Publications by authors named "Enrico Ammirati"

162 Publications

A Novel Artificial Urinary Sphincter (VICTO®) for the Management of Postprostatectomy Urinary Incontinence: Description of the Surgical Technique and Preliminary Results from a Multicenter Series.

Urol Int 2021 Feb 19:1-7. Epub 2021 Feb 19.

Department of Neuro-Urology, CTO-Spinal Cord Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy.

Aims: The objective of the study was to analyze short-term outcomes and safety profile of the newly designed artificial urinary sphincters (AUSs) VICTO® and VICTOplus®.

Methods: Data from the implant of VICTO® or VICTOplus® AUSs on a series of consecutive male patients with stress urinary incontinence (SUI) following radical prostatectomy (RP) were retrospectively collected in 3 tertiary referral centers between May 2017 and December 2019. Patients were affected by moderate-severe genuine SUI (200-400 or >400 g urine leakage in 24-h pad test) refractory to conservative treatment. Outcomes were evaluated through the 24-h pad test and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). Follow-up was scheduled after 3, 6, and 12 months and then when clinically needed. Nonparametric tests were applied in subgroup analyses.

Results: Seventeen patients were enrolled: 8 were implanted with the VICTO® device and 9 with VICTOplus®. The median age at surgery was 69 (interquartile range (IQR) 60-75) years. The median follow-up was 15 (IQR 12-18) months. At 12 months, the dry rate was 76.4% and the social continence rate was 94%. The postoperative complication rate was 17.6%. All complications were classified as Clavien-Dindo I. No difference in terms of outcomes was observed between the VICTO® and the VICTOplus® subgroups.

Conclusions: Preliminary outcomes of the VICTO® and VICTOplus® implantation are satisfactory. These devices may represent a safe and realistic solution for patients with moderate-severe SUI following RP.
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http://dx.doi.org/10.1159/000512722DOI Listing
February 2021

Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study.

J Am Coll Cardiol 2020 12;76(25):2982-3021

Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases.
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http://dx.doi.org/10.1016/j.jacc.2020.11.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755038PMC
December 2020

Association of White Matter Hyperintensities and Cardiovascular Disease: The Importance of Microcirculatory Disease.

Circ Cardiovasc Imaging 2020 Aug 28;13(8):e010460. Epub 2020 Jul 28.

Cardiothoracic and Vascular Department, Vita-Salute University and San Raffaele Hospital, Milan, Italy (F.M., P.G.C.).

Cardiac and cerebrovascular diseases are currently the leading causes of mortality and disability worldwide. Both the heart and brain display similar vascular anatomy, with large conduit arteries running on the surface of the organ providing tissue perfusion through an intricate network of penetrating small vessels. Both organs rely on fine tuning of local blood flow to match metabolic demand. Blood flow regulation requires adequate functioning of the microcirculation in both organs, with loss of microvascular function, termed small vessel disease (SVD) underlying different potential clinical manifestations. SVD in the heart, known as coronary microvascular dysfunction, can cause chronic or acute myocardial ischemia and may lead to development of heart failure. In the brain, cerebral SVD can cause an acute stroke syndrome known as lacunar stroke or more subtle pathological alterations of the brain parenchyma, which may eventually lead to neurological deficits or cognitive decline in the long term. Coronary microcirculation cannot be visualized in vivo in humans, and functional information can be deduced by measuring the coronary flow reserve. The diagnosis of cerebral SVD is largely based on brain magnetic resonance imaging, with white matter hyperintensities, microbleeds, and brain atrophy reflecting key structural changes. There is evidence that such structural changes reflect underlying cerebral SVD. Here, we review interactions between SVD and cardiovascular risk factors, and we discuss the evidence linking cerebral SVD with large vessel atheroma, atrial fibrillation, heart failure, and heart valve disease.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.010460DOI Listing
August 2020

[ANMCO/SIC Consensus document on the management of myocarditis].

G Ital Cardiol (Rome) 2020 Dec;21(12):969-989

S.C. Cardiologia, Dipartimento Cardiotoracovascolare, Azienda Sanitaria Universitaria Giuliano Isontina-ASUGI, Università di Trieste.

Myocarditis is an inflammatory heart disease that can occur acutely, as in acute myocarditis, or persistently, as in chronic myocarditis or chronic inflammatory cardiomyopathy. Different agents can induce myocarditis, with viruses being the most common triggers. Generally, acute myocarditis affects relatively young people and men more than women. Myocarditis has a broad spectrum of clinical presentations and evolution trajectories, although most cases resolve spontaneously. Patients with reduced left ventricular ejection fraction, heart failure symptoms, advanced atrioventricular block, sustained ventricular arrhythmias or cardiogenic shock (the latter known as fulminant myocarditis) are at increased risk for death and heart transplantation. The presentation of chronic inflammatory cardiomyopathy may be more subtle, with progressive symptoms of heart failure or appearance of rhythm disturbance, not rarely preceded by an infective episode. Autoimmune disorder or systemic inflammatory conditions can be another significant predisposing substrate of myocarditis, especially in women. Emerging causes of myocarditis are drug-related like the new anticancer therapies, the immune checkpoint inhibitors. In this Italian Association of Hospital Cardiologists (ANMCO) and Italian Society of Cardiology (SIC) expert consensus document on myocarditis, we propose diagnostic strategies for identifying possible causes of the disease and factors associated with increased risk. Finally, we propose potential treatments and when referring patients to tertiary centers, especially for high-risk patients. Even if endomyocardial biopsy is the invasive diagnostic tool for making definitive diagnosis and differentiation of histological subtypes (i.e., lymphocytic vs eosinophilic vs giant cell myocarditis), it is not always readily available in all centers. Thus, we propose when this exam is mandatory or when it can be postponed or substituted by cardiac magnetic resonance imaging. This document reflects the Italian perspective on managing patients with myocarditis and their follow-up, considering also current US and European scientific position statements.
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http://dx.doi.org/10.1714/3472.34551DOI Listing
December 2020

Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document.

Circ Heart Fail 2020 Nov 12;13(11):e007405. Epub 2020 Nov 12.

Vita Salute University and San Raffaele Hospital, Milano, Italy (P.G.C.).

Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673642PMC
November 2020

Management perspectives from the 2019 Wuhan international workshop on fulminant myocarditis.

Int J Cardiol 2021 02 26;324:131-138. Epub 2020 Oct 26.

Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. Electronic address:

Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested.
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http://dx.doi.org/10.1016/j.ijcard.2020.10.063DOI Listing
February 2021

Myocardial injury in COVID-19: When observations become reality.

Int J Cardiol 2021 01 26;323:295-296. Epub 2020 Oct 26.

De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy.

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http://dx.doi.org/10.1016/j.ijcard.2020.10.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586099PMC
January 2021

Myocarditis and inflammatory cardiomyopathy: current evidence and future directions.

Nat Rev Cardiol 2021 03 12;18(3):169-193. Epub 2020 Oct 12.

Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité - University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.

Inflammatory cardiomyopathy, characterized by inflammatory cell infiltration into the myocardium and a high risk of deteriorating cardiac function, has a heterogeneous aetiology. Inflammatory cardiomyopathy is predominantly mediated by viral infection, but can also be induced by bacterial, protozoal or fungal infections as well as a wide variety of toxic substances and drugs and systemic immune-mediated diseases. Despite extensive research, inflammatory cardiomyopathy complicated by left ventricular dysfunction, heart failure or arrhythmia is associated with a poor prognosis. At present, the reason why some patients recover without residual myocardial injury whereas others develop dilated cardiomyopathy is unclear. The relative roles of the pathogen, host genomics and environmental factors in disease progression and healing are still under discussion, including which viruses are active inducers and which are only bystanders. As a consequence, treatment strategies are not well established. In this Review, we summarize and evaluate the available evidence on the pathogenesis, diagnosis and treatment of myocarditis and inflammatory cardiomyopathy, with a special focus on virus-induced and virus-associated myocarditis. Furthermore, we identify knowledge gaps, appraise the available experimental models and propose future directions for the field. The current knowledge and open questions regarding the cardiovascular effects associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are also discussed. This Review is the result of scientific cooperation of members of the Heart Failure Association of the ESC, the Heart Failure Society of America and the Japanese Heart Failure Society.
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http://dx.doi.org/10.1038/s41569-020-00435-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548534PMC
March 2021

Outcome of patients on heart transplant list treated with a continuous-flow left ventricular assist device: Insights from the TRans-Atlantic registry on VAd and TrAnsplant (TRAViATA).

Int J Cardiol 2021 Feb 18;324:122-130. Epub 2020 Sep 18.

Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, CA, USA. Electronic address:

Background: Geographic variations in management and outcomes of individuals supported by continuous-flow left ventricular assist devices (CF-LVAD) between the United States (US) and Europe (EU) is largely unknown.

Methods: We created a retrospective, multinational registry of 524 patients who received a CF-LVAD (either HVAD or Heartmate II) between January 2008 and April 2017. Follow up spanned from date of CF-LVAD implant to post-HTx period with a median follow up of 44.8 months.

Results: The cohort included 299 (57.1%) EU and 225 (42.9%) US patients. Although the US cohort was significantly older with a higher prevalence of comorbidities, survival was similar between the cohorts (US 63.1%, EU 68.4% at 5 years, unadjusted log-rank test p = 0.43).Multivariate analyses suggested that older age, higher body mass index, elevated creatinine, use of temporary mechanical circulatory support prior CF-LVAD, and implantation of HVAD were associated with increased mortality. Among CF-LVAD patients undergoing HTx, the median time on CF-LVAD support was shorter in the US, meanwhile US donors were younger. Finally, the pattern of adverse events (stroke, gastrointestinal bleedings, late right ventricular failure, and driveline infection) during support differed significantly between US and EU.

Conclusions: Although waitlisted patients in the US on CF-LVAD have higher risk comorbid conditions, the overall outcome is similar in US and EU. Geographic variations with regards to donor characteristics, duration of CF-LVAD support prior to transplant, and adverse events on support can explain the disparity in the utilization of mechanical bridge to transplant strategy between US and EU.
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http://dx.doi.org/10.1016/j.ijcard.2020.09.026DOI Listing
February 2021

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence.

BJU Int 2020 Sep 15. Epub 2020 Sep 15.

Department of Urology, University Hospitals Leuven, Leuven, Belgium.

Objectives: To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

Patients And Methods: Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

Results: At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

Conclusions: Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.
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http://dx.doi.org/10.1111/bju.15242DOI Listing
September 2020

Extent and characteristics of carotid plaques and brain parenchymal loss in asymptomatic patients with no indication for revascularization.

Int J Cardiol Heart Vasc 2020 Oct 20;30:100619. Epub 2020 Aug 20.

Vita-Salute University and San Raffaele Hospital, Milan, Italy.

Background And Aims: Extent of subclinical atherosclerosis has been associated with brain parenchymal loss in community-dwelling aged subjects. Identification of patient-related and plaque-related markers could identify subjects at higher risk of brain atrophy, independent of cerebrovascular accidents. Aim of the study was to investigate the relation between extent and characteristics of carotid plaques and brain atrophy in asymptomatic patients with no indication for revascularization.

Methods And Results: Sixty-four patients (aged 69 ± 8 years, 45% females) with carotid stenosis <70% based on Doppler flow velocity were enrolled in the study. Potential causes of cerebral damage other than atherosclerosis, including history of atrial fibrillation, heart failure, previous cardiac or neurosurgery and neurological disorders were excluded. All subjects underwent carotid computed tomography angiography, contrast enhanced ultrasound for assessment of plaque neovascularization and brain magnetic resonance imaging for measuring brain volumes. On multivariate regression analysis, age and fibrocalcific plaques were independently associated with lower total brain volumes (β = -3.13 and β = -30.7, both p < 0.05). Fibrocalcific plaques were also independently associated with lower gray matter (GM) volumes (β = -28.6, p = 0.003). On the other hand, age and extent of carotid atherosclerosis were independent predictors of lower white matter (WM) volumes.

Conclusions: WM and GM have different susceptibility to processes involved in parenchymal loss. Contrary to common belief, our results show that presence of fibrocalcific plaques is associated with brain atrophy.
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http://dx.doi.org/10.1016/j.ijcha.2020.100619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452655PMC
October 2020

Takotsubo syndrome as a complication in a critically ill COVID-19 patient.

ESC Heart Fail 2020 Sep 4. Epub 2020 Sep 4.

Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

Coronavirus disease 2019 (COVID-19) patients with cardiac injury have an increased risk of mortality. It remains to be determined the mechanism of cardiac injury and the identification of specific conditions that affect the heart during COVID-19. We present the case of a 76-year-old woman with COVID-19 pneumonia that developed a takotsubo syndrome (TTS). Although the patient presented normal left ventricular ejection fraction and normal levels of troponin on admission, after 16 days in intensive care unit due to respiratory distress, she suddenly developed cardiogenic shock. Shock occurred few hours after a spontaneous breathing trial through her tracheostomy. Bed-side echocardiographic revealed apical ballooning promptly supporting the diagnosis of TTS. She was successfully treated with deep sedation and low dosage of epinephrine. The relevance of this case is that TTS can occur in the late phase of COVID-19. Awareness of late TTS and bed-side echocardiographic evaluation can lead to prompt identification and treatment.
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http://dx.doi.org/10.1002/ehf2.12912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754970PMC
September 2020

Late-sequalae of Kawasaki disease characterized by optical coherence tomography.

J Cardiovasc Med (Hagerstown) 2020 Aug 26. Epub 2020 Aug 26.

San Diego Cardiac Center and Sharp Memorial Hospital, San Diego, California, USA.

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http://dx.doi.org/10.2459/JCM.0000000000001083DOI Listing
August 2020

Longitudinal correlation of biomarkers of cardiac injury, inflammation, and coagulation to outcome in hospitalized COVID-19 patients.

J Mol Cell Cardiol 2020 10 20;147:74-87. Epub 2020 Aug 20.

Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China. Electronic address:

Background: Cardiac injury, as measured by troponin elevation, has been reported among hospitalized coronavirus disease 2019 (COVID-19) patients and portends a poor prognosis. However, how the dynamics of troponin elevation interplay with inflammation and coagulation biomarkers over time is unknown. We assessed longitudinal follow-up of cardiac injury, inflammation and coagulation markers in relation to disease severity and outcome.

Methods: We retrospectively assessed 2068 patients with laboratory-confirmed COVID-19 between January 29 and April 1, 2020 at Tongji Hospital in Wuhan, China. We defined cardiac injury as an increase in high sensitivity cardiac troponin-I (hs-cTnI) above the 99th of the upper reference limit. We explored the dynamics of elevation in hs-cTnI and the relationship with inflammation (interleukin [IL]-6, IL-8, IL-10, IL-2 receptor, tumor necrosis factor-α, C-reactive protein) and coagulation (d-dimer, fibrinogen, international normalized ratio) markers in non-critically ill versus critically ill patients longitudinally and further correlated these markers to survivors and non-survivors.

Results: Median age was 63 years (first to third quartile 51-70 years), 51.4% of whom were women. When compared to non-critically ill patients (N = 1592, 77.0%), critically ill (defined as requiring mechanical ventilation, in shock or multiorgan failure) patients (N = 476, 23.0%), had more frequent cardiac injury on admission (30.3% vs. 2.3%, p < 0.001), with increased mortality during hospitalization (38.4% vs. 0%, p < 0.001). Among critically ill patients, non-survivors (N = 183) had a continuous increase in hs-cTnI levels during hospitalization, while survivors (N = 293) showed a decrease in hs-cTnI level between day 4 and 7 after admission. Specifically, cardiac injury is an independent marker of mortality among critically ill patients at admission, day 4-7 and 8-14. Consistent positive correlations between hs-cTnI and interleukin (IL)-6 on admission (r = 0.59), day 4-7 (r = 0.66) and day 8-14 (r = 0.61; all p < 0.001) and d-dimer (at the same timepoints r = 0.54; 0.65; 0.61, all p < 0.001) were observed. A similar behavior was observed between hs-cTnI and most of other biomarkers of inflammation and coagulation.

Conclusions: Cardiac injury commonly occurs in critically ill COVID-19 patients, with increased levels of hs-cTnI beyond day 3 since admission portending a poor prognosis. A consistent positive correlation of hs-cTnI with IL-6 and d-dimer at several timepoints along hospitalization could suggest nonspecific cytokine-mediated cardiotoxicity.
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http://dx.doi.org/10.1016/j.yjmcc.2020.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438272PMC
October 2020

Mortality and Pre-Hospitalization use of Renin-Angiotensin System Inhibitors in Hypertensive COVID-19 Patients.

J Am Heart Assoc 2020 11 18;9(21):e017736. Epub 2020 Aug 18.

Division of CardiologyDepartment of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan China.

Background There has been significant controversy regarding the effects of pre-hospitalization use of renin-angiotensin system (RAS) inhibitors on the prognosis of hypertensive COVID-19 patients. Methods and Results We retrospectively assessed 2,297 hospitalized COVID-19 patients at Tongji Hospital in Wuhan, China, from January 10 to March 30, 2020; and identified 1,182 patients with known hypertension on pre-hospitalization therapy. We compared the baseline characteristics and in-hospital mortality between hypertensive patients taking RAS inhibitors (N=355) versus non-RAS inhibitors (N=827). Of the 1,182 hypertensive patients (median age 68 years, 49.1% male), 12/355 (3.4%) patients died in the RAS inhibitors group vs. 95/827 (11.5%) patients in the non-RAS inhibitors group (p<0.0001). Adjusted hazard ratio for mortality was 0.28 (95% CI 0.15-0.52, p<0.0001) at 45 days in the RAS inhibitors group compared with non-RAS inhibitors group. Similar findings were observed when patients taking angiotensin receptor blockers (N=289) or angiotensin converting enzyme inhibitors (N=66) were separately compared with non-RAS inhibitors group. The RAS inhibitors group compared with non-RAS inhibitors group had lower levels of C-reactive protein (median 13.5 vs. 24.4 pg/mL; p=0.007) and interleukin-6 (median 6.0 vs. 8.5 pg/mL; p=0.026) on admission. The protective effect of RAS inhibitors on mortality was confirmed in a meta-analysis of published data when our data were added to previous studies (odd ratio 0.44, 95% CI 0.29-0.65, p<0.0001). Conclusions In a large single center retrospective analysis we observed a protective effect of pre-hospitalization use of RAS inhibitors on mortality in hypertensive COVID-19 patients; which might be associated with reduced inflammatory response.
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http://dx.doi.org/10.1161/JAHA.120.017736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763411PMC
November 2020

Heart-Kidney Transplanted patient affected by COVID-19 pneumonia treated with tocilizumab on top of immunosuppressive maintenance therapy.

Int J Cardiol Heart Vasc 2020 Aug 17;29:100596. Epub 2020 Jul 17.

Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy.

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http://dx.doi.org/10.1016/j.ijcha.2020.100596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367013PMC
August 2020

ST-elevation acute myocardial infarction during COVID-19 pandemic: Are we missing the boat?

Int J Cardiol Heart Vasc 2020 Aug 8;29:100578. Epub 2020 Jul 8.

De Gasperis Cardio Center and Transplant Center, ASST Grande Ospedale Metropolitano Niguarda, Italy.

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http://dx.doi.org/10.1016/j.ijcha.2020.100578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340588PMC
August 2020

First experience with ATOMS system implant in neurogenic stress urinary incontinence.

Neurourol Urodyn 2020 08 15;39(6):1837-1841. Epub 2020 Jun 15.

Department of Neuro-Urology, CTO/Unipolar Spinal Cord Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy.

Aim: To evaluate efficacy and safety of ATOMS implant in neurogenic patients with stress incontinence performing clean intermittent catheterization (CIC).

Methods: We included all patients with neurogenic sacral/subsacral lesion and stress urinary incontinence, treated with ATOMS implant between January 2018 and March 2019. All patients received anamnesis, 24-hour pad test and pad count, physical examination, video urodynamic evaluation, Qualiveen questionnaire. All patients were followed up at 12 months after implantation. Patients were considered "continent" when dry or when wearing a security pad (social continence).

Results: We treated eight male patients with a median age of 25 years, four affected by myelomeningocele, and four by cauda equine syndrome. The median preoperative 24-hour pad test was 225 g (interquartile range [IQR]: 180-275). During the surgical procedure, we did not fill the cushion to prevent postoperative urethral injuries when performing CIC in the early postoperative time. At a 12-month follow-up, we had a significant reduction in postoperative 24-hour pad test (median value: 7.5 g; IQR: 0-16.25; P < .05). All patients reached continence. We had a significant reduction in the Qualiveen scores (P < .05). Patients demonstrated to be satisfied with the results of the intervention at the PGI-I questionnaire. The only complications were four cases of temporary scrotal edema (Clavien-Dindo 1) treated with conservative therapy. All patients resumed CIC without urethral traumatism nor catheter insertion difficulties. We had no cases of device infection nor device removal.

Conclusions: Implantation of ATOMS device seems to be an effective and safe minimally invasive procedure also in neurological patients with a low rate of postoperative complications.
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http://dx.doi.org/10.1002/nau.24433DOI Listing
August 2020

Dual implantation of penile prosthesis and ATOMS system for post-prostatectomy erectile dysfunction and urinary incontinence: a feasibility study.

Int J Impot Res 2020 Jun 4. Epub 2020 Jun 4.

A.O.U. Città della Salute e della Scienza di Torino-Presidio Unità Spinale Unipolare-SC Neurourologia, Turin, Italy.

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http://dx.doi.org/10.1038/s41443-020-0320-yDOI Listing
June 2020

Update on acute myocarditis.

Trends Cardiovasc Med 2020 Jun 1. Epub 2020 Jun 1.

"De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy.

Acute myocarditis (AM), a recent-onset inflammation of the heart, has heterogeneous clinical presentations, varying from minor symptoms to high-risk cardiac conditions with severe heart failure, refractory arrhythmias, and cardiogenic shock. AM is moving from being a definitive diagnosis based on histological evidence of inflammatory infiltrates on cardiac tissue to a working diagnosis supported by high sensitivity troponin increase in association with specific cardiac magnetic resonance imaging (CMRI) findings. Though experts still diverge between those advocating for histological definition versus those supporting a mainly clinical definition of myocarditis, in the real-world practice the diagnosis of AM has undoubtedly shifted from being mainly biopsy-based to solely CMRI-based in most of clinical scenarios. It is thus important to clearly define selected settings where EMB is a must, as information derived from histology is essential for an optimal management. As in other medical conditions, a risk-based approach should be promoted in order to identify the most severe AM cases requiring appropriate bundles of care, including early recognition, transfer to tertiary centers, aggressive circulatory supports with inotropes and mechanical devices, histologic confirmation and eventual immunosuppressive therapy. Despite improvements in recognition and treatment of AM, including a broader use of promising mechanical circulatory supports, severe forms of AM are still burdened by dismal outcomes. This review is focused on recent clinical studies and registries that shed new insights on AM. Attention will be paid to contemporary outcomes and predictors of prognosis, the emerging entity of immune checkpoint inhibitors-associated myocarditis, updated CMRI diagnostic criteria, new data on the use of temporary mechanical circulatory supports in fulminant myocarditis. The role of viruses as etiologic agents will be reviewed and a brief update on pediatric AM is also provided. Finally, we summarize a risk-based approach to AM, based on available evidence and clinical experience.
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http://dx.doi.org/10.1016/j.tcm.2020.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263216PMC
June 2020

Fulminant myocarditis triggered by OC43 subtype coronavirus: a disease deserving evidence-based care bundles.

J Cardiovasc Med (Hagerstown) 2020 07;21(7):529-531

'De Gasperis' Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan.

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http://dx.doi.org/10.2459/JCM.0000000000000989DOI Listing
July 2020

Risk scores did not reliably predict individual risk of mortality for patients with decompensated heart failure.

J Clin Epidemiol 2020 09 25;125:38-46. Epub 2020 May 25.

Department of Cardiology, Istituti Clinici Scientifici Maugeri, I.R.C.C.S, Pavia, Italy.

Objective: We investigated the performance of four prognostic tools in predicting 180-day mortality for patients admitted for acute decompensated heart failure (ADHF) by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) over a range of risk thresholds, in addition to discrimination and calibration.

Study Design And Setting: We studied 1,458 patients. The risk assessment was performed using the Acute Decompensated Heart Failure National Registry (ADHERE) model and the Get With The Guidelines (GWTG), ADHF/NT-proBNP, and Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND) risk scores.

Results: C-statistics ranged from 0.727 for the ADHERE model to 0.767 for the ADHF/NT-proBNP score. The ADHF/NT-proBNP risk score, the ADHERE model, and the ASCEND risk score, but not the GWTG risk score, were also well calibrated. Sensitivity and PPV were modest at the >30% risk threshold and ranged from 55% for the ADHF/NT-proBNP risk score to 38.8% for the ADHERE model and from 46.7% for the ADHF/NT-proBNP risk score to 42.1% for the ASCEND risk score, respectively. There was a modest agreement between the risk scores in classifying the patients across risk strata or in classifying those who died as being at >30% risk of death.

Conclusion: Although risk assessment tools work well for stratifying patients, their use in estimating the risk of mortality for individuals has limited clinical utility.
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http://dx.doi.org/10.1016/j.jclinepi.2020.05.020DOI Listing
September 2020

Urethral bulking with Bulkamid: An analysis of efficacy, safety profile, and predictors of functional outcomes in a single-center cohort.

Neurourol Urodyn 2020 06 14;39(5):1523-1528. Epub 2020 May 14.

Department of Neurourology, CTO-Spinal Cord Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy.

Aims: The aim of the present work is to analyze the safety profile, effectiveness, and favorable and unfavorable predictors of clinical outcome in urethral bulking with Bulkamid, and to better identify the ideal candidate for the procedure.

Methods: We included all consecutive female patients treated with urethral bulking with Bulkamid at our institution within 2 years. Patients were affected by stress urinary incontinence (SUI) or mixed incontinence. Incontinence severity was classified as "mild" (urinary leakage <50 g/die), "moderate" (50-200 g/die), or "severe" (>200 g/die) at 24-hours pad test. Clinical success was defined as "dry" (no pads); clinical failure included "partial improvement" (>50% 24-hours pad test reduction) and "no benefit" (<50% 24-hours pad test reduction). The χ and Mann-Whitney tests were performed to assess the predictors of clinical outcome.

Results: The success rate was 36.1% (n = 35). Forty-three patients (44.3%) reported continence improvement. Complications included eight urinary retention cases (8.2%). Statistically significant correlation was observed between incontinence severity and clinical outcome in thee χ test (P = .008). No significant correlation was found between functional outcome and urodynamic incontinence features, postoperative urinary retention, previous pelvic surgery, age, and other physiological, pathological, and urodynamics characteristics. Urinary retention following the surgical procedure appeared to be related to clinical success with nonsignificant P value (P = .10).

Conclusions: Bulkamid procedure could be proposed with good results in elderly patients or in patients requiring a low-invasive procedure with low risk of complications, affected either by SUI or mixed incontinence and with mild to moderate incontinence. Previous training to clean intermittent self-catheterization maneuver should be performed.
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http://dx.doi.org/10.1002/nau.24388DOI Listing
June 2020

Cardiovascular Considerations in Treating Patients With Coronavirus Disease 2019 (COVID-19).

J Cardiovasc Pharmacol 2020 05;75(5):359-367

Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA.

A novel betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly across the globe since December 2019. Coronavirus disease 2019 (COVID-19) has a significantly higher mortality rate than seasonal influenza and has disproportionately affected older adults, especially those with cardiovascular disease and related risk factors. Adverse cardiovascular sequelae, such as myocarditis, acute myocardial infarction, and heart failure, have been reported in patients with COVID-19. No established treatment is currently available; however, several therapies, including remdesivir, hydroxychloroquine and chloroquine, and interleukin (IL)-6 inhibitors, are being used off-label and evaluated in ongoing clinical trials. Considering these therapies are not familiar to cardiovascular clinicians managing these patients, this review describes the pharmacology of these therapies in the context of their use in patients with cardiovascular-related conditions.
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http://dx.doi.org/10.1097/FJC.0000000000000836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219860PMC
May 2020

SARS-CoV-2 inflames the heart. The importance of awareness of myocardial injury in COVID-19 patients.

Int J Cardiol 2020 07 6;311:122-123. Epub 2020 Apr 6.

Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

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http://dx.doi.org/10.1016/j.ijcard.2020.03.086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7134214PMC
July 2020

Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19).

JAMA Cardiol 2020 07;5(7):819-824

Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.

Importance: Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objective: To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms.

Design, Setting, And Participant: This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course.

Exposure: Cardiac involvement with COVID-19.

Main Outcomes And Measures: Detection of cardiac involvement with an increase in levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging.

Results: An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization.

Conclusions And Relevance: This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.
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http://dx.doi.org/10.1001/jamacardio.2020.1096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364333PMC
July 2020

Assessment of right ventricular function in advanced heart failure with nonischemic dilated cardiomyopathy: insights of right ventricular elastance.

J Cardiovasc Med (Hagerstown) 2020 Feb;21(2):134-143

Institute of Cardiology - University 'G. d'Annunzio' - Chieti.

Background: The right ventriculoarterial coupling (R-V/A), a measure of right ventricular systolic dysfunction (RVSD) adaptation/maladaptation to chronic overload, and consequent pulmonary hypertension, has been little investigated in nonischemic dilated cardiomyopathy (NIDCM). We examined the correlates of R-V/A and traditional echocardiographic indices of RVSD, over the spectrum of pulmonary hypertension and tertiles of mean pulmonary artery pressures (PAPm).

Methods: In 2016-2017, we studied 81 consecutive patients for heart transplant/advanced heart failure. Inclusion criteria were NIDCM, reduced ejection fraction (≤40%) and sinus rhythm. R-V/A was computed as the RV/pulmonary elastances ratio (R-Elv/P-Ea), derived from a combined right heart catheterization/transthoracic- echocardiographic assessment [right heart catheterization/transthoracic-echocardiographic (RHC/TTE)].

Results: A total of 68 patients (mean age 64 ± 7 years, 82% men) were eligible. After adjustments, R-Elv and P-Ea were higher in isolated postcapillary-pulmonary hypertension (Ipc-PH) than combined-pulmonary hypertension (Cpc-PH) (P = 0.004 and P = 0.002, respectively), whereas R-V/A progressively decreased over Ipc-PH and Cpc-PH (P = 0.006). According to PAPm increment, P-Ea congruently increased (P-Trend = 0.028), R-Elv progressively decreased (P-Trend<0.00)1, whereas R-V/A significantly worsened (P-Trend = 0.045). At the multivariable analysis, a reduced RV longitudinal function (TAPSE<17 mm) was positively associated with R-V/A impairment (<0.8) [odds ratio 1.41, 95% confidence interval (CI) (1.07--1.87), P = 0.015]. R-Elv and P-Ea showed good interobserver reliability [interclass correlation (ICC) 0.84, 95% CI (0.32--0.99), P = 0.012 and ICC 0.98, 95% CI (0.93--99), P < 0.001, respectively].

Conclusion: Among NIDCM HF patients, in a small cohort study, RHC/TTE-derived R-V/A assessment demonstrated good correlations with pulmonary hypertension types and RV functional status. These data suggest that R-V/A encloses comprehensive information of the whole cardiopulmonary efficiency, better clarifying the amount of RVSD, with good reliability.
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http://dx.doi.org/10.2459/JCM.0000000000000921DOI Listing
February 2020

Resident inflammatory cells in the myocardium of children: On the way to set histologic reference standards to differentiate normal myocardium from myocarditis.

Int J Cardiol 2020 03 17;303:64-65. Epub 2019 Dec 17.

Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital & UCL Institute of Cardiovascular Science, London, United Kingdom.

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http://dx.doi.org/10.1016/j.ijcard.2019.12.039DOI Listing
March 2020

Highlights from the International Journal of Cardiology Heart & Vasculature: Heart failure, atrial fibrillation, coronary artery disease and myocardial infarction.

Int J Cardiol Heart Vasc 2019 Dec 20;25:100443. Epub 2019 Nov 20.

Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany.

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http://dx.doi.org/10.1016/j.ijcha.2019.100443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6923494PMC
December 2019