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PCI Strategies in Acute Myocardial Infarction with Cardiogenic Shock

Patients complaining of chest pain after a traumatic event represent a diagnostic challenge for the cardiologist. These patients can definitely escape from common diagnostic tests (particularly ECG and markers of myocardial lysis) that may guide the cardiologist, mostly because symptoms are attributed to the trauma itself. On the other hand, if blunt cardiac injury is suspected (involving coronary arteries, aorta, pulmonary trunk, pericardium, myocardium or valves), the selection of the most appropriate diagnostic and therapeutic tools (i.e. antithrombotic therapy) should also consider trauma involvement of other organs. We here describe two emblematic cases as examples of the challenges that diagnosis and treatment of cardiac injury can bring.

A multidisciplinary approach has been used to evaluate the Late-Holocene modifications of the Kartalini basin (Georgia). Data from satellite images (Corona, Landsat, Russian aerial images, etc) and field surveying allowed to reconstruct the neotectonics in the area of Aradetis Orgora archaeological site.

BackgroundRecent research suggest that gut microbiome may play a fundamental role in athlete's health and performance. Interestingly, nutrition can affect athletic performance by influencing the gut microbiome composition. Among different dietary patterns, ketogenic diet represents an efficient nutritional approach to get adequate body composition in athletes, however, some concerns have been raised about its potential detrimental effect on gut microbiome. To the best of our knowledge, only one study investigated the effect of ketogenic diet on the gut microbiome in athletes (elite race walkers), whilst no studies are available in a model of mixed endurance/power sport such as soccer. This study aimed to investigate the influence of a ketogenic Mediterranean diet with phytoextracts (KEMEPHY) diet on gut microbiome composition in a cohort of semi-professional soccer players.Methods16 male soccer players were randomly assigned to KEMEPHY diet (KDP n = 8) or western diet (WD n = 8). Body composition, performance measurements and gut microbiome composition were measured before and after 30 days of intervention by 16S rRNA amplicon sequencing. Alpha-diversity measures and PERMANOVA was used to investigate pre-post differences in the relative abundance of all taxonomic levels (from phylum to genus) and Spearman's correlations was used to investigate associations between microbial composition and macronutrient intake. Linear discriminant analysis was also performed at the different taxonomic levels on the post-intervention data.ResultsNo differences were found between pre and post- dietary intervention for microbial community diversity: no significant effects of time (p = 0.056, ES = 0.486 and p = 0.129, ES = 0.388, respectively for OTUs number and Shannon's ENS), group (p = 0.317, ES = 0.180 and p = 0.809, ES = 0.047) or time × group (p = 0.999, ES = 0.01 and p = 0.230, ES = 0.315). Post-hoc paired Wilcoxon test showed a significant time × group effect for Actinobacteriota (p = 0.021, ES = 0.578), which increased in the WD group (median pre: 1.7%; median post: 2.3%) and decreased in the KEMEPHY group (median pre: 4.3%; median post: 1.7%). At genus level, the linear discriminant analysis in the post intervention differentiated the two groups for Bifidobacterium genus (pertaining to the Actinobacteria phylum), Butyricicoccus and Acidaminococcus genera, all more abundant in the WD group, and for Clostridia UCG-014 (order, family, and genus), Butyricimonas, Odoribacterter genera (pertaining to the Marinifilaceae family), and Ruminococcus genus, all more abundant in the KEMEPHY group.ConclusionsOur results demonstrate that 30 days of KEMEPHY intervention, in contrast with previous research on ketogenic diet and gut microbiome, do not modify the overall composition of gut microbiome in a cohort of athletes. KEMEPHY dietary pattern may represent an alternative and safety tool for maintaining and/or regulating the composition of gut microbiome in athletes practicing regular exercise. Due to the fact that not all ketogenic diets are equal, we hypothesized that each version of ketogenic diet, with different kind of nutrients or macronutrients partitioning, may differently affect the human gut microbiome.

Objectives The aim of the present analysis is to evaluate the clinical impact of chronic total occlusions (CTOs) recanalization in patients with left ventricular (LV) systolic dysfunction. Background According to contemporary knowledge, patient selection for percutaneous CTO revascularization is not yet standardized. In particular, data on outcomes in patients with LV systolic dysfunction undergoing percutaneous coronary intervention (PCI) for CTO are scarce. Methods From a total of 2,421 consecutive patients with at least one CTO, 436 patients with ejection fraction (EF) ≤45%, who were referred for coronary angiography between January 1998 and September 2014, were selected. Patients with successful recanalization of the target CTO were assigned to CTO-revascularized group and those with failed or not attempted recanalization to the CTO-not revascularized (CTO-NR) group. Study endpoints were all-cause death, cardiac death, and occurrence of myocardial infarction on follow-up. Results Out of 436 CTO patients with reduced EF, 228 (52.3%) were successfully recanalized and 208 patients (47.7%) were not, either due to CTO-PCI failure (n = 106, 24.3%) or because CTO-PCI was not attempted (n = 102, 23.4%). At long-term follow-up, CTO-NR patients had significantly higher rate of overall (p = .021) and cardiac mortality (p = .035) compared to those successfully revascularized. Conclusion In patients with systolic LV dysfunction (EF ≤ 45%), CTO revascularization was associated with significant lower rate of total and cardiac mortality compared to those with nonrevascularized CTO.

Purpose Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes patients in refractory cardiogenic shock. However, ECMO-related complications strongly affect the outcome, especially if a long-term LVAD is needed. Methods and materials We describe a new strategy in management of INTERMACS 1 patients consisting in early weaning from VA-ECMO with axillary Impella 5.0 as a bridge to LVAD implantation. Nine patients in two European centres are described. Results All patients were implanted with VA-ECMO for initial hemodynamic and metabolic stabilization. After a median time of 8 days, Impella 5.0 was implanted. Impella support allowed in all patients weaning from inotropes and from VA-ECMO (after a median time of 22 h). No patients had right ventricular failure after ECMO-weaning and most patients were mobilized and orally fed (88.9%) during Impella support. All patient underwent LVAD implantation after a median Impella time of 17 days. Only one patient had right-ventricular failure after LVAD implantation. All patients were discharged from hospital after a median time of 40 days. Conclusion Early weaning from VA-ECMO with Impella 5.0 as a bridge to LVAD is a safe and effective strategy in management of INTERMACS 1 patients. This approach minimizes ECMO-related complications and allows patient mobilization and right ventricular function optimization before LVAD implantation.

In the setting of HeartWare left ventricular assist device (HVAD, Medtronic) implantation, pre-pump blood flow obstruction has been described due to intraventricular thrombus formation occluding the inflow cannula. This phenomenon often evolves in suboptimal pump performance, and requires prompt management to prevent its progression. However, to date, effective strategies and tools for the diagnosis and management of this complication are poorly described. We report a case of HVAD inflow cannula obstruction that drove later in-pump thrombosis and, eventually, complete cannula occlusion, and discuss gap of knowledge and limitations of currently available diagnostic and therapeutic tools in this scenario. Furthermore, we reinforce the value of time-frequency analysis of the HVAD log files to early identify abnormal pump operation associated with inflow cannula obstruction despite unremarkable trends of pump parameters.

Aims Reoperation for bioprosthetic heart valve failure is associated with significant morbidity and mortality, particularly in high-risk patients. Transcatheter valve-in-valve (VIV) implantation may offer a less invasive alternative. The aim of this study was to report our initial experience with transcatheter VIV implantation to treat degenerated tissue valves. Methods and results VIV implantation with the Edwards SAPIEN transcatheter heart valve (THV; Edwards Lifesciences Inc, Irvine, CA, USA) was performed in 18 high-risk patients (STS 8.2±5.2%; logistic EuroSCORE 37.4±20.8%) with symptomatic bioprosthetic failure (17 aortic, one mitral). Valve Academic Research Consortium (VARC) definitions were applied for endpoint adjudication. Transfemoral access was the preferred vascular approach (16 patients, with the mitral VIV delivered anterogradely through the femoral vein; one transaxillary and one transapical). The majority (83%) of procedures were performed under local anaesthesia and sedation. Device success was achieved in all but one patient who had a final transaortic gradient ≥20mmHg. Acute kidney injury occurred in three patients (Stage 3 in 1), life-threatening or major bleeding in four patients, while major vascular complications occurred in one patient. Permanent pacemaker implantation was required in two patients. There were no deaths or neurological events at 30-day follow-up. At a median follow-up of 11 months (interquartile range 6-16), the mortality rate was 5.6% and all patients were in NYHA class II or lower. Conclusions Transcatheter implantation of the Edwards THV within a degenerated aortic bioprosthesis, performed predominantly via the transfemoral route, is feasible and associated with good periprocedural and clinical outcomes in high-risk surgical patients.

Background Limited real-world data comparing outcomes after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in intermediate-surgical-risk patients with aortic stenosis are available. Methods We identified 182 consecutive patients who underwent TAVR via the transfemoral (TF) route (November 2007-February 2011) and 111 moderate-to-high-risk historical case controls undergoing SAVR (August 2003-July 2008). Using propensity score matching based on clinical characteristics and surgical risk scores, we compared clinical outcomes in 111 matched patients. Valve Academic Research Consortium definitions were applied for end point adjudication. Results Baseline clinical characteristics, in particular Logistic European System for Cardiac Operative Risk Evaluation (23.2 +/- 15.1 vs 24.4 +/- 13.4) and Society of Thoracic Surgeons score (4.6 +/- 2.3 vs 4.6 +/- 2.6), were well matched between groups. Transfemoral TAVR was associated with more vascular complications (33.3% vs 0.9%, P < .001). On the other hand, acute kidney injury was more frequent after SAVR (8.1% vs 26.1%, P < .001). The rates of all-cause mortality in both TF-TAVR and SAVR groups was1.8% at 30 days (P = 1.00) and 6.4% and 8.1%, respectively, at 1 year (P = .80). At 1 year, the rate of cerebrovascular events was similar in the 2 groups (4.6% vs 9.1%, P = .19). Conclusions In this real-world cohort of intermediate-surgical-risk patients with aortic stenosis, TF-TAVR and SAVR were associated with similar mortality rates during follow-up but with a different spectrum of periprocedural complications. Furthermore, the survival rate after TF-TAVR in this group of elderly patients with intermediate Society of Thoracic Surgeons score was encouraging. (Am Heart J 2012;164:910-7.)

Detailed field mapping of a Middle Triassic carbonate buildup, the Latemar in the western Dolomites, northern Italy, has been carried out. The Latemar is an isolated carbonate buildup that nucleates on a fault-bounded structural high (horst) cut into the underlying late Anisian carbonate bank of the Contrin Fm. This study demonstrates that extensional synsedimentary tectonics is the main factor controlling its geometry and provides an age for this tectonic phase. In an early phase, slopes were mostly composed of well bedded, clinostratified grainstones and rudstones. In a later stage, the deposition of grainstones was accompanied by the emplacement of clinostratified megabreccias. The upper portion of slopes is a microbial boundstone with abundant Tubiphytes and patches or lenses of grainstone. Boundstones may occasionally expand into the platform interior and downward to the base of the slope. The depositional profile was that of a mounded platform. The buildup is dissected by a dense framework of high angle fractures and faults, and by magmatic and sedimentary dikes, exhibiting two principal directions trending NNW–SSE and ENE–WSW. Faults trending WNW–ESE were also observed. Magmatic dikes are related to the emplacement of the nearby Predazzo intrusion and are thus upper Ladinian. Kinematic indicators of strike-slip activity were observed on fault planes trending NNE–SSW and NNW–SSE, that can be attributed to Cenozoic Alpine tectonics. Faults, magmatic dikes and sedimentary dikes show systematic cross-cutting relationships, with strike-slip faults cutting magmatic dikes, and magmatic dikes cutting sedimentary (neptunian) dikes. ENE–WSW and WNW–ESE faults are cut by all other structures, and record the oldest tectonic activity in the region. Structural analysis attributes this tectonic phase to an extensional stress field, with a direction of maximum extension oriented ca. N–S. Several lines of evidence, including sealed faults and growth wedge geometries allow us to recognize this old tectonic phase as syndepositional, and to date it to the latest Anisian ( avisianum and crassus ammonoid biochronozones). The horse-shoe shape of the platform and its margins, rectilinear for long tracts, are explained by the existence of a network of extensional faults, whose activity lasted for part of the growth of the platform. The Latemar is thus a polygonal, fault-block platform controlled by synsedimentary tectonics. The resulting sedimentary architecture is that of a growth wedge, deposited probably on the uplifted side of a submerged half graben. Continuous reactivation of faults at platform margins locally determined anomalous facies transitions, with well layered platform interior directly in contact with the clinostratified slopes.

Il contributo affronta alcuni dei momenti più significativi della storia della scultura in Trentino nel corso del Sei e Settecento.