Giornale italiano di cardiologia最新文献

We report an unusual case of an elderly man presenting with formation and rupture of an epidermal inclusion cyst at the level of an implantable cardiac defibrillator (ICD) pocket. The lesion appeared 2 years after ICD implantation, mimicking a decubitus or a pocket infection. Surgical revision showed no signs of infection of the pocket, but the pedunculated lesion was rooted in the subcutaneous tissue, whit an implant base external to the ICD pocket, which was removed and analyzed histologically, confirming the diagnosis of epidermal inclusion cyst. The pathophysiological mechanism of cyst formation is discussed. This case highlights the importance of an increased attention to lesions that mimic infections of a cardiac implantable electronic device pocket, thus preventing unnecessary complete removal of the device system.

Percutaneous coronary intervention has revolutionized the management of coronary artery disease, yet in-stent restenosis (ISR) remains a clinical challenge, especially when complicated by calcification. Various techniques are available for the modification of calcified ISR, including super-high-pressure balloon dilation, in-stent rotational atherectomy, excimer laser coronary atherectomy and intravascular lithotripsy (IVL). This case report presents a challenging scenario of very late calcified ISR in a large coronary artery, highlighting diagnostic and interventional considerations. A patient with a history of multiple cardiovascular risk factors presented with infero-lateral ST-elevation myocardial infarction. Coronary angiography revealed severe very late ISR in the distal right coronary artery. Despite initial interventions, severe stent under-expansion persisted due to extensive calcification. The operator employed shockwave lithotripsy alongside a non-compliant balloon to achieve the vessel diameter and an optimal stent expansion. While the evidence for some interventions is limited, case series and registries suggest promising outcomes with IVL, particularly in refractory cases. Our proposed approach addresses the limitations posed by vessel diameter, demonstrating potential efficacy in this challenging case. This case report emphasizes the need for tailored therapeutic strategies and the integration of innovative techniques in managing calcified ISR, with IVL emerging as a promising option in selected cases.

Pulmonary embolism (PE) is commonly treated primarily with pharmacological therapy, while advanced reperfusion therapies (transcatheter or surgical) are considered only in cases of contraindications or failure of standard therapies. Treatment algorithms vary depending on the patient's risk, with patients at intermediate or high risk potentially requiring evaluation for such advanced reperfusion therapies. Critical scenarios, such as contraindications to systemic thrombolysis or failure of pharmacological protocols, necessitate the activation of a multidisciplinary pulmonary embolism response team (PERT) and prompt therapeutic escalation. Integrated in-hospital pathways and the extension of PERT at the provincial/regional level are recommended to improve access to advanced therapies and promote uniform management of PE. Larger randomized clinical trials are needed to assess the efficacy of transcatheter therapies compared to current standards. In conclusion, a multidisciplinary and standardized approach, supported by evidence-based guidelines, is essential to optimize PE management and improve clinical outcomes. The Italian Society of Interventional Cardiology (SICI-GISE) aims to promote such standardization nationally with this expert position paper, ensuring appropriateness and equity of care for patients, as well as fostering further scientific research and education.

Recently, an increase in the number of patients with severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) has been observed worldwide. In order to reduce waiting lists, provide to all patients referred to us equal access to care and to further improve the collaboration with spoke centers, we developed a specific Hub & Spoke specific protocol for TAVI. According to our protocol, a clinical selection (with echo and computed tomography scan) is done by Spoke centers, the case is discussed with a multidisciplinary team online and the procedure is planned (access, valve type size). At day 0, the patient is admitted in Spoke centers where blood samples are taken; at day 1, the patient is transferred to a Hub center for the TAVI procedure and after 2 h of observation, if no adverse events are registered, the patient is transferred back to the Spoke center. Since 2019, an agreement among our center and two hospitals has been signed. According to this Hub & Spoke model, a total of 72 patients with aortic stenosis were treated with TAVI (mean age 83 years, 48.6% female, median Society of Thoracic Surgeons risk 2.4 ± 1.1%, left ventricular ejection fraction 58.0 ± 7.75%). More frequently CoreValve Evolut R (47.2%) was used. Only 2 patients had a prolonged admission at Hub and were not transferred at day 1 (1 vascular complication and 1 intra-procedural resuscitated cardiac arrest). This Hub & Spoke model guaranteed shortening of waiting lists, more effective turnover of bed, equal access to care to patients referred to our center. In addition, it helped also to increase Awareness and education as well as appropriate training of the teams from spoke facilities.

Arrhythmogenic cardiomyopathy (CMA) is a cardiac disease characterized by non-ischemic ventricular scarring and electrical instability. The diagnosis of CMA still remains challenging today and requires the use of a set of criteria, since no single diagnostic test represents the gold standard. The first diagnostic criteria were defined and disseminated in 1994 and then revised in 2010, focusing mainly on right ventricular involvement. In 2019, an international panel of experts identified the limitations of the previous diagnostic criteria. The 2020 Padua criteria included a specific pathway for the diagnosis of left ventricular variants and emphasized the need for the use of cardiac magnetic resonance imaging in the characterization of myocardial scarring. These criteria were further refined and published in 2023 as European Task Force (TF) criteria, thus gaining international recognition.Exploring the history of CMA and its diagnosis, in this review we analyze the changes and progress in the 20 years that have occurred from the first version of the criteria in 1994 to the latest in European TF of 2023, highlighting the evolution of our knowledge of the pathobiology and morpho-functional characteristics of the disease. One of the most relevant updates is undoubtedly the introduction of the concept of "scarring/arrhythmogenic cardiomyopathy", a definition that enhances the main features of the pathology and emphasizes the multiplicity of phenotypes and clinical presentations independent of etiology.

The presence of metastatic cancer represents a high-risk condition for the treatment of heart disease requiring surgical or percutaneous procedures. We present the case of a 58-year-old man with pulmonary adenocarcinoma and renal metastases surviving more than 3 years after chemotherapy and immunotherapy suffering dyspnea and chest pain on minimal exertion due to 99% anterior coronary artery stenosis associated with severe aortic stenosis of a bicuspid valve. We treated the cardiac lesions in two steps by coronary angioplasty with drug-eluting stent implantation followed by percutaneous prosthetic aortic valve replacement. The procedures were successful with resolution of the symptoms and recovery of the usual ECOG-PS 0-1 functional capacity which persists 24 months after cardiac procedures. This case demonstrates that the multidisciplinary collaboration between oncologists and cardiologists with a personalized patient-centered approach allows to treat complex clinical situations successfully in the emerging category of patients surviving with metastatic cancer.

Infective endocarditis (IE) is an infective process involving the endocardium and, more frequently, the native heart valves, valvular prostheses and cardiac implantable electronic devices. IE can manifest with various non-specific symptoms making the diagnosis challenging. This condition is associated with high in-hospital and long-term mortality. Therefore, it is particularly important to prevent it by implementing an adequate antibiotic prophylaxis especially in patients at high risk undergoing invasive procedures. Moreover, it is pivotal to promptly diagnose IE, detect the presence of local and systemic complications, establish appropriate antibiotic therapy and identify the indication and timing for surgical treatment. In this focused review, we will provide answers to the most common questions regarding the epidemiology, causes, prophylaxis, diagnosis and antibiotic and surgical treatment of IE.

Immunotherapy has revolutionized the treatment of various cancers leading to a clear survival benefit with cured or long-surviving patients. Atherosclerosis and cancer share risk factors and molecular mechanisms and have as their common thread a state of chronic inflammation linked to a deregulation of the immune system. A growing body of evidence is accumulating on the potential worsening effect of immune checkpoint inhibitors on atherosclerosis, with subsequent worsening of patients' long-term cardiovascular risk. The molecular pathways implicated in the growth and deregulation of atherosclerotic plaques seem to be the same (CTLA-4, PD-1, PD-L1) as those on which the anti-tumor effect is exerted. Owing to the increasing number of cancer patients treated with immunotherapy and the improved survival with the possibility of prolonged disease control, it is necessary to know the potential increase in cardiovascular risk for atherosclerosis-related events and to establish all prevention measures to reduce it.