Evolving cardiovascular uses of direct-acting oral anticoagulants: a paradigm shift on the horizon?

Direct-acting oral anticoagulants (DOACs), by virtue of pharmacological properties perceived as innovative, are changing the therapeutic scenario of patients requiring short- and long-term anticoagulation. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirms that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy, effectiveness and unequivocally documents a clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (AF) and venous thromboembolism. The following issues are attracting considerable clinical interest: (a) identifying specific subpopulations of patients with AF most likely to benefit from one of these agents (the so-called tailored therapy), and (b) expanding therapeutic indications in emerging diseases characterized by arterial and venous thromboembolic risk.

Long term follow-up of "full metal jacket" of de novo coronary lesions with new generation Zotarolimus-eluting stents.

Background: Diffuse coronary artery disease treatment still remains a challenge for interventional cardiologists and cardiac surgeons. There are few data on full metal jacket (FMJ) stenting, especially with new-generation drug-eluting stents. We aimed to assess the efficacy and safety of FMJ with new-generation Zotarolimus-eluting stents (n-ZES).

Prospective multicentre clinical performance evaluation of second and third generation zotarolimus-eluting stents to treat patients with bifurcated coronary lesions.

Aim: To assess the "real world" clinical outcome of patients with bifurcated lesions undergoing percutaneous coronary intervention with implantation of second and third generations of zotarolimus-eluting stent.

Methods And Results: Nine Italian centres participated in a prospective multicentre clinical project evaluating the outcome of patients receiving zotarolimus-eluting Resolute stent and Resolute Integrity stents. Patients with bifurcated lesions entered this evaluation.

[Major epidemiological changes and clinical variables in patients undergoing a program of heart rehabilitation after cardiac surgery - MEPHISTOPHELES].

Background: Recent observational studies show an increase of more complex and critically ill patients referred to Italian cardiac rehabilitation (CR) departments; the exact mechanisms underlying this phenomenon, however, have not been clearly identified. The aim of our study was to evaluate the epidemiological and clinical changes that occurred over the last decade in patients hospitalized in CR departments with high admittance rates.

Methods: We have retrospectively evaluated all patients admitted between 2002 and 2009 to our division of CR (n = 3340, 1155 female, mean age 66.

Predictors for restoration of normal left ventricular function in response to cardiac resynchronization therapy measured at time of implantation.

There are no parameters predicting the individual probability of "full response" to cardiac resynchronization therapy (CRT). The aim of this work was to find prognostic factors of full clinical and echocardiographic responses (i.e.

[ST-elevation myocardial infarction: reperfusion strategy based on the results from large clinical trials].

The efficacy of reperfusion therapy, both pharmacological and mechanical, in patients with ST-elevation myocardial infarction (STEMI) is time-dependent. The relation is closer the earlier we are from symptom onset and is valid for thrombolysis within 6h and for primary angioplasty till to at least the twelfth hour. Benefits of reperfusion bring to an advantage both in terms of myocardial salvage and left ventricular systolic function and in terms of quality of life and long-term survival.

In vivo assessment of coronary stents with 64-row multidetector computed tomography: analysis of metal artifacts.

Objective: To evaluate stent-induced artifacts by 64-row multidetector computed tomography (MDCT).

Methods: We studied 26 stented patients with MDCT before conventional coronary angiography (CCA). The CT values were measured.

Low-risk profile for malignant ventricular arrhythmias and sudden cardiac death after surgical ventricular reconstruction.

Background: Although it has been recently demonstrated that there was no significant difference in total survival and clinical outcomes between patients who underwent coronary artery bypass grafting (CABG) with or without surgical ventricular reconstruction (SVR), the question of whether or not SVR decreases the arrhythmic risk profile in this population has not been clarified yet.

Objective: To determine the real incidence of sudden cardiac death (SCD) and sustained ventricular tachycardia/ventricular fibrillation (sustained VT/VF) in patients following CABG added to SVR and to define their clinical and echocardiographic parameters predicting in-hospital and long-term arrhythmic events (SCD + sustained VT/VF).

Methods: Pre- and postoperative clinical and echocardiographic values as well as postoperative electrocardiogram Holter data of 65 patients (21 female, 63 ± 11 years) who underwent SVR + CABG were retrospectively evaluated.

Sex-related differences in patients undergoing percutaneous unprotected left main stenting.

Aims: Percutaneous coronary intervention (PCI) is increasingly being used for unprotected left main (ULM) disease. Limited data are available on sex-related differences in this setting. We investigated gender-associated differences in patients undergoing stent-based PCI for ULM.

The embolic storm: dramatic peripheral complications of left ventricular thrombosis after myocardial infarction.

Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.

Arrhythmic risk evaluation during exercise at high altitude in healthy subjects: role of microvolt T-wave alternans.

Background: Altitude-induced sympathetic hyperactivity can elicit rhythm disturbances in healthy subjects, in particular during exercise.

Aim: To asses the real susceptibility of healthy myocardium to malignant ventricular arrhythmias during exercise at high altitude using microvolt T-wave alternans (MTWA).

Methods: We evaluated eight healthy trained participants (one female, 42 +/- 9 years) during a mountain climbing expedition on Gashembrum II (Pakistan, 8,150 m).

Clip-based arterial haemostasis after antegrade common femoral artery puncture.

Background: Given the frequent involvement of infra-popliteal arteries, an ipsilateral antegrade common femoral artery puncture (ACFAP) is usually preferred to a contralateral retrograde femoral access for percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). Because of the frequent difficulty to get a sufficient manual pressure on the puncture site, ACFAP is burdened by a high number of bleeding local complications, including retroperitoneal haematoma. We report a series of patients who consecutively received a clip-based arterial closure device after ACFAP and ipsilateral PTA for CLI.

Long-term survival in patients undergoing cardiac resynchronization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation.

Aims: To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricular junction (AVJ) ablation in these patients.

Methods And Results: Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF. Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs).

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy.

Background: Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients.

Aims: To compare functional and structural improvement, as well as long-term outcome, between diabetic and non-diabetic HF patients treated with cardiac resynchronization therapy (CRT).

Methods: We compared response to CRT in 141 diabetic and 214 non-diabetic consecutive patients.

Endovascular repair of thoracic aortic disease with the EndoFit stent-graft: short and midterm results from a single center.

Purpose: To analyze the outcomes of endovascular treatment of thoracic aortic pathologies performed at a single center with the EndoFit thoracic stent-graft system.

Methods: From January 2002 to January 2007, 41 patients (33 men; mean age 69.3+/-9.

Stent-graft treatment of late stenosis of the left common carotid artery following thoracic graft placement.

We report the case of a patient with subtotal occlusion of the origin of the left common carotid artery (CCA) following thoracic graft placement. Retrograde endovascular placement of a stent-graft by minimal cervical access was undertaken to repair the occlusive lesion of the left CCA and prevent future complications of endoluminal thoracic reconstruction. The retrograde endovascular repair of CCA lesions, as other authors have already suggested, may be the treatment of choice in "high-surgical-risk" patients.

Dipyridamole stress echocardiography stratifies outcomes of asymptomatic patients with recent myocardial revascularization.

Background: Patients with previous myocardial revascularization, even if symptom-free, remain at risk of subsequent cardiac events, so that a non-invasive tool able to stratify this population is wishful.

Objectives: To assess the prognostic value of dipyridamole stress echocardiography (DipSE) in a population of asymptomatic patients following complete myocardial revascularization, either by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).

Methods: We retrospectively evaluated 104 consecutive symptom-free patients (mean age 67+/-9.

Activity monitoring in heart failure patients with cardiac resynchronization therapy.

Background: Cardiac resynchronization therapy (CRT) improves functional capacity in heart failure patients. This study aimed to prospectively analyze long-term device-based monitoring of physical activity in patients undergoing CRT.

Methods And Results: The Activity Log Index (ALI), calculated by CRT devices, represents the percentage of time when acceleration exceeds a threshold and monitors the physical activity.

Long-term survival of patients with heart failure and ventricular conduction delay treated with cardiac resynchronization therapy.

This multicenter longitudinal observational trial was designed to analyze the long-term outcome of patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) alone or with implantable cardioverter-defibrillator (ICD) backup in a daily practice scenario. It is unknown whether the magnitude of survival benefits conferred by CRT in a daily practice scenario is comparable to what has been observed in randomized controlled trials and whether this benefit is sustained over the long term. The outcome of 1,303 consecutive patients with ischemic or nonischemic cardiomyopathy on optimal pharmacologic therapy treated from August 1, 1995 to August 1, 2004 at 4 European centers with CRT alone (44%) or with ICD backup for symptomatic HF and prolonged QRS duration was assessed.

Combined prognostic value of peak O(2) uptake and microvolt level T-wave alternans in patients with idiopathic dilated cardiomyopathy.

Background: Despite the great improvement in clinical management of patients with idiopathic dilated cardiomyopathy (DCM), sudden cardiac death (SCD) and death due to worsening heart failure (HF) remain a challenging problem. The assessment of oxygen consumption (peakVO(2)) has been recognized as an independent marker of mortality. Nevertheless peakVO(2) is not helpful in the risk stratification of SCD.

Atrial fibrillation in heart failure patients: prevalence in daily practice and effect on the severity of symptoms. Data from the ALPHA study registry.

Background: Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials.

Aims: To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status.

Methods And Results: Consecutive patients (N=3513) seen at nine Heart Failure Clinics were studied; 21.

A case of Guillain-Barrè syndrome following Staphylococcus aureus endocarditis.

Guillain-Barrè syndrome (GBS) is the most important cause of acute neuromuscular paralysis in western countries and it is preceded in almost all cases by an infectious disease such as Campylobacter Jejuni or Cytomegalovirus. However, GBS associated with previous bacterial endocarditis is very rare. We report the case of a 74-year-old man with GBS following Staphylococcus Aureus endocarditis affecting aortic valve.

Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and disease progression: the importance of performing atrioventricular junction ablation in patients with atrial fibrillation.

Objectives: The goal of this study was to investigate the effects of cardiac resynchronization therapy (CRT) in heart failure patients with permanent atrial fibrillation (AF) and the role of atrioventricular junction (AVJ) ablation.

Background: Cardiac resynchronization therapy has been proven effective in heart failure patients with sinus rhythm (SR). However, little is known about the effects of CRT in heart failure patients with permanent AF.