Clinical burden and predictors of non-cardiovascular mortality and morbidity in advanced heart failure

BACKGROUND

The changing demographic of heart failure (HF) increases the exposure to non-cardiovascular (non-CV) events. We investigated the distribution of non-CV mortality/morbidity and the characteristics associated with higher risk of non-CV events in patients with advanced HF.

METHODS

Patients from the HELP-HF registry were stratified according to the number of 2018 HFA-ESC criteria for advanced HF. Endpoints were non-CV mortality and non-CV hospitalization. Competing risk analyses were performed assessing the association between HFA-ESC criteria and study outcomes and the additional predictors of non-CV endpoints.

RESULTS

One thousand one hundred and forty-nine patients were included (median age 77 years-IQR 69-83). At 6, 12, 18 and 22 months, cumulative incidence of CV vs non-CV mortality was 13% vs 5%, 17% vs 8%, 20% vs 12%, 23% vs 12%, and of CV vs non-CV hospitalization was 26% vs 11%, 38% vs 17%, 45% vs 20%, 50% vs 21%. HFA-ESC criteria were associated with increasing adjusted risk of CV death, whereas no association was observed for CV hospitalization, non-CV death and non-CV hospitalization. Predictors of non-CV death were age, chronic obstructive pulmonary disease, dementia, preserved ejection fraction, >1 HF hospitalization and hemoglobin.

CONCLUSIONS

Patients with advanced HF are exposed to high, even though not predominant, burden of non-CV outcomes. HFA-ESC criteria aid to stratify the risk of CV death, but are not associated with lower competing risk of non-CV outcomes. Alternative factors can be useful to define the patients with advanced HF at risk of non-CV events in order to better select patients for treatments specifically reducing CV risk.

Prognostic role of mitral regurgitation in patients with advanced heart failure

AIM

The impact of mitral regurgitation (MR) in patients with advanced heart failure (HF) is poorly known. We aimed to evaluate the impact of MR on clinical outcomes of a real-world, contemporary, multicentre population with advanced HF.

METHODS

The HELP-HF registry enrolled patients with HF and at least one "I NEED HELP" criterion, at four Italian centres between January 2020 and November 2021. The population was stratified by none/mild MR vs. moderate MR vs. severe MR. Outcomes of interest were all-cause, cardiovascular (CV) death, the composite of all-cause death or first HF hospitalization, first HF hospitalization and recurrent HF hospitalizations.

RESULTS

Among 1079 patients, 429 (39.8%) had none/mild MR, 443 (41.1%) had moderate MR and 207 (19.2%) had severe MR. Patients with severe MR were most likely to be inpatients, present with cardiogenic shock, need intravenous loop diuretics and inotropes/vasopressors, have lower ejection fraction and higher natriuretic peptides. Estimated rates of all-cause death, CV death, and the composite of all-cause death or first HF hospitalization at 1 year increased with increasing MR severity. Compared with no/mild MR, severe MR was independently associated with an increased risk of CV death (adjusted HR 1.61, 95% CI 1.04-2.51, p = 0.033) and recurrent HF hospitalizations (adjusted HR 1.49, 95% CI 1.08-2.06, p = 0.015), but not with and increased risk of all-cause death, first HF hospitalization and composite outcome.

CONCLUSIONS

In unselected patients with advanced HF, severe MR was common and independently associated with an increased risk of CV death and of recurrent HF hospitalizations.

Obesity, heart failure with preserved ejection fraction, and the role of glucagon-like peptide-1 receptor agonists

Heart failure with preserved ejection fraction (HFpEF) has a high prevalence, affecting more than 50% of patients with heart failure. HFpEF is associated with multiple comorbidities, and obesity is one of the most common. A distinct phenotype has been proposed for obese patients with HFpEF. Recent data show the beneficial role of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for weight loss in diabetic and non-diabetic patients with obesity or overweight when given as adjunctive therapy to diet and exercise. The mechanisms of action are related to paracrine and endocrine signalling pathways within the gastrointestinal tract, pancreas, and central nervous system that delay gastric emptying, decrease appetite, augment pancreatic beta-cell insulin secretion, and suppress pancreatic glucagon release. These drugs are therefore potentially indicated for treatment of patients with HFpEF and obesity or overweight. Efficacy and safety need to be shown by clinical trials with a first one, Semaglutide Treatment Effect in People with obesity and heart failure with preserved ejection fraction (STEP HFpEF), recently concluded. The aim of the present review is to provide the pathophysiological and pharmacological rationale for GLP-1 RA administration to obese patients with HFpEF.

Exploring the Prognostic Performance of MECKI Score in Heart Failure Patients with Non-Valvular Atrial Fibrillation Treated with Edoxaban

INTRODUCTION

Risk stratification in heart failure (HF) is essential for clinical and therapeutic management. The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score is a validated prognostic model for assessing cardiovascular risk in HF patients with reduced ejection fraction (HFrEF). From the validation of the score, the prevalence of HF patients treated with direct oral anticoagulants (DOACs), such as edoxaban, for non-valvular atrial fibrillation (NVAF) has been increasing in recent years. This study aims to evaluate the reliability of the MECKI score in HFrEF patients treated with edoxaban for NVAF.

MATERIALS AND METHODS

This study included consecutive outpatients with HF and NVAF treated with edoxaban (n = 83) who underwent a cardiopulmonary exercise test (CPET). They were matched by propensity score with a retrospective group of HFrEF patients with NVAF treated with vitamin K antagonists (VKAs) from the MECKI score registry (n = 844). The study endpoint was the risk of cardiovascular mortality, urgent heart transplantation, or Left Ventricle Assist Device (LVAD) implantation.

RESULTS

Edoxaban patients were treated with a more optimized HF therapy and had different clinical characteristics, with a similar MECKI score. After propensity score, 77 patients treated with edoxaban were successfully matched with the MECKI-VKA control cohort. In both groups, MECKI accurately predicted the composite endpoint with similar area under the curves (AUC = 0.757 vs. 0.829 in the MECKI-VKA vs. edoxaban-treated group, respectively, p = 0.452). The two populations' survival appeared non-significantly different at the 2-year follow-up.

CONCLUSIONS

this study confirms the prognostic accuracy of the MECKI score in HFrEF patients with NVAF treated with edoxaban, showing improved predictive power compared to VKA-treated patients.

Inflammation in acute heart failure

Acute heart failure (AHF) represents a common clinical scenario that requires prompt evaluation and therapy and that is characterized by a high risk of mortality or subsequent rehospitalizations. The pathophysiology leading to AHF decompensation is still not fully understood. Significant activation of inflammatory pathways has been identified in patients with AHF, particularly in its most severe forms, and it has been hypothesized that systemic inflammation has a role in AHF pathogenesis. Several inflammatory mediators and cytokines, such as high sensitivity C-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1, soluble suppression of tumorigenicity 2 and galectin-3, have been shown to play a role in the pathogenesis, development and worsening of this condition with an independent prediction of adverse outcomes. This manuscript reviews the prevalence and prognostic value of systemic inflammation in AHF, as well as the potential role of anti-inflammatory therapies, focusing on available evidence from clinical trials and ongoing studies.

Cardiac contractility modulation: an effective treatment strategy for heart failure beyond reduced left ventricular ejection fraction?

Heart failure (HF) with preserved ejection fraction (HFpEF) causes a progressive limitation of functional capacity, poor quality of life (QoL) and increased mortality, yet unlike HF with reduced ejection fraction (HFrEF) there are no effective device-based therapies. Both HFrEF and HFpEF are associated with dysregulations in myocardial cellular calcium homeostasis and modifications in calcium-handling proteins, leading to abnormal myocardial contractility and pathological remodelling. Cardiac contractility modulation (CCM) therapy, based on a pacemaker-like implanted device, applies extracellular electrical stimulation to myocytes during the absolute refractory period of the action potential, which leads to an increase in cytosolic peak calcium concentrations and thereby the force of isometric contraction promoting positive inotropism. Subgroup analysis of CCM trials in HFrEF has demonstrated particular benefits in patients with LVEF between 35% and 45%, suggesting its potential effectiveness also in patients with higher LVEF values. Available evidence on CCM in HFpEF is still preliminary, but improvements in terms of symptoms and QoL have been observed. Future large, dedicated, prospective studies are needed to evaluate the safety and efficacy of this therapy in patients with HFpEF.

Multimodality imaging in the diagnostic management of concomitant aortic stenosis and transthyretin-related wild-type cardiac amyloidosis

Severe aortic stenosis (AS) is the most common valvular heart disease with a prevalence rate of more than 4% in 75-year-old people or older. Similarly, cardiac amyloidosis (CA), especially "wild-type transthyretin" (wTTR), has shown a prevalence rate ranging from 22% to 25% in people older than 80 years. The detection of the concomitant presence of CA and AS is challenging primarily because of the similar type of changes in the left ventricle caused by AS and CA, which share some morphological characteristics. The aim of this review is to identify the imaging triggers in order to recognize occult wtATTR-CA in patients with AS, clarifying the crucial step of the diagnostic process. Multimodality imaging methods such as echocardiography, cardiac magnetic resonance, cardiac computed tomography, and DPD scintigraphy will be analyzed as part of the available diagnostic workup to identify wtATTR-CA early in patients with AS.

Clinical implications of left atrial changes after optimization of medical therapy in patients with heart failure

AIMS

Limited data exist regarding the prognostic relevance of changes in left atrial (LA) dimensions in patients with heart failure (HF). We assessed changes in LA dimension and their relation with outcomes after optimization of guideline-directed medical therapy (GDMT) in patients with new-onset or worsening HF.

METHODS AND RESULTS

Left atrial diameter was assessed at baseline and 9 months after GDMT optimization in 632 patients (mean age 65.8 ± 12.1 years, 22.3% female) enrolled in BIOSTAT-CHF. LA adverse remodelling (LAAR) was defined as an increase in LA diameter on transthoracic echocardiography between baseline and 9 months. After the 9-month visit, patients were followed for a median of 13 further months. LAAR was observed in 247 patients (39%). Larger baseline LA diameter (odds ratio [OR] 0.90; 95% confidence interval [CI] 0.87-0.93; p < 0.001) and up-titration to higher doses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARBs) (OR 0.56; 95% CI 0.34-0.92; p = 0.022) were independently associated with lower likelihood of LAAR. LAAR was associated with an increased risk of the composite of all-cause mortality or HF hospitalization (log-rank p = 0.007 and adjusted hazard ratio 1.73, 95% CI 1.22-2.45, p = 0.002). The association was more pronounced in patients without a history of atrial fibrillation (p for interaction = 0.009).

CONCLUSION

Among patients enrolled in BIOSTAT-CHF, LAAR was associated with an unfavourable outcome and was prevented by ACEi/ARB up-titration. Changes in LA dimension may be a useful marker of response to treatment and improve risk stratification in patients with HF.

Value of the HFA-PEFF and H2FPEF scores in patients with heart failure and preserved ejection fraction caused by cardiac amyloidosis

Aims

The HFA-PEFF and H2FPEF scores have been developed to diagnose heart failure with preserved ejection fraction (HFpEF), and hold prognostic value. Their use in patients with HFpEF caused by cardiac amyloidosis (CA) has never been investigated.

Methods and results

We evaluated the diagnostic and prognostic value of the HFA-PEFF and H2FPEF scores in 304 patients from 3 cohorts with HFpEF caused by transthyretin (ATTR)-CA (n=160, 53%) or immunoglobulin light-chain (AL)-CA (n=144, 47%). A diagnosis of HFpEF was more likely using the HFA-PEFF score with 2 (1%), 71 (23%), and 231 (76%) patients ranked as having a low (0–1), intermediate (2–4) or high (5–6) probability of HFpEF, respectively. Conversely, 36 (12%), 179 (59%) and 89 (29%) of patients ranked as having a low (0–1), intermediate (2–5) or high (6–9) probability of HFpEF using the H2FPEF score. During a median follow-up of 19 months (interquartile range 8–40), 132 (43%) patients died. The HFA-PEFF score, but not the H2FPEF, predicted a high risk of all-cause death which remained significant after adjustment for age, AL-CA diagnosis, high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and echocardiographic parameters, including left ventricular (LV) global longitudinal strain, LV diastolic function and right ventricular function (hazard ratio 1.51, 95% confidence interval 1.16–1.95, p=0.002 for every 1-point increase in HFA-PEFF).

Conclusions

The HFA-PEFF score has a high sensitivity to diagnose HFpEF caused by CA and holds independent prognostic value for all-cause mortality, while the H2FPEF score does not.

Funding Acknowledgement

Type of funding sources: None.

Clinical impact of changes in mitral regurgitation severity after medical therapy optimization in heart failure

Background

Few data are available regarding changes in mitral regurgitation (MR) severity with guideline-recommended medical therapy (GRMT) in heart failure (HF). Our aim was to evaluate the evolution and impact of MR after GRMT in the Biology study to Tailored treatment in chronic heart failure (BIOSTAT-CHF).

Methods

A retrospective post-hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization.

Results

Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate-severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate-severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint (unadjusted hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.57–2.63; p < 0.001), also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR, 1.85; 95% CI 1.43–2.39; p < 0.001). Younger age, LVEF ≥ 50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of persistence of moderate-severe MR at 9 months, whereas older age was the only predictor of worsening MR.

Conclusions

Among patients with HF undergoing GRMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate-severe MR after GRMT was associated with worse outcome.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-01991-7.

132 Clinical characteristics and outcomes of a contemporary, real-world, single-centre cohort of patients with advanced heart failure

Aims

An increasing number of patients with heart failure (HF) progresses to an advanced stage, characterized by persistent and sever symptoms and worse prognosis. A detailed characterization of patients with advanced HF is needed to optimize clinical management and timely refer for heart transplant or left ventricular assist device implantation.

Methods and results

A retrospective analysis was performed on patients with HF who were admitted to hospital or performed an outpatient visit at our centre (Spedali Civili di Brescia, Brescia, Italy) from 1 January 2020 to 31 December 2020, and who had at least one of the following high-risk characteristics: (1) previous or ongoing requirement for inotropes; (2) persisting New York Heart Association (NYHA) class III or IV and/or persistently high natriuretic peptides (BNP or NT-proBNP); (3) end-organ dysfunction, defined as worsening renal or liver dysfunction in the setting of HF; (4) ejection fraction (EF) &lt;20%; (5) recurrent appropriate defibrillator shocks; (6) more than 1 hospitalization for HF in the last year; (7) persisting fluid overload and/or increasing diuretic requirement; (8) consistently low blood pressure (systolic blood pressure &lt;90–100 mmHg); and (9) inability to up-titrate or need to decrease/cease HF therapies, such as beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor-neprilysin inhibitors, or mineralocorticoid receptor antagonists. The updated 2018 Heart Failure Association (HFA)—European Society of Cardiology (ESC) criteria for defining advanced HF were evaluated. The primary endpoint was all-cause mortality; secondary endpoints were a composite of all-cause mortality or hospitalization for HF and a composite of all-cause mortality or hospitalization for any reason. Among 493 patients with HF who were hospitalized or performed an outpatient visit in 2020, 230 (46.7%) had at least one high risk criterion and were included in the study. Mean age was 75.5 ± 11.9 years, 156 patients (67.8%) were men, and 160 patients (69.6%) were hospitalized and included as inpatients. Median EF was 38% [interquartile range (IQR): 25–50%] and 117 patients (50.9%) had HF with reduced EF (&lt;40%); median NT-proBNP was 4044 (IQR: 2262–7664) pg/mL. Among the included 230 patients, 38 (16.5%) had all four updated HFA-ESC criteria defining advanced HF, 53 (23.0%) had American College of Cardiology (ACC)/American Heart Association (AHA) stage D, 21 (9.1%) had INTERMACS profile 1–3. In-hospital mortality was 10.6% (among inpatients). After a median follow-up of 301 (214–442) days, a total of 62 patients died (27.0%), and the secondary endpoints of all-cause death or HF hospitalization and all-cause death or any hospitalization were observed in 107 (46.5%) and 139 (60.4%) patients, respectively. Patients fulfilling all four updated HFA-ESC criteria for advanced HF had a higher risk of all-cause mortality (unadjusted HR: 2.06; 95% CI: 1.18–3.60; P = 0.011), also after adjustment for covariates of interest (adjusted HR: 2.20; 95% CI: 1.03, 4.70; P = 0.041).

Conclusions

In our contemporary, real-world cohort of HF patients with high-risk characteristics, mid-term prognosis was poor, and the use of updated HFA-ESC criteria defining advanced HF identified a subset at increased risk of mortality.

128 Clinical impact of changes in mitral regurgitation severity after optimization of medical therapy in heart failure: insights from BIOSTAT-CHF

Aims

Few data are available regarding changes in mitral regurgitation (MR) severity with guideline-directed medical therapy (GDMT) in heart failure (HF). We evaluated the evolution and impact of MR after GDMT in the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF).

Methods and results

A retrospective post hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization. Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate–severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate–severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint [unadjusted hazard ratio (HR), 2.03; 95% confidence interval (CI): 1.57–2.63; P &lt; 0.001], also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR: 1.85; 95% CI: 1.43–2.39; P &lt; 0.001). Younger age, LVEF ≥50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of moderate–severe MR at 9 months, whereas older age was the only predictor of worsening MR.

Conclusions

Among patients with HF undergoing GDMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate–severe MR after GRMT was associated with worse outcome.

Determinants of the protective effect of glucocorticoids on mortality in hospitalized patients with COVID-19: Insights from the Cardio-COVID-Italy multicenter study

Background

Glucocorticoid therapy has emerged as an effective therapeutic option in hospitalized patients with coronavirus disease 2019 (COVID-19). This study aimed to focus on the impact of relevant clinical and laboratory factors on the protective effect of glucocorticoids on mortality.

Methods

A sub-analysis was performed of the multicenter Cardio-COVID-Italy registry, enrolling consecutive patients with COVID-19 admitted to 13 Italian cardiology units between 01 March 2020 and 09 April 2020. The primary endpoint was in-hospital mortality.

Results

A total of 706 COVID-19 patients were included (349 treated with glucocorticoids, 357 not treated with glucocorticoids). After adjustment for relevant covariates, use of glucocorticoids was associated with a lower risk of in-hospital mortality (adjusted HR 0.44; 95% CI 0.26–0.72; p = 0.001). A significant interaction was observed between the protective effect of glucocorticoids on mortality and PaO₂/FiO₂ ratio on admission (p = 0.042), oxygen saturation on admission (p = 0.017), and peak CRP (0.023). Such protective effects of glucocorticoids were mainly observed in patients with lower PaO₂/FiO₂ ratio (<300), lower oxygen saturation (<90%), and higher CRP (>100 mg/L).

Conclusions

The protective effects of glucocorticoids on mortality in COVID-19 were more evident among patients with worse respiratory parameters and higher systemic inflammation.

Cardiogenic Shock due to COVID-19-Related Myocarditis in a 19-Year-Old Autistic Patient

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is mainly responsible for respiratory involvement but cardiac complications are also reported. Nevertheless, potential life-threatening conditions in young people have not been described. A 19-year-old male autistic patient was admitted with fever and cough. The chest radiography showed viral pneumonia and the nasopharyngeal swab detected SARS-CoV-2. He rapidly developed hypotension, oliguria and increased myocardial injury markers and was treated with adrenaline, antiviral drugs and mechanical ventilation. Echocardiography revealed diffuse myocardial hypo-akinesia and decreased left ventricular ejection fraction (LVEF). After several days of treatment, the patient was weaned off mechanical ventilation, LVEF recovered to 50% and laboratory tests showed a decrease of markers of myocardial injury. Coronavirus disease 2019 (COVID-19) can therefore severely affect myocardium with life-threatening complications and even young people can be involved.

Quality of life in men and women with heart failure: association with outcome, and comparison between the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5 dimensions questionnaire

Aims

We sought to analyse quality of life (QoL) measures derived from two questionnaires widely used in clinical trials, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL 5 dimensions (EQ‐5D), and to compare their prognostic value in men and women with heart failure and reduced ejection fraction (HFrEF).

Methods and results

From the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT‐CHF) we compared KCCQ and EQ‐5D at baseline and after 9 months in 1276 men and 373 women with new‐onset or worsening symptoms of HFrEF, who were sub‐optimally treated and in whom there was an anticipated up‐titration of guideline‐derived medical therapies. Women had significantly worse baseline QoL (median) as compared with men, both when assessed with KCCQ overall score (KCCQ‐OS, 44 vs. 53, P < 0.001) and EQ‐5D utility score (0.62 vs. 0.73, P < 0.001). QoL improved equally in women and men at follow‐up. All summary measures of QoL were independently associated with all‐cause mortality, with KCCQ‐OS showing the most remarkable association with mortality up to 1 year compared to the EQ‐5D scores (C‐statistic 0.650 for KCCQ‐OS vs. 0.633 and 0.599 for EQ‐5D utility score and EQ‐5D visual analogue scale, respectively). QoL was associated with all outcomes analysed, both in men and women (all P for interaction with sex >0.2).

Conclusion

Amongst patients with HFrEF, women reported significantly worse QoL than men. QoL was independently associated with subsequent outcome, similarly in men and women. The KCCQ in general, and the KCCQ‐OS in particular, showed the strongest independent association with outcome.

Impact of heart failure on the clinical course and outcomes of patients hospitalized for COVID-19. Results of the Cardio-COVID-Italy multicentre study

AIMS

To assess the prognostic value of a history of heart failure (HF) in patients with coronavirus disease 2019 (COVID-19).

METHODS AND RESULTS

We enrolled 692 consecutive patients admitted for COVID-19 in 13 Italian cardiology centres between 1 March and 9 April 2020. Mean age was 67.4 ± 13.2 years, 69.5% of patients were males, 90 (13.0%) had a history of HF, median hospitalization length was 14 days (interquartile range 9-24). In-hospital death occurred in 37 of 90 patients (41.1%) with HF history vs. 126 of those with no HF history (20.9%). The increased risk of death associated with HF history remained significant after adjustment for clinical variables related to COVID-19 and HF severity, including comorbidities, oxygen saturation, lymphocyte count and plasma troponin [adjusted hazard ratio (HR) for death: 2.25; 95% confidence interval (CI) 1.26-4.02; P = 0.006 at multivariable Cox regression model including 404 patients]. Patients with a history of HF also had more in-hospital complications including acute HF (33.3% vs. 5.1%, P < 0.001), acute renal failure (28.1% vs. 12.9%, P < 0.001), multiorgan failure (15.9% vs. 5.8%, P = 0.004) and sepsis (18.4% vs. 8.9%, P = 0.006). Other independent predictors of outcome were age, sex, oxygen saturation and oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen ratio (PaO₂ /FiO₂ ). In-hospital treatment with corticosteroids and heparin had beneficial effects (adjusted HR for death: 0.46; 95% CI 0.29-0.74; P = 0.001; n = 404 for corticosteroids, and adjusted HR 0.41; 95% CI 0.25-0.67; P < 0.001; n = 364 for heparin).

CONCLUSIONS

Hospitalized patients with COVID-19 and a history of HF have an extremely poor outcome with higher mortality and in-hospital complications. HF history is an independent predictor of increased in-hospital mortality.

Impact of COVID-2019 outbreak on prevalence, clinical presentation and outcomes of ST-elevation myocardial infarction

AIMS

The aim of this study was to report the prevalence, clinical features and outcomes of patients with ST-elevation myocardial infarction (STEMI) hospitalized during the Corona-Virus Disease 2019 (COVID-19) outbreak compared with those admitted in a previous equivalent period.

METHODS AND RESULTS

Eighty-five patients admitted for STEMI at a high-volume Italian centre were included. Patients hospitalized during the COVID-19 outbreak (21 February-10 April 2020) (40%) were compared with those admitted in pre-COVID-19 period (3 January-20 February 2020) (60%). A 43% reduction in STEMI admissions was observed during the COVID-19 outbreak compared with the previous period. Time from symptom onset to first medical contact (FMC) and time from FMC to primary percutaneous coronary intervention (PPCI) were longer in patients admitted during the COVID-19 period compared with before [148 (79-781) versus 130 (30-185) min; P = 0.018, and 75 (59-148)] versus 45 (30-70) min; P < 0.001]. High-sensitive troponin T levels on admission were also higher. In-hospital mortality was 12% in the COVID-19 phase versus 6% in the pre-COVID-19 period. Incidence of the composite end-point, including free-wall rupture, severe left ventricular dysfunction, left ventricular aneurysm, severe mitral regurgitation and pericardial effusion, was higher during the COVID-19 than the pre-COVID-19 period (19.6 versus 41.2%; P = 0.030; odds ratio = 2.87; 95% confidence interval 1.09-7.58).

CONCLUSION

The COVID-19 pandemic had a significant impact on the STEMI care system reducing hospital admissions and prolonging revascularization time. This translated into a worse patient prognosis due to more STEMI complications.

Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

Importance

Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objective

To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms.

Design, Setting, and Participant

This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course.

Exposure

Cardiac involvement with COVID-19.

Main Outcomes and Measures

Detection of cardiac involvement with an increase in levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging.

Results

An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization.

Conclusions and Relevance

This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.

COVID-19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

Patients with cardiovascular disease and, namely, heart failure are more susceptible to coronavirus disease 2019 (COVID‐19) and have a more severe clinical course once infected. Heart failure and myocardial damage, shown by increased troponin plasma levels, occur in at least 10% of patients hospitalized for COVID‐19 with higher percentages, 25% to 35% or more, when patients critically ill or with concomitant cardiac disease are considered. Myocardial injury may be elicited by multiple mechanisms, including those occurring with all severe infections, such as fever, tachycardia, adrenergic stimulation, as well as those caused by an exaggerated inflammatory response, endotheliitis and, in some cases, myocarditis that have been shown in patients with COVID‐19. A key role may be that of the renin–angiotensin–aldosterone system. Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infects human cells binding to angiotensin‐converting enzyme 2 (ACE2), an enzyme responsible for the cleavage of angiotensin II into angiotensin 1–7, which has vasodilating and anti‐inflammatory effects. Virus‐mediated down‐regulation of ACE2 may increase angiotensin II stimulation and contribute to the deleterious hyper‐inflammatory reaction of COVID‐19. On the other hand, ACE2 may be up‐regulated in patients with cardiac disease and treated with ACE inhibitors or angiotensin receptor blockers. ACE2 up‐regulation may increase the susceptibility to COVID‐19 but may be also protective vs. angiotensin II‐mediated vasoconstriction and inflammatory activation. Recent data show the lack of untoward effects of ACE inhibitors or angiotensin receptor blockers for COVID‐19 infection and severity. Prospective trials are needed to ascertain whether these drugs may have protective effects.

Characteristics and outcomes of patients hospitalized for COVID-19 and cardiac disease in Northern Italy

Aims

To compare demographic characteristics, clinical presentation, and outcomes of patients with and without concomitant cardiac disease, hospitalized for COVID-19 in Brescia, Lombardy, Italy.

Methods and results

The study population includes 99 consecutive patients with COVID-19 pneumonia admitted to our hospital between 4 March and 25 March 2020. Fifty-three patients with a history of cardiac disease were compared with 46 without cardiac disease. Among cardiac patients, 40% had a history of heart failure, 36% had atrial fibrillation, and 30% had coronary artery disease. Mean age was 67 ± 12 years, and 80 (81%) patients were males. No differences were found between cardiac and non-cardiac patients except for higher values of serum creatinine, N-terminal probrain natriuretic peptide, and high sensitivity troponin T in cardiac patients. During hospitalization, 26% patients died, 15% developed thrombo-embolic events, 19% had acute respiratory distress syndrome, and 6% had septic shock. Mortality was higher in patients with cardiac disease compared with the others (36% vs. 15%, log-rank P = 0.019; relative risk 2.35; 95% confidence interval 1.08–5.09). The rate of thrombo-embolic events and septic shock during the hospitalization was also higher in cardiac patients (23% vs. 6% and 11% vs. 0%, respectively).

Conclusions

Hospitalized patients with concomitant cardiac disease and COVID-19 have an extremely poor prognosis compared with subjects without a history of cardiac disease, with higher mortality, thrombo-embolic events, and septic shock rates.

Sacubitril/valsartan: from a large clinical trial to clinical practice

: The Prospective Comparison of Angiotensin Receptor Antagonist and Neprilysin Inhibitor with Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF) has shown a reduction in the risk of death and heart failure hospitalizations with sacubitril/valsartan, compared with enalapril, in patients with heart failure and reduced ejection fraction. Guidelines now recommend the substitution of angiotensin-converting enzyme inhibitors or AT1 blockers with sacubitril/valsartan in patients with heart failure and reduced ejection fraction. The aim of this review is to discuss factors that may have an impact on the implementation of these guidelines into clinical practice. The main limitation is that, based on the inclusion criteria of PARADIGM-HF, sacubitril/valsartan is not indicated in patients with heart failure and preserved ejection fraction, although they may be the majority of the patients with heart failure. The trial enrolled ambulatory patients and thus start of sacubitril/valsartan is not indicated in those hospitalized for heart failure. A drug's tolerability may be limited by hypotension with, however, a lower rate of renal dysfunction, compared with enalapril. The cost of the new treatment is also an issue. Similarly to what occurred when other neurohormonal antagonists have been introduced in clinical practice, increased awareness of poor heart failure outcomes and better patients' management programs may be of utmost importance for the implementation of this new agent.

Effects of ivabradine on endothelial function, aortic properties and ventricular-arterial coupling in chronic systolic heart failure patients

AIM

Heart rate (HR) is an important prognostic factor in patients affected by chronic heart failure (CHF); ivabradine has been demonstrated to significantly reduce nonfatal myocardial infarction and hospitalization rate for acute heart failure and to improve left ventricular (LV) reverse remodeling, quality of life, exercise capacity, and arterial elastance (Ea) in these patients. We aimed at evaluating the short-term effects of ivabradine on ventricular-arterial coupling (VAC), aortic stiffness, and endothelial function in stable patients with CHF.

METHODS

We evaluated 30 consecutive CHF patients (LVEF≤ 35%, NYHA class II) with sinus rhythm and HR ≥ 70 bpm on optimized pharmacological therapy. All of them underwent both transthoracic echocardiogram to assess aortic elastic properties (aortic distensibility, AD; aortic stiffness index, ASI; systolic aortic strain, SAS) and VAC, and peripheral arterial tonometry to measure endothelial function. Therapy with ivabradine 5 mg bid was added and each patient was evaluated with the same examinations after 4 months.

RESULTS

At the baseline, 73% of patients had impaired VAC and 63% endothelial dysfunction. After 4 months, there was a significant improvement in the VAC value (ΔVAC -0.10 ± 0.18, P = .021), mainly linked to Ea (ΔEa -0.40 ± 0.23 mm Hg/mL; P = .003). All the parameters of aortic elasticity underwent significant improvement (ΔAD 1.82 ± 1.43 cm² × dyn^- ¹, P = .004; ΔASI -4.73 ± 6.07, P = .033; ΔSAS -7.98 ± 4.37%, P = .003). Lastly, we also noted a significant improvement of endothelial function (Δ RHI 0.35 ± 0.35; P < .001). At follow-up 40% of patients had impaired VAC (P = .018) and 33% endothelial dysfunction (P = .038).

CONCLUSION

In patients with CHF adding ivabradine on top to the standard optimized medical therapy, when indicated, seems to improve endothelial function, aortic properties, and VAC.

Left ventricular function in rheumatoid arthritis during anti-TNF-α treatment: a speckle tracking prospective echocardiographic study

<p><strong>Aim</strong>. Rheumatoid arthritis (RA) shows a high risk for cardiovascular disease, including heart failure. Although TNF-α has been implicated in the pathogenesis of myocardial remodelling, TNF-α inhibition did not show any efficacy in patients with advanced heart failure and should be contraindicated in RA with cardiac complications. We aimed to assess global left ventricular (LV) systolic function using global longitudinal strain (GLS) as a measure of myocardial deformation, in a group of RA patients before and during anti-TNF-α treatment. <strong>Methods</strong>. 13 patients (female:male 7:6) affected by RA were prospectively followed for one year during anti TNF-α treatment. Every subject underwent echocardiography before starting anti-TNF-α drugs and after one year of treatment, to evaluate LV ejection fraction (EF), telediastolic diameter, telediastolic volume and global longitudinal strain (GLS) that was calculated using 2D speckle tracking as the mean GLS from three standard apical views (2, 3 and 4 -chambers). The patients showed a mean age of 43 years at RA onset (SD: 13) and a mean follow-up of 7.3 years (SD: 4.8). Steroid and methotrexate were used in 84.6% and 100%, respectively, in association with etanercept (6 cases), adalimumab (4 cases) and infliximab (3 cases). <strong>Results</strong>. Patients globally showed a normal EF before and after one year of treatment (mean: 65% and 65.7%, respectively). GLS did not differ before or after anti-TNF-α treatment (mean: -15.8% and -16.7%, respectively). <strong>Conclusion</strong>. Anti-TNF-α treatment did not significantly modify myocardial contractility after 12 months.</p><p> </p><p> </p>

Red cell distribution width and chronic heart failure: prognostic role beyond echocardiographic parameters

AIM

Red cell distribution width (RDW) is a measure of anisocytosis. Higher values are robustly associated to adverse outcome in several conditions, including chronic heart failure (HF). The present study aimed to compared its prognostic role with that of echocardiographic parameters in this kind of patients.

METHODS

32 stable and optimally treated chronic HF patients were enrolled. We excluded subjects suffering from valvular diseases or atrial fibrillation. They underwent blood sampling and echocardiographic examination. The primary endpoint of the study was cardiovascular death and/or HF hospitalization in the first year after enrolment.

RESULTS

49 patients reached the primary endpoint. RDW best cut-off at ROC curve was 14.45%. Univariate analysis associated mitral regurgitation grade, left ventricular ejection fraction (LVEF), posterior wall thickness (PWT), LV mass index, and RDW>14.45% to the primary endpoint. Multivariate regression analysis showed that LVEF, PWT, and RDW>14.45% predict the primary endpoint. Area under ROC curve was 0.808 for LVEF, 0.762 for NYHA class, and 0.761 for RDW.

CONCLUSION

In chronic HF patients RDW is a better predictor of adverse outcome than several echocardiographic parameters associated to outcome itself (LV mass index, mitral regurgitation grade), predicts prognosis even adjusting for those parameters, age and NYHA class, and is associated to several echocardiographic measurements. In conclusion, RDW can expand our tool bag in order to better follow-up these patients.

Clinical utility of postmortem microcomputed tomography of the fetal heart: diagnostic imaging vs macroscopic dissection

OBJECTIVES

Congenital cardiac malformations are commonly identified at perinatal autopsy, which can be challenging in fetuses of early gestation and in macerated fetuses. Our objective was to examine fetal complex congenital heart disease by microcomputed tomography (micro-CT), using standard autopsy as the gold standard.

METHODS

In this ethically approved study, ex-vivo isolated fetal heart and fetal heart-lung blocks underwent iodine preparation prior to micro-CT, and were fixed in formalin after the micro-CT examination. Images were acquired using a microfocus-CT scanner with individual specimen image optimization. Twenty-one indices assessed normally at autopsy were evaluated for each dataset. Cardiac dissection was performed using a dissecting microscope within 24 h of the micro-CT examination.

RESULTS

We examined six fetal hearts, comprising five with complex congenital cardiac malformations at a gestational age of 17-23 weeks and an anatomically normal heart of 23 weeks' gestation for reference. All specimens demonstrated excellent internal contrast at micro-CT examination, and the correct overall diagnosis was made in all cases. There was agreement for 114/126 indices assessed on micro-CT and at autopsy dissection (overall concordance of 95.8% (95% CI, 90.5-98.2%)). Micro-CT was particularly useful in the assessment of ventricular morphology in macerated fetuses.

CONCLUSIONS

Micro-CT of small ex-vivo fetal specimens can provide highly accurate three-dimensional rendering of complex congenital fetal heart disease. This approach represents a significant advance in postmortem imaging and confirms the potential of this technology for non-invasive examination of small fetuses and organs.

Postmortem microcomputed tomography (micro-CT) of small fetuses and hearts

OBJECTIVE

To assess the feasibility and utility of contrast-enhanced microcomputed tomography (micro-CT) for identifying structural anomalies in ex-vivo first- and second-trimester human fetuses and isolated fetal hearts.

METHODS

Radiopaque iodine staining and micro-CT scanning protocols were first developed in rodent studies and then used to examine routinely fixed whole human fetuses (n = 7, weight 0.1-90 g, gestational age, 7-17 weeks) and isolated fetal hearts (n = 14, weight 0.1-5.2 g, gestational age, 11-22 weeks). Samples were scanned using an isotropic resolution of 18 (and, if necessary, 9 or 35) µm and findings were interpreted jointly by four fetal pathologists, a fetal cardiologist and a radiologist. Samples with gestational ages ≥ 13 weeks also underwent conventional autopsy or dissection.

RESULTS

Micro-CT identified all anatomical structures and abnormalities documented by the macroscopic examination. In all seven cases involving fetuses ≤ 13 weeks (four fetuses, three isolated hearts), micro-CT excluded the presence of structural anomalies. In the remaining 14 cases, it provided all the information obtained with invasive autopsy or dissection and in seven of the 14 (two fetuses, five isolated hearts) it furnished additional diagnostic details.

CONCLUSIONS

This pilot study confirms the feasibility of postmortem contrast-enhanced micro-CT assessment of structural anomalies in whole small fetuses and fetal hearts. Further study is needed to confirm our findings, particularly in whole fetuses, and to define the extent to which this virtual examination might be used instead of conventional invasive autopsy.

Fetal echocardiography at 11-13 weeks by transabdominal high-frequency ultrasound

OBJECTIVES

To assess the accuracy of fetal echocardiography at 11-13 weeks performed by well-trained obstetricians using a high-frequency linear ultrasound transducer.

METHODS

Fetal echocardiography was performed by obstetricians immediately before chorionic villus sampling for fetal karyotyping at 11-13 weeks. Digital videoclips of the examination stored by the obstetrician were reviewed offline by a specialist fetal cardiologist.

RESULTS

The obstetrician suspected 95 (95%) of the 100 cardiac defects identified by the fetal cardiologist and made the correct diagnosis in 84 (84%) of these cases. In 54 fetuses, the defect was classified as major and in 46 it was minor. In 767 (86.6%) cases, the heart was normal and in 19 (2.1%) the views were inadequate for assessment of normality or abnormality. A subsequent second-trimester scan in the normal group identified major cardiac defects in four cases. Therefore, the first-trimester scan by the obstetricians and cardiologists identified 54 (93.1%) of the 58 major cardiac defects.

CONCLUSIONS

A well-trained obstetrician using high-resolution ultrasound equipment can assess the fetal heart at 11-13 weeks with a high degree of accuracy.

Reliability of the first-trimester cardiac scan by ultrasound-trained obstetricians with high-frequency transabdominal probes in fetuses with increased nuchal translucency

OBJECTIVE

To examine prospectively the reliability of ultrasound-trained obstetricians performing a first-trimester fetal cardiac scan with high-frequency transabdominal probes, by confirming normal or abnormal heart anatomy, in pregnancies referred for increased nuchal translucency thickness (NT).

METHODS

Trained obstetric operators assessed the fetal heart in 133 fetuses with increased NT (> 95th centile) at 11-14 weeks of gestation. A high-frequency transabdominal probe was used to confirm or refute normal cardiac anatomy rather than to establish a specific diagnosis. Following this preliminary screening by the ultrasound-trained obstetrician, specialized fetal echocardiographers rescanned the fetal heart in order to confirm the accuracy of the obstetric operators' findings and to establish a diagnosis in abnormal cases. Fetal cardiologists repeated the examinations at 20 and 32 weeks of pregnancy. Postnatal follow-up lasted 2 years. Twelve fetuses with normal karyotype and normal anatomy were lost to follow-up.

RESULTS

A total of 121 fetuses with increased NT between 11 and 14 weeks' gestation were studied. Congenital heart disease (CHD) was detected in 20/121 (16.5%) fetuses. In addition, there were three with mild ventricular disproportion, the right ventricle being larger than the left, considered as a minor non-specific cardiac abnormality. CHD was associated with chromosomal anomalies in 12/20 (60%) cases. Among the 121 fetuses, there was agreement between ultrasound-trained obstetricians and fetal cardiologists in 116 (95.9%) of the cases, and the ultrasound-trained obstetricians correctly identified 18 cases with major cardiac defects. However, there was disagreement in five cases: two with small ventricular septal defects and three with ventricular disproportion.

CONCLUSIONS

Our results provide evidence that obstetricians, trained to study the heart in the second trimester, can also differentiate reliably between normal and abnormal heart findings in the first trimester, when using a high-frequency transabdominal ultrasound probe.

Fetal echocardiography at the time of the nuchal translucency scan

OBJECTIVE

The fetal heart is not studied routinely in the first trimester because of technical and time limitations. Our aim was to assess the feasibility of performing a fetal cardiac study in pregnancies referred for nuchal translucency (NT) screening, using high-frequency linear transabdominal transducers with a specific ultrasound preset.

METHODS

A single trained operator assessed the fetal heart in pregnancies with a fetal crown-rump length (CRL) of 60-84 mm that had been referred for NT screening. A 15- or 6-MHz transabdominal linear transducer with a specific preset suitable mainly for color-flow mapping was used to confirm or refute normal cardiac anatomy rather than to establish a specific diagnosis. Fetuses having an increased risk for congenital heart disease were referred to a tertiary center for a further examination within 1 week. This group consisted of all fetuses with NT > 95(th) centile and those in which a family history or the initial heart scan increased the risk.

RESULTS

A total of 608 fetuses with a median CRL of 65 mm was examined between 2003 and 2005. A cardiac scan was performed successfully in 456 (75%) using a 15-MHz linear transducer alone, and the additional use of a 6-MHz transducer allowed diagnostic images to be obtained in a further 152. Normal cardiac anatomy was assessed confidently within 10 min in 517/608 (85%) pregnancies; in 85 (14%) a longer time was needed and six patients were rescheduled within 2 weeks because of non-diagnostic images at the initial scan. In 571/608 (94%) the risk for congenital heart disease (CHD) was not increased and the heart was considered normal at initial echocardiography; this was confirmed by later scans and at postnatal follow-up. In 37/608 (6%) fetuses the risk for CHD was increased (35 for NT > 95(th) centile and two for family history). In this group normal heart anatomy was described in 34 fetuses and confirmed by subsequent specialist echocardiography. Cardiac defects were suspected in three fetuses (all with increased NT) and confirmed by a fetal cardiologist in each case.

CONCLUSIONS

A trained operator can perform a fetal heart study during the NT screening test using transabdominal high-resolution transducers in an acceptable length of time.

First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study

This was a retrospective study of 17 patients (21 operated feet) treated with first metatarsophalangeal arthrodesis for hallux rigidus of varying severity levels. Patients were evaluated according to a modified American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal rating scale containing 60 subjective and 30 objective points. At an average follow-up time of 28.1 months, patients demonstrated a mean subjective improvement from 21.2 to 47.8/60, with mean total scores improving from 39.1 to 75.6/90. A comparison of pre- and postoperative radiographic angular measurements demonstrated a significant improvement (p = .001) in intermetatarsal, first metatarsal declination, and lateral talo-first metatarsal angles. Significant positive correlations were found between subjective results and patient age (p = .05) and the preoperative lateral talo-first metatarsal angles (p = .001).

Treatment of congenital convex pes valgus with navicular excision and subtalar arthroereisis: a case study

This article presents a case study of a 4-year-old female with a delayed diagnosis of congenital convex pes valgus. The severe soft-tissue contractures and osseous abnormalities in this case necessitated excision of the navicular and subtalar arthroereisis in addition to standard soft-tissue releases in order to achieve and maintain adequate reduction. A review of the literature and a discussion of these adjunctive techniques is provided to examine the concepts relevant to treatment of this condition.

External constant tension expansion of soft tissue for the treatment of ulceration of the foot and ankle

A clinical series of the management of 74 lesions in the foot and ankle region in 67 patients using a constant tension-approximating device is presented. The technical aspects of this methodology are detailed as they have been developed over the past 4 years. The indications, contraindications, and the requirements to obtain a successful result are discussed. The differences, as well as the possible advantages over other mechanical devices used in wound management, are discussed. The incidence and degree of complications are considered to be minimal when compared to both flap procedures and internal expansion technologies.

Necrotizing fasciitis in the lower extremity: a review and case presentation

Necrotizing fasciitis is a rare but potentially fatal disease which is often confused with cellulitis. By examining the pathogenesis, clinical presentation, treatment, and a representative case study, this article proposes to lend a broader perspective to this infection. Emphasis is placed on the necessity of surgical debridement in combination with antibiotic therapy to minimize the possible morbidity associated with this condition.

Isolated fusions of the hindfoot

Increasingly, isolated arthrodeses are being used to successfully manage disorders of the hindfoot. Their relative simplicity makes these procedures an attractive alternative to the triple arthrodesis. Each joint fusion is not without certain pitfalls, and issues such as the location of the pain, origin, planal dominance, and multiple joint involvement must be taken into consideration when choosing a specific procedure. With proper patient selection and careful technique, the surgeon will find these procedures provide a valuable addition to his/her armamentarium.

Modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon: operative technique and case study

This article presents an operative technique for modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon sheath. The procedure uses two stacked posterolateral subtalar joint portals, rather than the customary anterolateral and posterolateral portal combination. By visualizing the os trigonum with an arthroscope positioned in a distal portal and introducing instrumentation through a proximal portal, the ossicle may be quickly exposed and excised with minimal dissection. A case study with a 22-month follow-up and a discussion of os trigonum syndrome are included to illustrate this procedure as an alternative to open excision or traditional arthroscopic excision.

Talonavicular joint arthrodesis and Evans calcaneal osteotomy for treatment of posterior tibial tendon dysfunction

The purpose of this study was to evaluate the combination of talonavicular fusion and Evans calcaneal osteotomy for the treatment of posterior tibial tendon dysfunction. This was a retrospective study of 10 patients, mean age 48.7 years, who had continued pain despite 6 months of conservative treatment and a minimum Johnson and Strom stage II deformity. Patients completed a detailed questionnaire, were physically examined, and their postoperative improvement was graded according to the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Rating Scale. At a mean of 35 months (range 8-72 months) after surgery, patients demonstrated a significant improvement (p<.001) both in their subjective discomfort and in the structural alignment and function of their feet. The authors feel that this combination of procedures allows greater correction and stability than either procedure performed alone, and provides a viable alternative to triple arthrodesis.

Three select subungual pathologies: subungual exostosis, subungual osteochondroma, and subungual hematoma

Special attention has been given to the differences between subungual exostosis and subungual osteochondroma. Once a diagnosis has been made and symptoms persist, complete excision of the lesion with curettage of the base is the treatment of choice for both conditions. Subungual hematoma is an exquisitely painful condition that usually results from trauma, but may also be caused by systemic pathology, medication and drug reactions, and aging. Prompt decompression will significantly reduce pain and further damage to the nail bed and matrix. Radiographs must be taken because of the high incidence of associated distal phalangeal fracture. Patients must be warned that onycholysis, transient and permanent nail deformity, and infection are possible complications, even with the best treatment.

Stress fracture of the tarsal navicular: two unusual case reports

Stress fractures of the tarsal navicular are an uncommon entity in podiatric and orthopedic literature, being reported only 40 times. These cases were usually in the younger, active patient population. The cases reported in this paper were older individuals that were inactive. Both cases were originally misdiagnosed, but later shown to be stress fractures, one being the only hypertrophic nonunion recorded to date. The authors believe the stress-fractured navicular is often misdiagnosed, and probably more common than recently reported.