Effects of a medical admission unit on in-hospital patient flow and clinical outcomes.

BACKGROUND: the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists. METHODS: all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years. RESULTS: 2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001. CONCLUSIONS: over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.

Induced myocardial ischemia in candidates to liver transplantation without evidence of heart disease.

BACKGROUND: Coronary artery disease (CAD) is associated with perioperative liver transplantation (LT) mortality. In absence of a defined risk algorithm, we aimed to test whether stress echocardiography and coronary computed tomography angiography (CCTA) could detect CAD in end-stage liver disease (ESLD) patients without previous evidence of heart disease. METHODS: LT candidates ≥30 years underwent a cardiovascular (CV) assessment through stress echocardiography. CCTA was performed in patients ≥50 years with two or more CV risk factors (e.g. diabetes, CAD family history, dyslipidaemia). Coronary angiography (CAG) was scheduled when stress echocardiography and/or CCTA were positive. Sensibility, specificity, positive and negative predictive values of stress echocardiography and CCTA were assessed by numbers of coronary revascularization (true positives) and lack of acute coronary events over a mean follow-up of 3 years (true negatives). RESULTS: Stress echocardiography was performed in 273 patients, CCTA in 34 and CAG in 41. Eight patients had critical coronary lesions, and 19 not-critical lesions. Sensitivity, specificity, positive and negative predictive values were 50.0%, 90.2%, 13.3% and 98.4% for stress echocardiography and 100%, 76.7%, 36.4% and 100% for CCTA. Among 163 patients who underwent LT (57.6%), 16 died and 5 had major adverse CV events over a mean follow-up of 3 years. CONCLUSIONS: A very low prevalence of CAD in a selected population of ESLD at intermediate to high CV risk was found. A screening based on stress echocardiography and CCTA resulted in low incidence of post-LT acute coronary events in ELSD patients. CAD has no impact on mid-term survival.

Clinical Management of New-Onset Atrial Fibrillation in COVID-19 Patients Referred to a Tertiary Cardiac Arrhythmia Center after Hospital Discharge.

BACKGROUND: Available reports on the post-discharge management of atrial fibrillation (AF) in COVID-19 patients are scarce. The aim of this case series was to describe the clinical outcomes of new-onset AF in COVID-19 patients referred to a tertiary cardiac arrhythmia center after hospital discharge. METHODS: All consecutive patients referred to our center for an ambulatory evaluation from 18 May 2020 to 15 March 2022 were retrospectively screened. Patients were included in the current analysis if new-onset AF was diagnosed during hospitalization for COVID-19 and then referred to our clinic. RESULTS: Among 946 patients, 23 (2.4%) were evaluated for new-onset AF during COVID-19. The mean age of the study cohort was 71.5 ± 8.1 years; 87.0% were male. Median time from COVID-19 discharge and the first ambulatory evaluation was 53 (41.5-127) days; median follow-up time was 175 (83-336) days. At the in-office evaluation, 14 (60.9%) patients were in sinus rhythm, and nine patients were in AF. In 13.0% of cases, oral anticoagulation was stopped according to CHADS-VASc. Eight patients in AF were scheduled for electrical cardioversion; one patient was rate-controlled. Four patients were treated with catheter ablation (CA) during follow-up. Two post-cardioversion AF recurrences were detected during follow-up, while no recurrences were diagnosed among patients who underwent CA. CONCLUSION: Our data suggest that AF may not be considered as a simple bystander of the in-hospital COVID-19 course. Management of new-onset AF in post-COVID-19 patients referred to our clinic did not significantly differ from our usual practice, both in terms of long-term oral anticoagulation and in terms of rhythm control strategy.

Viral Myocarditis: Classification, Diagnosis, and Clinical Implications.

Myocarditis is an inflammatory disease of the myocardium with focal or diffuse involvement. Viral infections are the most common cause of myocarditis, especially in Western countries. A recent viral illness with gastroenteric or upper respiratory symptoms often precedes myocarditis. The absence of specific pathognomonic features in conjunction with the wide spectrum of clinical manifestations that range from subclinical cases to sudden cardiac death (SCD) makes myocarditis diagnosis particularly challenging. Moreover, myocarditis might represent a cause of initially unexplained dilated cardiomyopathy (DCM) and heart failure (HF), especially among children and young adults. Cardiac magnetic resonance imaging (CMR) is crucial for myocarditis diagnosis, because of its ability to detect interstitial edema during acute inflammation. Assessment of subepicardial or mid-myocardial fibrosis by late gadolinium enhancement (LGE) is typical for myocarditis. Cardiac arrhythmias are frequent events that may arise especially in more severe myocarditis cases. The most common form of arrhythmia is atrial fibrillation, followed by ventricular tachycardia. Documented arrhythmias have been reported more commonly with HIV myocarditis than other more common infections such as Adenovirus, Parvovirus B19, human Herpes virus 6, and Enterovirus. The mechanisms of arrhythmogenesis in myocardial inflammation are not fully understood; in the acute phase, the spectrum of arrhythmogenesis ranges from a direct effect on cardiomyocytes that leads to electrical instability and ion channel impairment to ischemia from coronary macro- or microvascular disease. In chronic myocarditis, instead, myocardial replacement with fibrosis promotes scar-mediated re-entrant ventricular arrhythmias. Observational data suggested the important role of CMR, with LGE being the strongest independent predictor of SCD, cardiac, and all-cause mortality. In acute myocarditis, the most common localization of subepicardial LGE dwells in the lateral wall. Patients with myocarditis that develop HF and arrhythmias usually show a larger LGE distribution involving several myocardial segments. Moreover, a mid-layer LGE in the interventricular septum is more frequent in acute myocarditis than in acute coronary syndromes cases. The risk of SCD in patients with wide areas of LGE is significant, and a shared decision-making approach is warranted. Nevertheless, there is no formal consensus about the extension of LGE to justify implantable cardioverter defibrillator (ICD) implantation in primary prevention.

Extensive intra-myocardial calcifications: Value of multimodality imaging.

BACKGROUND: Massive myocardial calcification is a very rare finding. INTRODUCTION: Accurate identification and characteriation may help the clinicians to determine the etiology and clinical significance. RESULTS: In this case, the diagnostic pathway excluded previous myocardial infarction, myocarditis, and calcium-phosphate disorders. A possible dystrophic etiology was considered. DISCUSSION: There are no standardized imaging features available to classify specific subtypes of intra-myocardial calcifications. The relative merits of computed tomography and cardiac magnetic resonance (CMR) in providing complimentary diagnostic information in the evaluation of calcific myocardial lesions are shown. CONCLUSION: Knowledge of the potential etiology and their imging patterns are important to provide a concise and accurate differential diagnosis.

Early diagnosis of cardiomyopathies by cardiac magnetic resonance. Overview of the main criteria.

Cardiomyopathies (CMPs) are diseases of the heart muscle. They include a variety of myocardial disorders that manifest with various structural and functional phenotypes and are frequently genetic. Myocardial disease caused by known cardiovascular causes (such as hypertension, ischemic heart disease, or valvular disease) should be distinguished from CMPs for classification and management purposes. Identification of various CMP phenotypes relies primarily upon echocardiographic evaluation. In selected cases, cardiac magnetic resonance imaging (CMR) or computed tomography may be useful to identify and localize fatty infiltration, inflammation, scar/fibrosis, focal hypertrophy, and better visualize the left ventricular apex and right ventricle.  CMR imaging has emerged as a comprehensive tool for the diagnosis and follow-up of patients with CMPs. The accuracy and reproducibility in evaluating cardiac structures, the unique ability of non-invasive tissue characterization and the lack of ionizing radiation, make CMR very attractive as a potential "all-in-one technique". Indeed, it provides valuable data to confirm or establish the diagnosis, screen subclinical cases, identify aetiology, establish the prognosis. Additionally, it provides information for setting a risk stratification (based on evaluation of proved independent prognostic factors as ejection fraction, end-systolic-volume, myocardial fibrosis) and follow-up. Last, it helps to monitor the response to the therapy. In this review, the pivotal role of CMR in the comprehensive evaluation of patients with CMP is discussed, highlighting the key features guiding differential diagnosis and the assessment of prognosis.

Pre-heart failure at 2D- and 3D-speckle tracking echocardiography: A comprehensive review.

Chronic heart failure (CHF) has different stages and includes pre-HF (PHF), a state of high risk of developing myocardial dysfunction and advanced CHF. Some major behavioral risk factors of PHF might predispose to biological risk factors such as obesity, diabetes mellitus, dyslipidemia, hypertension, myocardial infarction, and cardiomyopathy. These risk factors damage the myocytes leading to fibrosis, apoptosis, cardiac hypertrophy, along with alterations in cardiomyocyte' size and shape. A condition of physiological subcellular remodeling resulting into a pathological state might be developed, conducting to PHF. Both PHF and heart failure (HF) are associated with the activation of phospholipases and protease, mitochondrial dysfunction, oxidative stress and development of intra-cellular free Ca2+  [Ca2+ ]i overloading to an elevation in diastolic [Ca2+ ]i . Simultaneously, cardiac gene expression is activated leading to further molecular, structural and biochemical changes of the myocardium. The sub-cellular remodeling may be intimately involved in the transition of cardiac hypertrophy to heart failure. 2D- and 3D-speckle tracking echocardiography (STE) have been used to quantify regional alterations of longitudinal strain and area strain, through their polar projection, which permits a further assessment of both sites and degrees of myocardial damage. The examination of strain can identify sub-clinical cardiac dysfunction or cardiomyocyte remodeling. During remodeling of the myocardium cardiac strain is attenuated, therefore it is an indicator of disease assessment.

Percutaneous closure of a paravalvular prosthetic mitral leak complicated by need for acute hemodialysis.

A case of a severe paravalvular mechanical mitral prosthesis leak (PVL) in a high-risk surgical patient, complicated with acute heart failure at presentation is described. Considering the high surgical risk and the specific echocardiographic features that would prevent the interventional cardiologist to have a direct access to the PVL with a traditional vascular plug or duct occluder, a percutaneous PVL closure with an Amplatzer-Amulet (Abbott, Abbott Park, Illinois, United States) LAA device (28 mm) was chosen for the contiguity of the PVL to the left atrial appendage (LAA). A new-onset hemolysis post-PVL closure and severe renal failure requiring hemodialysis occurred after the procedure, treated with surgical device removal and leak suture. To the best of our knowledge, this is the first case that describes the attempt to close a PVL, contiguous to the LAA, using the Amulet device. The attempt to close a PVL with these features with an Amplatzer-Amulet device, although promising, does not appear completely safe to reach the goal, as in our case. In our opinion, the most important reasons are that specific technical recommendations and broad experiences are lacking. Indeed, specific outcomes of this kind of approach are, to date, still unknown.

Etiology and device therapy in complete atrioventricular block in pediatric and young adult population: Contemporary review and new perspectives.

Complete atrioventricular block (CAVB) is a total dissociation between the atrial and ventricular activity, in the absence of atrioventricular conduction. Several diseases may result in CAVB in the pediatric and young-adult population. Permanent right ventricular (RV) pacing is required in permanent CAVB, when the cause is neither transient nor reversible. Continuous RV apical pacing has been associated with unfavorable outcomes in several studies due to the associated ventricular dyssynchrony. This study aims to summarize the current literature regarding CAVB in the pediatric and young adult population and to explore future treatment perspectives.

Two-dimensional transthoracic echocardiographic finding of left atrial compression resulting from blunt trauma to the thoracic spine.

We present an adult female in whom two-dimensional transthoracic echocardiography demonstrated encroachment of the thoracic spine on the left atrium (LA) resulting in a very small, compressed LA cavity by a prominent thoracic spine shadow. Computed tomography (CT) scan of the chest showed compression of the LA produced by localized anterior deformation of the thoracic spine which had resulted from blunt injury to her spine following a fall from a swing several years previously.

Acute cardiac disease in the postpartum: What to think.

A rare case of a spontaneous coronary artery dissection (SCAD) in the postpartum of a 32-year-old woman is presented. Pregnancy-related SCAD is a potentially life-threatening condition. SCAD is triggered by nonatherosclerotic disease, typically affects young-aged women and is still often underdiagnosed. Cardiac magnetic resonance is crucial to demonstrate the ischemic origin of the disease. A conservative management is generally preferred in stable SCAD as most dissected segments will heal spontaneously over a few months. Additionally, the percutaneous coronary intervention is associated with high rate of complications and procedural failure. The aim of this case was to improve awareness of SCAD and to advise clinicians seeking aid with patient management.

Atrial fibrillation, an epiphenomenon of acute Stanford type-A aortic dissection with suspected intimo-intimal intussusception.

Supraventricular arrhythmias can sometimes be "only" epiphenomena appearing during acute hypoxia, pneumonia, pulmonary embolism, and thrombosis. Indeed, atrial fibrillation is not rare in acute aortic dissection as it is estimated in about one half of patients and may be secondary to a perfusion deficit of the sinoatrial node artery.

Cor triatriatum dexter associated with atrial septal defect: Management in a complex clinical case.

The coexistence of an atrial septal defect and a prominent eustachian valve is a rare congenital anomaly, rarely reported in literature. Differentiation between a giant eustachian valve and cor triatriatum dexter can be difficult. A case of a large atrial septal defect associated with cor triatriatum dexter diagnosed by echocardiography in an asymptomatic woman is reported. A watchful waiting strategy was adopted.