Publications by authors named "Leonardo Calò"

152 Publications

The uraemic hypertensive patient: a therapeutic challenge-right you are (if you think so).

Eur Heart J Suppl 2020 Nov 18;22(Suppl L):L44-L48. Epub 2020 Nov 18.

Department of Cardiology, Policlinico Casilino, Rome, Italy.

High blood pressure (BP) is a leading cause of chronic kidney disease (CKD) and at the same time represents its most frequent complication. High BP is an independent risk factor for advanced CKD; on the other hand, at least 40% of patients with normal glomerular filtration rate (GFR) and virtually all patients with GFR <30 mL/min are hypertensive. CKD and microalbuminuria are powerful risk factors for cardiovascular morbidity and mortality. Consequently, in uraemic hypertension, it is of utmost importance to carefully manage both high BP and microalbuminuria, in order to slow down the progression of kidney damage and to reduce the incidence of cardiovascular events. The first purpose of the medical treatment in hypertensive patients is to normalize BP, regardless of the drug used. Nevertheless, some drugs have an 'additional' nephroprotective effect at the same BP target achieved. In this regard, first-line drugs are definitely renin-angiotensin-aldosterone inhibitors, mainly for their proved efficacy in reducing hypertension-related kidney damage and proteinuria. Anyway, a combined approach (two or more drugs) is usually needed to achieve the optimal BP target and reduce the worsening of CKD.
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http://dx.doi.org/10.1093/eurheartj/suaa133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904065PMC
November 2020

Cardiovascular effects of COVID-19 lockdown in professional Football players.

Panminerva Med 2021 Feb 10. Epub 2021 Feb 10.

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

Background: The COVID-19 pandemic with the stay-at-home orders and lockdown has dramatically forced athletes to stop team training and competitions, causing deep changes in habits and lifestyle. Aim of this study was to evaluate in a retrospective single center study the cardiovascular (CV) health and fitness of elite football player after COVID-19 lockdown in Italy and to compare such findings with the 2019 off-season period, in order to identify potential differences in the CV features and outcomes.

Methods: All 29 professional Football players of the first male team were enrolled before resuming training and competition after COVID-19 lockdown and underwent several exams including physical examination, resting and stress electrocardiography (ECG), echocardiography, spirometry and blood tests.

Results: Median age was 27 years (23; 31), with no athlete being COVID-19 positive at the time of the evaluation. In comparison with the usual off-season 2-month detraining, significant differences were found for left ventricular (LV) mass (189g [172; 212] vs. 181g [167; 206], p=0.024) and LV mass index for body surface area (94g/m2 [85; 104] vs 88g/m2 [79.5; 101.5], p=0.017), while LV mass/fat free mass remained unchanged (2.8 g/Kg [2.6; 2.9] vs 2.9 g/Kg [2.6; 3.2], p=0.222). Respiratory function and metabolic profile were improved, while no significant changes were found in ECG findings, at rest and during exercise.

Conclusions: Prolonged abstinence from training and competitions induced by lockdown elicited significant changes in comparison with off-season in parameters ascribable to detraining, as the changes in LV mass, in respiratory function and in metabolic profile.
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http://dx.doi.org/10.23736/S0031-0808.21.04340-8DOI Listing
February 2021

Transcatheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy: Long-term results and clinical outcomes.

J Cardiovasc Electrophysiol 2021 Mar 24;32(3):657-666. Epub 2021 Jan 24.

Division of Cardiology, Department of Medical Sciences, "Città della Salute della Scienza" Hospital, University of Turin, Turin, Italy.

Introduction: Radiofrequency transcatheter ablation (RFCA) for atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) has been proven feasible. However, the long-term results of RFCA and its impact on clinical course of HCM are unknown. The aim of this study was to analyse clinical outcomes and long-term efficacy of RFCA in a multicentre cohort of patients with HCM and concomitant AF.

Methods: Patients with HCM and AF consecutively undergoing RFCA were included. Ablation failure was defined as recurrence of AF, atrial tachycardia, or flutter lasting more than 3 min and occurring after the blanking period.

Results: Overall, 116 patients with symptomatic AF refractory to antiarrhythmic drugs were included. Over a median follow-up of 6.0 years (interquartile range: 3.0-8.9 years) recurrence rate after a single RFCA was 32.3 per 100 patient/years with 26% of patients free from AF relapses at 6-year follow-up. Among patients experiencing AF recurrence, 51 (66%) underwent at least one redo-procedure. The overall recurrence rate considering redo-procedures was 12.6 per 100 patients/years with 53% of patients free from AF relapses at 6 years. At last follow-up, with an average of 1.6 procedures, 67 (61%) patients were in sinus rhythm (SR). Patients remaining in SR showed better functional status compared with those experiencing arrhythmic recurrences (NYHA Class 1.6 ± 0.1 vs. 2.0 ± 0.1, p = .009).

Conclusions: RFCA of AF in HCM patients is an effective and safe strategy favoring long-term SR maintenance, reduction of atrial arrhythmic events, and improved functional status. However, most patients need repeat procedures and continuation of antiarrhythmic drugs.
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http://dx.doi.org/10.1111/jce.14880DOI Listing
March 2021

Trends beyond the new normal: from remote monitoring to digital connectivity.

Eur Heart J Suppl 2020 Dec 23;22(Suppl Pt t):P8-P12. Epub 2020 Dec 23.

Clinical Department of Cardiology, University of Graz, Graz, Austria.

COVID pandemic emergency has forced changes from traditional in-person visits to application of telemedicine in order to overcome the barriers and to deliver care. COVID-19 has accelerated adoption of digital health. During this time, the distance is itself a prevention tool and the use of technology to deliver healthcare services and information has driven the discovery of mobile and connected health services. Health services should to be prepared to integrate the old model of remote monitoring of CIEDs and adopt new digital tools such as mobile Apps and connected sensors.
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http://dx.doi.org/10.1093/eurheartj/suaa170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757717PMC
December 2020

Predictors of Left Ventricular Scar Using Cardiac Magnetic Resonance in Athletes With Apparently Idiopathic Ventricular Arrhythmias.

J Am Heart Assoc 2021 Jan 31;10(1):e018206. Epub 2020 Dec 31.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health University of Padova Italy.

Background In athletes with ventricular arrhythmias (VA) and otherwise unremarkable clinical findings, cardiac magnetic resonance (CMR) may reveal concealed pathological substrates. The aim of this multicenter study was to evaluate which VA characteristics predicted CMR abnormalities. Methods and Results We enrolled 251 consecutive competitive athletes (74% males, median age 25 [17-39] years) who underwent CMR for evaluation of VA. We included athletes with >100 premature ventricular beats/24 h or ≥1 repetitive VA (couplets, triplets, or nonsustained ventricular tachycardia) on 12-lead 24-hour ambulatory ECG monitoring and negative family history, ECG, and echocardiogram. Features of VA that were evaluated included number, morphology, repetitivity, and response to exercise testing. Left-ventricular late gadolinium-enhancement was documented by CMR in 28 (11%) athletes, mostly (n=25) with a subepicardial/midmyocardial stria pattern. On 24-hour ECG monitoring, premature ventricular beats with multiple morphologies or with right-bundle-branch-block and intermediate/superior axis configuration were documented in 25 (89%) athletes with versus 58 (26%) without late gadolinium-enhancement (<0.001). More than 3300 premature ventricular beats were recorded in 4 (14%) athletes with versus 117 (53%) without positive CMR (<0.001). At exercise testing, nonsustained ventricular tachycardia occurred at peak of exercise in 8 (29%) athletes with late gadolinium-enhancement (polymorphic in 6/8, 75%) versus 17 athletes (8%) without late gadolinium-enhancement (=0.002), (<0.0001). At multivariable analysis, all 3 parameters independently correlated with CMR abnormalities. Conclusions In athletes with apparently idiopathic VA, simple characteristics such as number and morphology of premature ventricular beats on 12-lead 24-hour ambulatory ECG monitoring and response to exercise testing predicted the presence of concealed myocardial abnormalities on CMR. These findings may help cost-effective CMR prescription.
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http://dx.doi.org/10.1161/JAHA.120.018206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955495PMC
January 2021

Double-chambered left ventricle: An unusual finding in a middle-aged woman.

Echocardiography 2020 Dec 17. Epub 2020 Dec 17.

Policlinico Casilino, Rome, Italy.

Double-chambered left ventricle (DCLV) is a rare congenital abnormality and is characterized by the subdivision of the left ventricle into two separate chambers by an abnormal septum or muscle band. This rare congenital entity is usually diagnosed in the neonatal or pediatric age. Nevertheless, it can be asymptomatic and incidentally found in the adulthood. A comprehensive multimodality imaging approach is crucial for the correct final diagnosis.
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http://dx.doi.org/10.1111/echo.14931DOI Listing
December 2020

Mortality after cardioverter-defibrillator replacement: Results of the DECODE survival score index.

Heart Rhythm 2021 Mar 27;18(3):411-418. Epub 2020 Nov 27.

Institute of Cardiology, Department of Experimental, Diagnostic, and Specialty Medicine, Policlinico S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Background: Device replacement is the ideal time to reassess health care goals regarding continuing implantable cardioverter-defibrillator (ICD) therapy. Only few data are available on the decision making at this time.

Objectives: The goals of this study were to identify factors associated with poor prognosis at the time of ICD replacement and to develop a prognostic index able to stratify those patients at risk of dying early.

Methods: DEtect long-term COmplications after implantable cardioverter-DEfibrillator replacement (DECODE) was a prospective, single-arm, multicenter cohort study aimed at estimating long-term complications in a large population of patients who underwent ICD/cardiac resynchronization therapy - defibrillator replacement. Potential predictors of death were investigated, and all these factors were gathered into a survival score index (SUSCI).

Results: We included 983 consecutive patients (median age 71 years (63-78)); 750 (76%) were men, 537 (55%) had ischemic cardiomyopathy; 460 (47%) were implanted with cardiac resynchronization therapy - defibrillator. During a median follow-up period of 761 days (interquartile range 628-904 days), 114 patients (12%) died. In multivariate Cox regression analysis, New York Heart Association class III/IV, ischemic cardiomyopathy, body mass index < 26 kg/m, insulin administration, age ≥ 75 years, history of atrial fibrillation, and hospitalization within 30 days before ICD replacement remained associated with death. The survival score index showed a good discriminatory power with a hazard ratio of 2.6 (95% confidence interval 2.2-3.1; P < .0001). The risk of death increased according to the severity of the risk profile ranging from 0% (low risk) to 47% (high risk).

Conclusion: A simple score that includes a limited set of variables appears to be predictive of total mortality in an unselected real-world population undergoing ICD replacement. Evaluation of the patient's profile may assist in predicting vulnerability and should prompt individualized options, especially for high-risk patients.
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http://dx.doi.org/10.1016/j.hrthm.2020.11.024DOI Listing
March 2021

Interpretation of elevated high-sensitivity cardiac troponin I in elite soccer players previously infected by severe acute respiratory syndrome coronavirus 2.

Int J Cardiol 2021 03 23;326:248-251. Epub 2020 Nov 23.

Cardiovascular and Thoracic Department, IRCCS Ospedale Policlinico San Martino, Genova, Italia - Italian IRCCS Cardiovascular Network; Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (DIMI), Genova, Italy. Electronic address:

Objectives: To clarify the meaning of elevated cardiac troponin in elite soccer athletes previously infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and screened for cardiovascular involvement in the wake of competitive sport resumption.

Methods: We designed a retrospective cohort study with the collaboration of two Italian Serie A teams. Soccer players from both rosters (58 athletes) were systematically analysed. For every SARS-CoV-2 positive athlete, the Italian Soccer Federation protocol requested full blood tests including high-sensitivity cardiac troponin I (hs-cTnI), along with a complete cardiovascular examination. We extended the analysis to SARS-CoV-2 negative athletes.

Results: A total of 13/58 players (22.4%) suffered from SARS-CoV-2infection: all had a negative cardiovascular examination and 2/13 (15%) showed increased hs-cTnI values (120.8 pg/ml and 72,6 pg/ml, respectively; upper reference level 39.2 pg/ml), which did not track with inflammatory biomarkers. Regarding the 45/58 (77.6%) non infected athletes, a slight increase in hs-cTnI was observed in 2 (4.5%) subjects (values: 61 pg/ml and 75 pg/ml respectively). All hs-cTnI positive athletes (4/58, 7%) underwent cardiac magnetic resonance (CMR), that excluded any cardiac injury.

Conclusions: In our retrospective study, SARS-CoV-2 infection in elite soccer athletes was not associated to clinical or biomarkers abnormalities. Increased hs-cTnI was rare and not significantly associated with previous SARS-COV2 infection nor with pathological findings at CMR, albeit elevated hs-cTnI was numerically more prevalent in the infected group.
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http://dx.doi.org/10.1016/j.ijcard.2020.11.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682525PMC
March 2021

Differences between familial and sporadic dilated cardiomyopathy: ESC EORP Cardiomyopathy & Myocarditis registry.

ESC Heart Fail 2021 Feb 11;8(1):95-105. Epub 2020 Nov 11.

APHP, Centre de Référence des Maladies Cardiaques Héréditaires, ICAN, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France.

Aims: Dilated cardiomyopathy (DCM) is a complex disease where genetics interplay with extrinsic factors. This study aims to compare the phenotype, management, and outcome of familial DCM (FDCM) and non-familial (sporadic) DCM (SDCM) across Europe.

Methods And Results: Patients with DCM that were enrolled in the prospective ESC EORP Cardiomyopathy & Myocarditis Registry were included. Baseline characteristics, genetic testing, genetic yield, and outcome were analysed comparing FDCM and SDCM; 1260 adult patients were studied (238 FDCM, 707 SDCM, and 315 not disclosed). Patients with FDCM were younger (P < 0.01), had less severe disease phenotype at presentation (P < 0.02), more favourable baseline cardiovascular risk profiles (P ≤ 0.007), and less medication use (P ≤ 0.042). Outcome at 1 year was similar and predicted by NYHA class (HR 0.45; 95% CI [0.25-0.81]) and LVEF per % decrease (HR 1.05; 95% CI [1.02-1.08]. Throughout Europe, patients with FDCM received more genetic testing (47% vs. 8%, P < 0.01) and had higher genetic yield (55% vs. 22%, P < 0.01).

Conclusions: We observed that FDCM and SDCM have significant differences at baseline but similar short-term prognosis. Whether modification of associated cardiovascular risk factors provide opportunities for treatment remains to be investigated. Our results also show a prevalent role of genetics in FDCM and a non-marginal yield in SDCM although genetic testing is largely neglected in SDCM. Limited genetic testing and heterogeneity in panels provides a scaffold for improvement of guideline adherence.
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http://dx.doi.org/10.1002/ehf2.13100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835585PMC
February 2021

Sport activity in patients with cardiac implantable electronic devices: evidence and perspectives.

J Cardiovasc Med (Hagerstown) 2021 May;22(5):335-343

Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila.

Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.
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http://dx.doi.org/10.2459/JCM.0000000000001093DOI Listing
May 2021

Atrial fibrillation ablation long-term ESC-EHRA EORP AFA LT registry: in-hospital and 1-year follow-up findings in Italy.

J Cardiovasc Med (Hagerstown) 2020 Oct;21(10):740-748

Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza di Torino' Hospital, University of Turin, Turin.

Aim: To report the Italian data deriving from the European Society of Cardiology-EURObservational Research Program atrial fibrillation ablation long-term registry.

Methods And Results: Ten Italian centers enrolled up to 50 consecutive patients undergoing atrial fibrillation ablation. Of the 318 patients included, 5 (1.6%) did not undergo catheter ablation, 1 had ablation partially done and 62 were lost at 1-year follow-up. Women were less represented (23.6%) and the median age was 60.0 years. A total of 195 patients (62.3%) suffered paroxysmal atrial fibrillation, whereas only 9 (2.9%) had long-standing persistent atrial fibrillation. Most Italian patients (92.3%) were symptomatic but suffering fewer symptomatic events than patients enrolled in other countries (median of two events in the month preceding the ablation vs. three, respectively; P < 0.0001). The main finding of the study is that the success rate at 1 year, with and without antiarrhythmic drugs, was 76.4%, consistently with other participating countries (73.4%). This result was obtained however, with a significantly lower prevalence of 1-year adverse events (7.3 vs. 16.6%, P < 0.0001). Procedure duration and fluoroscopy total time resulted as being shorter in Italy (145 vs. 160, P = 0.0005 and 16.9 vs. 20.0 min, P = 0.0018, respectively); however, the radiation dose per BSA was greater (37.5 vs. 26.0 mGy/cm, P = 0.0022).

Conclusion: The demographic characteristics of patients undergoing atrial fibrillation ablation are similar to those reported in other countries. The success rate in Italy is consistent with those in other countries, whereas the complications rate is lower.
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http://dx.doi.org/10.2459/JCM.0000000000000999DOI Listing
October 2020

Contact-force monitoring increases accuracy of right ventricular voltage mapping avoiding "false scar" detection in patients with no evidence of structural heart disease.

Indian Pacing Electrophysiol J 2020 Nov - Dec;20(6):243-249. Epub 2020 Aug 6.

Cardiology Unit, Policlinico Casilino, Rome, Italy.

Purpose: Electroanatomical mapping (EAM) could increase cardiac magnetic resonance imaging (CMR) sensitivity in detecting ventricular scar. Possible bias may be scar over-estimation due to inadequate tissue contact. Aim of the study is to evaluate contact-force monitoring influence during EAM, in patients with idiopathic right ventricular arrhythmias.

Methods: 20 pts (13 M; 43 ± 12 y) with idiopathic right ventricular outflow tract (RVOT) arrhythmias and no structural abnormalities were submitted to Smarttouch catheter Carto3 EAM. Native maps included points collected without considering contact-force. EAM scar was defined as area ≥1 cm including at least 3 adjacent points with signal amplitude (bipolar <0.5 mV, unipolar 3,5 mV), surrounded by low-voltage border zone. EAM were re-evaluated offline, removing points collected with contact force <5 g. Finally, contact force-corrected maps were compared to the native ones.

Results: An EAM was created for each patient (345 ± 85 points). After removing poor contact points, a mean of 149 ± 60 points was collected. The percentage of false scar, collected during contact force blinded mapping compared to total volume, was 6.0 ± 5.2% for bipolar scar and 7.1 ± 5.9% for unipolar scar, respectively. No EAM scar was present after poor contact points removal. Right ventricular areas analysis revealed a greater number of points with contact force < 5 g acquired in free wall, where reduced mean bipolar and unipolar voltage were recorded.

Conclusions: To date this is the first work conducted on structurally normal hearts in which contact-force significantly increases EAM accuracy, avoiding "false scar" related to non-adequate contact between catheter and tissue.
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http://dx.doi.org/10.1016/j.ipej.2020.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691776PMC
August 2020

Catheter ablation of right atrial ganglionated plexi to treat cardioinhibitory neurocardiogenic syncope: a long-term follow-up prospective study.

J Interv Card Electrophysiol 2020 Aug 6. Epub 2020 Aug 6.

Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169, Rome, Italy.

Purpose: Several reports have focused on biatrial ganglionated plexi (GP) transcatheter ablation to treat cardioinhibitory neurocardiogenic syncope (CNS). Considering that anatomical studies showed a significant number of GP in the right atrium (RA), we hypothesized that RA "cardioneuroablation" could be an effective treatment for CNS.

Methods: Eighteen consecutive patients (mean age: 36.9 ± 11.2 years) with severe CNS were submitted to transcatheter ablation of GPs in the RA alone using an anatomical approach. Head up tilt test evaluation was performed during the follow-up period at 6, 12, and 24 months and in case of significant symptoms, while heart rate variability parameters were evaluated at patients discharge at 1, 3, 6, 12, 24, and 36 months after ablation.

Results: At a mean follow-up of 34.1 ± 6.1 months, 3 (16.6%) patients experienced syncopal episodes and 5 patients (27.7%) only prodromal episodes. Syncopal and prodromal recurrences were significantly decreased both in overall population (P = 0.001) and in symptomatic patients after ablation (P = 0.003). Heart rate variability analysis showed the loss of autonomic balance secondary to a reincrease of sympathetic tone after the acute phase faster than vagal tone more evident at 12 months (LF/HF vs preablation, P < 0.001) and persistent until 24 months. Finally, a good correlation was observed between symptomatic events and the extension of RF lesions in supero-, middle-, and infero-posterior RA areas (r = 0.73, P = 0.03; r = 0.85, P = 0.02; r = 0.87, P = 0.004, respectively).

Conclusions: Cardioneuroablation in the RA can be considered safe and an effective technique to treat CNS episodes.
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http://dx.doi.org/10.1007/s10840-020-00840-9DOI Listing
August 2020

Electrical synchronization achieved by multipoint pacing combined with dynamic atrioventricular delay.

J Interv Card Electrophysiol 2020 Aug 1. Epub 2020 Aug 1.

Cleveland Clinic, Cleveland, OH, USA.

Purpose: Multipoint pacing (MPP) improves left ventricular (LV) electrical synchrony in cardiac resynchronization therapy (CRT). SyncAV automatically adjusts atrioventricular delay (AVD) according to intrinsic AV intervals and may further improve synchrony. Their combination has not been assessed. The objective was to evaluate the improvement in electrical synchrony achieved by SyncAV combined with MPP in an international, multicenter study.

Methods: Patients with LBBB undergoing CRT implant with a quadripolar lead (Abbott Quartet™) were prospectively enrolled. QRS duration (QRSd) was measured by blinded observers from 12-lead ECG during: intrinsic conduction, BiV pacing (conventional biventricular pacing, nominal static AVD), MPP (2 LV cathodes maximally spaced, nominal static AVD), BiV + SyncAV, and MPP + SyncAV. All SyncAV offsets were individualized for each patient to yield the narrowest QRSd during BiV pacing. QRSd changes were compared by ANOVA and post hoc Tukey-Kramer tests.

Results: One hundred and three patients were enrolled (65.7 ± 12.1 years, 67% male, 37% ischemic, EF 26.4 ± 6.5%, PR 190.3 ± 39.1 ms). Relative to intrinsic conduction (QRSd of 165 ± 16 ms), BiV reduced QRSd by 11.9% to 145 ± 18 ms (P < 0.001 vs intrinsic), and MPP reduced QRSd by 13.3% to 142 ± 19 ms (P < 0.001 vs intrinsic). However, enabling SyncAV with a patient-optimized offset nearly doubled this QRSd reduction. BiV + SyncAV reduced QRSd by 22.0% to 128 ± 13 ms (P < 0.001 vs BiV), while MPP + SyncAV reduced QRSd further by 25.6% to 122 ± 14 ms (P < 0.05 vs BiV + SyncAV).

Conclusion: SyncAV can significantly improve acute electrical synchrony beyond conventional CRT, with further improvement achieved by superimposing MPP.
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http://dx.doi.org/10.1007/s10840-020-00842-7DOI Listing
August 2020

Assessment of OMT-28, a synthetic analog of omega-3 epoxyeicosanoids, in patients with persistent atrial fibrillation: Rationale and design of the PROMISE-AF phase II study.

Int J Cardiol Heart Vasc 2020 Aug 10;29:100573. Epub 2020 Jul 10.

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

We designed a placebo controlled, double-blind, randomized, dose-finding phase II study on OMT-28 in the maintenance of sinus rhythm after electrical cardioversion (DCC) in patients with persistent atrial fibrillation (PROMISE-AF). OMT-28 is a first-in-class, synthetic analog of 17,18-epoxyeicosatetetraenoic acid, a bioactive lipid mediator generated by cytochrome P450 enzymes from the omega-3 fatty acid eicosapentaenoic acid. OMT-28 improves Ca-handling and mitochondrial function in cardiomyocytes and reduces pro-inflammatory signaling. This unique mode of action may provide a novel approach to target key mechanism contributing to AF pathophysiology. In a recent phase I study, OMT-28 was safe and well tolerated and showed favorable pharmacokinetics. The PROMISE-AF study (NCT03906799) is designed to assess the efficacy (primary objective), safety, and population pharmacokinetics (secondary objectives) of three different doses of OMT-28, administered once daily, versus placebo until the end of the follow-up period. Recruitment started in March 2019 and the study will include a total of 120 patients. The primary efficacy endpoint is the AF burden (% time with any AF), evaluated over a 13-week treatment period after DCC. AF burden is calculated based on continuous ECG monitoring using an insertable cardiac monitor (ICM). The primary efficacy analysis will be conducted on the modified intention-to-treat (mITT) population, whereas the safety analysis will be done on the safety population. Although ICMs have been used in other interventional studies to assess arrhythmia, PROMISE-AF will be the first study to assess antiarrhythmic efficacy and safety of a novel rhythm-stabilizing drug after DCC by using ICMs.
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http://dx.doi.org/10.1016/j.ijcha.2020.100573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356118PMC
August 2020

Electrocardiographic voltage criteria in patients with hypertrophic cardiomyopathy.

J Cardiovasc Med (Hagerstown) 2020 Sep;21(9):696-703

Department of Cardiology, Policlinico Casilino.

Background: Several ECG voltage criteria have been proposed for the diagnosis of left ventricular hypertrophy (LVH). Notably, ECG criteria have been historically validated in concentric LVH but not in hypertrophic cardiomyopathy (HCM), wherein the hypertrophy pattern is typically asymmetric.

Objectives: The aim of our study was to evaluate the performance of ECG voltage criteria for LVH diagnosis in the HCM population.

Material And Methods: The electrocardiograms of 92 HCM patients and 41 sex- and age-matched controls were evaluated with the most frequently used ECG voltage criteria for LVH diagnosis. Cardiac magnetic resonance (MRI) was performed in HCM and controls in order to quantify LVH and its distribution.

Results: In the HCM population, the maximal diagnostic accuracy was achieved by Amplitude total and Amplitude total product criteria (58% for both), while the Cornell Voltage best performed in septal HCM (62%), the Sokolov in aVL and Gubner criteria in apical HCM (79% for both) and the Cornell Voltage and Product in anterior HCM (86% for both). All the ECG voltage criteria showed a poor correlation with left ventricular mass and maximal thickness measured by cardiac MRI.

Conclusions: In our study, only a few ECG voltage criteria used for the detection of LVH in clinical practice showed an acceptable performance in the HCM population. Further studies are needed to clarify the role of ECG for LVH detection in HCM patients.
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http://dx.doi.org/10.2459/JCM.0000000000001034DOI Listing
September 2020

Clinical characteristics of challenging catheter ablation procedures in patients with WPW syndrome: A 10 year single-center experience.

J Cardiol 2020 10 9;76(4):420-426. Epub 2020 Jun 9.

Division of Cardiology, Policlinico Casilino, Roma, Italy.

Background: Catheter ablation is the established treatment for patients with symptomatic Wolff-Parkinson-White syndrome (WPW). However, some patients undergo a challenging ablation or have recurrences during the early post-ablation phase. The aim of this study was to evaluate the clinical factors associated with an unsuccessful ablation outcome or repeated sessions.

Methods: Four hundred seventy-five symptomatic consecutive WPW patients (38.2±16.2 years old, 61% men, 69% with pre-excitation) who underwent an accessory pathway (AP) ablation from August 2005 to December 2015 were enrolled. When APs recurred, a redo ablation procedure was performed according to the patients' desire.

Results: Four hundred thirty-nine patients (92.4%) were cured by ablation, but it failed in 36 (7.6%) after the first procedure. Seventeen patients had AP recurrences during the acute phase within 36h post-ablation. On the other hand, 4 were identified after more than one year. In a multivariate logistic regression analysis, multiple, parahisian, and broad APs were significant independent predictors of recurrences after the 1st procedure, with odds ratios of 14.88 (p<0.001), 10.14 (p<0.001), and 6.88 (p<0.001), respectively. Finally, 468 patients (98.5%) received a successful ablation during a mean follow-up of 8.3±3.0 years. However, after the final procedure no significant predictors were recognized. Out of 508 total procedures, three major (0.6%) complications occurred.

Conclusions: Symptomatic WPW patients with multiple, parahisian, and broad APs had a significantly higher risk of recurrence. In half of the recurrence patients, AP recurrences were confirmed during the acute phase, but were rarely recorded in the very late phase.
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http://dx.doi.org/10.1016/j.jjcc.2020.05.003DOI Listing
October 2020

Hormonal prostate cancer therapies and cardiovascular disease: a systematic review.

Heart Fail Rev 2020 Jun 4. Epub 2020 Jun 4.

Clinical Oncology Unit, Istituto Neurotraumatologico Italiano (I.N.I.) Grottaferrata, via di S.Anna snc, Grottaferrata, 00046, Rome, Italy.

Therapeutic intervention for prostate cancer mostly relies on eliminating circulating androgen or antagonizing its effect at the cellular level. As the use of endocrine therapies grows, an under-reported incidence of cardiovascular toxicities occurs in prostate cancer patients. In this review, we summarize data of clinical studies, investigating the cardiovascular and metabolic alterations associated with the use of old and new endocrine drugs (gonadotropin-releasing hormone [GnRH] agonists and antagonists, androgen receptor inhibitors, 17α-hydroxylase/c-17,20-lyase [CYP17] inhibitor) in prostate cancer. To date, studies looking for links between cardiovascular complications and hormone-mediated therapies in prostate cancer have reached conflicting results. Several confounding factors, such as age of patients and related cardiovascular liability, other comorbidities, and use of concomitant drugs, have to be carefully evaluated in future clinical trials. Further research is needed given the continuous advancements being made in prostate cancer treatment.
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http://dx.doi.org/10.1007/s10741-020-09984-2DOI Listing
June 2020

Ventricular arrhythmias and risk stratification of cardiac sudden death in athletes.

Minerva Cardioangiol 2020 Apr;68(2):110-122

Division of Cardiology, Casilino Polyclinic, Rome, Italy -

Sudden cardiac death (SCD) of young athletes is an unexpected and tragic event that could occur during sport activities and is frequently related to ventricular arrhythmias. Identifying athletes at risk of SCD remains a major challenge. While specific characteristics of premature ventricular contractions are considered common and benign, other "uncommon" features should require more accurate investigations, in order to determine eligibility for competitive sports. The most common type of idiopathic premature ventricular contractions originates from ventricular outflow tract and is characterized by an ECG pattern with left bundle branch block and inferior QRS axis (infundibular pattern). Another pattern associated with a good prognosis is the "fascicular" morphology, characterized by a typical right bundle branch block, superior QRS axis morphology and QRS duration <130 ms. Conversely, other morphological features (such as left bundle branch block /intermediate or superior axis or right bundle branch block/intermediate or superior axis and wide QRS) correlate to an underlying substrate. In risk stratification setting, cardiac magnetic resonance plays a key role allowing an accurate identification of myocardial tissue abnormalities, which could affect athletes' prognosis. This review focuses on characteristics of premature ventricular contractions characteristics in terms of morphology, distribution, complexity and response to exercise and describes the possible underlying myocardial substrates. This review also critically analyzes the evaluation process of athletes with premature ventricular contractions necessary for an accurate risk stratification.
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http://dx.doi.org/10.23736/S0026-4725.20.05178-6DOI Listing
April 2020

Non-vitamin K antagonist oral anticoagulants and sport.

Minerva Cardioangiol 2020 Apr;68(2):98-109

Department of Cardiology, Casilino Polyclinic Hospital, Rome, Italy.

Physical activity is worldwide recommended for its benefits on cardiovascular system. There is an increasing number of people of all ages that approach sport activity both as leisure time physical activity and as competitive sport. It is always more frequent the request even from older subjects and cardiac patients to be allowed to practice physical activity. Some problems could arise when these subjects present or develop pathologic conditions that require specific pharmacological treatment, in particular an anticoagulation therapy. This review focalizes on the management of oral anticoagulant therapy (OAT) in patients practicing sport activity, especially due to atrial fibrillation and deep vein thrombosis, which represent two highly prevalent conditions, particularly with increasing age. Official recommendations in this field may appear limiting for patients, forbidding in the majority of cases sports at risk of trauma and consequent bleeding. These recommendations still resent the heritage of the "traditional" management of OAT, mainly represented by vitamin-K antagonists (VKAs). The non-vitamin K antagonist oral anticoagulants, with their more favorable pharmacokinetic-pharmacodynamic profile compare to VKAs, may now represent an opportunity to modify the approach to sport activity in patients with an indication to OAT. This review of the literature deals with possible strategies to overcome the present limitations for OAT subjects willing to pursue a healthy lifestyle, that include sport activity, minimizing at the same time their risk of bleeding.
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http://dx.doi.org/10.23736/S0026-4725.20.05177-4DOI Listing
April 2020

Prospective evaluation of the multisensor HeartLogic algorithm for heart failure monitoring.

Clin Cardiol 2020 Jul 18;43(7):691-697. Epub 2020 Apr 18.

Cardiology Division, Università Politecnica delle Marche, Ancona, Italy.

Background: The HeartLogic algorithm measures data from multiple implantable cardioverter-defibrillator-based sensors and combines them into a single index. The associated alert has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Hypothesis: We describe a multicenter experience of remote HF management by means of HeartLogic and appraise the value of an alert-based follow-up strategy.

Methods: The alert was activated in 104 patients. All patients were followed up according to a standardized protocol that included remote data reviews and patient phone contacts every month and at the time of alerts. In-office examinations were performed every 6 months or when deemed necessary.

Results: During a median follow-up of 13 (10-16) months, the overall number of HF hospitalizations was 16 (rate 0.15 hospitalizations/patient-year) and 100 alerts were reported in 53 patients. Sixty alerts were judged clinically meaningful, and were associated with multiple HF-related conditions. In 48 of the 60 alerts, the clinician was not previously aware of the condition. Of these 48 alerts, 43 triggered clinical actions. The rate of alerts judged nonclinically meaningful was 0.37/patient-year, and the rate of hospitalizations not associated with an alert was 0.05/patient-year. Centers performed remote follow-up assessments of 1113 scheduled monthly transmissions (10.3/patient-year) and 100 alerts (0.93/patient-year). Monthly remote data review allowed to detect 11 (1%) HF events requiring clinical actions (vs 43% actionable alerts, P < .001).

Conclusions: HeartLogic allowed relevant HF-related clinical conditions to be identified remotely and enabled effective clinical actions to be taken; the rates of unexplained alerts and undetected HF events were low. An alert-based management strategy seemed more efficient than a scheduled monthly remote follow-up scheme.
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http://dx.doi.org/10.1002/clc.23366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368302PMC
July 2020

Clinical and economic impact of multipoint left ventricular pacing: A comparative analysis from the Italian registry on multipoint pacing in cardiac resynchronization therapy (IRON-MPP).

J Cardiovasc Electrophysiol 2020 05 12;31(5):1166-1174. Epub 2020 Mar 12.

Division of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy.

Introduction: Early evidence suggests that multipoint left ventricular pacing (MPP) may improve response to cardiac resynchronization therapy (CRT). It is unknown whether this benefit is sustained and cost-effective. We used real-world data to evaluate long-term impact of MPP-ON clinical status, heart failure hospitalizations (HFH) and costs.

Methods: The Italian registry on multipoint left ventricular pacing is a prospective, multicenter registry of patients implanted with MPP-enabled CRT devices. For this analysis, clinical and echocardiographic data were collected through 24 months and compared between patients with (MPP-ON) or without (MPP-OFF) early MPP activation at implant. The total cost of each HFH was estimated with national Italian reimbursement rates.

Results: The study included 190 MPP-OFF and 128 MPP-ON patients with similar baseline characteristics. At 1 and 2 years, the MPP-ON group had lower rates of HFH vs MPP-OFF (1-year hazard ratio [HR]: 0.14, P = .0014; 2-year HR: 0.38, P = .009). The finding persisted in a subgroup of patients with consistent MPP activation through follow-up (1-year HR: 0.19; P = .0061; 2-year HR: 0.39, P = .022). Total HFH per-patient costs were lower in the MPP-ON vs the MPP-OFF group at 1 year (€101 ± 50 vs €698 ± 195, P < .001) and 2 years (€366 ± 149 vs €801 ± 203, P = .038). More MPP-ON patients had ≥5% improvement in ejection fraction (76.8% vs 65.4%, P = .025) and clinical composite score (66.7% vs 47.5%, P = .01).

Conclusions: In this multicenter clinical study, early MPP activation was associated with a significant reduction in cumulative HFH and related costs after 1 and 2 years of follow-up.
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http://dx.doi.org/10.1111/jce.14433DOI Listing
May 2020

ICD-measured heart sounds and their correlation with echocardiographic indexes of systolic and diastolic function.

J Interv Card Electrophysiol 2020 Jun 4;58(1):95-101. Epub 2020 Jan 4.

Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie, Monaldi Hospital, Naples, Italy.

Background: Novel implantable defibrillators (ICDs) allow first (S1) and third (S3) heart sounds to be measured by means of an embedded accelerometer. ICD-measured S1 and S3 have been shown to significantly correlate with hemodynamic changes in acute animal models. The HeartLogic algorithm (Boston Scientific) measures and combines multiple parameters, including S3 and S1, into a single index to predict impending heart failure decompensation. We evaluated the echocardiographic correlates of ICD-measured S1 and S3 in patients with ICD and cardiac resynchronization therapy ICD.

Methods: The HeartLogic feature was activated in 104 patients. During in-office visits, patients underwent echocardiographic evaluation, and parameters of systolic and diastolic function were correlated with S3 and S1 amplitude measured on the same day as the visit.

Results: S3 amplitude inversely correlated with deceleration time of the E-wave (r = -0.32; 95% CI -0.46 - -0.17; P < 0.001), and S1 amplitude significantly correlated with left ventricular ejection fraction (r = 0.17; 95% CI 0.03-0.30; P = 0.021). S3 > 0.9 mG detected a restrictive filling pattern with 85% (95% CI 72%-93%) sensitivity and 82% (95% CI 75%-88%) specificity, while S1 < 1.5 mG detected ejection fraction < 35% with 28% (95% CI 19%-40%) sensitivity and 88% (95% CI 80%-93%) specificity.

Conclusion: ICD-measured heart sound parameters are significantly correlated with echocardiographic indexes of systolic and diastolic function. This confirms their utility for remote patient monitoring when used as single sensors and their potential relevance when considered in combination with other physiological ICD sensors that evaluate various aspects of heart failure physiology.
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http://dx.doi.org/10.1007/s10840-019-00668-yDOI Listing
June 2020

Dynamic atrioventricular delay programming improves ventricular electrical synchronization as evaluated by 3D vectorcardiography.

J Electrocardiol 2020 Jan - Feb;58:1-6. Epub 2019 Oct 20.

Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands. Electronic address:

Background: Optimal timing of the atrioventricular delay in cardiac resynchronization therapy (CRT) can improve synchrony in patients suffering from heart failure. The purpose of this study was to evaluate the impact of SyncAV™ on electrical synchrony as measured by vectorcardiography (VCG) derived QRS metrics during bi-ventricular (BiV) pacing.

Methods: Patients implanted with a cardiac resynchronization therapy (CRT) device and quadripolar left ventricular (LV) lead underwent 12‑lead ECG recordings. VCG metrics, including QRS duration (QRSd) and area, were derived from the ECG by a blinded observer during: intrinsic conduction, BiV with nominal atrioventricular delays (BiV Nominal), and BiV with SyncAV programmed to the optimal offset achieving maximal synchronization (BiV + SyncAV Opt).

Results: One hundred patients (71% male, 40% ischemic, 65% LBBB, 32 ± 9% ejection fraction) completed VCG assessment. QRSd during intrinsic conduction (166 ± 25 ms) was narrowed successively by BiV Nominal (137 ± 23 ms, p < .05 vs. intrinsic) and BiV + SyncAV Opt (122 ± 22 ms, p < .05 vs. BiV Nominal). Likewise, 3D QRS area during intrinsic conduction (90 ± 42 mV ∗ ms) was reduced by BiV Nominal (65 ± 39 mV ∗ ms, p < .05 vs. intrinsic) and further by BiV + SyncAV Opt (53 ± 30 mV ∗ ms, p = .06 vs. BiV Nominal).

Conclusion: With VCG-based, patient-specific optimization of the programmable offset, SyncAV reduced electrical dyssynchrony beyond conventional CRT.
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http://dx.doi.org/10.1016/j.jelectrocard.2019.09.026DOI Listing
October 2019

Impact of multipoint pacing on projected battery longevity in cardiac resynchronization therapy. An IRON-MPP study sub-analysis.

J Cardiovasc Electrophysiol 2019 12 5;30(12):2885-2891. Epub 2019 Nov 5.

Department of Cardiology, Ospedale GB Grassi, Ostia, Italy.

Background: Multipoint pacing (MPP) may improve clinical outcomes in patients with cardiac resynchronization therapy defibrillators (CRT-D), but its impact on battery longevity in a real-world population has not been investigated in large trials.

Objective: Compare projected battery longevity in CRT-D patients with and without MPP during long-term follow-up.

Methods: The Italian registry on multipoint left ventricular pacing (IRON-MPP) is a prospective, multicenter registry of patients implanted with MPP-capable CRT-D devices. Projected battery longevity during follow-up was compared for patients with MPP (MPP ON) vs single-site (MPP OFF) left ventricular pacing at CRT-D implantation. A sub-analysis excluded crossover patients with MPP activation or deactivation occurring after implantation. A second sub-analysis excluded patients with a right or left ventricular pacing amplitude >2.5 V.

Results: Out of 237 CRT-D patients (71 ± 9 years, 81% male) followed for 1.9 ± 0.8 years, 102 (43%) had MPP ON at implantation. Programmed atrial and ventricular outputs and percentage of pacing were similar between groups. MPP was associated with a 0.44 years reduction in projected battery longevity (P = .03) during long-term follow-up. Results were similar for the first and second sub-analyses, with a 0.57 years (P < .001) and 0.71 years (P < .001) reduction in projected longevity, respectively.

Conclusion: In this long-term real-world registry, early MPP activation is associated with less than a 1-year reduction in projected battery life compared to single-site biventricular pacing.
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http://dx.doi.org/10.1111/jce.14254DOI Listing
December 2019

A case of recurrent acute myocardial infarction.

J Cardiovasc Med (Hagerstown) 2020 Mar;21(3):259-263

Department of Cardiology, Policlinico Casilino, Rome, Italy.

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http://dx.doi.org/10.2459/JCM.0000000000000883DOI Listing
March 2020

Out-of-hospital cardiac arrest due to idiopathic ventricular fibrillation in patients with normal electrocardiograms: results from a multicentre long-term registry.

Europace 2019 Nov;21(11):1670-1677

Electrophysiology Unit, Department of Cardiology, Fondazione Cardiocentro Ticino, via Tesserete 48, Lugano, Switzerland.

Aims : To define the clinical characteristics and long-term clinical outcomes of a large cohort of patients with idiopathic ventricular fibrillation (IVF) and normal 12-lead electrocardiograms (ECGs).

Methods And Results: Patients with ventricular fibrillation as the presenting rhythm, normal baseline, and follow-up ECGs with no signs of cardiac channelopathy including early repolarization or atrioventricular conduction abnormalities, and without structural heart disease were included in a registry. A total of 245 patients (median age: 38 years; males 59%) were recruited from 25 centres. An implantable cardioverter-defibrillator (ICD) was implanted in 226 patients (92%), while 18 patients (8%) were treated with drug therapy only. Over a median follow-up of 63 months (interquartile range: 25-110 months), 12 patients died (5%); in four of them (1.6%) the lethal event was of cardiac origin. Patients treated with antiarrhythmic drugs only had a higher rate of cardiovascular death compared to patients who received an ICD (16% vs. 0.4%, P = 0.001). Fifty-two patients (21%) experienced an arrhythmic recurrence. Age ≤16 years at the time of the first ventricular arrhythmia was the only predictor of arrhythmic recurrence on multivariable analysis [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.18-0.92; P = 0.03].

Conclusion : Patients with IVF and persistently normal ECGs frequently have arrhythmic recurrences, but a good prognosis when treated with an ICD. Children are a category of IVF patients at higher risk of arrhythmic recurrences.
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http://dx.doi.org/10.1093/europace/euz221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826207PMC
November 2019

Coronary Artery Fistula Diagnosed by Echocardiography during NSTEMI: Case Report and Review of Literature.

Case Rep Cardiol 2019 14;2019:5956806. Epub 2019 Aug 14.

Cardiology, Department of Life, Health & Environmental Sciences, University of L'Aquila, Italy.

Coronary artery fistulas are rare abnormal connections between a coronary artery and a cardiac chamber or a major vessel. Often, they are asymptomatic and the diagnosis is accidental. The case we present is the incidental finding of a fistula displayed with echocardiography during acute coronary syndrome (ACS). A 73-year-old man presented in the emergency room for non-ST-elevation ACS. Echocardiogram showed in a parasternal short axis view an abnormal diastolic flow inside the ventricular inferior wall. Angiography and CT confirmed the diagnosis of coronary fistula from the right coronary into the left ventricular cavity. A literature analysis with discussion about coronary fistulas classification and management was also performed.
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http://dx.doi.org/10.1155/2019/5956806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6710726PMC
August 2019