Showing papers by "Marco Zuin published in 2017"

Comparative Computed Flow Dynamic Analysis of Different Optimization Techniques in Left Main Either Provisional or Culotte Stenting.

Abstract: Background and objectives Provisional and culotte are the most commonly used techniques in left main (LM) stenting. The impact of different post-dilation techniques on fluid dynamic of LM bifurcation has not been yet investigated. The aim of this study is to evaluate, by means of computational fluid dynamic analysis (CFD), the impact of different post-dilation techniques including proximal optimization technique (POT), kissing balloon (KB), POT-Side-POT and POT-KB-POT, 2-steps Kissing (2SK) and Snuggle Kissing balloon (SKB) on flow dynamic profile after LM provisional or culotte stenting. Methods We considered an LM-LCA-LCX bifurcation reconstructed after reviewing 100 consecutive patients (mean age 71.4 ± 9.3 years, 49 males) with LM distal disease. The diameters of LAD and LCX were modelled according to the Finnet's law as following: LM 4.5 mm, LAD 3.5 mm, LCX 2.75 mm, with bifurcation angle set up at 55°. Xience third-generation stent (Abbot Inc., USA) was reconstructed and virtually implanted in provisional/cross-over and culotte fashion. POT, KB, POT-side-POT, POT-KB-POT, 2SK and SKB were virtually applied and analyzed in terms of the wall shear stress (WSS). Results Analyzing the provisional stenting, the 2SK and KB techniques had a statistically significant lower impact on the WSS at the carina, while POT seemed to obtain a neutral effect. In the wall opposite to the carina, the more physiological profile has been obtained by KB and POT with higher WSS value and smaller surface area of the lower WSS. In culotte stenting, at the carina, POT-KB-POT and 2SK had a very physiological profile; while at the wall opposite to the carina, 2SK and POT-KB-POT decreased significantly the surface area of the lower WSS compared to the other techniques. Conclusion From the fluid dynamic point of view in LM provisional stenting, POT, 2SK and KB showed a similar beneficial impact on the bifurcation rheology, while in LM culotte stenting, POT-KB-POT and 2SK performed slightly better than the other techniques, probably reflecting a better strut apposition.

Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean Arterial Pressure Index (AMAPI)

Abstract: Acute pulmonary embolism (PE) is the third cause of cardiovascular (CV) mortality. We evaluated a new risk index, named Age-Mean Arterial Pressure Index (AMAPI), to predict 30-day CV mortality in patients with acute PE. Data of 209 patients (44.0% male and 56.0% female, mean age 70.58 ± 14.14 years) with confirmed acute PE were retrospectively analysed. AMAPI was calculated as the ratio between age and mean arterial pressure (MAP), which was defined as [systolic blood pressure + (2 × diastolic blood pressure)]/3. To test AMAPI accuracy, a comparison with shock index (SI) and simplified pulmonary embolism severity index (sPESI) was performed. Patients were divided in two groups according their hemodynamic stability, or not, at admission. 30-day mortality rate, in all cases for CV events, was 10.5% (n = 22). Hemodynamically unstable patients had a higher AMAPI compare to those without hypotension at admission (1.28 ± 0.39 vs 0.78 ± 0.27, p < 0.0001). Receiving operative curve analyses (ROC) found the optimal cut-off for AMAPI in hemodynamically stable and unstable patients ≥0.9 and ≥0.92, respectively. In both groups, patients with an AMAPI over the cut-off were significantly older, hypotensive (both systolic and diastolic blood pressure), with a higher SI and lower MAP. In hemodynamically stable patients, 30-day CV mortality risk prediction was improved adding AMAPI ≥0.9 to both SI and sPESI (net reclassification improvement-NRI-of 14.2%, p = 0.0006 and 11.5%, p = 0.0002, respectively). In hemodynamically unstable patients NRI was 19.2%, p = 0.006. Mantel-Cox analysis revealed a statistical significant difference in the distribution of survival between hemodynamically stable patients with an AMAPI index ≥0.9 compared to those with an AMAPI <0.89 [log rank (Mantel-Cox) p < 0.0001] and in hemodynamically unstable patients with an AMAPI ≥0.92 [log rank (Mantel-Cox) p = 0.001]. AMAPI ≥0.90 and ≥0.92 predict 30-day CV mortality in hemodynamically stable and unstable patients with acute PE.

Systemic thrombolysis in acute pulmonary embolism: also a matter of "time".

Abstract: available literature, PE patients could receive systemic thrombolysis within 14 days from symptoms onset [5–7]. However, a maximal benefit has been observed when reperfusion treatment was earlier administered after the diagnosis [4, 8]. On the contrary, Goldhaber reported that patients who received thrombolysis between 6 and 14 days after PE symptoms or signs onset have the same effective response compared to those patients treated within 5 days after the PE onset [9]. Dalla Volta et al. in the PAIMS 2 trial, observed that Miller index at pulmonary angiography significantly decreased from diagnostic run to 2-h after alteplase infusion (28.3 ± 2.9 to 24.8 ± 5.2, p < 0.01) [10]. The proposed therapeutic window for systemic thrombolysis in acute PE appears very vague and without specific information. This lack of specificity could create ambiguous situation and could nullify the reperfusion therapy. However, most of the available data have been obtained using an “old” PE classification, mainly based on invasive hemodynamic assessment and Miller index. Moreover, these studies often enrolled few patients and in some cases mortality benefit could be underestimated due to the possible administration of rescue thrombolysis in deteriorated patients, previous treated only with anticoagulation. In clinical practice, are we always able to assess the reasons for which systemic thrombolysis has failed? Wrong dosage? Delay in the reperfusion treatment? The answer is obviously no and if happens catheter-direct treatment (CDT) could be a valid therapeutic alternative. In particular, CDT has been proposed in the latest ESC guidelines on acute PE as rescue therapy, when systemic thrombolysis resulted contraindicated or has failed [2]. Conversely, AHA guidelines recommend CFT as grade II C, when available [3]. Nowadays, several different endovascular techniques could be adopted in the treatment of massive PE. One of the simpler strategies is based on To the Editor,

Complete heart block as presenting symptom of massive pulmonary embolism in an elderly patient.

Abstract: A 68-year-old man presented to the emergency department due to recurrent episodes of syncope and shortness of breath during the previous two days. Her medical history included arterial hypertension and diabetes. She was not taking any negative chronotropic drugs but she referred a familial history of fatal pulmonary embolism and sudden cardiac death. At admission, blood pressure, pulse rate and peripheral oxygen saturation were 88/60 mmHg, 49 beats/min and 88%, respectively. ECG revealed a third-degree AV block (Figure 1A). Routine blood tests demonstrated an ultrasensitive cardiac troponin I (cTnI) of 225 ng/L (n.v. < 45 ng/L) and no evidences of electrolyte imbalances, while chest X-ray revealed no signs of heart failure. The woman required the placement of a temporary pacing but, after 4 h from the admission, she spontaneously recovered sinus rhythm remaining hemodynamically unstable (86/62 mmHg). A new ECG demonstrated sinus tachycardia, incomplete right bundle branch block (RBBB), S1Q3T3 pattern and Q waves in inferior and anteroseptal leads (Figure 1B). Considering the patient’s familial history, previous laboratory findings and the McGinn and White pattern observed after the spontaneous recovery of sinus rhythm, further investigations were performed. D-dimer level and N-terminal pro–B-type natriuretic peptide levels resulted 15.2 μg/mL (normal value < 0.50 μg/L) and 2019 pg/mL (normal value < 300 pg/mL), respectively, while cTnI further increased (502 ng/L). Bedsides, transthoracic echocardiography demonstrated an enlarged-hypokinetic right ventricle and diastolic dyskinesia of the interventricular septum, while doppler-derived pulmonary artery systolic pressure was 38 mmHg. The strongly suspect of acute pulmonary embolism (PE) was confirmed by the computed tomography angiography which demonstrated the presence

Could advanced drug delivery systems be the future in cardiovascular revascularization medicine

Abstract: Acute myocardial infarction, stroke and pulmonary embolism required a prompt revascularization to restore the normal blood flow as soon as possible. Fibrinolytic treatment has gradually become both dated and underused in the treatment of acute myocardial infarction, after the wide diffusion of cathlab and percutaneous transluminal coronary angioplasty. Conversely, the use of systemic thrombolysis remained a benchmark in the treatment of both ischemic stroke and massive pulmonary embolism. In daily clinical practice, the use of thrombolytic agents is often limited by absolute and/or relative contraindications and possible adverse events after the drug administration, as intracranial and/or extracranial bleeding events. To minimize these problems, during the last years, the introduction of nanotechnology in the field of cardiovascular revascularization medicine has created several fascinating results. In the present article, we describe these recent findings and their possible implications in future clinical practice.

Acute Pulmonary Embolism and Paradoxical Embolism in Patients with Patent Foramen Ovale: to Close or Not to Close…That is the Question!

Abstract: Nowadays, the treatment of patent foramen ovale (PFO) after acute pulmonary embolism (PE) remains matter of speculation Absence of both randomized trials and recommendations in current international guidelines complicate the decisions making in such patients In the present manuscript we discuss about the reasons for which PFO should be closed after acute PE

Topical anaesthesia before transradial approach for supraoartic vessels angiography and stenting in the elderly: a feasible alternative.

Abstract: Gianluca Rigatelli, Marco Zuin, Fabio Dell’Avvocata, Dobrin Vassiliev Section of Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy Department of Cardiology, Rovigo General Hospital, Rovigo, Italy Head Cardiology Department, Alexandroska University Hospital, Sofia, Bulgaria