Publications by authors named "Elena Pasotti"

49 Publications

[Sex and gender medicine: the foundation of gender medicine].

G Ital Cardiol (Rome) 2020 Aug;21(8):602-606

Centro Studi ANMCO, Fondazione per il Tuo cuore, Firenze.

"Sex and gender medicine" is the original name of gender medicine. It is important to define medical concepts without ignoring key terminology. The purpose of "sex and gender medicine" is to focus on both sex and gender differences, to analyze how these two sides of the human being overlap and, finally, to improve their medical understanding. On the one hand sex, besides defining male and female, refers to the biological differences among humans, animals, tissues and cells. On the other, the concept of gender is applicable only to humans, and includes identity, roles and relations in the society. However, despite its 20 years of history, gender medicine is still little known. Biological differences among cardiovascular diseases are ignored. Symptoms and their expressions, which may be different in women, are often described as "atypical" because of the masculine vision of the heart attack and pain. Similarly, anxious syndrome is often conceived as the first reason to explain chest discomfort in women. In reality, prejudices and vagueness around women still dominate prevention and medical treatment. Our objective is to distinguish the concepts of sex and gender in order to understand the best way to face differences and medical knowledge in both.
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http://dx.doi.org/10.1714/3405.33894DOI Listing
August 2020

A patient-centered multidisciplinary cardiac rehabilitation program improves glycemic control and functional outcome in coronary artery disease after percutaneous and surgical revascularization.

Cardiol J 2020 Feb 10. Epub 2020 Feb 10.

Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland.

Background: Cardiac rehabilitation (CR) is strongly associated with all-cause mortality reduction in patients with coronary artery disease (CAD). The impact of CR on pathological risk factors, such as impaired glucose tolerance (IGT), and functional recovery remains under debate. The aim of the present study is to determine whether CR has a positive effect on physical exercise improvement and on pathological risk factors in IGT and diabetic patients with CAD.

Methods: One hundred and seventy-one consecutive patients participating in a 3-month CR from January 2014 to June 2015 were enrolled. The primary endpoint was defined as an improvement of peak workload and VO2-peak; glycated hemoglobin (HbA1c) reduction was considered as a secondary endpoint.

Results: Euglycemic patients presented a significant improvement in peak workload compared to diabetic patients (from 5.75 ± 1.45 to 6.65 ± 1.84 METs, p = 0.018 vs. 4.8 ± 0.8 to 4.9 ± 1.4 METs). VO2-peak improved in euglycemic patients (VO2-peak from 19.3 ± 5.3 mL/min/kg to 22.5 ± 5.9, p = 0.003), while diabetic patients did not present a statistically significant trend (VO2-peak from 16.9 ± 4.4 mL/min/kg to 18.0 ± 3.8, p < 0.056). Diabetic patients have benefited more in terms of blood glucose control compared to IGT patients (HbA1c from 7.7 ± 1.0 to 7.4 ± 1.1 compared to 5.6 ± 0.4 to 5.9 ± 0.5, p = 0.02, respectively).

Conclusions: A multidisciplinary CR program improves physical functional capacity in CAD setting, particularly in euglycemic patients. IGT patients as well as diabetic patients may benefit from a CR program, but long-term outcome needs to be clarified in larger studies.
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http://dx.doi.org/10.5603/CJ.a2020.0006DOI Listing
February 2020

Post procedural risk assessment in patients undergoing trans aortic valve implantation according to the age, creatinine, and ejection fraction-7 score: Advantages of age, creatinine, and ejection fraction-7 in stratification of post-procedural outcome.

Catheter Cardiovasc Interv 2019 01 30;93(1):141-148. Epub 2018 Sep 30.

University Heart Center, University Hospital, Zurich, Switzerland.

Background: Post-procedural risk stratification based on renal function after trans aortic valve implantation (TAVI) was assessed by means of a modified age, creatinine, and ejection fraction (ACEF) score using the lowest glomerular filtration rate (GFR), obtained within 1 week after valve implantation. We refer to the score as ACEF-7 score.

Methods: The Zurich- and Cardiocentro Ticino TAVI-Cohorts comprised of 424, and 137 patients, who were not on hemodialysis and had already survived the first post-procedural week. Zurich patients were stratified into tertiles of ACEF-7 score (ACEF-7 ≤ 2.45 (n = 138), ACEF-7 2.46-4.38 (n = 142), and ACEF-7 ≥ 4.39 (n = 144) and compared for survival using KM curves. Euroscore II, Society of Thoracic Surgeons (STS), and ACEF were also calculated at baseline in all patients and assessed for prognostic significance in predicting the primary outcome of 1-year all-cause mortality using univariate and multivariate Cox regression models. Results were then confirmed in the Cardiocentro cohort.

Results: Six months (18.1% vs. 6.3% vs. 2.9% P < 0.001) and 1-year all-cause mortality (24.3% vs. 12.7% % vs. 5.8%, P < 0.001), as well as the composite of death or rehospitalization (35% vs. 20% vs. 11% P < 0.001) occurred significantly more frequently in the ACEF-7 compared to the other groups. Both Euroscore II and STS score were not predictors of mortality in our cohort. In a multivariate Cox regression model corrected for gender, Acute Kidney Injury, and baseline ACEF score, the ACEF-7 score was an independent predictor of 1-year all-cause mortality as a per point increment HR 1.512 [95% CI 1.227-1.862, P < 0.001] and as ACEF-7 (≥4.39); HR 5.541 [1.694-18.120]). In addition, the ACEF-7 tertiles showed a significant (P = 0.02) net reclassification improvement of 16% when compared to baseline tertiles of ACEF score, when assessing 1-year all-cause mortality.

Conclusion: Post-procedural risk stratification using the simple ACEF-7 score significantly better predicted long-term outcome than commonly used risk-scores. Practical implications could include contrast sparing and renal protection in high-risk patients, emphasizing the importance of preventative measures.
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http://dx.doi.org/10.1002/ccd.27806DOI Listing
January 2019

Radiological exposure of patients undergoing transcatheter aortic valve implantation in contemporary practice.

J Cardiovasc Med (Hagerstown) 2018 Oct;19(10):579-585

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Radiological exposure associated with transcatheter aortic valve implantation (TAVI) is unknown and might impact on broadening indications to lower risk patients. Radiological exposure of TAVI patients and its predictors are herein reported.

Methods: Radiological exposure derived from exams/procedures performed within 30 days preceding/following TAVI were acquired and converted into effective-dose. Total effective-dose was defined as the sum of each single dose derived from diagnostic/therapeutic sources. Univariable and multivariable analyses were performed to recognize correlates of exposure.

Results: Seventy-five patients aged 82.6 ± 6.0 years with a median Euroscore II 3.6 [IQR 1.93-6.65] were analysed. Median total effective-dose was 41.39 mSv [IQR 27.93-60.88], with TAVI accounting for 47% of it. Age (coefficient -0.031, 95% CI -0.060 to -0.002; P = 0.031) and previous history of cerebrovascular accidents (CVA; coefficient -0.545; 95% CI -1.039 to -0.010; P = 0.046) resulted as inversely correlated to total effective-dose (log-transformed), whereas left ventricular ejection fraction (LVEF) less than 50% (coefficient 0.430, 95% CI 0.031-0.828; P = 0.035) was directly associated.

Conclusion: Multiple radiological sources are responsible for the observed exposure, with TAVI being the prominent source. Age is inversely related to the radiological exposure.
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http://dx.doi.org/10.2459/JCM.0000000000000692DOI Listing
October 2018

Echocardiographic-fluoroscopic fusion imaging for transcatheter mitral valve repair guidance.

Eur Heart J Cardiovasc Imaging 2018 07;19(7):715-726

University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.

The echocardiographic-fluoroscopic fusion imaging is a new imaging system which has recently become available, with the proposal to facilitate catheters and device navigation during catheter-based structural heart disease interventions. Several reports have described the early developments and the first clinical experiences, but literature focusing on the practical applications of fusion imaging technology to mitral valve transcatheter interventions, and on its potential advantages and current limitations, is still limited. In this review, we, therefore, describe the role of this novel imaging system during Mitraclip, Cardioband, and paravalvular leak closure interventions. The technical principles and the fluoroscopic anatomy of the interatrial septum and mitral valve are also described.
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http://dx.doi.org/10.1093/ehjci/jey067DOI Listing
July 2018

[Inhibitors of PCSK9].

Rev Med Suisse 2017 Apr;13(558):821-825

Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano.

Observational data show a consistent association between elevated low density lipoproteins (LDL-C) and cardiovascular disease (CVD). Reduction of LDL-C reduces the risk of CVD as has been shown by many trials. Statins are currently the most effective drugs for lowering LDL-C, but can present side effects which might limit the prescribed dosage and prevent patients from reaching the recommended LDL levels. Although treated with statins important residual cardiovascular event risk remains in patients in primary and secondary prevention for CVD. The discovery of protein convertase subtilisin kexin 9 antibodies is a very promising new hypolipidemic treatment and the aim of this review is to explain their mechanism of action and to discuss safety and efficacy results of some phase III studies.
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April 2017

Echocardiographic-Fluoroscopic Fusion Imaging in Transseptal Puncture: A New Technology for an Old Procedure.

J Am Soc Echocardiogr 2017 Sep 7;30(9):886-895. Epub 2017 Jun 7.

King's College Hospital, London, United Kingdom.

In an era of catheter-based structural heart disease and left-side electrophysiologic interventions, transseptal puncture (TSP) is probably the most common transcatheter procedure. Experienced interventional cardiologists and electrophysiologists may safely perform TSP using fluoroscopic guidance alone. However, at present TSP is usually the first step in complex percutaneous catheter-based structural heart disease procedures and necessitate a precise site-specific TSP. Thus, in these procedures most interventional cardiologists perform TSP under fluoroscopic and two- or three-dimensional transesophageal echocardiographic guidance. The EchoNavigator system may provide a solution by fusing fluoroscopic and transesophageal echocardiographic images. In this review, the authors describe advantages and limitations of this new imaging system in guiding TSP and suggest specific echocardiographic-fluoroscopic fusion imaging perspectives that may facilitate TSP, making it potentially easier and safer.
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http://dx.doi.org/10.1016/j.echo.2017.05.001DOI Listing
September 2017

Evaluation of a protocol for same-day discharge after radial lounge monitoring in a southern Swiss referral percutaneous coronary intervention centre.

J Cardiovasc Med (Hagerstown) 2017 Aug;18(8):590-595

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Aims: The aim of the study was to retrospectively evaluate safety and patient satisfaction of same-day discharge after elective radial coronary angiography/percutaneous coronary intervention (PCI) after the implementation of a radial lounge facility.

Methods: All patients admitted to our radial lounge with a planned same-day discharge after an uncomplicated coronary angiography/PCI, having a co-living caregiver, were day enrolled in the study. Rates of same-day discharge, unplanned overnight stay, and in-hospital and first complications [death, myocardial infarction (MI), unplanned coronary angiography, access site hematoma, bleedings requiring hospitalization] were analysed; satisfaction was also evaluated through a questionnaire.

Results: From February 2015 to January 2016, 312 patients with a mean age of 66.6 ± 10.8 years were admitted to the radial lounge (coronary angiography, n = 232; PCIs, n = 80). Of them, 245 (78.5%) were discharged the same day. Mean radial lounge monitoring was 6:35 h (interquartile range 5:30-7:30 h). No episodes of death/MI/unplanned coronary angiography were observed both in same-day discharged and postponed patients. Reasons to postpone discharge were: PCI deemed to need prolonged monitoring in 31, patient's preference in 14, femoral shift in 13, surgery in four, chest pain in four, and bleeding in one. At day 1, 11 access site hematoma and one hospitalization for access site bleeding were reported. Patients reported complete satisfaction in 97% of cases. Unplanned overnight stay was common among PCIs patients (RR 6.2, 95% CI 3.9-9.9, P < 0.001).

Conclusion: A low rate of minor complications was observed in elective radial coronary angiography and PCIs showing the feasibility and safety of the development of an institutional protocol for same-day discharge after the implementation of a radial lounge facility.
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http://dx.doi.org/10.2459/JCM.0000000000000519DOI Listing
August 2017

Prevention of Contrast-Induced Acute Kidney Injury by Furosemide With Matched Hydration in Patients Undergoing Interventional Procedures: A Systematic Review and Meta-Analysis of Randomized Trials.

JACC Cardiovasc Interv 2017 02;10(4):355-363

Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland. Electronic address:

Objectives: The objective of this meta-analysis of randomized trials was to evaluate if the administration of furosemide with matched hydration using the RenalGuard System reduces contrast-induced acute kidney injury (CI-AKI) in patients undergoing interventional procedures.

Background: CI-AKI is a serious complication following angiographic procedures and a powerful predictor of unfavorable early and long-term outcomes.

Methods: Online databases were searched up to October 1, 2016, for randomized controlled trials. The primary outcome was the incidence of CI-AKI, and the secondary outcomes were need for renal replacement therapy, mortality, stroke, and adverse events.

Results: A total of four trials (n = 698) published between 2011 and 2016 were included in the analysis and included patients undergoing percutaneous coronary procedures and transcatheter aortic valve replacement. RenalGuard therapy was associated with a lower incidence of CI-AKI compared with control treatment (27 of 348 [7.76%] patients vs. 75 of 350 [21.43%] patients; odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.19 to 0.50; I = 4%; p < 0.00001) and with a lower need for renal replacement therapy (2 of 346 [0.58%] patients vs. 12 of 348 [3.45%] patients; OR: 0.19; 95% CI: 0.05 to 0.76; I = 0%; p = 0.02). No major adverse events occurred in patients undergoing RenalGuard therapy.

Conclusions: The main finding of this meta-analysis is that furosemide with matched hydration by the RenalGuard System may reduce the incidence of CI-AKI in high-risk patients undergoing percutaneous coronary intervention or transcatheter aortic valve replacement. However, further independent high-quality randomized trials should elucidate the effectiveness and safety of this prophylactic intervention in interventional cardiology.
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http://dx.doi.org/10.1016/j.jcin.2016.11.006DOI Listing
February 2017

Echocardiography-X-Ray Image Fusion.

JACC Cardiovasc Imaging 2016 09 25;9(9):1114-1117. Epub 2016 May 25.

Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

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http://dx.doi.org/10.1016/j.jcmg.2015.09.022DOI Listing
September 2016

Predictors of disagreement between prospectively ECG-triggered dual-source coronary computed tomography angiography and conventional coronary angiography.

Eur J Radiol 2016 Jun 22;85(6):1138-46. Epub 2016 Mar 22.

Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland. Electronic address:

Aims: To identify causes of misinterpretation in second generation, dual-source coronary computed tomography angiography (CCTA).

Methods: A retrospective re-interpretation was performed on 100 consecutive CCTA studies, previously performed with a 2×128 slice dual-source CT. Results were compared with coronary angiography (CA). CCTA and CA images were interpreted by 2 independent readers. At CCTA vessel diameter, image quality, plaque characteristics and localization (bifurcation vs. non) were described for all segments. Finally, aortic contrast-to-noise ratio (CNR) and the total Agatston calcium score were quantified. Agreement between CCTA and CA was assessed with the Kappa statistic after categorizing the stenosis severity at significant (≥50%) and critical (≥70%) cut-offs, and independent predictors of disagreement were determined by multivariable logistic regression, including patient characteristics such as body mass index (BMI), heart rate (HR), age and gender.

Results: Per-segment sensitivity and specificity at ≥50% and ≥70% stenosis was of 83-95%, and 73-97%, respectively. There was a substantial agreement between CCTA and CA (kappa-50%=0.78, SE=0.03; kappa-70%=0.72, SE=0.03). Worse motion-related quality score, smaller vessel diameter, calcification within the segment of interest and LAD location were independent predictors of disagreement at 50% stenosis. The same factors, excluded LAD location, in addition to bifurcation-location of the coronary lesion predicted misdiagnosis at 70% stenosis. HR per se and BMI did not predict disagreement.

Conclusion: According to the literature a substantial agreement between CCTA and CA was found. However, discrepancies exist and are mainly related with motion-related degradation of image quality, specific vessel anatomy and plaque characteristics. Awareness of such potential limitations may help guiding interpretation of CCTA.
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http://dx.doi.org/10.1016/j.ejrad.2016.03.021DOI Listing
June 2016

Combined Left Atrial Appendage Closure and Pacemaker Implant through a Single Right Femoral Vein Access.

Pacing Clin Electrophysiol 2016 Aug 13;39(8):900-2. Epub 2016 Apr 13.

Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Left atrial appendage (LAA) closure is indicated in patients with atrial fibrillation (AF) and high bleeding as well as thromboembolic risks. A subgroup of these patients may also present an indication for a single-chamber permanent pacemaker due to symptomatic low-rate AF or when "ablate and pace" strategy is indicated for rate control. A miniaturized wireless transcatheter pacing system (TPS) is now available as a single-chamber permanent pacemaker. This case presents how combined LAA closure and permanent pacemaker implant, by means of TPS, is feasible through a single femoral venous access.
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http://dx.doi.org/10.1111/pace.12849DOI Listing
August 2016

PCSK9 inhibitors: an overview on a new promising lipid-lowering therapy.

J Cardiovasc Med (Hagerstown) 2016 Apr;17(4):237-44

Cardiocentro Ticino, Lugano, Switzerland.

Atherosclerosis is characterized by cholesterol deposition in the arterial intima, with subsequent plaque formation and arterial disease. Low-density lipoprotein cholesterol (LDL-C) plays the most important role in the atherogenesis process, which is the substrate of cardiovascular disease and is the leading cause of death worldwide. Several studies show that a strict control of risk factors, particularly the reduction of LDL-C levels, is a cornerstone in primary and secondary prevention of coronary heart disease. Statins are currently the most effective drugs for lowering LDL-C, but the discovery of proprotein convertase subtilisin kexin 9 (PCSK9) has opened up new therapeutic options in lipid management. PCSK9 reduces LDL-receptors' recycling resulting in a decrease of LDL-C receptors on the surface of hepatocytes and an increase of LDL-C levels in plasma. Obviously, inhibition of PCSK9 has been associated with an increase of LDL-C receptors with subsequent lowering of plasma levels of LDL-C. The clinical development of monoclonal antibodies against PCSK9 has been achieved through phase I and II studies, and nowadays there are many ongoing phase III trials with promising preliminary results. The aim of this review is to update the evidence for PCSK9 monoclonal antibodies, such as evolocumab, alirocumab and bococizumab, in LDL-C management and to discuss their therapeutic perspectives based on the most recent clinical studies, with attention to side-effects.
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http://dx.doi.org/10.2459/JCM.0000000000000360DOI Listing
April 2016

Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man.

Circulation 2015 Dec;132(24):e377-9

From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.115.017630DOI Listing
December 2015

Cardiac Remodeling, Circulating Biomarkers and Clinical Events in Patients with a History of Atrial Fibrillation. Data from the GISSI-AF Trial.

Cardiovasc Drugs Ther 2015 Dec;29(6):551-561

IRCCS-Istituto di Ricerche Farmacologiche "MarioNegri", Via Giuseppe La Masa, 19, 20156, Milan, Italy.

Purpose: Atrial fibrillation (AF) is the most common arrhythmia and has an increasing impact on public health because of its morbidity and mortality. Clinical and diagnostic tests to predict the recurrence of arrhythmia and clinical events before AF becomes permanent are still an open issue.

Methods: 307 out of 1442 patients in sinus rhythm, at high risk of recurrence of AF enrolled in the GISSI-AF study, participated in a substudy with echocardiographic and biohumoral evaluation at baseline and at 12-month follow-up. The relations between biomarker concentrations and echocardiographic parameters with study endpoints in 1 year, were analysed by a stepwise multivariable Cox model (entry criteria p < 0.5 and stay criteria p < 0.2).

Results: The echocardiographic variables, cardiac markers and clinical variables considered in the statistical model indicated a higher concentration of NT-proBNP at baseline as the strongest factor related to time of first AF recurrence (HR 1.42; 95 %CI 1.23-1.46), first CV hospitalization (HR 1.58; 95 %CI 1.31-1.92) and increasing duration of recurrent AF (OR 2.16; 95 %CI 1.52-3.08). Valsartan treatment was not related to clinical events.

Conclusions: In patients in sinus rhythm with a history of AF a higher concentration of NT-proBNP at baseline was the strongest independent risk factor for first AF recurrence and its duration, and for the first hospital admission for cardiovascular reasons.
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http://dx.doi.org/10.1007/s10557-015-6624-3DOI Listing
December 2015

[The emerging role of three-dimensional transesophageal echocardiography in guiding the MitraClip procedure].

G Ital Cardiol (Rome) 2015 Oct;16(10):549-54

Fondazione Cardiocentro Ticino, Lugano, Svizzera.

Percutaneous edge-to-edge mitral valve repair with the MitraClip device has been shown to be a safe and effective procedure in selected patients with moderate-to-severe mitral regurgitation. Two-dimensional transesophageal echocardiography (2D TEE) is the primary imaging modality for guidance of the procedure. Real-time three-dimensional (3D) TEE has recently been used as additional imaging modality during the MitraClip procedure. In comparison with 2D TEE, 3D TEE provides additional information in several steps of the procedure, including precise positioning of the clip delivery system into the left atrium, correct alignment of the clip arms perpendicular to the coaptation line and confirmation of the correct grasping location. This review describes the relevant role of 3D TEE imaging during the procedure, but also its limitations.
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http://dx.doi.org/10.1714/2028.22038DOI Listing
October 2015

Tako-tsubo cardiomyopathy, acute coronary syndrome, or both?

Eur Heart J 2018 01;39(2):178

Cardiocentro Ticino, Lugano, Switzerland.

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http://dx.doi.org/10.1093/eurheartj/ehv127DOI Listing
January 2018

Three-dimensional transesophageal echocardiography in degenerative mitral regurgitation.

J Am Soc Echocardiogr 2015 Apr 14;28(4):437-48. Epub 2015 Feb 14.

Dipartimento di Cardiologia, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

The morphology of mitral valve (MV) prolapse and flail may be extremely variable, with dominant and secondary dynamic lesions. Any pathologic valve appears unique and different from any other. Three-dimensional (3D) transesophageal echocardiography is a powerful tool to evaluate the geometry, dynamics, and function of the MV apparatus and may be of enormous value in helping surgeons perform valve repair procedures. Indeed, in contrast to the surgical view, 3D transesophageal echocardiography can visualize MV prolapse and flail in motion and from different perspectives. The purpose of this special article is not to provide a comprehensive review of degenerative MV disease but rather to illustrate different types of mitral prolapse and flail as they appear from multiple 3D transesophageal echocardiographic perspectives using a series of clinical scenarios. Because in everyday practice, 3D transesophageal echocardiographic images of MV prolapse and flail are usually observed in motion, each scenario is accompanied by several videos. Finally, the authors provide for each scenario a brief description of the surgical techniques that are usually performed at their institution.
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http://dx.doi.org/10.1016/j.echo.2015.01.006DOI Listing
April 2015

Comparison of clinical and angiographic prognostic risk scores in elderly patients presenting with acute coronary syndrome and referred for percutaneous coronary intervention.

Swiss Med Wkly 2015 6;145:w14049. Epub 2015 Feb 6.

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly.

Methods: We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission. Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC).

Results: Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4-48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4-64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4-63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3-37; p <0.001; AUC = 0.77).

Conclusions: In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination.
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http://dx.doi.org/10.4414/smw.2015.14049DOI Listing
September 2015

Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

Open Heart 2014;1(1):e000056. Epub 2014 Apr 8.

Cantonal Hospital Lucerne , Lucerne , Switzerland ; University Hospital Zurich , Zurich , Switzerland.

Objective: Analyse 2-year outcomes after MitraClip therapy and identify predictors of outcome.

Methods: Consecutive patients (n=74) undergoing MitraClip therapy were included in the MitraSWISS registry and followed prospectively.

Results: A reduction of mitral regurgitation (MR) to ≤ mild was achieved in 32 (43%) patients and to moderate in 31 (42%) patients; 16/63 (25%) patients with initially successful treatment developed recurrent moderate to severe or severe MR during the first year and only 1 patient did so during the second year. At 2 years, moderate or less MR was more frequently present in patients with a transmitral mean gradient <3 mm Hg at baseline (73% vs 23%, p < 0.01) and in patients with a left atrial volume index (LAVI) <50 mL/m(2) at baseline (86% vs 52%, p=0.03). More than mild MR post MitraClip, N-terminal probrain natriuretic peptide ≥5000 ng/L at baseline, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were associated with reduced survival.

Conclusions: A mean transmitral gradient <3 mm Hg at baseline, an LAVI <50 mL/m(2), the absence of COPD and CKD, and reduction of MR to less than moderate were associated with favourable outcome. Given a suitable anatomy, such patients may be excellent candidates for MitraClip therapy. Between 1 and 2 years follow-up, clinical and echocardiographic outcomes were stable, suggesting favourable, long-term durability of the device.
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http://dx.doi.org/10.1136/openhrt-2014-000056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195933PMC
October 2014

Clinical utility of routine use of continuous transesophageal echocardiography monitoring during transvenous lead extraction procedure.

Heart Rhythm 2015 Feb 13;12(2):313-20. Epub 2014 Oct 13.

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Data on the use of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) procedures are scarce.

Objective: The purpose of this study was to assess the routine use of TEE during transvenous lead extraction.

Methods: From January 2009 to January 2014, TLE of 241 leads in 168 patients (mean age 70 ± 13 years, 129 male, left ventricular ejection fraction 37% ± 13%) was performed. Indication for TLE was lead dysfunction (56.5%), upgrade (27.0%), infection (13%), or other (3.1%). TLE techniques combined a mechanical approach amended by laser technique if required. Extraction procedures were performed with patients under general anesthesia with continuous invasive arterial blood pressure and TEE monitoring.

Results: TEE was possible in all except 1 patient. TEE images in different projections were acquired and stored before and immediately after extraction of each lead. TLE was complete for 236 of 241 leads (97.9%); 4 distal lead tips (1.7%) remained in situ, and 1 dual-coil implantable cardioverter-defibrillator electrode (0.4%) could not be removed. New TEE findings after TLE were observed in 7 of 161 cases (4.3%): pericardial effusion (mild in 4 [2.5%] and severe in 1 [0.6%]) and worsening of tricuspid valve insufficiency (2 patients [1.2%]). The only case of severe pericardial effusion occurred after laceration of the superior vena cava, which required immediate rescue surgery (0.6%, confidence interval 0.01-3.3). In all other cases, TEE findings did not entail immediate diagnostic or therapeutic measures.

Conclusion: New TEE findings produced during TLE necessitating immediate therapeutic measures occurred in only 0.6% of cases, suggesting the limited utility of routine continuous TEE monitoring during TLE.
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http://dx.doi.org/10.1016/j.hrthm.2014.10.013DOI Listing
February 2015

3D TEE during catheter-based interventions.

JACC Cardiovasc Imaging 2014 Mar;7(3):292-308

Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland.

Guidance of catheter-based procedures is performed using fluoroscopy and 2-dimensional transesophageal echocardiography (TEE). Both of these imaging modalities have significant limitations. Because of its 3-dimensional (3D) nature, 3D TEE allows visualizing the entire scenario in which catheter-based procedures take place (including long segments of catheters, tips, and the devices) in a single 3D view. Despite these undeniable advantages, 3D TEE has not yet gained wide acceptance among most interventional cardiologists and echocardiographists. One reason for this reluctance is probably the absence of standardized approaches for obtaining 3D perspectives that provide the most comprehensive information for any single step of any specific procedure. Therefore, the purpose of this review is to describe what we believe to be the most useful 3D perspectives in the following catheter-based percutaneous interventions: transseptal puncture; patent foramen ovale/atrial septal defect closure; left atrial appendage occlusion; mitral valve repair; and closure of paravalvular leaks.
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http://dx.doi.org/10.1016/j.jcmg.2013.10.012DOI Listing
March 2014

Personality traits, cardiac risk factors, and their association with presence and severity of coronary artery plaque in people with no history of cardiovascular disease.

J Cardiovasc Med (Hagerstown) 2014 May;15(5):423-30

aHuman Factors and Technologies in Health Care Centre, University of Bergamo, Bergamo, Italy bCentre of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, the Netherlands cDivision of Cardiology, Cardiocentro Lugano, Lugano, Switzerland dVilla Santa Maria Institute, Tavernerio, Italy.

Background: Coronary artery disease (CAD) is a multifactorial complex disease. The aim of the present study is to verify whether the personality traits in CAD are associated with coronary artery plaque (CAP) presence and severity in people with no history of cardiovascular disease.

Design: A cross-sectional monocenter study.

Methods: Seventy five individuals with no history of CAD underwent 64-slice computed tomography coronary angiography (CTCA) and were screened for traditional cardiac risk factors and for hostility, anger, and type D personality traits.

Results: In total, 48 patients (64%) had evidence of CAP, with mild (31%), moderate (33%), and severe (35%) coronary stenosis. Male sex, hypertension, being overweight, and number of cardiovascular risk factors increased the likelihood of CAP presence. Findings showed a significant difference between CAP presence vs. CAP absence for anger (26 vs. 30%, χ2 = 6.82) and type D personality (23 vs. 35%; χ2 = 8.23, P = 0.03), but not hostility (P > 0.05). Anger personality, and the type D subscale social inhibition, but not negative affectivity, were associated with an increased prevalence and severity of CAP. Univariate analysis confirms anger (odds ratio, OR = 1.38, 95% confidence interval, CI = 1.12-2.31), social inhibition (OR = 2.01, 95% CI = 1.81-2.93), 'negative affectivity by social inhibition' (OR = 1.24, 95% CI = 1.12-2.14), and type D personality (OR = 1.9, 95% CI = 1.11-2.03) as predictors of CAP presence. Moreover, multivariate analysis suggests social inhibition as also a unique CAP predictor (OR = 2.14, 95% CI = 1.89-2.96) after adjustment for having cardiac risk factors as a covariate.

Conclusion: The present data confirm the core role of traditional risk factors and suggest the primacy of social inhibition and anger personality traits in association with CAP presence and severity.
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http://dx.doi.org/10.2459/JCM.0b013e328365cd8cDOI Listing
May 2014

Combining personality traits with traditional risk factors for coronary stenosis: an artificial neural networks solution in patients with computed tomography detected coronary artery disease.

Cardiovasc Psychiatry Neurol 2013 3;2013:814967. Epub 2013 Oct 3.

University of Bergamo, Piazzale S. Agostino 2, P.O. Box 24129, Bergamo, Italy.

Background. Coronary artery disease (CAD) is a complex, multifactorial disease in which personality seems to play a role but with no definition in combination with other risk factors. Objective. To explore the nonlinear and simultaneous pathways between traditional and personality traits risk factors and coronary stenosis by Artificial Neural Networks (ANN) data mining analysis. Method. Seventy-five subjects were examined for traditional cardiac risk factors and personality traits. Analyses were based on a new data mining method using a particular artificial adaptive system, the autocontractive map (AutoCM). Results. Several traditional Cardiovascular Risk Factors (CRF) present significant relations with coronary artery plaque (CAP) presence or severity. Moreover, anger turns out to be the main factor of personality for CAP in connection with numbers of traditional risk factors. Hidden connection map showed that anger, hostility, and the Type D personality subscale social inhibition are the core factors related to the traditional cardiovascular risk factors (CRF) specifically by hypertension. Discussion. This study shows a nonlinear and simultaneous pathway between traditional risk factors and personality traits associated with coronary stenosis in CAD patients without history of cardiovascular disease. In particular, anger seems to be the main personality factor for CAP in addition to traditional risk factors.
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http://dx.doi.org/10.1155/2013/814967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3808723PMC
November 2013

Role of real-time three dimensional transoesophageal echocardiography as guidance imaging modality during catheter based edge-to-edge mitral valve repair.

Heart 2013 Aug 16;99(16):1204-15. Epub 2013 Feb 16.

Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland.

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http://dx.doi.org/10.1136/heartjnl-2012-302527DOI Listing
August 2013

Predictors for efficacy of percutaneous mitral valve repair using the MitraClip system: the results of the MitraSwiss registry.

Heart 2013 Jul 23;99(14):1034-40. Epub 2013 Jan 23.

Department of Cardiology, University Hospital Zurich, Zürich, Switzerland.

Background: Percutaneous mitral valve repair (MVR) using the MitraClip system has become a valid alternative for patients with severe mitral regurgitation (MR) and high operative risk.

Objective: To identify clinical and periprocedural factors that may have an impact on clinical outcome.

Design: Multi-centre longitudinal cohort study.

Setting: Tertiary referral centres.

Patients: Here we report on the first 100 consecutive patients treated with percutaneous MVR in Switzerland between March 2009 and April 2011. All of them had moderate-severe (3+) or severe (4+) MR, and 62% had functional MR. 82% of the patients were in New York Heart Association (NYHA) class III/IV, mean left ventricular ejection fraction was 48% and the median European System for Cardiac Operative Risk Evaluation was 16.9%.

Interventions: MitraClip implantation performed under echocardiographic and fluoroscopic guidance in general anaesthesia.

Main Outcome Measures: Clinical, echocardiographic and procedural data were prospectively collected.

Results: Acute procedural success (APS, defined as successful clip implantation with residual MR grade ≤2+) was achieved in 85% of patients. Overall survival at 6 and 12 months was 89.9% (95% CI 81.8 to 94.6) and 84.6% (95% CI 74.7 to 91.0), respectively. Univariate Cox regression analysis identified APS (p=0.0069) and discharge MR grade (p=0.03) as significant predictors of survival.

Conclusions: In our consecutive cohort of patients, APS was achieved in 85%. APS and residual discharge MR grade are important predictors of mid-term survival after percutaneous MVR.
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http://dx.doi.org/10.1136/heartjnl-2012-303105DOI Listing
July 2013

Sustained improvement in left ventricular function after bone marrow derived cell therapy in patients with acute ST elevation myocardial infarction. A 5-year follow-up from the Stem Cell Transplantation in Ischaemic Myocardium Study.

Swiss Med Wkly 2012 25;142:w13632. Epub 2012 Jul 25.

Fondazione Cardiocentro Ticino, Lugano, Switzerland.

Background: Intracoronary injection of autologous bone marrow-derived mononucleated cells (BM-MNC) may improve LV function shortly after acute ST elevation myocardial infarction (STEMI), but little is known about the long-term durability of the treatment effect.

Methods: In a single-centre trial a total of 60 patients with acute anterior STEMI, successful reperfusion therapy and a left ventricular ejection fraction (LVEF) of <50% were screened for the study. 23 patients were actively treated with intracoronary infusion of BM-MNC within a median of 3 days. The open-label control group consisted of 19 patients who did not consent to undergo BM-MNC treatment but agreed to undergo regular clinical and echocardiographic follow-up for up to 5 years after AMI.

Results: Whereas at 4 months there was no significant difference between the increase in LVEF in the BM-MNC group and the control group (+7.0%, 95%CI 3.6; 10.4) vs. +3.9%, 95%CI -2.1; 10), the absolute increase at 5 years remained stable in the BM-MNC but not in the control group (+7.95%, 95%CI 3.5; 12.4 vs. -0.5%, 95%CI -5.4; 4.4; p for interaction between groups = 0.035).

Discussion: In this single-centre, open-labelled study, intracoronary administration of BM-MNC is feasible and safe in the short term. It is also associated with sustained improvement of left ventricular function in patients with acute myocardial infarction, encouraging phase III studies to examine the potential BM-MNC effect on clinical outcome.
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http://dx.doi.org/10.4414/smw.2012.13632DOI Listing
January 2013

Side-by-side comparison of fluoroscopy, 2D and 3D TEE during percutaneous edge-to-edge mitral valve repair.

JACC Cardiovasc Imaging 2012 Jun;5(6):656-61

Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.

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http://dx.doi.org/10.1016/j.jcmg.2012.02.014DOI Listing
June 2012