Cardiology Unit Research Articles

A case series of forearm compartment syndrome complicating transradial cardiac catheterization

BackgroundAcute compartment syndrome following a transradial coronary approach is rare. However, as the incidence of coronary arterial disease increases due to lifestyle factors and multiple comorbidities, transradial coronary angiography has become more common for diagnostic and therapeutic purposes in cardiovascular centers. Despite its rarity, we encountered two cases of acute compartment syndrome within a 1-week interval in the cardiology unit of a tertiary hospital.Case presentationThe first case involved a 75-year-old woman diagnosed with non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram was performed via an uncomplicated right radial artery puncture. Following the procedure, the patient experienced significant swelling in the right forearm. An emergency fasciotomy release of the right forearm was conducted, revealing a gushing hematoma upon entering the flexor compartment. Fortunately, the wound healed well two months postoperatively with no functional deficits. In the second case, an 80-year-old man presented with severe angina pectoris upon exertion and was diagnosed with NSTEMI. The following day, he developed compartment syndrome in the left forearm, necessitating an emergency fasciotomy. Intraoperative examination revealed muscle bulging within the forearm compartments accompanied by extensive hematoma. Postoperatively, a deranged coagulation profile caused oozing from the wound. However, since there was no arterial bleeding, a compression dressing was applied. This led to a gradual drop in hemoglobin levels and worsened his heart condition. Despite resuscitative efforts and attempts to correct the coagulopathy, the patient experienced cardiorespiratory arrest and succumbed to ischemic heart disease in failure.ConclusionClinicians must remain vigilant in identifying this potentially limb-threatening condition. Patients with pre-existing anticoagulant therapy and underlying atherosclerotic disease are at a higher risk of bleeding complications. Implementing effective hemostasis techniques and promptly managing swelling can help prevent the occurrence of compartment syndrome. Timely assessment and maintaining a high level of clinical suspicion are paramount. If necessary, early consideration of decompressive fasciotomy is essential to avert catastrophic outcomes.

Trends in Coronary Artery Anomalies Detection by Coronary Computed Tomography Angiography (CCTA): A Real-Life Comparative Study before and during the COVID-19 Pandemic.

In the wake of the coronavirus disease 19 (COVID-19) pandemic, affecting healthcare systems globally, urgent research is needed to understand its potential repercussions on the diagnosis and management of cardiovascular disorders. This emphasises the importance of detecting coronary artery anomalies (CAAs), rare conditions that can range from benign to potentially life-threatening manifestations. We aimed to retrospectively assess the impact of the COVID-19 pandemic on the detection of various coronary anomalies using Coronary Computed Tomography Angiography (CCTA) within a regional tertiary cardiology unit in north-eastern Romania, focusing on perceived occurrence in the population under study, types, and related demographic and clinical factors. We analysed CCTA scans and investigated the trends in CAA detection among cardiology patients over a decade. We compared pre-COVID-19 and pandemic-era data to assess the impact of healthcare utilisation, patient behaviour, and diagnostic approaches on anomaly detection. Our analysis revealed a higher detection rate of CAAs during the pandemic (3.9% versus 2.2%), possibly highlighting differences in patient clinical profile and addressability changes presentation compared to the previous period. Origination and course anomalies, often linked to severe symptoms, were significantly higher pre-COVID-19 (64.1% versus 51.3%). Conversely, intrinsic CAAs, typically asymptomatic or manifesting later in life, notably increased during the pandemic (49.0% versus 61.4%; p = 0.020). Our study underscores a significant rise in CAA detection during the COVID-19 era, potentially linked to changes in cardiovascular and respiratory clinical patterns, with advanced imaging modalities like CCTA offering accuracy in identification.

Effects of tele-yoga on physical and psychological outcomes in patients living with ICD, a randomised controlled trial

Abstract Background Patients with long-term illness, including those living with an implantable cardioverter defibrillator (ICD), often suffer from symptoms of anxiety and depression, decreased health-related quality-of-life (HRQOL), and impaired functional capacity. Yoga, being a mind-body intervention, may improve all these outcomes. Purpose To determine effects of tele-yoga on exercise capacity and patient-reported outcome measures. Methods A single-blind (evaluator blinded) parallel two-arm RCT with 1:1 distribution. Participants were recruited from four hospitals in Sweden. Inclusion criteria: >18 years, admitted to a cardiology or intensive care units >48 hours during the last 36 months due to ICD implantation or ventricular arrhythmias, heart failure, or conditions in need of intensive care and now clinically stable. The participants were randomised to a control group receiving individual exercise advice or to the intervention group (tele-yoga). The intervention included performing live-streamed group-yoga for 60 min twice/week for 3 months and practicing yoga individually for a minimum of 10 min/day using an app. The group-sessions with approximately 10 participants were led by certified Mediyoga-instructors via the virtual video-platform ZOOM. The yoga form was Kundalini adapted to individuals with health conditions (Mediyoga). Two standardised yoga-programmes including different postures, breathing exercises and meditations were rotated. The primary endpoint of the study after 3 months was a combined endpoint consisting of change in functional capacity measured by 6-min walk test (6MWT), HRQOL (EQ-5D index/VAS) and symptoms of anxiety and depression (HADS). The used cut offs for change were 30 meters for 6MWT, a score >11 for EQ-5D VAS and ≥8 for anxiety/depression in HADS. Secondary endpoints included separate analysis of functional capacity, HRQOL and symptoms of anxiety/depression. Results In total, 311 participants were randomized to tele-yoga (n=156) and control (n=155), mean age 65.8 years, 30% women, 38% living with an ICD (whereof 62% had a primary preventive indication). Median attendance to yoga-sessions was 20 sessions for 12 weeks and 74% of the study participants were adherent to >16 tele-yoga sessions. There were no adverse events reported during yoga sessions or app usage. In this sub-group analysis involving the ICD cohort (n=118), there was a significant improvement in favour of the tele-yoga group in the combined primary endpoint (p=.011). When analysing them separately, there was a significant improvement in 6MWT (p=.002), but not in HRQOL in EQ-5D VAS or symptoms of anxiety and depression. No adverse events were reported during yoga sessions or app usage. Conclusion Digitally delivered mind-body training such as tele-yoga showed a significant improvement in the combined endpoint consisting of physical function, HRQOL and mental health. Tele-yoga may be a promising new form of rehabilitation for patients living with ICD.

The Outcome of Use of Intravenous Iron Carboxymaltose on the NYHA Class and the Six-Minute Walk-Test in Patients with Heart Failure: Assessing Functional Improvement

BACKGROUND: Chronic heart failure (CHF) significantly impairs quality of life and exercise capacity, often exacerbated by concurrent iron deficiency. Intravenous ferric-carboxymaltose (FCM) has shown promise in addressing these deficiencies, improving both biomarkers of iron status and functional outcomes. OBJECTIVE: To evaluate the effects of intravenous ferric-carboxymaltose on functional class and exercise capacity, as measured by the six-minute walk-test (6MWT), in patients with iron-deficient chronic heart failure. METHODS: This prospective, single-arm study was conducted from April to September 2023 at the Cardiology unit of Frontier Corps Teaching Hospital, Shakas Peshawar, and Mardan Medical Complex, Mardan, Pakistan. Participants underwent baseline evaluations including demographic information, medical histories, physical examinations, and functional tests such as the 6MWT. Follow-up evaluations after three months of FCM therapy assessed changes in functional indicators. Statistical analyses included tests for significance and descriptive statistics. RESULTS: Sixty patients participated, with a mean age of 55.87 ± 13.22 years and a mean BMI of 28.14 ± 9.71 kg/m^2. Initial assessments showed a mean LVEF of 33.54 ± 6.68%, with 75% classified as NYHA class III. Baseline 6MWT completion was 10 laps. Initial mean hemoglobin was 11.82 g%, MCV 78.48 fl, TSat 20.43%, and serum iron 50.55 mcg/dL. After treatment, hemoglobin increased to 13.65 g%, MCV to 80.23 fl, TSat to 23.05%, and serum iron to 55.40 mcg/dL. Participants completed 19 laps in the 6MWT, with 63.34% improving to NYHA class II. P-values were <0.0001 for these changes, indicating statistical significance. CONCLUSION: Intravenous ferric-carboxymaltose significantly enhances functional capacity and iron status in patients with CHF and iron deficiency, irrespective of anemia status. Future research should explore how comorbid conditions like hypertension, diabetes, and renal failure influence treatment outcomes.

Serologic Evaluation for Severe Acute Respiratory Syndrome Coronavirus 2 in Pediatric Heart Transplantation Recipients and Patients on a Pediatric Heart Transplantation Waiting List in a Quaternary Hospital

BackgroundThe COVID-19 pandemic has been a global reality for over three years. Serological studies have great importance for the comprehension of the virus's behavior in populations, as it can suggest the status of the epidemic in a community. This cross-sectional study aimed to analyze the serological profile for COVID-19 in patients before and after pediatric heart transplant. MethodsSerologies for IgG and IgM antibodies for Sars-CoV-2 were collected in patients of the Pediatric Cardiology and Congenital Heart Diseases unit of a Brazilian hospital between January and August 2022. In total, 174 patients were recruited: 28 on waiting list and 146 recipients. Information such as demographics (age, gender, state of origin), type of heart disease (congenital or acquired) and time after transplant were analyzed. ResultsOverall, 72 patients had a positive serology for anti-N antibodies (48,0%), being 62 transplant recipients and 10 patients on transplant waiting list, with positivity rates of 48,1% and 47,6%, respectively. Positivity rates for previously infected individuals were 62,5% and 62,1%, respectively. ConclusionsWe found that approximately half of the sample has developed IgM or IgG antibodies against the Sars-CoV-2 virus Serological studies are a relevant tool to public health for health promotion of vulnerable groups, and can be useful to future studies on the antibodies’ behavior. The duration and the level of protection given by these antibodies is still a subject being studied, and can become a key information for the protection of these populations if discovered in the future.

IMPACT OF DISCHARGE FROM A CARDIOLOGY UNIT ON OUTCOMES IN NON–ST ELEVATION MYOCARDIAL INFARCTION: AN ANALYSIS OF A NATIONWIDE ADMINISTRATIVE DATABASE

Abstract Background Current data on the prognostic impact of a specialist management of patients with acute coronary syndromes are scarce. Aim To evaluate the impact of the discharge of revascularized patients with Non–ST elevation myocardial infarction (NSTEMI) from a cardiology unit on their 1–year prognosis and to evaluate the differences in terms of effectiveness between discharge from a cardiology and non–cardiology unit and the whole management of the index hospitalization in a cardiology unit. Methods Retrospective nationwide cohort study enrolling consecutive patients older than 18 years admitted in 2019–2020 in Italy for a NSTEMI and undergoing percutaneous coronary intervention (PCI) within 48 hours from the index admission. Patients died within 30 days from the index admission were excluded from the analysis. Enrolled patients were classified based on the management department into: patients not discharged from a cardiology unit (group 1); patients not admitted but discharged from a cardiology unit (group 2); patients completely managed (admitted and discharged) in a cardiology unit (group 3). The outcome of interest was 1–year all–cause mortality. A Cox multivariate regression model was used to evaluate the impact of the management department on 1–year mortality. Results The study cohort consisted of 31950 NSTEMI events. Among them, 534 (1.6%) were allocated in group 1, 1160 (3.6%) in group 2 and 30256 (94.7%) in group 3. Patients completely managed by a cardiology unit were younger and less likely to be female than patients in other groups. The 1–year mortality was 14.4%, 8.4% and 3.8% (p<0.001) for group 1, group 2 and group 3, respectively (Figure). After adjustment for age, sex, and comorbidities, the hazard ratio (HR) for 1–year mortality was 2.4 (p<0.0001) and 1.7 (p<0.0001), in patients in group 1 and group 2, respectively, as compared with patients completely managed in a cardiology unit (group 3). Conclusion Complete management of index hospitalization or hospital discharge from a specialist unit alone improves the one–year prognosis of patients hospitalized with a diagnosis of NSTEMI in Italy.

HFPEF AND GLYCEMIC VARIABILITY: GHIDD TRIAL

Abstract Background Recently the guidelines of European Association of Preventive Cardiology reported that the prevalence of diabetes mellitus in patients with diastolic heart failure (HFpEF) is around 31%. Purpose In our study we evaluated the non diabetic patients with HFpEF with Glunovo® to evaluate the glycaemic variability in this population. Methods 100 patients with HFpEF admitted to cardiology units of 4 Italian centres on the major islands were enrolled consecutively. Glunovo® was applied to each enrolled patient for 7 days, At the end of the glycaemic monitoring were calculated for each patient the glycaemic variability and the incidence of hyperglycaemia and hypoglycaemia. Glycaemic variability refers to a blood glucose value of ≥ 200 mg / dL or ≤ 59 mg / dL detected more than 3 times in a day for at least 4 days. Overall, 43 males and 57 females were enrolled with a mean age of 69.3 years (39–87 years). All patients underwent a timely glucose measurement at admission which excluded the presence of hyperglycaemia. No potentially hyperglycaemic drugs were added to the treatment during the hospital stay. Results In 94 of the 100 patients enrolled it was possible to conclude the analysis, detecting the glycaemic variability, the point glycaemia values and the estimated glycated haemoglobin value. A glycaemia ≥200 mg/dL was found in 53 patients (56%) while a high glycaemic variability was found in 51 patients (54%). A blood glucose value <59 mg / dl was found in 48 patients (51%). Only 5 times the estimated glycated Hb values were> 7%. 32 of the patients who had at least 3 punctual glucose values ≥200 mg/dL were prescribed an oral glucose load curve, which in 100% of cases confirmed the diagnosis of diabetes.No statistically significant differences were found based on age group or sex. In the control group, consisting of 10 patients without DHF undergoing continuous glucose monitoring at one of the participating cardiology units, an unknown hyperglycaemia was found in only 1 patient (10%) and a glycaemic variability in only 1 patient (10%). Conclusions Our experience suggests an incidence of hyperglycaemia and glycaemic variability more then 65% in patients affected by HFpEF. If our data were reproducible on a large scale, a so high prevalence of diabetes in patients with HFpEF cold explain the efficacy of SGLT–2 inhibitor and GLP–1 Agonist in this class of patients.

A 20–YEAR FOLLOW–UP OF SUCCESSFUL SURGICAL MANAGEMENT OF DOUBLE–OUTLET RIGHT VENTRICLE WITH PULMONARY STENOSIS: A CASE REPORT

Abstract A 25–year–old man, suffering from worsening exertional dyspnea for 4 months, was referred to our Cardiology Unit. The patient was previously diagnosed with a late diagnosis of double outlet right ventricle (DORV), as well as pulmonary stenosis, VSD, and right–sided aortic arch for which he underwent a first surgical procedure around the age of 2 involving an intersternal anastomosis through a left lateral thoracotomy approach. A second intervention took place 2 years later for a radical correction of the anomaly through a median sternotomy. The patient had sporadic follow–up since then. A baseline ECG was performed, showing evidence of sinus rhythm, normal AV with a bifid P wave in lead II, slight RAD, incomplete RBBB, and asymmetric negative T waves from V1 to V3 and in aVL, and biphasic T waves in V4–V5. We performed an echocardiogram which showed: a dilated RA, a normal–sized LA, an apparently intact interatrial septum without evident shunts; a normal sized LV; EF 60%; a moderately dilated, hypertrophic and hypertrabeculated RV; FAC 33%; normal aortic flow; a minimal MR; a massive residual pulmonary insufficiency; a moderate TR; a dilatated pulmonary trunk; a normal–sized and collapsible IVC upon inspiration; PAPs of 70 mmHg; no pericardial effusion. A maximal exercise stress test appeared to be normal throughout. However, due to the severe pulmonary hypertension he was referred to our PH centre. While these patients are commonly affected by residual early or late left ventricular outflow tract obstruction, fortunately our patient was not. DORV is a relatively common congenital heart defect characterized by an abnormal connection between the ventricles and arteries, in which both the aorta and the pulmonary trunk are connected completely or predominantly to the right ventricle. The anatomical spectrum of this anomaly is quite large, and it can be associated with the presence of a VSD that often extends towards one or both of the arterial valves, allowing the flow of blood from the left ventricle to the aorta. An accurate diagnosis through echocardiography or CMR is essential in order to guide the surgical repair and the appropriate therapeutic approach for individuals affected by this anomaly. A successful surgical correction of DORV is essential, but it is important to be aware of the potential complications of post–operative PH (especially in patients with preoperative PH), which necessitates close surveillance and appropriate therapeutic management.

LONG–TERM FOLLOW–UP IN PATIENTS ON PCSK9 INHIBITOR THERAPY: COMBINING FAST TRACK STRATEGY AND OUTPATIENT MANAGEMENT

Abstract Background Dyslipidemia is a significant risk factor for cardiovascular diseases, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have emerged as an effective treatment option. This study aims to investigate the lipid profile in the long–term follow–up of dyslipidemic patients receiving PCSK9 inhibitor therapy in an entirely outpatient setting. Methods We enrolled 381 patients from our dyslipidemia outpatient clinic. Study population included both patients with a first dyslipidemia visit and those discharged from a cardiology unit with fast fast–track protocol. Patients were followed up at 6 (n = 252), 12 (n = 191), and 36 months (n = 77) to assess the effects of PCSK9 inhibitor therapy on lipid profile. Results At the 6–month follow–up, the total cholesterol levels decreased significantly (223.1±35.2 mg/dL vs 129.6±31.9 mg/dL p < 0.001) as LDL cholesterol levels (148±45 vs 72.6±46 mg/dL p < 0.001). The 12–month follow–up maintained similar levels of lowering (total cholesterol 123.6±39 mg/dL LDL 67.5±41 mg/dL p < 0.001) as well as the 36–month follow–up (total cholesterol 138.1±43 mg/dL LDL 71.6±44 mg/dL p < 0.001). No significant reductions in triglycerides and HDL levels were observed during follow–up. Conclusion The study highlights the feasibility and effectiveness of the long–term management of dyslipidemic patients with PCSK9 hypercholesterolemia in an entirely outpatient setting, including patients referred through the fast–track protocol.

AN ACUTE MYOCARDIAL INFARCTION IN A VERY YOUNG MAN DUE TO HYPERHOMOCYSTEINEMIA

Abstract Introduction A young 17–year–old boy smoker and obese was admitted to our cardiology unit for continuous oppressive chest pain radiating to the left arm that had arisen three days earlier. In the emergency room, he had performed blood tests with evidence of an increased troponin and an electrocardiogram that showed mild ST–elevation in inferior leads with ST depression in aVL. We performed an urgent transthoracic echocardiography examination that was unremarkable Investigation Once diagnosed with acute ST–segment elevation myocardial infarction, the patient underwent emergency coronary angiography. Coronary angiography highlighted an intermediate stenosis of the first branch diagonal to the proximal tract and a possible occlusion of the periapical branch of the anterior descending artery. It was decided not to perform PTCA as we could not exclude a distal coronary dissection and considering the vessel was of small caliber. We decided to complete the diagnostic process by performing a cardiac MRI showing edema in the apex and distal inferior wall and transmural gadolinium enhancement at the level of the septum and inferior wall of the distal section. In the context of the damaged wall a focal area of hypointensity to be referred to the "no–reflow" phenomenon Management The patient was treated with DAPT, low molecular weight heparin and high dose statin. A few hours after the coronary angiography the patient stopped having chest pain and remained asymptomatic for the rest of the hospital stay. We performed complete blood tests including with evidence of hyperhomocysteinemia. The lipid panel was normal. Hematological consultation recommended folate and Vitamine B12 treatment. After 12 months the patient is asymptomatic, has stopped smoking and continues to take DAPT. He repeated the echocardiogram which showed no alterations. Genetic testing was performed after hospital discharge and was positive for Methylenetetrahydrofolate reductase (MTHFR) homozygous mutation Conclusion Our clinical case shows a rare case of acute myocardial infarction in a very young person. Diagnosis and treatment were complicated by the extreme distality of the occlusion and the few modifiable risk factors identified (smoker, obesity and hyperhomocysteinemia). Hyperhomocysteinemia is an often underestimated cardiovascular risk factor associated with a high risk of cardiovascular events and multivessel coronary disease that should be sought in all young patients with AMI.

THE SIGN OF THE HORNS: A RARE CASE OF DOUBLE PERI–COMMISSURAL MITRAL FLAIL

Abstract A 80–year–old man with history of hypertension and dyslipidemia was admitted to our Cardiology Unit for exertional dyspnea (NYHA III) occurred during the last few days. The physical examination showed a systolic heart murmur (4/6 on Levine scale) and signs of pulmonary congestion. Transthoracic echocardiography revealed a massive mitral regurgitation (Fig.1) together with severe dilation of the left atrium, mild–to–moderate aortic regurgitation, high probability of pulmonary hypertension and normal biventricular systolic function. A transesophageal echocardiography (TEE) was performed to clarify mitral valve anatomy. A double flail of the posterior leaflet was present involving the peri–commissural portions due to a single chordal rupture on P1 scallop and a double chordal rupture on P3 scallop (Fig.2). P2 scallop was prolapsing and there was a billowing of the anterior leaflet. In addiction mitral annulus was dilated (antero–posterior diameter of 43 mm and intercommissural diameter of 45 mm). We named this finding “sign of the horns” for his 3D echocardiographic appearance (Fig.3) given the double flail resembling two fingers. A surgical correction was performed with 3 GoreTex neochords implantation on the posterior leaflet and an annuloplasty ring (Physio II n. 34) implantation during extracorporeal circulation through right anterior minithoracotomy. Surgical and echocardiographic results were optimal. The patient was discharged after 7 days of hospitalization. Conclusion Coexistence of a double peri–commissural flail in the same leaflet is a very rare echocardiographic finding and we named it “double horn sign”. TEE is an essential examination in this scenario in order to understand the exact mechanism of the regurgitation for an optimal preoperative planning.

DEVELOPMENT OF A HUB–SPOKE NETWORK FOR TRANSCATHTER AORTIC VALVE IMPLANTATION: THE INTERVENTIONAL CARDIOLOGY UNIT OF IRCCS SAN RAFFAELE HOSPITAL (OSR HUB–SPOKE)

Abstract Background The growing prevalence of aortic stenosis determined in recent years an increase in candidates for percutaneous aortic valve replacement (TAVI), bringing out a difficult access to this procedure. In order to reduce waiting lists and to guarantee the training of the Interventional Cardiologists of Centers not equipped with on–site cardiac surgery, we implemented a TAVI protocol with one Hub center, the Interventional Cardiology Unit of IRCCS San Raffaele Scientific Institute, Milan, and two participating Spoke Centers: the ASST–Franciacorta Chiari Center and Valduce Hospital, Como.The aim of this study is to report in hospital outcomes of patients treated using this model of Hub–Spoke Network. Methods Patients included in this model were selected in the Spoke center where baseline clinical evaluation with echocardiography and CT scan were performed (inclusion and exclusion criteria attached). The cases were then discussed with a multidisciplinary team on–line and the procedure planned (access, valve type size). Once the procedure was scheduled, the patients underwent a single day transport to the Hub Center where they underwent TAVI and a same day return to the Spoke Center. A bailout hospitalization in the Hub Center was available in case of major complication. All Spoke Centers patients who underwent TAVI procedures in our Center according to our protocol were included in this analysis. The primary study objective was in hospital major adverse cardiac events (all cause or cardiovascular mortality, stroke, myocardial infarction); secondary study objectives were technical success, prolonged recovery in Hub Center and major vascular complications. Results Since 2019, a total of 69 patients underwent TAVI with the Hub and Spoke model. Mean age was 83 years ± 6 and mean ejection fraction was 59% ± 7%. Two patients (2.9%) had a prolonged hospitalization in the Hub center for a major vascular complication and an intra–procedural cardiac arrest, successfully resuscitated. Technical success was reached in 97.1% of patients. One patient experimented an ischemic stroke after the return in the spoke center: in hospital MACE was than 1.4%. Conclusion Considering the growing prevalence of aortic stenosis, The Hub Spoke Model for TAVI guarantees reduction in waiting lists, "access to care" for patients referred to Spoke centers, involvement and improvement of skills of their Interventional Cardiologists, keeping a high level of safety and efficacy.

FOLATES–RELATED AND BONE MARROW DISORDERS PROMOTE ATRIAL CARDIOMYOPATHY INPATIENTS AFFECTED BY PAROXYSMAL ATRIAL FIBRILLATION VIA BOTH EPCS AND ENDOTHELIAL DYSFUNCTION

Abstract Background Atrial Cardiomyopathy (AC) has been recently postulated to explain those embolic strokes not due to atrial fibrillation (AF) and paradoxical embolism. Pathogenic mechanisms underlying AC are still largely unknown. Folate cycle disorders (FD) are a yet underrated pro–thrombotic dysmetabolism. FD could hinder both endothelial and circulating endothelial progenitor cell (EPCs) functioning, therefore providing one–shot explanation to both atrial fibrosis and endothelial dysfunction (ED). Purpose This study aims to enquire for the hypothesis that: 1) atrial fibrosis (AFib) would relate to FD (intended as both: a)MTHFR C677T inherited mutations and b)bone–marrow function disorders, here referring to erythropoiesis diversions) and 2) AF patients would show dysfunctional EPCs. Methods We studied 59 consecutive patients admitted to the cardiology Unit of the General Hospital“F.Miulli”, with preserved EF, subjected to AF ablation. AFib was quantified in term of percentage of bipolar peak–to–peak voltage points below 0,5mV with respect to the wholeness of picked points. Blood count cell was evaluated at the admission. MTHFR C677T genotypes and serum folate were assessed. EPCs isolation and characterization were performed by cytometry analysis (CD45, CD34, CD133, VEGFR2 and KDR). EPCs functional wound healing assay was performed to determine the percentage of EPCs able to "fix the wound” and compared with matched–controls. Results Baseline characteristics did not differ between Sample and Control groups (Fig. 1 – Left Table). % of Afib significantly differs between C677T MTHFR homozigosis patients (n=15) with respect to non–C677TMTHFR homozygosis patients (n=44) (Fig.1 – Right graph. – p < 0,02). Once univariate analysis was performed, subsequent multivariate analysis highlight highest fit, once merged RBC, RDW–SD and folates values were inputed (Fig.2 – superior graph. – R2=0,39;p=0,0001). Either RBC, RDW–SD and folates coefficient reached significance (p < 0,0001; p < 0,01; p < 0,05 respectively). Number of EPCs signifi cantly differs between AF patients and matched controls (Fig 2 – inferior graph. –p < 0,001). Conclusions Our findings support the hypothesis that genetically determined folates dysmetabolism (MTHFR dysfunction) promotes AFib via a complex cardiac–bone marrow networking involving circulatingEPCs and unraveled by erythropoiesis diversions. Such results suggest a pathogenic role of folate cycle disorders in the AC development.

25years of lipid-lowering therapy: secular trends in therapy of coronary patients.

Guidelines on dyslipidemia and lipid-lowering therapy (LLT) over the years recommend lower low-density lipoprotein cholesterol (LDL-C) goals by more intense therapy. Nevertheless, LDL‑C has increased in the general population. Real-world trends of LLT medication as well as of LDL‑C levels in cardiovascular high-risk patients are unclear. From 2158 patients who were referred for elective coronary angiography, lipid medication was analyzed at admission in three cardiovascular observational studies (OS) over the last 25years: OS1: 1999-2000, OS2: 2005-2008 and OS3: 2022-2023. The three studies were performed at the same cardiology unit of atertiary care hospital in Austria. The proportion of patients without LLT significantly decreased from OS1 through OS2 to OS3 (49.4%, 45.6%, and 18.5%, respectively, ptrend < 0.001). Moreover, the percentage of patients under high-intensity statin treatment significantly increased from 0% to 5.1%, and 56.5% (ptrend < 0.001). Significantly more patients became treated by more than one compound (OS1: 1.8%, OS2: 1.6%, OS3: 31.2%; ptrend < 0.001). In the latest OS3, atrend to fixed-dose combination of statins with ezetimibe was observed. Mean LDL‑C levels decreased from 129 mg/dL over 127 mg/dL to 83 mg/dL, respectively (ptrend < 0.001). Of the patients on high-intensity therapy 34% met the recent ESC/EAS goals (LDL-C < 55 mg/dL), but only 3% on non-intense therapy. We conclude that during the observational period of aquarter of acentury, treatment intensity increased and LDL‑C levels improved considerably. Guidelines apparently matter in this high-risk population and are considered by primary care physicians.

Optimizing the care management pathway of patients with ischemia and non-obstructive coronary arteries

Ischemia with non-obstructive coronary arteries (INOCA) is defined by the coexistence of anginal symptoms and demonstrable ischemia, with no evidence of obstructive coronary arteries. The underlying mechanism of INOCA is coronary microvascular dysfunction with or without associated vasospasm. INOCA patients have recurrent symptoms, functional limitations, repeated access to the emergency department, impaired quality of life and a higher incidence of cardiovascular events than the general population. Although well described in chronic coronary syndrome guidelines, INOCA remains underdiagnosed in clinical practice because of insufficient awareness, lack of accurate diagnostic tools, and poorly standardized and consistent definitions to diagnose, both invasively and non-invasively, coronary microvascular dysfunction.To disseminate current scientific evidence on INOCA as a distinct clinical entity, during 2022 we conducted at 30 cardiology units all over the country a clinical practice improvement initiative, with the aim of developing uniform and shared management pathways for INOCA patients across different operational settings. The present document highlights the outcomes of this multidisciplinary initiative.

Prevalence and Clinical Significance of Intraventricular Conduction Disturbances in Hospitalized Children.

Introduction: Data on the prevalence and clinical significance of interventricular conduction disturbances (IVCDs) in children are scarce. While incomplete right bundle branch blocks (IRBBBs) seem to be the most frequent and benign findings, complete bundle blocks and fascicular blocks are often seen in children with congenital/acquired cardiac conditions. This study aims to delineate the prevalence and the diagnostic accuracy of IVCD in children admitted to a paediatric cardiology unit. Methods: Children admitted to the paediatric cardiology unit between January 2010 and December 2020 who had an ECG were included in the study. IVCDs were diagnosed according to standard criteria adjusted for age. Results: Three thousand nine hundred and ninety-three patients were enrolled. The median age was 3.1 years (IQR: 0.0-9.2 years), and 52.7% were males. IVCDs were present in 22.5% of the population: 17.4% of the population presented with IRBBBs, 4.8% with a complete right bundle branch block (CRBBB), 0.1% with a complete left bundle branch block (CLBBB), 0.2% with a left anterior fascicular block (LAFB) and 0.2% with a combination of CRBBB and LAFB. Also, 26% of children with congenital heart disease had an IVCD, and 18% of children with an IVCD had previous cardiac surgery. The overall sensitivity of IVCD in detecting a cardiac abnormality was 22.2%, with a specificity of 75.5%, a PPV of 83.1% and an NPV of 15.1%, but the values were higher for CLBBB and LAFB. Conclusions: IVCDs were present in one-fifth of children admitted to the cardiology unit. IRBBB was the most frequent disturbance, while CRBBB, CLBBB and fascicular blocks were much rarer, though they had a higher predictive value for cardiac abnormalities.

The influence of diagnostic subgroups, patient- and hospital characteristics for the validity of cardiovascular diagnoses-Data from a Norwegian hospital trust.

Cardiovascular discharge diagnoses may serve as endpoints in epidemiological studies if they have a high validity. Aim was to study if diagnoses-specific characteristics like type, sub-categories, and position of cardiovascular diagnoses affected diagnostic accuracy. Patients (n = 7,164) with a discharge diagnosis of acute myocardial infarction, heart failure or cerebrovascular disease were included. Data were presented as positive predictive values (PPV) and sensitivity. PPV was high (≥88%) for acute myocardial infarction (n = 2,189) (except for outpatients). For heart failure (n = 4,026) PPV was 67% overall, but higher (>99%) when etiology or echocardiography was included. For hemorrhagic (n = 257) and ischemic (n = 1,034) strokes PPVs were 87% and 80%, respectively, with sensitivity of 79% and 75%. Transient ischemic attacks (n = 926) had PPV 56%, but sensitivity 86%. Primary diagnoses showed higher validity than subsequent diagnoses and inpatient diagnoses were more valid than outpatient diagnoses (except for transient ischemic attack). The diagnoses of acute myocardial infarction and heart failure where most valid when placed at cardiology units, while ischemic stroke when discharged from an internal medicine unit. The diagnoses of acute myocardial infarction and stroke had excellent validity when placed during hospital stays. Similarly, heart failure diagnoses had excellent validity when echocardiography was performed before placing the diagnosis, while overall the diagnoses of heart failure and transient ischemic attack were less valid. In conclusion, the results indicate that cardiovascular diagnoses based on objective findings such as acute myocardial infarction and stroke have excellent validity and may be used as endpoints in clinical epidemiological studies with less rigid validation.

Intramyocardial abscess and endoventricular thrombosis: a complex case

Infective endocarditis (IE) is today a public health problem, as the recent ESC Guidelines have also recalled. Abscesses can be complications of IE and their presence means that the infection is not controlled. We describe the complex case of a 57-year-old patient, presented in ED for fever and oleocranical bursitis, increase of cardiac enymes at blood samples. He was admitted to our Cardiology Unit because TTE showed a floating peduncolated formation in the left ventricle. The susequent TEE documented also the presence of a myocardial abscess, confirmed at cardiac MRI. Blood cultures were positive for MSSA and the man received specific antibiotic therapy. Anticoagulation treatment was started with UFH and then switched to Warfarin, surgical approach of the lesion would have been too dangerous according to Cardiac Surgeons. Serious and sudden neurological complications then followed, leading the patient to brain death in ICU.

Characteristics of Patients with Wellens Syndrome Who Underwent Coronary Angiogram: A Single Center Experience

Introduction: Wellens syndrome refers to a characteristic set of ECG abnormalities associated with simultaneous severe stenosis of the proximal part of the left anterior descending artery (LAD). Early intervention with percutaneous coronary intervention (PCI) is paramount otherwise may result in anterior wall myocardial infarction or even death.Objectives: The major objective of this study was to determine the clinical, echocardiographic and angiographic features which are specific to Wellens syndrome in order to diagnose the patients and manage them urgently to reduce morbidity and mortality.Methodology: 52 patients with Wellens syndrome were recruited for a descriptive cross-sectional study conducted in the cardiology unit of the National Hospital of Kandy, Sri Lanka. All the recruited patients underwent serial ECGs, blood for cardiac markers, and a comprehensive 2D echocardiogram within 24 hours of admission. An interviewer-administered questionnaire was used for data collection and all the data was analyzed by statistical package for the social sciences (SPSS) 23 software.Results: The majority of affected patients were males (71.2%). More than half of the participants had very severe stenosis of LAD (52.1%), one-fifth of them had severe stenosis (22.9%), and about one-third were suffering from triple vessel disease (TVD: 32.69%) according to the angiogram. Characteristically, 83% of diagnosed patients with Wellens syndrome had not complained of any pain during their diagnostic ECG tracing and the majority had normal cardiac troponin levels (82.7%) at the presentation.Conclusions: Even though the ECG findings of Wellens syndrome are highly specific (89%), due to either normal or slightly elevated levels of cardiac markers and the pain-free status of the patients at the presentation often mislead the physicians. Late diagnosis may result in extensive myocardial damage and even death. Therefore, early identification and intervention is vital.

Twinning International Pediatric Cardiology Fellowship Programs: A Transformative Educational Experience for Trainees with Potential for Global Adoption.

Over the last decade, having endured the COVID-19 pandemic, education and training in pediatric cardiology have undergone a profound disruptive transformation. Trainees experience considerable stress achieving all the competencies required to become a competent pediatric cardiologist. Often the quality of the training experienced by trainees, the approach to patients, and potential institutional preference in management strategy is heavily influenced by the center in which they train. We developed an online live twin program of education between Texas Children's Hospital, Houston, Texas and Children's Health at Crumlin Dublin Ireland in 2019. We explored using grounded theory whether a regular scheduled shared teaching program improved fellow education and training between both centers. Trainees were surveyed to evaluate the benefits and disadvantages of such a twin program. The majority (93%) found the sessions helpful from an educational standpoint with many trainees reporting it to be a transformative experience. Three important learning themes emerged: practice variation between centers, managing uncertainty in clinical practice and cognitive overload. This pedagogical model could be replicated across multiple international pediatric cardiology units and facilitate "collaborative learning" among centers across the globe. Furthermore, this novel educational model could also be adopted by other medical specialties.