Risultati per: Report aggiornato sulla qualità dell’aria in Europa (2015)

Circulation, Volume 150, Issue Suppl_1, Page A4120854-A4120854, November 12, 2024. Introduction:Familial hyper-alpha-lipoproteinemia (HALP) is a heterogenous genetic lipid disorder that is found in only 8% of the population and manifests as elevated HDL levels above the 90thpercentile. HALP is due to mutations in various genes including cholesteryl ester transfer protein (CETP), hepatic lipase, or apolipoprotein C-III (APOC3). While epidemiological studies have noted an inverse relationship between high HDL and the development of coronary artery disease, recent data have shown a lack of causal atheroprotective effects. We present a case of a patient with significantly elevated HDL and peripheral vascular disease.Case Description:Patient is a 64-year-old female with past medical history of peripheral artery disease with occlusion of the left femoral artery and popliteal arteries status post angioplasty, hypertension, type 2 diabetes, alcohol use, and CKD Stage 4 who presented to the advanced lipid clinic for management of elevated lipoproteins. Patient’s laboratory data was significant for total cholesterol (TC) of 375 mg/dL, a high-density lipoprotein (HDL) of >200 mg/dL, triglycerides (TG) of 66 mg/dL, and a low-density lipoprotein (LDL) of 175 mg/dL. Further testing revealed elevated apolipoprotein A-I of 231 mg/dL. Patient was subsequently initiated on a high intensity statin with improvement in her lipid panel with a TC of 247 mg/dL, HDL of 133 mg/dL, TG of 50 mg/dL, and LDL of 106 mg/dL, with plan for further uptitration of lipid therapy to target LDL

Circulation, Volume 150, Issue Suppl_1, Page A4124065-A4124065, November 12, 2024. Introduction:CHIP is associated with CAD and mortality. The prognostic relevance of CHIP for high-risk patients with confirmed CAD is unknown.Hypothesis:CHIP variants are associated with cardiovascular (CV) events and mortality in high-risk patients with known CAD in the ISCHEMIA Trials Biorepository.Methods:895 ISCHEMIA and ISCHEMIA-CKD (hereafter, ISCHEMIA Trials) participants with moderate-severe ischemia and next-generation sequencing performed for CHIP variant allele fractions of ≥2% (CHIP) and ≥10% (large CHIP) were included. Unadjusted and multivariable adjusted (age, sex, diabetes, eGFR not on HD, HD, and LVEF) associations of CHIP and large CHIP with a) ISCHEMIA Trials initial phase primary endpoint (CV death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, RCA) and b) ISCHEMIA Trials combined initial and extended follow-up phase (hereafter, Cumulative) endpoint of all-cause death .Results:Median (IQR) age of sequenced participants was 67 (56 – 79) years, 19% were female, 83% white, and 6% Hispanic. Hypertension (84%), diabetes (45%) and obesity (47%) were common, 26% had an eGFR 1 gene. Over 3.1 years of RCT follow-up there were 135 (20%), 32 (16%) and 15 (18%) primary endpoints for no CHIP, CHIP and large CHIP, respectively. Over 6.8 years of EXTEND follow-up, there were 126 (18%), 47 (23%) and 24 (29%) deaths in the no CHIP, CHIP and large CHIP groups, respectively. After multivariable adjustment there was no association between CHIP or large CHIP and CV events or mortality (Figure 1c).Conclusion:Neither CHIP nor large CHIP was associated with adverse outcomes in 895 high-risk individuals with confirmed CAD, despite a high prevalence of these mutations.

Circulation, Volume 150, Issue Suppl_1, Page A4141415-A4141415, November 12, 2024. Lead related venous obstruction (LRVO) is an often underrecognized complication of pacemaker implantation. Symptoms of LRVO may include mild asymmetric upper extremity swelling to highly morbid superior vena cava (SVC) syndrome. We present an unusual case of a 54-year-old man with a history of retained pacemaker leads placed 26 years ago who presents with abdominal distention, lower extremity edema, and shortness of breath. He was found to have new onset ascites and significant pleural effusions. A liver biopsy showed hepatic fibrosis and pleural studies were consistent with chylothorax. After significant workup and diagnostic testing, it was believed that he had late complications often seen in Fontan physiology, notably hepatic fibrosis, lymphatic leakage, and protein losing enteropathy. A venogram and pressure measurements were performed which confirmed obstruction at the junction of the SVC and right atrium with elevated central filling pressures and significant flow through a markedly dilated azygous vein. A lymphangiogram suggested lymphatic leakage through the thoracic duct. An SVC stent was placed in an attempt to relieve the obstruction but the patient had progressive hemodynamic compromise leading to placement of mechanical circulatory support. Ultimately, the patient underwent surgical extraction of the retained pacemaker leads and reconstruction of the superior vena cava and right atrial junction, leading to near-resolution of his symptoms. This unusual presentation of SVC syndrome as a late complication of retained pacemaker leads highlights the potential severity of cardiac implanted electronic device lead-related complications.

Circulation, Volume 150, Issue Suppl_1, Page A4139467-A4139467, November 12, 2024. Introduction:Acute coronary syndrome (ACS) has been generally considered a relative contraindication to coronary atherectomy.Aims:The objective of this study was to investigate the temporal trends and hospital variability in the use of coronary atherectomy and its outcomes among patients undergoing percutaneous coronary intervention (PCI) for ACS from a nationwide PCI registry in Japan.Methods:First, we analyzed the temporal trend in the use of rotational atherectomy (RA) and orbital atherectomy (OA) during PCI for ACS patients between 2014 and 2022 (822,237 PCIs from 1,269 hospitals). Next, we assessed the outcomes of the patients who underwent RA for ACS between 2019 and 2022 (7,421 patients across 662 hospitals). The primary outcome was in-hospital mortality after PCI. Patient outcomes associated with hospital PCI volumes and the device policy change on coronary atherectomy in Japan in 2020, which allowed operators to perform coronary atherectomy without on-site surgical backup, were also evaluated.Results:The rate of RA for ACS was low at 2.0% in the overall cohort (16,264/822,237 PCIs); the rate slightly increased from 1.9% in 2014-2019 to 2.1% in 2020-2022 (after the device policy change). The rate of PCI with OA for ACS was also low at 0.8% in 2021-2022 (1,404/185,141 PCIs). Increasing the complexity of baseline characteristics, including advanced age, diabetes, chronic kidney disease, dialysis, peripheral arterial disease, prior coronary artery bypass grafting, ST-segment elevation myocardial infarction, cardiac arrest within 24 h, cardiogenic shock within 24 h, three-vessel disease, and mechanical circulatory support during PCI was significantly associated with increased in-hospital mortality after PCI with RA in ACS patients (P

Circulation, Volume 150, Issue Suppl_1, Page A4145402-A4145402, November 12, 2024. INTRODUCTION:Peripartum cardiomyopathy (PPCM) is a form of systolic heart failure, which occurs late in pregnancy or within the first 5 months postpartum and it is the most common cause of death related to heart failure in pregnant women. To establish the diagnosis, other causes of heart failure must be ruled out and a left ventricular ejection fraction (LVEF)

Circulation, Volume 150, Issue Suppl_1, Page A4145166-A4145166, November 12, 2024. Background:Interest in hospital at home (HaH) has grown, driven by recognition of potential to ameliorate capacity constraints and lower total costs of care associated with traditional “brick-and-mortar” (BaM) hospitalizations. Heart failure (HF) patients often require decongestion with intravenous diuretics and titration of multiple guideline-directed medical therapies (GDMT). We aimed to demonstrate that a virtual HaH model represents a safe and feasible option for patients with acute heart failure (AHF).Methods:This was a retrospective cohort analysis of patients admitted to the Cleveland Clinic HaH after clinical and social screening and enrollment in HaH from 4/2023 to 1/2024 (Fig 1). Patients with AHF were identified through pre-specified ICD-10 codes. We performed chart abstraction to evaluate demographic characteristics, admissions, vitals, lab values, 30-day readmissions/death, use of individual HF medications, and tabulated GDMT scores among this cohort of HaH patients. Statistical analysis involved parametric and non-parametric paired analysis at admission and discharge.Results:81% of patients (78/96) with AHF that were offered HaH as an alternative to BaM hospitalization opted to enroll in HaH. Patient were of median age 81 years [IQR 16], median LVEF 51.0% [IQR 20], and median admission NTproBNP 3518 [IQR 4619]; 66% of patients were male. Among the cohort, 7 (8.9%) patients were readmitted 30 days from discharge, and there were no deaths in the cohort at 30 month follow-up. By paired analysis, there was a net increase in GDMT score. Systolic blood pressure, diastolic blood pressure, and weight significantly trended down after admission to the HaH (Fig 2).Conclusions:In an early cohort of patients, HaH was selected by most eligible patients over BaM hospital care. There were low rates of readmission and net improvement in GDMT use. HaH can be safe and effective for selected HF patients, though further prospective research is needed.

Circulation, Volume 150, Issue Suppl_1, Page A4122369-A4122369, November 12, 2024. Background:Internal mammary artery (IMA) side branch flow diversion post- coronary artery bypass grafting (CABG) and its role in coronary steal syndrome remains controversial. However, evident association persists when substantial side branches stem from the IMA, possibly due to relatively lower peripheral resistance as compared to higher coronary resistance. Intervention has shown promise in ameliorating reversible ischemia in these cases. Recanalization of previously occluded side branch is rare and has only been reported within a 6 month period. We report a case of recanalization of a previously occluded side-branch after 4 years with recurrence of symptoms.Case:A 63-year-old male underwent CABG with LIMA-LAD in 2020 and coil embolization of LIMA side branch for symptomatic coronary steal syndrome (figure 1). Angina recurred 3 years later, leading to right coronary artery stent placement. He now presents with palpitations and dyspnea on exertion. Vital signs and physical exam was unremarkable. ECG showed a normal sinus rhythm with no signs of ischemia. A 24-hour Holter showed significant polymorphic ventricular ectopy and episodes of sustained ventricular tachycardia (arrhythmic burden 12.4%). Transthoracic echocardiogram showed an ejection fraction of 71% and slightly decreased left ventricular global longitudinal strain (-16.6%).Decision-making:A diagnostic cardiac catheterization was performed which showed patency of bypass and stent with no signs of occlusion or restenosis, rather revealing a permeable, previously occluded side-branch (figure 2A) and resurgent coronary steal phenomenon. Repeat coiling was performed, achieving complete cessation of flow (figure 2B) and evident increased flow to the LAD. Resolution of symptoms was observed and post-procedure Holter showed normal sinus rhythm with no arrhythmic changes.Conclusion:Recanalization of an IMA side branch after complete occlusion with multiple coils is rare, particularly beyond 6 months. This appears to be the first reported case of the phenomenon, occurring after 4 years. Administration of heparin for recent stent placement, continuation of oral antiplatelet therapy and distal coil location may have contributed to restoration of flow, despite the presence of intraluminal coils. Repeat coiling proved successful in relieving symptoms.

Circulation, Volume 150, Issue Suppl_1, Page A4138624-A4138624, November 12, 2024. Case Presentation:A 67-year-old man with recurrent pleural effusions and concern for cirrhosis was referred for liver transplant. Pleural fluid was transudative by Light’s criteria with a high total protein level of 3.5 g/dL, which made hepatic hydrothorax unlikely. Liver biopsy confirmed congestive hepatopathy without advanced fibrosis. Transthoracic echocardiogram showed left ventricular (LV) ejection fraction 55%, right ventricular (RV) systolic pressure 35 mmHg, normal mitral annular tissue doppler velocities, and early diastolic septal bounce. Right and left heart catheterization showed prominent X and Y descent, elevated and equalized diastolic pressures, but no respiratory discordance in the LV-RV pressure gradient. As etiology of these findings were unclear, he underwent aggressive diuresis and hemodialysis, but repeat right heart catheterization showed persistently elevated right and left filling pressures. Cardiac MRI had no evidence of myocardial or pericardial inflammation/edema but showed pericardial thickening (7.9 mm) and septal bounce. There was no inspiratory septal shift, but the large pleural effusion appeared to limit diaphragm excursion. Given lack of respirophasic ventricular interdependence and thickened pericardium on MRI, CT was ordered, showing pericardial calcifications. Diagnosis of constrictive pericarditis was made, and patient underwent complete pericardiectomy. Pathology confirmed calcified and thick pericardium without acute inflammation. Post-operatively, patient developed RV failure, but recovered with inotrope support and was discharged with improvement in congestive symptoms.Discussion:Constrictive pericarditis classically exhibits respirophasic ventricular interdependence, but large pleural effusions may decrease respiratory variation in intrathoracic pressures, blunting this response. Normal mitral annulus tissue doppler velocities and lack of infiltrative process on cardiac MRI made restrictive cardiomyopathy unlikely. In the absence of respirophasic changes on multimodality testing, constriction can be diagnosed with other supportive features such as diastolic septal bounce, rapid Y descent, diastolic pressure equalization, and pericardial thickening and calcifications.

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Circulation, Volume 150, Issue Suppl_1, Page A4146986-A4146986, November 12, 2024. Case Description and Procedural Technique:86 year old female with a prior history of coronary artery bypass grafting presented with non-ST elevation MI underwent subtotal occlusion of vein graft supplying the large obtuse marginal artery.The left coronary bypass catheter was used to cannulate the vein graft, supplying the obtuse marginal artery. Balanced middleweight universal wire (BMW) was used to cross the lesion. Given the critical nature of the lesion, it was pre-dilated using a 2 mm balloon. Bare wire and emboshield NAV6 (2.5-4.8mm) embolic protection was then used for distal protection. Due to hemodynamically intolerance, direct stenting was opted for, and a 3.5 x 16 mm synergy stent was deployed over the BMW wire with accidental entrapment of the bare wire and embossed filter protection system behind the stent frame.We have then placed an un-inflated 2.5 mm balloon inside the stent frame over the BMW wire. A 1 mm sapphire balloon was advanced over the bare wire, and its distal tip was placed behind the proximal edge of the stent. It was then inflated at 8 atmospheres. Serial inflations behind the stent frame were done with slow advancement of the balloon, covering the entire length of the stent. The balloon was then upsized to 2 mm, and serial inflations were performed behind the stent frame. After creating enough lumen, the filter was pulled back and re-captured. The 2.5 mm balloon was then inflated inside the stent frame. The balloon was upsized to 3.5 mm for the good apposition of the stent frame. TIMI III flow was obtained without any complications.Discussion:Distal embolic protection with intravascular filters is often used during percutaneous intervention of saphenous venous grafts. Accidental entrapment of emboshield filter systems can occur behind the stent in emergent situations when buddy wire technique is used in the vein graft. Our technique describes removal of the entrapped filter in a safe manner keeping the stent frame in place without surgical intervention. A few similar cases have been reported in the literature with surgical removal of wire.

Circulation, Volume 150, Issue Suppl_1, Page A4118882-A4118882, November 12, 2024. Introduction:Sinus of Valsalva aneurysm (SVA) accounts for 3.5% of all congenital cardiac anomalies. Rupture occurs in 35% of cases and can lead to life-threatening fistulas, predominantly involving the right ventricle or right atrium.Description of Case:62-year-old female with hypertension and hypothyroidism presented to the ER with progressively worsening dyspnea over the past week. She also reported worsening lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. Chest X-ray showed large pleural effusions. Her ejection fraction was 66% ejection fraction with a fistula between the right sinus of Valsalva and the right atrium on transthoracic echocardiogram (TTE) which was also seen on transesophageal echocardiogram (TEE). Her heart failure was due to the fistula as she had no coronary artery disease on coronary angiogram. She had cardiothoracic surgery for fistula repair. Postoperatively, she developed complete heart block requiring a permanent pacemaker. She had no further complications and was discharged home in good condition.Discussion:SVA affects the right sinus (94%), with the non-coronary (5%) and left sinus (1%) being less commonly involved. Aneurysm rupture typically forms a fistula into the right ventricle (60%), right atrium (29%), left atrium (6%), or left ventricle (4%), and rarely into the pericardial cavity (1%). Symptoms vary by rupture size and location. TTE is the initial diagnostic tool but has limited sensitivity (50%) for detecting fistulas, whereas TEE has a 90% sensitivity. Cardiac MRI and CT can further refine diagnoses, and cardiac catheterization assesses coronary arteries preoperatively. Surgical closure with a patch is the primary treatment for ruptured SVA, significantly improving survival rates compared to non-surgical management.

Circulation, Volume 150, Issue Suppl_1, Page A4137165-A4137165, November 12, 2024. Background:Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI) and can be mitigated by using less iodinated contrast. The National Cardiovascular Data Registry (NCDR) supports quality improvement initiatives by providing quarterly, risk-adjusted, institutional AKI rates. However, it remains uncertain whether these efforts have reduced procedural contrast volume, particularly in high-risk patients.Aims:Examine temporal trends in contrast volume during PCI across different pre-procedural AKI risk strata.Methods:Within the NCDR CathPCI Registry, we identified PCIs performed between April 1, 2018, and December 31, 2022, and examined changes in mean contrast volume over time across different pre-procedural AKI risk strata defined by the validated NCDR AKI risk model. A multivariable hierarchical model, with the physician as a random effect, was constructed to assess the trend in contrast volume use over time.Results:Among 3,126,559 patients undergoing PCI (mean age = 66.8 ± 11.7 years, 69.4% men, and 39.9% elective procedures), contrast volume declined from a mean of 168.1±77.6 ml in Q2 2018 to 149.8±71.2 ml in Q4 2022 (p< 0.001 for trend) with the trend being consistent across AKI risk strata (Figure). After adjusting for patient and pre-procedural characteristics, the contrast volume declined by 18.9 ml (95%CI 19.1 to 18.6,P15%).Conclusions:PCI contrast administration has declined over time, and the average exposure was lowest in patients at highest risk for AKI, suggesting improved efforts to reduce AKI over time.

Circulation, Volume 150, Issue Suppl_1, Page A4134619-A4134619, November 12, 2024. Background:Ebstein anomaly (EA) is a rare congenital heart defect occurring in 1.2 to 5 in 100,000 live births, characterized by a downward displacement of the tricuspid valve, thin-walled right ventricle, and tricuspid valve regurgitation. It can present variably from asymptomatic cases to severe symptoms like arrhythmias and right-sided heart failure. EA is often associated with other anomalies such as interatrial communication and mitral valve prolapse. The condition can lead to accessory atrioventricular pathways, frequently resulting in Wolff-Parkinson-White syndrome (WPW), which involves abnormal heart electrical activity and increases the risk of sudden cardiac death. While the genetic basis of EA is not fully understood, it appears to involve multiple genes like FLNA and NKX2-5, MYH6, MYH7 suggesting a complex polygenic inheritance pattern. TNNT2 is known to be associated with Cardiomyopathy but has not been previously associated with EA and WPW.Case:In this report, we present findings from a lebanese family with EA, comprising 2 affected individuals. Whole exome sequencing in the affected individuals identified a pathogenic variant in the TNNT2 gene at coding strain position 260 (a missense mutation: C to T), resulting in the substitution of Proline with Leucine at position 87 in affected individuals (Figure 1). No variants were detected in any other candidate gene examined. Individuals I:1 and II:2 were found to be normal, with no EA findings on echocardiography.Methods:Whole exome sequencing in the patients involved collecting blood samples after obtaining consent. These samples were sent to Centogene lab, where genomic DNA is enzymatically fragmented. The regions of interest are then enriched using DNA capture probes, facilitating detailed genetic analysis.Results:The whole exome sequencing identified a heterozygous missense mutation in both the father and his daughter. This nonsynonymous variant is located on chromosome 1 (GRCh37) in the TNNT2 gene region. The specific variant, NM_001276345.1:c.260C >T p.(Pro87Leu), was found in both individuals.Conclusion:In conclusion, the genetic basis of EA is rather complex and remains poorly understood. It is established that mutations in the TNNT2 gene are linked to several cardiomyopathies, none of them overlap with the described phenotype of our patients. In this report, we therefore confirm the potential role of TNNT2 gene mutation in the genetic basis of familial EA with WPW.

Circulation, Volume 150, Issue Suppl_1, Page A4145384-A4145384, November 12, 2024. Introduction:Necrotizing enterocolitis (NEC) is a life-threatening condition of compromised gastrointestinal mucosa with risk of progression to ischemia, necrosis and perforation. The incidence and outcomes of NEC in infants with congenital heart disease (CHD) are incompletely understood.Hypothesis:Patients who develop NEC in the acute care cardiology unit (ACCU) are likely to have different patient characteristics and worse clinical outcomes than those who do not develop NEC.Aims:Describe differences in baseline characteristics and clinical outcomes in infants

Circulation, Volume 150, Issue Suppl_1, Page A4140549-A4140549, November 12, 2024. Introduction:Persistently elevated filling pressure leading to central venous congestion is associated with poor prognosis. This central venous congestion stimulates connective tissue hyperplasia causing tissue fibrosis and stiffness of the liver. However, risk stratification involving hepatic fibrosis in heart failure is limited.Research Question:Is liver stiffness associated with higher mortality in heart failure?Aims:To utilize liver stiffness measured by transient elastography as an imaging phenotype in HF risk stratification and prevention.Methods:De-identified data from 285 HF patients without pre-existing liver disease/cirrhosis, with liver stiffness measured (kPa) by transient elastography from 2015-2023 were extracted from TriNetX, a real-time, electronic, federated data network of 34 healthcare organizations. Liver stiffness was further classified as high and low with 8kPa as a cut-off. Comparisons employed the chi-square or Fisher’s exact test for categorical variables and the student’s t-test or Mann-Whitney-Wilcoxon test, as appropriate. Multivariable Cox proportional hazards models were applied to evaluate the association with mortality and readmissions in 30 days.Results:The mean age of the cohort is 65±11 years. The majority were women (57.9%). Participants were followed for a median of 3.8 (1.52-6.67) years; 83 out of 285 patients died. Multivariable analysis showed that 1 SD increase in liver stiffness was associated with increased mortality (HR 1.13, 95% CI 1.05-1.21; p

Circulation, Volume 150, Issue Suppl_1, Page A4135352-A4135352, November 12, 2024. Introduction:Living in an area with high Area Deprivation Index (ADI) is linked to worse cardiovascular disease (CVD) outcomes. However, the association of ADI with type 2 diabetes (T2D), a major CVD risk factor, is incompletely described. This knowledge may guide primary CVD prevention.Method:Rochester Epidemiology Project is a medical record linkage system of persons in southeast Minnesota and southwest Wisconsin. We identified 253,890 persons (aged 4–98 yrs on July 1, 2015) in 9 counties with >90% population coverage. ADI scores, from 2015 home addresses, were grouped into quartiles of low (Q1) to high (Q4) deprivation. We excluded persons with type 1 diabetes (T1D) or history of T2D and identified new T2D cases (2015-2020) using ICD codes, HbA1c and medications. We examined the association between ADI quartile and risk of incident T2D using Cox regression with persons right censored at death, T2D, T1D or last visit. Models were adjusted for age and gender, and reported adjusted hazard ratios (aHR [95% confidence interval]).Results:Age, gender, and race statistically differed across ADI quartiles (Table). Age × ADI interaction was significant (P