La fibrilación auricular es la arritmia cardiaca más frecuente, con una morbilidad significativa asociada a los síntomas, insuficiencia cardiaca y tromboembolia, que tienen relación con exceso de mortalidad. Durante los últimos 10 años, muchos centros de todo el mundo han descrito unas tasas elevadas de éxitos y pocas complicaciones tras una única intervención de ablación en pacientes con fibrilación auricular paroxística. Estudios recientes indican superioridad a corto y a largo plazo de la ablación percutánea respecto al tratamiento convencional con medicación antiarrítmica, en cuanto a recurrencia de la arritmia, calidad de vida y progresión de la arritmia. En consecuencia, la ablación percutánea se está convirtiendo en un tratamiento de primera línea para muchos pacientes con fibrilación auricular. Sin embargo, en los pacientes con fibrilación auricular persistente de larga evolución, la ablación percutánea es más compleja y laboriosa, y con frecuencia requiere intervenciones repetidas para alcanzar unas tasas de éxito igual de altas que en la fibrilación auricular paroxística. Sin embargo, en un futuro próximo, con más experiencia y el perfeccionamiento de la tecnología, la ablación percutánea de la fibrilación auricular podrá extenderse también a los pacientes con una fibrilación auricular de larga evolución.
BACKGROUND:Beta-blockers have provided evidence of improving survival in chronic heart failure patients. Specifically, the Cardiac Insufficiency Bisoprolol Study II has shown a significant reduction in mortality and morbidity among patients with moderate to severe chronic heart failure treated with bisoprolol. Our aim was to investigate the economic consequence of bisoprolol therapy in chronic heart failure patients in Italy.METHODS:Data were derived from the Cardiac Insufficiency Bisoprolol Study II trial. We conducted a cost-effectiveness analysis, comparing standard care with bisoprolol vs standard care with placebo in the perspective of the Italian National Health Service. We identified and quantified medical costs: drug costs according to the Italian National Therapeutic Formulary; specialist visits for initiation and up-titration of bisoprolol therapy and hospitalizations were quantified based on the Italian National Health Service tariffs (2005). Effects were measured in terms of mortality and morbidity reduction (number of deaths, life-years gained and frequency of hospitalizations). We considered an observational period of 1.3 years, i.e. the average follow-up recorded in the trial. Discounting was not performed because of the relatively short follow-up of patients. We conducted one- and multiway sensitivity analyses on unit cost and effectiveness. We also conducted a threshold analysis.RESULTS:The overall cost of care per 1000 patients treated for 1.3 years was estimated in Euro 2,075,548 in the bisoprolol group and in Euro 2,396,265 in the placebo group, resulting in a net saving of Euro 320,718. The number of additional patients alive with bisoprolol was 55 per 1000 patients, the number of lifeyears gained was 36 at 1.3 year.CONCLUSIONS:Bisoprolol therapy is dominant since it is both less costly and more effective than standard care. Results of sensitivity analysis showed that bisoprolol therapy remains dominant even to changes in unit cost of drug and hospitalizations.
UNLABELLED:BACKGROUND; Heart failure (HF) represents an important health issue in western countries, especially for the elderly, frail population. A number of HF patients must usually be assisted at home. No information is available about the usual care of HF patients in Italy. The aim of this study was to describe the characteristics of HF patients receiving homecare in the Italian general practice.METHODS:A questionnaire was sent to 320 general practitioners (GPs) involved in the Health Search project. Among these, 148 (46.2%) answered and 376 home-ridden HF patients (60.3% women, median age 85 years) were identified.RESULTS:257 (57%) patients were in NYHA class III or IV. Multiple relevant concomitant diseases occurred in 326 (86.7%) subjects. Only 140 (37.2%) patients were able to take their pills without any help; caregivers, mainly family members, were required 24 hours a day in 78.7% of cases. The length of homecare was > 1 year in 84.5% of cases.CONCLUSIONS:According to our data, thousands of HF patients are usually assisted at home for long periods in Italy. This is a very old group of subjects with heavy co-morbidity and a high need for continuous, prolonged assistance. Studies specifically aimed at the care of HF patients are needed.
The numerous controlled clinical trials performed recently in pulmonary arterial hypertension (PAH) can allow us to abandon a clinical-based treatment strategy and adopt an evidence-based therapy. The treatment algorithm is restricted to patients in NYHA class III or IV. The different treatments have been evaluated mainly in sporadic, idiopathic PAH and in PAH associated with scleroderma or to anorexigen use. Extrapolation of these recommendations to other PAH subgroups should be done with caution. High doses of calcium channel blockers are indicated only in the minority of patients who are responders to acute vasoreactivity testing. Patients in NYHA class III should be considered candidates for treatment with either an endothelin receptor antagonist, a prostanoid or a type 5 phosphodiesterase inhibitor. Continuous intravenous administration of epoprostenol is proposed as rescue treatment in NYHA class IV patients. Combination therapy can be attempted in selected cases. Balloon atrial septostomy and/or lung transplantation are indicated for refractory patients or when medical treatments are unavailable.
BACKGROUND:Large-scale utilization of drug-eluting stents (DES) presents significant economic limitations, related to the current high cost of the device and the absence of adequate reimbursement from the health care system. The aim of the study was to evaluate the cost of single-vessel and multivessel drug-eluting stenting and to compare it with the DRG funding level.METHODS:Between November 2003 and May 2004, we studied 100 consecutive patients who underwent a percutaneous coronary intervention (PCI) with DES, 50 single-vessel and 50 multivessel procedures, in order to evaluate the real procedure costs of DES. The cost fields calculated in the analysis included: costs for the materials and drugs used in each procedure, costs related to medical personnel and staff, costs for equipment depreciations, and costs for total hospitalization based on the length of stay in the coronary care unit and/or in the cardiology ward.RESULTS:With regard to the 50 patients with single-vessel disease, 63 lesions were treated with 58 DES. With regard to the 50 patients with multivessel disease, the average number of treated vessels was 2.3 and of lesions 2.8. An average of 2.7 DES per patient was implanted; glycoprotein Ilb/IIIa inhibitors were used in 70% of cases. The multivessel procedure necessitated an average of 1.62 guide catheters, 1.86 guides, 1.36 balloons, and 475 +/- 124 ml of contrast medium; the average endoscopy time was 16 +/- 8 min while the total procedural time was 106 +/- 37 min. The procedural success rate was 100% for both groups. The post-PCI hospital stay was 2.1 +/- 1.7 days for patients with single-vessel disease and 2.8 +/- 2.6 days for patients with multivessel disease; the total was 4.7 +/- 2.8 and 6 +/- 3.2 days respectively. The mean total cost of hospital stay for PCI and DES was 6390 +/- 2274 Euro for single-vessel PCI and 9828 +/- 3026 Euro for multivessel PCI, split as follows: materials 2915 +/- 963 Euro and 5294 +/- 1177 Euro, procedural costs 404 +/- 55 and 446 +/- 99 Euro, costs of hospital stay 3070 +/- 2024 Euro and 4089 +/- 2517 Euro respectively for single-vessel and multivessel PCI.CONCLUSIONS:The mean total cost of a single-vessel PCI with DES falls within the DRG 112 reimbursement level for coronary angioplasty of 7006 Euro, while that of multivessel PCI with multiple DES is about 40% above the same reimbursement level. Interestingly, the multivessel PCI cost with multiple DES does fall within the reimbursement amount related to DRG 107 for bypass surgery procedures (14,322 Euro).
The diagnosis of pulmonary embolism may be confounded by a clinical presentation that is often subtle or atypical. Therefore pulmonary angiography, although invasive, has been widely used to prove pulmonary embolism. The aim of this review is to discuss the value of non-invasive techniques, such as lung scan and chest computed tomography scan, in the diagnosis of pulmonary embolism. Ventilation-perfusion scan has demonstrated a very high specificity (97%) but a quite low sensitivity (41%) in the diagnosis of pulmonary embolism, while perfusion lung scan not associated with ventilation scan has shown a specificity of 92% and a considerably high sensitivity (87%). The chest computed tomography scan has not yet shown a definite degree of specificity and sensitivity in the diagnosis of pulmonary embolism, although we suppose that this technique will become widely used. However, we emphasize that the diagnosis of pulmonary embolism is not a mere technical problem.
Tako-tsubo cardiomyopathy is a recently described disease characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes. The disease takes its name from the typical left apical ballooning observed at left ventriculogram. Tako-tsubo cardiomyopathy was first described by Sato in 1990. Since then sporadic cases were reported by Japanese authors, and only a few European publications are available. We describe 2 cases of patients affected by this syndrome.
We report the case of a 73-year-old man with a history of previous aortic valve replacement in 1990 and rupture of an aortic dissection into the right atrium. The patient was admitted to the emergency room because of chest pain, stopped not long after. The electrocardiogram did not show any signs of ischemia and myocardial enzymes were not increased. Transthoracic echocardiography revealed aortic root dilation (maximum diameter 60 mm) extended to the aortic arch, and the presence of a flow from the ascending aorta to the right atrium (evocative of a fistula between the two chambers). The aortic valvular prosthesis function was good. Transesophageal echocardiography confirmed an aorta-right atrium fistula. Cardiac catheterization did not show any luminal obstructions in the coronary arteries; there was a small shunt from the aorta to the right atrium. The ascending aorta and the aortic root were replaced with a Dacron graft. Right and left sinuses were reimplanted to the graft. The fistula was repaired with 4-0 pledgeted Prolene sutures. The surgeon's diagnosis was "type A aortic dissection in a patient with an ascending aorta aneurysm and an old ascending aorta-right atrium fistula".
BACKGROUND:On May 2003 the Emilia-Romagna Regional Commission for Cardiology and Cardiac Surgery launched a project aimed at improving health service ability to adopt interventions of well-known effectiveness for the treatment of patients with acute myocardial infarction. One of the main goals was to stimulate the clinical and organizational responsibilities operating at the local level, in order to improve the frequency of use of primary percutaneous coronary intervention.METHODS:In assessing the overall impact of this regional project, an interrupted time series regression analysis was conducted, relying on information drawn from the regional hospital discharge database. Overall, 18 957 patients admitted for acute myocardial infarction during the period January 2001-June 2004 were considered.RESULTS:One year after the inception of the regional project, the estimate of its effect documented a statistically significant increase in the frequency of use of percutaneous coronary angioplasty (5.8%, 95% confidence interval 4.6%-6.9%), paralleled by an increase (3.2%, 95% confidence interval 1.14%-5.0%) in the number of those directly admitted to centers with interventional cardiology facilities. No effect was observed as for the proportion of patients admitted to highly specialized departments.CONCLUSIONS:Despite the obvious limitations due both to source of information and study design, our findings document that the regional project had indeed some tangible impact, although variable across the different geographic areas of the region, on key aspects of the patterns of care of patients with acute myocardial infarction.
BACKGROUND:The aim of this study was to assess the impact of gender on procedural and late clinical outcome in a large cohort of consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in a single center.METHODS:The study included a cohort of 542 consecutive diabetic patients (414 men, 128 women), undergoing PCI for stable and unstable angina. Clinical events were assessed every 6 months for a mean follow-up period of 24 months.RESULTS:Compared to men, women were older and less often smokers. Insulin requirement was present in a substantially higher percentage of women than men (27 vs 18%, p = 0.03). Presentation with stable angina was more frequent in women, whereas silent ischemia was more prevalent in men. Adverse baseline clinical and angiographic characteristics in women (smaller vessels and longer lesion lengths) were associated with a more frequent need for multiple coronary stenting (23 vs 15% women vs men, p < 0.001) and a higher incidence of peripheral complications (3.2 vs 1.2%, p = 0.049). However, there were no statistically significant gender-related differences in major in-hospital events. Long-term clinical outcome was similar with equivalent incidence of death (4.9 vs 5.3%, p = 0.8), nonfatal myocardial infarction (2.4 vs 4.5%, p = 0.1), need for surgical or repeat percutaneous revascularization between women and men.CONCLUSIONS:Diabetic patients show an increased rate of major adverse cardiac events and target vessel revascularization after PCI. In these patients, female gender is associated with higher procedural complexity and peripheral complications; however, long-term clinical outcome of diabetic women is similar to that of men.
BACKGROUND:Composite arterial grafts are presently being used ever more frequently in coronary bypass surgery. We assessed the composite radial artery and in situ left internal thoracic artery Y-graft by means of transthoracic echo-Doppler and myocardial perfusion scintigraphy (MPS).METHODS:In 53 patients who underwent complete myocardial revascularization using only this composite arterial graft, good transthoracic echographic images and pulsed Doppler signals of the Y-graft main stem were obtained at rest and early after standard exercise; the echographic parameters were measured. Stress/rest MPS was the gold standard for residual myocardial ischemia. The patients with negative MPS were divided into groups according to the number of coronary vessels grafted and their history of preoperative myocardial infarction.RESULTS:The diastolic-to-systolic ratio of the peak velocities and velocity-time integrals both at rest and after stress, and the stress-to-rest ratio of the diastolic peak velocities and diastolic velocity-time integrals in the negative MPS patients were significantly greater than in the 6 positive MPS patients. However, the restricted number of positive MPS cases limits the power of this statistical analysis. The stress-to-rest ratio of the diastolic velocity-time integrals in the patients with three grafted coronary vessels (median 2.3) and in those without preoperative myocardial infarction (median 2.1) were respectively greater than in the patients with two vessels grafted (median 1.7, p < 0.0001) and those with preoperative myocardial infarction (median 1.8, p = 0.0048).CONCLUSIONS:Dynamic assessment with transthoracic echo-Doppler of a composite arterial graft including the in situ left internal thoracic artery correlates with MPS. In patients with negative MPS, transthoracic echo-Doppler correlates with the myocardial demand.
In this report we present the case of a double aneurysm, which developed 1 week after pericardiocentesis because of cardiac perforation following aortic valvuloplasty in a newborn. The patient underwent successful surgical treatment through normothermic cardiopulmonary bypass with external plication of double aneurysm.
The original aim of atherectomy was to reduce restenosis by means of aggressive plaque debulking, and the failure of large randomized trials to show any advantage of atherectomy over balloon angioplasty restricted its wider application. However, single-center registries in which aggressive debulking was performed by experienced operators have reported favorable results in terms of reduced restenosis and improved clinical outcomes when atherectomy was performed before stenting. Plaque debulking reduces the potential for plaque shift and facilitates subsequent high-pressure stent expansion, smoothes the internal vessel surface, scaffolds intimal flaps, and prevents elastic recoil. It has also been demonstrated that atherectomy can play a role in the treatment of complex lesions (ostial left anterior descending coronary artery lesions, left main lesions, and bifurcations), in which plaque shift may compromise the result of the procedure. New-generation devices have shown that atherectomy can be safely and effectively used to treat even relatively small vessels. In the current era of drug-eluting stents characterized by a considerable reduction in restenosis rates, optimal stent geometry and final luminal diameter are still important predictors of restenosis. Given the possible role of plaque shifting at the edges of a stent in causing restenosis, debulking could be added to the local drug effect in complex lesions.
BACKGROUND:Primary percutaneous coronary intervention (pPCI) is the most effective reperfusion treatment of acute ST-segment elevation myocardial infarction (STEMI), but logistic- and organization-related problems affect its feasibility. The aim of this study was to investigate a) the requirements of reperfusion therapies, and b) the feasibility of pPCI as suggested by the current guidelines, in the Veneto Region.METHODS:With the aim to treat with pPCI most of the patients with high-risk STEMI regardless of the type of admitting hospital, a single treatment protocol was developed and shared by the majority of Cardiology Departments in the Veneto Region. Data of all consecutive patients with STEMI were prospectively recorded and subsequently and independently compared with administrative data.RESULTS:In 28 participating hospitals, 1160 consecutive patients with STEMI were enrolled during a 6-month period: in 999 symptom onset was < 12 hours. Based on the registry data, it is possible to estimate that 697 patients/million of inhabitants/year are admitted in Cardiology Departments with the initial diagnosis of STEMI: 86% are admitted < 12 hours from symptom onset and 58% of them have at least one characteristic of high risk. The strategy of immediate coronary angiography and possible PCI was carried out in 52.3% of eligible patients: in 55.8 and 47.5% of high- and low-risk STEMI and from 17.1 to 75.1% based on the type of admitting hospital. Recanalization with pPCI was obtained < 90 min from the diagnosis in 70 and 32% of patients treated on site and transferred, respectively.CONCLUSIONS:The absolute number of patients with STEMI eligible for reperfusion therapies is lower than previously reported. The reperfusion strategy based on pPCI was much more related to the type of admitting hospital than to the clinical characteristics of the patients. pPCI performed as suggested by the current guidelines is feasible in patients admitted in hospitals with interventional facilities available 24 hours/day, but in those who need to be transferred it is necessary to modify the existing pathways and/or treatment protocols.
Aortic arch replacement extended to the ascending and/or descending thoracic aorta with a single vascular graft may cause kinking of the prosthesis. We propose an artifact to obtain a curved prosthesis from a straight one for total aortic arch replacement without the risk of kinking.
The introduction of drug-eluting stents has significantly improved the immediate and long-term results following treatment of bifurcation coronary lesions. Despite these improvements, few questions are still without a clear answer. Among them the most important one is the need to use two stents vs provisional side branch stenting in true bifurcations. At present time the approach most frequently applied is to stent the main branch stenting to the side branch only for suboptimal results. In situations when the operator needs two stents as intention to treat we suggest the usage of the "Crush" or "V" technique. These two approaches have been utilized with good immediate and long-term results with sirolimus-eluting stents and with polymer-based paclitaxel-eluting stents. The usage of the "Crush" technique followed by final dilation of the side branch and with kissing balloon inflation has decreased. We recently evaluated results with this technique in 70 patients treated with sirolimus-eluting stents. The 6-month angiographic follow-up was available in 83% of the lesions and restenosis rate was 33% (7% main and side branches and 26% only side branch). No difference was observed in the restenosis rate on the main branch between lesions treated with final kissing balloon inflation and lesions without final kissing inflation (4% in the final kissing group vs 8% in the no final kissing group, p = 1.00). The restenosis rate on the side branch was lower in the final kissing group (17%) in comparison to the no final kissing group (42%) (p = 0.046). Similar results are achieved with polymer-based paclitaxel-eluting stents. The introduction of drug-eluting stents with selective usage of stenting the main and side branches applying the "Crush" or "V" techniques has significantly improved the results compared to bare metal stents in bifurcation lesions.
Cardiac resynchronization therapy (CRT) is a new therapeutic approach for a selected group of patients with symptomatic heart failure (NYHA functional class III-IV) despite optimal medical therapy, due to dilated cardiomyopathy of any etiology (left ventricular ejection fraction < or = 35% and left ventricular end-diastolic diameter > or = 55 mm), who present with electromechanical dyssynchrony (QRS > or = 130 ms). Safety and effectiveness of CRT have been demonstrated by several clinical trials, with patients achieving significant improvement in both clinical symptoms as well as functional status and exercise capacity. Furthermore, CRT has reduced morbidity of heart failure patients, while its impact in improving survival still remains to be clarified. Whether or not heart failure patients candidate to CRT should receive a defibrillator back-up remains debatable, although growing evidence is pointing to extensive use of a defibrillator in such a population.
