ANMCO position paper: 2022 focused update of appropriate use criteria for multimodality imaging: aortic valve disease.

This document addresses the evaluation of the Appropriate Use Criteria (AUC) of multimodality imaging in the diagnosis and management of aortic valve disease. The goal of this AUC document is to provide a comprehensive resource for multimodality imaging in the context of aortic valve disease, encompassing multiple imaging modalities. Clinical scenarios are developed in a simple way to illustrate patient presentations encountered in everyday practice.

Differential diagnosis of cardiac tumors: General consideration and echocardiographic approach.

Cardiac tumors may be primary (either benign or malignant) or secondary (malignant) and are first detected by echocardiography in most cases. The cardiologist often challenges their identification, the differential diagnosis and the best therapeutic approach. Malignant tumors have usually a poor prognosis, which may be significantly improved by appropriate and timely therapies. The echocardiographic aspects of benign and malignant cardiac tumors described in this article, along with a clinical evaluation may orient the differential diagnosis and aid in choosing the further steps useful to define the nature of the mass.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement.

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

The Strange Case of the Infarcted Myxoma.

In the setting of an acute coronary syndrome, the differential diagnosis between a thrombus and a myxoma may be cumbersome. We describe the case of a patient presenting with an acute coronary syndrome associated with an aneurysmatic apical left ventricular myxoma.

Thrombotic aortic restenosis after transapical SAPIEN valve implantation.

We describe a patient previously implanted with a SAPIEN Edwards valve by the transapical approach, who subsequently experienced a valve thrombosis. The literature on this subject is reviewed.

Sustainable whey proteins-nanostructured zinc oxide-based films for the treatment of chronic wounds: New insights from biopharmaceutical studies.

Chronic wounds represent silent epidemic affecting a large portion of the world population, especially the elders; in this context, the development of advanced bioactive dressings is imperative to accelerate wound healing process, while contrasting or preventing infections. The aim of the present work was to provide a deep characterization of the functional and biopharmaceutical properties of a sustainable thin and flexible films, composed of whey proteins alone (WPI) and added with nanostructured zinc oxide (WPZ) and intended for the management of chronic wounds. The potential of whey proteins-based films as wound dressings has been confirmed by their wettability, hydration properties, elastic behavior upon hydration, biodegradation propensity and, when added with nanostructured zinc oxide, antibacterial efficacy against both Gram-positive and Gram-negative pathogens, i.e. Staphylococcus aureus and Escherichia coli. In-vitro experiments, performed on normal human dermal fibroblasts, confirmed film cytocompatibility, also revealing the possible role of Zn2+ ions in promoting fibroblast proliferation. Finally, in-vivo studies on rat model confirmed film suitability to act as wound dressing, since able to ensure a regular healing process while providing effective protection from infections. In particular, both films WPI and WPZ are responsible for the formation in the wound bed of a continuous collagen layer similar to that of healthy skin.

St. Jude Trifecta versus Carpentier-Edwards Perimount Magna valves for the treatment of aortic stenosis: comparison of early Doppler-echocardiography and hemodynamic performance.

OBJECTIVE: Aim of this study was to compare the hemodynamic profiles of 2 aortic valve bioprostheses: the Carpentier Edwards Perimount Magna (CEPM) valve and the Trifecta valve. METHODS: 100 patients who underwent AVR for severe symptomatic AS between September 2011 and October 2012 were analyzed by means of standard trans-thoracic Doppler-echocardiography. RESULTS: Mean and peak gradients were significantly lower for the 21 mm Trifecta vs CEPM (11 +/- 4 vs 15 +/- 4 mmHg, and 20 +/- 6 vs 26 +/- 7 mmHg, respectively; all p < 0.05) and the 23 mm Trifecta vs CEPM (8 +/- 2 vs 14 +/- 4 mmHg, and 17 +/- 6 vs 25 +/- 9 mmHg; all p < 0.05). Effective orifice area tended to be slightly higher for the Trifecta valve. CONCLUSION: The new bioprosthetic valve Trifecta has an excellent hemodynamic profile, and lower trans-prosthesic gradients when compared to CEPM valve.

Antimicrobial Nano-Zinc Oxide Biocomposites for Wound Healing Applications: A Review.

Chronic wounds are a major concern for global health, affecting millions of individuals worldwide. As their occurrence is correlated with age and age-related comorbidities, their incidence in the population is set to increase in the forthcoming years. This burden is further worsened by the rise of antimicrobial resistance (AMR), which causes wound infections that are increasingly hard to treat with current antibiotics. Antimicrobial bionanocomposites are an emerging class of materials that combine the biocompatibility and tissue-mimicking properties of biomacromolecules with the antimicrobial activity of metal or metal oxide nanoparticles. Among these nanostructured agents, zinc oxide (ZnO) is one of the most promising for its microbicidal effects and its anti-inflammatory properties, and as a source of essential zinc ions. This review analyses the most recent developments in the field of nano-ZnO-bionanocomposite (nZnO-BNC) materials-mainly in the form of films, but also hydrogel or electrospun bandages-from the different preparation techniques to their properties and antibacterial and wound-healing performances. The effect of nanostructured ZnO on the mechanical, water and gas barrier, swelling, optical, thermal, water affinity, and drug-release properties are examined and linked to the preparation methods. Antimicrobial assays over a wide range of bacterial strains are extensively surveyed, and wound-healing studies are finally considered to provide a comprehensive assessment framework. While early results are promising, a systematic and standardised testing procedure for the comparison of antibacterial properties is still lacking, partly because of a not-yet fully understood antimicrobial mechanism. This work, therefore, allowed, on one hand, the determination of the best strategies for the design, engineering, and application of n-ZnO-BNC, and, on the other hand, the identification of the current challenges and opportunities for future research.

Clinical Utility of Three-Dimensional Echocardiography in the Evaluation of Mitral Valve Disease: Tips and Tricks.

Although real-time 3D echocardiography (RT3DE) has only been introduced in the last decades, its use still needs to be improved since it is a time-consuming and operator-dependent technique and acquiring a good quality data can be difficult. Moreover, the additive value of this important diagnostic tool still needs to be wholly appreciated in clinical practice. This review aims at explaining how, why, and when performing RT3DE is useful in clinical practice.

Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management.

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.

Congenitally corrected transposition of the great arteries with severely stenotic bicuspid aortic valve in an adult: a case report.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare disease accounting for 0.5-1.4% of patients with congenital heart disease. In this congenital cardiopathy, the left atrium is connected to the right ventricle, from which the aorta stems. We present a case of an adult with CCTGA associated with aortic stenosis and bicuspid aortic valve-an association not yet described to our knowledge.

Whey Proteins-Zinc Oxide Bionanocomposite as Antibacterial Films.

The use of toxic crosslinking agents and reagents in the fabrication of hydrogels is a frequent issue which is particularly concerning for biomedical or food packaging applications. In this study, novel antibacterial bionanocomposite films were obtained through a simple solvent casting technique without using any crosslinking substance. Films were made from a flexible and transparent whey protein matrix containing zinc oxide nanoparticles synthesised via a wet chemical precipitation route. The physicochemical and functional properties of the ZnO nanoparticles and of the composite films were characterised, and their antibacterial activity was tested against S. epidermidis and E. coli. The synthesised ZnO nanoparticles had an average size of about 30 nm and a specific surface area of 49.5 m2/g. The swelling ratio of the bionanocomposite films increased at basic pH, which is an appealing feature in relation to the absorption of chronic wound exudate. A n-ZnO concentration-dependent antibacterial effect was observed for composite films. In particular, marked antibacterial activity was observed against S. epidermidis. Overall, these findings suggest that this novel material can be a promising and sustainable alternative in the design of advanced solutions for wound dressing or food packaging.

An isolated anterior mitral leaflet cleft: a case report.

INTRODUCTION: The anterior mitral leaflet cleft is an unusual congenital lesion most often encountered in association with other congenital heart defects. The isolated anterior leaflet cleft is quite a rare anomaly and is usually cause of mitral valve regurgitation. The importance of the lesion is that it is often correctable. When feasible, cleft suture and, eventually, annuloplasty are preferable to valve replacement. Echocardiography is the first choice technique in the evaluation of mitral valve disease, providing useful information about valve anatomy and hemodynamic parameters. CASE PRESENTATION: We present a case of an isolated anterior mitral leaflet cleft producing moderate-severe mitral regurgitation correctly identified by echocardiography and successfully surgically corrected. CONCLUSION: Isolated cleft is a rare aberration, that has to be known in order to be diagnosed. Transthoracic and transesophageal echocardiography is the most useful non invasive technique for cleft diagnosis and to indicate the right surgical correction.

Preoperative scallop-by-scallop assessment of mitral prolapse using 2D-transthoracic echocardiography.

BACKGROUND: This study was conducted to assess the accuracy of harmonic imaging 2D-transthoracic echocardiography (2D-TTE) segmental analysis compared to surgical findings, in degenerative mitral regurgitation (MR). METHODS: Seventy-seven consecutive patients with severe degenerative MR were prospectively enrolled. Preoperative 2D-TTE with precise localization of prolapsing or flailing scallops/segments was performed. All patients underwent mitral valve surgical repair. Surgical reports (SR), including valve description, were used as references for comparisons. A postoperative control 2D-TTE was performed. RESULTS: Out of 462 scallops/segments studied, surgical inspection identified 102 prolapses or flails (22%), 92 of which had previously been detected by 2D-TTE (90.2% sensitivity, 100% specificity). Agreement between preoperative 2D-TTE segmental analysis and SR was 97.8% (k = 0.93; p < 0.0001). Sixty-nine out of 77 2D-TTE reports were completely concordant with SR (89.6% diagnostic accuracy). None of the 8 non-concordant 2D-TTE reports were in complete disagreement with SR. P2 scallop was always involved in posterior leaflet prolapse or flail and was described correctly by 2D-TTE in 68 out of 69 patients (98,7% agreement, k = 0,93; 98.5% sensitivity). The anterior leaflet was involved in 14 patients (18%); A2 segment was involved in all of those cases and was correctly detected by 2D-TTE in 13 (98,7% agreement, k = 0,95; 92,8% sensitivity). Antero-lateral and postero-medial para-commissural prolapse or flail had a lower prevalence (14% and 10% respectively), with 2D-TTE sensitivity respectively of 64% and 50%. CONCLUSIONS: 2D-TTE, performed by an experienced echo-lab, has very good diagnostic accuracy in localizing the scallops/segments involved in degenerative MR, particularly for the middle ones (P2-A2), which represent almost the totality of prolapses. More invasive, time consuming and expensive exams should be reserved to selected cases.

[Cardiovascular prevention in the elderly: limitations and opportunities]. / Prevenzione cardiovascolare negli anziani: limiti e opportunità.

The world's population is ageing; however, the prolonged life expectancy is barely associated with an increase of healthy aging, and an important part of this demographic shift is a rising susceptibility to development and progressive accumulation of multiple chronic illness, challenging healthcare systems. Aging, therefore, represents the major risk factor for multimorbidity, a milestone for progressive loss of resilience and age-related multisystem homeostatic dysregulation. Cardiovascular risk factors, time and comorbidities play a vicious role in the development of heart disease. Among the other comorbidities, age itself is one of the most important risk factors for the development of cardiovascular disease and the prevalence and incidence of cardiovascular disease in the elderly are significantly increased. Elderly subjects, particularly when frail and with comorbidities, however, are scarcely represented in primary and secondary prevention trial aimed to treat hypercholesterolemia, diabetes mellitus and arterial hypertension. In particular, concerns exist about whether treatment should more or less intensive according to tolerability and risk of interactions; as well as there is uncertainty about therapeutic targets at different ages.This article reviews the relationship between ageing and cardiovascular disease, focusing on several issues regarding cardiovascular prevention in the elderly.

[Imaging in acute aortic syndrome: not just dissection]. / L'imaging nella sindrome aortica acuta: non solo dissezione.

Acute aortic syndrome includes three main pathological conditions: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU). These are life-threatening conditions, therefore early diagnosis and interventional/surgical treatment are fundamental for the survival of affected individuals. While anatomical findings of classical AD provided by imaging techniques are known to all cardiologists, imaging findings of IMH and PAU are less known, as are their prognostic implications and consequences on management and treatment strategies. This review aims to describe and discuss findings and role of imaging techniques in patients with IMH and PAU.

[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies]. / Follow-up dei pazienti sottoposti ad intervento per dissezione aortica acuta di tipo A: evidenze e controversie.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

[ANMCO/SICI-GISE/SIC/SIECVI/SIRM Consensus document: Appropriateness of multimodality imaging in cardiovascular disease]. / Documento di consenso ANMCO/SICI-GISE/SIC/SIECVI/SIRM: Appropriatezza dell'imaging multimodale nelle patologie cardiovascolari.

The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.

[Role of multimodality imaging in the clinical evaluation of hypertrophic cardiomyopathy]. / Valutazione clinica della cardiomiopatia ipertrofica: ruolo dell'imaging multimodale.

Sarcomeric hypertrophic cardiomyopathy is the most common cardiovascular genetic disease. Clinical evaluation and comprehensive echocardiography are crucial for the diagnosis and early evaluation of the hypertrophic phenotype, but multimodality imaging approach is often required to better define diagnosis and differential diagnosis from phenocopies. This review aims to assess the role of multimodality imaging and, in particular, advanced echocardiography and cardiac magnetic resonance in relation to differential diagnosis and preclinical diagnosis, identification of different phenotypes, and assessment of disease progression and risk of sudden cardiac death. A multimodality imaging approach is also crucial for the selection of patients amenable to surgical or percutaneous septal myectomy and for guiding both procedures.