Search

Background MessengerRNA (mRNA) COVID-19 vaccination has been associated with a higher-than-expected occurrence of acute myocarditis. Scarce information is available on mid-term prognosis and changes in cardiac function, volumes, and tissue characterization on cardiac magnetic resonance (CMR). Methods Retrospective, multicenter study including patients with a definite diagnosis of acute myocarditis within 30 days from mRNA COVID-19 vaccination, with a confirmed myocarditis diagnosis based on endomyocardial biopsy (EMB) or autopsy or by the coexistence of positive biomarkers (troponin >99th upper reference limit or elevated creatine kinase myocardial band [CK-MB]) and cardiac MRI findings consistent with AM according to the 2018 updated Lake Louise Criteria. Results 77 patients (median age 25 years [IQR 20-35], 15% female) were included and followed-up for 147 days [IQR 74-215]. Follow-up CMR was available in n=49 patients and showed no changes in biventricular ejection fraction (EF) as compared to CMR at diagnosis (left ventricular EF: 59%[55-65]vs. 60%[57-64], p=0.507, right ventricular EF: 56%[52-62]vs. 57%[52-61], p=0.563, respectively). Late gadolinium enhancement was present in all patients at diagnosis and persisted in only n=39 (79.6%) at follow-up (p=0.001), generally sparing the anterior wall and the septum. N=10 (20.4%) had a persistent edema based on T2-weighted short tau inversion recovery (STIR) sequences, with predominant involvement of inferior or inferior-lateral walls. The proportion of patients with increased T1 and T2 mapping signals significantly decreased at follow-up (n=13 (68%) vs. n=4 (13%),p No differences in morpho-functional CMR parameters based on the type of vaccine administered were found (BNT162b2 Pfizer/BioNTech®, n=36, 73.5%, m-RNA-1273 Moderna®, n=13, 26.5%). Among patients with available follow-up (N=75, 97.4%), no major adverse cardiovascular events nor myocarditis recurrence or death were reported. Conclusions At mid-term follow-up, patients who experienced an acute myocarditis after a mRNA COVID-19 vaccine had preserved biventricular EF. The rate and localization of residual scar or edema on CMR is in line with classic viral myocarditis with a good prognosis. This new piece of information should further reassure patients who experience acute myocarditis after mRNA COVID-19 vaccination.

Aims To compare demographic characteristics, clinical presentation, and outcomes of patients with and without concomitant cardiac disease, hospitalized for COVID-19 in Brescia, Lombardy, Italy. Methods and results The study population includes 99 consecutive patients with COVID-19 pneumonia admitted to our hospital between 4 March and 25 March 2020. Fifty-three patients with a history of cardiac disease were compared with 46 without cardiac disease. Among cardiac patients, 40% had a history of heart failure, 36% had atrial fibrillation, and 30% had coronary artery disease. Mean age was 67 ± 12 years, and 80 (81%) patients were males. No differences were found between cardiac and non-cardiac patients except for higher values of serum creatinine, N-terminal probrain natriuretic peptide, and high sensitivity troponin T in cardiac patients. During hospitalization, 26% patients died, 15% developed thrombo-embolic events, 19% had acute respiratory distress syndrome, and 6% had septic shock. Mortality was higher in patients with cardiac disease compared with the others (36% vs. 15%, log-rank P = 0.019; relative risk 2.35; 95% confidence interval 1.08–5.09). The rate of thrombo-embolic events and septic shock during the hospitalization was also higher in cardiac patients (23% vs. 6% and 11% vs. 0%, respectively). Conclusions Hospitalized patients with concomitant cardiac disease and COVID-19 have an extremely poor prognosis compared with subjects without a history of cardiac disease, with higher mortality, thrombo-embolic events, and septic shock rates.

Aims To describe the characteristics of a cohort of patients with cardiac amyloidosis (CA) and to compare the two most common phenotypes of CA, transthyretin (ATTR) and immunoglobulin light-chain (AL). Methods and results One-hundred and eighty patients [n = 115 (64%) men, 74 ± 11 years] were retrospectively included from January 2013 to April 2021 in a single centre in Northern Italy. The majority [n = 102 (57%)] had ATTR-CA, whereas 78 patients (43%) had AL-CA. ATTR-CA patients were older (79 ± 7 vs. 66 ± 10 years, P Conclusions Despite ATTR-CA patients showed worse baseline characteristics, suggesting a more advanced disease at presentation, AL-CA phenotype was associated with a higher risk of all-cause death. Of note, CV mortality was comparable between the two groups.

Aims An increasing number of patients with heart failure (HF) progresses to an advanced stage, characterized by persistent and sever symptoms and worse prognosis. A detailed characterization of patients with advanced HF is needed to optimize clinical management and timely refer for heart transplant or left ventricular assist device implantation. Methods and results A retrospective analysis was performed on patients with HF who were admitted to hospital or performed an outpatient visit at our centre (Spedali Civili di Brescia, Brescia, Italy) from 1 January 2020 to 31 December 2020, and who had at least one of the following high-risk characteristics: (1) previous or ongoing requirement for inotropes; (2) persisting New York Heart Association (NYHA) class III or IV and/or persistently high natriuretic peptides (BNP or NT-proBNP); (3) end-organ dysfunction, defined as worsening renal or liver dysfunction in the setting of HF; (4) ejection fraction (EF) Conclusions In our contemporary, real-world cohort of HF patients with high-risk characteristics, mid-term prognosis was poor, and the use of updated HFA-ESC criteria defining advanced HF identified a subset at increased risk of mortality.

Aims HFA-PEFF and H2FPEF scores were developed to aid the diagnosis of heart failure with preserved ejection fraction (HFpEF) and have been associated with outcomes. We aimed to investigate the diagnostic and prognostic significance of these scores in patients with a specific phenotype of HFpEF, cardiac amyloidosis (CA). Methods and results In a retrospective, double-centre, observational study we included 171 patients with either transthyretin (ATTR) (n = 89, 52%) or light-chain (AL) (n = 82, 48%) cardiac amyloidosis and preserved left ventricular ejection fraction (LVEF). Patients were divided into three groups according to HFA-PEFF score (low, 0–1; intermediate 2–4; high 5–6) and H2FPEF score (low, 0–1; intermediate 2–5; high 6–9). None of the patients had a HFA-PEFF score of 0 or 1 (n = 0, 0%); 57 (33.3%) patients had HFA-PEFF score 2–4 and the majority (n = 114, 66.7%) had a high HFA-PEFF score. Twenty-eight (16.4%), 104 (60.8%), 39 (22.8%) patients had low, intermediate, and high H2FPEF score, respectively. During a median follow-up of 14.5 (6.5–30.2) months after diagnosis, 61 (35.7%) patients died. Patients with a high HFA-PEFF score had higher mortality, compared to those with an intermediate score (47.4% vs. 12.3%, P Conclusions Our results suggest that a low HFA-PEFF score successfully rules out CA diagnosis, whereas some CA patients present a low H2FPEF score, potentially misleading the diagnosis. HFA-PEFF but not H2FPEF score was associated with outcome in patients with CA.

Aims Several risk factors have been identified to predict worse outcomes in patients affected by SARS-CoV-2 infection. Prediction models are needed to optimize clinical management and to early stratify patients at a higher mortality risk. Machine learning (ML) algorithms represent a novel approach to identify a prediction model with a good discriminatory capacity to be easily used in clinical practice. Methods and results The Cardio-COVID is a multicentre observational study that involved a cohort of consecutive adult Caucasian patients with laboratory-confirmed COVID-19 [by real time reverse transcriptase—polymerase chain reaction (RT-PCR)] who were hospitalized in 13 Italian cardiology units from 1 March to 9 April 2020. Patients were followed-up after the COVID-19 diagnosis and all causes in-hospital mortality or discharge were ascertained until 23 April 2020. Variables with more than 20% of missing values were excluded. The Lasso procedure was used with a λ = 0.07 for reducing the covariates number. Mortality was estimated by means of a Random Forest (RF). The dataset was randomly divided in two subsamples with the same percentage of death/alive people of the entire sample: training set contained 80% of the data and test set the remaining 20%. The training set was used in the calibration procedure where a RF models in-hospital mortality with the covariates selected by Lasso. Its accuracy was measured by means of the ROC curve, obtaining AUC, sensitivity, specificity, and related 95% confidence interval (CI) computed with 10 000 stratified bootstrap replicates. From the RF the relative Variable Importance Measure (relVIM) was extracted to understand which of the selected variables had the greatest impact on outcome, providing a ranking from the most (relVIM = 100) to the less important variable. The model obtained was compared with the Gradient Boosting Machine (GBM) and with the logistic regression, where the predictions were cross validated. Finally, to understand if each model has the same performance in sample (training) and out of sample (test), the two AUCs were compared by means of the DeLong’s test. Among 701 patients enrolled (mean age 67.2 ± 13.2 years, 69.5% males), 165 (23.5%) died during a median hospitalization of 15 (IQR, 9–24) days. Variables selected by the Lasso were: age, Oxygen saturation, PaO2/FiO2, Creatinine Clearance and elevated Troponin. Compared with those who survived, deceased patients were older, had a lower blood oxygenation, a lower creatinine clearance levels and higher prevalence of elevated Troponin (all P Conclusions In a large COVID-19 population, we showed that a customizable ML-based score derived from clinical variables, is feasible and effective for the prediction of in-hospital mortality.

Aims Clinicians needs to identify patients with cardiac amyloidosis (CA) at an early stage, due to the availability of disease modifying therapies. Some echocardiographic findings may rise the suspicion of CA, also in patients with mild or no symptoms, addressing second level diagnostic tests. To investigate the prevalence of CA in consecutive patients ≥55 years undergoing clinically indicated, routine transthoracic echocardiogram (TTE) in Italy with echocardiographic signs suggestive of CA. Methods and results This is a prospective multicentric study conducted in Italy. It comprises two phases: 1) an observational phase consisting in a national survey on prevalence of possible echocardiographic red flags of CA in consecutive patients ≥55 years undergoing routine TTE (previously published) and 2) a CA diagnostic phase. Preliminary results of phase 2 are herein presented. Patients that in the phase 1 presented a CA-suggestive TTE (i.e. at least one red flag of CA in hypertrophic, non-dilated left ventricles) were re-evaluated for a cardiological visit. Those who consented to proceed in the study, underwent clinical evaluation, blood and urine tests and scintigraphy with bone tracer. Diagnosis of transthyretin related-CA (TTR-CA) was made in presence of Grades 2–3 Perugini uptake at scintigraphy and absence of monoclonal protein. The study was registered at ClinicalTrials.gov (#NCT04738266). Of the 5315 screened echocardiograms, 381 exams (7.2%) were classified as AC-suggestive. Two-hundred-twelve of the 381 patients with a CA-suggestive TTE underwent phase 2 study. Main reasons for the 169 non-entering patients into the phase 2 were death (n = 53) and refusal to participate (n = 85). Sixty-five of these 212 patients (31%; 17% considering also the 169 non-entering patients into the phase 2) had a diagnosis of CA. Finally, TTR-CA was diagnosed in 53 (25%) and AL-CA in 12 (5.7%) patients. Conclusions Among a cohort of consecutive unselected patients ≥55 years with echocardiographic findings suggestive of CA, the real prevalence of CA ranged from 17 up to 31%. Although TTR-CA was predominant, AL-CA was diagnosed in a significant amount of cases. TTE has a fundamental role in screening patients, raising the suspicion of CA and orienting diagnostic work-up for CA.

Aims Hereditary amyloidosis are rare diseases characterized by extracellular deposition of insoluble fibril proteins in target organs disrupting their structure and function. The APOA1 gene encodes the precursor of apolipoprotein AI (ApoAI), whose mature form is the major component of high-density lipoproteins. There are some clusters of ApoAI amyloidosis (AApoAI) worldwide, including in the Lombardy and Veneto regions. Patients with AApoAI often present with chronic kidney disease, liver and spleen enlargement, with occasional involvement of the heart, peripheral nervous system, and other organs. Patterns of cardiac disease in AApoAI have never been systematically investigated. Methods and results We examined all patients with an established diagnosis of AApoAI referred to a dedicated outpatient clinic in Brescia from 2010 to 2020. The cardiac screening included a transthoracic echocardiogram with 2D speckle-tracking analysis. One-hundred and eighty-nine patients were evaluated [n = 102 (54%) men, median age 55 years (interquartile range 42–67)]. Renal disease was present in 39% and liver disease in 31%. Almost all patients were in sinus rhythm (96%). Median left ventricular ejection fraction (LVEF) was 60% (55–66), and just 2% of patients had LVEF Conclusions In the largest series of patients with AApoAI so far, minor signs of cardiac disease emerged from transthoracic echocardiography. Nonetheless, some red flags of cardiac amyloidosis were found in some patients. Furthermore, the correlations between age and echocardiographic findings suggested a progressive increase in wall thickness, a decline in systolic and diastolic function, and a greater uncoupling between LV mass and contractility over time.