Gregory Dendramis

Brugada syndrome and Brugada phenocopy. The importance of a differential diagnosis.

To date Brugada syndrome (BrS) is considered a primary electrical heart disease and the diagnosis is based on precise clinical and electrocardiographic features. Many other diseases and conditions can lead to a Brugada-like ECG pattern but the vast majority of patients with BrS possess a structurally normal heart, which is consistent with the notion that this is a primary electrical heart disease. Presently, the terminology used in the literature to describe Brugada type 1 ECG pattern induced in patients without BrS is diverse and variable. Brugada phenocopies (BrP) are clinical entities that present with identical ECG patterns to those of true BrS but are elicited by various other clinical circumstances. They form a group of heterogeneous conditions that are perhaps the most difficult to differentiate from true congenital BrS due to identical ECG patterns and recently has been proposed an updated classification of conditions that may induce BrP and many criteria useful to differentiate BrP from BrS. A systematic diagnostic approach is crucial to avoid diagnostic errors that involve expenditure of time and resources, but above all it is useful to avoid to send patients without a real BrS to inopportune diagnostic and therapeutic paths that are sometimes burdened by considerable risks.

Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment

Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.

STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature.

Patients with ST segment elevation myocardial infarction and multivessel disease represent a high percentage of ischemic patient with a worse outcome than patient with single coronary artery disease. Therefore, initial management of these patients is of high importance, but unfortunately this is not clarified yet. We analyze the available literature trying to afford current doubts to determine which way of revascularization is to be preferred.

Coronary artery fistulas as a cause of angina: How to manage these patients?

Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.

Not all ST-segment elevations are myocardial infarction: Hyperkalemia and Brugada phenocopy

Several clinical conditions other than Brugada syndrome (BrS) can mimic acute ST-segment elevation myocardial infarction and Brugada phenocopies are a part of those conditions that can mimic either true BrS or acute myocardial infarction. Our manuscript shows an interesting and didactic case report of type-1 Class A Brugada phenocopy (BrP) induced by hyperkalemia and allow us to teach the systematic approach to the proper diagnosis of BrP. A prompt recognition of this clinical and electrocardiographic entity may expedite the initiation of appropriate treatments as illustrated in this case report.

Anesthetic and Perioperative Management of Patients With Brugada Syndrome

Brugada syndrome (BrS) is an arrhythmogenic disease reported to be one among the leading causes of cardiac death in subjects under the age of 40 years. In these patients, episodes of lethal arrhythmias may be induced by several factors or situations, and for this reason, management during anesthesia and surgery must provide some precautions and drugs restrictions. To date, it is difficult to formulate guidelines for anesthetic management of patients with BrS because of the absence of prospective studies, and there is not a definite recommendation for neither general nor regional anesthesia, and there are no large studies in merit. For this reason, in the anesthesia management of patients with BrS, the decision of using each drug must be made after careful consideration and always in controlled conditions, avoiding other factors that are known to have the potential to induce arrhythmias and with a close cooperation between anesthetists and cardiologists, which is essential before and after surgery. In conclusion, given the absence of large studies in literature, we want to focus on some general rules, which resulted from case series and clinical practice, to be followed during the perioperative and anesthetic management of patients with BrS.

[Coronary artery ectasia: etiopathogenesis, diagnosis and treatment].

Abstract Coronary ectasia is a dilation of coronary arteries, angiographically defined if the diameter of the artery is ≥ 1.5 times greater than that of the intact adjacent vascular segment. An association has been found between coronary artery ectasia and a broad spectrum of different diseases, first of all atherosclerotic coronary artery disease. The mechanisms that determine the abnormal dilatation of the vascular lumen and the etiology of coronary artery ectasia are still poorly understood. Various hypotheses have been formulated over the time, the most accredited between these recognizes as main responsible an uncontrolled activity of a particular family of enzymes that degrade the extracellular matrix, the metalloproteinases. This exaggerated activity can be due to an increase in the absolute sense of these enzymes and/or a reduction in the levels of their natural specific inhibitors. Coronary ectasia may have a variable clinical presentation. It is often an occasional finding detected at coronary angiography or following the occurrence of atypical chest pain, stable angina or even acute coronary syndrome. The frequent coexistence of coronary artery ectasia and atherosclerotic coronary artery disease and their common histopathological features have led to hypothesize that coronary ectasia may represent a variant of atherosclerosis. However, some significant differences between these two diseases leave open the hypothesis that coronary artery ectasia may be a pathological entity per se.

Clinical and angiographic outcome of a single center, real world population treated with a dedicated technique of implantation for bioresorbable vascular scaffolds. The FAtebenefratelli Bioresorbable Vascular Scaffold (FABS) registry

OBJECTIVES With this prospective study we aim at investigating the long-term outcome of a consecutive cohort of patients successfully treated with bioresorbable scaffold (BVS) implantation. BACKGROUND It is not clearly understood if there is a relation between the technique of BVS implantation and the outcome. METHODS Between December 2012 and December 2014, all consecutive patients treated with BVS were included in this registry and received an angiographic follow-up. After a run-in phase, all BVS were implanted using a specific technique consisting of aggressive predilation, correct scaffold sizing, visually determined, and high-pressure post-dilation with a noncompliance balloon. Primary endpoint was late lumen loss (LLL) at 1-year angiographic follow-up and ischemia-driven target-lesion revascularization (ID-TLR) at 2-year clinical follow-up. Secondary endpoints were the occurrence of binary restenosis, major adverse cardiac events (MACE), and every single component of MACE (cardiac death, myocardial infarction, TLR) at 2 years. RESULTS A total of 144 lesions in 122 patients treated consecutively with BVS, were enrolled. Diabetics were 29.5% and acute coronary syndrome at presentation occurred in 29.5% of patients. At the angiographic follow-up LLL was 0.38 ± 0.9. At 2-year clinical follow-up, ID-TLR occurred in eight patients (5.6%). We observed two cases of scaffold thrombosis (1.38%, one early and one very late). At multivariate statistical analysis, STEMI presentation remained a significant predictor for TLR. CONCLUSIONS In a complex, all-comers real world population, BVS implantation with a specific, and standardized technique showed to be feasible, with acceptable mid-term angiographic and long-term clinical outcome.

Large left ventricular metastasis in patient with liposarcoma.

: Metastases to the heart and pericardium are rare. We present a 44-year-old male with pleural dedifferentiated liposarcoma and multiple metastases, with no previous cardiological history and/or cardiac symptoms. A transthoracic echocardiogram during the advanced stage of disease showed a lobulated, large and mobile mass, with homogeneous echogenicity, attached to the basal posterior wall of the left ventricle via a broad base and with intracavitary growth. This mass extends to inferolateral and inferoseptal wall of the left ventricle.

Very Late Dislocation of an AMPLATZER Septal Occluder Device Suspected Thanks to a Recent Onset of Right-Axis Deviation.

Data on late complications after percutaneous closure of atrial septal defects (ASDs) are still sparse. This is the first report of a very late dislocation of an AMPLATZER septal occluder (ASO) device (St. Jude Medical, St. Paul, Minnesota) 14 years after placement. A 74-year-old Caucasian woman