Rheumatic and Degenerative Mitral Stenosis: From an Iconic Clinical Case to the Literature Review.

Mitral stenosis (MS) poses significant challenges in diagnosis and management due to its varied etiologies, such as rheumatic mitral stenosis (RMS) and degenerative mitral stenosis (DMS). While rheumatic fever-induced RMS has declined in prevalence, DMS is rising with aging populations and comorbidities. Starting from a complex clinical case of DMS, the aim of this paper is to review the literature on mitral stenosis by analyzing the available tools and the differences in terms of diagnosis and treatment for rheumatic and degenerative stenosis. Emerging transcatheter techniques, such as transcatheter mitral valve replacement (TMVR) and lithotripsy-facilitated percutaneous mitral commissurotomy (PMC), represent promising alternatives for DMS patients deemed unfit for surgery. In particular, intravascular lithotripsy (IVL) has shown potential in facilitating percutaneous interventions by fracturing calcific deposits and enabling subsequent interventions. However, larger prospective studies are warranted to validate these findings and establish IVL's role in DMS management. To further enhance this technique, research could focus on investigating the long-term outcomes and durability of mitral lithotripsy, as well as exploring its potential in combination with PMC or TMVR.

[Management of patent foramen ovale in non-cardiac surgery]. / Gestione della pervietà del forame ovale nella chirurgia non cardiaca.

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis.

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Terapia de aceitação e compromisso para redução do estresse em universitários: um estudo qualitativo / Acceptance and commitment therapy for university students: a qualitative study / Terapia de aceptación y compromiso para estudiantes universitarios: un estudio cualitativo

Este estudo teve como objetivo explorar a percepção de alunos de graduação em relação à sua participação em uma intervenção baseada na terapia de aceitação e compromisso (acceptance and commitment therapy[ACT]), para redução da inflexibilidade psicológica (IP) e do estresse em estudantes universitários. Parti­ciparam da pesquisa 21 alunos, de diferentes cursos de graduação, com idade média de 23,4 ± 5,61, sendo 71,4% do sexo feminino e 28,6% do sexo masculino. Os dados coletados nas entrevistas foram submetidos à análise de conteúdo e organizados em quatro categorias: experiência no programa, utilidade, viabilidade e sugestões e processos da ACT. Os resultados possibilitaram identificar que o programa foi uma experiên-cia positiva para os participantes. Além disso, constatou-se que a intervenção foi útil e viável, e possibili-tou que os estudantes desenvolvessem as habilidades necessárias para lidar melhor com as adversidades do dia a dia, sem que precisassem se afastar dos seus valores pessoais.

This study aims to explore undergraduate students' perception of their participation in an intervention, based on acceptance and commitment therapy (ACT), to reduce psychological inflexibility (PI) and stress in undergraduate students. Twenty­one students from different undergraduate programs participated in the research, with an average age of 23.4 ± 5.61, of whom 71.4% were female and 28.6% were male. The data collected in the interviews were submitted to content analysis and organized into four categories: experience in the program, utility, feasibility, and ACT suggestions and processes. The results made it possible to identify that the program was a positive experience for the participants, the intervention was useful and feasible and enabled students to develop the requirements to better deal with the adversities of daily life without departing from their personal values.

Este estudio tiene como objetivo explorar la percepción de los estudiantes de pregrado sobre su participa-ción en una intervención, basada en la terapia de aceptación y compromiso (acceptance and commitment therapy [ACT]), para reducir la inflexibilidad psicológica (IP) y el estrés en los estudiantes de pregrado. En la investigación participaron 21 estudiantes de diferentes carreras, con una edad promedio de 23,4 ± 5,61, de los cuales el 71,4% eran mujeres y el 28,6% hombres. Los datos recolectados en las entrevistas fueron sometidos a análisis de contenido y organizados en cuatro categorías: experiencia en el programa, utilidad, factibilidad y sugerencias y procesos de ACT. Los resultados permitieron identificar que el programa fue una experiencia positiva para los participantes, la intervención fue útil y factible y permitió a los estudian-tes desarrollar los requisitos necesarios para enfrentar mejor las adversidades de la vida diaria, sin apar-tarse de sus valores personales.

Patients younger than 70 undergoing transcatheter aortic valve implantation: Procedural outcomes and mid-term survival.

INTRODUCTION: Based on recent data, the indication for transcatheter aortic valve implantation (TAVI) is expanding to individuals at lower surgical risk, who are generally younger than subjects historically treated for severe aortic stenosis. Indeed, younger patients have traditionally been under-represented in current TAVI literature. The aim of the present study is to report about clinical features, procedural outcomes and mid-term outcomes of patients younger than 70 who underwent TAVI in a single high-volume center. MATERIALS AND METHODS: Consecutive patients younger than 70 years of age who underwent TAVI for severe, symptomatic aortic stenosis between 2007 and 2019 at a single, tertiary referral center have been included in this retrospective study. Procedural and mid-term outcomes were analyzed, comparing 1st generation with 2nd generation devices. RESULTS: Between 2007 and 2019, 1740 TAVI procedures were performed in our center. Among these, one hundred twenty-nine (7.4%) patients were younger than 70 years at the time of the intervention and were included in the present analysis. Fifty-eight patients (45%) were implanted with a 1st generation prosthesis while seventy-one patients (55%) were implanted with a 2nd generation device. Reasons which lead to a transcatheter approach in this population were: previous CABG (27.9%); porcelain aorta (24%); severe left ventricular systolic dysfunction (21.7%); prior chest radiation (19.4%); severe lung disease (8.5%); hemodynamic instability (7.0%); advanced liver disease (4.6%) and active cancer (3.9%). Overall device success rate was 89%, with no differences among 1st and 2nd generation devices. Threeyears all-cause mortality was 34%, with no difference among the two groups. Low incidence of aortic-valve re-intervention was observed at mid-term follow-up (late valve re-intervention = 2.3%). CONCLUSIONS: TAVI in young patient with appropriate indication for intervention is a safe procedure, associated with low rate of in hospital mortality and low rate of severe complications both with 1st and with 2nd generation devices. When considering long term durability, more data are needed; in our case series long-term follow up shows a good survival and also an extremely low rate of valve re-intervention.

Percutaneous mitral valve prostheses: 2019 update.

During the last few years, there has been significant advances in the treatment of patients with severe mitral incompetence either too high risk for surgery or inoperable, this because of the improvements in percutaneous mitral valve prostheses, as alternative to the transcatheter mitral repair techniques. Percutaneous mitral valve replacement offers several advantages over the repair techniques, such as the opportunity to treat mitral valve with different anatomic characteristics, even the more complex ones, and the occasion to correct completely mitral regurgitation. The development of such prostheses has been a long process, still on the making. During the initial stages of the procedure, the transapical approach was preferred. On the other hand, the transseptal approach, which has already been used in some patients, is the proper development path for this transcatheter technique. Many valvular prostheses have been produced, each using a different mechanism for secure anchoring and elimination of regurgitation. Early mortality for this procedure, although decreasing since the preliminary studies, is still high, not only because the technology is still in its initial phase but also for the very high risk of the patients treated. It is foreseeable, though, that in the near future, as the technology and patients selection improves, better results will follow.

Rotational atherectomy-based percutaneous coronary intervention and the risk of contrast-induced nephropathy.

BACKGROUND: Rotational atherectomy (RA)-related complications (e.g., no-reflow and perforation) may be associated with increased risk of contrast-induced nephropathy (CIN), causing hypotension, acute heart failure, and periprocedural myocardial infarction. Our aim was to evaluate the incidence of CIN in patients undergoing RA-based vs. non-RA-based percutaneous coronary intervention (PCI). METHODS: This single-center retrospective registry included all patients who underwent PCI between 2012 and 2016 for whom post-procedural creatinine was determined. Study endpoint was CIN, defined as an increase of serum creatinine ≥0.3 mg/dL or ≥50% from baseline within 72 h post-PCI. Propensity score matching (PSM) was performed to account for selection bias between RA and non-RA patients. RESULTS: Study population included 2580 patients: 70 (3%) had RA PCI and 2510 (97%) had non-RA PCI. Following PSM, there were 70 patients in RA and 280 patients in non-RA group with good overall adjustment between groups, although RA patients received larger contrast volume (263±126 vs. 224±118 mL, P=0.01) and showed higher Mehran risk score at baseline (11.1±6.6 vs. 8.9±4.8, P=0.01). The incidence of CIN was similar between RA and non-RA patients (15.7% vs. 13.2%, P=0.59). New need for dialysis was required in 0% vs. 0.7% patients, respectively (P=0.48). On multivariate analysis, RA PCI was not independently associated with development of CIN. CONCLUSIONS: Despite being performed in patients with a higher burden of comorbidities and with larger volumes of contrast, RA PCI is not associated with higher risk of CIN, compared with PCI in non-RA patients.

Sex and Transcatheter Aortic Valve Implantation: Impact of Female Sex on Clinical Outcomes.

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for severe symptomatic aortic stenosis in patients who are not suitable for surgery or are at high surgical risk. Approximately 50% of patients undergoing TAVI are female and this is reflected by a higher inclusion rate of women in TAVI trials. However, women undergoing TAVI have different baseline clinical characteristics in comparison to men, with fewer comorbidities and a more preserved left ventricular ejection fraction. This translates into favourable outcomes after TAVI, despite a higher rate of peri-procedural complications. This article discusses gender differences in terms of presentation, procedural characteristics and post-procedural results in patients with aortic stenosis undergoing TAVI, with particular focus on possible sex-specific factors affecting outcome.

Impact of Ascending Aorta Dilation on Mid-Term Outcome After Transcatheter Aortic Valve Implantation.

BACKGROUND: Severe aortic stenosis (AS) is often associated with ascending aorta dilation (AAD). AAD is amenable to surgical correction combined with aortic valve replacement. Transcatheter aortic valve implantation (TAVI) might represent a valid therapeutic option in these patients when AAD correction Is not indicated. The aim of the present study is to evaluate the impact of concomitant AAD on early and mid-term outcomes after TAVI for symptomatic severe AS. METHODS: This is a single-center observational study including patients undergoing transfemoral TAVI. All patients with previous surgery on the left ventricular outflow tract, aortic valve, or ascending aorta (except coronary artery bypass graft surgery) were excluded from the analysis. Patients undergoing TAVI for congenital aortic valve defects or subjects in whom a computed tomography (CT) scan was not available were excluded from the analysis. Ascending aortas were measured on CT scans using appropriate multiplanar reconstructions. Ascending aortas were qualified as dilated if the measurement was >40 mm. Study outcomes were death from any cause, significant paravalvular leaks (PVLs), and new permanent pacemaker (PPM) implant. RESULTS: The final population consisted of 680 subjects, 61% females, mean age 82 ± 7 years. One hundred subjects (15%) had AAD. No differences in terms of significant PVL or PPM implantation were found between subjects with or without AAD (P>.99 and P=.13, respectively). At a median follow-up of 498 ± 216 days, no significant difference in terms of mortality was found between subjects with or without AAD (P=.78). CONCLUSIONS: AAD does not appear to impact the mid-term outcomes in a cohort of subjects undergoing TAVI.

Risk of contrast-induced nephropathy in patients undergoing complex percutaneous coronary intervention.

BACKGROUND: Complex percutaneous coronary intervention (PCI) is associated with increased procedural challenges and high contrast load. We aimed to evaluate the association between complex PCI and contrast-induced nephropathy (CIN). METHODS: This single-center retrospective study included all-comers undergoing PCI between January 2012 and December 2016. Complex PCI was defined as a procedure with ≥1 of the following characteristics: 3 vessels treated, ≥3 stents implanted, two-stent bifurcation intervention, total stent length >60 mm, PCI on a chronic total occlusion, saphenous vein graft, or left main, protected PCI, use of rotational/laser atherectomy. CIN was defined as an increase in post-PCI creatinine of ≥0.3 mg/dl or ≥50% from baseline. RESULTS: We included 2660 patients (n = 1128 complex PCI, n = 1532 non-complex PCI). Complex PCI patients tended to be older, and had higher cardiovascular comorbidity and Mehran CIN risk score. They also had a higher prevalence of type B2/C lesions and need for mechanical circulatory support, and received a higher mean contrast volume (284 ±â€¯137 vs. 189 ±â€¯90 ml, p < 0.001). CIN incidence was similar in complex vs. non-complex PCI patients (12.1% vs. 11.5%, p = 0.63), as was the need for in-hospital dialysis (0.5% vs. 0.2%, p = 0.25). Upon multivariable adjustment, age, female sex, diabetes, ejection fraction, periprocedural hypotension, presentation with acute coronary syndrome, and contrast volume were independently associated with CIN, while complex PCI was not. CONCLUSIONS: Complex PCI is not associated with an increased risk of CIN in all-comers. Further studies should confirm our findings and investigate novel effective strategies to decrease the risk of this serious complication.

Ultra-Low Contrast Percutaneous Coronary Intervention to Minimize the Risk for Contrast-Induced Acute Kidney Injury in Patients With Severe Chronic Kidney Disease.

BACKGROUND: The incidence of contrast-induced acute kidney injury (CI-AKI) is particularly high in patients with severe chronic kidney disease (CKD). Novel contrast-sparing strategies are warranted to guarantee the benefit of revascularization in this challenging and growing patient population. We aimed to evaluate the feasibility of an ultra-low contrast volume percutaneous coronary intervention (ULC-PCI) protocol in patients with severe CKD. METHODS: The ULC-PCI protocol is based on the prespecification of the maximum contrast volume to be administered, extensive intravascular ultrasound (IVUS) and/or dextran-based optical coherence tomography (OCT) guidance, and use of diluted contrast media. We created a retrospective registry to compare the outcomes of the ULC-PCI protocol vs conventional angiography-based PCI in patients with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m², applying no angiographic or procedural restriction criteria. RESULTS: We included 111 patients (ULC-PCI group, n = 8; conventional group, n = 103). Baseline clinical and angiographic characteristics were similar between groups. Contrast volume (8.8 mL [interquartile range, 1.3-18.5] vs 90 mL [interquartile range, 58-140 mL]; P<.001) was markedly lower in the ULC-PCI group. Technical success was achieved in all ULC-PCI procedures; in 7 of the 8 cases (88%), the ULC-PCI protocol was also successful (contrast-volume-to-eGFR ratio <1). The incidence of CI-AKI was 0% vs 15.5% in the ULC-PCI and conventional groups, respectively (P=.28). Procedures in the ULC-PCI group included the use of rotational atherectomy, two-stent bifurcation PCI, and mechanically supported chronic total occlusion PCI. CONCLUSIONS: An ULC-PCI protocol in patients with advanced CKD is feasible, appears to be safe, and has the potential to decrease the incidence of CI-AKI, compared with angiographic guidance alone.

Noise reduction technology reduces radiation dose in chronic total occlusions percutaneous coronary intervention: a propensity score-matched analysis.

Chronic total occlusions (CTO) percutaneous coronary intervention (PCI) is associated with high radiation dose. Our study aim was to evaluate the impact of the implementation of a noise reduction technology (NRT) on patient radiation dose during CTO PCI. A total of 187 CTO PCIs performed between February 2016 and May 2017 were analyzed according to the angiographic systems utilized: Standard (n = 60) versus NRT (n = 127). Propensity score matching (PSM) was performed to control for differences in baseline characteristics. Primary endpoints were Cumulative Air Kerma at Interventional Reference Point (AK at IRP), which correlates with patient's tissue reactions; and Kerma Area Product (KAP), a surrogate measure of patient's risk of stochastic radiation effects. An Efficiency Index (defined as fluoroscopy time/AK at IRP) was calculated for each procedure. Image quality was evaluated using a 5-grade Likert-like scale. After PSM, n = 55 pairs were identified. Baseline and angiographic characteristics were well matched between groups. Compared to the Standard system, NRT was associated with lower AK at IRP [2.38 (1.80-3.66) vs. 3.24 (2.04-5.09) Gy, p = 0.035], a trend towards reduction for KAP [161 (93-244) vs. 203 (136-363) Gycm2, p = 0.069], and a better Efficiency Index [16.75 (12.73-26.27) vs. 13.58 (9.92-17.63) min/Gy, p = 0.003]. Image quality was similar between the two groups (4.39 ± 0.53 Standard vs. 4.34 ± 0.47 NRT, p = 0.571). In conclusion, compared with a Standard system, the use of NRT in CTO PCI is associated with lower patient radiation dose and similar image quality.

Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients Who Have Undergone Coronary Artery Bypass Grafting vs Those Who Have Not.

BACKGROUND: We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes. METHODS: We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up. RESULTS: Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P < 0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P < 0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P < 0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P < 0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent. CONCLUSIONS: Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up.

One Versus 2-stent Strategy for the Treatment of Bifurcation Lesions in the Context of a Coronary Chronic Total Occlusion. A Multicenter Registry.

INTRODUCTION AND OBJECTIVES: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry. METHODS: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization. RESULTS: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results. CONCLUSIONS: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies.

Changes in the non-protein thiol pool and production of dissolved gaseous mercury in the marine diatom Thalassiosira weissflogii under mercury exposure.

Two detoxification mechanisms working in the marine diatom Thalassiosira weissflogii to cope with mercury toxicity were investigated. Initially, the effect of mercury on the intracellular pool of non-protein thiols was studied in exponentially growing cultures exposed to sub-toxic HgCl(2) concentrations. T. weissflogii cells responded by synthesizing metal-binding peptides, named phytochelatins (PCs), besides increasing the intracellular pool of glutathione and gamma-glutamylcysteine (gamma-EC). Intracellular Hg and PC concentrations increased with the Hg concentration in the culture medium, exhibiting a distinct dose-response relationship. However, considerations of the PCs-SH:Hg molar ratio suggest that glutathione could also be involved in the intracellular mercury sequestration. The time course of the non-protein thiol pool and Hg intracellular concentration shows that PCs, glutathione and gamma-EC represent a rapid cellular response to mercury, although their role in Hg detoxification seems to lose importance at longer incubation times. The occurrence of a process of reduction of Hg(II) to Hg degrees and subsequent production of dissolved gaseous mercury (DGM) was also investigated at lower Hg concentrations, at which the PC synthesis doesn't seem to be involved. The significant (P<0.01) correlation between the cellular density in solution and the production of DGM suggests that this diatom is capable of directly producing DGM, both in light and dark conditions. This finding has been confirmed by the absence of DGM production in the culture media containing formaldehyde-killed cells. Finally, the relationship between these two different pathways of Hg detoxification is discussed.