Transthyretin amyloid cardiomyopathy in severe aortic stenosis submitted to valve replacement: a multicenter study.

Aim: To evaluate the prevalence of TTR amyloid cardiomyopathy (ATTR-CM) in severe aortic stenosis (SAS) patients, and to determine the independent predictors of major adverse events (MAE).Patients & methods: 91 SAS patients >65 years with an interventricular septum thickness ≥12.5 mm were referred for aortic valve replacement (AVR). 99mTc-DPD scintigraphy was applied to diagnose ATTR-CM, in the absence of monoclonal protein.Results: ATTR-CM was found in 11%. 78% of patients underwent AVR, but only 2 had ATTR-CM. There were no significant differences in the composite of all cause-mortality or cardiovascular hospitalizations. Lower left ventricle ejection fraction and not performing AVR were independent predictors of MAE.Conclusion: Not performing AVR was an independent predictor of MAE, regardless the ATTR-CM diagnosis.

Our study aimed to evaluate the number of people with severe narrowing of the aortic valve (SAS) and damage to the heart muscle caused to the deposition of filamentous structures composed of TTR (ATTR-CM), and to determine the independent predictors of severe undesirable medical occurrences (MAE). 91 patients >65 years with SAS and increased thickness of the heart muscle were referred to perform an aortic valve prosthesis implantation (AVR). A nuclear medicine exam was used to diagnose ATTR-CM, after excluding the deposition of filamentous structures composed of blood proteins in the heart muscle. ATTR-CM was found in 11%. 78% of patients underwent AVR, but only two had ATTR-CM. There were no significant differences in both death rate from all causes or hospitalizations from cardiovascular causes. A lower percentage of blood pumped out of the heart in each beat and not performing AVR independently predicted the occurrence of MAE in SAS patients, regardless the ATTR-CM diagnosis.

Remote monitoring of cardiac implantable electronic devices to predict acute clinical decompensation events.

BACKGROUND: Heart failure (HF) patients are at constant risk of decompensation, and urgent hospital admissions can be life-threatening events. Monitoring biological variables has been proved to be an important mechanism to anticipate decompensations. TriageHF is a validated diagnostic algorithm tool available on Medtronic® cardiac implantable electronic devices that combines physiological data to stratify a patient's risk of HF hospitalization in the following 30 days in low, medium or high risk. We aimed to evaluate the utility of TriageHF algorithm to predict the occurrence of acute clinical decompensation events (ACDE), including HF and non-HF cardiovascular events, within a 30-day period in a population of HF patients with reduced ejection fraction. METHODS: We reviewed the transmissions received by the Medtronic® Carelink™ Network between August 2022 and July 2023. The heart failure risk status (HFRS) and the device parameters contributing to that risk, from the previous 30 days, were collected, along with the occurrence of ACDEs within 30 days. RESULTS: We retrospectively assessed 207 transmissions from the 64 patients included in the study. Among the 93 medium HFRS transmissions, 16 (17.2%) resulted in ACDEs. For the 21 high HFRS transmissions, 10 (47.6%) resulted in ACDEs. Considering the ACDEs, 60.7% were preceded by an alarm-initiated transmission. Except for heart rate variability, each diagnostic parameter demonstrated effectiveness in stratifying risk for ACDEs. Optivol® and the Combined Heart Rhythm showed independent association with ACDEs (p < .001). Patients with medium and high HFRS were, respectively, 8.6 and 29.1 times more likely to experience an ACDE in the next 30 days than low risk patients. A medium-high HFRS conferred a sensitivity of 92.9% and a NPV of 97.8% for an ACDE. CONCLUSION: TriageHF is a useful method for predicting ACDEs and has the potential to trigger medical actions to prevent hospitalizations.

Assessing cardiac resynchronization therapy response in heart failure patients: a comparative analysis of efficacy and outcomes between transvenous and epicardial leads.

Cardiac resynchronization therapy (CRT) is an effective treatment for selected heart failure (HF) patients. Although transvenous implantation is the standard method, it is not feasible in some patients, so the epicardial lead emerges as an alternative. We aim to compare CRT response, procedure-related complications, and the occurrence of clinical outcomes between patients with transvenous and epicardial leads. In a single-center retrospective study, we enrolled consecutive HF patients submitted to CRT implantation with a defibrillator between 2013 and 2022. Clinical response was defined as an improvement of at least one of the New York Heart Association classes with no occurrence of cardiovascular death or HF hospitalization in the first year of follow-up. Echocardiographic response was attained with an increase in left ventricular ejection fraction 10% or a reduction of left ventricular end-diastolic volume >15% at 6-12 months after CRT implantation. Major adverse cardiovascular events (MACE) (cardiovascular mortality and HF hospitalization) and all-cause mortality were evaluated. From a total of 149 patients, 38% (n=57) received an epicardial lead. Clinical (63% versus 60%, p=0.679) and echocardiographic (63% versus 60%, p=0.679) responses were similar between the transvenous and epicardial groups. Patients in the transvenous group had a shorter hospital stay (2 versus 7 days, p<0.001). Procedure-related complications were comparable between groups (24% versus 28%, p=0.572), but left ventricular lead-related complications were more frequent in the transvenous group (14% versus 2%). During a median follow-up of 4.7 years, the rate of MACE was 30% (n=44), with no differences in both groups (p=0.591), neither regarding HF hospitalization (p=0.917) nor cardiovascular mortality (p=0.060). Nevertheless, the epicardial group had a higher rate of all-cause mortality (35% versus 20%, p=0.005), the majority occurring during long-term follow-up (>12 months), with no deaths in the postoperative period. Considering the comparable rates of CRT response, procedure-related complications, and MACE between groups, we conclude that epicardial lead is a feasible alternative for CRT when transvenous lead implantation is not possible. The occurrence of a higher number of all-cause deaths in epicardial patients in the long-term follow-up was mainly due to infectious complications (unrelated to the lead) and the progression of oncological/chronic diseases.

Skin cancer screening: the experience in South Portugal.

BACKGROUND: The number of skin cancer cases and related deaths continues to increase worldwide, including in Portugal. The lack of efficient health care leaves the southern Portuguese population at risk of presenting skin lesions at later stages. An initiative for skin cancer screening and medical care follow-up was created by the nonprofit organization Liga Portuguesa Contra o Cancro - Núcleo Regional do Sul (LPCC-NRS). METHODS: Information was gathered from 4,398 participants in several Southern Portugal regions, from January 2021 to July 2022. Descriptive and lesion risk statistical analyses were applied. RESULTS: Participants' characteristics were described, and risk assessment was performed differentially between premalignant (n = 577) and malignant lesions (n = 176). The main risk factor for both was male gender. From the described suspicious malignant lesions, 31.8% were confirmed (n = 56), among which there were 43 basal cell carcinomas (BCC), 9 cutaneous melanomas (CM), and 4 squamous cell carcinomas (SCC). CONCLUSIONS: Data analysis pointed to a need for improved participant recruitment, especially of male participants, and health literacy assessment in future screenings.

Real-world effectiveness of aromatase inhibitors and fulvestrant in HR+/HER2- advanced breast cancer: a snapshot of the last two years before conventional use of CDK 4/6 inhibitors in a Portuguese institution.

Background: Monotherapy with aromatase inhibitors and fulvestrant were the standard-of-care for hormone receptor-positive (HR+)/human epidermal growth factor receptor-type2 negative (HER2-) advanced breast cancer, before integration of cyclin-dependent kinase 4/6 inhibitors. Effectiveness data is essential for regulatory action, but little is known about real-world use of aromatase inhibitors and fulvestrant. Methods: A retrospective cohort study was conducted resorting to data from a cancer registry to identify adult women with HR+/HER- advanced breast cancer exposed to aromatase inhibitors or fulvestrant (31 May 2017-31 March 2019) at the main oncology hospital in Portugal. Cases were updated with follow-up until death or cut-off (31 March 2021) and pseudoanonymized data extracted. Primary outcome was overall survival (OS) and secondary time to treatment failure (TTF), estimated using survival analysis and compared with published trials. Results: 192 patients were distributed by subgroups according to the medicine. Letrozole: OS 30.8 (95% confidence interval (CI) 20.6-41.4); TTF 11.2 (95%CI 8.7-13.7). Exemestane: OS 22.1 (95%CI 9.7-34.6); TTF 6.0 (95%CI 4.1-7.8). Fulvestrant: OS 21.6 (95%CI 16.5-26.7); TTF 5.6 (95%CI 4.5-6.6). Conclusions: Estimated effectiveness (OS) of letrozole and fulvestrant was, respectively, 3.2-3.5 months lower than reported. The clinical meaning seems uncertain and may be explained a higher proportion of worse prognostic characteristics in patients treated in the real-world.

Fulminant Necrotizing Eosinophilic Myocarditis Successfully Treated With Veno-Arterial Extracorporeal Membrane Oxygenation and High-Dose Steroids

Abstract Fulminant necrotizing eosinophilic myocarditis (FNEM) is a rare form of EM characterized by biventricular heart failure with hemodynamic deterioration, often requiring inotropes or mechanical circulatory support. Here, we report a case of a 43-year-old healthy woman with FNEM who was admitted with acute heart failure that rapidly progressed to cardiogenic shock and electrical storm, culminating in cardiac arrest. Early diagnosis and prompt administration of corticosteroids in combination with veno-arterial extracorporeal membrane oxygenation allowed complete recovery of biventricular systolic function.

Draft Genome Sequences of Bacillus licheniformis and Bacillus paralicheniformis Strains Isolated from Irish Skim Milk Powder.

Nineteen Bacillus licheniformis strains and four strains of the closely related species Bacillus paralicheniformis were isolated from a variety of Irish medium-heat skim milk powders. The draft genome sequences of these 23 isolates provide valuable genetic data for research work relevant to dairy products and process development. The isolates are available at Teagasc.

Effectiveness of palbociclib with aromatase inhibitors for the treatment of advanced breast cancer in an exposure retrospective cohort study: implications for clinical practice.

BACKGROUND: New drugs for locally advanced or metastatic breast cancer have led to clinical benefits, aside with increasing costs to healthcare systems. The current financing model for health technology assessment (HTA) privileges real-world data. As part of the ongoing HTA, this study aimed to evaluate the effectiveness of palbociclib with aromatase inhibitors (AI) and compare it with the efficacy reported in PALOMA-2. METHODS: A population-based retrospective exposure cohort study was conducted including all patients initiating treatment in Portugal with palbociclib under early access use and registered in the National Oncology Registry. The primary outcome was progression free survival (PFS). Secondary outcomes considered included time to palbociclib failure (TPF), overall survival (OS), time to next treatment (TTNT), and proportion of patients discontinuing treatment due to  adverse events (AEs). The Kaplan-Meier method was used and median, 1- and 2-year survival rates were computed, with two-sided 95% confidence intervals (95%CI). STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines for reporting observational studies were used. RESULTS: There were 131 patients included. Median follow-up was 28.3 months (IQR: 22.7-35.2) and median duration of treatment was 17.5 months (IQR: 7.8-29.1). Median PFS was 19.5 months (95%CI 14.2-24.2), corresponding to a 1-year PFS rate of 67.9% (95%CI 59.2-75.2) and a 2-year PFS rate of 42.0% (95%CI 33.5-50.3). Sensitivity analysis showed median PFS would increase slightly when excluding those not initiating treatment with the recommended dose, raising to 19.8 months (95%CI 14.4-28.9). By considering only patients meeting PALOMA-2 criteria, we could observe a major difference in treatment outcomes, with a mean PFS of 28.8 months (95%CI 19.4-36.0). TPF was 19.8 months (95%CI 14.2-24.9). Median OS was not reached. Median TTNT was 22.5 months (95%CI 18.0-29.8). A total of 14 patients discontinued palbociclib because of AEs (10.7%). CONCLUSIONS: Data suggest palbociclib with AI to have an effectiveness of 28.8 months, when used in patients with overlapping characteristics to those used in PALOMA-2. However, when used outside of these eligibility criteria, namely in patients with less favorable prognosis (e.g., presence of visceral disease), the benefits are inferior, even though still favorable.

Cardioneuroablation for severe neurocardiogenic syncope.

INTRODUCTION AND OBJECTIVES: Cardioneuroablation (CNA), a technique based on radiofrequency ablation of cardiac vagal ganglia, was developed to treat recurrent vasovagal syncope (VVS) with a predominant cardioinhibitory component, as an alternative to pacemaker implantation. The aim of our study was to evaluate the safety and success rate of CNA guided by extracardiac vagal stimulation in patients with highly symptomatic cardioinhibitory VVS. METHODS: Prospective study of patients who underwent anatomically guided CNA at two cardiology centers. All patients had a history of recurrent syncope with a predominant cardioinhibitory component and refractory to conventional measures. Acute success was determined by the absence or significant reduction of cardiac parasympathetic response to extracardiac vagal stimulation. The primary endpoint was the recurrence of syncope during follow-up. RESULTS: In total, 19 patients (13 males; mean age 37.8±12.9 years) were included. Ablation was acutely successful in all patients. One patient had a convulsive episode after the procedure, which was deemed unrelated to the ablation, requiring admission to intensive care but without sequelae. No other complications occurred. At a mean follow-up of 21.0±13.2 months (range 3-42 months), 17 patients remained free of syncope. The remaining two patients had recurrence of syncope and, despite undergoing a new ablation procedure, required pacemaker implantation during follow-up. CONCLUSION: Cardioneuroablation, confirmed by extracardiac vagal stimulation, appears to be an effective and safe treatment option for highly symptomatic patients with refractory VVS with a predominant cardioinhibitory component, providing a new potential approach as an alternative to pacemaker implantation.

Mitral annular disjunction: Beyond mitral valve prolapse.

Mitral annular disjunction (MAD) is an easily identifiable entity on transthoracic echocardiography, but is still poorly recognized or ignored. It is often associated with mitral valve prolapse and is itself a risk marker for ventricular arrhythmias and sudden cardiac death, but the management and risk stratification of these patients is not systematized. Two clinical cases of MAD associated with mitral valve prolapse and ventricular arrhythmias are presented. The first case is of a patient with a history of surgical intervention on the mitral valve due to Barlow's disease. He presented to the emergency department with sustained monomorphic ventricular tachycardia requiring emergent electrical cardioversion. MAD with transmural fibrosis at the level of the inferolateral wall was documented. The second report is of a young woman with palpitations and frequent premature ventricular contractions on Holter with documentation of valvular prolapse and MAD, and focuses on the risk stratification approach. The present article offers a review of the literature regarding the arrhythmic risk of MAD and mitral valve prolapse, as well as a review of risk stratification in these patients.

Mortality in COVID-19 patients after proximal femur fracture surgery: a systematic review and meta-analysis.

BACKGROUND: COVID-19 infection first emerged in December 2019 in China and has since rapidly spread to become a worldwide pandemic. Orthopaedic surgery suffered a significant decline in the volume of surgical cases, while the orthopaedic trauma services maintained or increased the activity. Emergency operations for proximal femur fractures (PFF) in the elderly population assumed levels comparable to before the pandemic, with the 1-year mortality rate ranging from 14% to 36%. AIMS: To determine whether patients with PFF affected by COVID-19 have a higher risk of postoperative mortality through a systematic review and meta-analysis. METHODS: PubMed, Web of Science, Scopus and BMC were searched from January 2020 to January 2021 to identify original studies reporting the mortality in COVID-19 patients after PFF surgery. Study and participants' characteristics, mortality rate and odds ratio (OR) were extracted. Risk of bias assessment was carried, and visual inspection of the funnel plot was used to assess publication bias. A random-effects model for meta-analysis was adopted. RESULTS: Among 656 articles that came from the search query and hand-search, 10 articles were eligible after applying inclusion and exclusion criteria. Overall, the sum of the study participants was 1882, with 351 COVID-19 positive patients (18.7%) and a total number of 117 deaths, with an overall mortality rate of 33.3%. The mortality rate of COVID-19 positive patients varied from 14.8% to 60% and was higher than of those without COVID-19, with OR ranging from 2.424 to 72.00. The inverse variance method showed an OR = 3.652. All studies showed a statistically significant p-value. CONCLUSIONS: The postoperative mortality in hip fracture patients with concomitant COVID-19 was 3.65 times higher than the mortality in non-COVID patients. The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for postoperative mortality in the already susceptible hip fracture population.

Outra falha de bioprótese valvar cirúrgica: uma segunda solução transcateter valve-in-valve / Another failed surgical bioprosthetic valve: a second transcatheter valve-in-valve solution

A substituição transcateter valve-in-valve da valva mitral surgiu recentemente como uma alternativa cada vez mais utilizada nos pacientes de alto risco cirúrgico. O presente caso relata uma substituição de valva mitral transcateter valve-in-valve, por via transeptal, como tratamento da degeneração de uma bioprótese mitral cirúrgica e regurgitação grave, em paciente de 86 anos já submetido a uma substituição transcateter valve-in-valve aórtica, há 6 anos. Este caso enfatiza o papel crucial de uma avaliação pré-operatória cuidadosa, com uso de diferentes modalidades de exames de imagem, para planejamento do procedimento, em paciente com maior risco de obstrução da via de saída do ventrículo esquerdo, devido a um procedimento valve-in-valve aórtico prévio.

Transcatheter mitral valve-in-valve replacement has recently emerged as an increasingly common alternative for high surgical risk patients. We report a case of a successful transseptal transcatheter mitral valve-in-valve replacement for the treatment of a bioprosthetic mitral valve degeneration and severe regurgitation, in an 86-year-old patient who had undergone transcatheter aortic valve-in-valve procedure 6 years ago. This case emphasizes the crucial role of a careful preoperative assessment using multimodality imaging to plan the procedure, in a patient with higher risk of left ventricular outflow obstruction due to the previous transcatheter aortic valve-in- valve procedure.