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Aims We assessed the feasibility of cardiac magnetic resonance (CMR) and the role of myocardial strain in the diagnostic work-up of patients with acute myocardial infarction (AMI) and a clinical suspicion of cardiac rupture (CR). Methods and results Consecutive patients with AMI complicated by CR who underwent CMR were enrolled. Traditional and strain CMR findings were evaluated; new parameters indicating the relative wall stress between AMI and adjacent segments, named wall stress index (WSI) and WSI ratio, were analysed. A group of patients admitted for AMI without CR served as control. 19 patients (63% male, median age 73 years) met the inclusion criteria. Microvascular obstruction (MVO, P = 0.001) and pericardial enhancement (P < 0.001) were strongly associated with CR. Patients with clinical CR confirmed by CMR exhibited more frequently an intramyocardial haemorrhage than controls (P = 0.003). Patients with CR had lower 2D and 3D global radial strain (GRS) and global circumferential strain (in 2D mode P < 0.001; in 3D mode P = 0.001), as well as 3D global longitudinal strain (P < 0.001), than controls. The 2D circumferential WSI (P = 0.010), as well as the 2D and 3D circumferential (respectively, P < 0.001 and P = 0.042) and radial WSI ratio (respectively, P < 0.001 and P: 0.007), were higher in CR patients than controls. Conclusion CMR is a safe and useful imaging tool to achieve the definite diagnosis of CR and an accurate visualization of tissue abnormalities associated with CR. Strain analysis parameters can give insights into the pathophysiology of CR and may help to identify those patients with sub-acute CR.

Cerebrovascular accidents (CVAs) can complicate the follow-up of patients with acute myocardial infarction (AMI). Intracavitary blood stasis evaluation can be useful to stratify cardioembolic risk and optimize medical therapy. Cardiac magnetic resonance (CMR) imaging is increasingly used in AMI patients for prognostic purposes. Slow-flow artefact is common on T2-weighted images in presence of left ventricular (LV) blood stasis.In this observational retrospective study, all patients with AMI undergoing CMR in our hospital were included. T2-weighted images were used to assess the presence of LV blood stasis. Among the 209 patients enrolled (males 72%, mean age 61 ± 12 years), LV blood stasis was detected in 48 (23%) and was significantly more prevalent in patients with extensive anterior or antero-apical AMI, lower LV ejection fraction, greater infarct size and microvascular obstruction. During follow-up (54 months, IQR 41-70), 8 CVAs and 6 cardiovascular deaths occurred. LV blood stasis emerged as a significant risk factor for both endpoints (logRank p 0.001 and p = 0.008, respectively) and remained independent predictor of CVAs (HR 9.819, 95% CI 1.733-55.617, p = 0.010).LV blood stasis identified with CMR predicts the occurrence of CVAs in patients with AMI. These results may be helpful to personalize antithrombotic therapy for prevention strategies.

Background Cardiogenic shock (CS) is a systemic disorder associated with dismal short-term prognosis. Given its time-dependent nature, mechanical circulatory support may improve survival. Intra-aortic balloon pump (IABP) had gained widespread use because of the easiness to implant and the low rate of complications; however, a randomized trial failed to demonstrate benefit on mortality in the setting of acute myocardial infarction. Acute decompensated heart failure with cardiogenic shock (ADHF-CS) represents a growing resource-intensive scenario with scant data and indications on the best management. However, a few data suggest a potential benefit of IABP in this setting. We present the design of a study aimed at addressing this research gap. Methods and design The Altshock-2 trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with ADHF-CS will be randomized to early IABP implantation or to vasoactive treatments. The primary end point will be 60 days patients’ survival or successful bridge to heart replacement therapy. The key secondary end point will be 60-day overall survival; 60-day need for renal replacement therapy; in-hospital maximum inotropic score, maximum duration of inotropic/vasopressor therapy, and maximum sequential organ failure assessment score. Safety end points will be in-hospital occurrence of bleeding events (Bleeding Academic Research Consortium >3), vascular access complications and systemic (noncerebral) embolism. The sample size for the study is 200 patients. Implications The Altshock-2 trial will provide evidence on whether IABP should be implanted early in ADHF-CS patients to improve their clinical outcomes.

Background Although oral P2Y12 inhibitors are key in the management of patients with non-ST elevation acute coronary syndrome (NSTE-ACS), the optimal timing of their administration is not well defined. Objective to compare downstream and upstream oral P2Y12 inhibitors administration strategies in NSTE-ACS patients undergoing invasive management. Methods We performed a randomized, adaptive, open-label, multi-center, clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention (PCI) were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was superiority of the downstream over the upstream strategy on the combination of efficacy and safety events (net clinical benefit). Results We randomized 1449 patients to downstream or upstream oral P2Y12 inhibitor administration. A prespecified stopping rule for futility at interim analysis led the trial to be stopped. The rate of the primary endpoint, a composite of death due to vascular causes, non-fatal myocardial infarction or non-fatal stroke, and Bleeding Academic Research Consortium (BARC) type 3, 4 and 5 bleedings through day 30, did not differ significantly between the downstream and upstream groups (Absolute Risk Reduction (ARR%) -0.46 [-2.90; 1.90]).These results were confirmed among patients undergoing PCI (72% of population) and regardless of the timing of coronary angiography (within or after 24 hours from enrolment). Conclusions Downstream and upstream oral P2Y12 inhibitors administration strategies were associated with low incidence of ischemic and bleeding events and minimal numerical difference of event rates between treatment groups. These findings led to premature interruption of the trial and suggest the unlikelihood of enhanced efficacy of one strategy over the other. [Funded by the Italian Society of Interventional Cardiology (SICI-GISE)]

Background: Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR. Methods: We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR. Results: Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, P P P =0.03), and THV–sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02–1.1]; P Conclusions: Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV–sinus of Valsalva relation are at highest risk of impaired CA after TAVR.

A 61-year-old man suffering from myasthenia gravis with predominant bulbar involvement since 10 months before admission, was diagnosed with thymoma in April 2021. He had no relevant comorbidities except for history of polymorphic ventricular ectopic beats. In this regard, in 2019 he had undergone transthoracic echocardiogram and coronary computed tomography angiography, which resulted both normal. After 1 month, due to poor response to standard medical therapy with prednisone and pyridostigmine and in preparation for thymectomy, an intravenous immunoglobulins (IVIG) treatment was prescribed leading to mild clinical improvement (Myasthenia Gravis Foundation of America Clinical Classification IIIA—MGFA). Two weeks later, the patient underwent robotic-assisted thoracoscopic thymectomy without complications. Pathological findings were consistent with type B1 Thymoma classified as Masaoka Stage IIB (TNM Stage pT1a). After discharge the patient complained a rapid worsening of neurological symptoms (MGFA IIIB) leading to an urgent hospitalization for Myasthenia Gravis exacerbation in the middle of June. On admission Intravenous Immunoglobulins (IVIG) treatment was immediately started. After administration of the second IVIG dose, he had a myasthenic crisis complicated by refractory heart failure with significant increase of cardiac troponin up to 5.768 ng/L, requiring invasive ventilation, inotropic support and urgent transfer to the Cardiac Intensive Care Unit (CICU). The 2D echo showed severe left ventricular systolic dysfunction (LVEF 20%) with diffuse hypokinesis. The patient underwent cardiac catheterization and coronary angiography that confirmed severe reduction of the LVEF (LVEF 23%) with embolic occlusion of the distal posterior descending coronary artery (PDA) without other significant coronary artery stenosis. An endomyocardial biopsy was performed, which revealed cardiomyocytes of normal dimensions with sporadic cytoplasmic vacuolization and excluded signs of inflammation, fibrosis, necrosis and viral myocarditis. The day after the patient completed IVIG treatment. During the following days, despite persistence of severe left ventricular systolic dysfunction, he was successfully weaned form inotropic and ventilatory support. At neurological evaluation he reported persistence of severe bulbar involvement with upper and lower limbs weakness. Five days later, the patient had a sudden cardiac arrest for pulseless electrical activity. Advanced cardiac life support requiring inotropes and invasive ventilation was performed for 28 min before returning to spontaneous circulation. The echocardiogram excluded pulmonary embolism and mechanical complications but showed severe left ventricular systolic dysfunction. A new coronary angiography showed clear coronary arteries including PDA. Because of severe haemodynamic compromise, an Impella CP device was implanted and set at maximum support level (P8 flow, >3 L/min). A neurological exam revealed no severe neurological sequelae. As a result of the long CPR the patient had a massive left haemothorax, initially treated with multiple blood transfusions and pleural drainage. Two days later, due to persistence of haemodynamic instability and active pleural bleeding with incessant severe anaemia the case underwent a Heart Team discussion where it was decided to escalate Impella CP device to Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) and then perform a video-assisted thoracoscopic evacuation of the haemothorax. Both procedures were carried out without complications. The patient had an immediate haemodynamic improvement which led to rapid weaning from inotropic support. Haemoglobin was stable. The 2D echo showed significant improvement of the LVEF (40%). After 3 days, given the persistence of haemodynamic stability, ECMO device was removed and invasive ventilation stopped shortly afterwards. Eleven days later, another 2D echo demonstrated complete recovery of left ventricular systolic function (LVEF 59%). Notwithstanding, the patient reported a progressive worsening of neurological symptoms with generalized myasthenia and severe bulbar involvement (MGFA IVB) along with episodes of respiratory muscle fatigue requiring non-invasive ventilation. For this reason, the patient was transferred to Subintensive Respiratory Unit and the case underwent a new multidisciplinary discussion involving neurologists, cardiologists and haematologists. Specialists agreed upon potential causal role of IVIG treatment in transient left ventricular dysfunction and considered re-administration absolutely contraindicated. Thus, they prescribed five plasmapheresis treatments and up-titration of corticosteroid therapy (methylprednisolone up to 60 mg od). An immediate and outstanding improvement of neurological symptoms was obtained (MGFA IIIA) and the patient was discharged from hospital 1 week later.

Aims Out-of-hospital cardiac arrest (OHCA) affects around 1/1000 person-years. Following return of spontaneous circulation (ROSC), the patient can manifest neurological impairment. A targeted temperature management (TTM) protocol is recommended to prevent hypoxic–ischaemic brain damage in patients with coma after cardiac arrest. Neuro-prognostication remains substantial for the prediction of clinical outcomes. To study clinical characteristics, overall survival, and neurological outcome of patients with Glasgow Coma Scale (GCS) Methods Observational retrospective study evaluating all patients with OHCA of presumed cardiac cause and with GCS Results One-hundred and five patients out of 107 patients initially selected were included in the study (77% male, mean age 67 years). At 30 days, mortality was 41% and 53% of patients had a poor neurological outcome (Cerebral Performance Category, CPC, 3–5). Sixty-nine patients (66%) underwent TTM. In regard of the circumstances of OHCA, index event in a private place [OR = 3.12 (1.43–7.11), P = 0.005], ineffective rhythm changes during resuscitation manoeuvres [OR = 2.40 (1.05–5.47), P = 0.037] and a greater amount of adrenaline administered during resuscitation [OR = 1.62 (1.27–2.06), P Conclusions In our population, at 30 days after cardiac arrest, survival rate and the rate of good neurological outcome were comparable to those of the major international registries and studies. Even though patients treated with TTM did not demonstrate significant differences in terms of neurological outcome, this might be related to study-sample size and patient selection. Results in the literature are still controversial on this topic. The MIRACLE score showed a good performance, making it suitable for clinical use in our population. Similarly, the proposed multivariate models are potentially useful for the elaboration of simple and effective prognostic scores in neurological risk stratification.

Primary ventricular fibrillation (PVF) may occur in the early phase of ST-elevation myocardial infarction (STEMI) prior to primary percutaneous coronary intervention (PCI). Multiple electrocardiographic STEMI patterns are associated with PVF and short-term mortality including the tombstone, Lambda, and triangular QRS-ST-T waveform (TW). We aimed to compare the predictive value of different electrocardiographic STEMI patterns for PVF and 30-day mortality. We included a consecutive cohort of 407 STEMI patients (75% males, median age 66 years) presenting within 12 h of symptoms onset. At first medical contact, 14 (3%) showed the TW or Lambda ECG patterns, which were combined in a single group (TW-Lambda pattern) characterized by giant R-wave and downsloping ST-segment. PVF prior to primary PCI occurred in 39 (10%) patients, significantly more often in patients with the TW-Lambda pattern than those without (50% vs. 8%, p < 0.001). For the multivariable analysis, Killip class ≥3 (OR 6.19, 95% CI 2.37–16.1, p < 0.001) and TW-Lambda pattern (OR 9.64, 95% CI 2.99–31.0, p < 0.001) remained as independent predictors of PVF. Thirty-day mortality was also higher in patients with the TW-Lambda pattern than in those without (43% vs. 6%, p < 0.001). However, only LVEF (OR 0.86, 95% CI 0.82–0.90, p < 0.001) and PVF (OR 4.61, 95% CI 1.49–14.3, p = 0.042) remained independent predictors of mortality. A mediation analysis showed that the effect of TW-Lambda pattern on mortality was mediated mainly via the reduced LVEF. In conclusion, among patients presenting with STEMI, the electrocardiographic TW-Lambda pattern was associated with both PVF before PCI and 30-day mortality. Therefore, this ECG pattern may be useful for early risk stratification of STEMI.

Funding Acknowledgements Type of funding sources: None. Background Left ventricular thrombosis (LVT) is a possible complication following myocardial infarction (MI). Besides infarct size, risk factors for LVT include ST-elevated MI (STEMI), anterior and apical location, reduced left ventricular ejection fraction (LVEF) and the presence of microvascular obstruction. Echocardiography quantified myocardial strain has been associated with LVT following MI. Recently, global longitudinal strain, calculated with feature tracking (FT) - CMR, emerged as an independent predictor of major cardiovascular events following MI. Anyway, the relationship between abnormalities on FT-CMR and LVT following MI is still unexplored. Aim of our study is to investigate the possible association between abnormal strain on FT-CMR and LVT following apical STEMI. Methods We performed a retrospective analysis including all patients with a previous apical STEMI, who underwent CMR at our Institute between August 2013 and October 2020. Patients with ongoing anticoagulant therapy were excluded. Differences in global and segmental strain on CMR between patients with and without LVT were tested in a propensity-matched sample, using LVEF, age, gender, time from MI diagnosis and number of LV segments with transmural late gadolinium enhancement (LGE) as covariates to assign propensity score. Furthermore, difference in terms of apical to global radial strain percentual deviation (AGD), calculated as [(Global Radial Strain – Apical Radial Strain)/Global Radial Strain] * 100, was tested. Results Of 356 patients with apical STEMI undergoing CMR at our center, 37 (10.4%) were diagnosed with LVT. After performing a propensity score matching, we obtained a sample of 36 pairs, with a mean age of 65 (SD 11) years, and a median EF of 35% (IQR 27-42); 59 (82%) of them were male. A significant difference in terms of apical radial strain was found between the two groups, with a median strain of 10.75 (IQR 6.8–16.5) in patients without LVT compared to a value of 5.25 (IQR 2.7–9-6) in patients with LVT (p = 0.007). No differences were found in terms of global longitudinal, radial and circumferential strain (p = 0.19, p= 0.2 and p= 0.49 respectively) and segmental circumferential and longitudinal strain. When considering the AGD parameter, a significant difference was found between the two groups, with a median deviation of 12% (IQR -20; +48) in patients without LVT and 51% (IQR +47; +75) in patients with LVT (p= 0.0003). Furthermore, an AGD value of 26% was found to be the most accurate in terms of sensitivity and specificity applying a Receiver Operating Characteristic (ROC) curve analysis (AUC 0.74; CI 0.62-0.85). Conclusions Among patients with transmural MI involving LV apex, reduced apical radial strain on FT-CMR is associated with the presence of LV thrombosis. Furthermore, among patients developing LV thrombi, a greater apical radial strain deviation from the global one was found, with a threshold value of 26% at ROC curve analysis.

We present the case of a 18-year-old female with fulminant lymphocytic myocarditis caused by Parvovirus B19 (PVB19), successfully treated using temporary LVAD. In the literature there is no consensus on the surgical strategy. While some surgeons prefer to use a single device supporting only the LV, others prefer to start immediately with a biventricular supporting. At pre-procedural ultrasound evaluation, her anatomical features were not suitable for a percutaneous device such as the Impella. Thus, a temporary paracorporeal continuous flow LVAD was inserted. The heart recovery allowed LVAD removal 9 days after the implant. Supplementary Information The online version contains supplementary material available at 10.1007/s10047-021-01247-7.

INTRODUCTION: During the coronavirus disease-19 (COVID-19) outbreak in spring 2020, people may have been reluctant to seek medical care fearing infection. We aimed to assess the number, characteristics and in-hospital course of patients admitted for acute cardiovascular diseases during the COVID-19 outbreak. METHODS: We enrolled all consecutive patients admitted urgently for acute myocardial infarction, heart failure or arrhythmias from 1 March to 31 May 2020 (outbreak period) and 2019 (control period). We evaluated the time from symptoms onset to presentation, clinical conditions at admission, length of hospitalization, in-hospital medical procedures and outcome. The combined primary end point included in-hospital death for cardiovascular causes, urgent heart transplant or discharge with a ventricular assist device. RESULTS: A similar number of admissions were observed in 2020 (N = 210) compared with 2019 (N = 207). Baseline characteristics of patients were also similar. In 2020, a significantly higher number of patients presented more than 6 h after symptoms onset (57 versus 38%, P 

Although oral P2YThe purpose of this study was to compare downstream and upstream oral P2YWe performed a randomized, adaptive, open-label, multicenter clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was the superiority of the downstream versus the upstream strategy on the combination of efficacy and safety events (net clinical benefit).We randomized 1,449 patients to downstream or upstream oral P2YDownstream and upstream oral P2Y

Background Few studies prospectively assessed risk factors for ventricular fibrillation (VF) during a first myocardial infarction (MI). We designed a nation-wide study aiming to identify clinical and genetic characteristics associated with primary VF; and report here about clinical features. Methods PREDESTINATION (PRimary vEntricular fibrillation and suDden dEath during a firST myocardIal iNfArcTION) is an Italian case-control, prospective multicentre study. Cases are patients aged 18–80years with a first MI and at least one VF episodes occurring within 24h of symptoms onset, before reperfusion. Cases and controls are paired 1: 2 by gender and age (±5years). Results Among 1026 patients enrolled between 2007 and 2017, 970 entered the primary analysis: 375 cases and 595 controls (mean age 59years, 85% males). Multivariable analysis identified 5 independent predictors of primary VF: systolic blood pressure (OR 0.982, 95% CI: 0.98–0.99 for each mmHg) and K+ levels + levels obtained after VF, the OR associated with K+ levels Conclusions The present study identified 5 independent predictors of primary VF: familiarity, anterior MI, low systolic blood pressure, physical inactivity and hypokalaemia. Importantly, the last two risk factors are modifiable and, especially in the presence of a family history of sudden death, they should be avoided as much as possible.

BACKGROUND Few studies have examined the effect of transmurality of myocardial necrosis on coronary microcirculation. The aim of this study was to examine the influence of cardiac magnetic resonance-derived (GE-MRI) structural determinants of coronary flow reserve (CFR) after anterior myocardial infarction (STEMI), and their predictive value on regional functional recovery. METHODS Noninvasive CFR and GE-MRI were studied in 37 anterior STEMI patients after primary coronary angioplasty. The wall motion score index in the left descending anterior coronary artery territory (A-WMSI) was calculated at admission and follow-up (FU). Recovery of regional left ventricular (LV) function was defined as the difference in A-WMSI at admission and FU. The necrosis score index (NSI) and transmurality score index (TSI) by GE-MRI were calculated in the risk area. Baseline (BMR) and hyperemic (HMR) microvascular resistance, arteriolar resistance index (ARI), and coronary resistance reserve (CRR) were calculated at the Doppler echocardiography. RESULTS Bivariate analysis indicated that the CPK and troponin I peak, heart rate, NSI, TSI, BMR, the ARI, and CRR were related to CFR. Multivariable analysis revealed that TSI was the only independent determinant of CFR. The CFR value of >2.27, identified as optimal by ROC analysis, was 77% specific and 73% sensitive with accuracy of 76% in identifying patients with functional recovery. CONCLUSIONS Preservation of microvascular function after AMI is related to the extent of transmurality of myocardial necrosis, is an important factor influencing regional LV recovery, and can be monitored by noninvasive CFR.

Background: In patients who survived out-of-hospital cardiac arrest (OHCA), it is crucial to establish the underlying cause and its potential reversibility. Objective: The purpose of this study was to assess the incremental diagnostic and prognostic role of early cardiac magnetic resonance (CMR) in survivors of OHCA. Methods: Among 139 consecutive OHCA patients, the study enrolled 44 patients (median age 43 years; 84% male) who underwent coronary angiography and CMR ≤7 days after admission. The CMR protocol included T2-weighted sequences for myocardial edema and late gadolinium enhancement (LGE) sequences for myocardial fibrosis. Results: Coronary angiography identified obstructive coronary artery disease in 18 of 44 patients in whom CMR confirmed the diagnosis of ischemic heart disease by demonstrating subendocardial or transmural LGE. The presence of myocardial edema allowed differentiation between acute myocardial ischemia (n = 12) and postinfarction myocardial scar (n = 6). Among the remaining 26 patients without obstructive coronary artery disease, CMR in 19 (73%) showed dilated cardiomyopathy in 5, myocarditis in 4, mitral valve prolapse associated with LGE in 3, ischemic scar in 2, idiopathic nonischemic scar in 2, arrhythmogenic cardiomyopathy in 1, hypertrophic cardiomyopathy in 1, and takotsubo cardiomyopathy in 1. In this subgroup of 26 patients, 6 (23%) had myocardial edema. During mean follow-up of 36 ± 17 months, all 18 patients with myocardial edema had an uneventful outcome, whereas 9 of 26 (35%) without myocardial edema experienced sudden arrhythmic death (n = 1), appropriate defibrillator interventions (n = 5), and nonarrhythmic death (n = 3; P =.006). Conclusion: In survivors of OHCA, early CMR with a comprehensive tissue characterization protocol provided additional diagnostic and prognostic value. The identification of myocardial edema was associated with a favorable long-term outcome.

Cardiogenic shock (CS) is a rare disease that needs a rapid and multiparameter diagnosis and a timely, aggressive and multidisciplinary goal-oriented treatment. Recently published epidemiological studies and registries underline how SC represents an infrequent clinical entity still burdened by high mortality rates, substantially unchanged over the years. Currently, only few patients with CS are treated with circulatory assistance in dedicated centers. Some consensus documents and expert recommendations emphasize the importance of early diagnosis of CS, immediate pharmacological support, and treatment of precipitating causes, and stress the need for hospitalization in high-volume intensive care centers. The aim of this review is to show the instructions for the creation of a SC network, emphasizing the necessary elements, in agreement with available resources and existing health regulations for giving the same care opportunities to all the patients.

Background Non-traumatic out of hospital cardiac arrest (OHCA) is the leading cause of death worldwide, mainly due to acute coronary syndromes. Urgent coronary angiography with view to revascularisation is recommended in patients with suspected acute coronary syndrome. Diagnosis and management of patients with inconclusive coronary angiogram (unobstructed coronaries or unidentified culprit lesion) is challenging. We sought to assess the role of Cardiovascular Magnetic Resonance (CMR) in the diagnosis and management of OHCA survivors with an inconclusive coronary angiogram. Methods and results This is a retrospective multicentre CMR registry analysis of OHCA survivors with an inconclusive angiogram. Clinical, ECG and multi-modality imaging data were analysed. Clinical impact of CMR was defined as a change in diagnosis or management. Out of 174 OHCA survivors referred for CMR, 110 patients (63%, 84 male, median age 58) had an inconclusive angiogram. CMR identified a pathologic substrate in 76/110 patients (69%): ischemic heart disease was found in 45 (41%) and non-ischemic heart disease in 31 (28%). A structurally normal heart was found in 25 patients (23%) and non-specific findings in 9 (8%). As compared to trans-thoracic echocardiogram, CMR proved to be superior in identifying a pathologic substrate (69% vs 54%, p = 0.018). The CMR study carried a clinical impact in 70% of patients, determining a change in diagnosis in 25%, in management in 29% and a change in both in 16%. Conclusions CMR showed a promising role in the diagnostic work-up of OHCA survivors with inconclusive angiogram and its wider use should be considered.

Current risk stratification for sudden cardiac death (SCD) in nonischemic dilated cardiomyopathy (NIDC) relies on left ventricular (LV) dysfunction, a poor marker of ventricular electrical instability. Contrast-enhanced cardiac magnetic resonance has the ability to accurately identify and quantify ventricular myocardial fibrosis (late gadolinium enhancement [LGE]).To evaluate the impact of the presence and amount of myocardial fibrosis on arrhythmogenic risk prediction in NIDC.One hundred thirty-seven consecutive patients with angiographically proven NIDC were enrolled for this study. All patients were followed up for a combined arrhythmic end point including sustained ventricular tachycardia (VT), appropriate implantable cardioverter-defibrillator (ICD) intervention, ventricular fibrillation (VF), and SCD.LV-LGE was identified in 76 (55.5%) patients. During a median follow-up of 3 years, the combined arrhythmic end point occurred in 22 (16.1%) patients: 8 (5.8%) sustained VT, 9 (6.6%) appropriate ICD intervention, either against VF (n = 5; 3.6%) or VT (n = 4; 2.9%), 3 (2.2%) aborted SCD, and 2 (1.5%) died suddenly. Kaplan-Meier analysis revealed a significant correlation between the LV-LGE presence (not the amount and distribution) and malignant arrhythmic events (P.001). In univariate Cox regression analysis, LV-LGE (hazard ratio [HR] 4.17; 95% confidence interval [CI] 1.56-11.2; P = .005) and left bundle branch block (HR 2.43; 95% CI 1.01-5.41; P = .048) were found to be associated with arrhythmias. In multivariable analysis, the presence of LGE was the only independent predictor of arrhythmias (HR 3.8; 95% CI 1.3-10.4; P = .01).LV-LGE is a powerful and independent predictor of malignant arrhythmic prognosis, while its amount and distribution do not provide additional prognostic value. Contrast-enhanced cardiac magnetic resonance may contribute to identify candidates for ICD therapy not fulfilling the current criteria based on left ventricular ejection fraction.

A 55-year-old woman was referred to the emergency department of Padova University Hospital with acute chest pain extending up to the left shoulder. She had had fever a few days prior but no other symptoms. The patient, who was obese, smoked, and had a history of arterial hypertension, first received first-line amlodipine treatment that was interrupted because of poor compliance. No other traditional cardiovascular or thrombophilic risk factors were reported. One hour after the onset of chest pain, the patient called the emergency service; the electrocardiogram (ECG)3 recorded at home was unremarkable for acute ischemia (Fig. 1A). At the emergency department, after 80 min, the patient still complained of chest pain, the physical examination was negative, blood pressure was 220/110 mmHg, and heart rate was 78 beats/min. The results of the second ECG were the same as those of the first (Fig. 1B). Fig. 1. Electrocardiographic and imaging findings. First acute ECG recorded at home, unremarkable for acute ischemia (A); second ECG recorded at the emergency department (chest pain still present) not showing ST-segment elevation, but a more clear QS complex on V1–V3 (black rectangle) (B); coronary angiography showing the normal epicardial coronary artery, except the small caliber of the first septal branch of the anterior descending coronary artery (white circle on E) (C–E); T2-weighted sequence showing that the acute ischemic edema in the septum was detectable on the 4-chamber view (F); orthogonal views showing that on post-contrast CMR, the ischemic pattern of late gadolinium enhancement (white area) in the same region of the previously demonstrated edema confirmed the acute myocardial infarction (G–H); RCA, right coronary artery; LCX, left circumflex artery; LAD, left anterior descending artery. The initial cardiac troponin I (cTnI) concentration, obtained using a high-sensitivity assay (1), was markedly increased (57 ng/L) relative to the sex-dependent 99th percentile (16 ng/L). The …

Background A specific ECG pattern of presentation of ST-segment elevation acute myocardial infarction (STEMI), characterized by “triangular QRS-ST-T waveform” (TW), has been associated with poor in-hospital prognosis but longitudinal data on its incidence and clinical impact are lacking. We prospectively evaluated the incidence and prognostic meaning of the TW pattern in a cohort of consecutive STEMI patients. Methods All STEMI patients who presented within 12 h of symptoms onset and showed no complete bundle branch block or paced ventricular rhythm were included. The TW pattern was defined as a unique, giant wave (amplitude ≥ 1 mV) resulting from the fusion of the QRS complex, the ST-segment and the T-wave and showing a “triangular” morphology with a positive polarity in the leads exploring the ischemic region. Results Among 428 consecutive STEMI patients, 367 fulfilled the enrollment criteria. The TW pattern was identified in 5 of 367 patients (1.4%) on the admission ECG. This subset of STEMI patients with TW pattern significantly more often showed a left main coronary artery involvement (2/4, 50% vs 2/322, 0.6%; p Conclusions The TW pattern is an uncommon ECG finding, which reflects the presence of a large area of transmural myocardial ischemia and predicts cardiogenic shock accounting for high in-hospital mortality. When present, this ECG pattern should prompt aggressive therapeutic strategies, including mechanical support of circulation.

This study sought to evaluate the prevalence and potential role of myocardial bridging in the pathogenesis of apical ballooning syndrome (ABS).ABS is characterized by reversible left ventricular dysfunction, frequently precipitated by a stressful event, but the pathogenesis remains still unclear.Forty-two consecutive patients (40 female, mean age 66 ± 7 years) with ABS underwent echocardiography, cardiac magnetic resonance, coronary angiography (CA) with intravascular ultrasound, and computed tomography angiography (CTA). Myocardial bridging was diagnosed by CA when a dynamic compression phenomenon was observed in the coronary artery and by CTA when a segment of coronary artery was completely (full encasement) or incompletely (partial encasement) surrounded by the myocardium. The prevalence of myocardial bridging detected by CTA and CA in ABS patients was compared with 401 controls without ABS who underwent both CTA and CA.Myocardial bridging by CTA was observed in 32 ABS patients (76%): 23 with partial encasement and 9 with full encasement. All myocardial bridging was located in the mid segment of the left anterior descending coronary artery (LAD) with a mean length of 17 ± 9 mm. CA revealed myocardial bridging in 17 subjects (40%) (9 with partial encasement and 8 with full encasement by CTA). All subjects in which dynamic compression was observed by CA showed myocardial bridging by CTA, while none of the subjects with negative findings for myocardial bridging by CTA revealed dynamic compression by CA. Compared with controls, ABS patients showed a significant higher prevalence of myocardial bridging in the LAD either by CA (40% vs. 8%; p0.001) or by CTA (76% vs. 31%; p0.001).Our study showed that myocardial bridging of the LAD is a frequent finding in ABS patients as revealed both by CA and, mostly, by CTA, suggesting a role of myocardial bridging as potential substrate in the pathogenesis of ABS.

Under the Italian Law "Legge Balduzzi", which was issued after the sudden cardiac death of professional athletes Pier Mario Morosini and Vigor Bovolenta in 2012, the presence of an automated external defibrillator (AED) and personnel trained to perform cardiopulmonary resuscitation must be available in every Italian sports facility from 2016. In 2015 the national and local press reported 123 cases of sudden cardiac arrests (SCA) occurring in Italian sport facilities, corresponding to an estimated ≈0.2-0.4% of all SCA and to ≈0.6-1.2% of SCA in public places. The majority of SCA victims were males (93%) and35 years old (88%, median age 50 years). On the basis of the report of the event on the press, the rate of return of spontaneous circulation was 62% when an AED was used before emergency medical system arrival versus 9% when no bystander cardiopulmonary resuscitation or AED use by lay rescuers was mentioned. These data demonstrated that the Law has the potential to increase the survival to SCA in athletes; however, limiting the obligation of the presence of an AED only to sports facilities is not enough to decrease significantly the incidence of SCA in the general population.

Light chain deposition disease (LCDD) is a rare plasma cell dyscrasia consisting of nonamyloidotic deposition of misfolded immunoglobulin light chain (LC) in tissues and organs. Heart involvement is a rare and late event in the course of the disease.1 Therefore, such a nonfibrillar deposition of LC in the myocardium has so far been described only in few endomyocardial biopsies. Potentially lethal ventricular arrhythmias and a nondiagnostic echocardiogram are 2 clinical hallmarks of the disease.1,2 In addition, no other in vivo imaging of the condition is presently available. A 52-year-old man was admitted to the emergency department for syncope at rest. ECG showed a sinus rhythm with negative T waves in inferolateral leads alternating with ventricular bigeminism and episodes of torsades de pointes triggered by R-on-T phenomenon (Figure 1A). The previous history included serum IgGκ + κ monoclonal gammopathies and nephrotic syndrome. The bone marrow biopsy showed 60% clonal plasma cells, and the kidney biopsy examination by immunofluorescence and immunoelectron microscopy was consistent with LCDD. Light microscopic finding of kidney biopsy showed glomeruli with increased mesangial cellularity and nodular expansion of mesangial matrix; mesangial nodules were positive at periodic acid Schiff and trichrome stain (Figure 2A …

Background Although angiographic perfusion has been traditionally evaluated by myocardial blush grade (MBG), pathophysiologic features underlying different MBG and the persistent blush, traditionally called staining, have been poorly explained. The aim of the study was to evaluate the correlation between MBG and morphologic aspects on cardiac magnetic resonance (CMR). Methods Myocardial blush grade and morphologic aspects on contrast-enhanced CMR, with special reference to staining phenomenon and persistent microvascular damage (PMD), were evaluated in a consecutive series of patients with acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention. Results A total number of 294 AMI patients were enrolled and classified into 2 groups, that is, MBG 0/1 (115, 39%) and MBG 2/3 (179, 61%), according to the angiographic profile. By comparing MBG 0/1 versus MBG 2/3 patients, the former exhibited a larger enzymatic infarct size (P Conclusions In AMI patients treated by primary percutaneous coronary intervention, angiographic parameters of impaired reperfusion correlate with PMD as detected by contrast CMR. Among patients with MBG 0, the presence of the so-called staining phenomenon identifies a subgroup of patients with more severe PMD.

Objective The mechanism through which multivessel coronary artery disease (MVD) adversely affects the outcome of patients with ST-elevation myocardial infarction (STEMI) is poorly characterized. We assessed whether the impact of MVD on outcome of STEMI patients is because of ischemic damage after primary percutaneous coronary intervention (PPCI) or to late ischemic events. Methods From August 2005 to 2007, 288 STEMI patients treated by (bare metal) stent-PPCI were prospectively enrolled. The ischemic injury early after PPCI (evaluated by multiparametric approach) and the incidence of late adverse cardiovascular events were compared between the two groups. Results Compared with single vessel coronary artery disease, MVD patients (n=134) were older, with higher prevalence of diabetes, prior MI, anterior MI and higher collateral score. Myocardial perfusion as assessed by myocardial blush and SigmaST-segment resolution was similar in the two groups as well as the infarct size and microvascular obstruction as assessed by Troponin I and by the delayed enhancement of cardiac magnetic resonance. At clinical (98% complete) and echocardiogaphic (94% complete) follow-up (median 32 months) MVD patients showed a higher incidence of re-MI (6.1 vs. 1.3%), and urgent revascularization (8.3 vs. 2.7%) and worse left ventricular remodeling than single vessel disease patients. At propensity adjusted analysis MVD was an independent predictor of re-MI (odds ratio: 5.7) and ventricular remodeling (odds ratio: 2.2). Conclusion The impact of MVD on clinical outcome and remodeling of STEMI patients is not because of the extent of ischemic damage observed after PPCI, but to recurrent ischemic events during follow-up.

Our article on “arrhythmic” mitral valve prolapse (MVP)1 triggered a debate among clinical cardiologists about the implications in terms of diagnosis, risk stratification, and therapy. Thus, the letters by Sheppard et al and Providencia and Lambiase are welcome and give us the opportunity to be back on this hot topic. Sheppard et al, by studying a series of sudden cardiac death (SCD) victims with classic myxoid mitral valve degeneration, found similar features in terms of myocardial fibrosis in one or both papillary muscles and adjacent left ventricular free wall, although they did not specifically assess the inferobasal wall. Their findings further strengthen our hypothesis that left ventricular scarring in targeted areas subjected to higher mechanical stress is the substrate of electric instability in arrhythmic MVP and support a role for contrast-enhanced cardiac magnetic resonance for risk stratification in a selected subgroup of patients. Furthermore, the authors did not find a female preponderance …

Background— Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results— Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P P =0.004) and end-diastolic mitral annular diameters (median: 35.5 versus 31.5; P =0.042), prevalence of posterior systolic curling (34 [94%] versus 3 [19%]; P 1.5 (22 [61%] versus 4 [25%]; P =0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling ( R =0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P =0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P Conclusions— Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification.

Objectives: The impact of periprocedural (before primary percutaneous coronary angioplasty, PCI) abciximab administration on microvascular obstruction in patients with occluded infarct-related artery (IRA) is unknown. Methods: We studied 36 consecutive patients with first ST elevation myocardial infarction (STEMI) and occluded IRA treated with successful primary PCI within 12 h from symptom onset, who received intravenous abciximab immediately before PCI and 49 matched patients who did not receive abciximab as controls. All patients underwent delayed-enhanced magnetic resonance (DE-MR) 6 ± 2 days after PCI. Necrosis was judged as transmural when DE was extended to ≧75% of left ventricular (LV) segment thickness. Severe microvascular obstruction was identified as areas of late hypoenhancement surrounded by DE. Results: Time to treatment was comparable in the two groups (182 ± 60 vs. 188 ± 110 min, respectively). Transmurality and severe microvascular obstruction were present in 3.03 ± 2.8 versus 3.09 ± 2.9 (p = 0.9) and 1.05 ± 1.5 versus 1.06 ± 1.8 (p = 0.6) of LV segments, respectively, in the abciximab group versus controls. At multivariate analysis, severe microvascular obstruction was independently associated only with transmural necrosis (OR 1.5, p < 0.001) and age (OR 1.1, p = 0.02) but not with the use of abciximab. Conclusions: Severe microvascular obstruction after primary PCI of STEMI patients with occluded IRA is related to transmural necrosis but not to the use of abciximab.

Infarct size has been considered an established marker of left ventricular (LV) remodeling. We assessed the predictive value of myocardial/microvascular injury assessed by delayed enhanced magnetic resonance imaging (MRI) on LV remodeling and LV ejection fraction after primary coronary intervention (PCI) compared with peak troponin levels, an established index of myocardial infarct size. We performed MRI in 76 patients with first acute myocardial infarction 6 +/- 2 days after successful PCI. Necrosis was judged as transmural when delayed enhancement was extended to >or=75% of LV segment thickness. Severe microvascular obstruction was identified as areas of late hypoenhancement surrounded by delayed enhancement. Infarct size was expressed as an index by dividing the total percentage of delayed enhancement involvement by the number of LV segments. LV end-diastolic volume index and function were quantified by 2-dimensional echocardiography at 6 +/- 1 months after acute myocardial infarction. Remodeling was evaluated as a change in LV end-diastolic volume index at follow-up compared with baseline. At univariate analyses, transmural necrosis, severe microvascular obstruction, infarct size, and troponin level were correlated directly with remodeling and inversely with LV function at follow-up (p

Objectives This study sought to assess the relationship between duration of ischemia and both myocardial transmural necrosis (TN) and severe microvascular obstruction (SMO), by contrast-enhanced magnetic resonance (CE-MR), in patients with acute myocardial infarction (AMI) treated with angioplasty (PCI), and to estimate the risk of TN and SMO with the duration of ischemia. Background The impact of ischemic time on myocardial and microvascular injury is not well characterized in people. Methods We performed CE-MR in 77 patients with first AMI, 5 ± 3 days after successful PCI. The AMI was labeled as transmural if hyperenhancement at CE-MR was extended to ≥75% of the thickness in two or more ventricular segments. The SMO was identified as areas of late hypoenhancement surrounded by hyperenhanced tissue. The relationship between ischemic time and CE-MR evidence of SMO or TN was evaluated by logistic regression. Results Thirteen patients were excluded because of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 of the infarct-related artery. For the remaining 64 patients, the mean time to treatment was 190 ± 110 min, 45 (65%) patients had TN and 23 (39%) had SMO. Mean pain to balloon time was 90 ± 40 min, 110 ± 107 min, and 137 ± 97 min in patients without TN and SMO, with TN but without SMO, or with both TN and SMO, respectively (p = 0.001). Multivariate analysis showed that time delay was significantly associated both with TN (odds ratio per 30 min, 1.37, p = 0.032), and SMO (odds ratio per 30 min, 1.21; p = 0.021). Conclusions In AMI patients with impaired coronary perfusion undergoing PCI, the risk of TN and SMO increases with the duration of the ischemic time.

Ths study reports different mechanisms (i.e., microvascular spasm and discrete microinfarction) that may underlie different pattern of slow-reflow after elective coronary stenting on the basis of the different tissue level of perfusion achieved, assessed by blush grade and MRI. Catheter Cardiovasc Interv 2004;61:222–226. © 2004 Wiley-Liss, Inc.

Background— Mitral valve prolapse (MVP) may present with ventricular arrhythmias and sudden cardiac death (SCD) even in the absence of hemodynamic impairment. The structural basis of ventricular electric instability remains elusive. Methods and Results— The cardiac pathology registry of 650 young adults (≤40 years of age) with SCD was reviewed, and cases with MVP as the only cause of SCD were re-examined. Forty-three patients with MVP (26 females; age range, 19–40 years; median, 32 years) were identified (7% of all SCD, 13% of women). Among 12 cases with available ECG, 10 (83%) had inverted T waves on inferior leads, and all had right bundle-branch block ventricular arrhythmias. A bileaflet involvement was found in 70%. Left ventricular fibrosis was detected at histology at the level of papillary muscles in all patients, and inferobasal wall in 88%. Living patients with MVP with (n=30) and without (control subjects; n=14) complex ventricular arrhythmias underwent a study protocol including contrast-enhanced cardiac magnetic resonance. Patients with either right bundle-branch block type or polymorphic complex ventricular arrhythmias (22 females; age range, 28–43 years; median, 41 years), showed a bileaflet involvement in 70% of cases. Left ventricular late enhancement was identified by contrast-enhanced cardiac magnetic resonance in 93% of patients versus 14% of control subjects ( P Conclusions— MVP is an underestimated cause of arrhythmic SCD, mostly in young adult women. Fibrosis of the papillary muscles and inferobasal left ventricular wall, suggesting a myocardial stretch by the prolapsing leaflet, is the structural hallmark and correlates with ventricular arrhythmias origin. Contrast-enhanced cardiac magnetic resonance may help to identify in vivo this concealed substrate for risk stratification.

The case reported, who suffered prolonged coronary occlusion, was evaluated by repeated MRI images in the acute, subacute and chronic phase. Scans showed hemorrhagic myocardial infarction and massive endothelial injury and its evolution over time.

Out-of-hospital sudden cardiac arrest (OHCA) is a leading cause of death all over the world. Although the outcome of OHCA resulting from 'nonshockable' rhythms (asystole and pulseless electrical activity) is poor regardless of resuscitation efforts, 'shockable' rhythms such as ventricular tachycardia or fibrillation may carry a good prognosis if early defibrillation is performed. At present, simplified cardiopulmonary resuscitation techniques (hands-only cardiopulmonary resuscitation) and automated external defibrillators (AEDs) offer lay people the possibility to provide lifesaving treatment to OHCA victims in the critical minutes before the arrival of the emergency medical system. Programs aimed at increasing provision of cardiopulmonary resuscitation and use of AEDs by lay people have been set up in different countries, including Italy, and have contributed to improve survival rates. However, success of these programs critically depends on appropriate planning and design, and on cultural predisposition of witnesses to undertake immediate measures of resuscitation in the case of OHCA. Placement of a large number of AEDs may carry high costs and little benefits if it is uncoordinated and not preceded by educational campaigns to spread widely the 'culture of resuscitation' in the population.

The hypereosinophilic syndrome is characterized by persistent marked eosinophilia (≥1.5 eosinophils × 109/l) and evidence of eosinophil-mediated organ damage. Cardiac involvement due to hypereosinophilic syndrome includes the eosinophilic myocarditis (EM), the Loeffler endocarditis (LE), and the