Uso de anticoagulantes orales directos en pacientes con fibrilación auricular post implante de TAVI: resultados de una encuesta internacional / Use of anticoagulants in patients with atrial fibrillation undergoing transcatheter aortic valve implantation

BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) is beneficial in patients with symptomatic severe Aortic Stenosis (AS). There is no consensus about the best anticoagulation strategy for patients with a recent TAVI and with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) are effective to prevent embolic events with a significant lower incidence of bleeding. There is scarce evidence about the use of these drugs in patients undergoing TAVI. AIM: To assess the management of anticoagulation at the moment of discharge of patients with AF and TAVI. Material and Methods: A four question survey was sent to cardiologists involved in TAVI programs in different international centers. Results: The survey was answered by 72 interventional cardiologists. Even with the lack of randomized evidence, in most of the scenarios DOACs are prescribed at discharge in patients with indication for anticoagulation. Also, in patients with high bleeding risk, most cardiologists would perform a left atrial appendage closure. In patients with concomitant coronary artery disease, if a stent was recently implanted, prescription of the combination of a DOAC and one antiplatelet drug was the most common answer. In patients with a former coronary angioplasty, DOAC or Warfarin was the therapy of choice. CONCLUSIONS: In the absence of randomized data, interventional cardiologists prescribe DOACs at discharge to patients with AF and TAVI, without following current guidelines in most cases.

Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute Myocarditis.

BACKGROUND: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19-associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. METHODS: A total of 112 patients with suspected AM from 56 963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19-associated AM. RESULTS: AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19-associated pneumonia. Twenty-one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47; P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). CONCLUSIONS: AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.

Thoracic radiotherapy as a risk factor for heart ischemia in subjects treated with chest irradiation and chemotherapy and without classic cardiovascular RISK factors.

BACKGROUND AND PURPOSE: Radiation Induced Heart Disease (RIHD) represents a late effect of chest irradiation, contributing in increasing mortality rate in oncological patients by affecting pericardium, myocardium, valvs and coronaries. Currently, regarding the risk of Coronary Artery Disease (CAD), a cardiological screening involving exercise stress electrocardiography after 5-10 years from radiotherapy is advised. We sought to determine the rate of ischemia at exercise stress electrocardiography in a population of patients without cardiovascular risk factors who sustained radiotherapy, using a cohort of patients presenting with at least one cardiovascular risk factor as control group. DESIGN AND METHODS: A population of 115 patients who sustained chest irradiation (and associated chemotherapy), presenting without classic cardiovascular risk factors or typical symptoms suggesting CAD, was evaluated with exercise stress electrocardiography. 135 patients with at least one risk factor for cardiovascular disease candidate to stress testing for primary prevention or for atypical symptoms served as control group. RESULTS: The cohort of irradiated patients without classical cardiovascular risk factors is younger (48.7 ± 10.1 vs 60.5 ± 10.8 years, p < 0.001) and presents a lower percentage of males when compared with the control group. In this latter group 25.9% of subjects has diabetes, 62.9% dyslipidaemia, 67.4% hypertension and 19.2% actively smoke. Despite this important differences regarding classic cardiovascular risk factors, no significant differences were found in the number of positive exercise stress electrocardiography (10.4 vs 5.9%, p = ns). CONCLUSIONS: Chest irradiation represents a strong cardiovascular risk factor. In fact, prevalence of positive ECG-stress test is not different (nor higher and nor lower) in irradiated subjects without cardiovascular risk and not irradiated patients with classic cardiovascular risk.

Litoplastía iliaco-femoral para implante transcatéter de válvula órtica / Iliac-femoral lithoplasty for a transcatheter aortic valve implantation. Report of one case

Transcatheter aortic valve implantation (TAVI) has a lower perioperative risk than traditional surgery mostly when the transfemoral access is used. Some patients have anatomical conditions that contraindicate the use of this route. Lithoplasty is a novel technique that fractures calcium in coronary and peripheral arteries using pulsatile waves transmitted through an angioplasty balloon. We report an 83 year-old male with an aortic stenosis requiring TAVI, with severe calcification of his femoral and aortic arteries. A balloon lithoplasty of the right iliac-femoral tract was carried out, which allowed the use of the transfemoral route to install the aortic prosthesis. The patient had a good subsequent evolution.

ECMELLA: Uso combinado de dispositivos de asistencia ventricular izquierda en el manejo del shock cardiogénico postinfarto agudo al miocardio / Combined use of left ventricular assist devices in cardiogenic shock. Report of one case

We report a 55-year-old woman with a history of hypothyroidism and type 2 diabetes mellitus who consulted at the emergency room because of intermittent oppressive chest discomfort. At admission, electrocardiogram showed a complete atrioventricular block. A transthoracic echocardiogram disclosed severe left ventricular dysfunction. The patient developed cardiogenic shock that required the installation of the Impella system. An emergency coronary angiography showed an ostial occlusion of the anterior descending artery. Despite successful primary angioplasty, she persisted with refractory shock and progressive hypoxemia. A concomitant connection to the extracorporeal membrane oxygenation system (ECMO) was decided. The support of both devices allowed the stabilization of the patient and the improvement of perfusion parameters.

Cangrelor use in a 6-year-old patient undergoing complex percutaneous coronary intervention after post-surgical myocardial infarction.

Cangrelor is an intravenously administered P2Y12 receptor antagonist, which has been approved for adult patients undergoing percutaneous coronary intervention and, due to its unique pharmacokinetics, it allows effective and controllable peri-procedural platelet inhibition. We report the case of a 6-year-old child with anomalous origin of right coronary artery from aortic left coronary sinus, who underwent elective surgical replacement of stenotic and calcified conduit between the right ventricle and the main pulmonary artery. The surgery was complicated by acute myocardial infarction secondary to coronary extrinsic compression. The patient was successfully treated with urgent percutaneous coronary intervention (simultaneous V-stenting) and cangrelor infusion, subsequently switched to clopidogrel therapy.

Allogeneic peripheral blood stem cell transplantation and accelerated atherosclerosis: An intriguing association needing targeted surveillance. Lessons from a rare case of acute anterior myocardial infarction.

We report the case of a 23-year-old man who developed an acute ST-elevation myocardial infarction secondary to acute thrombotic occlusion of the proximal left anterior descending coronary artery five years after undergoing chemotherapy, radiotherapy, haematopoietic stem cell transplantation for acute lymphoblastic leukaemia and bulky mediastinal mass involving the pleura and pericardium. His medical history also included Graft versus Host Disease developed 13 months after transplantation and acute myocarditis three months before the actual hospital admission. To the best of our knowledge, coronary artery disease as a complication of haematopoietic stem cell transplantation and low-dose mediastinal radiation therapy in young patients has been rarely reported in the medical literature. Clinicians should have a high degree of suspicion of coronary artery disease in patients treated with allogeneic haematopoietic stem cell transplantation, especially in patients previously treated with target mediastinal radiotherapy, as a group at risk of premature and significantly accelerated atherosclerosis, in order to make a timely and correct diagnosis.

[Relevance of complete blood count parameters in the assessment of acute coronary syndromes: a combined hematological and cardiological perspective]. / Alterazioni dell'emocromo nella sindrome coronarica acuta: ematologi e cardiologi a confronto.

The aim of this review is to explore the available evidence concerning the relationship between the different parameters of the complete blood count, its pathophysiological changes and cardiovascular disease, specifically focusing on the acute ischemic setting. Erythrocytes, leukocytes and platelets undergo significant and more or less durable changes over time in response to conditions of systemic inflammatory, infectious and neoplastic disease. This is the reason why blood cell count parameters can (and should) be implemented in the global assessment of the patient with acute coronary syndrome.From the literature review it emerges that anemia and thrombocytopenia have an independent negative prognostic role in the medium and long term, being markers of the overall frailty of patients with ischemic heart disease. On the other hand, essential thrombocythemia and polycythemia vera, two chronic myeloproliferative neoplasms, are characterized by an important increase in thrombotic risk. Both conditions are given a brief description for the particular importance of the close collaboration between cardiologists and hematologists in the diagnosis and treatment of these diseases in the context of ischemic heart disease.

Implante percutáneo de válvula aórtica transcatéter por vía femoral en paciente joven con obesidad extrema / Trans femoral TAVI in extremely obese patient with severe aortic stenosis

RESUMEN:TAVI transfemoral en una paciente con obesidad extrema y estenosis aórtica severa. Una mujer extremadamente obesa (IMC 62.5 Kg/M2) con estenosis aórtica severa fue descartada para cirugía bariátrica y reemplazo valvular aórtico. Se efectuó una TAVI por vía transfemoral, sin anestesia general. Se describen cuidadosas técnicas para efectuar la punción femoral y su sellado posterior. La paciente se recuperó sin incidentes, la gradiente transvalvular aórtica se redujo significativamente y hubo mínima insuficiencia valvular.

ABSTRACT: An extremely obese woman (BMI 62.5 Kg/M2) with severe symptomatic aortic stenosis was discarded for bariatric surgery or aortic valve replacement. A transfemoral TAVI was performed, without general anesthesia. Careful techniques to perform and seal the transfemoral puncture are described. The patient recovered uneventfully with a significant decrease in aortic valve gradient and minimal aortic insufficiency.

Implante concomitante de MitraClip y cierre de orejuela izquierda: importancia de la puncoón transeptal y sus implicancias técnicas: caso clínico / Concomitant deployment of MitraClip devices and left atrial appendage closure: report of one case

We report a 65-years old woman with a history of permanent atrial fibrillation with high risk for ischemic and bleeding events. She developed a heart failure with severely impaired left ventricular ejection fraction and severe secondary mitral regurgitation. Given her high surgical risk, using transesophageal echocardiography guidance, a concomitant deployment of two MitraClip devices using a high-posterior septal puncture and a left atrial appendage closure with an Amplatzer Amulet occluder were performed through the same access.

Coronary Artery Aneurysm After Bioresorbable Scaffold Implantation in a Woman With an Acute Coronary Syndrome.

We herein report the case of an ST-elevation myocardial infarction due to bioresorbable vascular scaffold (BRS) failure. Optical coherence tomography (OCT) revealed the exact mechanism of late BRS stent thrombosis due to an acquired coronary aneurysm related to BRS. A drug eluting OCT-guided stenting over a failed BRS in the context of an acute coronary syndrome, with the simultaneous presence of a BRS thrombosis and coronary artery aneurysm, proved to be effective.

Portico Sheathless Transcatheter Aortic Valve Implantation via Distal Axillary Artery.

Transcatheter aortic valve implantation has been designed to treat older patients affected by severe aortic stenosis who are considered high-risk surgical candidates because of multiple comorbidities. The least invasive approach for transcatheter aortic valves implantation should be considered the transfemoral retrograde route, because it is minimally invasive and is feasible with local anesthesia and mild sedation. Despite significant technical improvements in recent years, the transfemoral approach is contraindicated in cases of severe peripheral artery disease. We describe the first case of a Portico transcatheter aortic valve implantation system (St. Jude Medical, Minneapolis, MN) made through the distal axillary artery in a 90-year-old patient affected by severe aortic stenosis.

Evolut R Implantation to Treat Severe Pure Aortic Regurgitation in a Patient With Mitral Bioprosthesis.

Transcatheter aortic valves have been designed to treat high-risk surgical candidates affected by severe aortic stenosis, but little is known about the use of transcatheter valves in patients with severe pure aortic regurgitation. We describe the implantation of Medtronic CoreValve Evolut R (Medtronic, Minneapolis, MN) to treat an 82-year-old patient affected by severe pure aortic regurgitation who underwent prior mitral valve replacement with a biological valve protruding into the left ventricular outflow tract.

Direct Flow Implantation in a Patient With Mechanical Mitral Prostheses.

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Direct Flow valve-in-valve implantation in a degenerated mitral bioprosthesis.

AIMS: Mitral valve reoperations due to failing bioprostheses, in patients affected by multiple comorbidities, are associated with high morbidity and mortality. Transcatheter techniques may evolve as complementary approaches to surgery in these patients at high risk for surgery. METHODS AND RESULTS: We describe a case of Direct Flow 25 mm transcatheter valve implantation as valve-in-valve in a degenerated mitral bioprosthesis through a transapical approach in a 63-year-old man affected by dilated cardiomyopathy. The patient was affected by Carpentier-Edwards 29 mm severe regurgitation. The 25 mm Direct Flow bioprosthesis was advanced through the mitral bioprosthesis into the left atrium and then positioned using the three independent positioning wires. Transoesophageal echocardiography evidenced normal Direct Flow function with no paravalvular regurgitation and a low transmitral gradient of 4 mmHg. CONCLUSIONS: Our successful experience, characterised by a Heart Team approach and multidisciplinary patient care, demonstrated the technical feasibility and procedural safety of Direct Flow valve-in-valve mitral implantation.

[A novel standard protocol of long-term follow-up shared with general practitioners after percutaneous coronary intervention: appropriateness and economic impact]. / Il follow-up del paziente sottoposto a rivascolarizzazione coronarica percutanea: impatto potenziale dell'applicazione di un percorso clinico-gestionale strutturato sull'integrazione ospedale-territorio e modulato sul rischio clinico del paziente.

BACKGROUND: Follow-up modalities for patients undergoing percutaneous coronary intervention (PCI) are not well defined and standard protocols have been not established. The purpose of this study was to assess: a) the frequency and patterns of cardiology visits, echocardiographic examinations and stress tests after PCI in clinical practice; b) the impact of a multidisciplinary protocol of long-term follow-up after PCI shared with general practitioners on the appropriateness and reduction in healthcare costs. METHODS: A total of 780 patients who underwent PCI in 2010 in two Italian hospitals were analyzed. The number of cardiological examinations (total, routine and clinically driven) performed during 2 years of follow-up were recorded and stratified according to the patient's risk profile. The latter was defined according to the multidisciplinary protocol. In addition, a simulation of the spread between provided and necessary tests (according to the multidisciplinary protocol) was carried out. RESULTS: The mean number of cardiological examinations per patient provided during follow-up was 5, of which 4.4 were routine tests in asymptomatic patients. Routine tests were performed more frequently in patients at low risk compared to those at higher risk. By applying the multidisciplinary protocol to the case mix and by merging clinical visit and stress test or echocardiographic examination, a reduction of 0.87 tests per patient/year would be expected. This reduction would result in a 39% decrease in follow-up examinations in this specific clinical setting. CONCLUSIONS: This observational study demonstrates that unnecessary cardiological clinical and functional tests are often performed in long-term follow-up of patients submitted to PCI. The application of a standard protocol of follow-up shared with general practitioners may help avoiding unnecessary consultations, thus reducing healthcare costs.

Iron Stores, Hepcidin, and Aortic Stiffness in Individuals with Hypertension.

BACKGROUND & AIMS: Iron accumulation within the arterial wall has been hypothesized to promote atherosclerosis progression. Aim of this study was to evaluate whether the hormone hepcidin and iron stores are associated with arterial stiffness in subjects with essential hypertension. METHODS: Circulating hepcidin, ferritin, and mutations in the hemochromatosis gene were compared between subjects included in the first vs. third tertile (n=284 each) of carotid-femoral pulse wave velocity (PWV) in an unselected cohort of patients with arterial hypertension. RESULTS: At univariate logistic regression analysis, high PWV was associated with higher ferritin levels (p=0.010), but lower hepcidin (p=0.045), and hepcidin ferritin/ratio (p<0.001). Hemochromatosis mutations predisposing to iron overload were associated with high PWV (p=0.025). At multivariate logistic regression analysis, high aortic stiffness was associated with older age, male sex, lower BMI, higher systolic blood pressure and heart rate, hyperferritinemia (OR 2.05, 95% c.i. 1.11-3.17 per log ng/ml; p=0.022), and lower circulating hepcidin concentration (OR 0.29, 95% c.i. 0.16-0.51 per log ng/ml; p<0.001). In subgroup analyses, high PWV was associated with indices of target organ damage, including micro-albuminuria (n=125, p=0.038), lower ejection fraction (n=175, p=0.031), cardiac diastolic dysfunction (p=0.004), and lower S wave peak systolic velocity (p<0.001). Ferritin was associated with cardiac diastolic dysfunction, independently of confounders (p=0.006). CONCLUSIONS: In conclusion, hyperferritinemia is associated with high aortic stiffness and cardiac diastolic dysfunction, while low circulating hepcidin with high aortic stiffness.