Risultati per: ESH: nuove linee guida complete per la gestione dell’ipertensione arteriosa

Circulation, Volume 148, Issue Suppl_1, Page A15023-A15023, November 6, 2023. Background:The benefit of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for non-culprit lesions with angiographically severe stenosis in patients with acute myocardial infarction (AMI) is unclearObjectivesWe evaluated the relationship between non-culprit lesion stenosis measured by quantitative coronary angiography (QCA) and the efficacy of FFR-guided PCIMethods:Severity of non-culprit lesion stenosis of 562 patients from FRAME-AMI (FFR vs. Angiography-Guided Strategy for Management of Non-Infarction Related Artery Stenosis in Patients with AMI) was measured using QCA in the core laboratory. The effect of FFR-guided versus angiography-guided PCI according to non-culprit lesion stenosis (QCA stenosis ≥70% or

Circulation, Volume 148, Issue Suppl_1, Page A15484-A15484, November 6, 2023. A 42-year-old female patient was admitted for lower limb edema. Laboratory tests showed nephrotic proteinuria (2.76g/24h). Serum-free λ light chains were 84.9 mg/L, with a κ/λ ratio of 0.12. Bone marrow examination detected 6% immature clonal plasma cells. Amyloid deposition was identified in a renal biopsy. Cardiac magnetic resonance (CMR) revealed normal left ventricular ejection fraction (LVEF), left ventricular circumferential late gadolinium enhancement (LGE), and elevated myocardial T1 value (1459ms) and extracellular volume (47.4%). She was diagnosed with AL amyloidosis and classed as IIIa by the Mayo Stage 2004. A hematologic complete response (CR) was achieved and sustained after treatment with sequencing cyclophosphamide, bortezomib, dexamethasone (CyBorD) and daratumumab regimen. The follow-up CMRs were underwent at 6, 12, and 18 months after starting chemotherapy, which monitored cardiac changes in reponse to CR. Unfortunately, there was no alleviation of cardiac involvement. CMR re-examination (at 42 months) revealed severe cardiac function impairment (LVEF 28%), and dramatically increased extracellular volume (66.2%). Then, she underwent heart transplantation (HTx) evaluated by the heart transplantation multidisciplinary team. Three months later, she was doing well, CMR demonstrated stable cardiac allograft function. Repeated endomyocardial biopsies showed no amyloid deposits. This case illustrates that cardiac amyloid deposition might be a dynamic process in AL amyloidosis and highlights the value of CMR in long-term monitoring and identifying the patients reached CR who need HTx.

Circulation, Volume 148, Issue Suppl_1, Page A16866-A16866, November 6, 2023. Background:In patients presenting with acute myocardial infarction (AMI) with left main (LM) culprit lesion and multivessel disease, percutaneous coronary intervention (PCI) of non-culprit lesions in LM culprit AMI is challenging and whether it reduces mortality and adverse events is unclear.Hypothesis:Complete revascularization will show better outcome than culprit-only revascularization in multi-vessel LM AMI PCI.Methods:We reviewed total of 16831 patients among from July 2016 to June 2020 Korean Acute Myocardial Infarction Registry (KAMIR) and 395 patients were enrolled with LM culprit multi-vessel AMI treated by PCI. We excluded in-hospital death 35 cases then categorized patients whether treated with complete revascularization (n=198) or culprit-only revascularization (n=162). Study outcome was a composite of major cardiac adverse events (MACE) including cardiac death, myocardial infarction, re-PCI, stent thrombosis and rehospitalization due to heart failure. We used propensity score (PS) matching method and cumulative event-free survival and MACE were analyzed over 3 years follow-up.Results:After PS matching, baseline and angiographic characteristics were similar between two groups (Complete group, n=142 versus Culprit-only group, n=142). Killip classification (Class IV : n=13 (9.2%) versus n=14 (9.9%),p-value=0.762) and initial diagnosis (STEMI : n=47 (33.1%) versus n=52 (36.6%),p-value=0.618) at admission were also not different between two groups. There was no difference in MACE between two groups (n=27 (19%) versus n=28 (19.7%), log-rank testp-value = 0.64).Conclusion:Although, other studies had shown better outcome of complete revascularization in multi-vessel AMI, in multi-vessel LM AMI PCI, complete revascularization should be carefully decided depending on the patient’s condition.

Circulation, Volume 148, Issue Suppl_1, Page A13661-A13661, November 6, 2023. Introduction:Complete Heart Block (CHB) is a commonly observed post-procedural complication associated with Transcatheter aortic valve replacement (TAVR) and Surgical aortic valve replacement (SAVR). Since 2016, limited data exists on In-hospital outcomes of TAVR and SAVR cases and rates of development of CHB.Methods:National Inpatient Sample 2016-2020 was used to identify and group TAVR and SAVR cases using appropriate ICD codes. Logistic regression was used to compare baseline characteristics and in-hospital outcomes.Results:590,615 patients underwent aortic valve replacement (AVR) from 2016-2020, of which 49.6% were TAVR and 50.4% were SAVR. The most common diagnosis for AVR in both groups was nonrheumatic trileaflet aortic stenosis (AS) (86.6% in TAVR group and 53.5% in SAVR group, p

Circulation, Volume 148, Issue Suppl_1, Page A16763-A16763, November 6, 2023. Abbreviations: DLBCL (diffuse large B cell lymphoma), CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone).Description of caseWe present the case of a 78-year-old female who presented initially with a right neck mass, abdominal pain, diarrhea, and recurrent pericardial effusions requiring pericardial window procedure.Biopsy of the neck mass demonstrated a DLBCL. Involvement of a right atrial mass attached to the septum in close relation to the tricuspid valve was seen on TEE. Metastatic disease to the lungs and liver was demonstrated on CT chest and abdomen respectively.The patient posteriorly developed symptomatic bradycardia that on electrocardiogram and telemetry monitoring was shown to be due to a complete heart block with junctional and ventricular escape beats with a rate of 30-40 beats per minute. Due to the anatomical characteristics of the right atrial mass, placement of a right ventricle leadless pacemaker (micra) was decided. The patient was started on mini-CHOP chemotherapy shortly afterwards.DiscussionPrimary cardiac lymphomas are a rare presentation accounting for less than 1% of all cardiac malignancies. Although rare, secondary involvement of the heart is more frequent than primary involvement and represents 20-25% of the cases. From all the broad subtypes of lymphomas, DLBCL is the most commonly found to affect the cardiac system, often being represented by alterations in the conduction system and causing congestive heart failure.The exact mechanism of the conduction abnormalities in the setting of cardiac lymphoma has not yet been well elucidated but is presumed to be either caused by an infiltration of the conduction system, direct mass burden effect, or a combination of both.It has been seen in similar cases that initiation of chemotherapy can help decrease the pacing requirements or even resolve completely the conduction abnormalities. In a few cases, permanent pacing is required. Metastatic disease to the heart is a marker for poor outcome and median survival with therapy after diagnosis is between 7 to 18 months.

Circulation, Volume 148, Issue Suppl_1, Page A16716-A16716, November 6, 2023. Introduction:Patients presenting with Complete Heart Block (CHB) are emergently referred for placement of a temporary transvenous pacemaker (TTVP) for hemodynamic stability. Data on the immediate management and outcomes of such patients are lacking.Methods:Data collected through retrospective chart review of patients presenting to the Emergency Department (ED) at 3 regional referral hospitals from 10/2017 to 9/2022 with a diagnosis of new CHB; included age, sex, clinical, laboratory and ECG data, medications, interventions and length of stay(LOS).Results:There were 230 patients (106 women), mean age 77 years. Of these 94 were on beta blockers, 55 on calcium channel blockers. Syncope, dizziness and dyspnea were common symptoms. Pause > 3 seconds was seen in 50 patients. Sympathomimetics were used in 55 patients and 179 patients were admitted to the ICU. There was no statistical difference in demographics, clinical features, ICU utilization and LOS. A TTVP was placed in 72(31%) and a Permanent Pacemaker (PPM) prior to discharge in 182 patients, a median of 1 day from ED presentation. By site, there were 71, 74 and 85 patients of whom TTVP was placed in 38%, 15% and 40% and a PPM in 76%, 82% and 79% in the 3 regional centers. The median LOS was 3 days. Univariate logistic regression was used to assess for predictors of TTVP placement (SAS® Version 9.4, Cary, NC). Syncope, Initial SBP, Shock, Pause > 3 seconds, Acute MI, and Serum K were associated with higher odds of patients getting TTVP. SBP > 160mmHg was associated with lower odds of needing TTVP.Conclusions:TTVP was infrequently needed (31%) among patients presenting to the ED with CHB. Initial SBP, Shock, Acute MI, Pause > 3sec and Serum K were associated with TTVP placement. Higher SBP was associated with lower odds of needing a TTVP. There seems to be a difference in TTVP utilization rate between centers. Prospective data related to the acute management of CHB is needed to identify variations in utilization of TTVP between centers.

Circulation, Volume 148, Issue Suppl_1, Page A17852-A17852, November 6, 2023. Introduction:Right atrial masses are ominous and have a broad differential including thrombus, primary cardiac tumors such as myxoma vs sarcoma, metastatic processes like lymphoma, and, rarely, autoimmune etiologies. In this case, an apple watch notification of bradycardia was a simple start to a complicated course of rapidly progressive conduction disease arising from an unusual presentation of cardiac sarcoidosis.Case Presentation:A 45-year-old previously healthy female originally presented to clinic with a one-month history of exertional dyspnea and palpitations with bradycardia noted on her Apple Watch and an ongoing event monitor revealing transient type II second-degree atrioventricular block. In the office, she was normotensive but bradycardic at 33 beats per minute with electrocardiogram revealing complete heart block with junctional escape. She was admitted for additional work-up with transesophageal echocardiogram (TEE) which was unrevealing. Cardiac magnetic resonance imaging (cMRI) identified two 2 x 2 cm right atrial masses that appeared hypermetabolic on cardiac fluorodeoxyglucose positron emission tomography (FDG cPET) in addition to bilateral hilar lymph nodes. A temporary-permanent pacemaker equipped with a lead capable of floating atrial bipolar sensing was placed while biopsy plans were arranged. Transbronchial ultrasound guided biopsy of the hilar lymph node returned benign. She then underwent two different attempts at transcatheter biopsy of the right atrial masses – one TEE guided, another intracardiac echo (ICE) guided – with most samples unrevealing except one with an inconclusive amount of spindle cells raising concerns for sarcoma. The decision was made to pursue cardiothoracic surgical resection of the right atrial masses with pathology returning with granulomatous lesions consistent with sarcoidosis.Discussion:Cardiac involvement is present in 25% of cases of sarcoidosis and most commonly manifests as conduction abnormalities, ventricular arrhythmia, and/or heart failure. Only a few cases of atrial masses are reported in the literature and its presence in this woman with heart block confounded the picture before a diagnostic biopsy of this treatable condition could be obtained.

Circulation, Volume 148, Issue Suppl_1, Page A13737-A13737, November 6, 2023. Background:Iatrogenic bradycardia and complete heart block can occur with medications commonly administered during general anesthesia.Case:A 79-year-old male with past medical history of coronary artery disease, hypertension, paroxysmal atrial fibrillation and a left bundle branch block, underwent elective lithotripsy procedure, baseline ECG demonstrated in Figure A. Post-operatively, he developed asymptomatic complete heart block approximately 3 minutes after receiving sugammadex, a paralytic reversal agent (see Figure B). He was admitted for monitoring and spontaneously converted to sinus rhythm after 10 hours. The patient was discharged home with a 30-day event monitor; no pauses or high-grade atrioventricular block was noted during the monitoring period. Three months later, he underwent ureteroscopy stent exchange; during the induction with propofol he developed asystole followed by cardiac arrest. CPR was initiated and had return to spontaneous circulation after 3 minutes. The patient was transferred to the ICU, however, once again complete heart block was observed.Clinical decision-making:This case highlights recurrent episodes of transient complete heart block in the setting of an underlying left bundle branch and first-degree AV block that were exacerbated by medications during general anesthesia. Because of his underlying conduction disease and recurrent complete heart block and subsequent cardiac arrest, he ultimately underwent insertion of permanent dual chamber pacemaker.Conclusion:Iatrogenic transient complete heart block is a rare but potentially fatal complication. Prompt diagnosis and clinical suspicion of reversible causes are warranted. Significant underlying conduction disease should be considered to decide the ideal therapeutic option.

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