Target-controlled infusion during MitraClip procedures in deep-sedation with spontaneous breathing.

OBJECTIVE: Percutaneous mitral valve repair with the MitraClip system is an alternative procedure for high-risk patients not suitable for conventional surgery. The MitraClip can be safely performed under general anesthesia (GA) or deep sedation (DS) with spontaneous breathing using a combination of propofol and remifentanil. This study aimed to evaluate the benefits of target-controlled infusion (TCI) of remifentanil and administration of propofol during DS compared with manual administration of total intravenous anesthesia (TIVA) medication during GA in patients undergoing MitraClip. We assessed the impact of these procedures in terms of remifentanil dose, hemodynamic profile, adverse events, and days of hospital stay after the process. PATIENTS AND METHODS: From March 2013 to June 2015 (mean age 73.5 ± 9,54), patients underwent transcatheter MitraClip repair, 27 received DS via TCI and 27 GA with TIVA. RESULTS: Acute procedural success was 100%. DS-TCI group, in addition to a significant reduction of remifentanil dose administrated (249 µg vs. 2865, p < 0.01), resulted in a decrease in vasopressor drugs requirement for hemodynamic adjustments (29.6% vs. 63%, p = 0.03) during the procedure and a reduction of hypotension (p = 0.08). The duration of postoperative hospitalization did not differ between the two groups (5.4 days vs. 5.8 days, p = 0.4). CONCLUSIONS: Administration of remifentanil by TCI for DS in spontaneously breathing patients offers stable anesthesia conditions, with a lower amount of drugs, higher hemodynamic stability, and decreased side effects.

Anatomic features in SCAD assessed by CCT: A propensity score matching case control study.

PURPOSE: Spontaneous coronary artery dissection (SCAD) may occur in middle age population without any cardiovascular risk factor. We retrospectively evaluated anatomic features of 11 patients with SCAD using a coronary arteries computed tomography (CCT), compared to age and sex balanced patients who underwent CCT. MATERIAL AND METHODS: CCT was performed in 11 patients (7 females and 4 males) as follow-up in patients with SCAD (left anterior descending - LAD or circumflex artery - Cx) and compared, using the propensity score matching analysis, with 11 healthy patients. Several anatomic features were evaluated: Left main (LM) length, angle between descending coronary artery (LAD) and its first branch, angle between LAD and LM, distance from the annulus to RCA (a-RCA distance) and LM (a-LM distance) ostia and their ratio; ratio between LM length and length a-LM and tortuosity score of the vessel with SCAD. A fluid dynamic analysis has been performed to evaluate the effects on shear stress of vessels wall. RESULTS: LM length was significantly shorter in patients with SCAD versus healthy subjects (P=0.01) as well as LM length/a-LM (P=0.03) and the angle between LAD and the first adjacent branch was sharper (P<0.01). Tortuosity score showed a statistically significant difference between groups (P<0.001). Fluid dynamic analysis demonstrates that, in SCAD group, an angle<90 degree is present at the first bifurcation and it can be a cause of increased strain on vessel wall in patients with high tortuosity of coronary artery. CONCLUSION: Tortuosity and angle between the LAD and the adjacent arterial branch combined may determine increased shear stress on the vessel wall that increases the risk of SCAD.

Effectiveness of the new generation transcatheter aortic valve in the real life studies. Review and meta-analysis.

OBJECTIVE: The aim of the meta-analysis was to assess post-procedural outcome of the new generation of transcatheter aortic valve implantation (TAVI) devices, focusing on the transfemoral and balloon-expandable SAPIEN 3 (Edwards Lifesciences Inc., Irvine, CA, USA), the self-expanding CoreValveTM Evolut series R and PRO (R/PRO)TM (Medtronic Inc., Minneapolis, MN, USA) and ACURATE neoTM transcatheter aortic valve (Symetis SA, a Boston Scientific company, Ecublens, Switzerland). MATERIALS AND METHODS: All observational studies were retrieved through PubMed computerized database from January 2014 until June 30th, 2019. The risk difference (RD) with the 95% confidence interval (CI) was used to assess the effectiveness of the intervention under comparison. The primary end point was 30-day mortality. Safety end points included: (i) stroke, (ii) moderate/severe paravalvular leak, and (iii) the need for new permanent pacemaker implantation. RESULTS: Meta-analysis demonstrated no significant differences as regards to either 30-day mortality or stroke for all the groups of prostheses under comparison. ACURATE neo was associated with significantly less new permanent pacemaker implantation compared to SAPIEN 3 (RD: -0.06; 95% CI -0.08 to -0.03; p<0.0001; I2=0%) or to EVOLUT R/PRO (RD: -0.06; 95% CI -0.09 to -0.02; p=0.0009; I2=0%). A significant reduction of new permanent pacemaker need was observed in the group of patients implanted with SAPIEN 3 compared to EVOLUT R/PRO (RD: -0.07; 95% CI -0.09 to -0.04; p<0.00001; I2=7%). The occurrence of moderate/severe leak was significantly increased in the group of patients implanted with ACURATE neo vs. SAPIEN 3 (RD: 0.04; 95% CI 0.02 to 0.05; p<0.00001; I2=0%). No significant differences were found between ACURATE neo vs. EVOLUT R/PRO (RD: -0.01; 95% CI -0.04 to 0.02; p=0.69; I2=0%) and between SAPIEN 3 vs. EVOLUT R/PRO (RD: -0.01; 95% CI -0.04 to 0.01; p=0.28; I2=73%). CONCLUSIONS: The results of the meta-analysis show that: (1) ACURATE neo was associated with significantly less new permanent pacemaker implantation than SAPIEN 3 and EVOLUT R/PRO; (2) SAPIEN 3 had significantly lower occurrence of moderate/severe valvular leak than ACURATE neo.

Meta-analysis of the impact on early and late mortality of TAVI compared to surgical aortic valve replacement in high and low-intermediate surgical risk patients.

OBJECTIVE: We studied the impact of transcatheter aortic valve implantation (TAVI) compared to the surgical aortic valve replacement (SAVR) on 30-day and one-year mortality from randomized controlled trials (RCTs) in patients with severe aortic stenosis at high or low-intermediate surgical risk. MATERIALS AND METHODS: All RCTs were retrieved through PubMed computerized database and the site https://www.clinicaltrials.gov from January 2010 until March 31st, 2019. The absolute risk reduction (RD) with the 95% confidence interval (CI) was used to assess the effectiveness of the intervention under comparison. We evaluated overall mortality rates at 30-day and one-year follow-up in the comparison between TAVI vs. SAVR. We also evaluated the role played by the site access for TAVI performed through the femoral or subclavian artery (TV-TAVI) vs. SAVR, or transapically (TA-TAVI) vs. SAVR. RESULTS: In the "as-treated population" the overall 30-day mortality was significantly lower in TAVI (p=0.03) with respect to SAVR. However, the analysis for TAVI subgroups showed that 30-day mortality was (1) significantly lower in TV-TAVI vs. SAVR (p=0.006), (2) increased, not significantly, in TA-TAVI vs. SAVR (p=0.62). No significant differences were found between TAVI vs. SAVR at one-year follow-up. CONCLUSIONS: The results of our meta-analysis suggest that TV-TAVI is a powerful tool in the treatment of severe aortic stenosis at high or low-intermediate surgical risk, with a significant lower mortality with respect to SAVR. On the contrary, SAVR seems to provide better results than TA-TAVI.

[Management programs for elderly patients with chronic heart failure]. / Programmi di gestione dell'anziano con scompenso cardiaco cronico.

PURPOSE: Most patients with heart failure are elderly with multiple coexisting diseases and heart failure is the most common discharge diagnosis in elderly hospitalized patients. Despite major advances in the pharmacotherapy of heart failure, hospitalization rates remain high, owing in large part to a multitude of psychosocial, behavioral, and financial factors that serve as barriers to effective compliance with prescribed treatment. In the last decade, several models have been proposed in order to optimise the long-term management of elderly patients with heart failure. DESIGN: A review of most significant and recent models available was performed. RESULTS: Several studies have documented the efficacy of specialized multidisciplinary heart failure disease management programs in terms of reducing hospital utilization, improving quality of life, functional capacity, patient satisfaction, compliance with diet and medications and decreasing cost of care. CONCLUSIONS: At present, the greatest challenge in managing elderly heart failure patients is to more effectively implement proven treatments and disease management systems.

["The memory effect" in healthy heart and transplanted heart. "Cor se ipse alit, se ipse movet, se ipse reget"]. / "L'effetto memoria" nel cuore sano e nel cuore trapiantato. "Cor se ipse alit, se ipse movet, se ipse reget".

The heart's memory, interpreted as information residue between a cardiac cycle and the subsequent one, is a very definite phenomenon (short- term memory) both in healthy subjects and in heart transplanted recipients. This "memory effect", we have observed by the autocorrelation and by the spectrum analysis of the values expressing the heartbeat acceleration variability (tachogram 24 h). The "memory effect" cannot be absolutely put down in heart transplanted recipients to interference or to the activity of the central and/or peripheral nervous system, because the heart transplanted is a denervated heart by definition. Moreover, an immediate regulating effect of hormonic factors in the short-term heartbeat regulation is not completely plausible. As already known, the heart transplanted responds to the emergency situation autonomously and autochthonously in proportion to the signals reaching it directly from the circle (vascular resistance, blood pressure, etc.). This implies the existence of functional memory that is likely to be inborn in the conduction system of the heart. Looking at the results of our research we can conclude: "cor se ipse alit, se ipse movet, se ipse reget" (it autonomously models itself to all the different modifications in the circle, it feeds itself as the organ propelling blood circulation and, if necessary, it carries on its kinetic activity autonomously).

[Anomalous origin of the right coronary artery from the pulmonary artery: a case report]. / Origine anomala della coronaria destra dalla arteria polmonare: descrizione di un caso clinico.

The abnormal origin of the right coronary artery from the pulmonary trunk is currently one of the most significant coronary anomalies that is not associated with diffuse atherosclerotic involvement. Because of the lack of specific symptoms, it is often the outcome of casual observation during heart surgery or autopsy. At times, the patients die of congestive heart failure or sudden death without even having had this anomaly diagnosed. We describe the case of a 41-year-old woman who came under our observation due to palpitations, both at rest and under stress, that were also associated with chest pain at times. Clinical and instrumental investigation revealed the abnormal origin of the right coronary artery from the pulmonary trunk, indicating that the symptoms were probably caused by intracoronary or intercoronary "stealing". The primary treatment of this pathology is based on surgical techniques, and it is constituted by the simple ligation of the anomalous vessel or the ligation of the right coronary artery, with saphenous vein by-pass grafting or the reimplantation of the right coronary artery into the aorta. We opted for reimplantation of the anomalous vessel into the aorta: a three-year follow-up has shown very good results, with complete disappearance of the symptoms.