Considerazioni condivise alla luce delle recenti novità nell’ambito dello scompenso cardiaco: ottimizzazione della gestione del paziente con scompenso cardiaco in medicina interna - Dal ricovero al follow-up

Nuova classificazione dello scompenso cardiaco: ridenominazione di Heart failure with mid-range ejection fraction in Heart failure with mildly reduced ejection fraction (HFmrEF), con raccomandazioni terapeutiche più precise in questa fascia di pazienti Il nuovo algoritmo per il trattamento dello scompenso cardiaco a frazione di eiezione ridotta: Simultaneous or Rapid Sequence Initiation of Quadruple Medical Therapy for Heart Failure Ottimizzazione della terapia: l’ospedalizzazione come opportunità. Impiego precoce di sacubitril/valsartan nel paziente ospedalizzato, stabilizzato. Effetti sulla riduzione della mortalità e delle re-ospedalizzazioni. Effetti sul rimodellamento cardiaco. Effetti sulla QoL Sicurezza dell’uso di sacubitril/valsartan anche in presenza di comorbidità e gestione dell’ipotensione Intervento di ottimizzazione della terapia anche nel paziente con scompenso cardiaco cronico ricoverato per altra patologia acuta Terapia delle comorbidità - non cardiovascolari: diabete, iperkaliemia, carenza di ferro e cancro Terapia non farmacologica ed educazione/formazione del paziente e del caregiver Gestione post-ricovero dello scompenso cardiaco: l’ambulatorio divisionale e la rete territoriale

Therapeutic Management of Ocular Ischemia in Takayasu’s Arteritis: A Case-Based Systematic Review

BackgroundTakayasu’s arteritis (TA) is a rare, chronic granulomatous large-vessel vasculitis that can lead to ocular ischemia. Ocular outcomes after therapeutic management in TA remain largely unknown. We herein conduct a case-based systematic review to address the current treatment options in this particular cohort.MethodsPubMed, Medline, and EMBASE databases were searched pertaining to ocular outcomes after systemic treatment in TA. Studies reporting ocular examinations before and after treatment in TA patients with ocular ischemia were included. Clinical characteristics, therapies, ocular outcomes, and complications were recorded.ResultsA 29-year-old woman with newly diagnosed TA showed dramatic regression of Takayasu’s retinopathy (TR) following balloon angioplasty. Optical coherence tomography angiography (OCTA) was used as a novel strategy for subsequent follow-up. A total of 117 eyes of 66 patients with a median age of 27 years were included for systematic review. TR was the most common ocular manifestation. Oral steroids were prescribed in nearly all patients (n = 65), followed by the use of methotrexate and antiplatelet therapy. Of the patients, 65.8% and 34.2% underwent open surgery and endovascular procedure, respectively. The median follow-up period was 12 weeks (interquartile range 8–33.5). Surgical therapy showed better ocular improvement (including visual and imaging responses) in both acute and chronic vision loss, along with fewer complications than medical therapy alone. In the surgical group, the visual prognosis was significantly better in patients with initial visual acuity better than 20/200 (p = 0.03) and those who underwent surgery before stage III TR (p = 0.01). Ocular outcomes were equivalent in the two surgical approaches.ConclusionClinicians should be familiar with ophthalmic manifestations of this potentially treatable complication in TA. Compared with medical therapy alone, surgical intervention might be a better choice for both acute and chronic vision loss. Surgery is best recommended before the onset of irreversible ischemia to the globe. A combined regimen (oral steroids, immunosuppressants, and antiplatelet drugs) might be effective for those with surgical contradictions or reluctance to an invasive procedure. Physicians should be aware of the importance of ocular examinations, including OCTA, during the diagnosis and follow-up in TA.

Care of the patient after valve intervention

This review aims to outline the current evidence base and guidance for care of patients post-valve intervention. Careful follow-up, optimisation of medical therapy, antithrombotics, reduction of cardiovascular risk factors and patient education can help improve patient outcomes and quality of life. Those with mechanical valves should receive lifelong anticoagulation with a vitamin K antagonist but in certain circumstances may benefit from additional antiplatelet therapy. Patients with surgical bioprosthetic valves, valve repairs and transcatheter aortic valve implantation also benefit from antithrombotic therapy. Additionally, guideline-directed medical therapy for coexistent heart failure should be optimised. Cardiovascular risk factors such as hyperlipidaemia, hypertension and diabetes should be treated in the same way as those without valve intervention. Patients should also be encouraged to exercise regularly, eat healthily and maintain a healthy weight. Currently, there is not enough evidence to support routine cardiac rehabilitation in individuals post-valve surgery or intervention but this may be considered on a case-by-case basis. Women of childbearing age should be counselled regarding future pregnancy and the optimal management of their valve disease in this context. Patients should be educated regarding meticulous oral health, be encouraged to see their dentist regularly and antibiotics should be considered for high-risk dental procedures. Evidence shows that patients post-valve intervention or surgery are best treated in a dedicated valve clinic where they can undergo clinical review and surveillance echocardiography, be provided with heart valve education and have access to the multidisciplinary valve team if needed.

Criteria for Endovascular Intervention in Type B Aortic Dissection

Background The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un-TBAD) remains controversial. There is a lack of consensus over whether pre-emptive TEVAR should be carried out in patients with un-TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un-TBAD may prove beneficial relative to pharmacotherapy alone. Methods and Materials PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen expansion, and mortality. Papers were selected based on title and abstract. Results Optimal medical therapy remains the mainstay treatment for patients with un-TBAD, however patients with un-TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, false lumen thrombosis, and aortic branch involvement may potentiate progression from un-TBAD to complicated TBAD. Short- and long-term outcomes associated with TEVAR for TBAD remain promising. Conclusion Pre-emptive TEVAR may be beneficial in patients with un-TBAD presenting with the above factors, however further prospective research into the optimal timing for TEVAR in un-TBAD is required.

Accessory and Cavitated Uterine Mass (ACUM) in an 18-Year-Old Woman: A Case Report and Literature Review

Background Accessory and cavitated uterine mass (ACUM) is a rare uterine anomaly newly recognized as a form of developmental Mullerian anomaly, which represents a non-communicating uterus-like mass within an otherwise normal uterus. It is a benign gynecological disease associated with severe dysmenorrhea and chronic pelvic pain, which is most common in young nullipara women, and sometimes develops in parous women. Clinical manifestations combined with imaging examinations including ultrasonography (USG), magnetic resonance imaging (MRI), and hysterosalpingography (HSG) are the means to establish a correct diagnosis. Medical therapy is only marginally effective, but laparoscopic surgery for complete mass excision is a feasible technique to relieve patient’s symptoms. Our article is aimed to report a case of ACUM in an 18-year-old woman and summarize the diagnostic criteria of ACUM. Case presentation : An 18-year-old woman was admitted for severe pain in the right lower abdomen during menstruation, which lasted more than 1 year. The patient was misdiagnosed with focal adenomyosis at our hospital on March 4, 2021. After 4 months, she was diagnosed with ACUM. Once diagnosis as focal adenomyosis, nonsteroidal anti-inflammatory drugs (NSAIDs) and gestrinone were administered to the patient. Following the diagnosis of ACUM, she received laparoscopic surgery. Our follow-up indicated that the symptom was significantly relief without drug therapy after sixty days postoperatively. Conclusions Clinical manifestations and imaging examinations are used to establish the diagnosis of ACUM. Medical therapy is only marginally effective, but laparoscopic surgery for complete mass excision is a feasible technique to solve the pain symptom. The prevalence and pathogenesis of ACUM and its reproductive outcomes on patients remain unclear, which calls for more and deeper research to study.