Catastrophic antiphospholipid syndrome immediately after coronary angiography: the unexpected complication.

A 44-year-old woman with obstetric antiphospholipid syndrome (APS) presented to our institution with suspected non ST-elevation myocardial infarction (NSTEMI). Shortly after coronary angiography, she developed diplopia, hypotension and chest pain with inferior ST elevation in 12-lead ECG. According to multidisciplinary evaluation, she promptly underwent systemic thrombolysis, with clinical and haemodynamic improvement. Eventually, a diagnosis of catastrophic APS was made, with multiorgan ischemic involvement confirmed by blood examinations and multimodal imaging techniques. A pluridisciplinary approach was central to define optimal medical therapy and in-hospital management that lead to clinical condition improvement at discharge. In this case, catastrophic APS was triggered or worsened by catheters insertion and invasive manoeuvres within the arterial lumen during coronary angiography. Recognizing catastrophic APS and its potential triggers, can be helpful to deliver prompt and accurate medical assistance. Moreover, in APS patients undergoing coronary angiography, preventive strategies are important to prevent possible unfavourable evolution in catastrophic APS.

International consensus statement on challenges for women in cardiovascular practice and research in the COVID-19 era.

The challenges to academic and professional development and career advancement of women in cardiology (WIC), imposed by the pandemic, not only impinge the female cardiologists' "leaky pipeline" but also make the "leakiness" more obvious. This consensus document aims to highlight the pandemic challenges WIC face, raise awareness of the gender equity gap, and propose mitigating actionable solutions derived from the data and experiences of an international group of female cardiovascular clinicians and researchers. This changing landscape has led to the need for highly specialized cardiologists who may have additional training in critical care, imaging, advanced heart failure, or interventional cardiology. Although women account for most medical school graduates, the number of WIC, particularly in mentioned sub-specialties, remains low. Moreover, women have been more affected by systemic issues within these challenging work environments, limiting their professional progression, career advancement, and economic potential. Therefore, it is imperative that tangible action points be noted and undertaken to ensure the representation of women in leadership, advocacy, and decision-making, and increase diversity in academia. Strategies to mitigate the negative impacts of the pandemic need to be taken during this COVID-19 pandemic to ensure WIC have a place in the field of Cardiology.

The relationship between anatomy and electrical parameters in His bundle pacing: A transthoracic echocardiography evaluation.

PURPOSE: The implantation site of the His bundle (HB) lead may influence pacing parameters. Our aim was to characterize the anatomical location of the HB lead tip and its relationship with acute electrical parameters. METHODS: Consecutive patients who underwent HB lead implantation, guided by standard fluoroscopy and electrophysiology, were prospectively enrolled. The relationship between HB lead tip and tricuspid valve plane (TVP) was assessed with post-procedure transthoracic echocardiography. RESULTS: Twenty-five patients were studied. In 11 patients (44%), the HB lead tip did not cross the TVP (A group): in 7 cases it was screwed in the right atrium at a mean distance of -6.1 mm from the TVP and, in 4 cases, at the level of the tricuspid annulus. In the remaining 14 patients (56%), the lead tip crossed the TVP (V group): it was screwed in the right ventricle at a mean distance of 9.3 mm from the TVP. A and V groups had comparable HB capture thresholds (1.6 ± 1 V vs 1.7 ± 0.7 V, 1 ms pulse-width; p = 0.66); selective HB capture was significantly more represented in the A group (91% vs 21%; p = 0.001). Significantly higher R-wave amplitudes were seen in the V group (6.7 ± 3 vs 2.5 ± 1.7 mV; p = 0.0004), and they positively correlated with the distance from the TVP (p = 0.0038). Atrial oversensing was never observed. CONCLUSION: In a consecutive cohort of HB pacing recipients, the rate of patients who had an effective HB capture in the atrium was substantial and was characterized by different electrophysiological properties than in the ventricle.

Additional benefits of nonconventional modalities of cardiac resynchronization therapy using His bundle pacing.

INTRODUCTION: Dyssynchrony persists in many patients despite cardiac resynchronization therapy (CRT). Aim of this proof-of-concept study was to achieve better CRT, with a QRS approximating the normal width and axis, by using His bundle pacing (HBP) and nonconventional pacing configurations. METHODS AND RESULTS: In 20 patients with CRT indications, we performed an acute intrapatient comparison between conventional biventricular (CONV) and three nonconventional pacing modalities: HBP alone, His bundle, and coronary sinus pacing (HBP + CS), and HBP + CS plus right ventricular pacing (TRIPLE). Electrical dyssynchrony was assessed by means of QRS width and axis; "quasi-normal" axis meant an R/S ratio ≥ 1 in leads I and V6 and ≤1 in V1. Mechanical dyssynchrony was assessed by speckle tracking echocardiography. QRS width was 153 ± 18 ms on CONV, shortened to 137 ± 16 ms on HBP + CS (P = .001) and to 130 ± 14 ms on TRIPLE (P = .001), while it remained unchanged on HBP (159 ± 32 ms; P = .17). The rate of patients with "quasi-normal" axis was 5% on CONV, and increased to 90% on HBP (P = .0001), to 63% on HBP + CS (P = .001), and to 44% on TRIPLE (P = .02). On radial strain analysis, the time-to-peak difference between anteroseptal and posterolateral segments was 143 ± 116 ms on CONV, shortened to 121 ± 127 ms on HBP (P = .79), to 67 ± 70 ms on HBP + CS (P = .02), and to 76 ± 55 ms on TRIPLE (P = .05). On discharge, HBP was chosen in 15% of patients, HBP + CS in 55%, and TRIPLE in 30%; CONV was never chosen. CONCLUSION: Nonconventional modalities of CRT provide acute additional electrical and mechanical resynchronization. An interpatient variability exists.

Syncope and paroxysmal atrioventricular block.

Current literature reveals three types of paroxysmal atrioventricular block (AVB) that can cause syncope: Intrinsic paroxysmal atrioventricular block is due to an intrinsic disease of the AV conduction system; this type of "cardiac syncope" is also called Stokes-Adams attack; Extrinsic vagal paroxysmal atrioventricular block is linked to the effect of the parasympathetic nervous system on cardiac conduction and is one of the mechanisms involved in "reflex syncope." Extrinsic idiopathic paroxysmal atrioventricular block is associated with low levels of endogenous adenosine and is supposed to be one of the mechanisms involved in "low-adenosine syncope." These three types of paroxysmal AVB present different clinical and electrocardiographic features. Additionally, the efficacy of cardiac pacing and theophylline therapy to prevent syncopal recurrences is also different for these three types of AVB.

Long-Term Outcome of Patients with Bifascicular Block and Unexplained Syncope Following Cardiac Pacing.

BACKGROUND: According to the ACC/AHA/HRS guidelines, cardiac pacing is reasonable in patients with bifascicular block (BF-B) and syncope when other causes have been excluded. The purpose of this study was to assess the long-term outcome of patients with BF-B and unexplained syncope following cardiac pacing. METHODS AND RESULTS: Between 2009 and 2015, we identified 43 consecutive patients (mean age of 78 ± 12 years, 64% males) who presented with syncope and BF-B and had received a pacemaker (PM). During a mean follow-up period of 31 ± 21 months, syncope recurred in seven patients (16%): 7% (95% standard error [SE] ± 3%) at 1 year and 18% (95% SE ± 7%) at 5 years. At univariable analysis, the only predictor of syncope recurrence was empiric pacing (P = 0.03). There were no syncope recurrences in the 12 patients who received a PM following a positive electrophysiological study (EPS) and the five patients with documentation of paroxysmal atrioventricular block (AVB) during cardiac monitoring (insertable loop recorder [ILR]), (EPS/ILR Group, n = 17) compared to seven of 26 (27%) patients who received empiric pacing (Empiric Group, n = 26; P = 0.02). Progression to high-degree AVB was documented during follow-up in 16 (37%) patients: nine of 17 (53%) patients in the EPS/ILR Group and seven of 26 (27%) patients in the Empiric Group (P = 0.11). There were no injuries reported during ILR monitoring. CONCLUSIONS: We have shown that syncope recurs not infrequently in patients with BF-B who received pacing for syncope. Nearly one in four patients who had empiric pacing suffered syncope recurrence compared to no recurrences in patients who received a PM following a positive EPS or documentation of transient AVB.

Syncope in patients paced for atrioventricular block.

AIMS: Although syncope is the main reason for cardiac pacing in ∼40% of patients affected by atrioventricular block (AVB), very few data are available on the benefit of cardiac pacing in preventing syncopal recurrences. METHODS AND RESULTS: We retrospectively evaluated 229 consecutive patients (124 males, age 80 ± 10 years) who had received a permanent pacemaker from January 2009 to December 2013 for AVB and syncope (94 patients, 41%) or AVB without syncope (135 patients, 59%). In patients with AVB and syncope, a third-degree or Mobitz II second-degree AVB had been documented in 73 and was only suspected in another 21, all of whom had bundle branch block. Follow-up was available in 223 patients. At 5 years, the actuarial syncope recurrence rate was 1% (95% CI, 0-3) in patients with documented AVB plus syncope and 3% (95% CI, 1-5) in those without syncope, whereas it was 14% (95% CI, 0-28) in patients with undocumented AVB plus syncope (P = 0.001). The actuarial combined recurrence rate of syncope and/or pre-syncope was 2% (95% CI, 0-4) in patients without syncope, 8% (95% CI, 0-17) in patients with documented AVB plus syncope, and 19% (95% CI, 1-37) in patients with undocumented AVB plus syncope, P = 0.002. All syncopes occurred in patients without overt structural heart disease (SHD), the corresponding actuarial estimate being 4% (95% CI, 0-6) at 1 year and 6% (95% CI, 4-8) at 5 years (P = 0.002 vs. patients with SHD). CONCLUSIONS: Cardiac pacing is highly effective in preventing syncopal recurrences when AVB is documented. Syncope may recur in a non-negligible minority of paced patients when AVB is suspected but not documented and in patients without SHD.

Diagnostic value of ischemia severity at myocardial perfusion imaging in elderly persons with suspected coronary disease.

AIMS: Myocardial perfusion and ischemia scores obtained from myocardial perfusion scintigraphy (MPS) have strong independent prognostic value in elderly individuals without known coronary artery disease (CAD). Herein we aimed to assess their independent diagnostic value and accuracy for CAD while considering different thresholds of myocardial ischemia. METHODS: We estimated the summed rest score (SRS), summed stress score (SSS) and summed difference score (SDS) in 322 elderly individuals (mean age 72 ±â€Š7 years, 68% men) who underwent coronary angiography following an MPS. Abnormal perfusion at stress was defined as an SSS greater than 3, and ischemia as an SDS of at least 2, and further categorized as mild (2-4), moderate (5-7) or severe (>7). Multivariate logistic regressions were used to establish the independent diagnostic value and accuracy of MPS parameters. RESULTS: CAD was diagnosed in 182 individuals (56%). In multivariate analysis accounting for clinical variables associated with CAD including the Framingham risk score, both SRS [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.01-1.18, P = 0.03] and SSS (OR 1.10, 95% CI 1.04-1.16, P = 0.0006) and SDS (OR 1.12, 95% CI 1.04-1.21, P = 0.003) were independently associated with CAD. An SSS greater than 3 was also independently associated with CAD (OR 2.51, 95% CI 1.43-4.39, P = 0.0013), whereas an SDS of 2 or greater was not (OR 1.62, 95% CI 0.89-2.93, P = 0.12), but only when at least 5 (OR 2.31, 95% CI 1.32-4.03, P = 0.003). The probability of CAD was proportional to the amount of myocardial ischemia in those with an SSS greater than 3, and lower and comparable in those with an SSS of at least 3 or an SSS greater than 3 with SDS of 1 or less (P = 0.19). Increasing the threshold of myocardial ischemia determined a decrease in sensitivity and increase in specificity of MPS for both diagnosis and severity of CAD. CONCLUSION: We established the diagnostic value and accuracy of continuous scores and thresholds of abnormal myocardial perfusion and ischemia previously validated in prognostic studies. Their more widespread use could potentially improve the diagnostic yield of coronary angiography in elderly individuals with suspected CAD.

Transient left ventricular and stomach apical ballooning syndromes: when the trigger is also a clinical emergency.

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of "apical stomach ballooning." Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.