Publications by authors named "Nazzareno Galiè"

207 Publications

Long-term echocardiographic findings after TAVR: 5-year follow-up in 400 consecutive patients.

Intern Emerg Med 2021 Mar 26. Epub 2021 Mar 26.

Cardiology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.

A little is known about long-term hemodynamic performance of the transcatheter heart valves (THVs). The aim of the present study was to assess hemodynamic outcome, structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) in patients treated with transcatheter aortic valve replacement (TAVR) five or more years ago. All consecutive patients treated at Bologna and Florence University Hospitals with TAVR between January 2008 and December 2013 were analyzed in a retrospective registry with regards to demographic, procedural and outcome data as well as follow-up data on mortality and echocardiographic characteristics. Standardized definitions were used to define outcomes and durability of the THVs. 400 patients were included in the study, mostly treated with transfemoral TAVR (71.8%), using first generation balloon-expandable (37%) or self-expanding (63%) devices. The 1-year mortality was 21.8% (87 patients) and 5-year mortality was 53.8% (215 patients). Median follow-up was 45.5 months (14.0-68.9) totaling 1516.7 patient/years, with the longest follow-up being 10.25 years. At least one follow-up echocardiogram was available for 320 patients (80%), SVD occurred in 19 of these patients (5.94%): moderate in 17 patients (5.31%) and severe in two patients (0.63%). The hemodynamic presentation was stenosis in most of the cases (12 patients). Late BVF was registered in 10 patients (3.13%) and this was mainly driven by transcatheter paravalvular leak closure (six patients) with subsequent good long-term outcome. Our results confirm that TAVR appears to be a long-lasting treatment strategy with low rates of structural valve degeneration and valve failure.
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http://dx.doi.org/10.1007/s11739-021-02689-wDOI Listing
March 2021

Donor-derived human herpesvirus 8 infection with kaposi sarcoma and kaposi sarcoma inflammatory cytokine syndrome in a heart transplant recipient: a case report.

Transpl Infect Dis 2021 Mar 26:e13609. Epub 2021 Mar 26.

1Heart Failure and Transplant Program, Cardiology Unit, IRCCS Azienda Ospedaliero, Universitaria di Bologna Policlinico S Orsola-Malpighi, University of Bologna, Bologna, Italy.

Human herpesvirus-8 (HHV-8) infection is associated with neoplastic and non-neoplastic diseases in immunocompromised patients. Kaposi sarcoma (KS) is a common malignancy reported in solid organ transplant recipients (SOTR). Kaposi sarcoma inflammatory cytokine syndrome (KICS), initially described in HIV patients, is characterized by high viral loads, elevated levels of cytokines, cytopenia, high fever, organ failure and poor outcome. We report the case of a 54-year-old patient who developed simultaneous occurrence of KS of lymph nodes and KICS as a complication of primary donor-transmitted HHV-8 infection, after heart transplantation (HT). The diagnosis, management and prognosis of this condition is unclear and needs a multidisciplinary approach.
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http://dx.doi.org/10.1111/tid.13609DOI Listing
March 2021

Clues and pitfalls in the diagnostic approach to cardiac masses: are pseudo-tumours truly benign?

Eur J Prev Cardiol 2021 Feb 28. Epub 2021 Feb 28.

Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, 40138 Bologna, Italy.

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http://dx.doi.org/10.1093/eurjpc/zwab032DOI Listing
February 2021

Pattern of arterial inflammation and inflammatory markers in people living with HIV compared with uninfected people.

J Nucl Cardiol 2021 Feb 10. Epub 2021 Feb 10.

Division of Cardiology, Department of Experimental Diagnostic and Specialty Medicine, IRCCS Policlinico di St.Orsola, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.

Study Design: To compare arterial inflammation (AI) between people living with HIV (PLWH) and uninfected people as assessed by F-Fluorodeoxyglucose (F-FDG)-positron emission tomography (PET).

Methods: We prospectively enrolled 20 PLWH and 20 uninfected people with no known cardiovascular disease and at least 3 traditional cardiovascular risk factors. All patients underwent F-FDG-PET/computed tomography (CT) of the thorax and neck. Biomarkers linked to inflammation and atherosclerosis were also determined. The primary outcome was AI in ascending aorta (AA) measured as mean maximum target-to-background ratio (TBR). The independent relationships between HIV status and both TBR and biomarkers were evaluated by multivariable linear regression adjusted for body mass index, creatinine, statin therapy, and atherosclerotic cardiovascular 10-year estimated risk (ASCVD).

Results: Unadjusted mean TBR in AA was slightly higher but not statistically different (P = .18) in PLWH (2.07; IQR 1.97, 2.32]) than uninfected people (2.01; IQR 1.85, 2.16]). On multivariable analysis, PLWH had an independent risk of increased mean log-TBR in AA (coef = 0.12; 95%CI 0.01,0.22; P = .032). HIV infection was independently associated with higher values of interleukin-10 (coef = 0.83; 95%CI 0.34, 1.32; P = .001), interferon-γ (coef. = 0.90; 95%CI 0.32, 1.47; P = .003), and vascular cell adhesion molecule-1 (VCAM-1) (coef. = 0.75; 95%CI: 0.42, 1.08, P < .001).

Conclusions: In patients with high cardiovascular risk, HIV status was an independent predictor of increased TBR in AA. PLWH also had an increased independent risk of IFN-γ, IL-10, and VCAM-1 levels.
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http://dx.doi.org/10.1007/s12350-020-02522-5DOI Listing
February 2021

Relationship Between Time From Diagnosis and Morbidity or Mortality in Pulmonary Arterial Hypertension: Results From the Phase III GRIPHON Study.

Chest 2021 Feb 3. Epub 2021 Feb 3.

Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria.

Background: Early initiation of pulmonary arterial hypertension (PAH) therapies is associated with improved long-term outcomes, yet data on the early use of prostacyclin pathway agents are limited. In these post hoc analyses of the GRIPHON study, the largest randomized controlled trial for PAH to date, the prognostic value of time from diagnosis and its impact on treatment response were examined.

Research Question: How does time from diagnosis impact morbidity and mortality events and response to selexipag treatment in patients with PAH?

Study Design And Methods: The GRIPHON study randomly assigned 1,156 patients with PAH to selexipag or placebo treatment. Patients were categorized post hoc into a time from diagnosis of ≤ 6 months and > 6 months at randomization. Hazard ratios (selexipag vs placebo) were calculated for the primary end point of morbidity and mortality events by time from diagnosis using Cox proportional hazard models.

Results: Time from diagnosis was ≤ 6 months in 34.9% and > 6 months in 65.1% of patients. Time from diagnosis was prognostic of morbidity and mortality, with newly diagnosed patients having a poorer long-term outcome than patients diagnosed for longer. Compared with placebo, selexipag reduced the risk of morbidity and mortality in patients with a time from diagnosis of ≤ 6 months and > 6 months, with a more pronounced effect in newly diagnosed patients (hazard ratio, 0.45 [95% CI, 0.33-0.63] and 0.74 [95% CI, 0.57-0.96], respectively; P = .0219 for interaction).

Interpretation: In the GRIPHON study, newly diagnosed PAH patients had a worse prognosis than patients with a longer time from diagnosis. The benefit of selexipag treatment on disease progression was more pronounced in patients treated earlier than in patients treated later.

Trial Registry: ClinicalTrials.gov; No.: NCT01106014; URL:www.clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.chest.2021.01.066DOI Listing
February 2021

Hyperglycemia, inflammatory response and infarct size in obstructive acute myocardial infarction and MINOCA.

Cardiovasc Diabetol 2021 Feb 2;20(1):33. Epub 2021 Feb 2.

Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Via Giuseppe Massarenti 9, Bologna, 40138, Italy.

Background: Hyperglycemia has been associated with increased inflammatory indexes and larger infarct sizes in patients with obstructive acute myocardial infarction (obs-AMI). In contrast, no studies have explored these correlations in non-obstructive acute myocardial infarction (MINOCA). We investigated the relationship between hyperglycemia, inflammation and infarct size in a cohort of AMI patients that included MINOCA.

Methods: Patients with AMI undergoing coronary angiography between 2016 and 2020 were enrolled. The following inflammatory markers were evaluated: C-reactive protein, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR). Myocardial infarct size was measured by peak high sensitivity troponin I (Hs-TnI) levels, left-ventricular-end-diastolic-volume (LVEDV) and left ventricular ejection fraction (LVEF).

Results: The final study population consisted of 2450 patients with obs-AMI and 239 with MINOCA. Hyperglycemia was more prevalent among obs-AMI cases. In all hyperglycemic patients-obs-AMI and MINOCA-NLR, NPR, and LPR were markedly altered. Hyperglycemic obs-AMI subjects exhibited a higher Hs-TnI (p < 0.001), a larger LVEDV (p = 0.003) and a lower LVEF (p < 0.001) compared to normoglycemic ones. Conversely, MINOCA patients showed a trivial myocardial damage, irrespective of admission glucose levels.

Conclusions: Our data confirm the association of hyperglycemic obs-AMI with elevated inflammatory markers and larger infarct sizes. MINOCA patients exhibited modest myocardial damage, regardless of admission glucose levels.
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http://dx.doi.org/10.1186/s12933-021-01222-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856791PMC
February 2021

The value of ECG changes in risk stratification of COVID-19 patients.

Ann Noninvasive Electrocardiol 2021 Jan 29:e12815. Epub 2021 Jan 29.

Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy.

Background: There is growing evidence of cardiac injury in COVID-19. Our purpose was to assess the prognostic value of serial electrocardiograms in COVID-19 patients.

Methods: We evaluated 269 consecutive patients admitted to our center with confirmed SARS-CoV-2 infection. ECGs available at admission and after 1 week from hospitalization were assessed. We evaluated the correlation between ECGs findings and major adverse events (MAE) as the composite of intra-hospital all-cause mortality or need for invasive mechanical ventilation. Abnormal ECGs were defined if primary ST-T segment alterations, left ventricular hypertrophy, tachy or bradyarrhythmias and any new AV, bundle blocks or significant morphology alterations (e.g., new Q pathological waves) were present.

Results: Abnormal ECG at admission (106/216) and elevated baseline troponin values were more common in patients who developed MAE (p = .04 and p = .02, respectively). Concerning ECGs recorded after 7 days (159), abnormal findings were reported in 53.5% of patients and they were more frequent in those with MAE (p = .001). Among abnormal ECGs, ischemic alterations and left ventricular hypertrophy were significantly associated with a higher MAE rate. The multivariable analysis showed that the presence of abnormal ECG at 7 days of hospitalization was an independent predictor of MAE (HR 3.2; 95% CI 1.2-8.7; p = .02). Furthermore, patients with abnormal ECG at 7 days more often required transfer to the intensive care unit (p = .01) or renal replacement therapy (p = .04).

Conclusions: Patients with COVID-19 should receive ECG at admission but also during their hospital stay. Indeed, electrocardiographic alterations during hospitalization are associated with MAE and infection severity.
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http://dx.doi.org/10.1111/anec.12815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994985PMC
January 2021

Target Lesion Failure With Current Drug-Eluting Stents: Evidence From a Comprehensive Network Meta-Analysis.

JACC Cardiovasc Interv 2020 12;13(24):2868-2878

Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, IRCCS Policlinico di St. Orsola, Alma Mater Studiorum Università di Bologna, Bologna, Italy.

Objectives: The aim of this study was to investigate the efficacy and safety of currently used drug-eluting stents (DES).

Background: Head-to-head comparisons among newer DES have shown conflicting results.

Methods: For this network meta-analysis, randomized controlled trials comparing different types of currently used DES were searched in PubMed, Scopus, and proceedings of international meetings. The primary endpoint was target lesion failure (TLF) at 1 year and at long-term follow-up.

Results: Seventy-seven trials with 99,039 patients were selected for this network meta-analysis. Among the 10 DES included in the meta-analysis, 4 received the most extensive investigation: Orsiro, XIENCE, Nobori/BioMatrix, and Resolute. At 1 year, the Orsiro stent was associated with lower rates of TLF compared with XIENCE (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.03), Resolute (OR: 0.81; 95% CI: 0.68 to 0.95; p = 0.01), and Nobori/BioMatrix (OR: 0.81; 95% CI: 0.67 to 0.98; p = 0.03). Orsiro had the highest probability to be the best (70.8%), with a surface under the cumulative ranking curve value of 95.9%. However, after a median follow-up period of 50 months (range: 24 to 60 months), no significant difference was apparent in the rates of TLF between any DES, although Orsiro still ranked as the best stent (58.6% probability to be the best). In addition, Orsiro had a lower rate of long-term definite stent thrombosis compared with Nobori/BioMatrix (OR: 0.60; 95% CI: 0.36 to 0.98; p = 0.04) and lower rates of definite and probable stent thrombosis compared with Resolute (OR: 0.66; 95% CI: 0.45 to 0.99; p = 0.04). No differences in cardiac mortality between any DES were observed.

Conclusions: Orsiro is associated with a lower 1-year rate of TLF compared with XIENCE, Resolute, and Nobori/BioMatrix but with an attenuation of the efficacy signal at long-term follow-up.
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http://dx.doi.org/10.1016/j.jcin.2020.09.014DOI Listing
December 2020

ERS Statement on Chronic Thromboembolic Pulmonary Hypertension.

Eur Respir J 2020 Dec 17. Epub 2020 Dec 17.

Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels less than 500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This Statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society (ERS), the International CTEPH Association (ICA) and the European Reference Network (ERN)-Lung in the pulmonary hypertension domain. The Statement summarises current knowledge but does not make formal recommendations for clinical practice.
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http://dx.doi.org/10.1183/13993003.02828-2020DOI Listing
December 2020

Single-photon cardiac imaging in patients with cardiac implantable electrical devices.

J Nucl Cardiol 2020 Nov 25. Epub 2020 Nov 25.

Department of Cardiology, IRCCS - Azienda Ospedaliero-Universitaria di Bologna - Policlinico di S.Orsola, Bologna, Italy.

Nuclear imaging techniques like single-photon emission computed tomography (SPECT) and radionuclide angiography have wide applications in patients receiving a cardiac implantable electrical device (CIED), who cannot usually undergo cardiac magnetic resonance. Our aim was to provide an update of single-photon imaging clinical applications, with a specific focus on CIED recipients. SPECT imaging is commonly used in CIED patients to assess myocardial perfusion, but it can also be used to evaluate myocardial viability, which is an important predictor of LV function improvement by cardiac resynchronization therapy (CRT). Radionuclide angiography has shown higher temporal resolution and reproducibility than SPECT in the evaluation of cardiac function and dyssynchrony. Left ventricular dyssynchrony as assessed by radionuclide angiography with phase analysis may be reliably used for CRT patient selection and evaluation of CRT response. SPECT imaging with meta-iodo-benzyl-guanidine allows for cardiac sympathetic innervation examination, which may be used for prognostic stratification of heart failure patients and prediction of ventricular tachyarrhythmias. Finally, promising results in CIED infection diagnosis have been shown by SPECT with radiolabeled autologous white blood cells.
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http://dx.doi.org/10.1007/s12350-020-02436-2DOI Listing
November 2020

Correlation between aortic root dimension and coronary ectasia.

Coron Artery Dis 2020 Oct 13. Epub 2020 Oct 13.

Department of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.

Background: Aortic aneurysms are associated with coronary artery ectasia (CAE). However, the relation between the extent of CAE and the severity of aortic dilatation is not understood. This study was undertaken to investigate the relationship between angiographic extension of CAE and aortic dimension.

Patients And Methods: We retrospectively include 135 patients with angiographic diagnosis of CAE defined as dilatation of coronary segment more than 1.5 times than an adjacent healthy one. Study population was divided in four groups according to the maximum diameter of ascending aorta beyond sinus of Valsalva obtained in the parasternal long-axis view (group 1: <40 mm; group 2: 40-45 mm; group 3: 45-55 mm; group 4: >55 mm or previous surgery because of aortic aneurysm/dissection. The relationship between aortic dimension and the extension of CAE was investigated by means of multivariable linear regression, including variables selected at univariable analysis (P < 0.1). The total estimated ectatic area (EEA total) was used as dependent variable.

Results: Baseline characteristics of study groups were well balanced. Patients in group 4 were more likely to have both higher neutrophil count and neutrophil to lymphocyte ratio. On univariable analysis ascending aorta diameter [Coef. = 0.075; 95% confidence interval (CI) 0.052-0.103, P < 0.01] and c-reactive protein (CRP) values [Coef. = 0.033, 95% CI 0.003-0.174, P = 0.04] showed a linear association with total EEA. After adjustment for CRP values only the ascending aorta diameter was still associated with the extent of CAE (95% CI 0.025-0.063, P < 0.01).

Conclusion: In patients with diagnosis of CAE, a strong linear association between aortic dimension and coronary ectasia extent exists.
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http://dx.doi.org/10.1097/MCA.0000000000000977DOI Listing
October 2020

Cost-effectiveness of cardiac resynchronization therapy.

J Med Econ 2020 Dec 21;23(12):1375-1378. Epub 2020 Oct 21.

Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy.

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http://dx.doi.org/10.1080/13696998.2020.1833893DOI Listing
December 2020

Optical coherence tomography assessment of macrophages accumulation in non-ST-segment elevation acute coronary syndromes.

J Cardiovasc Med (Hagerstown) 2020 Nov;21(11):860-865

Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Bologna.

Aims: To investigate in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) the prevalence and the features of optical coherence tomography (OCT)-detected macrophages accumulation in culprit plaques as compared with nonculprit plaques (NCP).

Methods: The study is a post-hoc analysis of a prospective study aimed at evaluating the relationship between aortic inflammation as assessed by F-fluorodeoxyglucose-PET and features of coronary plaque vulnerability as assessed by OCT. We enrolled 32 patients with first NSTE-ACS who successfully underwent three-vessel OCT.

Results: The median age was 65 (54-72) years and 27 patients (84%) were men. Culprit plaques were clinically defined. Overall, the rate of lipid plaques and lipid plaques containing macrophages were 6.4 and 4.2 per patient, respectively. Culprit plaques had a smaller minimal luminal area, a higher extension of lipid component and a thinner fibrous cap than NCPs. Macrophages accumulations were more likely found in culprit plaque (84 vs. 61%, P = 0.015) in which they had also a higher circumferential extension. On univariable analysis, macrophages accumulation extension had a higher association with culprit plaques (odds ratio = 4.42; 95% confidence interval; 2.54-9.15, P < 0.001) than the mere presence of macrophages accumulation (odds ratio = 3.36; 95% confidence interval; 1.30-8.66, P = 0.012). Culprit plaques with thrombus had a lower distance between macrophages accumulation and the luminal surface than culprit plaque with no thrombus (0.06 vs. 0.1 mm; P = 0.04).

Conclusion: In patients with NSTE-ACS, macrophages accumulations are more likely present in culprit plaque in which they disclose also a greater extension compared with those observed in NCP. The distance between macrophages accumulation and the luminal surface is lower in thrombotic culprit plaque than that in nonthrombotic culprit plaque.
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http://dx.doi.org/10.2459/JCM.0000000000001015DOI Listing
November 2020

Arrhythmic safety of hydroxychloroquine in COVID-19 patients from different clinical settings.

Europace 2020 12;22(12):1855-1863

Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy.

Aims: The aim of the study was to describe ECG modifications and arrhythmic events in COVID-19 patients undergoing hydroxychloroquine (HCQ) therapy in different clinical settings.

Methods And Results: COVID-19 patients at seven institutions receiving HCQ therapy from whom a baseline and at least one ECG at 48+ h were available were enrolled in the study. QT/QTc prolongation, QT-associated and QT-independent arrhythmic events, arrhythmic mortality, and overall mortality during HCQ therapy were assessed. A total of 649 COVID-19 patients (61.9 ± 18.7 years, 46.1% males) were enrolled. HCQ therapy was administrated as a home therapy regimen in 126 (19.4%) patients, and as an in-hospital-treatment to 495 (76.3%) hospitalized and 28 (4.3%) intensive care unit (ICU) patients. At 36-72 and at 96+ h after the first HCQ dose, 358 and 404 ECGs were obtained, respectively. A significant QT/QTc interval prolongation was observed (P < 0.001), but the magnitude of the increase was modest [+13 (9-16) ms]. Baseline QT/QTc length and presence of fever (P = 0.001) at admission represented the most important determinants of QT/QTc prolongation. No arrhythmic-related deaths were reported. The overall major ventricular arrhythmia rate was low (1.1%), with all events found not to be related to QT or HCQ therapy at a centralized event evaluation. No differences in QT/QTc prolongation and QT-related arrhythmias were observed across different clinical settings, with non-QT-related arrhythmias being more common in the intensive care setting.

Conclusion: HCQ administration is safe for a short-term treatment for patients with COVID-19 infection regardless of the clinical setting of delivery, causing only modest QTc prolongation and no directly attributable arrhythmic deaths.
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http://dx.doi.org/10.1093/europace/euaa216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543547PMC
December 2020

Preliminary Experience With Low Molecular Weight Heparin Strategy in COVID-19 Patients.

Front Pharmacol 2020 6;11:1124. Epub 2020 Aug 6.

Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy.

Background: Heparin administration in COVID-19 patients is recommended by expert consensus, although evidence about dosage, duration and efficacy are limited. We aim to investigate the association between different dosages of low molecular weight heparin (LMWH) and mortality among COVID-19 hospitalized patients.

Methods And Results: Retrospective study of 450 laboratory-confirmed COVID-19 patients admitted to Sant'Orsola Bologna Hospital from March 01 to April 10, 2020. Clinical, laboratory and treatment data were collected and analyzed. The in-hospital mortality between COVID-19 patients treated with standard prophylactic LMWH dosage vs. intermediate LMWH dosage was compared. Out of 450 patients, 361 received standard deep vein thrombosis (DVT) prophylaxis enoxaparin treatment (40-60mg daily) and 89 patients received intermediate enoxaparin dosage (40-60 mg twice daily) for 7 days. No significant differences in the main demographic characteristics and laboratory testings at admission were observed in the two heparin regimen subgroups, except for older age and prevalence of hypertension in the group treated with "standard" prophylaxis LMWH dosage. The intermediate LMWH administration was associated with a lower in-hospital all-cause mortality compared to the "standard" prophylactic LMWH dosage (18.8% vs. 5.8%, p = 0.02). This difference remained significant after adjustment with the propensity score for variables that differed significantly between the dosage groups (OR= 0.260, 95% CI 0.089-0.758, p=0.014).

Conclusions: Intermediate LMWH dosage seems to be associated with lower incidence of mortality compared to standard DVT prophylaxys in hospitalized COVID-19 patients. Our study paves the way to further pathophysiological investigations and controlled studies of anticoagulation therapy in Covid-19 disease.
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http://dx.doi.org/10.3389/fphar.2020.01124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424043PMC
August 2020

Routine minimalist transcatheter aortic valve implantation with local anesthesia only.

J Cardiovasc Med (Hagerstown) 2020 10;21(10):805-811

Cardiology Unit.

Aims: Conscious sedation instead of general anesthesia has been increasingly adopted in many centers for transfemoral transcatheter aortic valve replacement (TAVR). Improvement of materials and operators' experience and reduction of periprocedural complications allowed procedural simplification and adoption of a minimalist approach. With this study, we sought to assess the feasibility and safety of transfemoral TAVR routinely performed under local anesthesia without on-site anesthesiology support.

Methods: The routine transfemoral TAVR protocol adopted at our center includes a minimalist approach, local anesthesia alone with fully awake patient, anesthesiologist available on call but not in the room, and direct transfer to the cardiology ward after the procedure. All consecutive patients undergoing transfemoral TAVR between January 2015 and July 2018 were included. We assessed the rates of actual local anesthesia-only procedures, conversion to conscious sedation or general anesthesia and 30-day clinical outcomes.

Results: Among 321 patients, 6 received general anesthesia upfront and 315 (98.1%) local anesthesia only. Mean age of the local anesthesia group was 83.2 ± 6.9 years, Society of Thoracic Surgery score 5.8 ± 4.8%. A balloon-expandable valve was used in 65.7%. Four patients (1.3%) shifted to conscious sedation because of pain or anxiety; 6 patients (1.9%) shifted to general anesthesia because of procedural complications. Hence, local anesthesia alone was possible in 305 patients (96.8% of the intended cohort, 95% of all transfemoral procedures). At 30 days, in the intended local anesthesia group, mortality was 1.6%, stroke 0.6%, major vascular complications 2.6%. Median hospital stay was 4 days (IQR 3-7).

Conclusion: Transfemoral TAVR can be safely performed with local anesthesia alone and without an on-site anesthesiologist in the vast majority of patients.
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http://dx.doi.org/10.2459/JCM.0000000000001030DOI Listing
October 2020

Pulmonary vascular resistance and clinical outcomes in patients with pulmonary hypertension: a retrospective cohort study.

Lancet Respir Med 2020 09 27;8(9):873-884. Epub 2020 Jul 27.

Providence Veterans Affairs Medical Center, Providence, RI, USA; Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.

Background: In pulmonary hypertension subgroups, elevated pulmonary vascular resistance (PVR) of 3·0 Wood units or more is associated with poor prognosis. However, the spectrum of PVR risk in pulmonary hypertension is not known. To address this area of uncertainty, we aimed to analyse the relationship between PVR and adverse clinical outcomes in pulmonary hypertension.

Methods: We did a retrospective cohort study of all patients undergoing right heart catheterisation (RHC) in the US Veterans Affairs health-care system (Oct 1, 2007-Sep 30, 2016). Patients were included in the analyses if data from a complete RHC and at least 1 year of follow-up were available. Both inpatients and outpatients were included, but individuals with missing mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure, or cardiac output were excluded. The primary outcome measure was time to all-cause mortality assessed by the Veteran Affairs vital status file. Cox proportional hazards models were used to assess the association between PVR and outcomes, and the mortality hazard ratio was validated in a RHC cohort from Vanderbilt University Medical Center (Sept 24, 1998-June 1, 2016).

Findings: The primary cohort (N=40 082; 38 751 [96·7%] male; median age 66·5 years [IQR 61·1-73·5]; median follow-up 1153 days [IQR 570-1971]), included patients with a history of heart failure (23 201 [57·9%]) and chronic obstructive pulmonary disease (13 348 [33·3%]). We focused on patients at risk for pulmonary hypertension based on a mPAP of at least 19 mm Hg (32 725 [81·6%] of 40 082). When modelled as a continuous variable, the all-cause mortality hazard for PVR was increased at around 2·2 Wood units compared with PVR of 1·0 Wood unit. Among patients with a mPAP of at least 19 mm Hg and pulmonary artery wedge pressure of 15 mm Hg or less, the adjusted hazard ratio (HR) for mortality was 1·71 (95% CI 1·59-1·84; p<0·0001) and for heart failure hospitalisation was 1·27 (1·13-1·43; p=0·0001), when comparing PVR of 2·2 Wood units or more to less than 2·2 Wood units. The validation cohort (N=3699, 1860 [50·3%] male, median age 60·4 years [49·5-69·2]; median follow-up 1752 days [IQR 1281-2999]) included 2870 patients [77·6%] with mPAP of at least 19 mm Hg (1418 [49·4%] male). The adjusted mortality HR for patients in the mPAP of 19 mm Hg or more group and with PVR of 2·2 Wood units or more and pulmonary artery wedge pressure of 15 mm or less Hg (1221 [42·5%] of 2870) was 1·81 (95% CI 1·33-2·47; p=0·0002).

Interpretation: These data widen the continuum of clinical risk for mortality and heart failure in patients referred for RHC with elevated pulmonary artery pressure to include PVR of around 2.2 Wood units and higher. Testing the generalisability of these findings in at-risk populations with fewer cardiopulmonary comorbidities is warranted.

Funding: None.
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http://dx.doi.org/10.1016/S2213-2600(20)30317-9DOI Listing
September 2020

Impact of Elective, Uncomplicated Target Lesion Revascularization on Cardiac Mortality After Elective Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Disease.

Am J Cardiol 2020 08 13;128:94-100. Epub 2020 May 13.

Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Bologna, Italy.

This study sought to investigate the impact of elective, uncomplicated target lesion revascularization (TLR) on long-term cardiac mortality after percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease. Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in 1 interventional center in Northern Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HZ] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72). In conclusion, elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.
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http://dx.doi.org/10.1016/j.amjcard.2020.04.053DOI Listing
August 2020

Long-term outcome of prosthesis-patient mismatch after transcatheter aortic valve replacement.

Int J Cardiol 2020 Nov 5;318:27-31. Epub 2020 Jul 5.

Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy. Electronic address:

Background: Incidence and long-term clinical consequences of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) are still unclear.

Methods: We enrolled 710 consecutive patients who underwent TAVR. PPM was defined as absent if the index orifice area (iEOA) was >0.85 cm2/m2, moderate if the iEOA was between 0.65 and 0.85 cm2/m2 or severe if the iEOA was <0.65 cm2/m2.

Results: Among the 566 patients fulfilling the study criteria, the distribution of PPM was as follows: 50.5% none (n = 286), 43% moderate PPM (n = 243) and 6.5% severe PPM (n = 37). At 5-year follow-up, patients with severe PPM had a significantly higher incidence of the combined endpoint of cardiovascular death, acute myocardial infarction and stroke (p = .025) compared with the other patients. After adjusting the results for possible confounders, severe PPM remained an independent predictor of long-term adverse outcome (HR: 2.46; 95% Confidence Interval: 1.10-5.53). The independent predictors of severe PPM were valve-in-valve procedure and body mass index. Balloon-expandable valves were not associated with higher rates of severe PPM in comparison with self-expandable valves (8% vs. 5%, respectively, p = .245).

Conclusions: In our study severe PPM emerged as a risk factor for long-term major adverse cardiac and cerebrovascular events.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.033DOI Listing
November 2020

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses.

JACC Cardiovasc Imaging 2020 11 17;13(11):2400-2411. Epub 2020 Jun 17.

Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.

Objectives: This study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and F-fluorodeoxyglucose (F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.

Background: The diagnostic accuracy of cardiac CT and F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.

Methods: Of 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV, SUV), metabolic tumor volume, and total lesion glycolysis in F-FDG PET were used as diagnostic markers.

Results: Irregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses' nature. The mean SUV, SUV, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal F-FDG PET/CT parameter significantly increased the identification of malignancies.

Conclusions: Cardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions' nature. Similarly, F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.
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http://dx.doi.org/10.1016/j.jcmg.2020.03.021DOI Listing
November 2020

Predicting and improving outcomes of transcatheter aortic valve replacement in older adults and the elderly.

Expert Rev Cardiovasc Ther 2020 Oct 18;18(10):663-680. Epub 2020 Jun 18.

Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna , Bologna, Italy.

Introduction: Indications for transcatheter aortic valve replacement (TAVR) are progressively extending to younger and lower risk patients. In this scenario, minimizing periprocedural complications and optimizing procedural result are both crucial to achieve an excellent long-term outcome.

Areas Covered: In this review, we summarize the main strategies that can be adopted before, during, and after TAVR to predict and prevent complications, to optimize procedural results and ultimately improve outcomes, with an emphasis on more recent evidence, new devices, and new techniques.

Expert Opinion: In the next future TAVR will probably represent the first treatment option for patients affected by aortic valve stenosis who are candidates to receive a biological valve. Continuous refinement of TAVR devices has been key to allow safer and most effective procedures and further progress is expected. Development of new techniques and devices, such as ultrasound-guided puncture and intravascular lithotripsy, will expand safety and eligibility to transfemoral procedures. Effective preemptive measures for coronary occlusion have been developed. Open issues include cerebral protection, re-access to coronary arteries, post-procedural management, and therapy.
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http://dx.doi.org/10.1080/14779072.2020.1778465DOI Listing
October 2020

Prevalence and Incidence of Atrial Fibrillation in a Large Cohort of Adrenal Incidentalomas: A Long-Term Study.

J Clin Endocrinol Metab 2020 08;105(8)

Endocrinology and Diabetes Prevention and Care Unit, Department of Medical and Surgical Sciences, University Alma Mater Studiorum of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy.

Context: Chronic glucocorticoids excess leads to morphological and functional cardiac alterations, a substrate for arrhythmias. Autonomous cortisol secretion (ACS) in adrenal incidentalomas is a model of chronic endogenous hypercortisolism.

Objective: To investigate prevalence and incidence of atrial fibrillation (AF) in a large cohort of patients with ACS.

Design: Retrospective study.

Setting: University hospital.

Patients: Patients evaluated between 1990 and 2018 for adrenal incidentalomas (n = 632), without pheochromocytoma, primary aldosteronism, Cushing syndrome, congenital adrenal hyperplasia, and adrenal malignancy. Cortisol after 1-mg dexamethasone suppression test < or > 50 nmol/L defined nonsecreting tumors (NST) (n = 420) and ACS (n = 212), respectively.

Intervention: Assessment of AF at baseline (n = 632) and during a median follow-up of 7.7 years retrospectively (NST, n = 249; ACS, n = 108). Comparison with general population.

Main Outcome Measure: Prevalence and incidence of AF.

Results: AF prevalence was higher in patients with ACS (8.5%) than NST (3.1%, P = 0.003) and the general population (1.7%; P < 0.001 vs ACS, P = 0.034 vs NST). The age-adjusted rate ratio to the general population was 1.0 for NST and 2.6 for ACS. AF was associated with ACS (odds ratio, 2.40; 95% confidence interval [CI], 1.07-5.39; P = 0.035). The proportion of patients with AF at last evaluation was higher in ACS (20.0%) than NST (11.9%; P = 0.026). ACS showed a higher risk of incident AF than NST (hazard ratio, 2.95; 95% CI, 1.27-6.86; P = 0.012), which was associated with post-dexamethasone cortisol (hazard ratio, 1.15; 95% CI, 1.07-1.24; P < 0.001), independently of known contributing factors.

Conclusions: Patients with adrenal incidentalomas and ACS are at risk of AF. Electrocardiogram monitoring may be recommended during follow-up.
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http://dx.doi.org/10.1210/clinem/dgaa270DOI Listing
August 2020

Subacute pericardial abscess after aortic valve replacement: a case report.

BMC Infect Dis 2020 May 13;20(1):342. Epub 2020 May 13.

Department of Experimental, Diagnostic and Specialty Medicine-DIMES (Padiglione 23), University of Bologna, Via Giuseppe Massarenti 9, 40138, Bologna, Italy.

Background: Purulent pericarditis is an infectious disease, frequently caused by gram-positive bacteria, that is rarely observed in healthy individuals, and is often associated with predisposing conditions.

Case Presentation: Here, we present the case of an Escherichia coli post-surgical localized purulent pericarditis complicated by transient constrictive pericarditis and its diagnostic and therapeutic management.

Conclusions: Our case report focuses on the importance of imaging-guided treatment of purulent pericardial diseases, in particular on the emerging role of 18 F-labelled 2-fluoro-2-deoxy-D-glucose Positron Emission Tomography/Computed Tomography in pericardial diseases and on the management of transient constrictive pericarditis, often seen after thoracic surgery.
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http://dx.doi.org/10.1186/s12879-020-05063-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218556PMC
May 2020

Primary malignant pericardial tumour in Lynch syndrome.

BMC Cancer 2020 Mar 6;20(1):191. Epub 2020 Mar 6.

Department of Experimental, Diagnostic and Specility Medicine - DIMES- Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Background: This case represents the first report of malignant primary cardiac tumour in a patient with Lynch Syndrome associated with MSH2 pathogenic variant.

Case Presentation: A 57-year-old woman with previous ovarian cystadenocarcinoma was admitted to the emergency room for hematic pericardial effusion. Multimodal diagnostic imaging revealed two solid pericardial vascularized masses. After pericardiectomy, the final histological diagnosis was poorly differentiated pleomorphic sarcomatoid carcinoma. During follow-up she developed an ampulla of Vater adenocarcinoma. Genetic analysis identified an MSH2 pathogenic variant.

Conclusion: This case contributes to expand the tumour spectrum of Lynch syndrome, suggesting that MSH2 pathogenic variants cause a more complex multi-tumour cancer syndrome than the classic Lynch Syndrome. In MSH2 variant carriers, symptoms such as dyspnoea and chest discomfort might alert for rare tumours and a focused cardiac evaluation should be considered.
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http://dx.doi.org/10.1186/s12885-020-6677-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059379PMC
March 2020

Secondary Prevention Medical Therapy and Outcomes in Patients With Myocardial Infarction With Non-Obstructive Coronary Artery Disease.

Front Pharmacol 2019 31;10:1606. Epub 2020 Jan 31.

Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy.

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous entity with relevant long-term major cardiovascular events. Several trials have demonstrated that dual antiplatelet therapy (DAPT), β-blocker, renin-angiotensin-aldosterone system (RAAS) inhibitor and statin therapy improve the prognosis in patients with obstructive myocardial infarction (ob-MI). However, evidence on the best medical therapy for secondary prevention in MINOCA patients is lacking.

Purpose: To investigate the effects of secondary prevention treatments at discharge on mid-term outcomes in MINOCA.

Methods: Patients with acute myocardial infarction (MI) undergoing early coronary angiography between 2016 and 2018 were extracted from a clinical database. The diagnosis of MINOCA was made according to 2016 ESC MINOCA Position Paper criteria. Second-level diagnostic work-up including cardiac magnetic resonance was performed to exclude non-ischemic troponin elevation cause. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis and Cox regression models. All confirmed MINOCA were followed in our outpatient clinics. The primary end-points were all-cause mortality, re-hospitalization for MI and a composite outcome including all-cause mortality, hospitalization for MI and ischemic stroke (MACE).

Results: Out of 1,141 AMI who underwent coronary angiography, 134 were initially diagnosed as MINOCA. Patients with MINOCA were less likely to receive secondary prevention treatments than patients with obstructive coronary artery disease (CAD) MI (respectively, 42.1% vs 81.8% for DAPT; 75.5% vs 89.6% for β-blockers; 64.7% vs 80.3% for RAAS inhibitor and 63.9% vs 83% for statins). Based on the diagnostic work-up completed during the first month after discharge, a final sample of 88 patients had confirmed MINOCA. During an average follow-up of 19.35 ± 10.65 months, all-cause mortality occurred in 11 (12.5%) patients, recurrence of MI in 4 (4.5%), and MACE in 15 (17.0%) patients. Patients treated with RAAS inhibitors and statins had a significantly longer survival. On the contrary, no increase in survival was found in patients treated with β-blockers or DAPT. Cox multivariable analysis, including all secondary prevention drugs, showed that only RAAS inhibitors were associated with reduced all cause-mortality and MACE.

Conclusion: This prospective study suggests that RAAS inhibitor therapy provides mid-term beneficial effects on outcomes in MINOCA patients; in contrast, dual antiplatelet, β-blocker and statin therapy had no effects on mortality and MACE. These results should be considered preliminary and warrant confirmation from larger studies.
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http://dx.doi.org/10.3389/fphar.2019.01606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005107PMC
January 2020

Coronary Protection to Prevent Coronary Obstruction During TAVR: A Multicenter International Registry.

JACC Cardiovasc Interv 2020 03 12;13(6):739-747. Epub 2020 Feb 12.

Cedars-Sinai Medical Center, Los Angeles, California.

Objectives: The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR).

Background: Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality.

Methods: Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019.

Results: Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in "valve-in-valve" procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia <4 mm was present in 75.0% of patients with DCO compared with 30.4% of patients without DCO (p = 0.19).

Conclusions: In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO.
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http://dx.doi.org/10.1016/j.jcin.2019.11.024DOI Listing
March 2020

Risk assessment in pulmonary arterial hypertension: Insights from the GRIPHON study.

J Heart Lung Transplant 2020 04 21;39(4):300-309. Epub 2020 Jan 21.

Department of Respiratory Medicine and German Center of Lung Research, Hannover Medical School, Hannover, Germany.

Background: Approaches to risk assessment in pulmonary arterial hypertension (PAH) include the noninvasive French risk assessment approach (number of low-risk criteria based on the European Society of Cardiology and European Respiratory Society guidelines) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) 2.0 risk calculator. The prognostic and predictive value of these methods for morbidity/mortality was evaluated in the predominantly prevalent population of GRIPHON, the largest randomized controlled trial in PAH.

Methods: GRIPHON randomized 1,156 patients with PAH to selexipag or placebo. Post-hoc analyses were performed on the primary composite end-point of morbidity/mortality by the number of low-risk criteria (World Health Organization functional class I-II; 6-minute walk distance >440 m; N-terminal pro-brain natriuretic peptide <300 ng/liter) and REVEAL 2.0 risk category. Hazard ratios and 95% confidence intervals were calculated using Cox proportional hazard models.

Results: Both the number of low-risk criteria and the REVEAL 2.0 risk category were prognostic for morbidity/mortality at baseline and any time-point during the study. Patients with 3 low-risk criteria at baseline had a 94% reduced risk of morbidity/mortality compared to patients with 0 low-risk criteria and were all categorized as low-risk by REVEAL 2.0. The treatment effect of selexipag on morbidity/mortality was consistent irrespective of the number of low-risk criteria or the REVEAL 2.0 risk category at any time-point during the study. Selexipag-treated patients were more likely to increase their number of low-risk criteria from baseline to week 26 than placebo-treated patients (odds ratio 1.69, p = 0.0002); similar results were observed for REVEAL 2.0 risk score.

Conclusions: These results support the association between risk profile and long-term outcome and suggest that selexipag treatment may improve risk profile.
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http://dx.doi.org/10.1016/j.healun.2019.12.013DOI Listing
April 2020

Impact of coronary bypass or stenting on mortality and myocardial infarction in stable coronary artery disease.

Int J Cardiol 2020 06 23;309:63-69. Epub 2020 Jan 23.

Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy.

Background: To assess whether coronary bypass (CABG) or stenting reduce the risk of mortality and myocardial infarction (MI) compared with optimal medical therapy (OMT) in stable coronary artery disease (CAD).

Methods: We performed a systematic review and network meta-analysis of contemporary randomized controlled trials comparing OMT, CABG and different stent types in stable CAD. All-comer trials were included if the rate of patients with acute myocardial infarction (AMI) was≤20%. Endpoints were all-cause mortality and MI.

Results: Ninety-seven trials including 75,754 patients were analyzed at a weighted mean follow up of 42.5 months. Compared to OMT, CABG was associated with a lower risk of death (OR = 0.84; 95%CI:0.71-0.97). After exclusion of trials in left main and/or multivessel disease(LM/MVD) this benefit was not statistically significant (OR = 0.89; 95%CI:0.74-1.06). CABG was associated with a lower risk of MI (OR = 0.67;95%CI: 0.49-0.91) showing, however, a certain degree of inconsistency (p=0.10). None of the stent types included was associated with a lower risk of death. However, durable-polymer-CoCr-everolimus-eluting stent, by mixed evidence, after exclusion of either LM/MVD (OR = 0.73;95%CI: 0.54-0.98) or all-comer/post-MI trials (OR = 0.62;95%CI:0.39-0.98) was associated with a lower risk of MI than OMT. Similar findings, by indirect evidence, were confirmed for bio-absorbable-polymer-CoCr-sirolimus eluting stent (LMV/MVD trials excluded OR = 0.46; 95%CI = 0.29-0.74, all-comer/post-MI trials excluded: OR = 0.41;95%CI:0.22-0.79).

Conclusions: In stable CAD, CABG reduces the risk of mortality and MI compared to OMT, especially in patients with higher extent of CAD. Our study suggests that some of second and latest-generation drug-eluting stents may reduce the risk of MI. Future research should confirm these latter findings.
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http://dx.doi.org/10.1016/j.ijcard.2020.01.054DOI Listing
June 2020

Association of the European Society of Cardiology echocardiographic probability grading for pulmonary hypertension with short and mid-term clinical outcomes after heart valve surgery.

Vascul Pharmacol 2020 Feb - Mar;125-126:106648. Epub 2020 Jan 3.

Institute of Cardiology, University of Pisa, Pisa, Italy. Electronic address:

Background And Aims: Pulmonary hypertension (PH) is associated with higher mortality and morbidity after valvular heart surgery, mainly through its adverse effect on right ventricular hemodynamic. Recently, the European Society of Cardiology (ESC) PH guidelines introduced a PH probability grading that lists additional parameters related to right ventricular dimensions. We evaluated the impact of such score on short- and mid-term outcomes in patients undergoing left heart valvular surgery.

Methods And Results: We included 60 consecutive patients (mean age 70 ± 9 years) undergoing left heart valvular surgery with or without coronary artery bypass. Patients were divided into 3 groups according to the PH probability: "low" (n = 18), "intermediate" (n = 18), or "high" (n = 24). The high PH probability group had higher rate of World Health Organization-Functional Class (WHO-FC) III and IV, hemodynamic complications, deaths, major bleeding events and infections after heart surgery than the other groups. A "high" PH probability was associated with reduced right ventricular systolic function, as measured by the fractional area change (FAC), but not with the tricuspid annular plane systolic excursion (TAPSE).

Conclusion: The high PH probability as evaluated by the ESC PH echocardiographic probability model, is associated with increased short- and mid-term mortality and morbidity and reduced right ventricular systolic function after cardiac surgery, Thus, additional echocardiographic parameters assessing PH probability are valuable tools to stratify risk in patients undergoing cardiac surgery.
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http://dx.doi.org/10.1016/j.vph.2020.106648DOI Listing
October 2020

Beyond the World Symposium on Pulmonary Hypertension: practical management of pulmonary arterial hypertension and evolving concepts.

Eur Heart J Suppl 2019 Dec 17;21(Suppl K):K1-K3. Epub 2019 Dec 17.

Department of Experimental, Diagnostic and Specialty Medicine, DIMES Alma Mater Studiorum University of Bologna, Via Zamboni, 33 - 40126 Bologna - Partita, Italy.

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http://dx.doi.org/10.1093/eurheartj/suz209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915054PMC
December 2019