Publications by authors named "Giuseppe Biondi Zoccai"

787 Publications

Differential impact of type 1 and type 2 diabetes mellitus on outcomes among 1.4 million US patients undergoing percutaneous coronary intervention.

Cardiovasc Revasc Med 2021 Aug 19. Epub 2021 Aug 19.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK. Electronic address:

Background: The aim was to determine the impact of diabetes mellitus (DM) on outcomes after percutaneous coronary intervention (PCI). There is limited data on the impact of DM and its subtypes among patients who underwent PCI during hospitalization.

Methods: All PCI hospitalizations from the National Inpatient Sample (October 2015-December 2018) were stratified by the presence and subtype of DM. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in type 1 DM (T1DM) and type 2 DM (T2DM) compared to no-DM.

Results: Out of 1,363,800 individuals undergoing PCI, 12,640 (0.9%) had T1DM and 539,690 (39.6%) had T2DM. T1DM patients had increased aOR of major adverse cardiovascular and cerebrovascular events (MACCE) (1.26, 95%CI 1.17-1.35), mortality (1.56, 95%CI 1.41-1.72), major bleeding (1.63, 95%CI 1.45-1.84), and stroke (1.75, 95%CI 1.51-2.02), while T2DM patients had only increased aOR of MACCE (1.02, 95%CI 1.01-1.04), mortality (1.10, 95%CI 1.08-1.13) and stroke (1.22, 95%CI 1.18-1.27), compared to no-DM patients. However, both T1DM and T2DM had lower aOR of cardiac complications (0.87, 95%CI 0.77-0.97 and 0.87, 95%CI 0.85-0.89, respectively), in comparison to no-DM patients. When accounting for the indication, both DM subgroups had higher aOR of MACCE, mortality, and stroke compared to no-DM patients in the acute coronary syndrome setting (p < 0.001, for all), while only increased aOR of stroke (1.59, 95%CI 1.17-2.15 for T1DM and 1.12, 95%CI 1.05-1.20 for T2DM) persisted in the elective setting.

Conclusions: Patients with DM who have undergone PCI during hospitalization are more likely to experience adverse in-hospital outcomes, and T1DM patients are a particularly high-risk cohort.
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http://dx.doi.org/10.1016/j.carrev.2021.08.018DOI Listing
August 2021

Autoimmune diseases in patients undergoing percutaneous coronary intervention: A risk factor for in-stent restenosis?

Atherosclerosis 2021 Sep 5;333:24-31. Epub 2021 Aug 5.

Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Piazza G. Cesare 11, Bari (BA), 70120, Italy.

Background And Aims: Despite the relation between autoimmune diseases and increased atherosclerotic risk is established, the influence of autoimmune disorders on in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is only partly known. ISR is an aberrant reparative process mainly characterized by an increased number of vascular smooth muscle cells and excessive deposition of extracellular proteoglycans and type III collagen. Chronic inflammation, always present in autoimmune diseases, modulates the endothelial response to PCI. Aim of this review is to resume the current evidence on the association between ISR and autoimmune diseases, focusing on pathogenic mechanisms and therapeutic targets.

Methods: We conducted a comprehensive review of the literature on the relationship between ISR and insulin-dependent diabetes mellitus (IDDM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid-antibodies syndrome (APS), inflammatory bowel diseases (IBD), and Hashimoto's thyroiditis (HT).

Results: Patients affected with IDDM, RA, SLE, APS, IBD and HT proved to face higher rates of ISR compared to the general population. The endothelial dysfunction seems the principal common pathogenic pathway for ISR and is attributed to both the immune system disorder and the systemic inflammation. Some evidence suggested that methotrexate and anti-tumor necrosis factor treatments can be effective in reducing ISR, while antibodies against vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 showed to reduce neointimal hyperplasia in animal models.

Conclusions: Autoimmune diseases are a risk factor for ISR. The study of the potential cardiovascular benefits of the current therapies, mainly anti-inflammatory drugs, and the pursuit of innovative treatments appear of paramount interest.
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http://dx.doi.org/10.1016/j.atherosclerosis.2021.08.007DOI Listing
September 2021

Characteristics and outcomes of MitraClip in octogenarians: Evidence from 1853 patients in the GIOTTO registry.

Int J Cardiol 2021 Aug 8. Epub 2021 Aug 8.

Division of Cardiology, AOU Policlinico "G. Rodolico - San Marco", Università di Catania, Catania, Italy.

Background: We aimed at appraising features and outcomes of patients undergoing MitraClip treatment according to their age.

Methods: We queried the prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) multicenter registry dataset including 19 Italian centers performing MitraClip implantation, distinguishing patients <80 vs ≥80 years of age.

Results: In total, 1853 patients were included, 751 (40.5%) octogenarians and 1102 (59.5%) non-octogenarians. Several baseline and procedural features were significantly different, including gender, regurgitation etiology, and functional class (all p < 0.05). In-hospital outcomes were similarly satisfactory, with death occurring in 18 (2.4%) and 32 (2.9%, p = 0.561), respectively, and improvement in mitral regurgitation in 732 (97.4%) and 1078 (97.8%, p = 0.746), respectively. After a mean follow-up of 15 months, death occurred in 152 (20.2%) and 264 (24.0%), and cardiac death in 85 (11.3%) and 138 (12.5%), respectively (both p > 0.05). Rehospitalization for heart failure and the composite of cardiac death or rehospitalization for heart failure were significantly less common in octogenarians: 63 (8.4%) vs 156 (14.2%, p < 0.001), and 125 (16.6%) vs 242 (22.0%, p = 0.005), respectively. Multivariable analysis showed that these differences were largely due to confounding features, as after adjustment for baseline, clinical and imaging characteristics no significant difference was found for the above clinical endpoints.

Conclusions: Transcatheter mitral valve repair with the MitraClip in carefully selected octogenarians appears feasible and safe, and is associated with favorable clinical outcomes at mid-term follow-up.
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http://dx.doi.org/10.1016/j.ijcard.2021.08.010DOI Listing
August 2021

Prediction of radial crossover in acute coronary syndromes: derivation and validation of the MATRIX score.

EuroIntervention 2021 Aug 11. Epub 2021 Aug 11.

Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.

Background: The radial artery is recommended by international guidelines as the default vascular access in patients with acute coronary syndromes (ACS) managed invasively. However, crossover from radial to femoral access is required in 4-10% of cases and has been associated with worse outcomes. No standardised algorithm exists to predict the risk of radial crossover.

Aims: We sought to derive and externally validate a risk score to predict radial crossover in patients with ACS managed invasively.

Methods: The derivation cohort consisted of 4,197 patients with ACS undergoing invasive management via the randomly allocated radial access from the MATRIX trial. Using logistic regression, we selected predictors of radial crossover and developed a numerical risk score. External validation was accomplished among 3,451 and 491 ACS patients managed invasively and randomised to radial access from the RIVAL and RIFLE-STEACS trials, respectively.

Results: The MATRIX score (age, height, smoking, renal failure, prior coronary artery bypass grafting, ST-segment elevation myocardial infarction, Killip class, radial expertise) showed a c-index for radial crossover of 0.71 (95% CI: 0.67-0.75) in the derivation cohort. Discrimination ability was modest in the RIVAL (c-index: 0.64; 95% CI: 0.59-0.67) and RIFLE-STEACS (c-index: 0.66; 95% CI: 0.57-0.75) cohorts. A cut-off of ≥41 points was selected to identify patients at high risk of radial crossover.

Conclusions: The MATRIX score is a simple eight-item risk score which provides a standardised tool for the prediction of radial crossover among patients with ACS managed invasively. This tool can assist operators in anticipating and better addressing difficulties related to transradial procedures, potentially improving outcomes.
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http://dx.doi.org/10.4244/EIJ-D-21-00441DOI Listing
August 2021

Commissural alignment with new-generation self-expanding transcatheter heart valves during aortic replacement.

Cardiovasc Revasc Med 2021 Jul 30. Epub 2021 Jul 30.

Interventional Cardiology Unit, Cardiovascular Department, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.

Preserving coronary artery access is a crucial goal during transcatheter aortic valve replacement (TAVR) procedures, especially in case of self-expandable transcatheter heart valve (SE-THV) implantation. In this light, a proper commissural alignment is needed to avoid the risk of coronary obstruction and to permit easy vessels re-cannulation for diagnostic and interventional purposes. New-generation SE-THVs have been furnished of different markers, able to guide operators to perform a correct commissural alignment. In this case series, we describe key procedural aspects of commissural alignment for the different available SE-THVs, providing a step-by-step tutorial for each device. Lastly, we illustrate a commissural alignment in a contrast-zero TAVR.
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http://dx.doi.org/10.1016/j.carrev.2021.07.027DOI Listing
July 2021

Long-term (≥15 years) Follow-up of Percutaneous Coronary Intervention of Unprotected Left Main (From the GRAVITY Registry).

Am J Cardiol 2021 10 27;156:72-78. Epub 2021 Jul 27.

Cardio Center, Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy.

Long term survival and its determinants after Percutaneous Coronary Intervention (PCI) on Unprotected Left Main Coronary Artery (ULMCA) remain to be appraised. In 9 European Centers 470 consecutive patients performing PCI on ULMCA between 2002 and 2005 were retrospectively enrolled. Survival from all cause and cardiovascular (CV) death were the primary end points, while their predictors at multivariate analysis the secondary ones. Among the overall cohort 81.5% of patients were male and mean age was 66 ± 12 years. After 15 years (IQR 13 to 16), 223 patients (47%) died, 81 (17.2%) due to CV etiology. At multivariable analysis, older age (HR 1.06, 95%CI 1.02 to 1.11), LVEF < 35% (HR 2.97, 95%CI 1.24 to 7.15) and number of vessels treated during the index PCI (HR 1.75, 95%CI 1.12 to 2.72) were related to all-cause mortality, while only LVEF <35% (HR 4.71, 95%CI 1.90 to 11.66) to CV death. Repeated PCI on ULMCA occurred in 91 (28%) patients during the course of follow up and did not significantly impact on freedom from all-cause or CV mortality. In conclusion, in a large, unselected population treated with PCI on ULMCA, 47% died after 15 years, 17% due to CV causes. Age, number of vessels treated during index PCI and depressed LVEF increased risk of all cause death, while re-PCI on ULMCA did not impact survival.
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http://dx.doi.org/10.1016/j.amjcard.2021.06.008DOI Listing
October 2021

Interplay between climate, pollution and COVID-19 on ST-elevation myocardial infarction in a large metropolitan region.

Minerva Med 2021 Jul 26. Epub 2021 Jul 26.

Universidad de Buenos Aires, Facultad de Ciencias sociales, Instituto de Investigaciones Gino Germani, Buenos Aires, Argentina.

Background: Collective risk factors such as climate and pollution impact on the risk of acute cardiovascular events, including ST-elevation myocardial infarction (STEMI). There is limited data however on the precise temporal and independent association between these factors and STEMI, and the potentially interacting role of government policies against Coronavrus Disease 2019 (COVID-19), especially for Latin America.

Methods: We retrospectively collected aggregate data on daily STEMI admissions at 10 tertiary care centers in the Buenos Aires metropolitan area, Argentina, from January 1, 2017 to November 30, 2020. Daily measurements for temperature, humidity, atmospheric pressure, wind direction, wind speed, and rainfall, as well as carbon monoxide (CO), nitrogen dioxide, and particulate matter <10 μm (PM10), were retrieved. Exploratory analyses focused on key COVID-19-related periods (eg first case, first lockdown), and stringency index quantifying the intensity of government policy response against COVID-19.

Results: A total of 1498 STEMI occurred over 1430 days, for an average of 0.12 STEMI per center (decreasing from 0.130 in 2018 to 0.102 in 2020, p=0.016). Time series analysis showed that lower temperature and higher concentration of CO and PM10 were all significantly associated with an increased rate of STEMI (all p<0.05), whereas COVID-19 outbreak, lockdown, and stringency of government policies were all inversely associated with STEMI (all p<0.05). Notably, environmental features impacted as early as 28 days before the event (all p<0.05), even if same or prior day associations proved stronger (all p<0.05). Multivariable analysis suggested that maximum temperature (p=0.001) and PM10 (p=0.033) were the strongest predictor of STEMI, even after accounting for COVID-19-related countermeasures (p=0.043).

Conclusions: Lower temperature and higher concentrations of CO and PM10 are associated with significant increases in the rate of STEMI in a large Latin American metropolitan area. The reduction in STEMI cases seen during the COVID-19 pandemic is at least in part mediated by improvements in pollution, especially reductions in PM10.
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http://dx.doi.org/10.23736/S0026-4806.21.07748-XDOI Listing
July 2021

Implantation of one, two or multiple MitraClips for transcatheter mitral valve repair: insights from a 1824-patient multicenter study.

Panminerva Med 2021 Jul 26. Epub 2021 Jul 26.

Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-Universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy.

Background: Transcatheter mitral valve repair (TMVR) with the MitraClip device is an established treatment for mitral regurgitation (MR). More than one MitraClip may be implanted if a single one does not reduce MR adequately. We aimed at appraising the outlook of patients undergoing implantation of one, two or multiple MitraClips for TMVR.

Methods: Exploiting the ongoing prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) Study dataset, we compared patients, procedural details and outcomes distinguishing those receiving one, two or multiple MitraClips. The primary endpoint was the composite of 1-year cardiac death or rehospitalization for heart failure. Additional endpoints included all cause death, surgical mitral repair, and functional class. Multivariable adjusted Cox proportional hazard analysis was used for confirmatory purposes.

Results: As many as 1824 patients were included: 718 (39.4%) treated with a single MitraClip, and 940 (51.5%) receiving two MitraClips, and 166 (9.1%) receiving three or more. Significant differences were found for baseline features, including age, female gender, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, prior myocardial infarction, atrial fibrillation, permanent pacemaker, cardiac resynchronization therapy, implantable cardioverter defibrillator, and prior mitral valve repair (all p<0.05). Several imaging features were also different, including left ventricular dimensions, MR severity and proportionality, mitral valve area, flail leaflet, and pulmonary vein flow (all p<0.05). Among procedural features, significant differences were found for anesthesia type, MitraClip type, fluoroscopy, device, and operating room times, postprocedural mitral gradient, residual MR, smoke-like effect, device success partial detachment and surgical conversion (all p<0.05). In-hospital death occurred more frequently in patients receiving multiple MitraClips, and the same applied severe residual MR (all p<0.05). Mid-term follow-up (15±13 months) showed significant difference in the risk of death, cardiac death, rehospitalization for heart failure, and their composites, mainly, but not solely, associated with multiple MitraClips (all p<0.05). Adjusted analysis confirmed the significantly increased risk of composite adverse events when comparing the multiple vs single MitraClip groups (p=0.014 for death and rehospitalization, p=0.013 for cardiac death or rehospitalization).

Conclusions: Implantation of one or two MitraClips is associated with favorable clinical outcomes. Conversely, bail-out implantation of three or more MitraClips may portend a worse long-term prognosis.
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http://dx.doi.org/10.23736/S0031-0808.21.04497-9DOI Listing
July 2021

Effects of Experimental Interventions to Improve the Biomedical Peer-Review Process: A Systematic Review and Meta-Analysis.

J Am Heart Assoc 2021 Aug 19;10(15):e019903. Epub 2021 Jul 19.

Department of Medical-Surgical Sciences and Biotechnologies Sapienza University of Rome Latina Italy.

Background Quality of the peer-review process has been tested only in small studies. We describe and summarize the randomized trials that investigated interventions aimed at improving peer-review process of biomedical manuscripts. Methods and Results All randomized trials comparing different peer-review interventions at author-, reviewer-, and/or editor-level were included. Differences between traditional and intervention-modified peer-review processes were pooled as standardized mean difference (SMD) in quality based on the definitions used in the individual studies. Main outcomes assessed were quality and duration of the peer-review process. Five-hundred and seventy-five studies were retrieved, eventually yielding 24 randomized trials. Eight studies evaluated the effect of interventions at author-level, 16 at reviewer-level, and 3 at editor-level. Three studies investigated interventions at multiple levels. The effects of the interventions were reported as mean change in review quality, duration of the peer-review process, acceptance/rejection rate, manuscript quality, and number of errors detected in 13, 11, 5, 4, and 3 studies, respectively. At network meta-analysis, reviewer-level interventions were associated with a significant improvement in review quality (SMD, 0.20 [0.06 to 0.33]), at the cost of increased duration of the review process (SMD, 0.15 [0.01 to 0.29]), except for reviewer blinding. Author- and editor-level interventions did not significantly impact peer-review quality and duration (respectively, SMD, 0.17 [-0.16 to 0.51] and SMD, 0.19 [-0.40 to 0.79] for quality, and SMD, 0.17 [-0.16 to 0.51] and SMD, 0.19 [-0.40 to 0.79] for duration). Conclusions Modifications of the traditional peer-review process at reviewer-level are associated with improved quality, at the price of longer duration. Further studies are needed. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020187910.
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http://dx.doi.org/10.1161/JAHA.120.019903DOI Listing
August 2021

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis.

J Thorac Cardiovasc Surg 2021 Jun 2. Epub 2021 Jun 2.

New York University Grossman School of Medicine, New York, New York, NY.

Objectives: The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.

Methods: A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.

Results: From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.

Conclusions: No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.036DOI Listing
June 2021

Antithrombotic Therapy for Vascular Disease and Intervention: The Best Is Yet to Come?

J Cardiovasc Pharmacol 2021 Sep;78(3):334-335

Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy.

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http://dx.doi.org/10.1097/FJC.0000000000001092DOI Listing
September 2021

Impact of chronic use of heat-not-burn cigarettes on oxidative stress, endothelial dysfunction and platelet activation: the SUR-VAPES Chronic Study.

Thorax 2021 06 19;76(6):618-620. Epub 2021 Apr 19.

IRCCS NeuroMed, Pozzilli, Italy.

Tobacco habit still represents the leading preventable cause of morbidity and mortality worldwide. Heat-not-burn cigarettes (HNBCs) are considered as an alternative to traditional combustion cigarettes (TCCs) due to the lack of combustion and the absence of combustion-related specific toxicants. The aim of this observational study was to assess the effect of HNBC on endothelial function, oxidative stress and platelet activation in chronic adult TCC smokers and HNBC users. The results showed that both HNBC and TCC display an adverse phenotype in terms of endothelial function, oxidative stress and platelet activation. Future randomised studies are strongly warranted to confirm these data.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215900DOI Listing
June 2021

A novel algorithm for the computation of the diastolic pressure ratio in the invasive assessment of the functional significance of coronary artery disease.

Panminerva Med 2021 Jun;63(2):206-213

Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy -

Background: Invasive functional assessment is a mainstay in the management of patients with coronary artery disease (CAD), but there is uncertainty on the comparative accuracy of diagnostic indices of functional significance. We aimed to validate the diagnostic performance of a novel non-hyperemic diastolic pressure ratio (dPR).

Methods: We performed a retrospective analysis including two separate registries (VERIFY 2, Latina, Italy) of patients in whom functional indices were measured for lesions with angiographically moderate severity. On top of fractional flow reserve, distal coronary pressure (Pd)/aortic pressure (Pa) ratio, instantaneous wave-free ratio (iFR) and diastolic pressure ratio (dPR) were computed using a novel dedicated algorithm over 4 consecutive beats. Agreement/discrepancy between indexes was appraised Bland-Altman analysis, area under the receiver operating characteristic curve (AUC), and unsupervised machine learning.

Results: A total of 525 lesions from 479 patients were included. The novel dPR was highly correlated with iFR (R=0.99, P<0.001), with a mean difference of -0.004±0.014. The diagnostic performance of dPR (best cutoff value: ≤0.89) against iFR was as follows: accuracy =96%; sensitivity =94%; specificity =97%; positive-predictive value =94%; and negative-predictive value =96%. Additionally, AUC to predict iFR≤0.89 was 0.99, which was significantly higher than that of Pd/Pa (0.97, P<0.001). In the iFR range of 0.85-0.93 ("grey zone"), the diagnostic performance was well maintained (accuracy =91%; sensitivity =87%; specificity =93%; and AUC=0.96). Results were supported also by unsupervised learning analysis.

Conclusions: This multicenter registry suggests this novel dPR algorithm provides results that are numerically equivalent to iFR. Pending further studies, physicians may consider using this novel dPR algorithm to gauge the functional significance of a coronary lesion.
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http://dx.doi.org/10.23736/S0031-0808.20.04202-0DOI Listing
June 2021

Use of post-mortem chest computed tomography in Covid-19 pneumonia.

Forensic Sci Int 2021 Aug 27;325:110851. Epub 2021 May 27.

Department of Health Care Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Background And Aim: COVID-19 is an extremely challenging disease, both from a clinical and forensic point of view, and performing autopsies of COVID-19 deceased requires adequately equipped sectorial rooms and exposes health professionals to the risk of contagion. Among one of the categories that are most affected by SARS-Cov-2 infection are the elderly residents. Despite the need for prompt diagnoses, which are essential to implement all isolation measures necessary to contain the infection spread, deceased subjects in long-term care facilities are still are often diagnosed post-mortem. In this context, our study focuses on the use of post-mortem computed tomography for the diagnosis of COVID-19 infection, in conjunction with post-mortem swabs. The aim of this study was to assess the usefulness of post-mortem whole CT-scanning in identifying COVID-19 pneumonia as a cause of death, by comparing chest CT-findings of confirmed COVID-19 fatalities to control cases.

Materials And Methods: The study included 24 deceased subjects: 13 subjects coming from long-term care facility and 11 subjects died at home. Whole body CT scans were performed within 48 h from death in all subjects to evaluate the presence and distribution of pulmonary abnormalities typical of COVID-19-pneumonia, including: ground-glass opacities (GGO), consolidation, and pleural effusion to confirm the post-mortem diagnosis.

Results: Whole-body CT scans was feasible and allowed a complete diagnosis in all subjects. In 9 (69%) of the 13 cases from long-term care facility the cause of death was severe COVID 19 pneumonia, while GGO were present in 100% of the study population.

Conclusion: In the context of rapidly escalating COVID-19 outbreaks, given that laboratory tests for the novel coronavirus is time-consuming and can be falsely negative, the post-mortem CT can be considered as a reliable and safe modality to confirm COVID-19 pneumonia. This is especially true for specific postmortem chest CT-findings that are rather characteristic of COVID-19 fatalities.
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http://dx.doi.org/10.1016/j.forsciint.2021.110851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154189PMC
August 2021

Clinical use of cangrelor: a real world multicenter experience from South Italy Insights from the M.O.Ca. registry.

Panminerva Med 2021 Jun 1. Epub 2021 Jun 1.

Cardiovascular Diseases Section, Cardiothoracic Department (DAI), University of Bari, Bari, Italy.

Background: Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and oral P2Y12 inhibitor (P2Y12-I) represents the standard of care for patients with acute coronary syndromes (ACS) or with chronic coronary syndromes (CCS) treated with percutaneous coronary intervention (PCI). Cangrelor, the first intravenous P2Y12-I, is deemed to overcome the drawbacks of the oral administration; nevertheless real world data on this new drug are scanty. We sought to investigate routine clinical use of cangrelor in four interventional centers of Italy.

Methods: We enrolled 241 consecutive patients (196 ACS, 45 CCS) treated with cangrelor during PCI. Drug administration modalities and in-hospital clinical outcomes were evaluated. A subanalysis in patients selected on the basis of the CHAMPION Phoenix trial inclusion/exclusion criteria (CHAMPION-like subpopulation) was also performed.

Results: Cangrelor was mainly utilized in ACS patients, who presented poorer clinical conditions and higher bleeding risk. Cangrelor was given only in P2Y12-I naïve patients; switch to clopidogrel was always done at the end of the infusion, while ticagrelor or prasugrel were prevalently given 30 minutes before. In-hospital mortality was 10.0% and GUSTO moderate/severe bleeding was 2.5%. Bleeding data showed nevertheless to be in line with the CHAMPION Phoenix results in the "CHAMPION-like" subpopulation.

Conclusions: Cangrelor was predominantly used in ACS with modalities substantially in accord with the label indications. Poor clinical outcomes are due to the prevalent utilization in highly challenging clinical settings, nevertheless the rate of bleeding and stent thrombosis are in line with the randomized trials if analyzed in a subpopulation of comparable risk profile.
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http://dx.doi.org/10.23736/S0031-0808.21.04437-2DOI Listing
June 2021

How to fill the GAPS-I in secondary prevention: application of a strategy based on GLP1 analogues, antithrombotic agents, PCSK9 inhibitors, SGLT2 inhibitors and immunomodulators.

Panminerva Med 2021 Jun 1. Epub 2021 Jun 1.

Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.

The continuous progress in cardiovascular (CV) risk prevention strategies has led to an impressive reduction in mortality and recurrent ischemic events in patients with coronary artery disease (CAD). However, the control of several CV risk factors remains suboptimal in many CAD patients, with a high rate of recurrent events, underlying the need for more new prevention strategies. The GAPS-I (GLP1 analogues, Antithrombotic agents, PCSK9 inhibitors, SGLT2 inhibitors and Immunomodulators) strategy offers a promising potential in patients with a high-residual CV risk, who are frequently encountered in daily practice, by offering an individualised and structured approach to addressing their individual risk factors. The current review summarises the evidence to date on each of its components, with respect to clinical outcomes and economic feasibility. The current evidence points to an efficacy of GAPS-I in reducing MACE and mortality, without a compromise on safety, albeit with the need for longer follow-up data. Key Points: - Secondary prevention remains suboptimal in many CAD patients, highlighting the need for innovative prevention strategies. - The present review discusses the current evidence on efficacy of the GAPS-I strategy in reducing MACE and mortality in patients with CAD. - The GAPS-I strategy, if widely adopted, provides a promising potential to assist cardiologists in managing patients at a heightened risk for further CV events.
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http://dx.doi.org/10.23736/S0031-0808.21.04284-1DOI Listing
June 2021

Urinary Dickkopf-3 and Contrast-Associated Kidney Damage.

J Am Coll Cardiol 2021 Jun;77(21):2667-2676

Laboratory of Interventional Cardiology and Department of Cardiology, Mediterranea Cardiocentro, Naples, Italy. Electronic address:

Background: Administration of iodinated contrast medium (CM) during invasive cardiovascular procedures may be associated with impairment of kidney function.

Objectives: Urinary dickkopf-3 (DKK3), a stress-induced renal tubular epithelium-derived glycoprotein, has been identified as a biomarker predicting both acute kidney injury (AKI) and persistent kidney dysfunction.

Methods: Urinary DKK3/creatinine ratio (uDKK3/uCr), urine and serum neutrophil gelatinase-associated lipocalin (uNGAL, sNGAL) and serum cystatin C (sCyC) were assessed in 458 patients with chronic kidney disease scheduled for invasive cardiovascular procedures requiring CM administration with universal adoption of nephroprotective interventions. Contrast-associated AKI (CA-AKI) was defined as serum creatinine increase ≥0.3 mg/dl at 48 h after CM administration. Persistent kidney dysfunction was defined as persistent estimated glomerular filtration rate reduction ≥25% at 1 month compared with baseline.

Results: CA-AKI occurred in 64 or the 458 patients (14%), and baseline uDKK3/uCr ≥491 pg/mg was the best threshold for its prediction. Net reclassification improvement (NRI) was significantly increased by adding baseline uDKK3/uCr to the Mehran, Gurm, and National Cardiovascular Data Registry (NCDR) scores (all p < 0.05), and the same applied to integrated discrimination improvement (IDI) when adding uDKK3/uCr to the Gurm and NCDR scores (p < 0.001). Persistent kidney dysfunction occurred in 57 of the 458 patients (12%) and baseline uDKK3/uCr ≥322 pg/mg appeared as the best threshold for its prediction. Adding baseline uDKK3/uCr to the Mehran, Gurm, and NCDR scores significantly increased IDI and NRI (all p < 0.001).

Conclusions: Baseline uDKK3/uCr seems to be a reliable marker for improving the identification of patients with chronic kidney disease undergoing invasive coronary and peripheral procedures at risk for AKI and persistent kidney dysfunction.
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http://dx.doi.org/10.1016/j.jacc.2021.03.330DOI Listing
June 2021

The Novel FlexNav Delivery System for Transcatheter Aortic Valve Implantation With the Portico Device: A Case Series.

J Invasive Cardiol 2021 06 10;33(6):E474-E478. Epub 2021 May 10.

Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Via Domitiana km 30.00, 81030 Castel Volturno, Italy.

Background: Transcatheter aortic valve implantation (TAVI) is a safe and beneficial treatment for patients with severe symptomatic aortic stenosis at high and intermediate surgical risk. Success rates for TAVI continue to increase due to more refined procedural approaches and devices, and above all, to the improvements in procedural knowledge by TAVI operators. The development of a new delivery system represents an important evolutionary process in the TAVI procedure, both for the type of device and for the operators, as it may substantially expand indications, success rates, and safety. FlexNav (Abbott Cardiovascular) is a novel delivery system designed to improve ease and precision of TAVI using the Abbott Portico valve. Despite limited results on its advantages, such as those provided in the PORTICO investigational device exemption substudy, uncertainty persists on the actual role of FlexNav in real-world practice.

Methods And Results: We hereby present our preliminary experience with FlexNav in a consecutive series of 18 patients undergoing TAVI with Portico valve in early 2020 (3 with axillary access). Procedural results were excellent, as shown by the absence of deaths, strokes, and major vascular complications (95% confidence interval, 0%-18.5%), and pacemaker implantation in 3 subjects (21.4%; 95% confidence interval, 4.7%-50.8%).

Conclusions: Despite the small sample size, the present case series suggests that adoption of the FlexNav novel delivery system for TAVI with Portico valve is feasible and safe, and holds the promise of further improving early and long-term results of this procedure.
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June 2021

Is COVID-19 the deadliest event of the last century?

Eur Heart J 2021 08;42(30):2876-2879

UOC UTIC Emodinamica e Cardiologia, Santa Maria Goretti Hospital, Via Antonio Canova, 04100 Latina, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehab083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194507PMC
August 2021

Association of admitting physician specialty and care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI): insights from a national registry.

Eur Heart J Qual Care Clin Outcomes 2021 May 12. Epub 2021 May 12.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom (UK).

Background: Little is known about the association between admitting physician specialty and care quality and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).

Methods & Results: We identified 288,420 patients hospitalised with NSTEMI between 2010-2017 in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP) database. The cohort was dichotomised according to care under a non-cardiologist (n = 146,722) and care under a cardiologist (n = 141,698) within the first 24 hours of admission to hospital. Patients admitted under a cardiologist were significantly younger (70-years vs 75 years, P < 0.001), and less likely to be female (32% vs 39%, P < 0.001). Independent factors associated with admission under a cardiologist included: prior history of percutaneous coronary intervention (PCI) (OR:1.04, 95% CI:1.01-1.07, P = 0.04), hypercholesterolaemia (OR: 1.17, 95% CI: 1.15-1.20, P < 0.001), hypertension (OR: 1.03, 95% CI: 1.01-1.04, P = 0.01) and admission to an interventional centre (OR: 3.90, 95% CI: 3.79 - 4.00, P < 0.001). Patients admitted under cardiology were more likely to receive optimal pharmacotherapy, undergo invasive coronary angiography (79% vs 60%, P < 0.001), and receive revascularization in the form of percutaneous coronary intervention (PCI) (52% vs 36%, P < 0.001). Following propensity score matching, odds of in-hospital all-cause mortality (OR:0.81, 95% CI: 0.79-0.85, P < 0.001), reinfarction (OR:0.78, 95% CI: 0.66-0.91, P = 0.001) and major adverse cardiovascular events (MACE) (OR: 0.81, 95% CI: 0.78-0.84, P < 0.001) were lower in patients admitted under a cardiologist.

Conclusion: Patients with NSTEMI admitted under a cardiologist within 24 hours of hospital admission were more likely to receive guideline directed management and had better clinical outcomes.
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http://dx.doi.org/10.1093/ehjqcco/qcab038DOI Listing
May 2021

Association Between Epicardial Adipose Tissue and Stroke.

Front Cardiovasc Med 2021 21;8:658445. Epub 2021 Apr 21.

Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil.

Epicardial adipose tissue (EAT) is correlated with endothelial dysfunction, metabolic syndrome, increased mortality and recent studies showed a possible association with the increased risk of stroke. We performed a systematic review of studies evaluating the association between EAT and stroke. Eighty studies met the inclusion criteria and were consequently analyzed. The review had Five main findings. First, the increased epicardial fat thickness (EFT) may be associated with the stroke episode. Second, regardless of the imaging method (echocardiography, MRI, and CT) this association remains. Third, the association of metabolic syndrome and atrial fibrillation seems to increase the risk of stroke. Fourth, this systematic review was considered as low risk of bias. Despite being unable to establish a clear association between EAT and stroke, we have organized and assessed all the research papers on this topic, analyzing their limitations, suggesting improvements in future pieces of research and pointing out gaps in the literature. Furthermore, the mechanistic links between increased EAT and stroke incidence remains unclear, thus, further research is warranted.
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http://dx.doi.org/10.3389/fcvm.2021.658445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096977PMC
April 2021

Editorial for "Diagnostic Performance of a Lower-Dose Contrast Enhanced 4D Dynamic MR Angiography of the Lower Extremities at 3 T Using Multi-Segmental Time Resolved Maximum Intensity Projections".

J Magn Reson Imaging 2021 09 6;54(3):775-776. Epub 2021 May 6.

Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.

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http://dx.doi.org/10.1002/jmri.27663DOI Listing
September 2021

Efficacy of sodium-glucose cotransporter-2 inhibitors in heart failure patients treated with dual angiotensin receptor blocker-neprilysin inhibitor: an updated meta-analysis.

Eur Heart J Cardiovasc Pharmacother 2021 Jul;7(4):e74-e76

Department of Medicine, Center for Integrated Research and Unit of Drug Sciences, University Campus Bio-Medico, Via Alvaro Del Portillo 21, 00168 Rome, Italy.

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http://dx.doi.org/10.1093/ehjcvp/pvab034DOI Listing
July 2021

Direct and indirect effects of COVID-19 on acute coronary syndromes: Can we pick the worst?

Int J Cardiol 2021 07 24;335:19-20. Epub 2021 Apr 24.

Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Castel Volturno, Italy; Unità Operativa di Emodinamica, Santa Lucia Hospital, San Giuseppe Vesuviano, Italy.

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http://dx.doi.org/10.1016/j.ijcard.2021.04.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064824PMC
July 2021

Expanding the role of fractional flow reserve derived from computed tomography (FFR) for the non-invasive imaging of patients with coronary stents: rise of the machines?

Eur Radiol 2021 09 23;31(9):6589-6591. Epub 2021 Apr 23.

Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy.

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http://dx.doi.org/10.1007/s00330-021-07974-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062143PMC
September 2021

Reduction in emergency access for acute myocardial infarction during the COVID-19 pandemic: a survey from the greater area of Rome, Italy.

Minerva Cardiol Angiol 2021 Apr 7. Epub 2021 Apr 7.

Division of Cardiology, Department of Medical Sciences, Università Tor Vergata, Rome, Italy.

Background: On March 9, 2020, the Italian government imposed a national lockdown to tackle the COronaVIrus Disease 19 (COVID-19) pandemic, including stay at home recommendations. The precise impact of COVID-19 scare and lockdown on emergency access for acute myocardial infarction (MI) is still subject to debate.

Methods: Data on all patients undergoing invasive coronary angiography at 9 hospitals in the greater area of Rome, Italy, between February 19, 2020 and March 29, 2020, 9, 2020, were retrospectively collected. Incidence of ST-elevation MI (STEMI), and non-ST-elevation MI (NSTEMI), as well as corresponding percutaneous coronary intervention (PCI), was compared distinguishing two different 20-day time periods (before vs on or after March 10, 2020).

Results: During the study period, 1,068 patients underwent coronary angiography, 142 (13%) with STEMI and 169 (16%) with NSTEMI. The average daily number of STEMI decreased from 4.3 before the lockdown to 2.9 after the lockdown (p=0.021). Similarly, the average daily number of NSTEMI changed from 5.0 to 3.5 (p=0.028). The average daily number of primary PCI changed from 4.2 to 2.9 (p=0.030), while the average daily number of PCI for NSTEMI changed from 3.5 to 2.5 (p=0.087). For STEMI patients, the time from symptom onset to hospital arrival (onset-to-door time less than three hours) showed a significant increase after the lockdown (p=0.018), whereas door-to-balloon time did not change significantly from before to after the lockdown (p=0.609).

Conclusions: The present study, originally reporting on the trends in STEMI and NSTEMI in the Rome area, highlights that significant decreases in the incidence of both acute coronary syndromes occurred between February 19, 2020 and March 29, 2020, together with increases in time from symptom onset to hospital arrival, luckily without changes in door-to-balloon time.
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http://dx.doi.org/10.23736/S2724-5683.21.05516-2DOI Listing
April 2021

Ischemia-Reperfusion Injury: Can We Stop the Curing-Hurting Paradox?

J Cardiovasc Pharmacol 2021 04;77(4):427-429

Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.

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http://dx.doi.org/10.1097/FJC.0000000000000992DOI Listing
April 2021
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