Marco Zuin

Antihypertensive Treatment in the Elderly and Very Elderly: Always “the Lower, the Better?”

Arterial hypertension (HT) is age dependent and, with the prolongation of life expectancy, affects more and more elderly people. In the elderly, HT is a risk factor for organ damage and cardiovascular (CV) events. Both pharmacologic and nonpharmacologic reduction of blood pressure (BP) is associated with a corresponding decrease in systolic-diastolic or isolated systolic HT. Clinical trials have shown that BP lowering is associated with a decrease in stroke and other CV events. Therefore, BP reduction per se appears more important than a particular class of antihypertensive drugs. The benefit of antihypertensive treatment has been confirmed up to the age of 80 years, remaining unclear in the octogenarians. The benefit in lowering diastolic BP between 80 and 90 mmHg is well established, while that of lowering systolic BP below 140 mmHg requires further confirmations.

Differentiation of cardiac thrombus from cardiac tumor combining cardiac MRI and 18F-FDG-PET/CT Imaging

Radiological differentiation of an unknown cardiac masse is often a challenging issue. 18F-FDG-PET/CT imaging was performed to evaluate a left ventricle mass visualized on transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) in a patient with an history of ischemic heart disease. The metabolically inert area on the PET/CT, corresponding to the relatively homogenous hypodensity in the LV, was thought to represent an old organized LV thrombus. Histopathological examination confirmed the imaging diagnosis.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience

BACKGROUND/PURPOSE The neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker in acute myocardial infarction (AMI). The aim of our study is to demonstrates the correlation between SYNTAX score (SXs) and NLR and its association with 1-year cardiovascular (CV) mortality in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI). METHODS/MATERIALS Over 6 consecutive years, (1st January 2010 and 1st January 2016) 6560 patients (4841 males and 1719 females, mean age 64.36±11.77years) were admitted for AMI and treated with PCI within 24-h. The study population was divided into tertiles based on the SXs. RESULTS Both in STEMI and NSTEMI groups, neutrophils and the SXs were significantly higher (p<0.0001) in upper versus lower among NLR tertiles and a significant correlation was found between the NLR and SXs (r=0.617, p<0.0001 and r=0.252, p<0.0001 for STEMI and NSTEMI groups, respectively). One-year CV mortality significantly raised up among the NLR tertiles in both STEMI and NSTEMI patients (p<0.0001). Multivariate analysis revealed that, after adjusting SXs and PAD, an NLR (≥3.9 and ≥2.7 for STEMI and NTEMI patients, respectively) was an independent significant predictor of 1-year CV mortality (OR 2.85, 95% CI 1.54-5.26, p=0.001 and OR 2.57, 95% CI 1.62-4.07, p<0.0001 for STEMI and NSTEMI respectively.) CONCLUSIONS: NLR significantly correlates with SXs and is associated with 1-year CV mortality in patients with STEMI or NSTEMI treated with PCI within 24-h.

Long-Term Outcomes and Complications of Intracardiac Echocardiography-Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients.

BACKGROUNDS Long-term fate of patients submitted to patent foramen ovale (PFO) closure is still unclear. The aim of the study was to evaluate the incidence of atrial fibrillation (AF), aortic or atrial free wall erosion, device thrombosis (DT), new onset or worsening of mitral valve regurgitation (MVR), and recurrent cerebral ischemic events in the long-term follow up after intracardiac echocardiography (ICE)-aided PFO closure in a large population. METHODS We reviewed the medical and instrumental data of 1,000 consecutive patients (mean age 47.3 ± 17.1 years, females) prospectively enrolled in 2 centres over a 13 years period (February 1999-February 2012) for R-to-L shunt ICE-aided catheter-based closure using different devices. RESULTS Immediate success was 99.8%. Implanted devices were Amplatzer PFO Occluder in 463 patients (46.3%), Amplatzer ASD Cribriform Occluder in 420 patients (42.0%), Premere Occlusion System in 95 patients (9.5%), and Biostar Occluder in 22 patients (2.2%). On a mean follow-up of 12.3 ± 0.6 years (minimum 4- maximum 17 years), permanent AF occurred in 0.5%, DT was apparent in 0.5%, new onset or worsening of MVR was observed in 0.2%, whereas recurrent cerebral ischemic events were 0.8%. Occlusion rate was 93.8%. No aortic or atrial free wall erosion has been observed. CONCLUSION ICE-aided closure of PFO using different devices, appeared very safe and effective on very long-term follow up with low incidence of erosion, DT, recurrent ischemic events, MVR new onset or worsening, and permanent AF.

Hybrid metal/scaffold-jacket versus full-metal jackets in left anterior descending coronary artery diffuse disease: Differences in radiation exposure and fluoroscopic/procedural times☆

BACKGROUND/PURPOSE Bioabsorbable vascular scaffolds (BVS) are made from a radiolucent material. Their multiple implantations on a single long diffused segment requires a specific technique with imaging magnification, which could cause an increase in dose delivered during percutaneous coronary intervention (PCI) procedure. We aimed to identify differences in radiation dose, fluoroscopy and procedural times in Hybrid DES+ multiple BVS (Absorb, Abbott Inc., USA) implantation (hybrid metal/scaffold jacket) versus multiple III generation Drug-eluting stents (DES) (full-metal jacket) in patients with long and diffuse coronary artery disease of the left anterior descending (LAD) coronary artery. METHODS/MATERIALS Patients with long and diffuse LAD disease were enrolled in a registry from 1st February 2015 to 1st February 2017. Patients treated with hybrid DES/BVS (at least three) jacket (n=72 procedure) were compared with a 2:1 matched cohort of exclusive multiple overlapped DES (full-metal jacket) patients in the same period (n=114 procedures). RESULTS Patients had similar baseline characteristics due to matching. Radiation exposure (6035.7±2846.8 vs 4251.1±1787.3cGy∗cm2, p<0.0001, Δ=1784.5±1055.6), fluoroscopy time (16.2±4.5 vs 9.1±2.4, p<0.0001) and procedure time (64.2±18.5 vs 5 8.7±13.5, p=0.02) were higher in patients treated using hybrid metal/scaffold jacket compared that regular full-metal jacket. CONCLUSION The use of hybrid metal/scaffold jacket for the treatment of long and diffuse disease of LAD is associated with a higher fluoroscopy time and radiation exposure compared to full-metal jacket, quantifiable in approximately 35%.

Rheolytic thrombectomy in patient with acute pulmonary embolism, heparin-induced thrombocytopenia and recent stoke. When percutaneous treatment is the only therapeutic alternative

To report the combined use of rheolytic thrombectomy (RT) and inferior vena cava (IVC) filter placement in the setting of acute pulmonary embolism (PE), heparin-induced thrombocytopenia (HIT) type II (HIT-II) and recent ischemic stroke. A 66-year-old man with an HIT-II and recent ischemic stroke was referred to our institution from a secondary regional center for acute PE and left deep vein thrombosis (DVT), confirmed at chest computed tomography (CT) and lower limb ultrasound, respectively. RT was attempted because intravenous heparin anticoagulation was contraindicated by the patient’s medical history while recent ischemic stroke contraindicated thrombolysis. An Angiojet® catheter was used to perform RT. An IVC filter was placed after the procedure. The patient was discharged after 13 days and did very well, both at the 6- and 12-month follow-ups, with no recurrence of the venous thromboembolism. This case demonstrates the usefulness of RT in treating acute PE in clinically difficult scenarios, especially when thrombolytic therapy is contraindicated.

Mathematics and Cardiovascular Interventions: Role of the Finite Element Modeling in Clinical Decision Making

Nowadays, mathematical and numerical models are becoming increasingly important in cardiovascular medicine. In mathematics, the finite element method (FEM) is a numerical technique used to analyze complex structures. This method subdivided a whole problem domain into simpler parts, called finite

Trattamento percutaneo dell'embolia polmonare: diffusione e utilizzo della metodica in centri cardiologici interventistici italiani. Risultati dell'indagine conoscitiva PETER

BACKGROUND Reperfusion in acute pulmonary embolism (PE) by percutaneous techniques is a valid therapeutic option when there is a formal contraindication to or failure of thrombolysis. In the last years, an increasing number of patients with acute PE have been treated with these techniques. METHODS In order to obtain a map of current availability and use of percutaneous techniques in PE, on behalf of the ANMCO Pulmonary Circulation Area, 56 Italian interventional cardiology and radiology departments, equipped with technology for percutaneous embolectomy, were invited to participate in a national survey. Questionnaires were e-mailed to each department from April to May 2015. RESULTS Thirty-one out of 56 centers (54.8% in the North, 9.7% in the Center and 35.5% in the South of Italy) answered to the questionnaire. Percutaneous techniques were available in 90% of the cardiology departments involved, reporting also a good experience with their use in PE (77.4%). Only two responders were interventional radiology departments. AngioJet(®) and EkoSonic Endovascular System(®) (64.7% and 19.4%, respectively) were the most common devices used. Overall, in 2014, 62 patients were treated with percutaneous techniques, mainly in the North of the country. With regard to local diagnostic and therapeutic protocols, 61.3% of respondents reported owning one. Great interest was provided by participants in adhering to this national multicenter registry. CONCLUSIONS Our results show the interest of Italian cardiology departments about percutaneous techniques as a therapeutic option for acute PE. Percutaneous techniques are largely available but still underused in routine clinical practice.

Complex coronary bifurcation revascularization by means of very minimal crushing and ultrathin biodegradable polymer DES: Feasibility and 1-year outcomes of the “Nano-crush” technique

AIM To assess feasibility and 1-year outcomes of ultrathin biodegradable polymer double stenting using a very minimal crushing (nano-crush technique) in a series of patients with large (≥2.5mm) complex coronary bifurcation. METHODS From January 2015 to June 2016, patients referred for large (≥2.5mm) complex coronary bifurcation percutaneous coronary interventions (PCI) were enrolled to receive Orsiro (Biotronik Inc., Bulack, Switzerland) double stenting using a very minimal crush technique (nano-crush). Per our institutional protocol, follow-up was conducted by physical examination at 1, 6, 12month and yearly whereas angiographic control was eventually scheduled at 6-8months on the basis of symptoms recurrence or/and positive induced ischemia tests. RESULTS Fifty-two patients (15 females mean age 77.2±6.2years) were enrolled. Mean angles between main branch and side branch were 63.6±21.3°. The mean diameter and length of implanted stents were 3.8±0.4mm and 27.1±8.7mm in main branch and 2.8±0.3mm and 22.1±.7.1mm in side branch. Immediate success was 100%. Clinical follow-up was available for 100% of patients: at a mean follow-up of 12.0±2.6months, no patient death, or acute myocardial infarction or target vessel revascularization were observed. Angiographic follow-up was available in 25/52 patients (48%) at a mean time from the procedure of 7.2±0.5months and showed no significant angiographic restenosis. CONCLUSIONS The revascularization of complex large (≥2.5mm) coronary bifurcation disease using the nano-crush technique and the ultrathin polymer biodegradable stent appeared feasible in our small study with promising 1year outcomes.

Short-term outcome of patients with history of significant coronary artery disease following acute pulmonary embolism

Pulmonary embolism (PE) is the third leading cause of cardiovascular death after myocardial infarction and stroke [1]. As already described, patients with cardiovascular disease (CVD) have a higher prevalence of PE [2,3]. However, limited data regard the short-term survival of subjects with history of significant coronary artery disease (CAD) after acute PE is available. For this reason, we sought to evaluate the prevalence and the impact of significant CADon an 8-monthmortality after acute PE. We retrospectively analysed 238 consecutive patients with confirmed PE, enrolled between January 2006 to December 2015 at the Cardiology Department of Rovigo General Hospital. The local Ethics Committee approved the study and all procedures were in accordance with the Declaration of Helsinki andwith institutional guidelines. Inclusion criteria were acute symptomatic PE, with or without DVT, as confirmed by computed tomography pulmonary angiography (CTPA) within 24 h from the admission. Patients with previous history of symptomatic PE, no significant CAD, life expectancy less than six months or aged b18 years old were excluded. For the entire enrolled population, personal medical history was always analysed by reviewing previous medical records. In particular, significant CAD was defined as a stenosis equal to or above 50% in a main coronary artery or in one of the other branches. Coronary angiography records have been evaluated by 2 experienced physicians. In the analysis, the entire population was divided into two groups on the basis of presence or absence of significant CAD (CAD and No-CAD, respectively). Follow-up has been performed through phone call, clinical visit andmedical electronic records to assess the overall outcomes and mortality at 8 months after PE. Baseline characteristics are reported as means and standard deviations for continuous variables. Categorical variables were expressed as percentage rates and compared with the Pearsons χ2 test. Kaplan–Meier survival analysis was performed to assess the survival using log-rank (Mantel–Cox) analysis. This study included 238 consecutive patients (109 men and 129 women, aged 71.03 ± 15.3 years). Prevalence of significant CAD was 16.4% (n = 39), without difference in the distribution across gender (48.2% vs 51.3%, p = ns, for men and women respectively). Patients with PE and previous significant CAD were younger than those without