Gender differences in acute coronary syndromes patterns during the COVID-19 outbreak.

BACKGROUND: Mortality from acute coronary syndromes (ACS) is strictly related to early management. As female patients usually experience longer delays before diagnosis and treatment, we assessed whether women were more affected by the dramatic drop in hospital admissions for ACS during the Covid-19 pandemic. METHODS: We performed a retrospective analysis of clinical and angiographic characteristics of consecutive patients who were admitted for ACS at 15 hospitals in Northern Italy comparing men and women data. The study period was defined as the time between the first confirmed case of Covid-19 in Italy (February 20, 2020) and March 31, 2020. We compared hospitalization rates between the study period and two control periods: the corresponding period during the previous year (February 20 to March 31, 2019) and the earlier period during the same year (January 1 to February 19, 2020). Incidence rate ratios comparing the study period with each of the control periods were calculated with the use of Poisson regression. RESULTS: Of the 547 patients who were hospitalized for ACS during the study period, only 127 (23%) were females, accounting for a mean of 3.1 admissions per day, while ACS hospitalized males were 420, with a mean of 10.2 admissions per day. There was a significant decrease driven by a similar reduction in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) diagnosis in both sexes compared to the control periods. A trend toward a greater reduction in admitted females was shown in the intra-year control period (46% admission reduction in females vs 37% in males, with females accounting for 26% of ACS, P=0.10) and a significant reduction when compared to the previous year control period (40% admission reduction in females vs 23% in males, with females accounting for 28% of ACS, P=0.03), mainly related to Unstable Angina diagnosis. CONCLUSION: The Covid-19 pandemic period closed the gap between men and women in ACS, with similar rates of reduction of hospitalized STEMI and NSTEMI and a trend toward greater reduction in UA admission among women. Furthermore, many typical differences between males and females regarding ischemic heart disease presentations and vessel distribution were leveled.

Large Left Ventricular Aneurysm and Multifocal Myocardial Involvement in a Patient With Systemic Sclerosis.

A 43-year-old man with systemic sclerosis and chest pain had negative T waves in precordial electrocardiographic leads. The echocardiogram showed a large left ventricular apical accessory chamber. The coronary arteries were normal. Cardiac magnetic resonance imaging (MRI) showed a large fibrotic aneurysm and a small patch of midwall late enhancement in the septum. The aneurysm was surgically removed. At the 8-month follow-up, cardiac MRI showed the appearance of a new nodular lesion in the anterior wall, causing a localized wall motion abnormality. Myocardial involvement in patients with systemic sclerosis can be severe, and cardiac MRI evaluation is fundamental.

Trends of percutaneous coronary intervention in Italy in the last 10 years.

AIMS: To study the trends in the use of percutaneous coronary interventions (PCIs) in Italy between 2005 and 2014. METHODS: Publicly available data were obtained from the Italian Society of Invasive Cardiology (GISE), which organizes an annual audit of public and private cardiac catheterization laboratories. RESULTS: During the 10 years, more than 1.3 million PCIs were performed. The total number of PCIs per year increased by 23%, and reached 2342 procedures/million inhabitants in 2014: this was driven by a 91% increase in primary PCIs (PPCIs) for acute myocardial infarction, with the number of PPCIs/million inhabitants that nearly doubled from 291 to 536. Although the number of PCIs/million inhabitants was not homogeneously distributed over the country: even in 2014, it was higher in northern regions (2545) than in central (2229) or southern Italy and the islands (2138). CONCLUSION: The number of PCIs performed in Italy has steadily grown over the last decade. The trend was driven by a striking increase in the number of PPCIs for patients with acute myocardial infarction. The increase in the number of PCIs/million inhabitants was higher in northern Italy.

Coronary and atrial compression by a giant cardiac hemangioma.

A 57-year-old asymptomatic man showed a round echo-dense mass, partially occupying the left atrium on echocardiography. Magnetic resonance localized the mass in the atrioventricular groove, inside the pericardial space, and showed a large hepatic mass too. Computed tomography revealed significant compression of the left main coronary artery and of the left pulmonary veins outlet. The tumor was surgically removed and diagnosed as hemangioma. Heart hemangiomas are extremely rare; they are usually asymptomatic but sometimes they grow rapidly, causing various symptoms. In our case, life-threatening compression of the left main coronary artery and of the pulmonary veins warranted the intervention.

Assessment of coronary artery stenosis severity and location: quantitative analysis of transmural perfusion gradients by high-resolution MRI versus FFR.

OBJECTIVES: This study sought to test the hypothesis that transmural perfusion gradients (TPG) on adenosine stress myocardial perfusion cardiac magnetic resonance (CMR) predict hemodynamically significant coronary artery disease (CAD) as defined by fractional flow reserve (FFR). BACKGROUND: Myocardial ischemia affects the subendocardial layers of the left ventricular myocardium earlier and more severely than the outer layers, and the identification of TPG should be sensitive and specific for the diagnosis of CAD. Previous studies have shown that high spatial resolution myocardial perfusion CMR allows quantitation of TPG between the subendocardium and the subepicardium. METHODS: Sixty-seven patients (53 men, age 61 ± 9 years) underwent coronary angiography and high-resolution (1.2 × 1.2-mm in-plane) adenosine stress perfusion CMR at 3.0-T. TPG was calculated for 3 coronary territories. Visual analysis was performed to identify myocardial ischemia. FFR was measured in all vessels with ≥50% severity stenosis. FFR <0.8 was considered hemodynamically significant. In a training group of 30 patients, the optimal threshold of TPG to detect significant CAD was determined (Group 1). This threshold was then tested prospectively in the remaining 37 patients (Group 2). RESULTS: In Group 1, a 20% TPG provided the best diagnostic threshold on both per-segment and per-patient analysis. Applied to Group 2, this threshold yielded a sensitivity of 0.78, specificity of 0.94, and area under the curve of 0.86 for the detection of CAD in a per-segment analysis and of 0.89, 0.83, and 0.86 in a per-patient analysis, respectively. TPG had a similar diagnostic accuracy to visual assessment. Linear regression analysis showed a relationship between TPG and FFR values, with r = 0.63 (p < 0.001). CONCLUSIONS: The quantitative analysis of transmural perfusion gradients on high-resolution myocardial perfusion CMR accurately predicts hemodynamically significant CAD as defined by FFR. A TPG diagnostic threshold of 20% is as accurate as visual assessment.

A direct comparison of the sensitivity of CT and MR cardiac perfusion using a myocardial perfusion phantom.

BACKGROUND: Direct comparison of CT and magnetic resonance (MR) perfusion techniques has been limited and in vivo assessment is affected by physiological variability, timing of image acquisition, and parameter selection. OBJECTIVE: We precisely compared high-resolution k-t SENSE MR cardiac perfusion at 3 T with single-phase CT perfusion (CTP) under identical imaging conditions. METHODS: We used a customized MR imaging and CT compatible dynamic myocardial perfusion phantom to represent the human circulation. CT perfusion studies were performed with a Philips iCT (256 slice) CT, with isotropic resolution of 0.6 mm(3). MR perfusion was performed with k-t SENSE acceleration at 3 T and spatial resolution of 1.2 × 1.2 × 10 mm. The image contrast between normal and underperfused myocardial compartments was quantified at various perfusion and photon energy settings. Noise estimates were based on published clinical data. RESULTS: Contrast by CTP highly depends on photon energy and also timing of imaging within the myocardial perfusion upslope. For an identical myocardial perfusion deficit, the native image contrast-to-noise ratio (CNR) generated by CT and MR are similar. If slice averaging is used, the CNR of a perfusion deficit is expected to be greater for CTP than MR perfusion (MRP). Perfect timing during single time point CTP imaging is difficult to achieve, and CNR by CT decreases by 24%-31% two seconds from the optimal imaging time point. Although single-phase CT perfusion offers higher spatial resolution, MRP allows multiple time point sampling and quantitative analysis. CONCLUSION: The ability of CTP and current optimal MRP techniques to detect simulated myocardial perfusion deficits is similar.

Stress cardiomyopathy and arrhythmic storm in a 14-year-old boy.

Stress cardiomyopathy is a newly described reversible cardiomyopathy, characterized by transient cardiac dysfunction usually precipitated by intense emotional or physical stress. Apart from the classical apical ballooning syndrome (Takotsubo), it is now increasingly recognized that the spectrum of stress cardiomyopathies is quite wide, with significant individual variations in clinical and morphological pattern. Very recently, it has been suggested that, in young boys in stressful situations, atypical forms of stress cardiomyopathy could be associated with malignant arrhythmias. We describe the case of a 14-year-old boy, in whom stress cardiomyopathy with mid-ventricular ballooning started with an arrhythmic storm.

Percutaneous closure of a giant coronary arteriovenous fistula using free embolization coils in an adult patient.

Coronary artery fistulae may sometimes be asymptomatic and may spontaneously close, but they may also cause angina, myocardial infarction, endocarditis, atrial fibrillation and heart failure. Therefore, in patients with big or symptomatic fistulae, intervention is mandatory. In the literature, most of the patients who underwent transcatheter coil embolization of coronary artery fistulae were children; this is because of the early onset of symptoms in the most severe cases, but also because many adult patients are usually referred to surgery. We describe the case of an adult patient presenting with heart failure and a giant tortuous coronary fistula, with high shunt flow from right coronary artery to right atrium, which was successfully treated with transcatheter closure with free embolization coils. The most challenging technical aspect of transcatheter coil embolization is the precise release of the spirals.

Percutaneous treatment of left main coronary stenosis as a late complication of bentall operation for acute aortic dissection.

Severe ostial left main coronary stenosis developed 35 days after successful Bentall-type operation for acute aortic dissection. Treatment of this kind of complication is usually performed with open chest coronary artery bypass grafting. In our case, treatment with percutaneous transluminal coronary angioplasty and stenting of the lesion immediately after diagnostic coronary angiography was performed successfully, with persisting good results at 9-month clinical follow-up.