Several studies reported a high incidence of pulmonary embolism (PE) among patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, but detailed data about clinical ...characteristics, risk factors of these patients and prognostic role of PE are still lacking. We aim to evaluate the occurrence of pulmonary embolism among patients with SARS-CoV-2 infection, and to describe their risk factors, clinical characteristics, and in-hospital clinical outcomes.
This is a multicenter Italian study including 333 consecutive SARS-CoV-2 patients admitted to seven hospitals from February 22 to May 15, 2020. All the patients underwent computed tomography pulmonary angiography (CTPA) for PE detection. In particular, CTPA was performed in case of inadequate response to high-flow oxygen therapy (Fi02≥0.4 to maintain Sp02≥92%), elevated D-dimer (>0.5μg/mL), or echocardiographic signs of right ventricular dysfunction. Clinical, laboratory and radiological data were also analyzed.
Among 333 patients with laboratory confirmed SARS-CoV-2 pneumonia and undergoing CTPA, PE was detected in 109 (33%) cases. At CTPA, subsegmental, segmental, lobar and central thrombi were detected in 31 (29%), 50 (46%), 20 (18%) and 8 (7%) cases, respectively. In-hospital death occurred in 29 (27%) patients in the PE-group and in 47 (21%) patients in the non-PE group (p = 0.25). Patients in PE-group had a low rate of traditional risk factors and deep vein thrombosis was detected in 29% of patients undergoing compression ultrasonography. In 71% of cases with documented PE, the thrombotic lesions were located in the correspondence of parenchymal consolidation areas.
Despite a low rate of risk factors for venous thromboembolism, PE is present in about 1 out 3 patients with SARS-CoV-2 pneumonia undergoing CTPA for inadequate response to oxygen therapy, elevated D-dimer level, or echocardiographic signs of right ventricular dysfunction. In most of the cases, the thromboses were located distally in the pulmonary tree and were mainly confined within pneumonia areas.
Hypertension is associated with more severe disease and adverse outcomes in COVID-19 patients. Recent investigations have indicated that hypertension might be an independent predictor of outcomes in ...COVID-19 patients regardless of other cardiovascular and noncardiovascular comorbidities. We explored the significance of coronary calcifications in 694 hypertensive patients in the Score-COVID registry, an Italian multicenter study conducted during the first pandemic wave in the Western world (March-April 2020). A total of 1565 patients admitted with RNA-PCR-positive nasopharyngeal swabs and chest computed tomography (CT) at hospital admission were included in the study. Clinical outcomes and cardiovascular calcifications were analyzed independently by a research core lab. Hypertensive patients had a different risk profile than nonhypertensive patients, with more cardiovascular comorbidities. The deceased hypertensive patients had a greater coronary calcification burden at the level of the anterior descending coronary artery. Hypertension status and the severity cutoffs of coronary calcifications were used to stratify the clinical outcomes. For every 100-mm
increase in coronary calcium volume, hospital mortality in hypertensive patients increased by 8%, regardless of sex, age, diabetes, creatinine, and lung interstitial involvement. The coronary calcium score contributes to stratifying the risk of complications in COVID-19 patients. Cardiovascular calcifications appear to be a promising imaging marker for providing pathophysiological insight into cardiovascular risk factors and COVID-19 outcomes.
Since December 2019, the dramatic escalation in coronavirus (COVID-19) cases worldwide has had a significant impact on health care systems. Family physicians (FPs) have played a critical role in the ...coordination of care.
In April 2020, we performed an online prospective survey to assess the impact of the pandemic on FPs' practices.
Three hundred FPs were included. Mean age was 53.6 ± 13.5 years. Before the pandemic, 60.2% reported >75 outpatient visits/week, which reduced down to an average of <20/week for 79.8% of FPs; 24.2% of FPs discontinued home visits, while for 94.7% of FPs there was a >50% increase in the number of telephone consultations. Concern related to the risk of contagion was elevated (≥3/5 in 74.6%) and even higher to the risk of infecting relatives and patients (≥3/5 in 93.3%). The majority of FPs (87%) supported the role of telemedicine in the near future. Satisfaction regarding the network with hospitals/COVID-19-dedicated wards received a score ≤2/5 in 46.9% of cases.
The COVID-19 pandemic has had a significant impact on the working practices of FPs. A collaboration is needed with well-established networks between FPs and referral centers to provide new insights and opportunities to inform future working practices.
Stent implantation represents the standard of care in coronary intervention. While a short stent implanted on a focal lesion located on the left anterior descending artery (LAD) seems a reasonable ...alternative to an internal mammary implant, the same for long stents is still debated.
We reported the long-term data of 531 consecutive patients who underwent Percutaneous Coronary Intervention (PCI) with long stents in two highly specialized centres. The main inclusion criteria were the implantation of stents longer than 30 mm on the LAD and a minimum follow-up (FU) of five years. The primary endpoint was mortality, and the secondary endpoints were any myocardial infarction (MI), target vessel and lesion revascularization (TVR and TLR, respectively), and stent thrombosis (ST) observed as definite, probable, or possible.
In this selected population with characteristics of complex PCI (99.1%), the long-term follow-up (mean 92.18 ± 35.5 months) estimates of all-cause death, cardiovascular death, and any myocardial infarction were 18.3%, 10.5%, and 9.3%, respectively. Both all-cause and cardiovascular deaths are significantly associated with three-vessel disease (HR 6.8; confidence of interval (CI) 95% 3.844-11.934;
< 0.001, and HR 4.7; CI 95% 2.265-9.835;
< 0.001, respectively). Target lesion (TLR) and target vessel revascularization (TVR) are associated with the presence of three-lesion disease on the LAD (HR 3.4; CI 95% 1.984-5.781;
< 0.001; HR 3.9 CI 95% 2.323-6.442;
< 0.001, respectively). Re-PCI for any cause occurred in 31.5% of patients and shows an increased risk for three-lesion stenting (HR 4.3; CI 95% 2.873-6.376;
< 0.001) and the treatment of bifurcation with two stents (HR 1.6; 95% CI 1.051-2.414;
= 0.028). Stent thrombosis rate at the 5-year FU was 4.4% (1.3% definite; 0.9% probable; 2.1% possible), including a 1.7% rate of very-late thrombosis. The stent length superior to 40 mm was not associated with poor outcomes (all-cause death
= 0.349; cardiovascular death
= 0.855; MI
= 0.691; re-PCI
= 0.234; TLR
= 0.805; TVR
= 0.087; ST
= 0.189).
At an FU of longer than five years, patients treated with stents longer than 30 mm in their LAD showed acceptable procedural results but poor outcomes.
The rates of in-hospital mortality following percutaneous interventional procedures (PIP) during the COVID-19 pandemic period compared to the non-pandemic period has not been reported so far.
We ...retrospectively enrolled all consecutive patients admitted for PIP across five centers from February 2020 to May 2020.
A total of 4092 PIP were performed during the reference periods. The total number of procedures dropped from 2380 to 1712 (28.0% reduction). Overall in-hospital mortality increased from 1.1% in 2019, to 2.6% in 2020 (63% relative increase).
During the COVID-19 pandemic, in-hospital all-cause mortality significantly increased in patients admitted for cardiological PIP.
Aims. Several studies have unveiled the great heterogeneity of COVID-19 pneumonia. Identification of the “vascular phenotype” (involving both pulmonary parenchyma and its circulation) has prognostic ...significance. Our aim was to explore the combined role of chest computed tomography (CT) scan and electrocardiogram (ECG) at hospital admission in predicting short-term prognosis and to draw pathophysiological insights. Methods and Results. We analyzed the chest CT scan and ECG performed at admission in 151 consecutive COVID-19 patients admitted between 20 March and 4 April 2020. All-cause mortality within 30 days was the primary endpoint. Median age was 71 years (IQR: 62–76). Severe pneumonia was present in 25 (17%) patients, and 121 (80%) had abnormal ECG. During a median follow-up of 7 days (IQR: 4–13), 54 (36%) patients died. Deceased patients had more severe pneumonia than survivors did (80% vs. 64%, p = 0.044). ECG in deceased patients showed more frequently atrial fibrillation/flutter (17% vs. 6%, p = 0.039) and acute right ventricular (RV) strain (35% vs. 10%, p < 0.001), suggesting the “vascular phenotype”. ECG signs of acute RV strain (HR 2.46, 95% CIs 1.36–4.45, p = 0.0028) were independently associated with all-cause mortality in multivariable analysis, and in the likelihood ratio test, showed incremental prognostic value over chest CT scan, age, and C-reactive protein. Conclusions. Combining chest CT scan and ECG data improves risk stratification in COVID-19 pneumonia by identifying a distinctive phenotype with both parenchymal and vascular damage of the lung. Patients with severe pneumonia at chest CT scan plus ECG signs of acute RV strain have an extremely poor short-term prognosis.
Background
Coronary access after transcatheter aortic valve implantation (TAVI) with supra-annular self-expandable valves may be challenging or un-feasible. There is little data concerning coronary ...access following transcatheter aortic valve-in-valve implantation (ViV-TAVI) for degenerated surgical bioprosthesis.
Aims
To evaluate the feasibility and challenge of coronary access after ViV-TAVI with the supra-annular self-expandable ACURATE neo valve.
Materials and methods
Sixteen patients underwent ViV-TAVI with the ACURATE neo valve. Post-procedural computed tomography (CT) was used to create 3D-printed life-sized patient-specific models for bench-testing of coronary cannulation. Primary endpoint was feasibility of diagnostic angiography and PCI. Secondary endpoints included incidence of challenging cannulation for both diagnostic catheters (DC) and guiding catheters (GC). The association between challenging cannulations with aortic and transcatheter/surgical valve geometry was evaluated using pre and post-procedural CT scans.
Results
Diagnostic angiography and PCI were feasible for 97 and 95% of models respectively. All non-feasible procedures occurred in ostia that underwent prophylactic “chimney” stenting. DC cannulation was challenging in 17% of models and was associated with a narrower SoV width (30 vs. 35 mm,
p
< 0.01), STJ width (28 vs. 32 mm,
p
< 0.05) and shorter STJ height (15 vs. 17 mm,
p
< 0.05). GC cannulation was challenging in 23% of models and was associated with narrower STJ width (28 vs. 32 mm,
p
< 0.05), smaller transcatheter-to-coronary distance (5 vs. 9.2 mm,
p
< 0.05) and a worse coronary-commissural overlap angle (14.3° vs. 25.6
o
,
p
< 0.01). Advanced techniques to achieve GC cannulation were required in 22/64 (34%) of cases.
Conclusion
In this exploratory bench analysis, diagnostic angiography and PCI was feasible in almost all cases following ViV-TAVI with the ACURATE neo valve. Prophylactic coronary stenting, higher implantation, narrower aortic sinus dimensions and commissural misalignment were associated with an increased challenge of coronary cannulation.
Concomitant severe mitral-tricuspid regurgitation is observed in up to 30% of patients with reduced left ventricular ejection fraction. In symptomatic subjects at high surgical risk, transcatheter ...treatment is a viable option in the presence of suitable anatomy. We present a case of mitral regurgitation worsening after TriClip (Abbott, Abbott Park, IL) implantation in a patient with a previous successful MitraClip (Abbott) intervention. The correction of tricuspid regurgitation by catheter repair improves overall hemodynamics, but it can sometimes paradoxically worsen mitral regurgitation, as herein displayed. Clinical care is needed to detect tricuspid regurgitation repair-induced worsening of mitral regurgitation and ensure optimal management.
Une insuffisance mitrale/tricuspidienne sévère concomitante est observée chez jusqu’à 30 % des patients présentant une fraction d’éjection ventriculaire gauche réduite. Chez les sujets symptomatiques à risque chirurgical élevé, le traitement transcathéter est une option viable en présence d’une anatomie adaptée. Nous présentons un cas d’aggravation de l'insuffisance mitrale survenu après l’implantation du dispositif TriClip (Abbott, Abbott Park, IL) chez un patient ayant déjà bénéficié d’une intervention MitraClip (Abbott) réussie. La correction de l'insuffisance tricuspidienne par réparation par cathéter améliore l’hémodynamique globale, mais elle peut parfois paradoxalement aggraver l'insuffisance mitrale, comme dans le cas présenté ici. Le clinicien doit faire preuve de vigilance pour détecter l’aggravation de l'insuffisance mitrale induite par la réparation de la valve tricuspide régurgitante et assurer une prise en charge optimale.
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