MIRACLE2 Score Compared With Downtime and Current Selection Criterion for Invasive Cardiovascular Therapies After OHCA

BACKGROUND

The MIRACLE2 score is the only risk score that does not incorporate and can be used for selection of therapies after out-of-hospital cardiac arrest (OHCA).

OBJECTIVES

This study sought to compare the discrimination performance of the MIRACLE2 score, downtime, and current randomized controlled trial (RCT) recruitment criteria in predicting poor neurologic outcome after out-of-hospital cardiac arrest (OHCA).

METHODS

We used the EUCAR (European Cardiac Arrest Registry), a retrospective cohort from 6 centers (May 2012-September 2022). The primary outcome was poor neurologic outcome on hospital discharge (cerebral performance category 3-5).

RESULTS

A total of 1,259 patients (total downtime = 25 minutes; IQR: 15-36 minutes) were included in the study. Poor outcome occurred in 41.8% with downtime <30 minutes and in 79.3% for those with downtime >30 minutes. In a multivariable logistic regression analysis, MIRACLE2 had a stronger association with outcome (OR: 2.23; 95% CI: 1.98-2.51; P < 0.0001) than zero flow (OR: 1.07; 95% CI: 1.01-1.13; P = 0.013), low flow (OR: 1.04; 95% CI: 0.99-1.09; P = 0.054), and total downtime (OR: 0.99; 95% CI: 0.95-1.03; P = 0.52). MIRACLE2 had substantially superior discrimination for the primary endpoint (AUC: 0.877; 95% CI: 0.854-0.897) than zero flow (AUC: 0.610; 95% CI: 0.577-0.642), low flow (AUC: 0.725; 95% CI: 0.695-0.754), and total downtime (AUC: 0.732; 95% CI: 0.701-0.760). For those modeled for exclusion from study recruitment, the positive predictive value of MIRACLE2 ≥5 for poor outcome was significantly higher (0.92) than the CULPRIT-SHOCK (Culprit lesion only PCI Versus Multivessel PCI in Cardiogenic Shock) (0.80), EUROSHOCK (Testing the value of Novel Strategy and Its Cost Efficacy In Order to Improve the Poor Outcomes in Cardiogenic Shock) (0.74) and ECLS-SHOCK (Extra-corporeal life support in Cardiogenic shock) criteria (0.81) (P < 0.001).

CONCLUSIONS

The MIRACLE2 score has superior prediction of outcome after OHCA than downtime and higher discrimination of poor outcome than the current RCT recruitment criteria. The potential for the MIRACLE2 score to improve the selection of OHCA patients should be evaluated formally in future RCTs.

[Out-of-hospital cardiac arrest: University of Trieste students' skills on resuscitative maneuvers and automated external defibrillator]

BACKGROUND

Out-of-hospital cardiac arrest is the third leading cause of death in industrialized countries. Although most cardiac arrests are witnessed, survival is only 2-10%, since bystanders are often unable to correctly perform cardiopulmonary resuscitation (CPR). This study aims to assess the theoretical and practical knowledge of CPR and the use of the automatic external defibrillator in university students.

METHODS

The study involved a total of 1686 students from 21 different faculties of the University of Trieste, 662 students from healthcare faculties and 1024 from non-healthcare faculties. Basic life support and early defibrillation (BLS-D) courses and retrainings after 2 years are mandatory for students in their final 2-year healthcare faculties at the University of Trieste. Through the platform "EUSurvey" from March to June 2021, they were given an online questionnaire of 25 multiple choice questions to investigate the performance of BLS-D.

RESULTS

In the overall population, 68.7% knew how to diagnose a cardiac arrest and 47.5% knew the time frame after which irreversible brain damage occurs. Practical knowledge was analyzed by evaluating the correct answers to all four questions on performing CPR (i.e. hand position during compressions, frequency of compressions, depth of compressions, and ventilation-compression ratio). Health faculties students have better theoretical and practical knowledge of CPR than their colleagues of non-healthcare faculties, with better overall knowledge on the all four practical questions (11.2% vs 4.3%; p<0.001). Final-year medical students of the University of Trieste, who attended the BLS-D course and underwent retraining after 2 years, have achieved better results than first year medical students (without BLS-D training) (38.1% vs 2.7%; p<0.001).

CONCLUSION

Mandatory BLS-D training and retraining leads to a better knowledge of cardiac arrest management and consequently a better patient outcome. In order to improve patient survival, heartsaver (BLS-D for laics) training should be extended as obligatory in all university courses.

The impact of COVID-19 on myocardial infarctions, strokes and out-of-hospital cardiopulmonary arrests: an observational retrospective study on time-sensitive disorders in the Friuli Venezia Giulia region (Italy)

The COVID-19 global pandemic has changed considerably the way time-sensitive disorders are treated. Home isolation, people's fear of contracting the virus and hospital reorganisation have led to a significant decrease in contacts between citizens and the healthcare system, with an expected decrease in calls to the Emergency Medical Services (EMS) of the Friuli-Venezia Giulia (FVG) region. However, mortality in clinical emergencies like acute ST-elevation myocardial infarction (STEMI), stroke and out-of-hospital cardiopulmonary arrest (OHCA) remained high. An observational retrospective cross-sectional study was carried out in FVG, taking into account the period between March 1, 2020, and May 31, 2020, the first wave of the COVID-19 pandemic, and comparing it with the same period in 2019. The flow of calls to the EMS was analysed and COVID-19 impact on time-sensitive disorders (STEMIs, ischemic strokes and OHCPAs) was measured in terms of hospitalisation, treatment and mortality. Despite a -8.01% decrease (p value ˂0.001) in emergency response, a 10.89% increase in calls to the EMS was observed. A lower number of advanced cardiopulmonary resuscitations (CPR) (75.8 vs 45.2%, p=0.000021 in April) and ROSC (39.1 vs 11.6%, p=0.0001 in April) was remarked, and survival rate dropped from 8.5 to 5%. There were less strokes (-27.5%, p value=0.002) despite a more severe onset of symptoms at hospitalisation with NHISS˃10 in 38.47% of cases. Acute myocardial infarctions decreased as well (-20%, p value=0.05), but statistical significances were not determined in the variables considered and in mortality. Despite a lower number of emergency responses, the number of calls to the EMS was considerably higher. The number of cardiac arrests treated with advanced CPR (ALS) was lower, but mortality was higher. The number of strokes decreased as well, but at the time of hospitalisation the clinical picture of the patient was more severe, thus affecting the outcome when the patient was discharged. Finally, STEMI patients decreased; however, no critical issues were observed in the variables taken into account, neither in terms of response times nor in terms of treatment times.

466 OUT-OF-HOSPITAL CARDIAC ARREST: UNIVERSITY OF TRIESTE STUDENTS’ KNOWLEDGE OF CARDIOPULMONARY RESUSCITATION AND DEFIBRILLATOR USE

Background

Out-of-hospital cardiac arrest (OHCA) is the third leading cause of death in industrialized countries. Although most cardiac arrests are witnessed, survival is only 2-10%, since bystanders are often unable to correctly perform cardio-pulmonary resuscitation (CPR). This study aims to assess the theoretical and practical knowledge of CPR and the use of the automatic external defibrillator (AED) in university students.

Materials and methods

The study involved a total of 1686 students from 21 different faculties of the University of Trieste, 662 students from health faculties and 1024 from non-health faculties. Basic life support and early defibrillation (BLSD) courses have been included in health faculties and made mandatory for students in their final years. Through the platform “EUSurvey” from March to June 2021, they were given an online questionnaire of 25 multiple choice questions to investigate the performance of BLSD.

Results

In the overall population, only 68.7% knew how to diagnose a cardiac arrest and the 47.5% knew the time frame after which irreversible brain damage occurs. Practical knowledge was analysed by evaluating the correct answers to all four questions on performing CPR (hand position during compressions, frequency of compressions, depth of compressions, and ventilations-compressions ratio). Health faculties students have better theoretical and practical knowledge of CPR than their colleagues in non-health faculties (11,2% vs 4,3%; p value &lt;0.001). Final-year medical students, who attended the BLSD course and underwent retraining, have achieved better results than first year medical students (38,1% vs 2,7%; p value &lt;0.001).

Discussion

The knowledge of cardiac arrest needs to be improved in the overall university population. The obligatory inclusion of BLSD courses in healthcare degree courses has led to a significant increase in knowledge on the issue. Given this, we believe it is important to extend these courses to all university students.

485 PROGNOSTIC IMPACT OF TREATMENTS EVOLUTION IN STEMI: INSIGHTS FROM A PRIMARY PCI REGISTRY

Objective

We aimed to evaluate in a real world primary percutaneous coronary intervention (pPCI) registry the impact of the evolution of evidence-based treatments on prognosis, comparing different decades of treatment.

Methods

Consecutive STEMI patients undergoing pPCI at University Hospital of Trieste, Italy, were enrolled in a pPCI registry. Outcomes were evaluated during two successive periods: the first cohort (old treatments cohort) included STEMI patients treated between January 2007 and December 2012, and the second cohort (new treatments cohort), included STEMI patients treated between January 2013 and December 2020. Cox regression models were performed to predict the risk of the study primary endpoint (PE) a composite of all cause death, reinfarction and re-PCI at 5 years. The secondary endpoint was all cause of mortality at 5 years. Moreover, we evaluated the incidence of stent thrombosis at 12 months.

Results

A total of 2425 STEMI patients, 947 in the old treatments cohort and 1478 in the new treatments cohort were analysed. The mean age of the population was 66 ± 12.5 years, most were males (74.3%), 20.2% were diabetics, and 12% presented in Killip class III-IV. At 5-years of follow-up the new treatments cohort compared to the old treatments cohort presented a lower rate of primary outcome (18.5% vs 23.1%, p=0.006) and mortality (15.5% vs 19.9%, p=0.006). At Cox regression model adjusted for baseline differences between the two cohorts, patients in the new treatments cohort had lower risk of PE (HR 0.717, 95% CI 0.567–0.907, p=0.006) and mortality (HR 0.662, 95% CI 0.509–0.860, p=0.002). When considering both clinical and procedural variables, complete revascularization (HR 0.459, 95% CI 0.265–0.796, p=0.006) and the administration of prasugrel or ticagrelor (HR 0.721, 95% CI 0.524–0.992, p=0.013) were independent predictors of PE as well as of 5 years mortality. The new treatments cohort compared to the old treatments cohort had more frequent use of radial approach (83.1% vs 24.4%, p&lt;0.001) and had lower ischaemia time (3.05 vs 3.45 hours, p&gt;0.001), however they were not associated with PE. Patients receiving prasugrel or ticagrelor or drug eluting stent (DES) were at lower risk of stent thrombosis at 12 months (HR 0.502, 95% CI 0.280–0.900, p=0.021).

Conclusions

In a real-word STEMI population the prognosis of patients is improved in the last decades, and this was associated to the use of new antithrombotic treatments and to the implementation of complete revascularization. The application of new evidence-based therapies in clinical practise is fundamental to improve patient prognosis because the benefits demonstrated by clinical trials have translated into a benefit in the real-world population.

[The Regional Registry of Sudden Cardiac Death of Friuli Venezia Giulia. Protocols, best practices and results of a multidisciplinary project]

With the regional law n. 26 of December 30, 2020, the Friuli Venezia Giulia Region wanted to promote the establishment of the Regional Register of Sudden Cardiac Death, with the aim of favoring the study of all those deaths that occurred suddenly and unexpectedly under the age of 50 years in which it is not possible to trace the cause of death with certainty. Such dramatic events, difficult to quantify considering the complexity of data collection, are often accepted with resignation without any further investigation of the possible causes. The Regional Register of Sudden Cardiac Deaths of Friuli Venezia Giulia was born from this premise and from the awareness of the importance of going back with a rigorous scientific methodology and through a multidisciplinary approach, to the diagnosis of hereditary heart diseases which, when determined, allow the enrollment of relatives in a cardiological screening process and, therefore, primary prevention of potentially fatal events. The authors describe the operating procedures feeding the Regional Register and present the results of the first year of activity on 26 cases.

[ANMCO Position paper: Cardiovascular disease in women - prevention, diagnosis, treatment and organization of care]

Cardiovascular diseases are still the main cause of death among women despite the improvements in treatment and prognosis achieved in the last 30 years of research. The determinant factors and causes have not been completely identified but the role of "gender" is now recognized. It is well known that women tend to develop cardiovascular disease at an older age than men, and have a high probability of manifesting atypical symptoms not often recognized. Other factors may also co-exist in women, which may favor the onset of specific cardiac diseases such as those with a sex-specific etiology (differential effects of estrogens, pregnancy pathologies, etc.) and those with a different gender expression of specific and prevalent risk factors, inflammatory and autoimmune diseases and cancer. Whether the gender differences observed in cardiovascular outcomes are influenced by real biological differences remains a matter of debate.This ANMCO position paper aims at providing the state of the research on this topic, with particular attention to the diagnostic aspects and to care organization.

MIRACLE2 Score and SCAI Grade to Identify Patients With Out-of-Hospital Cardiac Arrest for Immediate Coronary Angiography

OBJECTIVES

The purpose of this study was to evaluate the impact of performing immediate coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) with stratification of predicted neurologic injury and cardiogenic shock on arrival to a center.

BACKGROUND

The role of immediate CAG for patients with OHCA is unclear, which may in part be explained by the majority of patients dying of hypoxic brain injury.

METHODS

Between May 2012 and July 2020, patients from 5 European centers were included in the EUCAR (European Cardiac Arrest Registry). Patients were retrospectively classified into low vs high neurologic risk (MIRACLE₂ score 0-3 vs ≥4) and degree of cardiogenic shock on arrival (Society for Cardiovascular Angiography and Interventions [SCAI] grade A vs B-E). A multivariable logistic regression analysis including immediate CAG was performed for the primary outcome of survival with good neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge.

RESULTS

Nine hundred twenty-six patients were included in the registry, with 405 (43.7%) in the low-risk group and 521 (56.3%) in the high-risk group. Immediate CAG was independently associated with improved survival with good neurologic outcome in the low MIRACLE₂ risk group with ST-segment elevation myocardial infarction (OR: 11.80; 95% CI: 2.24-76.74; P = 0.048) and with SCAI grade B to E shock (OR: 3.23; 95% CI: 1.10-9.50; P = 0.031). No subgroups, including those with ST-segment elevation myocardial infarction and with SCAI grade B to E shock, achieved any benefit from early CAG in the high MIRACLE₂ group.

CONCLUSIONS

Combined classification of patients with OHCA with 12-lead electrocardiography, MIRACLE₂ score 0 to 3, and SCAI grade B to E identifies a potential cohort of patients at low risk for neurologic injury who benefit most from immediate CAG.

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BACKGROUND

Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.

METHODS

We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.

RESULTS

Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality.

CONCLUSIONS

In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Effect of prehospital treatment in STEMI patients undergoing primary PCI

Background

The appropriate timing to administer antithrombotic therapies in ST‐elevation myocardial infarction (STEMI) remains uncertain. This study aims to evaluate the role of antithrombotic therapy administration at first medical contact (FMC) compared with the administration in the Cathlab.

Methods

We conducted a “before‐after” observational study enrolling STEMI undergoing primary percutaneous coronary intervention (PCI). Outcomes were evaluated during two successive periods, before (control group: aspirin only at FMC) and after (pretreated intervention group: heparin, aspirin plus ticagrelor at FMC) the introduction of a new regional pretreatment protocol.

Results

A total of 537 consecutive patients (300 in control vs. 237 in intervention group) were enrolled. The pretreated compared with no pretreated population showed better basal reperfusion, expressed as basal Thrombolysis in Myocardial Infarction (TIMI)‐flow (p for trend p < 0.001). Pretreated population showed lower frequency of TIMI 0 (56.5% vs. 73.7%, odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.32–0.67, p < 0.001) and higher frequency of TIMI 2‐3 (33.3% vs. 19.3% OR: 2.0, 95% CI: 1.38–2.00, p < 0.001) and TIMI 3 (14.3% vs. 9.7%, OR: 1.56, 95% CI: (0.92–2.65), p = 0.094). Pretreated compared with no pretreated population showed reduced infarct size expressed as Troponin Peak (20,286 (8726–75,027) versus 48,676 (17,229–113,900), p = 0.001), and higher left ventricular ejection fraction at discharge (53% (44–59) vs. 50% (44–56), p = 0.027). In‐hospital BARC ≥ 2 bleeding were similar (2.1% vs. 2.0%, p = 0.929, in pretreated versus no pretreated population, respectively).

Conclusion

This study provides support for an early pretreatment strategy in STEMI patients and confirmed the importance of an efficient organization of STEMI networks which allow initiation of antithrombotic treatment at FMC.

86 STEMI and multivessel disease: medical therapy amplifies the benefit of complete myocardial revascularization

Aims

Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularization strategies. However, the potential predictors of outcomes on top of different revascularization strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularization strategies and the potential impact of medical therapy.

Methods and results

Using a propensity score approach, the impact of two treatment strategies was analysed—staged non-culprit revascularization group vs. culprit-lesion-only percutaneous coronary intervention (PCI) group—on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularization. Moreover, models were further adjusted for medication at discharge. Among 1385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21–65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularization group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24–0.82; P = 0.01), lower CVD (HR, 0.34; 95% CI, 0.14–0.82; P = 0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24–0.86; P = 0.02). Use of renin–angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27–0.95; P = 0.03), and both renin–angiotensin inhibitors (HR, 0.52; 95% CI, 0.32–0.86; P = 0.01) and beta blockers (HR, 0.48; 95% CI, 0.29–0.79; P = 0.01) were associated with lower all-cause death.

Conclusions

In a real-word STEMI population with multivessel disease, staged non-culprit revascularization was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularization and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularization.

350 Effect of pre-hospital treatment for STEMI patients undergoing primary PCI

Aims

The appropriate timing to administer antithrombotic therapies in ST-elevation myocardial infarction (STEMI) remains uncertain. This study aims to evaluate the role of antithrombotic therapy administration at first medical contact (FMC) compared to the administration in the Cathlab.

Methods and results

We conducted a ‘before-after’ observational study enrolling STEMI undergoing primary percutaneous coronary intervention (PCI). Outcomes were evaluated during two successive periods, before (control group: aspirin only at FMC) and after (pre-treated intervention group: heparin, aspirin plus ticagrelor at FMC) the introduction of a new regional pre-treatment protocol. 537 consecutive patients (300 in control vs. 237 in intervention group) were enrolled. The pre-treated compared to no pre-treated population showed better basal reperfusion, expressed as basal thrombolysis in myocardial Infarction (TIMI)-flow (p for trend P &lt; 0.001). Pre-treated population showed lower frequency of TIMI 0 (56.5% vs. 73.7%, OR: 0.46, 95% CI: 0.32–0.67, P &lt; 0.001) and higher frequency of TIMI 2–3 (33.3% vs. 19.7%; OR: 2.0; 95% CI: 1.38–2.00, P &lt; 0.001) and TIMI 3 [14.3% vs. 9.7%, OR: 1.56, 95% CI: (0.92–2.65), P = 0.094]. Pre-treated compared to no pre-treated population showed reduced infarct size expressed as Troponin Peak [20 286 (8726–75027) vs. 48 676 (17229–113900), P = 0.001], and higher left ventricular ejection fraction at discharge [53% (44–59) vs. 50% (44–56), P = 0.027]. In-Hospital BARC ≥2 bleeding were similar (2.1% vs. 2.0%, P = 0.929, in pre-treated vs. no pre-treated population, respectively).

Conclusions

This study provides support for an early pre-treatment strategy in STEMI patients and confirmed the importance of an efficient organization of STEMI networks which allow initiation of antithrombotic treatment at FMC.

STEMI and Multivessel Disease: Medical Therapy Amplifies the Benefit of Complete Myocardial Revascularisation

BACKGROUND

Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularisation strategies. However, the potential predictors of outcomes on top of different revascularisation strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularisation strategies and the potential impact of medical therapy.

METHODS

Using a propensity score approach, the impact of two treatment strategies was analysed -staged non-culprit revascularisation group vs culprit-lesion-only percutaneous coronary intervention (PCI) group -- on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularisation. Moreover, models were further adjusted for medication at discharge.

RESULTS

Among 1,385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21-65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularisation group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24-0.82; p=0.01), lower CVD (HR, 0.34; 95% CI, 0.14-0.82; p=0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24-0.86; p=0.02). Use of renin-angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27-0.95; p=0.03), and both renin-angiotensin inhibitors (HR, 0.52; 95% CI, 0.32-0.86; p=0.01) and beta blockers (HR, 0.48; 95% CI, 0.29-0.79; p=0.01) were associated with lower all-cause death.

CONCLUSIONS

In a real-word STEMI population with multivessel disease, staged non-culprit revascularisation was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularisation and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularisation.

Treatment of Functional Mitral Regurgitation in Heart Failure

PURPOSE OF REVIEW

To analyze the current state of the art of functional mitral regurgitation (FMR) treatment.

RECENT FINDINGS

The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.

Prognostic relevance of pericardial effusion in STEMI patients treated by primary percutaneous coronary intervention: a 10-year single-centre experience

BACKGROUND

Pericardial effusion is frequent in the acute phase of ST-segment elevation myocardial infarction. However, its prognostic role in the era of primary percutaneous coronary intervention is not completely understood.

METHODS

We investigated the association between pericardial effusion, assessed by transthoracic echocardiography, and survival in a large cohort of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention, enrolled in the Trieste primary percutaneous coronary intervention registry from January 2007 to March 2017. Multivariable analysis and a propensity score approach were performed.

RESULTS

A total of 1732 ST-segment elevation myocardial infarction patients were included. Median follow-up was 45 (interquartile range 19-79) months. Pericardial effusion was present in 246 patients (14.2%). Thirty-day all-cause mortality was similar between patients with and without pericardial effusion (7.8% vs. 5.4%, P=0.15), whereas crude long-term survival was worse in patients with pericardial effusion (26.2% vs. 17.7%, P≤0.01). However, at multivariable analyses the presence of pericardial effusion was not associated with long-term mortality (hazard ratio 1.26, 95% confidence interval 0.86-1.82, P=0.22). Matching based on propensity scores confirmed the lack of association between pericardial effusion and both 30-day (hazard ratio 1, 95% confidence interval 0.42-2.36, P=1) and long-term (hazard ratio 1.14, 95% confidence interval 0.74-1.78, P=0.53) all-cause mortality. Patients with pericardial effusion experienced a higher incidence of free wall rupture (2.8% vs. 0.5%, P<0.0001) independently of the entity of pericardial effusion.

CONCLUSIONS

In acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, the onset of pericardial effusion after ST-segment elevation myocardial infarction is not independently associated with short and long-term higher mortality. Free wall rupture has to be considered rare compared to the fibrinolytic era and occurs more frequently in patients with pericardial effusion, suggesting a close monitoring of these patients in the early post-primary percutaneous coronary intervention phase.

Prognostic Value of Global Longitudinal Strain-Based Left Ventricular Contractile Reserve in Candidates for Percutaneous Correction of Functional Mitral Regurgitation: Implications for Patient Selection

PURPOSE

Patients with symptomatic heart failure (HF), reduced left ventricular ejection fraction (LVEF), and high-grade functional mitral regurgitation (MR) may benefit from percutaneous edge-to-edge mitral valve repair (PMVR). However, patient selection still remains a central issue. We sought to investigate the potential role of the global longitudinal strain- (GLS-) based left ventricular contractile reserve (LVCR) at dobutamine stress echocardiography (DSE) in this setting.

METHODS

Thirty-three stable HF patients (MR grade ≥ 3+; median LVEF, 29%; median GLS, -8.3%) who were candidates for PMVR were prospectively enrolled. All patients underwent DSE to assess LVCR (LVEF increase ≥ 5%; GLS increase ≥ 2%; stroke volume [SV] increase ≥ 20% of the measured SV value).

RESULTS

After DSE, a positive LVCR_LVEF was detected in 21 patients (64%), positive LVCR_GLS in 12 patients (36%), and positive LVCR_SV in 14 patients (42%). LVCR_GLS was associated with better symptom relief, MR improvement, and LV reverse remodeling in a short-term follow-up. A significant improvement of GLS during DSE (hazard ratio [HR], 0.549; 95% CI, 0.395-0.765; P < .001), along with history of HF hospitalization (HR, 1.48; 95% CI, 1.119-1.967; P = .006) and beta-blocker therapy (HR, 0.146; 95% CI, 0.046-0.462; P = .001), were independently associated with risk of death/heart transplantation/HF-related hospitalizations.

CONCLUSIONS

LVCR, assessed by speckle-tracking DSE, is associated with better results after PMVR in the setting of advanced HF. Improvement of longitudinal function emerged, beyond the ejection fraction, as an independent predictor of outcomes and could improve the selection of best candidates for the percutaneous correction of functional MR.

Right Ventricular Dysfunction in Right Coronary Artery Infarction: A Primary PCI Registry Analysis

Right ventricular involvement in inferior myocardial infarction (MI) was historically associated with a poor prognosis. However, few studies addressed the impact of right ventricular (RV) dysfunction in the primary percutaneous intervention (pPCI) era. Our aim was to assess the prognostic significance of RV dysfunction in right coronary artery (RCA) related MI treated with pPCI.

METHODS

A total of 298 patients with a RCA related MI undergone pPCI between January 2011 and June 2015 were included. RV dysfunction was defined by a RV-FAC <35% at echocardiographic examination and further divided into mild (RV-FAC between 35 and 25%) and moderate-severe (RV-FAC <25%). RV function before discharge was reassessed in 95% of the study cohort. The primary endpoint was overall mortality. Median follow-up was 29 months.

RESULTS

In RCA related MI, moderate-severe (HR 5.882, p = 0.002, 95% CI 1.882-18.385) but not mild RV dysfunction independently predicted lower survival at follow-up along with age (HR 1.104, p <0.001, CI 1.045-1.167). Importantly, patients recovering RV function at discharge showed a lower mortality (p = 0.001) vs patients with persistent moderate-severe RV dysfunction) that approached the risk of patients without RV dysfunction at presentation.

CONCLUSION

In RCA related MI treated with pPCI, RV dysfunction was one of the strongest independent predictor of lower overall survival. However, patients with only transient RV dysfunction showed a better prognosis compared to patients who had persistent RV dysfunction. The focus on intensive support management of the RV in the first hours after pPCI may be important to overcome the acute phase and to promote RV recovery.

[Tricuspid regurgitation and indications for treatment]

Tricuspid regurgitation is a frequent valvular heart disease, particularly in the elderly and in association with other left-sided heart diseases. It has an adverse prognostic impact, with progressively increasing mortality as the degree of regurgitation increases. Isolated or combined (with mitral and/or aortic) surgery remains the treatment of choice, provided operative risk is acceptable. Several transcatheter treatment techniques, currently in early clinical or preclinical study phase, could provide alternative treatment options for patients with high surgical risk.

[ANMCO/SICI-GISE document on antiplatelet therapy in patients with acute coronary syndrome]

Antiplatelet therapy is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS). Over the last years, several studies have evaluated old and new oral or intravenous antiplatelet agents in ACS patients. In particular, research was focused on assessing superiority of two novel platelet ADP P2Y12 receptor antagonists (i.e., prasugrel and ticagrelor) over clopidogrel. Several large randomized controlled trials have been undertaken in this setting and a wide variety of prespecified and post-hoc analyses are available that evaluated the potential benefits of novel antiplatelet therapies in different subsets of patients with ACS. The aim of this document is to review recent data on the use of current antiplatelet agents for in-hospital treatment of ACS patients. For each drug or class of drugs, strong evidence and/or areas of uncertainty that warrant further research are highlighted by examining 10 subgroups of patients with ACS.

[Multidisciplinary position paper on the management of patent foramen ovale in the presence of cryptogenic cerebral ischemia - Italian version 2013]

There is no generally accepted consensus on the management of patent foramen ovale (PFO) in the presence of cryptogenic cerebral ischemia, because of the lack of conclusive evidence. The aim of this position paper was to develop and promote a joint approach based on available data that may be shared by different specialists, while waiting for definite results from randomized controlled trials. A position statement was produced involving the major national scientific societies. The task force members were nominated by the presidents and/or executive boards of each society or working group, as appropriate, based on their previous work in relevant topic areas. Specific task force working groups prepared the drafts. In order to achieve maximum agreement, these drafts were merged and distributed to the scientific societies for local evaluation. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by all scientific societies. The following issues were addressed: definitions of transient ischemic attack (TIA) and both symptomatic and asymptomatic cryptogenic stroke; formulation of a diagnostic workup for patients with clinical event(s) and PFO; recommendations regarding medical and interventional treatment options considering individual risk factors based on the three available randomized trials and other observational studies; recommendations regarding requirements for operators and centers in Italy; definition of a follow-up evaluation protocol. In conclusion, available data provided the basis for the first multi-society position paper on the management of cryptogenic stroke/TIA and PFO.

Management of patients with patent foramen ovale and cryptogenic stroke: a collaborative, multidisciplinary, position paper: executive summary

OBJECTIVES

To organize a common approach on the management of patent foramen ovale (PFO) and cryptogenic stroke that may be shared by different specialists.

BACKGROUND

The management of PFO related to cryptogenic stroke is controversial, despite an increase in interventional closure procedures.

METHODS

A consensus statement was developed by approaching Italian national cardiological, neurological, and hematological scientific societies. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. Drafts were outlined by specific task force working groups. To obtain a widespread consensus, these drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by scientific societies.

RESULTS

Definitions of transient ischemic attack and both symptomatic and asymptomatic cryptogenic strokes were specified. A diagnostic workout was identified for patients with candidate event(s) and patient foramen ovale to define the probable pathogenesis of clinical events and to describe individual PFO characteristics. Further recommendations were provided regarding medical and interventional therapy considering individual risk factors of recurrence. Finally, follow-up evaluation was appraised.

CONCLUSIONS

Available data provided the basis for a shared approach to management of cryptogenic ischemic cerebral events and PFO among different Italian scientific societies. Wider international initiatives on the topic are awaited.

[ANMCO statement on prevention of thromboembolism in atrial fibrillation and role of the new oral anticoagulants]

The introduction in the therapeutic armamentarium of three new oral anticoagulants for the prevention of thromboembolism in atrial fibrillation (AF) has stimulated the development of this position paper from the Italian Association of Hospital Cardiologists (ANMCO). First, the pathophysiology of arterial thromboembolism in AF is reviewed, describing the mechanisms of action of the new oral anticoagulants, their pharmacology and pharmacokinetics, and highlighting differences and similarities observed in preclinical studies and trials. Stratification of thromboembolic and bleeding risk is made using different risk scores; a comprehensive analysis of the various international guidelines should emphasize convergences or divergences. An in-depth examination of the limitations of current therapeutic strategies for the prevention of stroke in non-valvular AF provides insight into the difficulty in maintaining adequate adherence to therapy with warfarin and a constant and effective anticoagulation, without wide fluctuations in prothrombin time international normalized ratio (INR) values. Clinical trials of new oral anticoagulants for AF are discussed in detail in the present document, with a focus on similarities and differences, efficacy and safety data, and the net clinical benefit of each new oral anticoagulant. Results obtained in elderly patients, or in patients with renal, liver and ischemic heart disease or previous stroke are reported separately, as well as those regarding combination therapy with antiplatelet agents. Finally, this document provides indications, practical applications and cost-effectiveness analysis of each new oral anticoagulant. It is of utmost importance to know how treatment should be started, how you should switch from warfarin, which patients should be maintained on warfarin, how and when cardioversion, catheter ablation or appendage closure should be performed, what drug and food interactions may affect these medications, and how treatment adherence may be improved to avoid therapy discontinuation. An accurate examination of the risk of bleeding is also provided, with special reference to laboratory monitoring of renal and hepatic function, timing for discontinuing these medications prior to surgery, and treatment of patients with major and minor bleeding.

Contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention without acute left ventricular ejection fraction impairment

The prognostic relevance of direct contrast toxicity in patients treated with primary percutaneous coronary intervention remains unclear, owing to the confounding hemodynamic effect of acute left ventricular ejection fraction (LVEF) impairment on kidney function estimation. In the present study, 644 consecutive patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were prospectively enrolled. Contrast-induced nephropathy (CIN) was defined as an increase in serum creatinine >25% or a decrease in the estimated glomerular filtration rate (eGFR) <25% from baseline in the first 72 hours. The primary end point of the study was major adverse cardiovascular events at 1 year (composite of death, myocardial infarction, target lesion revascularization, and bleeding). Among the global population, the interaction between the LVEF and eGFR at admission to define CIN was statistically significant (p <0.001). When only the 385 patients without acute LVEF impairment (i.e., those with LVEF ≥40%) were considered, 27 (7%) developed postprocedural CIN that was associated with increased major adverse cardiovascular events rate at 1 year of clinical follow-up (38% vs 9%; p <0.001). On adjusted Cox multivariate analysis, CIN was an independent predictor of worse outcomes, both when defined according to creatinine (hazard ratio 3.81, 95% confidence interval 1.71 to 8.48, p = 0.001) or eGFR (hazard ratio 3.77, 95% confidence interval 1.53 to 9.28, p = 0.004) variations. In conclusion, in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, LVEF has a significant interaction with eGFR. When only patients without acute LVEF impairment were considered, CIN confirmed its negative prognostic effect on the 1-year clinical outcomes.

Clinical outcome of patients with microinvasive adenocarcinoma of the uterine cervix

BACKGROUND

The objective of this analysis was to present the clinical outcome of patients with microinvasive adenocarcinoma (AC) of the uterine cervix treated at the Department of Obstetrics and Gynecology between 1999 and 2010.

MATERIALS AND METHODS

The authors analysed 125 patients with microinvasive AC. The analysis involved the following parameters: women's age at surgery, type of surgery, number of positive lymph nodes, and patient's survival. Additionally, a questionnaire regarding history and symptoms before diagnosis and postoperative follow-up was developed and analysed specifically for this study.

RESULTS

The mean women's age at surgery was 40.58 +/- 9.58 years. In 70 women (56%), the performed treatment was conization, 34 women (27.2%) underwent simple hysterectomy, and 24 (19.2%) women had radical hysterectomy. In 14 (11.2%) women, the margins of the cone were not disease-free, in nine of them the authors later performed radical hysterectomy. From 14 women who became pregnant after treatment, 13 (16.9%) of them gave birth. One of the 125 patients diagnosed with microinvasive AC died and the cause of death was rectal carcinoma.

CONCLUSION

The authors may conclude that conservative management of patients with microinvasive AC is safe when exact evaluation of tumor extension and surgical margins of the cone are considered, and results in very low risk of recurrence, lymph node disease, and death caused by cancer.

Reversal of angiodysplasia-derived anemia after transcatheter aortic valve implantation

Aortic valve stenosis associated with angiodysplasia (Heyde's syndrome) and consequent anemia had previously been reported to benefit from surgical aortic valve replacement. In this clinical case an 89-year-old patient with chronic angiodysplasia-derived anemia, characterized by acute phases of active gastrointestinal bleeding experienced a normalization of hemoglobin values after a trans-catheter aortic valve implantation (TAVI) of a self-expandable aortic valve prosthesis (CoreValve, Medtronic Inc., Minneapolis, MN, USA). This is the first, to our knowledge, reported clinical case of remission of angiodysplasia-derived anemia after TAVI.

Comparison of nerve content in removed parametrial tissue after classic radical hysterectomy and nerve-sparing radical hysterectomy--histologic evaluation

PURPOSE OF INVESTIGATION

The aim of this study was to find whether nerve-sparing radical hysterectomy resulted in a lower amount of nerves in the removed parametrial tissue.

METHODS

Histological specimens from nerve-sparing radical hysterectomy (28 cases) were compared with those obtained after classic radical hysterectomy (26 cases). Width of the parametria and vaginal cuff were measured. Using a point counting technique, nerve areal density was determined in cross sections of resected parametria at 0.5 cm (A), 1 cm (B), 1.5 cm (C) from the cervix.

RESULTS

The width of the resected parametria was smaller in the study group (right side p < 0.013; left side; p < 0.011). The nerve areal density in the lateral part of the right parametrium was lower in the study group (p < 0.01) (Student's t-test). CCONCLUSION: Modified radical hysterectomy is less radical and is nerve-sparing.

Müllerian papilloma in a patient with Proteus syndrome: case report and review of the literature

BACKGROUND

Müllerian papilloma is a rare benign tumor of the female genital tract. It mostly affects girls less than five years old. After the treatment long-term follow-up is needed as there is a chance of recurrence, but even then the prognosis is excellent.

CASE

A 19-year-old girl with Proteus syndrome presented with vaginal bleeding. The histological examination revealed Müllerian papilloma of the uterine cervix and large bilateral ovarian cystadenomas. The patient was treated with a radical operation, because there were signs of more aggressive behavior in the tumor. The patient is alive and free of disease five years after the operation.

CONCLUSION

The medical care of patients affected by rare disorders depends heavily on experiences gained from cases published in the medical literature. Since there is not much experience with tumors in Proteus syndrome we believe that this case can aid in shedding light on this subject.

Advanced embryonal rhabdomyosarcoma of the uterine cervix: a case report

BACKGROUND

Primary embryonal rhabdomyosarcoma (RMS) arising from the uterine cervix is a rare and extremely malignant entity. Young women aged 12-26 years are mostly affected. Before the introduction of effective adjuvant chemotherapy, the prognosis of these lesions was poor.

CASE

A 16-year-old girl presented with vaginal bleeding. The histological examination revealed embryonal RMS of the uterine cervix. The patient was treated with a combination of surgery, chemotherapy and radiotherapy. The patient was alive and free of disease five years after the operation.

CONCLUSION

A combined modality approach to treating RMS using surgery, multidrug chemotherapy, and radiotherapy has significantly improved survival. The medical community should keep in mind that embryonal RMS of the uterine cervix, despite its malignancy and rarity, can be cured if timely and adequate treatment is given.

[If heart failure or cardiac arrest complicate pregnancy and delivery]

Physiological adaptation to pregnancy exposes mother's cardiovascular system to relevant hemodynamic overload. These changes and other specific conditions of pregnancy, such as amniotic embolism, can point out unrecognized preexisting heart disease or, in the presence of some cofactors, be burdensome even for healthy hearts. Thus, tragic cases of heart failure or cardiac arrest may occur, whose management requires several considerations with respect of trying to save two lives at the same time, the need for drugs potentially harmful to the fetus, and assessment of emergent cesarean section.

Prognostic significance of topoisomerase II alpha and collagen IV immunoexpression in cervical cancer

OBJECTIVE

The immunohistochemical (IHC) expression of topoisomerase II alpha and collagen IV was studied in cervical cancer. The results of IHC expression for both markers were compared to the clinical and histological factors predicting the course of disease.

METHODS

In 114 patients with cervical cancer, treated at the Department of Gynecology and Obstetrics, University Medical Centre Ljubljana between 1995 and 1999, the tumor tissue was analyzed using standard IHC staining (IHS) procedures for topoisomerase II alpha and collagen IV. The obtained results were compared to those obtained by clinical, pathomorphological and morphometric prognostic factors, and the impact of the analyzed factors on the outcome of disease was assessed.

RESULTS

A high percentage of IHC expression of topoisomerase II alpha was present in 55.3%, and to collagen IV in 28.1% of cervical cancer patients. In the multivariate analysis the IHS intensity to collagen IV was significantly associated with lymphovascular invasion (OR = 5.906; 95% CI 2.18-15.96). Kaplan-Meier analysis showed a statistically significantly better survival in initial cervical cancer stages (p = 0.001), in tumors with a higher degree of differentiation (p = 0.049), more shallow depth of invasion (p = 0.004), smaller horizontal tumor spread (p = 0.001), in cases with no lymph node metastases (p = 0.001) and no lymphovascular space invasion (p = 0.001), in younger age groups (p = 0.001) and in women with regular menstrual cycles (p = 0.001).

CONCLUSION

IHC expression of topoisomerase II alpha and collagen IV was significantly correlated with defense reaction. A negative and weak IHC to collagen IV was a statistically significant independent predictive variable for lymphovascular invasion, related to metastatic spread in the lymph nodes. The two analyzed IHC markers indicate the existence of factors at the molecular level that might complement the assessment of cervical cancer prognosis, resulting in the appropriate choice of type and extent of treatment.

Choroidal melanoma metastasized to the ovary: case report and review of the literature

BACKGROUND

Malignant melanoma metastases to the female genital tract in only 2.5% of cases. Melanoma is characterized by clinical variability and unpredictable biological behavior with long remissions and relapses that develop rapidly.

CASE AND REVIEW

A 57-year-old woman was admitted for hypogastric pain and weight loss. She had presented enucleation of the right eye six years before for malignant choroid melanoma. Gynaecological examination revealed enlarged ovaries. Bilateral salpingo-oophorectomy, hysterectomy, and omentectomy were performed. Final pathology diagnosed a choroidal metastatic melanoma (CMM). The patient died seven months later. Only seven cases of CMM have been reported in the literature. Patients affected by CMM ranged in age from 38 to 83 years (median 51.2 years), the time to relapse ranged from 3-25 years (median 51.2 years), the size of the cysts ranged from 4-17 cm (median 9.7 cm) and the survival period ranged from 2-14 months (median 8.1 months).

CONCLUSION

Malignant melanoma is misdiagnosed because of lack of discriminatory symptoms, increased tumor markers, characteristic imaging findings and the capacity to mimic other tumors. Today CMM still represents a challenge for gynecologic oncologists.

Giant pelvic retroperitoneal liposarcoma: case report

BACKGROUND

Pelvic retroperitoneal liposarcomas are rare tumors of mesenchymal origin. We present a case of a giant pelvic well-differentiated liposarcoma of the retroperitoneum in a woman, presenting with a large abdominal mass.

CASE

A 62-year-old woman presented with a rapid abdominal enlargement. Pelvic examination revealed a huge mass occupying the whole pelvis and part of the right abdomen. At surgery, the pelvic organs were displaced to the right side by a retroperitoneal mass that marginally involved the part of the posterior abdominal wall, left parietal peritoneum of the diaphragm, left colic flexure and the left adnexa. The huge mass, uterus, and both adnexa were removed; hemicolectomy and latero-lateral anastomosis were carried out. No adjuvant irradiation was given. The patient is alive and free of disease five years after the operation.

CONCLUSION

The gynecologist should consider retroperitoneal liposarcoma in the differential diagnosis of large pelvic or abdominal masses.

Amelanotic malignant melanoma of the uterine cervix with ten-year follow-up

BACKGROUND

Malignant melanoma (MM) accounts for 3% of cancers that affect women and results in less than 1% of cancer deaths. It is characterized by clinical variability and unpredictable biological behavior. Fewer than ten cases of amelanotic MM (AMM) have been reported in literature.

CASE

A 61-year-old woman was admitted for vaginal spotting. A huge, soft cervix with an exophytic lesion was biopsied. A clear cell carcinoma, FIGO Stage IB1, was diagnosed and radically treated. The final pathology showed an AMM of the cervix positive for PAS and HMB 45. The patient is clinically free of disease ten years postoperatively.

CONCLUSION

Malignant melanoma of the cervix is often misdiagnosed because of non discriminatory features and the capacity to mimic other tumors. Malignant melanoma of the cervix needs to be diagnosed as quickly as possible because a timely therapy and a long and careful follow-up might result in better survival.

Clinical audit of patients with cervical cancer in Slovenia. Data analysis from 2003-2006

PURPOSE OF INVESTIGATION

From 2003 to 2006 the data on Slovenian cervical cancer patients who regularly attended a gynecologist were gathered. Data were analyzed in order to improve the efficiency of the cervical cancer screening program.

METHODS

Data on all patients newly diagnosed with cervical cancer were collected at three central clinics in Slovenia. The results are a presentation and comparison of detailed information on some characteristics of cervical cancer patients of the group that regularly visited a gynecologist and of the other group who did not. Data were processed by descriptive epidemiological methods. Mantel-Haenzel chi2 and Fisher's p tests were used to evaluate statistical significance.

RESULTS

On average, 55% of patients with cervical cancer underwent a gynecological examination five years before the diagnosis. The patients who regularly attended their gynecologist were, in all age groups, statistically significantly younger, the stage of cervical cancer at diagnosis was statistically significantly lower (p = 0.01) and were, in statistically significantly higher percentage, treated surgically (p < 0.01). From 2003 to 2006, each patient had on average five examinations at her gynecologist within the period of five years to six months before the diagnosis of cervical cancer. The average number of collected smear samples was 3.2.

CONCLUSION

From the results of our analysis, it may be concluded that improvements are needed in Slovenia in the field of screening for and early detection of cervical cancer.

Syncope in a patient presenting to the emergency room with chest pain, shock, and neurological disorders

Transient left ventricular dysfunction associated with apical ballooning at echocardiography or angiography has been described in many overlapping clinical settings: neurological disorders, such as subarachnoid haemorrhage and stroke, pheochromocytoma, and the recent takotsubo syndrome. We describe the case of an elderly woman presenting with syncope, chest pain, electrocardiographic abnormalities, mild enzymatic release, and transient left ventricular apical ballooning, mimicking an anterior wall acute coronary syndrome with shock, following a subarachnoid haemorrhage that could not be detected upon admission.The pathophysiological mechanisms of myocardial damage during catecholamine surge cannot be completely explained by epicardial coronary vasoconstriction or microvascular spasm and subsequent ischaemia; also direct catecholamine-mediated myocyte injury may play a role in myocardial stunning.

Efficiency of three surgical procedures in eliminating high-risk human papillomavirus infection in women with precancerous cervical lesions

PURPOSE OF INVESTIGATION

To establish the efficiency of laser vaporization (LV), large loop excision of the transformation zone (LLETZ) and cold knife conization, done for precancerous cervical lesions, in eliminating high-risk human papillomavirus (HPV) infection. Additionally, we determined whether the same HPV genotype persisted after surgery.

METHODS

A total of 214 women were tested for HPV infection by the Hybrid Capture II (HCII) test prior to surgery. HPV-positive women were followed by HCII test ten months after surgery. In persistently HPV-positive women, HPV genotypes were determined by PCR - PGMY09/PGMY11.

RESULTS

The HCII test showed elimination of HPV infection after LV, LLETZ and cold knife conization in 67.6%, 86.3%, and 100% (p < 0.05) of women, respectively. In seven (38.9%) women a different HPV genotype was found to be present after surgery, the corrected efficiency thus being 79.4%, 92.7% and 100% (p = NS), respectively.

CONCLUSIONS

The three analyzed surgical procedures are effective in eliminating high-risk HPV infection. HPV testing is useful at follow-up, since it can identify a small proportion of women requiring close surveillance and potential treatment.