Non invasive evaluation of cardiomechanics in patients undergoing MitrClip procedure

Abstract BACKGROUND: In the last recent years a new percutaneous procedure, the MitraClip, has been validated for the treatment of mitral regurgitation. MitraClip procedure is a promising alternative for patients unsuitable for surgery as it reduces the risk of death related to surgery ensuring a similar result. Few data are present in literature about the variation of hemodynamic parameters and ventricular coupling after Mitraclip implantation. METHODS: Hemodynamic data of 18 patients enrolled for MitraClip procedure were retrospectively reviewed and analyzed. Echocardiographic measurements were obtained the day before the procedure (T0) and 21 ± 3 days after the procedure (T1), including evaluation of Ejection Fraction, mitral valve regurgitation severity and mechanism, forward Stroke Volume, left atrial volume, estimated systolic pulmonary pressure, non invasive echocardiographic estimation of single beat ventricular elastance (Es(sb)), arterial elastance (Ea) measured as systolic pressure • 0.9/ Stroke Volume, ventricular arterial coupling (Ea/Es(sb) ratio). Data were expressed as median and interquartile range. Measures obtained before and after the procedure were compared using Wilcoxon non parametric test for paired samples. RESULTS: Mitraclip procedure was effective in reducing regurgitation. We observed an amelioration of echocardiographic parameters with a reduction of estimated systolic pulmonary pressure (45 to 37,5 p = 0,0002) and left atrial volume (110 to 93 p = 0,0001). Despite a few cases decreasing in ejection fraction (37 to 35 p = 0,035), the maintained ventricular arterial coupling after the procedure (P = 0,67) was associated with an increasing in forward stroke volume (60,3 to 78 p = 0,05). CONCLUSION: MitraClip is effective in reducing mitral valve regurgitation and determines an amelioration of hemodynamic parameters with preservation of ventricular arterial couplin

Biopharmaceutical Assessment of Mesh Aerosolised Plasminogen, a Step towards ARDS Treatment

Acute respiratory distress syndrome (ARDS) is a severe complication of lung injuries, commonly associated with bacterial, fungal and viral infections, including SARS-CoV-2 viral infections. ARDS is strongly correlated with patient mortality and its clinical management is very complex, with no effective treatment presently available. ARDS involves severe respiratory failure, fibrin deposition in both airways and lung parenchyma, with the development of an obstructing hyaline membrane drastically limiting gas exchange. Moreover, hypercoagulation is related to deep lung inflammation, and a pharmacological action toward both aspects is expected to be beneficial. Plasminogen (PLG) is a main component of the fibrinolytic system playing key roles in various inflammation regulatory processes. The inhalation of PLG has been proposed in the form of the off-label administration of an eyedrop solution, namely, a plasminogen-based orphan medicinal product (PLG-OMP), by means of jet nebulisation. Being a protein, PLG is susceptible to partial inactivation under jet nebulisation. The aim of the present work is to demonstrate the efficacy of the mesh nebulisation of PLG-OMP in an in vitro simulation of clinical off-label administration, considering both the enzymatic and immunomodulating activities of PLG. Biopharmaceutical aspects are also investigated to corroborate the feasibility of PLG-OMP administration by inhalation. The nebulisation of the solution was performed using an Aerogen (R) Solo (TM) vibrating-mesh nebuliser. Aerosolised PLG showed an optimal in vitro deposition profile, with 90% of the active ingredient impacting the lower portions of a glass impinger. The nebulised PLG remained in its monomeric form, with no alteration of glycoform composition and 94% of enzymatic activity maintenance. Activity loss was observed only when PLG-OMP nebulisation was performed under simulated clinical oxygen administration. In vitro investigations evidenced good penetration of aerosolised PLG through artificial airway mucus, as well as poor permeation across an Air-Liquid Interface model of pulmonary epithelium. The results suggest a good safety profile of inhalable PLG, excluding high systemic absorption but with good mucus diffusion. Most importantly, the aerosolised PLG was capable of reversing the effects of an LPS-activated macrophage RAW264.7 cell line, demonstrating the immunomodulating activity of PLG in an already induced inflammatory state. All physical, biochemical and biopharmaceutical assessments of mesh aerosolised PLG-OMP provided evidence for its potential off-label administration as a treatment for ARDS patients

Accoppiamento ventricolo arterioso in pazienti con shock settico

Lo studio della cardiomiopatia in corso di shock settico risulta difficile in ambito clinico dato il particolare pattern emodinamico che caratterizza questo tipo di patologia. La diagnosi accurata e il trattamento della disfunzione miocardica in corso di sepsi permettono tuttavia di migliorare l'oucome dei pazienti. L'analisi dell'accoppiamento ventricoloarterioso consente di analizzare lo stato di contrattilità intriseca miocardica e l'efficienza energetica del sistema ventricolo arterioso. In questo lavoro è stata effettuata un'analisi ecocardiografica single beat dell'accoppiamento ventricolo arterioso di 14 pazienti con shock settico ricoverati presso la Rianimazione del Dipartimento Cardio-Toracico

Gestión de conflictos: la mediación social

OBJETIVO: la reconciliación asegurada por el Derecho se demuestra a menudo insuficiente y lenta en la efectiva solución del conflicto. La mediación, como nueva forma democrática del “hacer justicia” en los conflictos sociales, es un nuevo proyecto para la contención de los tiempos, de los costes, del formalismo y de la rigidez del juicio ordinario y que al mismo tiempo puede llevar a cabo una justicia psicológica cercana a los individuos. MÉTODO: investigaciones en los Tribunales, en los Organismos de mediación y comparación de análisis estadísticos nacionales sobre la mediación y sobre juicios pendientes del 2012 al 2015. RESULTADOS: las indagaciones estadísticas y las investigaciones enfatizan que la mediación en Italia, desde el momento de entrada en vigor (marzo 2011) de la Ley 28/2010 a hoy, es un organismo utilizado cada vez más como sistema de gestión de conflictos mejorando, por tanto, las relaciones sociales y reduciendo los tiempos y costes de la justicia. Desde el 2014 al 2015 las causas han disminuido un 9,5% y el porcentaje de los intentos obligatorios de mediación respecto al total de los procedimientos de mediación, en el 2015, ha sido del 81,6%. Es más, las estadísticas demuestran cómo con la participación directa de las partes, aumentan las resoluciones de controversias. De hecho, cuando la parte invitada comparece, lo que sucede en el 44,9% de los casos, el éxito positivo de las mediaciones es del 43,5%. CONCLUSIONES: la mediación no es una simple técnica para resolver conflictos, sino un proyecto de sociedad nueva que está contribuyendo a pasar de un orden antiguo, pensado como sometimiento del ciudadano a las decisiones superiores, a un orden innovador, útil en el tercer milenio, basado en la participación real y activa del individuo en la gestión de la vida cotidiana colectiva. La mediación es una bisagra fundamental para poder llevar a cabo un salto de cualidad en la gestión de conflictos. Sería oportuna una masiva campaña mediática que hiciera conocer a los ciudadanos la verdadera cara y potencialidad de la mediación.OBJECTIVE: the pacification ensured by law it is often inadequate and slow for the effective solution of the conflict. Mediation, as a new democratic form of "justice" in social conflicts, is a new project to save time, costs, the formality and rigidity of the ordinary proceedings and at the same time it can implement a psychological justice nearby individuals. METHOD: researches in the Courts, in mediation systems and comparison of national statistical surveys on mediation and on pending cases from 2012 to 2015. RESULTS: statistical surveys and researches put in evidence that mediation in Italy, since the entry into force (March 2011) of the Law 28/2010 to date, is increasingly used as a party-sharing system institution and no more as order imposed for conflict management improving, therefore, social relationships and reducing time and costs of criminal proceedings. From 2014 to 2015 the causes decreased by 9.5% and the percentage of mandatory mediation efforts compare to the total of the mediation processes, always in 2015, was equal to 81.6%. And yet, statistics show that, with the direct participation of the parties, increase the solution of the disputes. In fact, when the referred persons appear, and what it happens in 44.9% of cases, the positive outcome of mediations is about 43.5%. CONCLUSION: mediation is not a simple technique to resolve conflicts, but a project of a new society that is helping to pass from the ancient order as submission of the citizen to superior decisions towards an innovative order, to be used in the third millennium, based on real and active participation of the individual to the collective management of everyday life. Mediation is an unbreakable key to make a quantum leap in conflict management. It would be opportune massive media campaign to make citizens aware of the true face and the potential of mediation

The Potential Role of Aerosolized Phosphodiesterase 3 Inhibitor Enoximone in the Management of Coronavirus Disease 2019 Hypoxemia: A Case Report

Despite the various parenchymal presentation of coronavirus disease 2019 (COVID-19) pneumonia, the involvement of the vascular component, the reduction of perfusion in noninjured part of the lung and secondary right to left shunt play an important role in the genesis of the respiratory insufficiency. We present the case of a 72-year-old woman admitted to Livorno Hospital for severe respiratory insufficiency due to SARS-CoV-2 infection unresponsive to noninvasive in whom administration of nebulized phosphodiesterase 3 (PDE3) inhibitor enoximone was able to improve oxygenation avoiding tracheal intubation. Intravenous infusions of phosphodiesterase inhibitors are commonly used as pulmonary vasodilators in the management of pulmonary hypertension. This is the first case showing that inhaled route administration of PDE3 inhibitor enoximone could be important in the management of COVID-19 hypoxemia, to restore perfusion in noninjured part of the lung, improving oxygenation and avoiding risks of systemic infusion

Transesophageal echocardiography during MitraClip® procedure

The percutaneous mitral valve (MV) repair procedure performed with the MitraClip delivery system is increasingly used to treat severe mitral regurgitation in high-risk patients. The treatment involves percutaneous insertion and positioning of a clip between the MV leaflets. Transesophageal echocardiography (TEE) plays a key role in the procedure by providing information regarding clip navigation, clip alignment to the MV coaptation line, transmitral advancement of the system, leaflet grasping, confirmation of valve tissue catching, and assessment of the final result. Real-time 3-dimensional TEE has increasing value in percutaneous MV repair providing high-quality visualization of both the heart and the intravascular devices. Optimal visualization by 3-dimensional TEE is obtained through both the atrial and ventricular aspects. In contrast to MV surgery, where TEE is involved in the prebypass assessment phase and in evaluation of the final repair, TEE is mandatory to guide management during MitraClip repair. Cardiac anesthesiologists may provide assistance to interventional cardiologists during the procedure itself in addition to their anesthetic-related tasks

Life-threatening paradoxical thromboembolism in a patient with patent foramen ovale

Abstract Background Venous thromboembolism represents the third most frequent acute cardiovascular syndrome worldwide. Its clinical manifestations are deep vein thrombosis and/or pulmonary embolism. Despite a considerable mortality, diagnosis is often missed.  Case presentation We report the management of a female patient with high-risk pulmonary thromboembolism treated initially with thromboaspiration, complicated by embolus jailing in a patent foramen ovale. In this situation, left cardiac chambers and systemic circulation were jeopardized by this floating embolus. Conclusions High-risk pulmonary embolism requires reperfusion strategy but sometimes mechanical thromboaspiration may be not fully successful; transesophageal echocardiography led to a prompt diagnosis of this unexpected finding; in this very particular case, open surgery represented a bail-out procedure to avoid cerebral and systemic embolism