivolol, a highly selective beta1-adrenergic receptor-blocker, increases basal and stimulated endothelial nitric oxide (NO)-release. It is unknown, whether coronary perfusion is improved by the increase in NO availability. Therefore, we sought to evaluate the effect of nebivolol on coronary flow reserve (CFR) and collateral flow. METHODS: Doppler-flow wire derived coronary flow velocity measurements were obtained in ten controls and eight patients with coronary artery disease (CAD) at rest and after intracoronary nebivolol. CFR was defined as maximal flow during adenosine-induced hyperemia divided by resting flow. In the CAD group, collateral flow was determined after dilatation of a flow-limiting coronary stenosis. Collateral flow index (CFI) was defined as the ratio of flow velocity during balloon inflation divided by resting flow. RESULTS: CFR at rest was 3.0+/-0.6 in controls and 2.1+/-0.4 in CAD patients. After intracoronary doses of 0.1, 0.25, and 0.5 mg nebivolol, CFR increased to 3.4+/-0.7, 3.9+/-0.9, and 4.0+/-0.1 (p<0.01) in controls, and to 2.3+/-0.7, 2.6+/-0.9, and 2.6+/-0.5 (p<0.05) in CAD patients. CFI decreased significantly with intracoronary nebivolol and correlated to changes in heart rate (r=0.75, p<0.001) and rate-pressure product (r=0.59, p=0.001). DISCUSSION: Intracoronary nebivolol is associated with a significant increase in CFR due to reduction in resting flow (controls), or due to an increase in maximal coronary flow (CAD patients). CFI decreased with nebivolol parallel to the reduction in myocardial oxygen consumption.

Early impairment of myocardial function in systemic sclerosis: non-invasive assessment by Doppler myocardial and strain rate imaging.

BACKGROUND: Aim of the present study was to analyze both left (LV) and right ventricular (RV) myocardial function in patients with Systemic Sclerosis (SSc), and their relation to other instrumental features of the disease. METHODS AND RESULTS: Twenty-five healthy subjects and 23 age- and sex-comparable asymptomatic patients classified as having either diffuse (11 patients) or limited form (12 patients) of SSc underwent clinical examination, serological tests, high-resolution chest-CT, standard Doppler echo, pulsed Doppler myocardial imaging (DMI) and strain rate imaging (SRI) of both LV and RV lateral walls. By chest-CT, 11 patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 8 patients, and anti Scl-70 in 15 patients. LV diameters and ejection fraction were comparable between the two groups, while RV end-diastolic diameter was increased in SSc (p<0.01). Tricuspid inflow E/A ratio was slightly decreased in SSc (p<0.01), while systolic pulmonary pressure was increased (p<0.001). Pulsed DMI detected in SSc impaired myocardial RV early-diastolic (Em) peak velocity (p<0.0001), and prolonged myocardial time intervals at tricuspid annulus level. In SSc, peak systolic RV SR and strain were both reduced in basal, middle and apical RV lateral free walls, and in basal and middle LV lateral walls. By multivariate analysis, independent inverse association of RV peak Em velocity with both Rodnan Skin Score (p<0.0005) and pulmonary systolic pressure (p<0.0001), as well as independent inverse correlation of the same RV peak Em velocity with pulmonary fibrosis (<0.0005) in SSc patients were observed. In addition, RV Em was an independent predictor of the anti Scl-70 antibody pattern (p<0.001). CONCLUSIONS: Pulsed DMI and SRI are valuable non-invasive and easy-repeatable tools for detecting RV and LV myocardial involvement caused by SSc, and may therefore be useful to early identify patients with more diffused and severe form of SSc.

Associations of right ventricular myocardial function with skin and pulmonary involvement in asymptomatic patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of the skin and specific internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult. The aim of the present study was to analyze both left and right ventricular (RV) myocardial function in patients with SSc, and their relation to other instrumental features of the disease. METHODS: Twenty-five healthy subjects and 23 age- and sex-comparable asymptomatic patients classified as having either diffuse (11 patients) or limited cutaneous (12 patients) SSc underwent clinical examination, serological analysis, high-resolution chest computed tomography, standard Doppler echocardiography and pulsed Doppler myocardial imaging (DMI) of both the mitral and tricuspid annuli. SSc was classified using the modified Rodnan skin score (mRSS) into high mRSS (score > or = 10) and low mRSS (score < 10). RESULTS: Serological antibody analysis revealed the presence of antinuclear antibody in all patients, an anticentromere pattern in 8 patients, and anti-Scl-70 antibodies in 15 patients. Eleven patients were diagnosed with interstitial pulmonary fibrosis at chest computed tomography. Standard Doppler echocardiography revealed that the left ventricular mass index and ejection fraction were comparable between the two groups, while the RV end-diastolic diameter was increased in SSc (p < 0.01). The tricuspid inflow peak E and E/A ratio were slightly decreased in SSc (p < 0.01), while the systolic pulmonary pressure was increased (p < 0.0001). DMI analysis revealed, in SSc, an impaired RV myocardial early-diastolic (Em) peak velocity (p < 0.001) as well as a prolonged myocardial relaxation time (RTm) (p < 0.001) only at the tricuspid annulus level, even after correction for age, sex, heart rate and left ventricular mass index. Independent inverse associations of the RV Em peak velocity with both the Rodnan skin score (beta coefficient = -0.62, p < 0.0005) and the pulmonary systolic pressure (beta coefficient = 0.71, p < 0.0001), as well as the independent inverse correlation of the same RV Em peak velocity with interstitial pulmonary fibrosis (odds ratio 0.68, 95% confidence interval 0.45-0.83, p < 0.0005) in SSc patients were assessed at multivariate analysis. In addition, the RV Em velocity was an independent predictor of the anti-Scl-70 antibody pattern (odds ratio 0.68, 95% confidence interval 0.45-0.83, p < 0.01). Of note, a RV Em peak velocity < 0.11 m/s well selected SSc patients with pulmonary artery pressure > 35 mmHg, pulmonary fibrosis, a high mRSS, and an anti-Scl-70 antibody pattern. CONCLUSIONS: The relationships of RV myocardial diastolic dysfunction with both skin and pulmonary involvement as well as with the serological antibody pattern emphasizes the ability of DMI to identify patients with a more diffuse and severe form of SSc. This issue may be critical for the early identification of those SSc patients who are at higher risk of cardiac impairment, ideally when they are still asymptomatic before developing severe vasculopathy.

Induction of tissue factor in the arterial wall during recurrent thrombus formation.

OBJECTIVE: Tissue factor (TF) is normally expressed at low levels in the media of blood vessels, but it is readily induced after vessel injury. It is not known whether vascular damage per se or thrombus formation is responsible for this phenomenon. METHODS AND RESULTS: Cyclic flow variations (CFVs), attributable to recurrent thrombus formation, were induced in stenotic rabbit carotid arteries with endothelial injury. CFVs were observed for 30 minutes and 2, 4, and 8 hours in different groups of animals. Another group of rabbits pretreated with hirudin before inducing arterial damage to inhibit thrombus formation was observed for 8 hours. Arterial sections were immunostained for TF. Undamaged arteries served as controls. In additional rabbits, in situ hybridization experiments were performed. No TF expression was observed in the media of control vessels, whereas a progressive increase in TF mRNA and protein expression was observed in carotid arteries as CFVs progressed. No increase in TF expression was observed in animals pretreated with hirudin. In vitro experiments demonstrated that TF mRNA is induced in smooth muscle cells stimulated with activated platelets as well as with some platelet-derived mediators. CONCLUSIONS: This phenomenon may contribute to sustain intravascular thrombus formation after the initial thrombogenic stimulus.