Breast Regional Anesthesia Practice in the Italian Public Health System (BRA-SURVEY): A Survey-Based National Study.

BACKGROUND: Breast cancer is the most common malignancy in women. Surgery is a mainstay therapy unfortunately burdened by complications as severe postoperative pain. Regional anesthesia may play a role in a multimodal strategy for prevention and treatment of postoperative pain. The main purpose of this survey was to investigate the rate of use of regional anesthesia techniques in patients undergoing breast surgery in the Italian public hospital system. METHODS: We designed an online survey that consisted of 22 questions investigating the anesthesia management of breast surgery, particularly focused on regional anesthesia. The survey lasted from November 18, 2019 to February 28, 2020. Directors of anesthesia departments of 168 Italian public health system hospitals were contacted and invited to forward the survey to every anesthesiologist in their unit. RESULTS: A total of 935 anesthesiologists received the survey; among them 460 entered the final analysis. Regional anesthesia was not used by 44.6% of the anesthesiologists and lack of experience/training was the main cause (75.6%). Logistic regression models revealed that anesthesiologists with more than 15 years of experience (odds ratio [OR] = 0.55; 95% confidence interval [CI], 0.33-0.93) or working most of their days in intensive care unit (ICU) compared to operating theater (OR = 0.25; 95% CI, 0.14-0.43) were less likely to perform regional anesthesia techniques. CONCLUSIONS: Low implementation of regional anesthesia techniques in breast surgery emerges from our survey and the major reason cited is a lack of proper training. An improved training program in regional anesthesia, especially in residents' curricula, could be useful to increase its rate of use and to standardize its practice.

[Sudden cardiac death in athletes: is it always not preventable?]. / La morte cardiaca improvvisa negli atleti: è sempre non prevenibile?

Sudden cardiac death (SCD) in athletes is a rare but tragic event particularly considering that in some cases it is preventable. In young athletes with cardiovascular disease the risk of SCD is 2,5 times higher than in non-athletes. In young athletes (<35 years old), the most common causes of SCD are related to pre-existing cardiovascular disorders including hypertrophic cardiomyopathy, congenital coronary anomalies, arrhythmogenic right ventricular dysplasia, commotio cordis, some channelopathies and cardiac sarcoidosis. Actually there are two approches to pre-participation athletic screening: the American one based on anamnesis and physical examination and the European one based on anamnesis, physical examination and ECG at rest. However, some disorders responsible for SCD can't be suspected through these exams and it could be useful to implement preparticipation athletic screening.

Role of bisoprolol in patients with long QT syndrome.

BACKGROUND: Long QT syndrome (LQTS) is a disorder of ventricular repolarization usually treated with ß-blockers, mostly with propanolol and nadolol. The aim of our study was to evaluate the role of bisoprolol in LQTS patients. METHODS: A total of 34 patients were evaluated in an average follow-up time of 93 months: 31 months without treatment, 31 months in treatment with nadolol or propanolol and 31 months in treatment with bisoprolol. The average age of patients at diagnosis was 17.3 years. The enrolled patients were followed through a semiannual electrocardiogram and an annual 24-hour Holter monitoring. All patients underwent genotyping, routine hematologic tests, and an echocardiogram. RESULTS: In 93 months there were 2 major and 12 minor cardiovascular events. Both the major events occurred in absence of ß-blocking therapy. Of the 12 minor cardiovascular events 3 occurred in absence of treatment, 7 during treatment with nadolol or propranolol, and 2 during treatment with bisoprolol. The mean heart rate at 24 h Holter was 87 bpm without treatment, 71 bpm in patients treated with propanolol and nadolol, and 70 bpm in patients treated with bisoprolol. There were not statistically significant differences between the three groups in the mean QTc. CONCLUSIONS: Beta-blocking therapy is the cornerstone of LQTS therapy but actually there is no clear indication about which beta-blocker should be used. In our experience bisoprolol proved to be less harmful and easier to manage than propranolol and nadolol in patients with LQTS, with the same effectiveness in preventing major cardiovascular events.

[Morpho-volumetric assessment of the right ventricle: a comparison between three-dimensional echocardiography and cardiac magnetic resonance]. / Valutazione morfo-funzionale del ventricolo destro: confronto tra ecocardiografia e risonanza magnetica cardiaca.

The morpho-volumetric assessment of the right ventricle (RV) is useful in the diagnosis and prognosis of many congenital and acquired cardiovascular diseases. The complexity of the right ventricular shape does not allow an adequate and satisfactory evaluation of the RV. Two-dimensional (2D) echocardiography is the most used tool for the assessment of RV function, as it is a noninvasive, reproducible and widespread technique, but the geometric assumptions required for measurement of RV volumes reduce its accuracy. At present, cardiac magnetic resonance is the gold standard for the evaluation of RV volumes because it does not need any assumption and is reproducible, though not always available. This imaging tool allows to follow-up patients and to monitor drug therapy. On the other hand, three-dimensional (3D) echocardiography overcomes several limitations of 2D echocardiography, in that it provides an estimation of RV volumes obtained through a real 3D data set, obtaining sections which cannot be technically achieved with 2D echocardiography. It is therefore useful to compare data on RV volumes and function obtained with 3D echocardiography versus cardiac magnetic resonance, mainly considering the lower costs and higher portability and availability of echocardiography.

[Diagnosis, prognosis and treatment of "myocardial bridging": state of the art and unresolved issues]. / Diagnosi, prognosi e terapia del "ponte intramiocardico": stato dell'arte e questioni irrisolte.

The current gold standard for the diagnosis of myocardial bridging is conventional coronary angiography; however, it shows only indirect signs of the disease, due to the systolic compression of the artery caused by the myocardial bridge with narrowing of the lumen and diastolic relaxation. On the other hand, computed tomography coronary angiography, even though exposing to radiation, clearly demonstrates the intramural course, the overlying muscular bands and the surrounding tissues also in asymptomatic patients and in absence of systolic compression. The prognosis of patients with myocardial bridge is usually good, but further studies are needed to evaluate the long-term prognosis of these patients, the adequate diagnostic and preventive approach and to better discern which patients should be candidate to medical, percutaneous or surgical treatment.

[Cardiorenal syndrome: the role of new biochemical markers]. / Sindrome cardiorenale: il ruolo dei nuovi marker biochimici.

Cardiorenal syndrome is a pathophysiological heart and kidney disorder, in which acute or chronic dysfunction of one organ induces a damage in the other. It's a syndrome more and more often encountered in clinical practice and this implies the need to recognize the syndrome through biochemical markers with a good sensitivity and specificity, since its earliest stages in order to optimize therapy. In addition to widely validated biomarkers, such as BNP, pro BNP, creatinine, GFR and cystatin C, other promising molecules are available, like NGAL (neutrophil gelatinase-associated lipocalin, KIM-1 (kidney injury molecule-1), MCP-1 (monocyte chemotactic peptide), Netrin-1, interleuchin 18 and NAG (N-acetyl-ß-glucosa-minidase). The role of these emerging biomarkers is still not completely clarified: hence the need of new clinical trials.

Right Heart Thrombus in an Adult COVID-19 Patient: A Case Report.

INTRODUCTION: Right heart thrombus (RiHTh) can be considered a rare and severe condition associated with thromboembolic phenomena. A case is described of a COVID-19 patient presenting with an isolated thrombus in the right ventricle. CASE PRESENTATION: An 80-years-old Caucasian male was admitted in an intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome. The patient showed signs of hemodynamic instability, elevated cardiac troponin I and altered coagulation. On further assessment, a thrombotic mass near the apex of the right ventricle was detected. Moreover, the apex and the anteroseptal wall of the right ventricle appeared akinetic. Following the administration of a therapeutic dose of unfractionated heparin over a forty-eight hour period, re-evaluation of the right chambers showed that the thrombotic mass had resolved entirely. CONCLUSION: COVID-19 patients could constitute a population at risk of RiHTh. Routine use of echocardiography and a multidisciplinary approach can improve the management of this condition.

Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management.

Long QT syndrome incidence is increasing in general population. A careful pre-, peri- and post-operative management is needed for patients with this syndrome because of the risk of Torsades de Pointes and malignant arrhythmias. The available data regarding prevention of lethal Torsades de Pointes during anesthesia in patients with long QT syndrome is scant and conflicting: only case reports and small case series with different outcomes have been published. Actually, there are no definitive guidelines on pre-, peri- and post-operative anesthetic management of congenital long QT syndrome. Our review focuses on anesthetic recommendations for patients diagnosed with congenital long QT syndrome furnishing some key points for preoperative optimization, intraoperative anesthetic agents and postoperative care plan, which could be the best for patients with c-long QT syndrome who undergo surgery.