The diagnostic utility of transthoracic echocardiography for the diagnosis of infective endocarditis in the real world of the Italian Registry on Infective Endocarditis.

BACKGROUND: The choice of the imaging modality (transthoracic [TTE] vs. transesophageal echocardiography [TEE]) for the diagnosis of infective endocarditis (IE) depends on different variables. Aim of the present study is to provide updated data on the diagnostic sensitivity and the clinical usefulness of TTE vs. TEE from the Italian Registry on IE (RIEI). METHODS: The RIEI has enrolled consecutive cases of IE in every participating centre, evaluating diagnostic and therapeutic data from a real world practice perspective. RESULTS: From July 2007 to October 2010, 658 consecutive cases with definite IE according to Duke criteria have been enrolled in the RIEI (483 males). The following diagnostic echocardiographic exams were performed: 616 TTE (94%) and 476 TEE (72%). A positive TTE was recorded in 399 cases (65%), an uncertain TTE in 108 cases (17%), and a negative TTE in 109 cases (18%). For TEE, a positive study was reported in 451 cases (95%), uncertain in 13 cases (2.7%), and negative in 12 cases (2.5%) (P < 0.001). This difference is not evident in patients with tricuspid valve IE or i.v. drug addiction, and in Streptococcus bovis or Streptococcus viridans IE. TTE was significantly more performed before the admission and earlier than TEE during admission (P = 0.000). TTE was mainly responsible for the initial diagnosis in 59%. TEE contributed to changing the therapeutic approach in 42%. CONCLUSIONS: In the real world, TTE is performed earlier and more commonly, and it is the major echocardiographic tool for the initial diagnosis. TEE confirms its superior diagnostic sensitivity in most cases, although it is relatively underused.

Acute myocarditis following Comirnaty vaccination in a healthy man with previous SARS-CoV-2 infection.

Myopericarditis following mRNA Covid-19 vaccination has recently been reported to health authorities in a lot of countries. They can occur in very rare cases after either the Moderna (mRNA-1273 - Spikevax) or Pfizer-BioNTech (BNT162b2 - Comirnaty) vaccination. Cases predominately occur in younger adult men within 14 days following the second dose. In this article, we present a 56 year-old man with no prior medical history, whit the exception of a mild Covid-19 infection 4 months earlier, who experienced an episode of acute epigastric pain, profuse sweating, tachycardia, hypotension 4 days after the first dose of BNT162b2 vaccine. Troponin I level was elevated. Chest X-ray, electrocardiogram, echocardiogram, coronary angiography didn't show significant abnormalities. Cardiac Magnetic Resonance showed a pattern of acute myocarditis. The condition appeared to be self-limited and the patient recovered without specific therapy. No report of acute myocarditis was observed in the BNT162b2 and mRNA-1273 trials and very rare cases, in comparison to given doses, have been reported to pharmacovigilance systems worldwide. Further surveillance and evaluation of this side effect are warranted to establish the correct balance of benefits and risks of Covid-19 mRNA vaccines, above all in children and younger people (categories with the higher reactogenicity and the lower risk of Covid-19 complications). At the present time the benefits of Covid-19 vaccination significantly exceed possible risks.

[Under-reporting of adverse drug reactions, a problem that also involves medicines subject to additional monitoring. Preliminary data from a single-center experience on novel oral anticoagulants]. / Mancata segnalazione di reazioni avverse ai farmaci: un problema che riguarda anche farmaci sottoposti a monitoraggio addizionale. Dati preliminari di un singolo centro sui nuovi anticoagulanti orali.

BACKGROUND: Spontaneous reporting system is the most widely used method by pharmacovigilance centers. Its "voluntary nature" represents the main cause of adverse drug reaction (ADR) under-reporting phenomena. The aim of this study was to point out the issue of ADR under-reporting from doctors, particularly serious ADRs and adverse reactions caused by medicinal products subject to additional monitoring, such as novel oral anticoagulants (NOACs). METHODS: Only serious ADRs were analyzed, defined as death, life-threatening ADR, hospitalization (initial or prolonged), disability (significant or permanent), congenital anomaly. Firstly, we analyzed suspected adverse reaction alerts to NOACs submitted to the Area Vasta 2 (ASUR Marche) pharmacovigilance center, from June 16, 2013 to January 14, 2017. Then, we examined alerts coming from all over Italy and from the Marche Region in the same time period. Secondly, the analysis was focused on the Senigallia hospital (where we had an easy access to the medical records archive); patients who experienced an ADR in that time period were identified retrospectively and an alert was submitted. Thirdly, from January 15, 2017 to March 15, 2017, suspected ADR alerts were submitted prospectively. RESULTS: Phase 1: in 43 months, 1625 alerts were submitted from all over Italy, 18 from the Marche Region (one of them from the Senigallia hospital). Phase 2: 8 suspected serious ADRs were collected retrospectively (2 fatal and 3 life-threatening). Phase 3: in only 2 months, 7 serious ADRs were observed prospectively (2 fatal and 1 life-threatening). CONCLUSIONS: Our study shows that among doctors the under-reporting phenomenon is remarkable and it also involves medicinal products subject to additional monitoring and serious ADRs, including deaths.

Pulmonary tumor thrombotic microangiopathy: the challenge of the antemortem diagnosis.

Pulmonary tumor thrombotic microangiopathy (PTTM) is known as a rare and severe cancer-related pulmonary complication. Nowadays, fewer than 80 cases have been reported in the literature and very few cases have been diagnosed antemortem. We describe an autopsy case of PTTM associated with cancer of unknown origin. A 56-year-old male patient came to our attention due to a 2-day history of dyspnea. Analysis of the clinical context in combination with laboratory and imaging tests led us to suspect acute pulmonary thromboembolism. However, the computed tomography pulmonary angiogram was negative for thromboembolism; on the contrary it revealed multiple lymphadenopathy. Microscopic pulmonary tumor embolism was suspected and a lymph node biopsy was planned. However, the patient's condition progressively worsened; death occurred 3 days after admission. After autopsy, histologically extensive neoplastic emboli involved the small pulmonary arteries and arterioles, often admixed with fibrin thrombi. The involved and noninvolved arteries also demonstrated fibrocellular intimal proliferation causing marked luminal stenosis and occlusion. These pathological features were characteristic of PTTM, which should be distinguished from microscopic tumor embolism and should be considered in the differential diagnosis of acute/subacute cor pulmonale and pulmonary hypertension in cancer as well as in noncancer patients. We propose a review of the literature and an algorithm to improve PTTM antemortem diagnosis.

[Dronedarone: a real innovation or a mere second-best choice? How to find the way among guidelines, regulatory agencies and daily clinical practice]. / Dronedarone: una reale innovazione o solo una valida seconda scelta? Come districarsi tra linee guida, agenzie regolatorie e pratica clinica quotidiana.

Dronedarone is the antiarrhythmic drug with the most complete and wide literature preceding its marketing. Most of these studies showed a good efficacy along with an excellent risk profile, especially in low- and medium-risk patients. Recently, updates of European, American and even Italian guidelines gave dronedarone its own spot into the antiarrhythmic armamentarium, recommending its use both for rhythm control and rate control in non-permanent atrial fibrillation. In Italy, however, dronedarone prescription is still possible only when amiodarone is not tolerated, making dronedarone a mere second choice of its older "relative". Moreover, patients taking dronedarone must undergo a strict alanine aminotransferase and bilirubin follow-up, which usefulness in predicting drug-induced liver damage (probably idiosyncratic in nature and therefore unpredictable) is far from demonstrated. The aim of this review is to sum up actual evidences on dronedarone, describe how these evidences had been differently transposed by panel of experts and drug agencies into guidelines and recommendations, and define the current difficulties encountered by the cardiologist in the correct use of this new antiarrhythmic agent in clinical practice.