"Natural" History of Operated Type A Aortic Dissection.

We describe the case of a 66-year-old gentleman with a previous replacement of the ascending aorta for an acute Type A aortic dissection who did not attend any scheduled follow-up visit. Seventeen years later, he presented to our institution with severe aortic regurgitation and with a giant aneurysmal dilation of the abdominal aorta.

Symptoms-to-emergency-call timing delay in acute coronary syndrome before and during COVID-19: independent predictors and their impact on mortality.

BACKGROUND: The COVID-19 pandemic severely impacted global health. The aim of this study was to compare predictors of symptoms-to-emergency-call timing delay in acute coronary syndrome (ACS) and their impact on mortality before and during the COVID-19 outbreak. METHODS: We collected sociodemographic, clinical data, procedural features, preadmission and intra-hospital outcomes of consecutive patients admitted for ACS in seventeen Italian centers from March to April 2018, 2019, and 2020. RESULTS: In 2020, a 32.92% reduction in ACS admissions was observed compared to 2018 and 2019. Unstable angina, typical and atypical symptoms, and intermittent angina were identified as significant predictors of symptoms-to-emergency-call timing delay before and during the COVID-19 pandemic (P<0.005 for all the items). Differently from 2018-2019, during the pandemic, hypertension and dyspnea (P=0.002 versus P=0.490 and P=0.001 vs. P=0.761 for 2018-2019 and 2020, respectively) did not result as predictors of delay in symptoms-to-emergency-call timing. Among these predictors, only the atypical symptoms (HR 3.36; 95% CI: 1.172-9.667, P=0.024) in 2020 and the dyspnea (HR 2.64; 95% CI: 1.345-5.190, P=0.005) in 2018-2019 resulted significantly associated with higher mortality. Finally, the family attendance at the onset of the symptoms resulted in a reduction in symptoms-to-emergency-call timing (in 2020 P<0.001; CI: -1710.73; -493.19) and in a trend of reduced mortality (HR 0.31; 95% CI: 0.089-1.079, P=0.066) in 2020. CONCLUSIONS: During the COVID-19 outbreak, atypical symptoms and family attendance at ACS onset were identified, respectively, as adverse and favorable predictors of symptoms-to-emergency-call timing delay and mortality.

One-year performance of thin-strut cobalt chromium sirolimus-eluting stent versus thicker strut stainless steel biolimus-eluting coronary stent: a propensity-matched analysis of two international all-comers registries.

OBJECTIVES: Recent improvements in coronary stent design have focussed on thinner struts, different alloys and architecture, more biocompatible polymers, and shorter drug absorption times. This study evaluates safety and efficacy of a newer generation thin-strut cobalt chromium sirolimus-eluting coronary stent (SES, Ultimaster) in comparison with a second-generation thicker strut stainless steel biolimus-eluting stent (BES, Nobori) in percutaneous coronary intervention (PCI) practice. METHODS: A propensity score analysis was performed to adjust for differences in baseline characteristics of 8137 SES patients and 2738 BES patients of two PCI registries (e-Ultimaster and NOBORI 2). An independent clinical event committee adjudicated all endpoint-related adverse events. RESULTS: The use of SES, as compared with BES was associated with a significantly lower rate of myocardial infarction (MI) (1.2% vs 2.2%; P = 0.0006) and target vessel-related MI (1.1% vs 1.8%; P = 0.002) at 1 year. One-year composite endpoints of all predefined endpoints were lower in patients undergoing SES implantation (target lesion failure: 3.2% vs 4.1%; P = 0.03, target vessel failure: 3.7% vs 5.0%; P = 0.003, patient-oriented composite endpoint 5.7% vs 6.8%; P = 0.03). No significant differences between SES and BES were observed in all-cause death (2.0% vs 1.6%; P = 0.19), cardiac death (1.2% vs 1.2%; P = 0.76) or stent thrombosis (0.6% vs 0.8%; P = 0.43). CONCLUSIONS: These findings suggest an improved clinical safety and efficacy of a newer generation thin-strut SES as compared with a second-generation thicker strut BES.

Common cardiovascular risk factors and in-hospital mortality in 3,894 patients with COVID-19: survival analysis and machine learning-based findings from the multicentre Italian CORIST Study.

BACKGROUND AND AIMS: There is poor knowledge on characteristics, comorbidities and laboratory measures associated with risk for adverse outcomes and in-hospital mortality in European Countries. We aimed at identifying baseline characteristics predisposing COVID-19 patients to in-hospital death. METHODS AND RESULTS: Retrospective observational study on 3894 patients with SARS-CoV-2 infection hospitalized from February 19th to May 23rd, 2020 and recruited in 30 clinical centres distributed throughout Italy. Machine learning (random forest)-based and Cox survival analysis. 61.7% of participants were men (median age 67 years), followed up for a median of 13 days. In-hospital mortality exhibited a geographical gradient, Northern Italian regions featuring more than twofold higher death rates as compared to Central/Southern areas (15.6% vs 6.4%, respectively). Machine learning analysis revealed that the most important features in death classification were impaired renal function, elevated C reactive protein and advanced age. These findings were confirmed by multivariable Cox survival analysis (hazard ratio (HR): 8.2; 95% confidence interval (CI) 4.6-14.7 for age ≥85 vs 18-44 y); HR = 4.7; 2.9-7.7 for estimated glomerular filtration rate levels <15 vs ≥ 90 mL/min/1.73 m2; HR = 2.3; 1.5-3.6 for C-reactive protein levels ≥10 vs ≤ 3 mg/L). No relation was found with obesity, tobacco use, cardiovascular disease and related-comorbidities. The associations between these variables and mortality were substantially homogenous across all sub-groups analyses. CONCLUSIONS: Impaired renal function, elevated C-reactive protein and advanced age were major predictors of in-hospital death in a large cohort of unselected patients with COVID-19, admitted to 30 different clinical centres all over Italy.

Coronavirus disease 2019 and cardiovascular implications.

: The coronavirus disease 2019 (COVID-19) has important implications for the cardiovascular care of patients. COVID-19 interacts with the cardiovascular system on multiple levels, increasing morbidity in patients with underlying cardiovascular conditions and favoring acute myocardial injury and dysfunction. COVID-19 infection may also have long-term implications for overall cardiovascular health. Many issues regarding the involvement of the cardiovascular system remain controversial. Despite angiotensin-converting enzyme 2 serving as the site of entry of the virus into the cells, the role of angiotensin-converting enzyme inhibitors or AT1 blockers requires further investigation. Therapies under investigation for COVID-19 may have cardiovascular side effects. Treatment of COVID-19, especially the use of antivirals, must be closely monitored. This article is a review of the most updated literature.

From biodegradable polymers to bioresorbable vascular scaffolds: available evidence in the era of new-generation drug-eluting stents.

New-generation drug-eluting stents (DES) encompass a large variety of coronary devices, featuring thin struts, biocompatible durable or biodegradable polymer coatings, and limus-eluting drugs. Due to improved early and long-term outcomes among patients undergoing percutaneous coronary intervention, new-generation metallic DES are recommended in almost all patient and lesion subsets. Available evidence from randomized trials indicates a similar safety and efficacy profile between biodegradable and durable polymers new-generation DES. Recently, polymer-free DES provided promising results particularly as alternative to bare-metal stents. Ultimately, although remaining conceptually solid, bioresorbable vascular scaffolds represent an immature technology owing to increased risk of thrombosis. In this review, we summarized current evidence about contemporary coronary devices.

Radiological anatomy of upper limb arteries and their anatomical variability: implications for endovascular treatment in critical hand ischemia.

Critical hand ischemia (CHI) is a quite uncommon but highly disabling condition, generally caused by chronic occlusive arterial disease. For a correct approach to the endovascular treatment of these patients, good knowledge of the normal vascular anatomy and of the most frequently encountered vascular anatomical variations is of paramount importance. In the present paper a description of the normal vascular anatomy of the upper limb and of the most commonly encountered anatomical variations is provided, focusing on the implications for endovascular treatment of patients with CHI. Moreover, data of 151 patients with 172 critically ischemic hands treated at our institution between 2004 and 2016 are presented.

Angiographic study of upper limb vascularization in a large cohort of hemodialysis patients with critical hand ischemia.

BACKGROUND: Critical hand ischemia (CHI) is a not rare condition in patients with end-stage-renal-disease on hemodialysis (HD), and presents devastating consequences due to its impact on life quality. In HD patients CHI may be related to three main conditions: obstruction of the big upper limb arteries, obstruction of the small hand and finger arteries, and the steal effect of a hemodialysis access. The aim of this study was to describe the angiographic pattern of upper limb vascularization and associated cardiovascular risk factors, in a large cohort of consecutive HD patients with CHI studied in our center. METHODS: In our center 114 HD consecutive patients (age 64±10 years) with a total of 132 upper limbs affected by CHI (21 with rest pain and 93 with tissue loss) underwent angiography in our center. The majority of them were diabetic males. We computed the prevalence of obstructive disease for each vascular segment of the upper limb. RESULTS: Above-the-elbow arteries were mostly spared, while below-the-elbow and hand arteries were extensively affected. We found a stenosis or occlusion in humeral artery (2.3%), radial (61.4%) or ulnar (90.1%) arteries, deep palmar arch (51.5%), superficial palmar arch (58.3%) and digital arteries (72.4%). In 42.4% of cases an ipsilateral functioning arteriovenous fistula was present. CONCLUSIONS: CHI in HD patients is a result of below-the-elbow and hand vessel obstruction and is not primarily related to dialysis access.

Upper limb ischemia from arterial thromboembolism: a comprehensive review of incidence, etiology, clinical aspects, diagnostic tools, treatment options and prognosis.

Upper limb thromboembolism is a relatively uncommon clinical syndrome that mainly affects elderly patients with cardiovascular comorbidities. Atrial fibrillation has been recognized as the main cause. However, many other cardiac and non-cardiac disorders have been identified as possible sources of upper limb thromboemboli. From a clinical point of view, upper limb thromboembolism represents a vascular emergency so that the delay in diagnosis and treatment is highly likely to imply dramatic complications. Therefore, prompt recognition and treatment is mandatory as well as identification and correction of risk factors. Despite its clinical relevance, data in literature are lacking and sparse, most likely because upper limb thromboembolism has a relatively low prevalence in the general population. We sought to write a simple but comprehensive review of this topic, thus proving cardiologists and critical care physicians with the essential tools to recognize and treat upper limb thromboembolism, identifying and correcting also its risk factors and causes.

Prevalence and Impact of Co-morbidity Burden as Defined by the Charlson Co-morbidity Index on 30-Day and 1- and 5-Year Outcomes After Coronary Stent Implantation (from the Nobori-2 Study).

Co-morbidities have typically been considered as prevalent cardiovascular risk factors and cardiovascular diseases rather than systematic measures of general co-morbidity burden in patients who underwent percutaneous coronary intervention (PCI). Charlson co-morbidity index (CCI) is a measure of co-morbidity burden providing a means of quantifying the prognostic impact of 22 co-morbid conditions on the basis of their number and prognostic impact. The study evaluated the impact of the CCI on cardiac mortality and major adverse cardiovascular events (MACE) after PCI through analysis of the Nobori-2 study. The prognostic impact of CCI was studied in 3,067 patients who underwent PCI in 4,479 lesions across 125 centers worldwide on 30-day and 1- and 5-year cardiac mortality and MACE. Data were adjusted for potential confounders using stepwise logistic regression; 2,280 of 3,067 patients (74.4%) had ≥1 co-morbid conditions. CCI (per unit increase) was independently associated with an increase in both cardiac death (odds ratio [OR] 1.47 95% confidence interval [CI] 1.20 to 1.80, p = 0.0002) and MACE (OR 1.29 95% CI 1.14 to 1.47, p ≤0.0011) at 30 days, with similar observations recorded at 1 and 5 years. CCI score ≥2 was independently associated with increased 30-day cardiac death (OR 4.25, 95% CI 1.24 to 14.56, p = 0.02) at 1 month, and this increased risk was also observed at 1 and 5 years. In conclusion, co-morbid burden, as measured using CCI, is an independent predictor of adverse outcomes in the short, medium, and long term. Co-morbidity should be considered in the decision-making process when counseling patients regarding the periprocedural risks associated with PCI, in conjunction with traditional risk factors.

Outcomes in patients with acute and stable coronary syndromes; insights from the prospective NOBORI-2 study.

BACKGROUND: Contemporary data remains limited regarding mortality and major adverse cardiac events (MACE) outcomes in patients undergoing PCI for different manifestations of coronary artery disease. OBJECTIVES: We evaluated mortality and MACE outcomes in patients treated with PCI for STEMI (ST-elevation myocardial infarction), NSTEMI (non ST-elevation myocardial infarction) and stable angina through analysis of data derived from the Nobori-2 study. METHODS: Clinical endpoints were cardiac mortality and MACE (a composite of cardiac death, myocardial infarction and target vessel revascularization). RESULTS: 1909 patients who underwent PCI were studied; 1332 with stable angina, 248 with STEMI and 329 with NSTEMI. Age-adjusted Charlson co-morbidity index was greatest in the NSTEMI cohort (3.78±1.91) and lowest in the stable angina cohort (3.00±1.69); P<0.0001. Following Cox multivariate analysis cardiac mortality was independently worse in the NSTEMI vs the stable angina cohort (HR 2.31 (1.10-4.87), p = 0.028) but not significantly different for STEMI vs stable angina cohort (HR 0.72 (0.16-3.19), p = 0.67). Similar observations were recorded for MACE (<180 days) (NSTEMI vs stable angina: HR 2.34 (1.21-4.55), p = 0.012; STEMI vs stable angina: HR 2.19 (0.97-4.98), p = 0.061. CONCLUSIONS: The longer-term Cardiac mortality and MACE were significantly worse for patients following PCI for NSTEMI even after adjustment of clinical demographics and Charlson co-morbidity index whilst the longer-term prognosis of patients following PCI STEMI was favorable, with similar outcomes as those patients with stable angina following PCI.

Dialysis access pseudoaneurysm: endovascular treatment with a covered stent.

Iatrogenic pseudoaneurysms of the brachial artery are rare complications of haemodialysis access procedures and can lead to substantial morbidity and mortality if not managed promptly; however, surgery is also associated with the potential risk of severe complications. We describe the clinical and radiological findings relating to a dialysed patient who developed a huge iatrogenic pseudoaneurysm of the brachial artery (due to an inadvertent artery puncture), which was successfully treated by means of the percutaneous implantation of a polytetrafluoroethylene (PTFE)-covered stent.

Does echocardiography play a role in the clinical diagnosis of congenital absence of pericardium? A case presentation and a systematic review.

Congenital absence of pericardium is an uncommon cardiac defect with variable clinical presentations. The detection of this malformation is clinically relevant because of potential complications such as fatal myocardial strangulation, myocardial ischemia and sudden death. Physical examination, chest radiograph and ECG are not helpful for the diagnosis. Echocardiography may accurately identify abnormalities in myocardial wall motion and in cardiac silhouette that may strongly suggest the diagnosis that is confirmed by magnetic resonance imaging (MRI) or computed tomography scan. A case presentation and a review of the literature with emphasis on the role of echocardiography are presented.