Massimo Baravelli

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients.

Cardio-oncology in targeting the HER receptor family: the puzzle of different cardiotoxicities of HER2 inhibitors

The HER family of tyrosine kinase receptors includes several members that are clinically important targets in cancer therapies, in particular HER1 (the EGF receptor) and HER2, other members include HER3 and HER4. Trastuzumab, a humanized monoclonal antibody and lapatinib, a tyrosine kinase inhibitor, are drugs that target HER2, which is highly expressed in 20-30% of breast cancers. Trastuzumab is recommended as an adjuvant therapy for lymph node positive, HER2-positive breast cancers, or node-negative cancer with high-risk of recurrence, as well as in stage IV cancers. One serious side effect of trastuzumab is cardiomyocyte dysfunction, resulting in reduced heart contractile efficiency. The incidence of collateral effects on the heart with trastuzumab therapy increases in people with cardiovascular risk factors, heart disease and when combined with other chemotherapeutics. When cardiotoxicity was observed with trastuzumab, several studies have addressed potential cardiac damage of trastuzumab itself and lapatinib. The differences in cardiovascular effects of these two compounds are somewhat unexpected and suggest distinct mechanisms of action, which have clear implications in clinical application and prevention of cardiotoxicity in cardio-oncological approaches.

Acute superior vena cava syndrome after insertion of implantable cardioverter defibrillator

We describe a rare case of superior vena cava syndrome that occurred a few hours after insertion of an implantable cardioverter defibrillator through the right subclavian vein in a patient with previous dual chamber DDD pacemaker. The patient was successfully treated with anticoagulant therapy showing a fast clinical and instrumental improvement.

Tako-tsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection.

Tako-tsubo cardiomyopathy is a form of reversible left ventricular dysfunction, with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. The precise clinical features and etiologic basis of this syndrome remain unclear, although an association with emotional or stressful triggers has been recognized. We describe the first case of this syndrome complicated with a ventricular septal perforation and dissection.

Arrhythmic Risk Evaluation during Exercise at High Altitude in Healthy Subjects: Role of Microvolt T‐Wave Alternans

Background: Altitude‐induced sympathetic hyperactivity can elicit rhythm disturbances in healthy subjects, in particular during exercise.

Clip-based arterial haemostasis after antegrade common femoral artery puncture

BACKGROUND Given the frequent involvement of infra-popliteal arteries, an ipsilateral antegrade common femoral artery puncture (ACFAP) is usually preferred to a contralateral retrograde femoral access for percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). Because of the frequent difficulty to get a sufficient manual pressure on the puncture site, ACFAP is burdened by a high number of bleeding local complications, including retroperitoneal haematoma. We report a series of patients who consecutively received a clip-based arterial closure device after ACFAP and ipsilateral PTA for CLI. METHODS Thirty patients (73+/-6 years; 18 men; 100% diabetes) admitted to our hospital because of CLI consecutively underwent peripheral PTA after an ACFAP and received a clip-based arterial closure device. Time to haemostasis was defined as the interval elapsed between clip deployment and first observed haemostasis. All patients were mobilized after 6 h. Follow-up was 30 days. RESULTS All patients were on double anti-platelet therapy. At the end of the procedure, Activation Clotting Time was 226+/-37 s. Procedural success in delivering the clip was 100%. Time to haemostasis was 21+/-19 s. No major local vascular complications and in particular no retroperitoneal bleeding were documented. All patients could be discharged within the following 3 days. No major complications were noted during a 30 days follow-up. CONCLUSIONS The use of a clip-based arterial closure device after ACFAP for peripheral PTA in CLI seems to be safe and effective.

Low-risk profile for malignant ventricular arrhythmias and sudden cardiac death after surgical ventricular reconstruction.

Background:  Although it has been recently demonstrated that there was no significant difference in total survival and clinical outcomes between patients who underwent coronary artery bypass grafting (CABG) with or without surgical ventricular reconstruction (SVR), the question of whether or not SVR decreases the arrhythmic risk profile in this population has not been clarified yet.

Atrio sinistro gigante in una paziente con scompenso cardiaco riacutizzato

A 71-year-old woman was admitted to our institution with symptoms and signs of acute congestive heart failure. The patient had a long history of rheumatic heart disease and, in 1974, she had undergone mitral valve replacement with a single tilting-disk mechanical valve. Transthoracic echocardiography showed a giant left atrium, measuring 18.5 cm longitudinally and 17 cm transversely from the apical four-chamber view with a volume of 1706 ml/m2 body surface area, associated with intense spontaneous echocontrast. Massive tricuspid regurgitation and severe pulmonary hypertension were diagnosed. It could be hypothesized that the giant left atrium may have contributed to the development of acute decompensated heart failure resulting in a significant reduction of left ventricular preload.

The embolic storm : dramatic peripheral complications of left ventricular thrombosis after myocardial infarction

Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.

Hemodynamic Mechanisms of Exercise-Induced Pulmonary Hypertension in Patients with Lymphangioleiomyomatosis: The Role of Exercise Stress Echocardiography

Background: The pathogenesis of pulmonary hypertension (PH) in lymphangioleiomyomatosis (LAM) has not yet been completely clarified. The aim of this study was to conduct a noninvasive evaluation of the main hemodynamic mechanisms of exercise‐induced PH in patients with LAM, assessed using exercise stress echocardiography. Methods: Fifteen patients with LAM (mean age, 47 ± 13 years; all women) without resting PH were enrolled in a prospective single‐center study and compared with 15 healthy female control subjects (mean age, 45.2 ± 8 years; P = .65). A complete echocardiographic study with Doppler tissue imaging was performed at baseline and during semisupine symptom‐limited exercise testing to evaluate (1) left ventricular systolic and diastolic function, (2) right ventricular contractile function, (3) estimated pulmonary capillary wedge pressure, (4) estimated systolic and mean pulmonary artery pressure, and (5) estimated pulmonary vascular resistance. Results: Compared with healthy control subjects, patients with LAM during exercise showed echocardiographic signs of right ventricular overload and right ventricular systolic dysfunction and significant increases in mean pulmonary artery pressure (14.4 ± 6.5 vs 4.2 ± 3.1 mm Hg, P < .0001), pulmonary vascular resistance (+68.3 ± 42.1 vs −0.1 ± 18.3 dyne‐sec/cm5, P < .0001), and, unexpectedly, pulmonary capillary wedge pressure (+8.3 ± 5.3 vs −0.5 ± 1.3 mm Hg, P < .0001). Conclusions: Exercise‐induced PH in patients with LAM could be related not only to hypoxic pulmonary vascular vasoconstriction during exercise (precapillary PH) but also to a significant exercise‐induced increase in estimated pulmonary capillary wedge pressure, probably secondary to diastolic dysfunction (postcapillary PH). HIGHLIGHTSThe mechanisms of effort intolerance in patients with LAM remain unclear.ESE allows a complete left and right heart evaluation of patients with lung diseases.A stress echocardiographic protocol in patients with LAM was tested.Exercise‐induced PH in LAM could have both a pre‐ and a postcapillary component.