Sicurezza ed efficacia dell'approccio transgiugulare per l'estrazione transvenosa di elettrocateteri da defibrillazione.

Nella presente tesi si riporta l’esperienza dell’Aritmologia Pisana su 15 anni di estrazione transvenosa di elettrocateteri mediante tecnica di dilatazione meccanica con multipli approcci venosi. E’ stata valutata fattibilità, efficacia e sicurezza di questa tecnica di estrazione in presenza di elettrocateteri da defibrillazione, investigando inoltre la potenziale associazione tra caretteristiche cliniche e del catetere nel determinare la complessità della procedura. Metodi e risultati La tecnica consiste in un primo tentativo di trazione manuale, seguito da dilatazione meccanica dal sito venoso di impianto e se necessario il successivo utilizzo dell'approccio transgiugulare. Lo studio di coorte comprende 545 pazienti consecutivi, portatori di ICD, sottoposti a procedura di estrazione transvenosa di elettrocateteri da defibrillazione presso il nostro istituto dal gennaio 1997 al Dicembre 2012. La semplice trazione manuale è risultata efficace nella rimozione di elettrocateteri nel 6% dei pazienti, la dilatazione meccanica eseguita attraverso il sito venoso di accesso ha aumentato la percentuale di successo al 89% fino ad arrivare ad una percentuale pari al 99% quando è stato utilizzato l’approccio transgiugulare. Non sono state osservate complicanze maggiori. L’età del catetere, la fissazione passiva e la presenza di doppio coil risultano essere fattori indipendenti che predicono una procedura di estrazione più impegnativa e la necessità di utilizzo di dilatazione meccanica delle aderenze. Tuttavia solo il tempo intercorso dall'impianto del catetere è risultato essere associato alla necessità dell’utilizzo dell’approccio transgiugulare. In particolar modo un periodo maggiore di 20 mesi prediceva la necessità dell’utilizzo di dilazione meccanica dal sito venoso di accesso, mentre un periodo maggiore di 55 mesi prediceva la necessità di virare verso l’approccio transgiugulare. Conclusioni: L’estrazione transvenosa meccanica di elettrocateteri da defibrillazione è una procedura complessa ma sicura ed efficace. La fissazione passiva e la presenza di doppio coil predicono una procedura di estrazione più impegnativa; il tempo intercorso dall'impianto del catetere è l’unico fattore indipendente predittore di necessità di dilatazione meccanica e di successivo passaggio ad approccio transgiugulare. Tali osservazioni dovrebbero essere considerate ogni qual volta si pianifichi una procedura di estrazione

CMB-S4 Science Book, First Edition

This book lays out the scientific goals to be addressed by the next-generation ground-based cosmic microwave background experiment, CMB-S4, envisioned to consist of dedicated telescopes at the South Pole, the high Chilean Atacama plateau and possibly a northern hemisphere site, all equipped with new superconducting cameras. CMB-S4 will dramatically advance cosmological studies by crossing critical thresholds in the search for the B-mode polarization signature of primordial gravitational waves, in the determination of the number and masses of the neutrinos, in the search for evidence of new light relics, in constraining the nature of dark energy, and in testing general relativity on large scales

CMB-S4 Science Book, First Edition

This book lays out the scientific goals to be addressed by the next-generation ground-based cosmic microwave background experiment, CMB-S4, envisioned to consist of dedicated telescopes at the South Pole, the high Chilean Atacama plateau and possibly a northern hemisphere site, all equipped with new superconducting cameras. CMB-S4 will dramatically advance cosmological studies by crossing critical thresholds in the search for the B-mode polarization signature of primordial gravitational waves, in the determination of the number and masses of the neutrinos, in the search for evidence of new light relics, in constraining the nature of dark energy, and in testing general relativity on large scales

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Segment-Specific Susceptibility of Carotid Artery to Atherosclerotic Risk Factors: a Study by Ultrasound Integrated Backscatter Analysis in Patients With Intermediate Carotid Stenoses

Background: integrated backscatter analysis (IBS) of the reflected ultrasound signal represents a validated tool for tissue characterization of carotid plaque. However, little is known about the association between the acoustic properties of plaque-free carotid wall and plaque. Aim: to compare the IBS of the intima-media layer (IM) of common carotid artery (CCA), widely used as index of preclinical atherosclerosis, with that of the carotid plaques, and to evaluate their association with cardiovascular (risk factors in patients with multiple carotid plaques in different arterial segments. Methods: thirty-eight high-risk patients were studied (25 males, mean age 69±11, all dyslipidemic under statins, 81 treated hypertensives, 21 type 2 diabetics, 39 with clinical CAD, no current smokers) with 87 plaques (stenoses....

Prognostic value of cardiac power output to left ventricular mass in patients with left ventricular dysfunction and dobutamine stress echo negative by wall motion criteria

Cardiac power output to left ventricular mass (power/mass) is an index of myocardial efficiency reflecting the rate at which cardiac work is delivered with respect to the potential energy stored in the left ventricular mass. In the present study, we sought to investigate the capability of power/mass assessed at peak of dobutamine stress echocardiography to predict mortality in patients with ischaemic cardiomyopathy and no inducible ischaemia

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