Publications by authors named "Enrico Fabris"

95 Publications

Prevalence and predictors of persistent sinus rhythm after elective electrical cardioversion for atrial fibrillation.

J Cardiovasc Med (Hagerstown) 2021 Apr 20. Epub 2021 Apr 20.

Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy.

Aims: To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation.

Methods: We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion.

Results: Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70 ± 10 years; 74% men). At 12 months, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12 months had a lower baseline left ventricle ejection fraction (LVEF) (49.1 ± 16 vs. 59.7 ± 9%, P = 0.02) and had more frequently a history of atrial fibrillation more than 12 months (55 vs. 34% P = 0.003). At the multivariate analysis, only the duration of the disease beyond 12 months (OR 0.26, 95% CI: 0.08-0.88, P = 0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, P = 0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, P = 0.001) were associated with the probability of maintaining sinus rhythm at 12 months.

Conclusion: In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.
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http://dx.doi.org/10.2459/JCM.0000000000001182DOI Listing
April 2021

Impact of renin-angiotensin system inhibitors on mortality during the COVID Pandemic among STEMI patients undergoing mechanical reperfusion: Insight from an international STEMI registry.

Biomed Pharmacother 2021 Jun 16;138:111469. Epub 2021 Mar 16.

Complexo Hospetaliero Universitario La Coruna, La Coruna, Spain.

Background: Concerns have been raised on a potential interaction between renin-angiotensin system inhibitors (RASI) and the susceptibility to coronavirus disease 2019 (COVID-19). No data have been so far reported on the prognostic impact of RASI in patients suffering from ST-elevation myocardial infarction (STEMI) during COVID-19 pandemic, which was the aim of the present study.

Methods: STEMI patients treated with primary percutaneous coronary intervention (PPCI) and enrolled in the ISACS-STEMI COVID-19 registry were included in the present sub-analysis and divided according to RASI therapy at admission.

Results: Our population is represented by 6095 patients, of whom 3654 admitted in 2019 and 2441 in 2020. No difference in the prevalence of SARSCoV2 infection was observed according to RASI therapy at admission (2.5% vs 2.1%, p = 0.5), which was associated with a significantly lower mortality (adjusted OR [95% CI]=0.68 [0.51-0.90], P = 0.006), confirmed in the analysis restricted to 2020 (adjusted OR [95% CI]=0.5[0.33-0.74], P = 0.001). Among the 5388 patients in whom data on in-hospital medication were available, in-hospital RASI therapy was associated with a significantly lower mortality (2.1% vs 16.7%, OR [95% CI]=0.11 [0.084-0.14], p < 0.0001), confirmed after adjustment in both periods. Among the 62 SARSCoV-2 positive patients, RASI therapy, both at admission or in-hospital, showed no prognostic effect.

Conclusions: This is the first study to investigate the impact of RASI therapy on the prognosis and SARSCoV2 infection of STEMI patients undergoing PPCI during the COVID-19 pandemic. Both pre-admission and in-hospital RASI were associated with lower mortality. Among SARSCoV2-positive patients, both chronic and in-hospital RASI therapy showed no impact on survival.
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http://dx.doi.org/10.1016/j.biopha.2021.111469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962982PMC
June 2021

Pre-Hospital Antiplatelet Therapy for STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: What We Know and What Lies Ahead.

Thromb Haemost 2021 Mar 7. Epub 2021 Mar 7.

Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands.

Early recanalization of the infarct-related artery to achieve myocardial reperfusion is the primary therapeutic goal in patients with ST-elevation myocardial infarction (STEMI). To decrease the duration of ischaemia, continuous efforts have been made to improve pre-hospital treatment and to target the early period after symptom onset. In this period the platelet content of the fresh coronary thrombus is maximal and the thrombi are dynamic, and thus more susceptible to powerful antiplatelet agents. There have been substantial advances in antiplatelet therapy in the last three decades with several classes of oral and intravenous antiplatelet agents with different therapeutic targets, pharmacokinetics, and pharmacodynamic properties. New parenteral drugs achieve immediate inhibition of platelet aggregation, and fast and easy methods of administration may create the opportunity to bridge the initial gap in platelet inhibition observed with oral P2Y inhibitors. Moreover, potential future management of STEMI could directly involve patients in the process of care with self-administered antiplatelet agents designed to achieve rapid reperfusion. However, the potential anti-ischaemic benefits of potent antiplatelet agents will need to be balanced against their risk of increased bleeding. This study presents a comprehensive and updated review of pre-hospital antiplatelet therapy among STEMI patients undergoing primary percutaneous intervention and explores new therapies under development.
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http://dx.doi.org/10.1055/a-1414-5009DOI Listing
March 2021

Variation in treatment strategy for NSTEMI: A complex phenomenon.

Int J Cardiol 2021 May 30;331:14-16. Epub 2021 Jan 30.

Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.ijcard.2021.01.030DOI Listing
May 2021

Bioresorbable Vascular Scaffold With Optimized Implantation Technique: Long-Term Outcomes From a Single-Center Experience.

J Invasive Cardiol 2021 Feb 14;33(2):E115-E122. Epub 2021 Jan 14.

Interventional Cardiology Unit GVM Care and Research Maria Cecilia Hospital, Cotignola, Ravenna, Italy.

Background: Previous randomized controlled trials demonstrated a higher rate of stent thrombosis with bioresorbable vascular scaffold (BVS) implantation as compared with second-generation drug-eluting stent in selected patients/lesions. However, long-term outcomes of BVS implantations that utilize an optimized technique (OIT) in unselected patients/lesions are lacking. The aim of this study was to assess the real-world, long-term clinical outcomes of BVS (Absorb; Abbott Vascular) with OIT.

Methods And Results: In a cohort of 156 patients, a total of 347 BVS devices (435 lesions) were implanted, with intravascular ultrasound (IVUS) guidance utilized in 303 (87.3%) of the scaffolds. The primary efficacy endpoint was target-lesion revascularization (TLR) and the primary safety endpoint was scaffold thrombosis. Despite performing routine high-pressure postdilation, postintervention IVUS detected BVS underexpansion/malapposition in 53 scaffolds (28.7%), requiring further postdilation. At a median follow-up of 60 months (interquartile range, 45-73 months), TLR and scaffold thrombosis occurred in 16 patients (10.3%) and 1 patient (0.6%), respectively. At univariable analysis, IVUS-guided scaffold implantation was associated with lower TLR (odds ratio, 0.24; 95% confidence interval, 0.09-0.62; P<.01).

Conclusion: The use of first-generation BVS with OIT in real-world patients/lesions was associated with acceptable long-term outcomes.
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February 2021

COVID-19 impact on ST-elevation myocardial infarction incidence rate in a Italian STEMI network: a U-shaped curve phenomenon.

J Cardiovasc Med (Hagerstown) 2021 05;22(5):344-349

Cardiovascular Department.

Background: Public health emergencies such as the COVID-19 outbreak may impact on the incidence rate of ST-elevation myocardial infarction (STEMI) in severely affected areas. However, this phenomenon demands attention also in areas where media and patients were focused on the COVID-19 pandemic, but the healthcare system was not overwhelmed by the huge number of COVID-19 patients.

Methods And Results: In this observational study, we compared the incidence rate of all consecutive STEMI patients admitted at the University Hospital of Trieste, Italy, during March and April 2020 with the same 2 months of the previous 5 years (2015-2019). Patient characteristics were compared between 2020 and 2019.The incidence rate of STEMI admission in March-April 2020 was lower than those in March-April 2015-2019, 36 vs. 56 cases per 100 000 inhabitants/year [relative risk (RR) 0.65, 95% confidence interval (95% CI) 0.42-0.96, P = 0.045]. Considering that the incidence rates were constant in the past years (P = 0.24), the turnaround in 2020 is most likely due to the COVID-19 outbreak. Interestingly, this reduction was a dynamic phenomenon with a U-shaped curve during the 2-month period. System-of-care times were similar between 2020 and 2019; however in 2020, patients presented more frequently signs of heart failure compared to 2019 (Killip class ≥2 in 68% vs. 29%, P = 0.003).

Conclusion: During the COVID-19 outbreak, we observed a marked reduction in the STEMI incidence rate. This U-shaped phenomenon demands attention because a potential cause for the decrease in STEMI incidence may include the avoidance of medical care. Public campaigns aiming to increase awareness of ischemic symptoms may be needed during community outbreak.
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http://dx.doi.org/10.2459/JCM.0000000000001153DOI Listing
May 2021

NT-proBNP level before primary PCI and risk of poor myocardial reperfusion: Insight from the On-TIME II trial.

Am Heart J 2021 03 31;233:78-85. Epub 2020 Dec 31.

Department of Cardiology, Isala Heart Center, Zwolle, The Netherlands; Maastricht University Medical Center, Department of Cardiology, Maastricht, The Netherlands; Zuyderland Medical Center, Department of Cardiology, Heerlen, The Netherlands. Electronic address:

Background: N-terminal fragment of the brain natriuretic peptide prohormone (NT-proBNP), a marker for neurohumoral activation, has been associated with adverse outcome in patients with myocardial infarction. NT-proBNP levels may reflect extensive ischemia and microvascular damage, therefore we investigated the potential association between baseline NT-proBNP level and ST-resolution (STR), a marker of myocardial reperfusion, after primary percutaneous coronary intervention (pPCI).

Methods: we performed a post-hoc analysis of the On-TIME II trial (which randomized ST-elevation myocardial infarction (STEMI) patients to pre-hospital tirofiban administration vs placebo). Patients with measured NT-proBNP before angiography were included. Multivariate logistic-regression analyses was performed to investigate the association between baseline NTproBNP level and STR one hour after pPCI.

Results: Out of 984 STEMI patients, 918 (93.3%) had NT-proBNP values at baseline. Patients with STR <70% had higher NT-proBNP values compared to patients with complete STR (>70%) [Mean ±SD 375.2 ±1021.7 vs 1007.4 ±2842.3, Median (IQR) 111.7 (58.4-280.0) vs 168.0 (62.3-601.3), P <.001]. At multivariate logistic regression analysis, independent predictors associated with higher risk of poor myocardial reperfusion (STR <70%) were: NT-proBNP (OR 1.17, 95%CI 1.04-1.31, P = .009), diabetes mellitus (OR 1.87, 95%CI 1.14-3.07, P = .013), anterior infarct location (OR 2.74, 95% CI 2.00-3.77, P <.001), time to intervention (OR 1.06, 95%CI 1.01-1.11, P = .021), randomisation to placebo (OR 1.45, 95%CI 1.05-1.99, P = .022).

Conclusions: In STEMI patients, higher baseline NT-proBNP level was independently associate with higher risk of poor myocardial reperfusion, supporting the potential use of NT-proBNP as an early marker for risk stratification of myocardial reperfusion after pPCI in STEMI patients.
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http://dx.doi.org/10.1016/j.ahj.2020.12.017DOI Listing
March 2021

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry.

Cardiovasc Diabetol 2020 12 18;19(1):215. Epub 2020 Dec 18.

Central Hospital of Medical University of Lodz, Łódź, Poland.

Background: It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes-ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19.

Methods: The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality.

Results: A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73-0.85, p < 0.0001) and without diabetes (IRR 0.81 (95% CI: 0.78-0.85, p < 0.0001) (p int = 0.40). We observed a significant heterogeneity among centers in the population with and without diabetes (p < 0.001, respectively). The heterogeneity among centers was not related to the incidence of death due to COVID-19 in both groups of patients. Interaction was observed for Hypertension (p = 0.024) only in absence of diabetes. Furthermore, the pandemic was independently associated with a significant increase in door-to-balloon and total ischemia times only among patients without diabetes, which may have contributed to the higher mortality, during the pandemic, observed in this group of patients.

Conclusions: The COVID-19 pandemic had a significant impact on the treatment of patients with STEMI, with a similar reduction in primary PCI procedures in both patients with and without diabetes. Hypertension had a significant impact on PCI reduction only among patients without diabetes. We observed a significant increase in ischemia time and door-to-balloon time mainly in absence of diabetes, that contributed to explain the increased mortality observed in this group of patients during the pandemic.

Trial Registration Number: NCT04412655.
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http://dx.doi.org/10.1186/s12933-020-01196-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747477PMC
December 2020

Beta-blocker effect on ST-segment: a prespecified analysis of the EARLY-BAMI randomised trial.

Open Heart 2020 12;7(2)

Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.

Objective: The effect of early intravenous (IV) beta-blockers (BBs) administration in patients undergoing primary percutaneous coronary intervention (pPCI) on ST-segment deviation is unknown. We undertook a prespecified secondary analysis of the Early Beta-blocker Administration before primary PCI in patients with ST-elevation Myocardial Infarction (EARLY-BAMI) trial to investigate the effect of early IV BB on ST-segment deviation.

Methods: The EARLY-BAMI trial randomised patients with ST-elevation myocardial infarction (STEMI) to IV metoprolol (2×5 mg bolus) or matched placebo before pPCI. The prespecified outcome, evaluated by an independent core laboratory blinded to study treatment, was the residual ST-segment deviation 1 hour after pPCI (ie, the percentage of patients with >3 mm cumulative ST deviation at 1 hour after pPCI).

Results: An ECG for the evaluation of residual ST-segment deviation 1 hour after pPCI was available in 442 out of 683 randomised patients. The BB group had a lower heart rate after pPCI compared with placebo (71.2±13.2 vs 74.3±13.6, p=0.016); however, no differences were noted in the percentages of patients with >3 mm cumulative ST deviation at 1 hour after pPCI (58.6% vs 54.1%, p=0.38, in BB vs placebo, respectively) neither a significant difference was found for the percentages of patients in each of the four prespecified groups (normalised ST-segment; 1-3 mm; 4-6 mm;>6 mm residual ST-deviation).

Conclusions: In patients with STEMI, who were being transported for primary PCI, early IV BB administration did not significantly affect ST-segment deviation after pPCI compared with placebo. The neutral result of early IV BB administration on an early marker of pharmacological effect is consistent with the absence of subsequent improvement of clinical outcomes.
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http://dx.doi.org/10.1136/openhrt-2020-001316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737101PMC
December 2020

Bridging the gap: Current and future insights for improving suboptimal platelet inhibition in STEMI.

Int J Cardiol 2021 Apr 23;328:40-45. Epub 2020 Nov 23.

Department of Cardiology, Isala, Zwolle, the Netherlands; Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands.

Antiplatelet therapy is one of the cornerstones in the acute treatment of patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI). However, hemodynamic changes and delayed intestinal absorption of P2Y inhibitors leads to a delay in the onset of antiplatelet effects resulting in a gap of platelet inhibition. Several strategies have been proposed to bridge this gap, such as pre-hospital administration of antiplatelet therapy, higher loading doses of P2Y inhibitors, crushing or chewing tablets, subcutaneous or intravenous administration of platelet inhibitors, or use of pain relievers alternative to opioids that do not delay intestinal absorption of oral platelet inhibitors. These strategies may improve platelet inhibition with the goal of optimizing clinical outcomes in the acute phase of STEMI. In this review we present current and future insights for bridging the gap in platelet inhibition in STEMI patients undergoing primary PCI.
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http://dx.doi.org/10.1016/j.ijcard.2020.11.042DOI Listing
April 2021

Duration of dual antiplatelet therapy after myocardial infarction: Insights from a pooled database of the SMART-DATE and DAPT-STEMI trials.

Atherosclerosis 2020 12 9;315:55-61. Epub 2020 Nov 9.

Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background And Aims: The optimal duration of dual antiplatelet therapy (DAPT) after myocardial infarction (MI) in patients treated with second-generation drug-eluting stent (DES) is unclear, therefore, we aim to evaluate the ischemic and bleeding risk according to DAPT duration using a pooled-analysis of two randomized trials.

Methods: MI patients treated with durable-polymer second-generation DES from two randomized trials, SMART-DATE and DAPT-STEMI, were pooled. The primary endpoint was a composite of net adverse clinical events (NACEs) defined by all-cause mortality, any MI, stroke and BARC 3-5 bleeding, between 6 and 18 months after index percutaneous coronary intervention.

Results: A total of 2016 patients were analyzed, 1014 were treated with 6-month DAPT versus 1002 patients with ≥12-month DAPT duration. The primary endpoint occurred in 2.7% vs 2.5% (HR 1.07; 95%CI 0.62-1.85, p = 0.80) of cases, in 6 vs ≥ 12-month DAPT, respectively. The composite of cardiac death, MI and stroke was similar (2% vs 1.6%, HR 1.24, 95%CI 0.65-2.4, p = 0.52). BARC 3-5 bleeding occurred more frequently in the ≥12-month DAPT (0.2% vs 0.9%, HR 0.22, 95%CI 0.05-1.02 p = 0.05, log rank p = 0.03). MI occurred more frequently in the 6-month DAPT (1.6% vs 0.6%, HR 2.66, 95%CI 1.04-6.79, p = 0.04). Stent thrombosis was similar in both arms (0.7% vs 0.5%, p = 0.26).

Conclusions: Six vs ≥ 12-month DAPT, followed by aspirin alone, resulted in comparable NACEs in patients with event-free MI at six months after durable-polymer DES implantation. However, single therapy with aspirin beyond the 6 months reduced bleeding rates but was associated with a higher rate of MI compared to ≥12-month DAPT.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.11.003DOI Listing
December 2020

Impact of COVID-19 Pandemic on Mechanical Reperfusion for Patients With STEMI.

J Am Coll Cardiol 2020 11;76(20):2321-2330

Division of Cardiology, Ospedale "Sant'Anna", Ferrara, Italy.

Background: The fear of contagion during the coronavirus disease-2019 (COVID-19) pandemic may have potentially refrained patients with ST-segment elevation myocardial infarction (STEMI) from accessing the emergency system, with subsequent impact on mortality.

Objectives: The ISACS-STEMI COVID-19 registry aims to estimate the true impact of the COVID-19 pandemic on the treatment and outcome of patients with STEMI treated by primary percutaneous coronary intervention (PPCI), with identification of "at-risk" patient cohorts for failure to present or delays to treatment.

Methods: This retrospective registry was performed in European high-volume PPCI centers and assessed patients with STEMI treated with PPPCI in March/April 2019 and 2020. Main outcomes are the incidences of PPCI, delayed treatment, and in-hospital mortality.

Results: A total of 6,609 patients underwent PPCI in 77 centers, located in 18 countries. In 2020, during the pandemic, there was a significant reduction in PPCI as compared with 2019 (incidence rate ratio: 0.811; 95% confidence interval: 0.78 to 0.84; p < 0.0001). The heterogeneity among centers was not related to the incidence of death due to COVID-19. A significant interaction was observed for patients with arterial hypertension, who were less frequently admitted in 2020 than in 2019. Furthermore, the pandemic was associated with a significant increase in door-to-balloon and total ischemia times, which may have contributed to the higher mortality during the pandemic.

Conclusions: The COVID-19 pandemic had significant impact on the treatment of patients with STEMI, with a 19% reduction in PPCI procedures, especially among patients suffering from hypertension, and a longer delay to treatment, which may have contributed to the increased mortality during the pandemic. (Primary Angioplasty for STEMI During COVID-19 Pandemic [ISACS-STEMI COVID-19] Registry; NCT04412655).
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http://dx.doi.org/10.1016/j.jacc.2020.09.546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834750PMC
November 2020

Antithrombotic therapy in heart failure and sinus rhythm: the ongoing search for a better match of patients to therapy.

Eur J Heart Fail 2020 Nov 1. Epub 2020 Nov 1.

CardioCentro Ticino, Lugano and University of Bern, Bern, Switzerland.

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http://dx.doi.org/10.1002/ejhf.2045DOI Listing
November 2020

Cardiac Tumors: Diagnosis, Prognosis, and Treatment.

Curr Cardiol Rep 2020 10 10;22(12):169. Epub 2020 Oct 10.

Cardiovascular Department, Azienda Sanitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy.

Purpose Of Review: Cardiac masses frequently present significant diagnostic and therapeutic clinical challenges and encompass a broad set of lesions that can be either neoplastic or non-neoplastic. We sought to provide an overview of cardiac tumors using a cardiac chamber prevalence approach and providing epidemiology, imaging, histopathology, diagnostic workup, treatment, and prognoses of cardiac tumors.

Recent Findings: Cardiac tumors are rare but remain an important component of cardio-oncology practice. Over the past decade, the advances in imaging techniques have enabled a noninvasive diagnosis in many cases. Indeed, imaging modalities such as cardiac magnetic resonance, computed tomography, and positron emission tomography are important tools for diagnosing and characterizing the lesions. Although an epidemiological and multimodality imaging approach is useful, the definite diagnosis requires histologic examination in challenging scenarios, and histopathological characterization remains the diagnostic gold standard. A comprehensive clinical and multimodality imaging evaluation of cardiac tumors is fundamental to obtain a proper differential diagnosis, but histopathology is necessary to reach the final diagnosis and subsequent clinical management.
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http://dx.doi.org/10.1007/s11886-020-01420-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547967PMC
October 2020

Intra-coronary Imaging for the Evaluation of Plaque Modifications Induced by Drug Therapies for Secondary Prevention.

Curr Atheroscler Rep 2020 Oct 6;22(12):76. Epub 2020 Oct 6.

Cardio-toraco-vascular Department, Careggi University Hospital, Florence, Italy.

Purpose Of Review: Patients diagnosed with coronary artery disease are at a high risk of subsequent cardiovascular events; therefore, secondary prevention in the form of therapeutic lifestyle changes, and drug therapies is vital. This article aims to review potential application of intra-coronary imaging for the evaluation of plaque modifications, induced by medications for secondary prevention for CAD.

Recent Findings: Intra-coronary imaging provides detailed information on the atherosclerotic plaque which is the primary pathological substrate for the recurrent ischemic cardiovascular events. These modalities can detect features associated with high risk and allow serial in vivo imaging of lesions. Therefore, intravascular imaging tools have been used in landmark studies and played a role in improving our understanding of the disease processes. Changes in size and plaque composition over time can be evaluated by these tools and may help understanding the impact of a treatment. Moreover, surrogate imaging end points can be used when testing new drugs for secondary prevention.
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http://dx.doi.org/10.1007/s11883-020-00890-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538414PMC
October 2020

Comparison of different prediction models for the indication of implanted cardioverter defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy.

ESC Heart Fail 2020 Sep 23. Epub 2020 Sep 23.

Cardio-thoraco-vascular Department, University of Trieste, Trieste, Italy.

Aims: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a high risk of sudden cardiac death. Three different prediction models for the indication of implanted cardioverter defibrillator (ICD) are now available: the 5 year ARVC risk score, the International Task Force Consensus (ITFC) criteria, and the Heart Rhythm Society (HRS) criteria. We compared these three prediction models in a validation cohort of patients with definite ARVC.

Methods And Results: In a cohort of 140 patients with definite ARVC, the 5 year ARVC risk score and the ITFC and HRS criteria were compared for the prediction of a major combined endpoint of sudden cardiac death, appropriate ICD intervention, resuscitated cardiac arrest, and sustained ventricular tachycardia. During the follow-up, 65 major events occurred. The 5 year ARVC risk score with a threshold >10%, derived from the maximally selected rank statistic, predicted 62 (95%) events [odds ratio (OR) 9.1, 95% confidence interval (CI) 2.6-32, P = 0.0006], the ITFC criteria 53 (81%, OR 4.8, 95% CI 2.2-10.3, P = 0.0001), and the HRS criteria 29 (45%, OR 4.2, 95% CI 1.9-9.3, P = 0.0003). At the analysis of decision curve for ICD implantation, a 5 year ARVC risk score >10% showed a greater net benefit than the ITFC and HRS criteria over a wide range of threshold probability of events. Finally, at multivariate analysis, the 5 year ARVC risk score >10% was the only independent predictor of major events.

Conclusions: The 5 year score with a threshold of >10% was more effective for predicting events than the ITFC and HRS criteria.
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http://dx.doi.org/10.1002/ehf2.13019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755004PMC
September 2020

Atrial fibrillation in dilated cardiomyopathy: Outcome prediction from an observational registry.

Int J Cardiol 2021 Jan 25;323:140-147. Epub 2020 Aug 25.

Cardiovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy.

Background: Little is known about the role of different types of atrial fibrillation (AF) in dilated cardiomyopathy (DCM). We investigated the epidemiological and prognostic impact of different types of AF in DCM during long-term follow-up.

Method: We evaluated consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry. Uni- and multivariable, extended Kaplan-Meier and propensity score-matching analyses were performed for a composite outcome including death/heart transplantation/ventricular-assist device implantation.

Results: Out of 1181 DCM patients (71% males, age 49 ± 15 years, left ventricular ejection fraction 33 ± 11%), 46 (3.9%) had baseline permanent AF (permAF), while 66 (5.6%) had a history of paroxysmal/persistent AF. Compared with sinus rhythm (SR) patients, permAF patients were older (48 ± 15 vs. 61 ± 11 respectively, p = 0.001), were more frequently in NYHA class III-IV (18% vs. 30%, p = 0.002) and had larger left atrium diameter (40 ± 8 vs. 50 ± 10 mm, respectively). Paroxysmal/persistent AF patients had intermediate characteristics between permAF and SR. During a median follow-up of 135 (75-210) months, 63 patients developed permAF (0.45 new cases/100patients/year). At multivariable analysis, permAF as a time-dependent variable was an independent outcome predictor (HR 2.45; 95% C.I. 2.61-3.63, p < 0.001), together with creatinine, NYHA class, restrictive filling pattern and moderate-severe mitral regurgitation, while paroxysmal/persistent AF was neutral. Propensity score-matching analysis confirmed the higher rate of primary outcome events in patients with baseline or incident permAF versus patients without permAF during a very long-term follow-up (70% vs. 20%, p < 0.001).

Conclusions: PermAF in a large DCM cohort had low prevalence and incidence but had a relevant. prognostic role on hard outcomes.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.062DOI Listing
January 2021

Viral presence-guided immunomodulation in lymphocytic myocarditis: an update.

Eur J Heart Fail 2021 Feb 20;23(2):211-216. Epub 2020 Aug 20.

Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata (ASUITS), University of Trieste, Trieste, Italy.

Latest statements from European and American societies recommend to rule out viral presence in endomyocardial biopsy (EMB) via polymerase chain reaction (PCR) analysis before starting immunosuppression or immunomodulation in acute lymphocytic myocarditis presenting with life-threatening scenarios. However, recommendations in myocarditis are mostly based on heterogeneous studies enrolling patients with inflammatory cardiomyopathies and established heart failure rather than acute myocarditis. Thus, definitive evidence of a survival benefit from immunomodulation guided by viral presence is currently lacking. Finally, distinguishing innocent bystanders from causative agents among EMB-detected viruses remain challenging and a major goal to achieve in the near future. Therefore, considerable divergence remains between official recommendations and clinical practice, including the possibility of starting immunosuppressive therapy empirically, without knowing viral PCR results. This review systematically discusses the unsolved issues of immunomodulation guided by viral presence in acute lymphocytic myocarditis, namely (i) virus epidemiology and prognosis, (ii) variability of viral presence rates, (iii) the role of potential viral bystander findings, and (iv) the main results of immunosuppression controlled trials in lymphocytic myocarditis. Furthermore, a practical approach for the critical use of viral presence analysis in guiding immunomodulation is provided, highlighting its importance before starting immunosuppression or immunomodulation. Future, multicentre studies are needed to address specific scenarios such as fulminant lymphocytic myocarditis and a virus-tailored management as for parvovirus B19.
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http://dx.doi.org/10.1002/ejhf.1969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405140PMC
February 2021

Cardiac amyloidosis: do not forget to look for it.

Eur Heart J Suppl 2020 Jun 25;22(Suppl E):E142-E147. Epub 2020 Mar 25.

Cardiovascular Department, Azienda Sanitaria Universitaria Integrata, University of Trieste (ASUITS), Trieste, Italy.

Amyloidosis is a systemic disease due to buildup of protein material in the extracellular space, which can affect the heart, mainly in its light chain and transtyretin forms. Historically this condition has been considered very uncommon, and it was certainly under-diagnosed. Today is well known that in certain group of patients its prevalence is, indeed, very high (25% in patients over the age of 80 years; 32% in patients over 75 years with heart failure and preserved systolic function, and 5% in post-mortem series of hypertrophic cardiomyopathy). Some genetically determined form of transthyretin amyloidosis are quite common in certain populations, such as Caribbean origin African-Americans. The wide spectrum of signs, symptoms, and first-level tests often overlapping among various other conditions, represent a diagnostic challenge for the clinical cardiologist. The opportunity to reach the diagnosis with non-invasive testing (first and foremost scintiscan with bone markers), as well as encouraging results of newer classes of drugs, raised the interest in this condition, so far burdened by an ominous prognosis. Early diagnosis of amyloidosis should always be guided by clinical suspicion but should also be supported by a multidisciplinary approach, aimed at optimizing the prognosis of the condition. Despite the newer drugs now available, a late diagnosis affect negatively the prognosis, and the opportunity to implement therapies (e.g. liver transplant in ATTR, or bone marrow transplant in AL) able to cure or at least delay the progression of the disease.
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http://dx.doi.org/10.1093/eurheartj/suaa080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270903PMC
June 2020

Accuracy of right atrial pressure estimation using a multi-parameter approach derived from inferior vena cava semi-automated edge-tracking echocardiography: a pilot study in patients with cardiovascular disorders.

Int J Cardiovasc Imaging 2020 Jul 19;36(7):1213-1225. Epub 2020 Mar 19.

Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Turin, Italy.

The echocardiographic estimation of right atrial pressure (RAP) is based on the size and inspiratory collapse of the inferior vena cava (IVC). However, this method has proven to have limits of reliability. The aim of this study is to assess feasibility and accuracy of a new semi-automated approach to estimate RAP. Standard acquired echocardiographic images were processed with a semi-automated technique. Indexes related to the collapsibility of the vessel during inspiration (Caval Index, CI) and new indexes of pulsatility, obtained considering only the stimulation due to either respiration (Respiratory Caval Index, RCI) or heartbeats (Cardiac Caval Index, CCI) were derived. Binary Tree Models (BTM) were then developed to estimate either 3 or 5 RAP classes (BTM3 and BTM5) using indexes estimated by the semi-automated technique. These BTMs were compared with two standard estimation (SE) echocardiographic methods, indicated as A and B, distinguishing among 3 and 5 RAP classes, respectively. Direct RAP measurements obtained during a right heart catheterization (RHC) were used as reference. 62 consecutive 'all-comers' patients that had a RHC were enrolled; 13 patients were excluded for technical reasons. Therefore 49 patients were included in this study (mean age 62.2 ± 15.2 years, 75.5% pulmonary hypertension, 34.7% severe left ventricular dysfunction and 51% right ventricular dysfunction). The SE methods showed poor accuracy for RAP estimation (method A: misclassification error, ME = 51%, R = 0.22; method B: ME = 69%, R = 0.26). Instead, the new semi-automated methods BTM3 and BTM5 have higher accuracy (ME = 14%, R = 0.47 and ME = 22%, R = 0.61, respectively). In conclusion, a multi-parametric approach using IVC indexes extracted by the semi-automated approach is a promising tool for a more accurate estimation of RAP.
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http://dx.doi.org/10.1007/s10554-020-01814-8DOI Listing
July 2020

Impact of patient delay in a modern real world STEMI network.

Am J Emerg Med 2020 06 19;38(6):1195-1198. Epub 2020 Feb 19.

Cardiovascular Department, University of Trieste, Trieste, Italy.

Background: The impact of patient delay on left ventricular ejection fraction (LVEF), when system delay has performance that meets the current recommended guidelines, is poorly investigated.

Methods: We evaluated a cohort of STEMI patients treated with primary percutaneous coronary intervention (pPCI) and with an ECG STEMI diagnosis to wire crossing time (ETW) ≤120 min. Independent predictors of pre-discharge decreased LVEF (≤45%) were analyzed.

Results: 490 STEMI patients with both ETW time ≤120 min and available pre-discharge LVEF were evaluated. Mean age was 64.2 ± 12 years, 76.2% were male, 19.5% were diabetics, 42.7% had and anterior myocardial infarction (MI), and 9.8% were in Killip class III-IV. Median time of patient's response to initial symptoms (patient delay) was 58,5 (IQR 30;157) minutes and median ETW time was 78 (IQR 62-95) minutes. 115 patients (23.4%) had pre-discharge LVEF ≤45%. At multivariable analysis independent predictors of decreased LVEF (≤45%) were anterior MI (OR 4,659, 95% CI 2,618-8,289, p < 0,001), Killip class (OR 1,449, 95% CI 1,090-1,928, p = 0,011) and patients delay above the median (OR 2,030, 95% CI 1,151-3.578, p = 0,014). These independent predictors were confirmed in patients with ETW time ≤90 min.

Conclusions: When system delay meets the recommended criteria for pPCI, patient delay becomes an independent predictor of pre-discharge LVEF. These findings provide further insights into the potential optimization of STEMI management and identify a target that needs to be improved, considering that still a significant proportion of patients continue to delay seeking medical care.
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http://dx.doi.org/10.1016/j.ajem.2020.02.028DOI Listing
June 2020

Hat-Marker Orientation to Minimize Neo-Commissural Overlap With Coronaries During CoreValve Evolut TAVR.

JACC Cardiovasc Interv 2020 03 26;13(6):782-783. Epub 2020 Feb 26.

Cardiovascular Department, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1016/j.jcin.2019.11.034DOI Listing
March 2020

Intravascular Imaging Guidance of Left Main PCI: Nice to Have or Must Have?

JACC Cardiovasc Interv 2020 02;13(3):358-360

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; The Cardiovascular Research Foundation, New York, New York.

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http://dx.doi.org/10.1016/j.jcin.2019.11.009DOI Listing
February 2020

[Cardiological counseling and perioperative management of heart disease patients. Protocol of the University of Trieste - Year 2019].

G Ital Cardiol (Rome) 2019 Dec;20(12):706-721

S.C. Cardiologia, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITs).

The management of patients with heart disease or suspected heart disease, who are hospitalized and/or who should undergo surgery or an invasive procedure, is very complex for the comorbidities often present, the multiple therapies taken and the frequent presence of advanced cardiac devices.The purpose of this document is to provide indications and standardize the behavior of different clinicians in the management of heart disease patients or those with suspected heart disease in order (i) to manage acute cardiac conditions with appropriate timing and accuracy, and (ii) to define the cardiovascular risk in the individual patient with appropriate timing and indications, allowing patients to face any surgery or invasive procedure with the lowest risk correlated to his heart disease.
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http://dx.doi.org/10.1714/3271.32380DOI Listing
December 2019

Endomyocardial fibrosis of the right ventricle: A case report of successful surgery.

J Card Surg 2020 Feb 28;35(2):460-463. Epub 2019 Nov 28.

IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy.

Aims: The case we report, shows a successful treatment of right ventricle endomyocardial fibrosis.

Materials And Methods: Surgical therapy by endocardial decortication seems to be beneficial for many patients with advanced disease who are in functional-therapeutic class III or IV. The operative mortality rate is high, but successful surgery has a clear benefit on symptoms and seems to favourably affect survival as well.
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http://dx.doi.org/10.1111/jocs.14378DOI Listing
February 2020

Natural history of spontaneous coronary dissections.

Coron Artery Dis 2020 09;31(6):569-570

Cardiovascular Department, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1097/MCA.0000000000000833DOI Listing
September 2020

Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors on Top of Ticagrelor in STEMI: A Subanalysis of the ATLANTIC Trial.

Thromb Haemost 2020 Jan 21;120(1):65-74. Epub 2019 Nov 21.

Department of Cardiology, Isala, Zwolle, The Netherlands.

Background:  Glycoprotein IIb/IIIa inhibitors (GPIs) in combination with clopidogrel improve clinical outcome in ST-elevation myocardial infarction (STEMI); however, finding a balance that minimizes both thrombotic and bleeding risk remains fundamental. The efficacy and safety of GPI in addition to ticagrelor, a more potent P2Y12-inhibitor, have not been fully investigated.

Methods:  1,630 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were analyzed in this subanalysis of the ATLANTIC trial. Patients were divided in three groups: no GPI, GPI administration routinely before primary PCI, and GPI administration in bailout situations. The primary efficacy outcome was a composite of death, myocardial infarction, urgent target revascularization, and definite stent thrombosis at 30 days. The safety outcome was non-coronary artery bypass graft (CABG)-related PLATO major bleeding at 30 days.

Results:  Compared with no GPI ( = 930), routine GPI ( = 525) or bailout GPI ( = 175) was not associated with an improved primary efficacy outcome (4.2% no GPI vs. 4.0% routine GPI vs. 6.9% bailout GPI;  = 0.58). After multivariate analysis, the use of GPI in bailout situations was associated with a higher incidence of non-CABG-related bleeding compared with no GPI (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.32-6.64;  = 0.03). However, routine GPI use compared with no GPI was not associated with a significant increase in bleeding (OR 1.78, 95% CI 0.88-3.61;  = 0.92).

Conclusion:  Use of GPIs in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome. A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation.
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http://dx.doi.org/10.1055/s-0039-1700546DOI Listing
January 2020

Treatment of Functional Mitral Regurgitation in Heart Failure.

Curr Cardiol Rep 2019 11 16;21(11):139. Epub 2019 Nov 16.

Cardiovascular Department, University of Trieste, Via Valdoni 7, 34129, Trieste, Italy.

Purpose Of Review: To analyze the current state of the art of functional mitral regurgitation (FMR) treatment.

Recent Findings: The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.
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http://dx.doi.org/10.1007/s11886-019-1221-xDOI Listing
November 2019