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Baldetti L, den Uil CA, Fiore G, Gallone G, Romagnolo D, Peveri B, Cianfanelli L, Calvo F, Gramegna M, Pazzanese V, Sacchi S, Dias-Frias A, Ajello S, Scandroglio AM. Pulmonary artery elastance as a predictor of hospital mortality in heart failure cardiogenic shock. ESC Heart Fail 2024. [PMID: 38710587 DOI: 10.1002/ehf2.14817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 05/08/2024] Open
Abstract
AIMS The initial bundle of cares strongly affects haemodynamics and outcomes in acute decompensated heart failure cardiogenic shock (ADHF-CS). We sought to characterize whether 24 h haemodynamic profiling provides superior prognostic information as compared with admission assessment and which haemodynamic parameters best predict in-hospital death. METHODS AND RESULTS All patients with ADHF-CS and with available admission and 24 h invasive haemodynamic assessment from two academic institutions were considered for this study. The primary endpoint was in-hospital death. Regression analyses were run to identify relevant predictors of study outcome. We included 127 ADHF-CS patients [65 (inter-quartile range 52-72) years, 25.2% female]. Overall, in-hospital mortality occurred in 26.8%. Non-survivors were older, with greater CS severity. Among admission variables, age [odds ratio (OR) = 1.06; 95% confidence interval (CI): 1.02-1.11; Padj = 0.005] and CPIRAP (OR = 0.62 for 0.1 increment; 95% CI: 0.39-0.95; Padj = 0.034) were found significantly associated with in-hospital death. Among 24 h haemodynamic univariate predictors of in-hospital death, pulmonary elastance (PaE) was the strongest (area under the curve of 0.77; 95% CI: 0.68-0.86). PaE (OR = 5.98; 95% CI: 2.29-17.48; Padj < 0.001), pulmonary artery pulsatility index (PAPi, OR = 0.77; 95% CI: 0.62-0.92; Padj = 0.013) and age (OR = 1.06; 95% CI: 1.02-1.11; Padj = 0.010) were independently associated with in-hospital death. Best cut-off for PaE was 0.85 mmHg/mL and for PAPi was 2.95; cohort phenotyping based on these PaE and PAPi thresholds further increased in-hospital death risk stratification; patients with 24 h high PaE and low PAPi exhibited the highest in-hospital mortality (56.2%). CONCLUSIONS Pulmonary artery elastance has been found to be the most powerful 24 h haemodynamic predictor of in-hospital death in patients with ADHF-CS. Age, 24 h PaE, and PAPi are independently associated with hospital mortality. PaE captures right ventriclar (RV) afterload mismatch and PAPi provides a metric of RV adaptation, thus their combination generates four distinct haemodynamic phenotypes, enhancing in-hospital death risk stratification.
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Affiliation(s)
- Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Corstiaan A den Uil
- Department/Division of Cardiology and Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Giorgio Fiore
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, City of Health and Science University Hospital of Turin, Turin, Italy
| | - Davide Romagnolo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Beatrice Peveri
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - André Dias-Frias
- Cardiology Department, Santo António University Hospital Center, Porto, Portugal
| | - Silvia Ajello
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Anna Mara Scandroglio
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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De Cristofaro J, Sacchi S, Baldetti L, Calvo F, Gramegna M, Pazzanese V, Peveri B, Cianfanelli L, Ajello S, Scandroglio AM. Cat Scratch Endocarditis. JACC Case Rep 2024; 29:102201. [PMID: 38361554 PMCID: PMC10865220 DOI: 10.1016/j.jaccas.2023.102201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/21/2023] [Accepted: 12/11/2023] [Indexed: 02/17/2024]
Abstract
We reported a case of blood culture-negative infective endocarditis on a native valve, where the clinical presentation was exclusively related to extensive cerebral ischemia secondary to multiple systemic septic cardioembolic events. The cause was ascribed to subacute Bartonella henselae infection, presumably transmitted by cat scratch, documented by positive serologic findings.
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Affiliation(s)
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | - Beatrice Peveri
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
| | | | - Silvia Ajello
- Cardiac Intensive Care Unit, San Raffaele University Hospital, Milan, Italy
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Rizza V, Maranta F, Cianfanelli L, Cartella I, Maisano F, Alfieri O, Cianflone D. Subacute postoperative atrial fibrillation after heart surgery: Incidence and predictive factors in cardiac rehabilitation. J Arrhythm 2024; 40:67-75. [PMID: 38333376 PMCID: PMC10848578 DOI: 10.1002/joa3.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 02/10/2024] Open
Abstract
Background Postoperative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery (CS). It may occur between the 1st and the 4th postoperative day as acute POAF or between the 5th and the 30th as subacute (sPOAF). sPOAF is associated with higher thromboembolic risk, which consistently increase patients' morbidity. Neutrophil-to-lymphocyte ratio (NLR) is a low-cost inflammatory index proposed as possible POAF predictor. Identification of patients' risk categories might lead to improved postoperative outcomes. Methods The aim was to assess the incidence of sPOAF and to identify possible predictors in patients performing cardiovascular rehabilitation (CR) after CS. A single-center cohort study was performed on 737 post-surgical patients admitted to CR on sinus rhythm. Continuous monitoring with 12-lead ECG telemetry was performed. We evaluated the predictive role of anamnestic, clinical, and laboratory data, including baseline NLR. Results Subacute POAF was documented in 170 cases (23.1%). At the multivariate analysis, age (OR 1.03; p = .001), mitral valve surgery (OR 1.77; p = .012), acute POAF (OR 2.97; p < .001), and NLR at baseline (OR 1.13; p = .042) were found to be independent predictive factors of sPOAF following heart surgery. Conclusions sPOAF is common after CS. Age, mitral valve procedures, acute POAF, and preoperative NLR were proved to increase sPOAF occurrence in CR. NLR is an affordable and reliable parameter which might be used to qualify the risk of arrhythmias at CR admission. Identification of new predictors of postoperative atrial fibrillation may allow to improve patients' prognosis.
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Affiliation(s)
- Vincenzo Rizza
- Vita‐Salute San Raffaele UniversityMilanItaly
- Cardiac Rehabilitation UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Francesco Maranta
- Cardiac Rehabilitation UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Iside Cartella
- School of Medicine and SurgeryMilano‐Bicocca UniversityMilanItaly
| | - Francesco Maisano
- Cardiac Surgery UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Ottavio Alfieri
- Cardiac Surgery UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Domenico Cianflone
- Vita‐Salute San Raffaele UniversityMilanItaly
- Cardiac Rehabilitation UnitIRCCS San Raffaele Scientific InstituteMilanItaly
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Rizza V, Maranta F, Cianfanelli L, Cartella I, Alfieri O, Cianflone D. Imaging of the Diaphragm Following Cardiac Surgery: Focus on Ultrasonographic Assessment. J Ultrasound Med 2023; 42:2481-2490. [PMID: 37357908 DOI: 10.1002/jum.16291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
Diaphragm dysfunction is a common complication following cardiac surgery. Its clinical impact is variable, ranging from the absence of symptoms to the acute respiratory failure. Post-operative diaphragm dysfunction may negatively affect patients' prognosis delaying the weaning from the mechanical ventilation (MV), extending the time of hospitalization and increasing mortality. Ultrasonography is a valid tool to evaluate diaphragmatic impairment in different settings, like the Intensive Care Unit, to predict successful weaning from the MV, and the Cardiovascular Rehabilitation Unit, to stratify patients in terms of risk of functional recovery failure. The aim of this review is to describe the pathophysiology of post-cardiac surgery diaphragm dysfunction, the techniques used for its diagnosis and the potential applications of diaphragm ultrasound.
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Affiliation(s)
| | - Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Vita-Salute San Raffaele University, Milan, Italy
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
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Peretto G, Maranta F, Cianfanelli L, Sala S, Cianflone D. Outcomes of inflammatory cardiomyopathy following cardiac rehabilitation. J Cardiovasc Med (Hagerstown) 2023; 24:59-61. [PMID: 36574301 DOI: 10.2459/jcm.0000000000001388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Giovanni Peretto
- Myocarditis Disease Unit.,Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute.,San Raffaele Vita-Salute University
| | - Francesco Maranta
- San Raffaele Vita-Salute University.,Department of Cardiac Rehabilitation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Department of Cardiac Rehabilitation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simone Sala
- Myocarditis Disease Unit.,Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute
| | - Domenico Cianflone
- San Raffaele Vita-Salute University.,Department of Cardiac Rehabilitation, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Pili G, Cianfanelli L, Maranta F, Rizza V, Castiglioni A, De Bonis M, Cianflone D. 250 POST-PERICARDIOTOMY SINDROME: A DESCRIPTIVE ANALYSIS OF A NEGLECTED SYNDROME. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Post-pericardiotomy syndrome (PPS) is a condition in which the surgical incision of the pericardium provokes the onset of pericardial and/or pleural effusion as a result of the inflammatory response inside the pericardial and/or the pleural space. PPS is a common complication following cardiac surgery (CS) and it has a significant impact on post-surgical patients’ management. Thus, it would be useful to find predictors in order to stratify patients in terms of risk of PPS and define tailored Cardiovascular Rehabilitation (CR) programmes.
Purpose
The aim of this study was to assess the incidence and to elucidate the features of PPS in a population of patients undergoing cardiac surgery. Secondly, the study was focused on the findings of likeable predictors of PPS and PPS’ relapse.
Methods
A prospective cohort study was performed on 156 patients who underwent cardiac surgery and then were admitted to the CR Unit of our institute. Among the 156-patients population, 26 patients developed post-pericardiotomy syndrome. Pre-operative and post-operative anamnestic and clinical data were collected to define the baseline characteristics of the population. The predictive role of anamnestic data, type of surgical procedure and laboratory parameters was evaluated. Treatment was then started in the PPS population, analysed and compared to the outcome. Data were collected during CR hospital stay and after discharge, during follow up check-ups. During CR hospital stay, the analysis regarded first and second line medical therapy, which was started in case of persistence, worsening or relapse of the pericardial and/or pleural effusion. After discharge, the analysis considered the outcome of the therapy at a defined deadline. Binary logistic regression analysis was performed to identify possible predictors of PPS and PPS’ relapse. All the variables with a univariate p-value <0.150 or clinically relevant were entered into the multivariate model.
Results
The population comprehends 156 patients. PPS patients presented with pleural effusion pre surgical intervention in 3 cases (11.5% vs 0%; p-value < 0.001) and showed more frequently pericardial effusion early after surgery (53.8% vs 8.5%; p-value < 0.001). In 3 patients (1.9%) drainage of pleural effusion was needed (7.7% vs 0.8%, p-value= 0.019). At admission in the CR Unit 26 patients (16.6%) presented or subsequently developed PPS. Pericardial effusion was classified as mild in 18 patients (69.2%), moderate in 7 patients (26.9%) and severe in 1 patient (3.8%); the median value of pericardial effusion at diagnosis was 7.5 mm, while the median value of the maximum pericardial effusion was 9.5 mm. During in-hospital stay, a first line medical therapy was administered to 26 PPS patients (100%): 13 patients (50%) needed a switch to a second line therapy, 4 patients (15.4%) needed invasive treatment of the effusion, 3 patients (11.5%) needed percutaneous pleural drainage and 2 patients (7.7%) needed percutaneous pericardial drainage. Medical therapy’ collateral effects occurred in 7 patients (26.95%). PPS therapy at discharge was administered to 22 patients (84.6%). At follow up, pericardial effusion occurred in 9 patients (36%), pleural effusion occurred in 3 patients (12%). Relapse of pleuro/pericardial effusion after therapy suspension occurred in 3 patients (12%) and consequently, pleuro/pericardial effusion resolution was obtained in 23 patients (92%). The median time of therapy interruption at follow up was 27 days (7–60). Binary logistic regression was performed to identify the clinical predictors of PPS and PPS’ relapse, the multivariate analysis did not find statistical significance for independent predictors of both conditions.
Conclusion
The PPS is a common complication of cardiac surgery. Further studies are needed to determine novel possible PPS predictors. Possible indicators of PPS relapse should be identified in patients with possible discontinuation of treatment.
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Gulletta S, Falasconi G, Cianfanelli L, Centola A, Paglino G, Cireddu M, Radinovic A, D’Angelo G, Marzi A, Sala S, Fierro N, Bisceglia C, Peretto G, Di Muzio N, Della Bella P, Vergara P, Dell’Oca I. Patients with Cardiac Implantable Electronic Device Undergoing Radiation Therapy: Insights from a Ten-Year Tertiary Center Experience. J Clin Med 2022; 11:jcm11174990. [PMID: 36078921 PMCID: PMC9457044 DOI: 10.3390/jcm11174990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The number of patients with cardiac implantable electronic devices (CIEDs) receiving radiotherapy (RT) is increasing. The management of CIED-carriers undergoing RT is challenging and requires a collaborative multidisciplinary approach. Aim: The aim of the study is to report the real-world, ten-year experience of a tertiary multidisciplinary teaching hospital. Methods: We conducted an observational, real-world, retrospective, single-center study, enrolling all CIED-carriers who underwent RT at the San Raffaele University Hospital, between June 2010 and December 2021. All devices were MRI-conditional. The devices were programmed to an asynchronous pacing mode for patients who had an intrinsic heart rate of less than 40 beats per minute. An inhibited pacing mode was used for all other patients. All tachyarrhythmia device functions were temporarily disabled. After each RT session, the CIED were reprogrammed to the original settings. Outcomes included adverse events and changes in the variables that indicate lead and device functions. Results: Between June 2010 and December 2021, 107 patients were enrolled, among which 63 (58.9%) were pacemaker carriers and 44 (41.1%) were ICD carriers. Patients were subjected to a mean of 16.4 (±10.7) RT sessions. The most represented tumors in our cohort were prostate cancer (12; 11%), breast cancer (10; 9%) and lung cancer (28; 26%). No statistically significant changes in device parameters were recorded before and after radiotherapy. Generator failures, power-on resets, changes in pacing threshold or sensing requiring system revision or programming changes, battery depletions, pacing inhibitions and inappropriate therapies did not occur in our cohort of patients during a ten-year time span period. Atrial arrhythmias were recorded during RT session in 14 patients (13.1%) and ventricular arrhythmias were observed at device interrogation in 10 patients (9.9%). Conclusions: Changes in device parameters and arrhythmia occurrence were infrequent, and none resulted in a clinically significant adverse event.
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Affiliation(s)
- Simone Gulletta
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Correspondence:
| | - Giulio Falasconi
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Lorenzo Cianfanelli
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Alice Centola
- Centro Cardiologico Monzino, Via Carlo Parea 4, 20138 Milan, Italy
| | - Gabriele Paglino
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Manuela Cireddu
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Andrea Radinovic
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giuseppe D’Angelo
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Alessandra Marzi
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Simone Sala
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Nicolai Fierro
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Caterina Bisceglia
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Nadia Di Muzio
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Pasquale Vergara
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Italo Dell’Oca
- Department of Arrhythmology and Cardiac Electrophysiology, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
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Pedicino D, Severino A, Di Sante G, De Rosa MC, Pirolli D, Vinci R, Pazzano V, Giglio AF, Trotta F, Russo G, Ruggio A, Pisano E, d’Aiello A, Canonico F, Ciampi P, Cianflone D, Cianfanelli L, Grimaldi MC, Filomia S, Luciani N, Glieca F, Bruno P, Massetti M, Ria F, Crea F, Liuzzo G. Restricted T-Cell Repertoire in the Epicardial Adipose Tissue of Non-ST Segment Elevation Myocardial Infarction Patients. Front Immunol 2022; 13:845526. [PMID: 35880176 PMCID: PMC9307872 DOI: 10.3389/fimmu.2022.845526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Aims Human epicardial adipose tissue, a dynamic source of multiple bioactive factors, holds a close functional and anatomic relationship with the epicardial coronary arteries and communicates with the coronary artery wall through paracrine and vasocrine secretions. We explored the hypothesis that T-cell recruitment into epicardial adipose tissue (EAT) in patients with non-ST segment elevation myocardial infarction (NSTEMI) could be part of a specific antigen-driven response implicated in acute coronary syndrome onset and progression. Methods and Results We enrolled 32 NSTEMI patients and 34 chronic coronary syndrome (CCS) patients undergoing coronary artery bypass grafting (CABG) and 12 mitral valve disease (MVD) patients undergoing surgery. We performed EAT proteome profiling on pooled specimens from three NSTEMI and three CCS patients. We performed T-cell receptor (TCR) spectratyping and CDR3 sequencing in EAT and peripheral blood mononuclear cells of 29 NSTEMI, 31 CCS, and 12 MVD patients. We then used computational modeling studies to predict interactions of the TCR beta chain variable region (TRBV) and explore sequence alignments. The EAT proteome profiling displayed a higher content of pro-inflammatory molecules (CD31, CHI3L1, CRP, EMPRINN, ENG, IL-17, IL-33, MMP-9, MPO, NGAL, RBP-4, RETN, VDB) in NSTEMI as compared to CCS (P < 0.0001). CDR3-beta spectratyping showed a TRBV21 enrichment in EAT of NSTEMI (12/29 patients; 41%) as compared with CCS (1/31 patients; 3%) and MVD (none) (ANOVA for trend P < 0.001). Of note, 11/12 (92%) NSTEMI patients with TRBV21 perturbation were at their first manifestation of ACS. Four patients with the first event shared a distinctive TRBV21-CDR3 sequence of 178 bp length and 2/4 were carriers of the human leukocyte antigen (HLA)-A*03:01 allele. A 3D analysis predicted the most likely epitope able to bind HLA-A3*01 and interact with the TRBV21-CDR3 sequence of 178 bp length, while the alignment results were consistent with microbial DNA sequences. Conclusions Our study revealed a unique immune signature of the epicardial adipose tissue, which led to a 3D modeling of the TCRBV/peptide/HLA-A3 complex, in acute coronary syndrome patients at their first event, paving the way for epitope-driven therapeutic strategies.
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Affiliation(s)
- Daniela Pedicino
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Daniela Pedicino, ; ; orcid.org/0000-0002-4218-3066
| | - Anna Severino
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Di Sante
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Medicina e Chirurgia, Sezione di Anatomia Umana, Clinica e Forense, Università di Perugia, Perugia, Italy
| | - Maria Cristina De Rosa
- Istituto di Scienze e Tecnologie Chimiche “Giulio Natta” (SCITEC) - Consiglio Nazionale delle Ricerche (CNR), Rome, Italy
| | - Davide Pirolli
- Istituto di Scienze e Tecnologie Chimiche “Giulio Natta” (SCITEC) - Consiglio Nazionale delle Ricerche (CNR), Rome, Italy
| | - Ramona Vinci
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Pazzano
- Paediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, Bambino Gesù Children’s Hospital Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Ada F. Giglio
- Dipartimento di Cardiologia, Aziende Socio Sanitarie Territoriali (ASST) Fatebenefratelli Sacco, Milano, Italy
| | | | - Giulio Russo
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Aureliano Ruggio
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Eugenia Pisano
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessia d’Aiello
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Canonico
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pellegrino Ciampi
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
| | - Maria Chiara Grimaldi
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Filomia
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Luciani
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Franco Glieca
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Cardiac Rehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
| | - Piergiorgio Bruno
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Massetti
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Ria
- Dipartimento di Medicina e Chirurgia traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanna Liuzzo
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Dipartimento di Scienze Cardiovascolari e Pneumologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Russo F, Turco A, Adamo M, D'Ascenzo F, Iannaccone M, De Benedictis M, Cianfanelli L, Branca L, Rolandi A, Ferlini M, De Ferrari GM, Boccuzzi G, Chieffo A. [Percutaneous treatment of acute pulmonary embolism: state of the art]. G Ital Cardiol (Rome) 2022; 23:13S-21S. [PMID: 35848913 DOI: 10.1714/3838.38223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute pulmonary embolism (PE) is a common disease associated with high mortality rates that vary widely according to patient clinical presentation and hemodynamic status. According to international guidelines, systemic thrombolysis (ST) is the mainstem treatment in patients with high risk PE and intermediate-high risk PE evolving towards hemodynamic decompensation, showing lower mortality compared with anticoagulant therapy alone despite a high rate of bleeding events. Considering that a large proportion of patients presents contraindication to ST, catheter-directed therapies (CDTs) could tackle some unsolved issues, targeting the treatment to the pulmonary arteries, avoiding the dreaded complications of ST.The aim of this review is to describe the current indication for CDTs in terms of patient selection and timing of treatment, to describe contemporary available medical devices and techniques, discussing current knowledge of safety and efficacy and the importance of multidisciplinary team in PE management.
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Affiliation(s)
- Filippo Russo
- Emodinamica e Cardiologia Interventistica, IRCCS Ospedale San Raffaele, Milano
| | - Annalisa Turco
- Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Marianna Adamo
- Cardiologia ed Emodinamica, ASST Spedali Civili di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Università degli Studi, Brescia
| | - Fabrizio D'Ascenzo
- Divisione di Cardiologia, Dipartimento di Scienze Mediche, Città della Salute e della Scienza, Torino
| | - Mario Iannaccone
- Laboratorio di Cardiologia Interventistica, Ospedale San Giovanni Bosco, Torino
| | | | | | - Luca Branca
- Cardiologia ed Emodinamica, ASST Spedali Civili di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Università degli Studi, Brescia
| | - Andrea Rolandi
- Divisione di Cardiologia, E.O. Ospedali Galliera, Genova
| | - Marco Ferlini
- Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Gaetano Maria De Ferrari
- Divisione di Cardiologia, Dipartimento di Scienze Mediche, Città della Salute e della Scienza, Torino
| | - Giacomo Boccuzzi
- Laboratorio di Cardiologia Interventistica, Ospedale San Giovanni Bosco, Torino
| | - Alaide Chieffo
- Emodinamica e Cardiologia Interventistica, IRCCS Ospedale San Raffaele, Milano
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10
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Maranta F, Cianfanelli L, Rizza V, Cartella I, Pistoni A, Avitabile M, Meloni C, Castiglioni A, De Bonis M, Alfieri O, Cianflone D. Diaphragm Dysfunction after Cardiac Surgery: Insights from Ultrasound Imaging during Cardiac Rehabilitation. Ultrasound Med Biol 2022; 48:1179-1189. [PMID: 35351317 DOI: 10.1016/j.ultrasmedbio.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/31/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
Diaphragm dysfunction is common after cardiac surgery and can be evaluated with ultrasonography (US). We aimed at assessing with US the incidence of diaphragmatic dysfunction and the impact of cardiovascular rehabilitation (CR) on its recovery. A single-center cohort study was performed. Patients were enrolled after cardiac surgery. The 6-min walking test (6MWT) and diaphragm US were performed at CR admission and after 10 rehabilitative sessions. One hundred eighty-five patients were eligible for final analysis. One hundred thirty-one patients (70.8%) were found to have diaphragm dysfunction (excursion <2 cm). After CR, 68 patients regained normal diaphragmatic function; those with persistent dysfunction had a lower level of functional performance on the 6MWT (metabolic equivalents of tasks: 3.3 vs. 3.6, p = 0.013). The patients who underwent combined surgery (adjusted odds ratio [aOR] = 4.09, p = 0.001) and those with post-operative pneumothorax (aOR = 3.02, p = 0.042) were at increased risk of failure to improve diaphragmatic excursion. US parameters were more powerful tools in predicting diaphragmatic evolution compared with the 6MWT indexes: baseline diaphragm excursion and thickening fraction were associated with complete diaphragmatic functional recovery after CR (aOR = 9.101, p < 0.001, and aOR = 1.058, p = 0.020 respectively). US is a valuable tool for the assessment of post-operative diaphragmatic dysfunction and can identify patients at risk of diaphragmatic recovery failure.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Iside Cartella
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Anna Pistoni
- General Practitioner Lombardy Training Program, Pavia, Italy
| | - Maria Avitabile
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Meloni
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Castiglioni
- Vita-Salute San Raffaele University, Milan, Italy; Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Vita-Salute San Raffaele University, Milan, Italy; Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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11
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Russo F, Cianfanelli L, Galli M, Chizzola G, Bossi I, Chieffo A, Montorfano M. P262 ULTRASOUND–ASSISTED THROMBOLYSIS OF HIGH RISK AND INTERMEDIATE–HIGH RISK PULMONARY EMBOLISM: A MULTICENTRE REAL WORLD EXPERIENCE IN LOMBARDY REGION. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartj/suac012.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Acute pulmonary embolism (PE) is associated with high morbidity and mortality rate. Catheter–directed treatments (CDTs) seem a therapeutical option in case of sistemic thrombolysis (ST) contraindication or failure. Ultrasound–assisted thrombolysis (USAT) allows low–dose thrombolytic loco–regional infusion facilitated by ultrasounds.
Methods and Results
A multicentre retrospective observational cohort study was conducted among 4 Cardiovascular Interventional Centres in Lombardy Region to evaluate safety and efficacy of USAT in high risk and intermediate–high risk PE patients presenting with contraindications to ST. Patients at high risk were included in case of USAT because of ST contraindications. Patients at intermediate–high risk were included in case of rescue USAT. Loco–regional thrombolysis was performed using rTPA. Procedural success was defined as successful catheters‘ deployment in pulmonary arteries and patient survival during the procedure. Bleeding were defined according to BARC criteria. Echocardiographic evaluation to determine the prevalence of right ventricular (RV) dysfunction and pulmonary hypertension was performed at presentation, discharge and follow–up. Between 2011 and 2021, 109 patients were included. 21.1% presented with high risk PE, the remaining 78.9% with intermediate–high risk. Procedural success was obtained in 99.1% of the cases; major bleedings occurred in 9.2%, minor bleedings in 11.9% and vascular complications in 7.3% of the patients. 91.7% of patients were alive at discharge. In–hospital all–cause mortality was higher in high risk patients (26.1% vs 3.5%; p = 0.003) that showed a steep decline in survival as compared to intermediate–high risk patients that constantly maintained a high survival rate throughout the observation period. At six–months follow–up 3 patients in intermediate–high risk group died so that the overall mortality remains higher in high risk patients (26.1% vs 7%; p = 0.018). No re–hospitalization for recurrent PE at six–months occurred. Prevalence of RV dysfunction and pulmonary hypertension significantly decreased from hospital admission to discharge and to six–months follow–up (p–value <0.0001 for all comparisons).
Conclusions
Our experience shows good short and mid–term outcomes in USAT in high risk and intermediate–high risk PE patients with contraindications to ST, suggesting that it might be considered in a neglected subset of patients with no alternative therapeutical options.
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Affiliation(s)
- F Russo
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - L Cianfanelli
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - M Galli
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - G Chizzola
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - I Bossi
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - A Chieffo
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
| | - M Montorfano
- IRCCS OSPEDALE SAN RAFFAELE, MILANO; ASST LARIANA, OSPEDALE SANT‘ANNA, COMO; ASST SPEDALI CIVILI, BRESCIA; ASST GRANDE OSPEDALE METROPOLITANO NIGUARDA, MILANO
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12
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Russo F, Cianfanelli L, Chieffo A, Galli M, Chizzola G, Bossi I, Capsoni N, Branca L, de Lorenzo L, Zaccone G, Ancona MB, Guerrieri R, Montorfano M. Ultrasound-assisted thrombolysis in high or intermediate-high risk pulmonary embolism patients with contraindications to systemic thrombolysis: A retrospective multicentre experience. Thromb Res 2022; 214:40-43. [DOI: 10.1016/j.thromres.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
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13
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Zweiker D, Melillo F, D’Angelo G, Radinovic A, Marzi A, Cianfanelli L, Altizio S, Limite LR, Paglino G, Frontera A, Nakajima K, Brugliera L, Malatino L, Della Bella P, Mazzone P. Working on the dirty side—the ipsilateral subclavian access for temporary pacing after lead extraction. J Arrhythm 2022; 38:192-198. [PMID: 35387138 PMCID: PMC8977584 DOI: 10.1002/joa3.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/23/2021] [Accepted: 01/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background Temporary pacing is necessary in pacemaker‐dependent patients after transvenous lead extraction (TLE) for cardiac implantable electronic device infection. In case of unavailability of other accesses, we propose to use the ipsilateral subclavian access (ISA) combined with a standard permanent active fixation lead for the temporary pacemaker and present preliminary data. Methods We consecutively enrolled patients undergoing TLE who received a temporary pacemaker using the ISA between August 2016 and April 2020 at our centre. Results During the observation period, 36 patients undergoing TLE for pocket infection (72.2%), endocarditis (25.0%) or other causes received a temporary pacemaker over the ISA. Their mean age was 77.0 ± 10.7 years, and 13.9% were female. Complete TLE was achieved in 94.4%. There were no major periprocedural complications. Intra‐hospital mortality was 11.1%. Pocket revision was performed in 19.4%. During long‐term follow‐up (23 ± 13 months), 8.3% had a relapse of local pocket infection and 2.8% needed rehospitalization for reintervention. Conclusions Temporary pacing using a standard permanent active fixation lead using the ISA is a convenient alternative to conventional venous accesses. However, risks of implanting a lead into a previously infected area have to be taken into account.
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Affiliation(s)
- David Zweiker
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
- Third Clinical Department for Cardiology and Intensive Care Klinik Ottakring Vienna Austria
- Division of Cardiology Medical University of Graz Graz Austria
| | - Francesco Melillo
- Department of Cardiovascular Imaging Unit, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Giuseppe D’Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Andrea Radinovic
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Alessandra Marzi
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit IRCCS San Raffaele Scientific Institute Milan Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Luca R. Limite
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Gabriele Paglino
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Antonio Frontera
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Kenzaburo Nakajima
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Luigia Brugliera
- Cardiac Rehabilitation Unit IRCCS San Raffaele Scientific Institute Milan Italy
| | - Lorenzo Malatino
- Department of Clinical and Experimental Medicine University of Catania Catania Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute Vita‐Salute University and San Raffaele Hospital Milan Italy
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14
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Pannone L, D'Angelo G, Gulletta S, Falasconi G, Brugliera L, Frontera A, Cianfanelli L, Baldetti L, Ossola P, Melillo F, De Blasi G, Malatino L, Landoni G, Margonato A, Della Bella P, Zacchetti D, Vergara P. Amiodarone in ventricular arrhythmias: still a valuable resource? Rev Cardiovasc Med 2021; 22:1383-1392. [PMID: 34957778 DOI: 10.31083/j.rcm2204143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/06/2022] Open
Abstract
Ventricular arrhythmias still represent an important cause of morbidity and mortality, especially in patients with heart failure and reduced left ventricular ejection fraction. Amiodarone is a Class III Vaughan-Williams anti-arrhythmic drug widely used in ventricular arrhythmias for its efficacy and low pro-arrhythmogenic effect. On the other hand, a significant limitation in its use is represented by toxicity. In this review, the pharmacology of the drug is discussed to provide the mechanistic basis for its clinical use. Moreover, all the latest evidence on its role in different clinical settings is provided, including the prevention of sudden cardiac death, implanted cardioverter defibrillators, ischemic and non-ischemic cardiomyopathies. A special focus is placed on everyday clinical practice learning points, such as dosage, indications, and contraindications from the latest guidelines.
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Affiliation(s)
| | - Giuseppe D'Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | - Simone Gulletta
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | | | - Luigia Brugliera
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | - Antonio Frontera
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | | | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | | | | | - Gabriele De Blasi
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | - Lorenzo Malatino
- Department of Clinical and Experimental Medicine, University of Catania, 95131 Catania, Italy
| | - Giovanni Landoni
- Vita-Salute University, 20132 Milan, Italy.,Anesthesia Intensive Care, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | | | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
| | - Daniele Zacchetti
- Vita-Salute University, 20132 Milan, Italy.,Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Pasquale Vergara
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele University Hospital, 20132 Milan, Italy
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15
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Limite LR, Radinovic A, Cianfanelli L, Altizio S, Peretto G, Frontera A, D'Angelo G, Baratto F, Marzi A, Ancona F, Ingallina G, Capogrosso C, Stella S, Melillo F, Agricola E, Della Bella P, Mazzone P. Outcome of left atrial appendage closure using cerebral protection system for thrombosis: no patient left behind. Pacing Clin Electrophysiol 2021; 45:23-34. [PMID: 34841552 DOI: 10.1111/pace.14398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/26/2021] [Accepted: 10/31/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) thrombosis increases the risk of stroke and its management has to be assessed. The aim of the present study is to evaluate short and long-term safety and efficacy of a standardized approach of percutaneous LAA closure (LAAC) routinely using a cerebral protection device (CPD) in patients with LAA thrombosis or sludge (LAAT). METHODS We prospectively enrolled 14 consecutive patients with atrial fibrillation complicated by LAAT presenting in a high-volume tertiary center. In seven patients (50%) LAAT was found after anticoagulant withdrawal for severe bleedings and in the remaining half LAAT was found despite appropriate anticoagulant therapy. All patients were treated with a standardized interventional approach of LAAC routinely using a CPD and guided by transoesophageal echocardiography. RESULTS Mean age was 68 ± 14 years and nine patients (64%) were male. Mean CHA2 DS2 -VASc and HAS-BLED scores were 3.3 ± 1.6 and 2.3 ± 1.1, respectively. Six patients (42.8%) presented organized thrombi while eight LAA sludge (57.1%). In 13 patients (92.8%) CPD was positioned through a right radial arterial access. Procedural success was achieved in all patients. In one patient we assisted to embolization of the thrombus during deployment of the device in the absence of neurological consequences. During a mean follow up of 426 ± 307 days, one patient died for non-cardiac cause while no embolic event or major bleeding were reported. CONCLUSION In an unselected cohort, LAAC with the systematic use of CPD was a feasible, safe and effective therapeutic option for LAAT both acutely and after long-term follow-up.
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Affiliation(s)
- Luca Rosario Limite
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Radinovic
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Frontera
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe D'Angelo
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Baratto
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Marzi
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Capogrosso
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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16
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Maranta F, Cianfanelli L, Grippo R, Alfieri O, Cianflone D, Imazio M. Post-pericardiotomy syndrome: insights into neglected postoperative issues. Eur J Cardiothorac Surg 2021; 61:505-514. [PMID: 34672331 DOI: 10.1093/ejcts/ezab449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/01/2021] [Accepted: 07/27/2021] [Indexed: 12/20/2022] Open
Abstract
ABSTRACT OBJECTIVES Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge. METHODS A literature review was performed that included relevant prospective and retrospective studies on the subject. RESULTS PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention. CONCLUSIONS Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Rocco Grippo
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Imazio
- Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Udine, Italy
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17
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Gulletta S, Della Bella P, Pannone L, Falasconi G, Cianfanelli L, Altizio S, Cinel E, Da Prat V, Napolano A, D'Angelo G, Brugliera L, Agricola E, Landoni G, Tresoldi M, Rovere PQ, Ciceri F, Zangrillo A, Vergara P. QTc interval prolongation, inflammation, and mortality in patients with COVID-19. J Interv Card Electrophysiol 2021; 63:441-448. [PMID: 34291390 PMCID: PMC8295006 DOI: 10.1007/s10840-021-01033-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 01/08/2023]
Abstract
Purpose Systemic inflammation has been associated with corrected QT (QTc) interval prolongation. The role of inflammation on QTc prolongation in COVID-19 patients was investigated. Methods Patients with a laboratory-confirmed SARS-CoV-2 infection admitted to IRCCS San Raffaele Scientific Institute (Milan, Italy) between March 14, 2020, and March 30, 2020 were included. QTc-I was defined as the QTc interval by Bazett formula in the first ECG performed during the hospitalization, before any new drug treatment; QTc-II was the QTc in the ECG performed after the initiation of hydroxychloroquine drug treatment. Results QTc-I was long in 45 patients (45%) and normal in 55 patients (55%). Patients with long QTc-I were older and more frequently males. C-Reactive protein (CRP) and white blood cell (WBC) count at hospitalization were higher in patients with long QTc-I and long QTc-II. QTc-I was significantly correlated with CRP levels at hospitalization. After a median follow-up of 83 days, 14 patients (14%) died. There were no deaths attributed to ventricular arrhythmias. Patients with long QTc-I and long QTc-II had a shorter survival, compared with normal QTc-I and QTc-II patients, respectively. In Cox multivariate analysis, independent predictors of mortality were age (HR = 1.1, CI 95% 1.04–1.18, p = 0.002) and CRP at ECG II (HR 1.1, CI 95% 1.0–1.1, p = 0.02). Conclusions QTc at hospitalization is a simple risk marker of mortality risk in COVID-19 patients and reflects the myocardial inflammatory status.
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Affiliation(s)
- Simone Gulletta
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Falasconi
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lorenzo Cianfanelli
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Savino Altizio
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Elena Cinel
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Valentina Da Prat
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Napolano
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe D'Angelo
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigia Brugliera
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Cardiac Imaging Unit, Cardio-Thoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Querini Rovere
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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18
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Rizza V, Maranta F, Cianfanelli L, Grippo R, Meloni C, Avitabile M, Castiglioni A, De Bonis M, Alfieri O, Cianflone D. Subacute postoperative atrial fibrillation after heart surgery: incidence and predictive factors in cardiac rehabilitation. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes.
Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS).
Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR).
Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p < 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p < 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p < 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p < 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin > 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period.
Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.
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Affiliation(s)
- V Rizza
- University Vita-Salute San Raffaele, Milan, Italy
| | - F Maranta
- San Raffaele Scientific Institute, Milan, Italy
| | | | - R Grippo
- San Raffaele Scientific Institute, Milan, Italy
| | - C Meloni
- San Raffaele Scientific Institute, Milan, Italy
| | - M Avitabile
- San Raffaele Scientific Institute, Milan, Italy
| | | | - M De Bonis
- University Vita-Salute San Raffaele, Milan, Italy
| | - O Alfieri
- University Vita-Salute San Raffaele, Milan, Italy
| | - D Cianflone
- University Vita-Salute San Raffaele, Milan, Italy
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19
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Lembo R, Landoni G, Cianfanelli L, Frontera A. Air pollutants and SARS-CoV-2 in 33 European countries. Acta Biomed 2021; 92:e2021166. [PMID: 33682802 PMCID: PMC7975964 DOI: 10.23750/abm.v92i1.11155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2021] [Indexed: 12/03/2022]
Abstract
Background and aim: A potential correlation between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and air pollution has been suggested in some nationwide studies. It is not clear whether air pollution contributes to the spread of SARS-CoV-2 and related coronavirus disease 2019 (COVID-19) and to increase mortality. Methods: Data on COVID-19 incidence, mortality rate, air pollution, and greenhouse gas element of 33 European countries were extracted from public available databases and analysed with Pearson correlation analysis for the overall population and normalizing for the population over 65 years. Results: Air pollutant agents such as particulate matter <10µm (PM10), particulate matter <2.5µm (PM2.5), ammonia (NH3), sulphur dioxide (SO2), non-methane volatile organic compounds (NMVOCs), nitrogen dioxide (NO2) and greenhouse gas elements recorded showed a remarkable correlation with cumulative positive number of SARS-CoV-2 cases and with cumulative number of COVID-19 deaths. PM2.5 (r = 0.68, p-value = 0.0001 for cumulative positive cases; r = 0.73, p-value <0.0001 for cumulative deaths) and nitrogen oxides (r = 0.85, p-value <0.0001 for cumulative positive cases; r = 0.70, p-value 0.0001 for cumulative deaths) were among the pollutant agents with the strongest correlation for both positive cases and deaths. Conclusions: High levels of pollution in European countries should be considered a potential risk for severe COVID-19 and SARS-CoV-2-related death. (www.actabiomedica.it)
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Affiliation(s)
- Rosalba Lembo
- IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan, Italy.
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan, Italy, Vita-Salute San Raffaele University, Milan, Italy.
| | | | - Antonio Frontera
- IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan, Italy.
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20
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Baldetti L, Beneduce A, Cianfanelli L, Falasconi G, Pannone L, Moroni F, Venuti A, Sacchi S, Gramegna M, Pazzanese V, Calvo F, Gallone G, Pagnesi M, Cappelletti AM. Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism: A systematic review and meta-analysis. Artif Organs 2021; 45:569-576. [PMID: 33277695 DOI: 10.1111/aor.13876] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents a therapeutic option for cardiopulmonary support in patients with high-risk pulmonary embolism (PE); however, no definite consensus exists on ECMO use in high-risk PE. Hence, we aim to provide insights into its real-world use pooling together all available published experiences. We performed a systematic review and pooled analysis of all published studies (up to April 17, 2020) investigating ECMO support in high-risk PE. All studies including at least four patients were collectively analyzed. Study outcomes were early all-cause death (primary endpoint) and relevant in-hospital adverse events. A total of 21 studies were included in the pooled analysis (n = 635 patients). In this population (mean age 47.8 ± 17.3 years, 44.5% females), ECMO was indicated for cardiac arrest in 62.3% and immediate ECMO support was pursued in 61.9% of patients. Adjunctive reperfusion therapies were implemented in 57.0% of patients. Pooled estimate rate of early all-cause mortality was 41.1% (95% CI 27.7%-54.5%). The most common in-hospital adverse event was major bleeding, with an estimated rate of 28.6% (95%CI 21.0%-36.3%). At meta-regression analyses, no significant impact of multiple covariates on the primary endpoint was found. In this systematic review of patients who received ECMO for high-risk PE, pooled all-cause mortality was 41.1%. Principal indication for ECMO was cardiac arrest, cannulation was chiefly performed at presentation, and major bleeding was the most common complication.
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Affiliation(s)
- Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Moroni
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Venuti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Torino, Italy
| | - Matteo Pagnesi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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21
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Maranta F, Cianfanelli L, Rizzo M, Cianflone D. Filling the gap between Guidelines and Real World in the cardiovascular approach to the diabetic patients: the need for a call to action. Int J Cardiol 2020; 329:205-207. [PMID: 33388398 DOI: 10.1016/j.ijcard.2020.12.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Manfredi Rizzo
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Department of Medicine, School of Medicine, University of South Carolina, Columbia, SC, USA
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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22
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Baldetti L, Beneduce A, Cianfanelli L, Falasconi G, Pannone L, Moroni F, Venuti A, Gramegna M, Pazzanese V, Calvo F, Gallone G, Cappelletti A. Use of extracorporeal membrane oxygenation in acute pulmonary embolism: a pooled analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
High-risk acute pulmonary embolism (PE) is burdened by a mortality as high as 65%. VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) may offer a cardiopulmonary support and a precious time window to ensure pulmonary reperfusion therapies. No definite consensus exists on the use of VA-ECMO in high-risk PE patients as only sparse observational studies are available yielding conflicting outcomes.
Purpose
To provide insights on the use of ECMO in acute high-risk PE pooling together all available published experiences to date.
Methods
Two authors (LB, AB) searched PubMed, Embase, BioMedCentral and Google Scholar, from inception to 18/09/2019. All published clinical studies investigating ECMO support in patients with high-risk acute PE were evaluated for inclusion.
Results
Literature search identified 384 observational studies: a total of 66 were included for 584 acute high-risk PE patients receiving ECMO support. Mean age was 46.8±16.8 years (44% female). Most patients presented with cardiac arrest (56%) or obstructive shock (42%). Diagnosis of PE was confirmed by computed tomography (CT) in 72%, performed before ECMO cannulation in 65%. Echocardiography was obtained in 89%. Right ventricle dilatation or dysfunction was found in 90% and 87%. ECMO was primarily employed as upfront treatment (63%), in the VA-ECMO configuration (94%). ECMO was equally employed in conjunction with interventional/surgical pulmonary reperfusion treatments (38%), with thrombolysis (35%) and without adjunctive procedures (40%). Mean ECMO support duration was 100.3±12.9 hours. Notably, 92% received thrombolysis before ECMO cannulation. ECMO bailout implant was mostly adopted in patients receiving thrombolysis (81% vs 19%; p=0.010), as a rescue therapy. Most common reperfusion procedures were surgical embolectomy (28%), catheter-directed thrombolysis (12%) and transcatheter embolectomy (12%). The majority of these procedures (81%) took place after ECMO cannulation. Mean total hospital stay was 17.8±11.6 days. Hospital survival rate was 54% and did not differ in upfront vs bailout ECMO (p=0.184) and between thrombolysis, interventional procedure and ECMO alone recipients (p=0.423). Neurologic death and non-fatal neurologic injury occurred both in 10%. Most patients (70%) were successfully weaned off ECMO, while 30% died on support and 7% died after ECMO removal. Acute kidney injury was the most common complication (47%). Major bleeding occurred in 19% and was fatal for 5%. Patients undergoing thrombolysis had a tendency towards higher rates of major bleeding (48% vs 23%; p=0.05). At a mean follow-up of 365.0 (IQR 202.5–365.9) days, overall survival rate was 85% in those surviving hospitalization.
Conclusions
In this pooled population consisting mostly of cardiac arrest/obstructive shock PE patients, ECMO strategy was associated with acceptable in-hospital survival and was frequently used in conjunction with other reperfusion treatments.
Central Illustration
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- L Baldetti
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - A Beneduce
- San Raffaele Hospital, Cardiovascular Interventions Unit, Milan, Italy
| | - L Cianfanelli
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - G Falasconi
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - L Pannone
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - F Moroni
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - A Venuti
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - M Gramegna
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - V Pazzanese
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - F Calvo
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
| | - G Gallone
- Hospital Citta Della Salute e della Scienza di Torino, Division of Cardiology, Turin, Italy
| | - A.M Cappelletti
- San Raffaele Hospital, Cardiac Intensive Care Unit, Milan, Italy
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23
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Pagnesi M, Baldetti L, Beneduce A, Cianfanelli L, Falasconi G, Pannone L, Moroni F, Venuti A, Gramegna M, Pazzanese V, Calvo F, Gallone G, Cappelletti AM. Reperfusion Strategies in Patients With High-Risk Acute Pulmonary Embolism Needing Extracorporeal Membrane Oxygenation Support: A Systematic Review. J Cardiothorac Vasc Anesth 2020; 35:S1053-0770(20)31047-8. [PMID: 34756353 DOI: 10.1053/j.jvca.2020.09.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Matteo Pagnesi
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Unit of Cardiovascular Interventions, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Unit of Cardiovascular Interventions, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Moroni
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Angela Venuti
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Torino, Italy
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24
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Frontera A, Cianfanelli L, Vlachos K, Landoni G, Cremona G. Severe air pollution links to higher mortality in COVID-19 patients: The "double-hit" hypothesis. J Infect 2020; 81:255-259. [PMID: 32447007 PMCID: PMC7240268 DOI: 10.1016/j.jinf.2020.05.031] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In areas of SARS-CoV-2 outbreak worldwide mean air pollutants concentrations vastly exceed the maximum limits. Chronic exposure to air pollutants have been associated with lung ACE-2 over-expression which is known to be the main receptor for SARS-CoV-2. The aim of this study was to analyse the relationship between air pollutants concentration (PM 2.5 and NO2) and COVID-19 outbreak, in terms of transmission, number of patients, severity of presentation and number of deaths. METHODS COVID-19 cases, ICU admissions and mortality rate were correlated with severity of air pollution in the Italian regions. RESULTS The highest number of COVID-19 cases were recorded in the most polluted regions with patients presenting with more severe forms of the disease requiring ICU admission. In these regions, mortality was two-fold higher than the other regions. CONCLUSIONS From the data available we propose a "double-hit hypothesis": chronic exposure to PM 2.5 causes alveolar ACE-2 receptor overexpression. This may increase viral load in patients exposed to pollutants in turn depleting ACE-2 receptors and impairing host defences. High atmospheric NO2 may provide a second hit causing a severe form of SARS-CoV-2 in ACE-2 depleted lungs resulting in a worse outcome.
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Affiliation(s)
- Antonio Frontera
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy.
| | | | | | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy; Vita-Salute San Raffaele University of Milan, Italy.
| | - George Cremona
- IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy.
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25
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Mazzone P, Peretto G, Radinovic A, Limite LR, Marzi A, Sala S, Cireddu M, Vegara P, Baratto F, Paglino G, D’Angelo G, Cianfanelli L, Altizio S, Lipartiti F, Frontera A, Bisceglia C, Gulletta S, Bella PD. The COVID-19 challenge to cardiac electrophysiologists: optimizing resources at a referral center. J Interv Card Electrophysiol 2020; 59:321-327. [PMID: 32425656 PMCID: PMC7232930 DOI: 10.1007/s10840-020-00761-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
Abstract
Purpose To describe how a referral center for cardiac electrophysiology (EP) rapidly changed to comply with the ongoing COVID-19 healthcare emergency. Methods We present retrospective data about the modification of daily activities at our EP unit, following the pandemic outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Italy. In particular, in the context of a pre-existing “hub-and-spoke” network, we describe how procedure types and volumes have changed in the last 3 months. Results Since our institution was selected as a COVID-19 referral center, the entire in-hospital activity was reorganized to assist more than 1000 COVID-positive cases. Only urgent EP procedures, including ventricular tachycardia ablation and extraction of infected devices, were both maintained and optimized to meet the needs of external hospitals. In addition, most of the non-urgent EP procedures were postponed. Finally, following prompt internal reorganization, both outpatient clinics and on-call services underwent significant modification, by integrating telemedicine support whenever applicable. Conclusion We presented the fast reorganization of an EP referral center during the ongoing COVID-19 healthcare emergency. Our hub-and-spoke model may be useful for other centers, aiming at a cost-effective management of resources in the context of a global crisis.
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Affiliation(s)
- Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Andrea Radinovic
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Luca Rosario Limite
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Alessandra Marzi
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Simone Sala
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Manuela Cireddu
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Pasquale Vegara
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Francesca Baratto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Gabriele Paglino
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giuseppe D’Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Lorenzo Cianfanelli
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Savino Altizio
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Felicia Lipartiti
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Antonio Frontera
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Caterina Bisceglia
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Simone Gulletta
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Vita-Salute University and San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
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Toscano E, Altizio S, Cianfanelli L, Denti P, Stella S, Capogrosso C, De Bonis M, Buzzatti N, Godino C, Latib A, Montorfano M, Camici PG, Castiglioni A, Alfieri O, Agricola E. P43673D analysis of mitral annular reshape with third generation MitraClip XTr in functional and degenerative mitral regurgitation. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
The 3rd generation Mitraclip XTr was recently introduced to improve device performance, through longer clip arms that should allow better grasping of the mitral leaflets, thus improving coaptation and results eventually. Several studies have demonstrated additional effects such as the reshape of the mitral annulus immediately after clip implantation.
The aim of our study was to evaluate the mitral valve (MV) annular remodelling with MitraClip XTr.
Between March 2018 and November 2018, 75 consecutive patients were enrolled. The population was divided in two groups: functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR).
The 3D MV datasets at baseline and immediately after the procedure were acquired and then analysed with semiautomatic MVQ software (QLAB Cardiac 3DQ v.10.0; Philips Medical Systems).
The software provides the following parameters: annular diameters (antero-posterior, AP, and inter-commissural, IC), circumference, area, height and ellipsicity (IC/AP ratio as percentage); saddle-index, defined as annular height to IC diameter ratio was derived.
The 3D post-processing was feasible in 54 patients (108 3D datasets): 28 had FMR (52%) and 26 had DMR (48%).
An average of 1.8 clips per patient were implanted: 2 clips in 38 (70%), 1 clip in 14 (26%) and 3 clips in 2 (4%) patients. The position was central in 93% of the procedures.
Results are reported in table 1. In the FMR group, a reduction in the AP diameter (p=0.001), an increase in both IC diameter (p=0.001) and annular ellipsicity (p<0.001) were observed.
In the DMR group, an increase in annular ellipsicity (p=0,008) and in saddle-index (p<0.05) were observed.
Table 1 Functional mitral regurgitation (N=28) Degenerative mitral regurgitation (N=26) Pre-clip Post-clip P-value Pre-clip Post-clip P-value IC diameter (mm) 39.3±4.2 41.9±4.1 0.001 40.9±6.5 41.8±5.8 0.257 AP diameter (mm) 32.8±4.6 30.4±3.2 0.001 32.6±4.8 31.7±4.5 0.199 Annular Height (mm) 5.1±1.8 5.4±1.8 0.336 4.8±1.9 5.7±2.2 0.026 3D circumference (mm) 122.7±15.1 123.5±11 0.718 123.5±19.0 124.0±17.1 0.812 3D area (mmq) 1128.0±280 1113.7±206 0.752 1160±346.7 1156.8±318.0 0.926 Annular ellipsicity (%) 121.5±12.2 138.5±11.8 0.0005 125.9±9.6 132.4±10.7 0.008 Saddle index 13.0±4 13.0±4 0.957 11.8±4.2 13.6±4.2 0.048
Our study demonstrates that the XTr implantation produces a MV annular remodelling both in FMR and DMR probably with different mechanisms. In FMR the MV annulus resulted more elliptical, wheras in DMR the geometrical modifications involve both the ellipsicity and the saddle-shape morphology.
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Affiliation(s)
- E Toscano
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - S Altizio
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - L Cianfanelli
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - P Denti
- San Raffaele Hospital of Milan (IRCCS), Cardiac Surgery Department, Milan, Italy
| | - S Stella
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - C Capogrosso
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - M De Bonis
- San Raffaele Hospital of Milan (IRCCS), Cardiac Surgery Department, Milan, Italy
| | - N Buzzatti
- San Raffaele Hospital of Milan (IRCCS), Cardiac Surgery Department, Milan, Italy
| | - C Godino
- San Raffaele Hospital of Milan (IRCCS), Interventional Cardiology Department, Milan, Italy
| | - A Latib
- San Raffaele Hospital of Milan (IRCCS), Interventional Cardiology Department, Milan, Italy
| | - M Montorfano
- San Raffaele Hospital of Milan (IRCCS), Interventional Cardiology Department, Milan, Italy
| | - P G Camici
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
| | - A Castiglioni
- San Raffaele Hospital of Milan (IRCCS), Cardiac Surgery Department, Milan, Italy
| | - O Alfieri
- San Raffaele Hospital of Milan (IRCCS), Cardiac Surgery Department, Milan, Italy
| | - E Agricola
- San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory, Milan, Italy
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Maranta F, Cartella I, Pistoni A, Cianfanelli L, Cerea P, Castiglioni A, De Bonis M, Alfieri O, Cianflone D. P4385Diaphragm dysfunction following cardiac surgery: role of ultrasound imaging for initial and follow-up assessment during cardiac rehabilitation. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Diaphragm dysfunction is a common complication of cardiac surgery, often underdiagnosed. Ultrasonography (US) is a promising technique for diaphragmatic assessment. Few trials have been conducted using US after heart surgery and no clear data exist on the recovery of diaphragm function after cardiovascular rehabilitation (CR).
Purpose
The aim of this study is to evaluate post-cardiac surgery diaphragm dysfunction using US and to assess the impact of an inpatient CR programme on its functional recovery.
Methods
In a single-centre prospective cohort study 97 consecutive patients hospitalised in our CR Unit were enrolled. 14 patients underwent aortic valve replacement, 38 mitral valve repair or replacement, 14 coronary artery bypass grafting (CABG), 22 combined surgery, and 9 other surgical interventions. We performed diaphragm US at admission and after 10 rehabilitative sessions. The following parameters were assessed: thickening fraction (TF) in B-mode on the right intercostal projections, and excursion, time of inspiration, time of a respiratory cycle and contraction velocity in M-mode on right anterior subcostal projections.
Results
After cardiac surgery, the incidence of diaphragm dysfunction and paralysis were 60% and 1%, respectively. Patients with TF <20% at admission showed a significant improvement in TF (13.30%, IQR 8.69–17.39 vs 27.27%, IQR 21.05–31.58; p<0.001), excursion (1.67cm, IQR 1.3–2.1 vs 2.23cm, IQR 1.9–2.7; p<0.001), time of inspiration (0.9s, IQR 0.9–1.07 vs 1.01s, IQR 0.87–1.13; p=0.005), time of a respiratory cycle (2.67s, IQR 2.38–3.05 vs 3.07s, IQR 2.68–3.35; p<0.001) and velocity (1.81cm/s, IQR 1.14–2.33 vs 2.24cm/s, IQR 1.92–2.76; p<0.001). On the contrary, in patients with a TF>20%, no additional improvement was observed. In both groups, there was a significant improvement in the parameters of physical performance.
In particular, in the group with a TF<20%, the distance covered during the 6MWT (300m, IQR 205–370 vs 555m, IQR 450–612; p<0.001) and the energy cost of physical activity (2.60, IQR 2.13–2.92 vs 4.09, IQR 3.44–4.50; p<0.001) increased while the perception of exertion (Borg Scale 11, IQR 11–13 vs 13, IQR 12–13; p=0.011) was reduced. At the 10th day assessment, 51.5% of the total population had a recovery of diaphragm function, whilst 48.5% had a failure of recovery (TF relative change between admission and discharge <60%). The multivariate analysis identified CABG as an independent predictor of failure of diaphragm recovery (OR 5.44; CI 1.10–26.84, p=0.037).
Conclusion
US might be a valuable part of routine clinical practice for initial and follow-up assessment of patients after open-heart surgery. CR showed to be an effective strategy to improve diaphragm parameters in patients with post-surgical dysfunction. Progressive evaluation of diaphragm function may drive personalised rehabilitation programmes.
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Affiliation(s)
- F Maranta
- San Raffaele Scientific Institute, Milan, Italy
| | - I Cartella
- University Vita-Salute San Raffaele, Milan, Italy
| | - A Pistoni
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - P Cerea
- University of Milan-Bicocca, Cardiology, Milan, Italy
| | | | - M De Bonis
- University Vita-Salute San Raffaele, Milan, Italy
| | - O Alfieri
- San Raffaele Scientific Institute, Milan, Italy
| | - D Cianflone
- University Vita-Salute San Raffaele, Milan, Italy
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28
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Maranta F, Pistoni A, Cartella I, Cianfanelli L, Cerea P, De Bonis M, Castiglioni A, Alfieri O, Cianflone D. P2522A new scoring system to stratify post-surgical valvular patients during cardiovascular rehabilitation: derivation and validation study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Guidelines underline the importance of Cardiovascular Rehabilitation (CR) in post-surgical valvular patients both for the functional recovery and the monitoring of complications. However, there are no established indicators to better categorise their risk and to identify the real probability of recovery.
Purpose
The aim of this study is to propose and validate a scoring system to appropriately stratify post-surgical valvular patients in order to individualise CR programmes.
Methods
A retrospective study was conducted on 1480 post-surgical valvular patients hospitalized in our CR Unit (902 M – 578 F; median age of 64 years, IQR 53–73). 485 patients underwent single heart valve repair, 408 single heart valve replacement, 237 single heart valve surgery and additional interventions, 249 multiple valve interventions and 101 multiple heart valves and additional interventions. Subjects were randomised in two groups for data analysis: a Derivation (D; n=1000) and a Validation (V; n=480) group. Initially, in group D we assessed the predictive value of anamnestic, clinical and laboratory variables for major complications and functional recovery. We created two scoring systems for these outcomes and, subsequently, we validated them on group V. Finally, we interlaced them in an operative algorithm.
Results
Chronic kidney disease (OR 2.588; 95% CI 1.232–5.436; p=0.012), sternal surgical re-synthesis (OR 7.757; 95% CI 2.042–29.471; p=0.003), post-surgical transfusions (OR 2.419; 95% CI 1.407–4.161; p=0.001) and Troponin T peak >1400 μg/L (OR 2.441; 95% CI 1.418–4.200; p=0.001) were independent predictors for the occurrence of major complications in group D. Age (OR 0.958; 95% CI 0.9339–0.977; p<0.001), post- surgical transfusions (OR 1.981; 95% CI 1.160–3.380; p<0.001) and METS at admission (OR 0.032; 95% CI 0.017–0.061; p<0.001) were independent predictors of a higher functional recovery in group D. When the two scoring systems were validated on group V, we obtained a z score of 0.07 (p=0.941) for the major complications risk score and a z score of 1.23 (p=0.219) for the functional recovery stratification system, respectively, indicating a very reliable model. We proceeded to build an operative algorithm to stratify patients and propose personalised CR strategies.
Conclusions
We identified predictors to stratify the risk of complications and to define the probability of recovery in post-surgical valvular patients undergoing CR. The proposed final operative algorithm may be a unique tool to support the cardiologist to tailor rehabilitation programmes. This may lead to better outcomes and reduction of healthcare expenditure with optimisation in the use of available resources.
Acknowledgement/Funding
None
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Affiliation(s)
- F Maranta
- San Raffaele Scientific Institute, Milan, Italy
| | - A Pistoni
- University Vita-Salute San Raffaele, Milan, Italy
| | - I Cartella
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - P Cerea
- University of Milan-Bicocca, Cardiology, Milan, Italy
| | - M De Bonis
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - O Alfieri
- San Raffaele Scientific Institute, Milan, Italy
| | - D Cianflone
- University Vita-Salute San Raffaele, Milan, Italy
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29
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Maranta F, Cianfanelli L, Regoni M, Cianflone D. Cardiologist and Diabetologist crosstalk in the era of cardiovascular outcome trials of novel glucose-lowering drugs. IJC Heart & Vasculature 2018; 21:80-86. [PMID: 30402533 PMCID: PMC6205052 DOI: 10.1016/j.ijcha.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 12/11/2022]
Abstract
The prevalence of type 2 diabetes continues to increase and cardiovascular (CV) diseases remain the leading cause of death in diabetic patients. Diabetologists and Cardiologists have to work together in order to provide the best management to these patients. After years of disappointing studies showing no reduction of CV events with strict glycaemic control, some of the novel glucose-lowering drugs (GLDs) seem to offer a new approach to tackle the problem, since the CV outcome trials (CVOTs-D) of liraglutide, semaglutide, empagliflozin and canagliflozin have demonstrated not only their CV safety but also their efficacy in the reduction of CV morbidity and mortality. Along with the initial enthusiasm, concerns have been raised about the economical sustainability of long-term therapies considering higher costs of new molecules relative to the traditional ones. As expenses in the medical field are on the rise, healthcare systems need to balance the positive impact of an intervention and its overall cost. This review is meant to offer the Cardiologists a different point of view on the positive influence of GLDs, in the light of the main trials in the CV fields they are familiar with. The purpose of this article is to critically review the magnitude of the CVOTs-D results by the analysis of their statistical determinants, to establish the extent of the GLDs positive impact on patients with both diabetes and CV disease. The analysis has been performed taking into account models and statistical determinants used in the main landmark cardiology trials. It is fundamental to translate the result of CVOTs-D in clinical practice: the interdisciplinary crosstalk between the Cardiologist and Diabetologist is of paramount importance in order to fully exploit the power of the new available pharmacological strategies.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Via Olgettina 48/60, 20132 Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Via Olgettina 48/60, 20132 Milan, Italy
| | - Maria Regoni
- Neuropsychopharmacology Unit, Division of Neuroscience, San Raffaele Scientific Institute, Via Olgettina 48/60, 20132 Milan, Italy
| | - Domenico Cianflone
- San Raffaele Vita-Salute University, Via Olgettina 58, 20132 Milan, Italy
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30
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Maranta F, Fossati L, Cerea P, Cianfanelli L, Pagnesi M, Cartella I, Pistoni A, Negri S, Cianflone D. P1244Neutrophil to lymphocyte ratio: a new preoperative predictive index of postoperative atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- F Maranta
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - L Fossati
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - P Cerea
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - L Cianfanelli
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - M Pagnesi
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - I Cartella
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - A Pistoni
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - S Negri
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - D Cianflone
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
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31
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Cerea P, Maranta F, Fossati L, Cianfanelli L, Pagnesi M, Cartella I, Pistoni A, Negri S, Cianflone D. P2558A novel scoring system and decisional algorithm to predict functional recovery after heart valve surgery. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- P Cerea
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - F Maranta
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - L Fossati
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - L Cianfanelli
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - M Pagnesi
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - I Cartella
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - A Pistoni
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - S Negri
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
| | - D Cianflone
- San Raffaele Hospital of Milan (IRCCS), Cardiovascular Rehabilitation, Milan, Italy
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32
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Torreggiani M, Cianfanelli L, Colucci M, Esposito V, Catucci D, Semeraro L, Grosjean F, Dal Canton A, Palladini G, Merlini G, Esposito C. MP078MORPHO-FUNCTIONAL CORRELATIONS IN RENAL AMYLOIDOSIS. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw183.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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