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Few data are available on long-term drug therapy and its potential prognostic impact after Takotsubo syndrome (TTS). Aim of the study is to evaluate clinical characteristics and long-term outcome of TTS patients on Renin Angiotensin system inhibitors (RASi). TTS patients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Median follow-up was 31 (Interquartile range 12-56) months. Comparison of RASi treated vs. untreated patients was performed within the overall population and after 1:1 propensity score matching for age, sex, comorbidities, type of trigger and in-hospital complications. clinicaltrials.gov, NCT04361994, https://clinicaltrials.gov/study/NCT04361994 Of the 2453 TTS patients discharged alive, 1683 (68%) received RASi therapy. Patients with RASi were older (age 71 ± 11 vs 69 ± 13 years, P =.01), with higher prevalence of hypertension (74% vs 53%, P <.01) and diabetes (19% v s15%, P =.01), higher admission left ventricular ejection fraction (LVEF) (41 ± 11% vs 39 ± 12%, P <.01) and lower rates of in-hospital complications (18.9% vs 29.6%, P <.01). At multivariable analysis, RASi therapy at discharge was independently associated with lower mortality (HR 0.63, 95% CI 0.45-0.87, P <.01). Survival analysis showed that at long term, patients treated with RASi had lower mortality rates in the overall cohort (log-rank P =.001). However, this benefit was not found among patients treated with RASi in the matched cohort (log-rank P =.168). Potential survival benefit of RASi were present, both in the overall and matched cohort, in 2 subgroups: patients with admission LVEF ≤ 40% (HR 0.54 95% CI 0.38-0.78, P =.001; HR 0.59, 95% CI 0.37-0.95, P =.030) and diabetes (HR 0.41, 95% CI 0.23-0.73, P =.002; HR 0.41, 95% CI 0.21-0.82, P =.011). Long-term therapy with RASi after a TTS episode was not associated with lower mortality rates at propensity score analysis. However, potential survival benefit can be found among patients with admission LVEF ≤ 40% or diabetes. [Display omitted] [ABSTRACT FROM AUTHOR]

The whole-body bioelectrical phase-angle (PhA) is emerging as a new tool in stratifying prognosis in patients with both acute (AHF) and chronic heart failure (CHF). To evaluate the determinants of PhA in HF patients. We analyzed data from 900 patients with AHF or CHF (mean age: 76±10 years, 54% AHF). Clinical, serum biochemical, echocardiographic and bioelectrical measurements were collected from all of patients. PhA was quantified in degrees. Congestion was assessed by a multiparametric approach, including the presence of peripheral edema, brain natriuretic peptides (BNP) plasma levels, blood urea nitrogen to creatinine ratio (BUN/Cr), and relative plasma volume status (PVS) calculated by Kaplan-Hakim's formula. Geriatric Nutritional Risk Index (GNRI) was adopted as indicator for nutritional status. At univariate analysis, PhA was significantly lower in females, in patients with peripheral edema, and AHF. PhA significantly correlates age, BNP, PVS, BUN/Cr, and GNRI. At multivariate analysis, congestion biomarkers emerged as the major determinant of PhA as they explained the 34% of data variability, while age, GNRI, and gender only explained 6%, 0.5%, and 0.5%, respectively (adjusted R 2 = 0.41). In particular, PVS (regression of coefficient B =−0.17) explained the 20% of PhA variability, while peripheral congestion (B =−0.27) and BNP (B =−0.15) contributed to 10% and 2%, respectively. The main determinant of bioelectrical PhA in patients with HF is congestion and PVS in particular, while nutritional status has marginal impact. [ABSTRACT FROM AUTHOR]

• Congestion is a marker of adverse prognosis in patients with heart failure (HF). • BNP, ePVS, BIVA, and BUN/Cr ratio are independent prognostic biomarkers in HF. • Combining BNP, eVPS, BIVA, and BUN/Cr explain the 40% risk of death in HF. Congestion is a marker of adverse prognosis in patients with heart failure (HF). In addition to brain natriuretic peptide (BNP), estimated plasma volume status (ePVS), bioimpedance vector analysis (BIVA), and blood urea nitrogen/creatinine ratio (BUN/Cr) are emerging as new markers for congestion. The aim of this study was to evaluate the prognostic value of BNP, ePVS, BIVA, and BUN/Cr in HF. We analyzed the data from 436 patients with acute or chronic heart failure (AHF, n = 184, and CHF, n = 252, respectively). BNP, ePVS, hydration index (HI%), and BUN/Cr were collected from all patients at admission. The endpoint was all-cause mortality. Ninety-two patients died after a median follow-up of 463 days (IQR: 287–669). The cumulative mortality of all of the patients was 21% (31% and 13% in AHF and CHF, respectively, p < 0.0001). The optimal cut-offs for death occurrence were BNP: >441 pg/mL, ePVS: >5.3 dL/gr, HI: >73.8%, BUN/Cr: >25. Multivariate Cox regression analysis maintained an independent predictive value for mortality (HR 2. 1, HR 2.2, HR 2.1, and HR 1.7; C-index 0.756). AHF status was no longer associated with death. Together, these variables explained 40% of the risk of death (R 2 adjusted = 0.40). Patients with all four parameters below or above their optimal cut-off had mortality rates of 4% and 59%, respectively. BNP, ePVS, BIVA, and BUN/Cr at admission provide independent and complementary prognostic information in patients with HF and, when combined, explain the 40% risk of death in these patients independent from the acute or chronic HF condition. [ABSTRACT FROM AUTHOR]

The pathophysiology of peripheral congestion is poorly investigated in patients with acute heart failure (AHF). to evaluate the relative contribution of serum colloid osmotic pressure (COP), relative plasma volume status (PVS), biomarkers of renal function, electrolytes, haemoglobin, and brain natriuretic peptide (BNP) in peripheral fluid overload using bioimpedance vector analysis (BIVA). We retrospectively analysed data from 485 patients with AHF. Hydration status was evaluated by semiquantitative and quantitative approach using BIVA (R/Xc graph) and Hydration Index (HI), respectively. COP was calculated from albumin and total protein concentration, while relative PVS was calculated from validated equations. Congestion assessed by BIVA was observed in 304 (63%) patients and classified as mild (30%), moderate (42%), and severe (28%). On univariate analysis, HI was inversely correlated with COP (P < 0.01), glomerular filtration rate (P < 0.01), and haemoglobin (P < 0.01), while positive correlations were found for relative PVS (P < 0.05), BNP (P < 0.01), and blood urea nitrogen (BUN; P < 0.01). On stepwise multivariate analysis, COP explained 12% of the total variability, while BUN, PVS, haemoglobin, and BNP added a further 6%, 4%, 2%, and 1%, respectively, to the final explanatory model. COP was the major determinant of the presence and entity of peripheral congestion assessed by BIVA. BUN, PVS, haemoglobin, and BNP revealed reduced influence on congestion as compared with COP. Routine laboratory testing could be useful in peripheral fluid accumulation. Future studies should evaluate the relationship between COP and pharmacological target therapies for the fluid management of AHF patients. [ABSTRACT FROM AUTHOR]

Abstract The Digital Twin is a representation of characteristics and behavior of a factory according to various levels of detail and the scope it addresses. Its full range of capabilities can be exploited when it is synchronized with the real world. Indeed, in this case, it can be used to mirror the real operating conditions for simulating the real-time behavior, and thus forecasting factory performances. However, we are still far from its large-scale diffusion. The purpose of this work is to analyze both the major challenges that still have to be faced and some potential solutions for each of the identified challenges. [ABSTRACT FROM AUTHOR]

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Objective To evaluate the role of bioelectrical impedance vector analysis (BIVA) and brain natriuretic peptide (BNP) in detecting peripheral congestion in heart failure (HF). Background BIVA/BNP are biomarkers for congestion in acute (ADHF) and chronic HF. Methods 487 ADHF and 413 chronic HF patients underwent BIVA and BNP tests. Results BIVA was more accurate than BNP in detecting peripheral congestion both in ADHF (AUC 0.88 vs 0.57 respectively; p < 0.001) and chronic HF patients (AUC 0.89 vs 0.68, respectively; p < 0.001). In ADHF patients, the optimal BNP cut-off for discriminating presence or absence of edema was >870 pg/mL (PPV = 48% and NPV = 58%) whereas in chronic HF it was >216 pg/mL (PPV = 18% and NPV = 95%). The BIVA detected edema when the vector fell into the lower pole of 75th percentile tolerance ellipse (PPV = 84% and NPV = 78%) in ADHF, the lower pole of 50% (PPV = 68% and NPV = 95%) in chronic HF. Conclusions In HF patients, BIVA is an easy, fast technique to assess peripheral congestion, and is even more accurate than BNP. [ABSTRACT FROM AUTHOR]

Objectives: The objectives were to ascertain the prevalence of renal impairment among patients with a takotsubo cardiomyopathy (TTC) episode and whether clinical outcomes are related to renal function.Methods: A total of 108 consecutive subjects with TTC were enrolled in a multicenter registry and followed for a mean period of 429 days. Renal function was evaluated during hospitalization in terms of acute kidney injury/failure and estimated glomerular filtration rate (eGFR). Incidence of death, rehospitalization, and recurrence of TTC during follow-up was recorded.Results: Raised creatinine levels can be found during hospitalizations for TTC episodes (analysis of variance P<.001). Incidence of acute kidney injury was 10%; that of acute kidney failure was 1%. Admission eGFR levels were proportional to the duration of hospitalization (r = -0.28, P<.01). Estimated GFR nadir values were related to adverse events at follow-up (log-rank P<.001). The hazard ratio of adverse events at follow-up in subjects with severe renal impairment (nadir eGFR <30 mL/[min 1.73 m(2)]) vs those with eGFR >60 mL/(min 1.73 m(2)) was 1.817 (95% confidence interval, 1.097-3.009; P<.05).Conclusions: Raised creatinine levels and impaired renal function may be found in patients with TTC. Lower eGFR values during hospitalization are associated with longer hospitalizations and higher rates of adverse events at follow-up. Renal function during a TTC episode should be carefully evaluated. [ABSTRACT FROM AUTHOR]

Contemporary libraries have changed quickly their social role and function due to the proliferation and diversification of multimedia digital documents, becoming complex networks able to support communication and collaboration among the various distributed users communities. Technologies have not grown in step with the needs generated by this new approach, except in specific areas and implications. Hence the need to design an integrated digital library architecture that covers by advanced techniques the whole spectrum of functionality, without which the same social and cultural function of a modern digital library is at risk. This paper briefly describes an architecture that aims to bridge this gap, bringing together the experience, expertise and software systems developed by university and companies researchers. A prototype of the system is under development. [ABSTRACT FROM AUTHOR]

Background: We conducted a prospective study of the clinical outcomes and health-related quality of life after implantation of the CorCap support device (Acorn Cardiovascular Inc, St Paul, MN) for dilated cardiomyopathy. Methods: The criteria adopted for CorCap implantation were dilated cardiomyopathy (left ventricular [LV] end-diastolic diameter ≥ 60 mm, LV ejection fraction ≤ 0.30 and > 0.10), and New York Heart Association functional class II or III despite maximal medical therapy. Echocardiographic follow-up and evaluation with the Short Form-36 questionnaire were performed. Results: Included were 39 patients: 5 in New York Heart Association class II and 32 in class III. At 13.3 ± 2.5 months of follow-up, a statistically significant improvement was evident in mean LV volume (LV end-systolic volume from 202 ± 94 to 138 ± 72 ml. p = 0.005) and systolic function (LV ejection fraction from 0.26 ± 0.05 to 0.36 ± 0.05, p < 0.001). The mean LV sphericity index was significantly increased at the end of the follow-up (p = 0.009). Ischemic etiology, diabetes, advanced age, and LV ejection fraction of less than 0.15 predicted lesser reversal of the LV alterations. Operative mortality was 5.1%. Cumulative follow-up mortality was 10.2%. The average Physical Health domain scores (Physical Functioning, Role Physical, General Health) were improved. Average Mental Health domain scores were also increased. Conclusions: The cardiac support device obtains reverse remodelling of the LV and is useful to improve the quality of life of patients with dilated cardiomyopathy and New York Heart Association class III symptoms of heart failure. The integration of different and complementary strategies (cardiac support device and resynchronization therapy) may represent the key to success for more complex patients, although further studies are required. [Copyright &y& Elsevier]

Background: Although an increasing number of symptomatic patients with atrial fibrillation (AF) are being treated with percutaneous radiofrequency ablation, the actual long-term success rate of this procedure remains uncertain. The increasing availability of minimally invasive techniques has made surgery progressively more appealing, especially because of its superior capacity to create transmural lesions. Methods: In a group of 46 patients with paroxysmal or persistent “lone” AF, who were refractory to medical treatment or had arrhythmia recurrences after a transcatheter procedure, we performed epicardial radiofrequency ablation by a minimally invasive, monolateral thoracoscopic approach. Mean operative time was 85 ± 35 minutes, and intensive care unit and hospital stays were, respectively, 18.7 ± 5.1 hours and 4.1 ± 1.4 days. There were no deaths and only 1 serious complication due to severe bleeding requiring conversion to median sternotomy. Results: At the 6-month follow-up (Holter monitoring), 40 patients (87%) were in stable sinus rhythm. Of the 6 recurrences that we observed, 5 occurred in patients with persistent AF and 1 in a patient with paroxysmal AF (p < 0.01). Conclusions: Minimally invasive monolateral thoracoscopic radiofrequency ablation is safe and apparently effective. If these findings are confirmed on larger populations followed for longer periods, this procedure may become a viable proposal for treating refractory lone AF. [Copyright &y& Elsevier]

Background. The minor technical and time requirements with respect to the maze operation combined with a comparable efficacy has led to an increasing popularity of left atrial approaches to treat atrial fibrillation. We report our experience with a left atrial procedure based on extensive use of epicardial radiofrequency ablation in an effort to minimize cardiac arrest time.Methods. A total of 132 consecutive patients with atrial fibrillation (121 chronic, 11 paroxysmal) undergoing open heart surgery had combined intraoperative ablation. An original set of left atrial lesions was performed using a radiofrequency linear catheter. Most of the ablations were performed epicardially before aortic cross-clamping. Patients with contraindications to the epicardial approach had the whole lesion set performed endocardially.Results. The mean cardiac arrest time spent for open heart ablations was significantly shorter (5.2 ± 0.9 minutes with modern catheters) when the epicardial approach was used (107 of 132 patients, 81%). Hospital mortality was 0.8%. Freedom from atrial fibrillation was 77% 3 years after the operation. Of all the variables analyzed, only age at surgery and early postoperative arrhythmias increased the risk of recurrent atrial fibrillation. Overall 3-year survival was 94%. The 3-year actuarial freedom from stroke was 98%. No patient required implantation of a permanent pacemaker. Atrial contractility was recovered in all patients with stable sinus rhythm.Conclusions. Left atrial radiofrequency ablation allows recovery of sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who undergo open heart surgery. The epicardial radiofrequency approach is a safe and effective means to cure atrial fibrillation with negligible technical and time requirements. [Copyright &y& Elsevier]

Pericardial annuloplasty has been used as an alternative to prosthetic annuloplasty. One drawback of pericardial annuloplasty is the risk of cinching of tissues during knot tying, possibly leading to uncontrolled downsizing and to complications such as mitral stenosis and systolic anterior motion of the anterior leaflet. A simple modification of the sequence of knot tying is described to avoid this complication. [Copyright &y& Elsevier]

Pulmonary embolism may be often promptly diagnosed just by bedside echocardiography, in the case of new onset severe right ventricular enlargement, increased pulmonary pressure and dyspnea. However, CT confirmation could be required in the presence of contrasting findings during diagnostic work up. We report the case of a 79-year old woman who presented with acute dyspnea, right ventricular enlargement and leftward septal shift. Despite first diagnosis of pulmonary embolism, an irregular mass was detected at CT scan in mid left lung, apparently infiltrating left pulmonary artery branches, without signs of evident pulmonary thrombo-embolism. Visceral pleural and lymphonodular infiltration suspected for malignancy was also present. We hypothesize that acutely increased pulmonary pressures and enlarged right ventricle were caused by the infiltrating pulmonary mass, presumably a lung tumor, partly involving left pulmonary artery branches and by tumor pulmonary embolism. A diagnosis of pulmonary thrombo-embolism exclusively based on echocardiography may be occasionally misleading without a careful diagnostic work-up. [ABSTRACT FROM AUTHOR]

Objective: Cardiac operations in elderly patients are increasingly frequent and imply major clinical, ethical, and economic issues. Operative and 5-year results of cardiac operations in patients aged 79 years or more are known in limited series, and a debate is ongoing on the appropriateness of selection of patients for surgery. Methods: We retrospectively reviewed our experience in 6802 patients aged 79 years or more who had received a cardiac operation. Surgical candidates were selected according to functional status, crude operative risk, and social context and were managed according to a multimodality protocol. Results: Mean age was 82 years and surgery was nonelective in 1613 cases (23.5%, 31 salvage). Procedures consisted of valve replacement (aortic, 2817; mitral, 532; and tricuspid, 2 cases), valve repair (aortic, 66; mitral, 532; and tricuspid, 232 cases), coronary bypass grafting (12,034 coronary vessels bypassed), and replacement of the thoracic aorta (ascending, 315; arch, 28 cases). Overall operative mortality was 3.4%. Nonelective presentation, need for aortic counterpulsation, cardiopulmonary bypass time, blood transfusion, depressed systolic function, and chronic lung disease predicted operative mortality. Five-year cumulative mortality was 7.5%. Poor systolic function, previous myocardial infarction, and combined coronary/mitral surgery predicted late mortality. The operative risk of nonagenarians operated on electively did not differ from that of risk-matched octogenarians. Conclusions: Cardiac surgery in elderly and very elderly patients can be performed with acceptable mortality provided that accurate selection and a multifactorial risk evaluation are adopted. Whenever possible, nonelective operations should be avoided and earlier surgery should be encouraged. Five-year survival and functional recovery are good. [Copyright &y& Elsevier]