Abstract A fit-and-well 52-year-old worker, with negative familiar story, was admitted to Emergency Department (ED) with haemodynamically unstable but well bore broad complex tachycardia of 180 b.p.m. (Figure 1). Twenty years before the patient had heart-surgery to repair atrial septal venous sinus defect with patch. The defect determined anomalous pulmonary venous return in right atrium with left to right shunt and moderate pulmonary hypertension. The surgery, 20 years before, was complicated by a single event of supraventricular tachycardia pharmacology resolved. Next follow-up was normal although at transthoracic echocardiography severe right ventricular (RV) dilation was reported. In the ED the patient had palpitation but not chest pain or dyspnoea. General clinical examination was normal but he was hypertensive (170/137 mmHg) and with heart rate of 180 b.p.m. Valsalva manoeuver was performed and adenosine (6 mg–12 mg–12 mg) was administered without benefit. Eventually, the patient was cardioverted to sinus rhythm with a single 100 J shock. His baseline ECG (Figure 2) showed sinus rhythm, normal axis, as well as right bundle branch block and T-wave inversion in leads V1–V4 and a waves with a small spike upward in lead V1 which represent characteristic epsilon waves. Successively patient was admitted to Cardiology Department where transthoracic echocardiography showed severe RV dilation and moderate hypokinesia with a tricuspid annular plane excursion of 15 mm, TAV 9.6 cm/s, fractional area change of 29%. The right atrium was moderate dilated (volume 70 ml, indexed volume 35.53 ml/m2). Left chambers were normal. No shunts were observed. An electrophysiology study with isoprenaline infusion was performed but no arrhythmias were induced. Cardiac magnetic resonance imaging (MRI) was normal save for global RV dilatation, increased RV end diastolic volume (156 ml/m2), and global RV systolic dysfunction (reduction of RV ejection fraction 31%). Arrhythmogenic cardiomyopathy was excluded as patient’s background suggested RV dilation was due the overload caused by the history of left–right shunt. Blood tests and personal history negative initially exclude myocarditis and cardiac MRI confirmed the absence of oedema. An accurate ECG analysis excluded Brugada syndrome. Following discussion between electrophysiologists, clinical cardiologists, and the patient who first need to be informed, trans-venous ICD was implanted. 179 Figure 1ECG in ED. Figure 2 Baseline ECG. Figure 3 Cardiac MRI.
Abstract Alpha‐linolenic acid (ALA) is a long‐chain polyunsaturated essential fatty acid of the Ω3 series found mainly in vegetables, especially in the fatty part of oilseeds, dried fruit, berries, and legumes. It is very popular for its preventive use in several diseases: It seems to reduce the risk of the onset or decrease some phenomena related to inflammation, oxidative stress, and conditions of dysregulation of the immune response. Recent studies have confirmed these unhealthy situations also in patients with severe coronavirus disease 2019 (COVID‐19). Different findings (in vitro, in vivo, and clinical ones), summarized and analyzed in this review, have showed an important role of ALA in other various non‐COVID physiological and pathological situations against “cytokines storm,” chemokines secretion, oxidative stress, and dysregulation of immune cells that are also involved in the infection of the 2019 novel coronavirus. According to the effects of ALA against all the aforementioned situations (also present in patients with a severe clinical picture of severe acute respiratory syndrome‐(CoV‐2) infection), there may be the biologic plausibility of a prophylactic effect of this compound against COVID‐19 symptoms and fatality.
CONTEXT: The COVID-19 pandemic is probably the most challenging health crisis of the modern era as international health systems were not prepared to fight a virus whose capacity of spread is still being debated. The following are the two main challenges: the management of patients with acute infection of SARS-CoV-2, which needs more attention to have results in brief time, and the prevention of resultant neglect of patients who are not infected but need constant care for their chronic diseases. AIMS: To prevent the deaths from the "indirect effect" of the virus, the main aim was, with the help of telemedicine, to follow-up patients with high risk of poor outcome and to develop a protective system to reduce emergency department and hospitalizations access. The secondary aim was to develop an efficient telehealth model to be applied also after the COVID-19 pandemic. SETTINGS AND DESIGN: The study was voluntary and observational on patients enrolled between March and May 2020, during the first wave of the Italian pandemic. The project involved primary care and specialist physicians, nurses, informatics, and administrative services in the complex unity of primary care in Catanzaro Lido, Calabria Region. MATERIALS AND METHODS: Data such as blood pressure, heart rate, blood oxygenation, and glycemia were recorded using sphygmomanometer, oximeter, and glucometer and were communicated with a smartphone or a Bluetooth directly to a control room. The alerts were stratified according to the common emergency code: green for low risk, yellow for intermediate risk, red for high risk, and critic red for very high risk. RESULTS: Regarding patients with glycemic alerts, totally, 2135 were alert, 25% of them were at high risk, but only in 1 single case (0.04%), the intervention of 118 was necessary. The rest was resolved by telemedicine system with the help, when necessary, of first-level medical intervention. In 6.1% of cases, a specialist advice was required. Moreover, cardiovascular alerts were all resolved by the telemedicine system. CONCLUSIONS: The results obtained are preliminary but satisfying, a clear sign of how telemedicine could improve the management of disease chronicity but also of infectious disease.
Heart transplantation (HT) represents the mainstream therapy of end-stage heart failure for selected patients with a median survival of more than 10 years after surgery and substantial improvement in quality of life. Current guidelines suggest a variety of examinations including invasive (coronary angiography and endomyocardial biopsy (EBM) and non-invasive methods (echocardiography, stress echocardiography, computed tomography, PET and MRI) to monitor HT patients. Guidelines do not specify the timing of echocardiographic evaluations and do not recommend echocardiography as an alternative to serial EMB in rejection monitoring [2]. They still recommend as gold standard coronary angiography to be done 1 year after surgery and every 2 years after. In this review we will discuss the advantages of non-invasive techniques over the invasive ones for an adequate follow-up of HT patients.
In the evaluation of cardiomyopathies, cardiac computed tomography (CCT) is predominantly used for assessing congenital or acquired coronary artery diseases as a potential etiology underlying the observed myocardial abnormalities. However, its utility is expected to expand. We present a case of an asymptomatic patient with claustrophobia who sought medical attention due to frequent ventricular beats. The resting electrocardiogram revealed repolarization abnormalities characterized by flattened T-waves in the lateral leads and low QRS voltages in the peripheral leads, whereas transthoracic echocardiography was normal. CCT accurately identified hypodense areas indicative of fibrofatty infiltration within the inferolateral and anterior walls of the left ventricle. Furthermore, late iodine contrast-phase imaging revealed subepicardial late enhancement striae in the same regions. These imaging findings were pivotal in establishing a diagnosis of left-dominant arrhythmogenic cardiomyopathy. This clinical vignette underscores the potential of CCT in tissue characterization, particularly when cardiac magnetic resonance imaging is contraindicated or unavailable.
Heart transplantation (HT) is the established treatment for end-stage heart failure, significantly enhancing patients’ survival and quality of life. To ensure optimal outcomes, the routine monitoring of HT recipients is paramount. While existing guidelines offer guidance on a blend of invasive and non-invasive imaging techniques, certain aspects such as the timing of echocardiographic assessments and the role of echocardiography or cardiac magnetic resonance (CMR) as alternatives to serial endomyocardial biopsies (EMBs) for rejection monitoring are not specifically outlined in the guidelines. Furthermore, invasive coronary angiography (ICA) is still recommended as the gold-standard procedure, usually performed one year after surgery and every two years thereafter. This review focuses on recent advancements in non-invasive and contrast-saving imaging techniques that have been investigated for HT patients. The aim of the manuscript is to identify imaging modalities that may potentially replace or reduce the need for invasive procedures such as ICA and EMB, considering their respective advantages and disadvantages. We emphasize the transformative potential of non-invasive techniques in elevating patient care. Advanced echocardiography techniques, including strain imaging and tissue Doppler imaging, offer enhanced insights into cardiac function, while CMR, through its multi-parametric mapping techniques, such as T1 and T2 mapping, allows for the non-invasive assessment of inflammation and tissue characterization. Cardiac computed tomography (CCT), particularly with its ability to evaluate coronary artery disease and assess graft vasculopathy, emerges as an integral tool in the follow-up of HT patients. Recent studies have highlighted the potential of nuclear myocardial perfusion imaging, including myocardial blood flow quantification, as a non-invasive method for diagnosing and prognosticating CAV. These advanced imaging approaches hold promise in mitigating the need for invasive procedures like ICA and EMB when evaluating the benefits and limitations of each modality.
Around 25%-40% of ischemic strokes are cryptogenic, with no identifiable cause despite thorough evaluation. The mechanisms behind cryptogenic strokes are often embolic, frequently originating from occult cardiac sources. An unroofed coronary sinus (UCS), a rare congenital anomaly, involves a partial or complete absence of the coronary sinus roof, leading to a connection between the left atrium and the coronary sinus. This defect can be asymptomatic or present with symptoms such as paradoxical embolism due to shunting. We present the case of a 70-year-old male with prolonged chest pain and a history of neurological symptoms, who was later diagnosed with a UCS (types III and IV) through cardiac computed tomography (CCT). A cardiac bubble test confirmed a right-to-left shunt, which was not detected on transthoracic echocardiography. This case underscores the importance of considering advanced imaging techniques such as CCT in the diagnosis of cryptogenic stroke, as echocardiography may miss defects due to poor visualization of posterior cardiac structures.
After almost a year in the COVID-19 era, nothing has been done to assess facial masks currently available for professionals and for the general public, to improve the efficacy of the masks or to promote their correct use. Yet, it is paramount to produce and use masks able to guarantee the absolute virus isolation or, at least, to limit the effect of the pandemic, and to have masks with lower efficiency but able to reduce the contagion nevertheless. In addition, national and international health institutions failed to deliver rational guidelines able to assess the effectiveness of facial mask in reducing the spreading of the virus and guidance on the correct use of facial masks both for healthcare workers and for the people. Facial masks available in the market in most cases are simply not appropriate because they are intended for other purposes. Some parameters aimed to assess and define facial masks, in fact, as the Bacterial Filtration efficiency (BFE) or the Particle Filtration Efficiency (PFE), are not suitable to define prevention devices for general population during viral pandemics: devices projected according to these factors are aimed to preserve patients during surgery operations or to protect workers from air pollutants. Thus, masks designed for the containment of a pandemic (facial masks intended for public health purposes) and for the prevention of the infection (facial masks intended as personal protective equipment) must have specific characteristics. Failing to deliver such features or the inadequate use of those masks that are already available can result in harm for both individuals and the population. The aim of this chapter, then, is to rationally analyze, according to a scientific approach, the antiviral mask issue.
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