Minerva cardiology and angiology最新文献

Background: Previous studies have highlighted the role of inflammatory and nutritional markers in predicting outcomes in cardiovascular diseases. However, to our knowledge, no study has explored the impact of the combination of these two aspects on outcome of patients undergoing transcatheter aortic valve implantation (TAVI). This study aims to assess the predictive value of the pre-procedural platelet-to-lymphocyte ratio (PLR)/albumin ratio on one-year mortality in this population METHODS: This retrospective observational study screened 867 patients who underwent TAVI between December 2018 and September 2023 at our tertiary center, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy. After excluding patients with systemic inflammatory or autoimmune diseases (223), cancer (257), acute or chronic infections (22), and those with missing data (77), the final cohort comprised 288 patients. PLR and albumin levels were calculated from pre-procedural blood samples, and the PLR/albumin ratio was subsequently derived. The prognostic discriminatory capacity and cutoff value of the PLR/albumin ratio were assessed using multivariate Cox regression and ROC analysis, respectively.

Results: Individually both PLR and albumin were confirmed as independent predictors of post-TAVI 1-year mortality (odds ratios: 1.01 and 0.83, respectively), but their association with outcome was sensibly increased when considered together as PLR/albumin ratio (odds ratio: 1.33 [95% CI: 1.1-1.6, P=0.007]). In particular, PLR/albumin ratio >4.69 showed the best predictive capacity (AUC 0.69, sensitivity 56.25%, specificity 83.27%) for patients at higher risk of mortality in the first year after TAVI. No other clinical covariate demonstrated such comparable outcome predictive strength.

Conclusions: A high PLR/albumin ratio resulted as independent one-year mortality predictor in patients undergoing TAVI procedure. The proposed combination of inflammatory and nutritional markers outperformed the value of single parameters. Its integration into pre-procedural TAVI work-out could be represent a further improvement of individualized risk stratification.

Background: Prolonged dual antiplatelet therapy (DAPT) with ticagrelor 60 mg is recommended in post-myocardial infarction (MI) patients at moderate to high ischemic risk. Beyond physician-led discontinuation, persistence with therapy in real-world settings may be limited due to adverse effects and patient choices. The aim of this study is to assess the real-world incidence of non-compliance with prolonged DAPT and to elucidate reasons for discontinuation.

Methods: A retrospective observational study was conducted in three high-volume Italian PCI centers, involving patients with prior MI (1-3 years before) prescribed with ticagrelor 60 mg twice daily. Demographic, clinical, and procedural data were collected, with follow-up to determine therapy discontinuation and reasons for it.

Results: Among 244 enrolled patients, mean age was 66 years, and 83.6% were male. During follow-up (mean duration: 27.6 months), 10.2% (95% CI: 6.7% to 14.8%) discontinued ticagrelor. Key reasons included voluntary decision (40.0% [21.1% to 61.3%]) and bleeding events (40.0% [21.1% to 61.3%]), with some switching to high-dose regimens post-revascularization. In univariate analysis, ticagrelor discontinuation was significantly associated with female sex, higher BMI, prior PCI or CABG, high bleeding risk, and the absence of multivessel disease or primary PCI. However, in multivariable analysis, only multivessel disease remained independently associated with a lower likelihood of discontinuation (P<0.001).

Conclusions: Real-world persistence with prolonged DAPT remains a challenge, often hindered by patient-driven discontinuation and adverse events. Enhanced patient education on therapy benefits and adherence may improve long-term outcomes.

Transplant coronary artery disease (TCAD) represents a severe complication after heart transplantation, modulated by hypercholesterolemia. Management of dyslipidemia in this setting is complex due to interactions between statins and immunosuppressants resulting in an increased risk of rhabdomyolysis and the potential of immunosuppressants themselves to elevate LDL and triglyceride levels. Inclisiran, an mRNA inhibitor of PCSK9, has demonstrated high efficacy without reported pharmacokinetic interactions and a favorable administration regimen. We present the first case of treatment with inclisiran after heart transplantation. We report the case of a 67-year-old male patient who underwent heart transplantation in 2011 with a high cardiovascular risk profile and a history of statin intolerance, treated with ezetimibe. In 2022, due to severe TCAD and elevated LDL-C levels (125 mg/dL), treatment with inclisiran (300 mg on days 0 and 90 and then every 6 months) was initiated in addition to ezetimibe. Lipid and immunosuppressant levels were monitored during follow-up visits. After two doses of Inclisiran, at 6 months, LDL-C was reduced to 69 mg/dL, without side effects or significant alterations in immunosuppressant levels. Subsequently, LDL-C levels showed a further reduction to 31 mg/dL and remained controlled (51 mg/dL and 28 mg/dL in subsequent follow-ups). Despite the reduction in LDL-C, the patient showed progression of TCAD, requiring multiple percutaneous revascularizations. This case suggests the potential value of inclisiran in the treatment of dyslipidemia in heart transplant patients with TCAD, especially in the presence of statin intolerance or risk of drug interactions. The infrequent administration regimen is advantageous in such patients with a high medication burden and can be made to coincide with follow-up visits. However, the progression of TCAD despite LDL-C reduction highlights the multifactorial nature of the disease, with a significant immunological component still not effectively controlled by current preventive therapies.

Background: Multiple valvular heart disease (M-VHD) is a common condition, often involving aortic stenosis (AS) plus a mitral or tricuspid valve disease. We aim to evaluate the evolution and prognostic impact of M-VHD in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods: A retrospective cohort study was conducted on patients who underwent TAVI in a tertiary care center between January 2016 and December 2022. Echocardiography was performed before and after TAVI. The primary endpoint was the composite of all-cause mortality and cardiovascular hospitalizations during follow-up.

Results: A total of 159 patients (88 women; mean [SD] age, 80.8 [7.8] years) with severe AS and M-VHD were identified. Seventy-two (45.3%) had mitral regurgitation, 69 (43.4%) had tricuspid regurgitation, and 18 (11.3%) had mitral stenosis. After TAVI, 77 patients (48.4%) experienced an improvement of the concomitant valve disease, while 82 did not. Female gender (OR:0.25, 95%CI:0.11-0.56, P<0.001), pacemaker implantation (OR:0.37, 95%CI:0.14-0.98, P=0.046) and rheumatic etiology (OR:0.25, 95%CI:0.09-0.74, P=0.012) were negatively associated with improvement. At a median follow-up of 31 months (26-51), patients with no improvement had an increased occurrence of the composite endpoint compared to their counterparties, (P=0.028). On multivariable analysis, NYHA class III/IV (HR:2.04, 95%CI:1.02-4.08, P=0.044) and creatinine (HR:1.43, 95%CI:1.06-1.94, P=0.019) were associated with a higher risk of the endpoint, while the improvement of concomitant valve disease emerged as protective factor (HR:0.46, 95%CI:0.25-0.85, P=0.013).

Conclusions: Concomitant valve disease improved in roughly half of M-VHD patients after TAVI. Patients with post-TAVI improvement of the second valve lesion had better clinical outcomes at long-term follow-up.

Background: Heart failure (HF) remains a leading cause of hospitalization globally, exerting significant strain on healthcare systems and impacting patients' quality of life. Seasonal changes in climate and temperature are known to affect HF-related outcomes. This study investigates the seasonal variations in hospitalization outcomes among HF patients in the United States.

Methods: We conducted a retrospective analysis of the National Inpatient Sample (NIS) database, focusing on patients aged over 18 years with a primary diagnosis of HF from 2018 to 2020, using the ICD-10-CM codes. Our primary outcomes of interest included trends in clinical characteristics, inpatient mortality rates, and length of hospital stay (LOS). In addition, inflation-adjusted healthcare costs for each patient were also analyzed. Statistical analyses included weighted logistic and linear regression, adjusting for patient-level factors (age, sex, race, comorbidities, insurance type, and median household income) and hospital-level factors (bed size, region, and teaching status). Inpatient mortality, length of stay, and inflation-adjusted hospital costs were analyzed. Mortality risk factors were assessed using multivariate models, with costs converted to 2019 dollars using standardized inflation adjustments.

Results: We identified 3,820,865 weighted HF hospitalizations, with peak admissions in winter (32.20%), followed by spring (29.73%), autumn (28.68%), and summer (9.39%). The mean patient age was highest in winter (69.5±0.06 years) and lowest in summer (68.7±0.07 years), P<0.001. Comorbidities showed seasonal variations, with hypertension, diabetes, and obesity more prevalent in summer, while acute myocardial infarction was more frequent in winter. White, Hispanic, and Asian/Pacific Islander patients experienced higher winter hospitalizations, whereas Black patients had increased admissions in autumn. Hospitalizations were most common among patients in the lowest income quartile (33.23%). The overall in-hospital mortality rate was 2.28%, highest in winter (2.40%) and lowest in summer (2.11%), P<0.001. The average length of stay (LOS) was 5.24 days (95% CI: 5.20-5.28), increasing from 5.19 days (95% CI: 5.12-5.25) in 2018 to 5.31 days (95% CI: 5.25-5.38) in 2020. Inflation-adjusted costs rose from $57,166 in 2018 to $65,961 in 2020, with significant seasonal differences.

Conclusions: Seasonal variations markedly influence HF-related hospitalizations and outcomes, with winter showing the highest hospitalization and mortality rates, especially among White, Hispanic, and Asian/Pacific Islander patients.

Acute coronary syndromes (ACS) are frequently the first manifestation of cardiovascular disease and require timely intervention. Primary percutaneous coronary intervention (pPCI) significantly reduces mortality and major adverse cardiovascular events in patients with ST-elevation myocardial infarction (STEMI). However, despite successful epicardial recanalization, pPCI can be complicated by inadequate myocardial reperfusion, a phenomenon known as coronary no-reflow (NR) or microvascular obstruction (MVO), which is associated with adverse outcomes. The aim is to describe a novel interventional approach - the saline technique - for the treatment of MVO following stent implantation during pPCI. The saline technique consists of a rapid, manual intracoronary injection of 10 mL of saline over 2-4 seconds using a 6-Fr thrombus aspiration catheter positioned distally to the stented segment. The aim is to rapidly increase distal coronary pressure and volume, promoting microvascular recruitment and displacement of micro-emboli and vasoconstrictive agents. A diagnostic step using distal angiography precedes treatment to confirm MVO. Preliminary data from a single-center matched cohort (N.=32) showed that the Saline Technique significantly improved TIMI flow grade and ST-segment resolution compared to standard care. No major complications were observed. Post-procedural Index of Microvascular Resistance (IMR) was reduced in most cases. The saline technique is a safe, cost-effective, and rapidly deployable option for managing coronary NR/MVO. While promising, these findings are hypothesis-generating and require confirmation in larger, randomized trials.

Background: Procedure-related vascular and bleeding complications after transcatheter aortic valve implantation (TAVI) still represents an important issue that impact on patients' mortality and morbidity. The aim of this study was to compare the effectiveness of single or double suture-based devices (SBDs) combined with a plug-based device to obtain large bore arteriotomy hemostasis after transfemoral (TF) TAVI.

Methods: Consecutive patients with available preprocedural computed tomography angiography (CTA) assessment undergoing 14Fr TF-TAVI from February 2018 to May 2023 at our Institution were considered. Patient receiving single or double SBD combined with a plug-based device were compared after propensity score matching. The primary outcomes were major vascular complications and type 2 to 4 bleeding due to endovascular closure system failure according VARC-3 criteria.

Results: Among a total of 490 patients, 130 matched pairs of patients were compared. At 30 days, there was no difference in major vascular complications (0.0% vs. 2.3%, P=0.25) and in type 2 to 4 bleedings (4.6% vs. 6.2%, P=0.78) between two matched groups. No difference in 30-day (1.5% vs. 3.8%, P=0.45) and one-year (12.0% vs. 9.5%, P=0.60) all-cause death was observed.

Conclusions: A simpler strategy with single SBD had comparable safety and effectiveness to the use of double SBD when combined to a plug-base device after 14 Fr TF-TAVI.

Background: The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients presenting with multi-vessel (MV) coronary artery disease (CAD) and acute myocardial infarction (MI) has not been systematically addressed. Accordingly, we performed a frequentist network meta-analysis with the aim of assessing the prognostic impact of different PCI strategies.

Methods: We conducted an electronic research for studies including angiography-guided and functional-guided complete revascularization in patients with acute MI from 2001 to 30^th November 2023. Endpoints of interest were cardiovascular mortality, all-cause mortality, spontaneous MI and any revascularization.

Results: Twelve randomized clinical trials involving 11,581 patients fulfilled the inclusion criteria. Functional-guided complete PCI was associated with lower cardiovascular death compared to culprit-only PCI (incidence rate ratio [IRR] 0.61, 95% confidence interval [CI] 0.39-0.96; P=0.033). Both complete functional- and angio-guided PCI reduced the risk of further revascularization compared to culprit-only PCI (IRR 0.37, 95% CI 0.24-0.55, P<0.001, and IRR 0.33, 95% CI 0.20-0.52, P<0.001, respectively). Both complete functional- and angio-guided PCI resulted in a non-significant reduction of spontaneous MI compared to culprit-only PCI strategy (IRR 0.76, 95% CI 0.50-1.15; P=0.20 and IRR 0.72, 95% CI 0.47-1.12; P=0.15, respectively). No significant differences were found regarding other study endpoints and other comparisons.

Conclusions: In patients with MI and MV CAD, undergoing successful PCI of IRA, a complete revascularization strategy, regardless of the specific approach, was associated with a lower incidence of repeat revascularization compared with a culprit-only strategy. Complete functional-guided revascularization resulted in lower incidence of cardiovascular death, whereas a complete angio-guided approach did not show the same benefit.

Viral heart disease comprises of two cardiovascular entities being evoked by viral infection: acute viral myocarditis and viral cardiomyopathy. Viral myocarditis may completely resolve leaving no traceable sign or cause ongoing inflammation with subsequent development of hypokinetic dilated/non-dilated cardiomyopathy. The exact epidemiology of viral myocarditis remains unknown due to its sometimes asymptomatic course, but according to the Global Burden of Disease Study 2019, the prevalence of myocarditis in young adults is estimated to range between 6.1 per 100,000 in men and 4.4 per 100,000 in women, with the most common viral etiology. According to the literature viral genome can be found in considerable percentage (up to 67,4%) of endomyocardial biopsy specimens obtained from patients with idiopathic left ventricular dysfunction- suggesting viral etiology of the cardiomyopathy. In this review we would like to enlighten most common types of arrhythmias and conduction disorders as well as their prevalence in patients with viral heart disease. Moreover, our paper depicts probable pathological mechanisms in which viruses induce arrhythmias and cardiac conduction system disease in both, acute viral infection and chronic viral disease. We would also like to highlight unresolved problem of sudden death protection in the course of acute myocarditis.