Azienda Ospedaliera Bolognini Seriate

The ongoing digital transformation is reshaping organizational and care delivery models in cardiology, positioning telemedicine as a pivotal tool to address increasing clinical and demographic complexity. This ANMCO position paper presents a comprehensive and critical overview of telemedicine applications in cardiovascular care, with a focus on its role in strengthening hospital-community integration, its deployment within hospital-based healthcare systems, and the associated regulatory and operational frameworks. The analysis encompasses the management of chronic cardiovascular conditions, such as heart failure and atrial fibrillation, through telemonitoring, telecontrol, televisit, and teleconsultation. Additionally, it explores the use of digital technologies in post-myocardial infarction follow-up, oral anticoagulation management, preoperative assessment, and care for elderly patients. The position paper also highlights the challenges and opportunities linked to digital infrastructure, interoperability, data protection, and healthcare professional training.

BackgroundThe Micra leadless pacemaker provides a lead-free alternative to traditional transvenous pacemakers, significantly reducing complications associated with leads and device pockets. Although the initial application of leadless pacemakers was limited to centers with on-site cardiac surgery due to the technical demands, recent evidence suggests that implantation can be safely extended to centers without cardiac surgery capabilities. However, comprehensive comparisons of outcomes between these settings remain scarce.AimsThis study aimed to assess the safety, feasibility, and clinical outcomes of Micra leadless pacemaker implantation across centers with and without cardiac surgery. The analysis focused on acute complications, device performance, and patient follow-up.MethodsA retrospective study was conducted on 1,899 patients who received a Micra pacemaker between May 2015 and September 2024 at 23 centers participating in the One Hospital Clinical Service (OHCS) initiative. Patients were classified into two groups: those treated at centers with cardiac surgery (CS, n=1,025) and those without (No-CS, n=874). The primary endpoint was the rate of acute complications within 15 days post-implantation. Secondary endpoints included device performance and clinical outcomes at 12 months.ResultsThe overall acute complication rate was 0.6%, with no significant difference between CS (0.5%) and No-CS (0.8%; p=0.391) groups. Procedural times were shorter in No-CS centers (41.2 ± 19.8 minutes) compared to CS centers (46.1 ± 19.3 minutes; p<0.001), and fluoroscopy times also tended to be lower. Both groups showed comparable device performance and patient outcomes during the follow-up period. Differences in procedural techniques were noted; for example, No-CS centers more frequently utilized venography to facilitate the introduction of the delivery system, while CS centers used contrast imaging more often before device release.ConclusionThe findings of this study support that Micra leadless pacemaker implantation can be safely performed in centers without cardiac surgery, achieving comparable outcomes to those with on-site surgical facilities. These results suggest that with adequate training and emergency protocols, non-surgical centers can safely adopt leadless pacemaker technology, potentially expanding access to this advanced pacing solution across diverse healthcare settings.

BackgroundsAfter a decade since the introduction of leadless pacemaker (L‐PM), its use is still limited. The aim of this survey is to evaluate how this technology is perceived by electrophysiologist members of a National scientific society in clinical practice.MethodsA questionnaire with 22 questions was posted in the reserved area of the society website. The multiple‐choice questions concerned the center's characteristics, patient selection criteria, limitations to the L‐PM use, implant procedures, and follow‐up. Additionally, non‐implanting centers were also allowed to participate by completing the initial nine questions.ResultsNinety‐two responders participated in this survey: 59% implanted <20 L‐PM yearly and 31% did not implant L‐PM. The three main reasons to choose an L‐PM were anatomic contraindications to a transvenous pacemaker, the patient's high infective risk, and previous lead extraction, accounting for 78%, 74%, and 64% of the responses, respectively. Age >60 years was indicated as more suitable by most of the responders. Among the implanting centers, the main limitation to a wider adoption was cost (49%), the lack of atrial pacing (28%), the absence of a dedicated extraction tool, and data on replacement (22%). The L‐PM implant was performed with only local anesthesia in 77% of the centers and was associated with limited procedure duration and fluoroscopy time even in low‐volume centers.ConclusionsAlthough the L‐PM implant is not a particularly complex procedure, these data confirm that its use is currently limited to selected patients of older age. Cost decreases and new developments might increase the adoption of this technology.

BackgroundHeart failure and type 2 diabetes are prevalent public health issues in Europe. These complex chronic conditions require extensive pharmacological management, ongoing self-care, and behavioral changes. Despite the known benefits of lifestyle changes, such as regular exercise and better control of blood sugar levels, patients may need help implementing the recommended changes. This study aims to assess the effectiveness of a telemedicine program for managing heart failure and type 2 diabetes at home. The program focuses on promoting lifestyle changes.Methods and analysisDuring scheduled outpatient cardiology evaluations, eligible patients are recruited and randomly assigned to either an intervention or control group in a 1:1 ratio. The intervention group receives support from a nursing case manager through a structured home-based teleassistance program and a trainer for daily physical activity stimulation. They also have access to teleconsultations with cardiologists and diabetes specialists as needed, telemonitoring of vital signs, and daily step tracking. An app records and monitors daily drug treatment, glycemia, blood pressure, heart rate, and other clinical parameters. Patients can also self-report symptoms and communicate via a chat and videoconference system with a Nurse Case Manager. The control group receives routine care. Data collection occurs before intervention and 6 months after baseline during a new outpatient cardiology evaluation. The primary outcome is to measure the difference in the distance walked during a 6-min walk test between baseline and after 6 months. The key secondary outcomes include improving the disease status and physical activity profile. Data will be analyzed according to the intention-to-treat principles.DiscussionThis study will provide evidence on the efficacy of a telemedicine home-based management model to maintain correct lifestyles in patients with both heart failure and type 2 diabetes, improving self-management, their empowerment on the diseases, and increasing their knowledge and ability to recognize symptoms early.Trial registrationClinicalTrials.gov NCT05633784. Registered on November 30, 2022.

Aims. We described our advancement in the field of robotic cardiac surgery, particularly in the context of coronary revascularization. We will outline how the application of the Da Vinci® X Surgical System in coronary surgery is safe, feasible, and reproducible after an adequate familiarization with the docking system, that could come from a previous mitral valve robotic program, and after a sufficient learning time period. Methods. Between February 2021 and December 2023, a cohort of 33 patients underwent coronary artery revascularization surgery, involving robotic harvesting of the left mammary artery and off‐pump hand‐direct bypass to the left descending coronary artery or marginal coronary artery. In cases of hybrid revascularization, percutaneous coronary intervention with drug‐eluting stent placement was performed either before or after surgery. Results. There were no mortalities within 30 days and at 1 year of follow‐up after surgery. Notably, 70% of patients were extubated in the operating room immediately following the surgical procedure. The median postoperative mechanical ventilation time was 0 [0–4] hours, and the median length of stay in the intensive care unit was 21 [20–48] hours. A progressive reduction of the console and instrumental Da Vinci® X Surgical System was underling after the 21st patient. Conclusion. The promising outcomes observed in this series highlight that robotic‐assisted coronary artery bypass represents a well‐established technique that could be reproducible, especially when integrated into a hybrid strategy. Initiating a program in robotic‐assisted coronary artery bypass surgery can be effectively attained in particularly when a well‐established background in Da Vinci® X Surgical System utilization is achieved.

Introduction: Hepatic artery anomalies (HAA) may have an impact on surgical and oncological outcomes of patients undergoing pancreaticoduodenectomy (PD). Methods: Patients who underwent PD at our institution between July 2015 and January 2020 were retrospectively reviewed and classified into two groups: group 1, with presence of HAA, and group 2, with no HAA. A weighted logistic regression model was employed to assess the association between HAA and postoperative complications, and to assess the association between HAA and R status in patients with pancreatic cancer. Results: 502 patients were considered for analysis, with 75 (15%) of them in group 1. They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. Most patients underwent surgery for a malignancy (n = 451; 90%); among them, vascular resection was performed in 69 cases (15%). The presence of a HAA was reported at preoperative imaging only in 4 cases (5%) and the aberrant vessel was preserved in 72% of patients. At weighted multivariable logistic regression analysis, HAA were not associated to higher odds of morbidity (odds ratio [OR]: 0.753, 95% confidence interval [CI]: 0.543–1.043) nor to R1 status in case of pancreatic cancer (OR: 1.583, 95% CI: 0.979–2.561). Conclusion: At our institution, the presence of HAA does not have an impact on postoperative outcomes or affects oncological clearance after PD. Hospitals’, surgeons’, volume and systematic review of preoperative imaging are all factors that help reduce possible adverse events.

We present the case of a 58-years-old caucasian male who was hospitalized in our hospital with an early diagnosis of a jejunal tumor. However, all the instrumental and laboratory testing conducted were inconclusive and a preoperative diagnosis was not established. Patient was scheduled for surgery and en-bloc resection of the jejunal mass was performed. Microscopic analysis of the specimen reported the presence of intense mixed lympho-granulocytic inflammatory infiltrate of the mucosa associated with entamoeba parasites and a diagnosis of intestinal ameboma was ruled out. Ameboma is a rare complication of chronic amoebic colitis. usually found in the cecum and ascending colon. To our knowledge, this is the first case of an intestinal ameboma involving the jejunum to be reported in medical literature.

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment. To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance. We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms "lumen apposing metal stent", "LAMS", "endoscopic ultrasound" and "choledochoduodenostomy" or "gallbladder" or "pancreatic fluid collections". We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy. The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC. LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

Funding AcknowledgementsType of funding sources: None.BackgroundStructural and functional remodeling of left and right atrium (LA-RA) are predictors of the risk of hospitalization and mortality. These are chronic and complex processes, dependent on an adaptive response implemented by the atrial myocytes against stressors of an electrical, mechanical and metabolic nature. Atrial fibrillation (AF) is the most common condition associated with remodeling of both atria, of which it can be cause and effect at the same time: atrial enlargement, interstitial fibrosis and myocardial distension. Often the first manifestation of AF is cryptogenic stroke (CS) which is associated with a high rate of recurrence and adverse long-term follow-up outcomes, mainly due to its unknown etiology often leading to secondary prevention ineffective. Asymptomatic (AF) may play an important pathophysiological role to detect CS. Evidence has demonstrated the efficacy of AF ablation in restoring the structure of the LA and, consequently, in favoring the maintenance of sinus rhythm. However, little is known regarding the evaluation of RA remodeling and its variation over time in patients with FA.Aim of the studyEvaluate the relationship between echocardiographic parameters of LA and RA function, and the occurrence of AF revealed by continuous ECG monitoring through insertable cardiac monitors (ICM) implant in a cohort of patients with CSMethodsSingle-center retrospective study. A total of 204 patients who suffered from cryptogenic stroke underwent ICM between May 2013 and July 2022. All detected AF episodes lasting more than 30 seconds were considered, according to Guidelines. All patients underwent to Transthoracic Echocardiography (TTE) to study on LA and RA function, including both standard and longitudinal strain-derived parameters. Transesophageal Echocardiography (TEE) was also performed to exclude embolic sources.ResultsDuring a median follow-up period of 15.3 months (interquartile range, 7.4 / 23.5), continuous ECG monitoring revealed AF in 96 patients (47.0%). Many echocardiographic parameters, such as LA maximum and minimal volume were significantly associated with the occurrence of AF, suggesting the worst atrial function in the AF group. Furthermore, multivariable regression analysis revealed that peak atrial contraction strain of both atria were independently associated with AF (p < 0.001,respectively).ConclusionIn patients with cryptogenic CS, LA and RA strain analysis are strong and independent predictors of the occurrence of AF despite clinical and morpho-functional echocardiographic parameters.