The prophylactic use of negative-pressure wound therapy after cardiac surgery: a meta-analysis

Surgical site infections (SSIs) pose a frequent complication in cardiac surgery patients and lead to increased patient discomfort and extended hospitalization. This meta-analysis aimed to evaluate the protective role of single-use negative-pressure wound therapy (sNPWT) devices on closed surgical wounds after cardiac surgery, and explored their potential preventive application across all cardiac surgery patients. A comprehensive literature search was conducted on ScienceDirect, focusing on studies related to "negative pressure wound therapy" or "PICO negative pressure wound therapy" combined with "cardiac surgery" or "sternotomy," published between 2000 and 2022. Inclusion criteria encompassed case-control studies comparing sNPWT with traditional dressings on closed cardiac surgical incisions in adult patients undergoing median sternotomy without immediate postoperative infective complications, with available details on SSIs. A retrospective analysis of cases treated with sNPWT in our centre was also performed. The meta-analysis revealed a protective role of sNPWT, indicating a 44% risk reduction in overall SSIs (odds ratio 0.56) and a 40% risk reduction in deep wound infections (odds ratio 0.60). Superficial wound infections, however, showed non-significant protective effects. A single-centre study aligned with the meta-analysis findings, confirming the efficacy of sNPWT and was included in the meta-analysis. In conclusion, the meta-analysis and the single-centre study collectively support the protective role of negative pressure wound therapy against overall and deep SSIs, suggesting its potential prophylactic use on all cardiac surgery populations.

Percutaneous Left Atrial Appendage Occlusion: What the Practising Physician Should Know

Non-valvular AF is a common clinical condition associated with an increased risk of thromboembolic complications. As a consequence, oral anticoagulant therapy (OAT) is the cornerstone of non-valvular AF management. Despite the well-established efficacy of OAT, many patients cannot receive this preventive therapy due to bleeding or a high risk of bleeding. The fact that more than 90% of thrombi are formed in the left atrial appendage has led to the development of alternative methods to reduce the embolic risk. Left atrial appendage occlusion (LAAO) is a non-pharmacological option for preventing cardioembolic events in patients with non-valvular AF with a contraindication to OAT. The demand for LAAO procedures is growing exponentially and clinicians should consider this alternative option when managing patients with a contraindication to OAT. This review summarises the current thinking about LAAO.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Some good reasons to proceed with the occlusion of the auricle

Atrial fibrillation (AF) is the most common arrhythmia. The most fearful complication of AF is represented by cardio-embolic stroke and 30% of ischaemic strokes are attributable to AF. The prevention of cardio-embolic risk is therefore based on oral anticoagulant therapy (OAT). Some categories of patients do not benefit from OAT. These are patients at increased bleeding risk and with varying degrees of contraindication to long-term anticoagulant therapy. On the opposite are those patients who develop an embolic event related to AF despite a well-conducted OAT. These types of patients benefit from an interventional approach, percutaneous closure of the left auricle (LAAO), aimed at eliminating what is the primary source of AF-related thrombo-embolism, precisely the left auricle. Percutaneous closure of the left auricle has proven to be an effective and safe procedure, significantly reducing the bleeding risks of patients who, after the procedure, will no longer have to take OAT. Furthermore, it has been shown to be effective in reducing cardio-embolic risk. Uncertainty still remains as to what is the optimal antithrombotic therapy after LAAO. In any case, LAAO represents a valid alternative to OAT for those patients in whom it is contraindicated or ineffective.

Long-term survival after TAVR in patients with low flow-low gradient vs high gradient aortic valve stenosis

Introduction

Transcatheter aortic valve replacement (TAVR) has become the treatment of choice in elderly patients affected by severe aortic stenosis (AS). In patients with low-flow low-gradient (LFLG) AS, a clear benefit of TAVR over conservative treatment has been demonstrated. Notwithstanding, patients with classical LFLG (cLFLG) AS have shown worse early post-procedural outcomes compared to those with high-gradient (HG) AS.

Purpose

Given the absence of data, we aimed to evaluate long-term survival (up to 10 years) after TAVR in patients with cLFLG and paradoxical LFLG (pLFLG) AS as compared to those with HG-AS.

Methods

Consecutive patients undergoing TAVR at our center with a minimum 5-year follow up (i.e. treated between June 2007 and December 2016) were considered for this analysis. According to baseline echocardiography, patients were divided in three groups: 1) HG-AS (MG >40 mmHg); 2) cLFLG-AS (MG <40 mmHg, EF <50%); and 3) pLFLG-AS (MG <40 mmHg, EF >50%). The study endpoint was post-procedural all-cause mortality. To test differences in long-term outcomes among groups, survival curves using the Kaplan Meier estimator were plotted and compared with the log-rank test. To adjust for possible baseline confounders, a propensity score weighted survival analysis was then performed (standard mean deviation <0.1 for all the considered covariates).

Results

A total of 574 subjects were included in the analysis (419 [73%] HG-AS; 91 [15%] pLFLG-AS; and 64 [11%] cLFLG-AS). Median survival time was 4.8 years [IQR 2.3–6.2], with a maximum of 12.3 years. Patients with cLFLG-AS presented higher baseline cardiovascular risk compared to those with both HG-AS and pLFLG-AS. At unadjusted survival analysis, patients with cLFLG-AS showed the worst long-term prognosis after TAVR (overall log-rank test p=0.023). However, after propensity weighted adjustment, the long-term survival of patients with cLFLG-AS was similar to those with HG-AS (p=0.77). Patients with pLFLG and HG-AS presented similar survival rate. Unadjusted (Panels A and C) and adjusted (Panels B and D) survival curves are reported in Figure 1. Out of 64 patients with cLFLG-AS, 43 (67%) presented an improvement in LV-EF (>15% from the baseline value) within the first year after TAVR. LV-EF improvement, but not baseline LV-EF, was apparently related to longer post-TAVR survival (Figure 2).

Conclusion

In the current study, patients with cLFLG-AS had worse long-term survival after TARV as compared to either HG or pLFLG-AS subjects. This difference was not present after adjusting for possible baseline confounders. Thus, the low-flow state condition per se might have a lower impact on long term prognosis of TAVR patients than previously hypothesized. Post-TAVR LV-EF recovery was common among patients with cLFLG-AS and was associated with improved long-term survival.

Funding Acknowledgement

Type of funding sources: None.

Acute idiopathic pericarditis: the importance of guideline-based treatment to avoid recurrence

Background

Acute pericarditis (AP) usually resolves with first-line treatment, but it may recur. Recurrences are attributed to a deranged immunity, but it is unclear if they may also be related to inappropriate treatment.

Purpose

The aim of our study was to clarify the potential role of inappropriate treatment on relapse episodes in AP.

Methods

Consecutive patients prospectively followed-up over 20 years at Padua University Cardio-immunology outpatient clinic were included. Clinical and instrumental findings were recorded at diagnosis and at each follow-up. Spectrum, appropriateness, efficacy and side effects of therapies received by patients before and after referral to our centre were considered. The distribution of recurrence-free survival probability was estimated using Kaplan-Meier method; impact of the covariates of interest on the outcome was assessed using Cox univariate analysis models.

Results

The study included 144 patients (57% male, mean age 50 years, 143 Caucasian and 1 African). 139 patients had AP, which was recurrent in 63; 5 had constrictive pericarditis. Etiology was idiopathic/presumed-viral in 112 patients, bacterial in 1, secondary to pericardial injury in 26, to Dressler syndrome in 2, and to a systemic immune-mediated disease in 3. At diagnosis, 68% were in NYHA class I; 9% developed cardiac tamponade; 84% received non-steroidal-anti-inflammatory drugs (NSAIDs), 54% colchicine and 19% corticosteroids. Treatment was not in line with ESC guidelines in 31% of patients for NSAIDs, in 12% for steroids and in 28% for colchicine, requiring readjustment. All patients with constrictive pericarditis underwent uncomplicated pericardiectomy. No patient was dead at last follow-up. Estimated recurrence-free-survival probability was 86% at 1st year, 58% at 5th, 52% at 10th. Variables which tended to be associated with a higher risk of recurrence were: cardiac tamponade at diagnosis, left heart failure, concomitant immune-mediated diseases, history of recurrence, inappropriate treatment with colchicine, inappropriate treatment with NSAIDs, III or IV NYHA class at diagnosis. Treatment of acute/recurrent forms before referral did not appear in line with the international recommendations in terms of daily dosage or duration, or both, in 43 patients for NSAIDs, in 17 for corticosteroids and in 39 for colchicine, which was omitted despite the absence of contraindications (Table 1). Following treatment adjustment to international guidelines, 107 patients with relapsing pericarditis obtained complete remission; only 13 (9%) of our AP patients showed a truly treatment-refractory form that required a second-line therapy.

Conclusion

When treated according to international guidelines, pericarditis has usually a favorable course, even in its most adverse presentations. Treatment inaccuracies seems to account, at least in part, to disease recurrences.

Funding Acknowledgement

Type of funding sources: None.

Machine-learning algorithms for prediction of survival by stress echocardiography in chronic coronary syndromes

Background

Stress echocardiography (SE) is based on regional wall motion abnormalities and coronary flow velocity reserve (CFVR). They recognise different and complementary pathophysiological targets, and show independent and incremental value in predicting survival [1]. The approach based on machine-learning (ML) has the recognised potential to identify unsuspected patterns, and this can be especially relevant in the field of risk stratification by cardiac functional stress testing due to multiple parameters used in comprehensive stress testing and the variable weight of covariates [2].

Aim

To assess SE outcome data analysis with ML approach.

Methods

We included 6,881 prospectively recruited and retrospectively analyzed patients (median age 67 years, IQR 59–74) with suspected (n=4,279) or known (n=2,602) coronary artery disease submitted to clinically-driven dipyridamole SE in 5 Italian institutions (Figure 1). The primary outcome measure was all-cause death. A Random Forest Survival model has been implemented to model the survival function according to the patient's characteristics. The Random Forest predicted response dependency on covariates has been investigated by reporting the variable dependence and the partial dependency plot (Figure 2). A web application was developed to predict the survival function according to the patients' characteristics. The external validation cohort was made of additional 1,002 patients recruited by a single, independent center in the same time period.

Results

During a median duration of follow-up of 3.4 years (IQR 1.6–7.5), 814 (12%) patients died. The mortality risk was higher for patients aged more than 60 years, resting ejection fraction <60%, resting WMSI, positive delta WMSI scores, and CFVR <3.0. The C-index performance (perfect prediction=1) was 0.79 in the internal validation cohort and 0.81 in the external, independent validation data set. Survival functions for individual patient were easily obtained with an open-access web-app.

Conclusion

An ML approach can be fruitfully applied to outcome data obtained with SE. Survival showed a constantly increasing relationship between survival and CFVR <3.0 and stress-rest wall motion score index >0. Since processing is largely automated, this approach can be easily scaled to larger and more comprehensive data sets to further refine stratification, guide therapy and be ultimately adopted as an open-source on-line decision tool.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was partially funded by CNR-MIUR (National Research Council, Italian Ministry of University and Research) Ageing subproject.

Stent Dislodgment and Retrieval During Percutaneous Coronary Intervention

During PCI, stent entrapment and dislodgment in the coronary arteries is a rare but potentially fatal complication that can lead to emergent cardiac surgery. Percutaneous stent retrieval is an alternative way to solve this challenging complication while avoiding cardiac surgery.

Validation of a Nomogram to Predict Long Term Outcomes After Curative Surgery for Gastric Cancer in an Italian Cohort of Patients

AIM OF THE STUDY

Nomograms have been proposed to assess prognosis following curative surgery for gastric cancer. The objective of the current study was to evaluate the performance of the Gastric Cancer Collaborative Group nomograms developed in 2014 by Kim et al., using a cohort of patients from a 10-year single institution experience in gastric cancer management.

PATIENTS AND METHODS

We retrospectively reviewed patients who underwent curative-intent surgery for histologically confirmed gastric cancer at First Surgical Clinic of Padua University Hospital (Italy) from January 2010 to May 2020. Univariable and multivariable Cox proportional hazard models were employed to assess the effect of the variables of interest on mortality and recurrence. Multivariable analysis was performed by considering the variables included in the Gastric Cancer Collaborative Group nomograms in order to validate them. The performance of the nomograms was evaluated using Harrell's C-index and calibration plots.

RESULTS

Overall, 168 patients were included, with a median follow-up of 20.1 months. On multivariable analysis, tumor location, lymph node ratio, and pathological T stage were associated with recurrence; age, tumor location, lymph node ratio, and pT stage were associated with OS (overall survival). The nomograms had good discriminatory capability to classify both OS (C-index: 0.75) and DFS (disease-free survival) (C-index 0.72). The corrected C-Index for DFS based on the AJCC staging system revealed better prediction (C-Index 0.75), while the corrected C-Index for OS had worse discrimination ability compared with the current nomogram (C-Index 0.72).

CONCLUSIONS

The Gastric Cancer Collaborative Group nomograms demonstrated good performances in terms of prediction of both OS and DFS on external validation. The two nomograms are easy to apply, and variables included are widely available to most facilities.

Allergic Myocardial Infarction: An Unusual Cause of Stent Thrombosis

Our case confirms that an allergic insult can cause an acute myocardial infarction in a stable coronary disease setting. It also suggests that type 3 Kounis syndrome must be suspected in cases of apparently unexplained "very late" stent thrombosis.

Predictors of inappropriate shock in Brugada syndrome patients with a subcutaneous implantable cardiac defibrillator

BACKGROUND

Subcutaneous implantable cardioverter defibrillators (S-ICDs) avoid complications secondary to transvenous leads, but inappropriate shocks (ISs) are frequent. Furthermore, IS data from patients with Brugada syndrome (BrS) with an S-ICD are scarce.

OBJECTIVE

We aimed to establish the frequency and predictors of IS in this population.

METHODS

We analyzed the clinical and electrocardiographic characteristics, automated screening test data, device programming, and IS occurrence in adult patients with BrS with an S-ICD.

RESULTS

Thirty-nine patients were enrolled (69% male, mean age at diagnosis 46 ± 13 years, mean age at implantation 48 ± 13 years). During a mean follow-up of 26 ± 21 months, 18% patients experienced IS. Patients with IS were younger at the time of diagnosis (36 ± 8 vs. 48 ± 13 years, p = .018) and S-ICD implantation (38 ± 9 vs. 50 ± 23 years, p = .019) and presented with spontaneous type 1 Brugada electrocardiogram pattern more frequently at diagnosis or during follow-up (71% vs. 25%, p = .018). During automated screening tests, patients with IS showed lower QRS voltage in the primary vector in the supine position (0.58 ± 0.26 vs. 1.10 ± 0.35 mV, p = .011) and lower defibrillator automated screening score in the primary vector in the supine (123 ± 165 vs. 554 ± 390 mV, p = .005) and standing (162 ± 179 vs. 486 ± 388 mV, p = .038) positions. Age at diagnosis was the only independent predictor of IS (hazard ratio = 0.873, 95% confidence interval: 0.767-0.992, p = .037).

CONCLUSION

IS was a frequent complication in patients with BrS with an S-ICD. Younger age was independently associated with IS. A more thorough screening process might help prevent IS in this population.

Feasibility and reproducibility of right ventricle stress echocardiography and its capability to assess the right ventricle contractile reserve of patient with at least trivial tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND. Stress echocardiography (SE) is widely used for the assessment of left ventricular (LV) function, diagnostic and prognostic stratification of patients with coronary artery disease and for assessment of mitral and aortic valve disease. However, the assessment of the right ventricle (RV) in general, and in particular in regard to the contractile reserve of the RV in patients with tricuspid valve (TV) disease is an area that has not been previously explored in adult patients. The physiology and function of the RV is different than that of the LV and the use of SE provides the possibility to test both systolic and diastolic function of the RV in response to increased loading conditions. This can potentially be used to assess the RV function prior to surgery  and to predict which subset of patients may benefit from intervention on the TV before the RV displays signs of failure

PURPOSE. We therefore propose a study to investigate the potential use of SE for the assessment of RV function in adult patients. The aim is to evaluate the feasibility of RV SE in any patients with more than trivial tricuspid regurgitation (TR) and to assess the presence and degree of RV contractile reserve.

METHODS. We enrolled 81 patients undergoing a phisical or dobutamine SE for CV risk stratification or chest pain. Inclusion criteria were age≥ 18 years, normal baseline RV function (FAC> 35%, TAPSE> 16 mm). Exclusion criteria were presence of RV dysfunction, pulmonary stress hypertension, positive stress test for left myocardial ischemia, presence of moderate or severe valvular disease, grade III or higher diastolic dysfunction at baseline, severe respiratory, renal or hepatic dysfunction. We evaluated the average values of TAPSE, fractional area change (FAC), S wave, sPAP (pulmonary systolic blood pressure), RV strain during baseline and at the peak of the effort. We also assessed the reproducibility of these measurement between two different expert operators (blind analysis).

RESULTS. We were able to measure the RV parameters both during baseline and at the peak of the effort in all patients, demonstrating an excellent feasibility. Differences in parameters collected at baseline and at peak were assessed using paired Wilcoxon signed rank test. All variables showed a statistical significant increase (p < 0.001) at peak compared to the baseline. Average percentage increases at peak were 31.1% for TAPSE, 24,8% for FAC, 50,6% for S wave, 55,2% for PAPS and 39.8 % for RV strain. Bland-Altman method was used to evaluate the agreement between measurements collected by two separate operators and it showed  good Intraclass Correlation Coefficients  (Figure).

CONCLUSIONS. RV SE proved to be feasible and showed little inter-operator variability  in patients with at least trivial TR. It provided valuable informations about RV contractile  reserve that may help stratifying the risk of RV failure in patients undergoing TV surgery.

Abstract Figure

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

BACKGROUND

Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH.

METHODS

This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed.

RESULTS

The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%.

CONCLUSIONS

Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Predictors of death and heart transplantation in biopsy-proven myocarditis: a machine-learning approach

Background

Risk stratification for death and heart transplantation (HTx) in myocarditis is complex. A random forest (RF) is a tree-based machine learning technique (MLT) which is being increasingly used for clinical data analysis; it allows the detection of complex relationships between the outcome of interest and the covariates, overcoming the limits of traditional statistical analysis (i.e. regression approaches). Purpose To assess the potential role of clinical and diagnostic features at presentation as predictors of death and HTx in biopsy (Bx)-proven myocarditis using RF. Methods From January 1993 to August 2019, we consecutively enrolled 357 patients with Bx-proven myocarditis (65% male, median age 39 years, interquartile range (IQR) 26–51). An RF approach for survival data was used. Variables included in the analysis were: histology type by Bx, NYHA, type of presentation (infarct-like, arrhythmia, heart failure), viral genome detection on Bx, serum antiheart (AHA), antiintercalated disk (AIDA), anticardiac endothelial cells (AECA), antinuclear (ANA) autoantibodies, immunosuppressive therapy, cardiac catheterisation (left ventricular enddiastolic volume (LVEDV), mean capillary wedge pressure, right and left ventricular enddiastolic pressure) and 2-D echocardiographic measures (LVEDV, left ventricular ejection fraction (LVEF) at presentation and at follow-up, right ventricular fractional area change (FAC%), right ventricular diastolic area). Results The median follow-up time was of 1352 days (IQR 423.25–2535.75). At the end of follow-up, 42 patients were dead or transplanted. The 1-year, 5-year, and 10-year survival probabilities were of 0.928, 0.854, and 0.817, respectively. The most relevant predictors of death or HTx identified by the RF algorithm (according to the variable importance measure) were histological type, NYHA, clinical presentation, LVEF, and FAC%. Among the circulating auto-antibodies AECA were found to be the most important. Histological type was the strongest predictor of death/HT (100% relative importance, (RI)), giant cell myocarditis having a lower survival probability compared to other types. The next stronger predictors were advanced (III-IV) NYHA and heart failure presentation with lower survival probabilities (90% and 84% RI respectively). AECA-positive patients had lower survival probability compared to AECA negative ones (20% RI). The RF algorithm revealed an excellent predictive performance in the correct identification of all alive patients, with only 5 dead patients being misclassified (balanced accuracy 94%).

Conclusions

Autoimmune features, i.e Giant cell myocarditis and AECA, as well as severity of heart failure and of left ventricular disfunction at presentation were the strongest predictors of dismal prognosis. Our RF approach provides a new automated powerful tool for accurate risk stratification for death/HTx in Bx-proven myocarditis.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Budget Integrato per la Ricerca dei Dipartimenti (BIRD, year 2019), Padova University, Padova, Italy (project Title: Myocarditis: genetic background, predictors of dismal prognosis and of response to immunosuppressive therapy.)

Vascular Assisted Tracking for Challenging Transradial Percutaneous Intervention

BACKGROUND

TRA is recommended as the preferred approach to perform coronary angiography and PCI. Despite this, TRA-PCI is burdened by a high access site crossover rate. Assisted-tracking techniques (balloon-assisted tracking and pigtail-assisted tracking) have showed to solve some of the issues related with challenging TRA procedures, but few data exist about procedural outcomes. Aim of the study was to evaluate the efficacy and safety of the assisted-tracking (AsTra) techniques during transradial (TRA) percutaneous coronary intervention (PCI).

METHODS

From January 2016 to December 2019, 1682 TRA-PCI procedures were performed. Starting from January 2018, AsTra techniques were adopted in 72 cases of challenging TRA-PCI, and clinical data, procedural results and 30 days follow-up data were retrospectively collected. Because not all interventionalists used AsTra techniques, we had the opportunity to evaluate if their utilization influenced TRA-PCI rates. To this purpose, we identified two groups of interventionalists and tested the hypothesis that these techniques could lead to a significant improvement in TRA-PCI rates.

RESULTS

Between January 2016 and December 2019, TRA-PCI rates increased from 68.5% to 95%. The TRA-PCI success rate increased significantly for interventionalists who adopted assisted-tracking techniques (p-value < 0.0001 for year 2019; p-value = 0.003 for year 2018).

CONCLUSIONS

Assisted-tracking techniques appear to be effective in increasing TRA-PCI rates. Their use is associated with low complication and low access crossover rates.

Conservative Management of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is caused by separation of the vessel wall and hematoma development. We demonstrate that SCAD often resolves spontaneously, with an average period of 35 days from the event usually sufficient to demonstrate angiographic healing.

Association between air pollution and Pediatric Intensive Care Units hospitalization rates

Background

In the last years air pollution has been linked to an increased risk of several children respiratory pathologies, especially low respiratory tract infections. In more severe cases, the child could be hospitalized in Pediatric Intensive Care Unit (PICU). The present study aims to evaluate the association between the exposure to air pollution and (i) PICU admissions and (ii) hospitalization rates among children with a previous PICU admission.

Methods

PICU admissions due to respiratory diseases were collected from 2010 to 2019 in Padua hospital (Italy) based on a large clinical Italian register. Furthermore, for subjects admitted in 2013, all subsequent hospitalizations have been tracked until 2019 from hospital discharge records. Environmental data were obtained from monitoring stations located within 20 km from the children residence. A conditional logistic regression based on a time-stratified case-crossover design will be performed to evaluate the association between hospital admissions and NO2, PM2.5 and PM10 in aerodynamic diameter.

Results

The registry contains data about more than 30000 PICU admissions, of which around 30 % are of children under one year of age. An increased prevalence for respiratory diseases' admissions, from 18% in 2010 to 24% in 2019 can be observed. More than 400 children were admitted to Padua's PICU in 2013. In the following years, all these subjects experienced at least one hospitalization (median 2, [IQR 1-5]) for more than 2000 hospital admissions from 2014 up to 2019.

Conclusions

Exposure of infants to air pollution could lead to more severe outcome as hospitalization as a result of a vulnerable lung condition that eases virus infections. This condition identifies a particularly frail population. With this approach, an association between air pollution and PICU admissions could be investigated in order to adopt public health policies aimed at safeguarding this frail population.

Key messages

The study would detect an association between air pollution and hospital admissions as severe outcomes in infants and children. Furthermore, this is the first study that would assess if there is an association between these two factors in more frail subjects already hospitalized in a Pediatric Intensive Care Unit.

851Predictors and causes of inappropriate shocks by subcutaneous defibrillators (S-ICD) in a cohort of sardinian Brugada syndrome patients

Funding Acknowledgements

Project Code CRP- 6175. Regione Autonoma della Sardegna

Background

The subcutaneous defibrillator (S-ICD) is an attractive option for patients with Brugada syndrome (BrS) at high risk, as it is highly effective to prevent arrhythmic sudden cardiac death (SCD) while avoiding some of the complications associated to transvenous devices. However, S-ICD are not free from complications, one of the most common being inappropriate shocks.

Objective

To assess the causes and predictors of inappropriate shocks by subcutaneous defibrillators (S-ICD) in a cohort of sardinian BrS patients

Methods

From February 2013 to September 2019, 373 patients were diagnosed as BrS patients. Sixty-five patients were considered to be at high risk of SCD, and implanted with an ICD. Of them, 36 were implanted with an S-ICD. Patients went through regular follow-up visits (physical examination, 12-lead ECG, device interrogation, occurrence of symptoms). Appropriate and inappropriate shocks were analyzed to establish their cause.

Results

Thirty-six BrS patients were implanted with an S-ICD (9.7% of the total BrS group, 55% of ICD implants). Twenty-four patients (67%) were male, mean age at diagnosis was 45± 14 y.o., and 31 (86%) were probands.  Seventeen patients (47%) had a family history of SCD. Ten patients (28%) had a spontaneous type 1 ECG at diagnosis and 14 (19%) had an spontaneous type 1 ECG at least once since the diagnosis , 2 patients (5.7%) had a type 1 ECG during fever, and 11 (31%) presented an S wave ≥40 msec in lead DI. Twelve patients (33%) underwent EP study, and 8 (67%) were inducible for ventricular fibrillation.

During a mean follow-up of 46 ± 67 months, 2 patients (6%) had appropriate shocks, while 5 (14%) had inappropriate shocks. The rate between inappropriate and appropriate shock was 2.5.  The causes of inappropriate shock were T-wave oversensing (4 patients, 80%) and air entrapment (1 patient, 20%).

Gender, proband status, sport practice, family history of SCD, type 1 ECG during fever, S wave ≥40 msec in lead DI, VF inducibility EP study, or the presence of symptoms during the follow-up (vaso-vagal syncope, arrhythmic syncope, nocturnal enuresis, ventricular fibrillation, atrial fibrillation) did not associated with inappropriate shock; neither did the technique of screening for S-ICD (manual or automated tool) nor the selected vector of sensing of the S-ICD.

A spontaneous type 1 ECG at diagnosis (4 (80%) versus 6 (21%), p = 0.009), or at any time from diagnosis during follow-up (4 (80%) versus 10 (33%), p = 0.0049) and having a high-pass filter programmed OFF/not available [3 (75% versus 7 (25%), p = 0.044], were significantly associated with inappropriate shock of S-ICD in these population.

Conclusions

Brugada syndrome patients implanted with S-ICD present a higher rate of inappropriate shock compared to appropriate shock (2.5 times). Patients with spontaneous type 1 ECG are at  higher risk to receive inappropriate shock from S-ICDs, while programming a high-pass filter ON may prevent some of these episodes.

Rendered OCT Imaging of an Impressive Stent Malapposition in the Left Main Coronary Artery

This case emphasizes the need to use intravascular imaging to optimize stent implantation in the left main coronary artery. Despite recommendations, intravascular imaging is still widely under-utilized. The recently developed stent apposition OCT software (OPTIS Stent Optimization Software; Abbott Vascular) confirmed its usefulness in optimizing stent implantation in unprotected left main PCI.

Anomalous Origin of Right Coronary Artery From Left Sinus of Valsalva

We present the imaging series of a 52-year-old woman with no cardiovascular risk factors who was admitted for acute coronary syndrome without persistent ST elevation (NSTEMI). Coronary angiography and cardiac computed tomography demonstrated anomalous origination of the coronary artery from the opposite sinus (ACAOS), which is an uncommon coronary anomaly; the incidence is about 1.07% in general, and only 0.12%-0.9% in the case of right ACAOS. The clinical consequences can be relevant if the ectopic artery has intramural intussusception or courses between the aorta and pulmonary artery.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

[Cerebral amyloid angiopathy and atrial fibrillation: a dangerous union]

Intracranial hemorrhage (ICH) is the major complication of oral anticoagulant therapy. Cerebral amyloid angiopathy (CAA) is an age-related disease characterized by the pathological deposition of β-amyloid protein in leptomeningeal and cortical cerebral vessels. Such vascular alterations expose to the risk of spontaneous vascular rupture. The main clinical manifestations are represented by ICH, cognitive decline and transient focal neurological episodes (TFNE). In the patient subgroup with TFNE, a misdiagnosis with transient ischemic attack may have catastrophic consequences, resulting in a significant increase in the risk of spontaneous ICH within weeks after clinical onset, with potentially devastating consequences if anticoagulant therapy is started.The prevention of bleeding complications related to CAA is based on disease knowledge. This is particularly relevant because non-pharmacological treatment options, including percutaneous left atrial appendage occlusion, are emerging as an alternative to traditional anticoagulant therapies in patients at high bleeding risk.

Hidden culprit lesion: beyond coronary angiography

: Coronary imaging is a useful tool to identify wall vessel disease also in the absence of obstructive stenosis.

[Atrial fibrillation in severe and end stage renal disease: from oral anticoagulation therapy to percutaneous left atrial appendage occlusion]

Non-valvular atrial fibrillation (AF) is the most frequent arrhythmia in the general population and its prevalence increases with age. The prevalence and incidence of AF is high in patients with chronic kidney failure (CKD). The most important complication associated with AF, both in the general population and in that with CKD, is thromboembolic stroke. For this reason, in patients with AF, the Guidelines indicate oral anticoagulant therapy (OAT) with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for thromboembolic risk prevention. Patients with severe CKD and, in particular, with end stage renal disease (ESRD) undergoing renal replacement therapy, often have both a high thromboembolic and hemorrhagic risk and therefore present both an indication and a contraindication to OAT. In addition, patients with severe or ESRD were excluded from trials that showed the efficacy of different antithrombotic drugs in patients with AF. Thus there is no evidence of the effectiveness of OAT in this population. This review deals with the issues related to OAT in patients with severe or end stage CKD and the possible use of percutaneous closure of the left auricula (LAAO), recently proposed as an alternative in patients with an absolute contraindication of OAT in this population.

Challenging Aorto-Coronary Occlusion: Which Solution?

Aorto-coronary occlusion is a particularly difficult lesion to treat, especially in an emergent setting. To our knowledge, this is the first description of the use of a microcatheter not to support the guidewire, but to open an aorto-coronary calcific occlusion with anterograde approach in an emergent situation.

Percutaneous Management of Left Atrial Appendage Perforation: Keep Calm and Think Fast

Left atrial appendage (LAA) perforation is a possible complication not only after release of the closure device, but also during the diagnostic phase due to sheath positioning in the LAA. We present an 83-year-old woman with permanent atrial fibrillation and high thromboembolic and bleeding risk who was admitted for elective percutaneous LAA closure. During angiographic study, she suddenly became hypotensive. Heart perforation with leakage of contrast in the pericardial space was evident and imaging confirmed cardiac tamponade. Rapid release of the closure device and pericardial evacuation allowed the operators to successfully manage the cardiac tamponade and avoid a surgical option.

An Impressive Case of "Honeycomb" In-Stent Restenosis

Our image shows an impressive "honeycomb" pattern of neoatherosclerosis in the context of very late in-stent restenosis. In this case, OCT excluded the most common mechanisms of late in-stent restenosis, underlying the complexity of this unpredictable disease.

[Balloon-assisted tracking technique to preserve radial access during percutaneous coronary intervention]

Transradial access for cardiac catheterization and percutaneous coronary intervention is recommended by international guidelines to reduce vascular complications. Unfortunately, some factors such as female sex, shorter body surface area and older age, were found to be independent predictors of transradial cardiac catheterization failure. The balloon-assisted tracking technique is a smart trick to avoid crossover from radial to femoral access in case of spasm, tortuosity, or stenosis.

Bayesian Machine Learning Techniques for revealing complex interactions among genetic and clinical factors in association with extra-intestinal Manifestations in IBD patients

The objective of the study is to assess the predictive performance of three different techniques as classifiers for extra-intestinal manifestations in 152 patients with Crohn's disease. Naïve Bayes, Bayesian Additive Regression Trees and Bayesian Networks implemented using a Greedy Thick Thinning algorithm for learning dependencies among variables and EM algorithm for learning conditional probabilities associated to each variable are taken into account. Three sets of variables were considered: (i) disease characteristics: presentation, behavior and location (ii) risk factors: age, gender, smoke and familiarity and (iii) genetic polymorphisms of the NOD2, CD14, TNFA, IL12B, and IL1RN genes, whose involvement in Crohn's disease is known or suspected. Extra-intestinal manifestations occurred in 75 patients. Bayesian Networks achieved accuracy of 82% when considering only clinical factors and 89% when considering also genetic information, outperforming the other techniques. CD14 has a small predicting capability. Adding TNFA, IL12B to the 3020insC NOD2 variant improved the accuracy.

A wire-flooring model for inducing lameness in broilers: evaluation of probiotics as a prophylactic treatment

Bacterial chondronecrosis with osteomyelitis (BCO) is the most common cause of lameness in commercial broilers. Bacteria entering the blood via translocation from the respiratory system or gastrointestinal tract spread hematogenously to the proximal epiphyseal-physeal cartilage of rapidly growing femora and tibiae, causing BCO. We tested the hypothesis that rearing broilers on wire flooring should increase the incidence of BCO by persistently imposing additional torque and shear stress on susceptible leg joints. We also tested the hypothesis that probiotics might attenuate bacterial translocation and thereby reduce the incidence of BCO. In 5 independent experiments using 4 commercial lines, broilers grown on wire flooring developed lameness attributable predominately to BCO. The fastest-growing birds were not necessarily the most susceptible to lameness on wire flooring, nor did the genders differ in susceptibility in the 2 experiments that included both male and female broilers. The pathogenesis of BCO is not instantaneous, and accordingly, many broilers that did not exhibit lameness, nevertheless, did possess early pathognomonic lesions. These subclinical lesions were equally likely to develop in the right or left leg. The lesion status of the proximal femoral head did not determine the lesion status of the ipsilateral or contralateral proximal tibial head and vice versa. Broilers reared on wire flooring consistently had higher incidences of lameness than hatch-mates reared on wood-shavings litter. Adding probiotics to the diet beginning at 1 d of age consistently reduced the incidence of lameness for broilers reared on wire flooring. These experiments indicate that probiotics administered prophylactically may constitute an alternative to antibiotics for reducing lameness attributable to BCO. Rearing broilers on wire flooring provides an important new research model for investigating the etiology, pathogenesis, and treatment strategies for BCO.

Monitoring of heavy metal deposition in Northern Italy by moss analysis

A survey of heavy metal deposition in the mountainous territories of Northern Italy was carried out in 1995-96. Moss samples (mainly Hylocomium splendens) were collected in a dense network of sites (about 3.2 sites/1000 km(2)) and the data of metal concentrations in moss tissues were statistically correlated with environmental and climatic factors, as well as with bulk deposition of elements and elemental concentrations in the soil. Three main geographic patterns of metal concentration in mosses could be defined: (1) Fe, Ni, and Cr, all derived both by soil particulates and anthropogenic emissions connected with ferrous metal manufacturing, were mostly concentrated in Northwestern Italy; (2) Cu and Zn, as typical multi-source elements, showed rather high concentrations with little ranges of variation over the whole area and small peaks reflecting local source points; (3) Cd and Pb reflected long-distance transport and showed highest concentrations in the regions with highest precipitation, especially in the Eastern Alps.