Low-density lipoprotein cholesterol (LDL-C) plays a crucial role in the development of atherosclerosis. Statin therapy is the standard treatment for lowering LDL-C in primary and secondary prevention. However, some patients do not reach optimal LDL-C target levels or do not tolerate statins, especially when taking high doses long-term. Combining statins with different therapeutic approaches and testing other new drugs is the future key to reducing the burden of cardiovascular disease (CVD). Recently, several new cholesterol-lowering drugs have been developed and approved; others are promising results, enriching the pharmacological armamentarium beyond statins. Triglycerides also play an important role in the development of CVD; new therapeutic approaches are also very promising for their treatment. Familial hypercholesterolemia (FH) can lead to CVD early in life. These patients respond poorly to conventional therapies. Recently, however, new and promising pharmacological strategies have become available. This narrative review provides an overview of the new drugs for the treatment of dyslipidemia, their current status, ongoing clinical or preclinical trials, and their prospects. We also discuss the new alternative therapies for the treatment of dyslipidemia and their relevance to practice.
Background: The aim of our study was to determine the feasibility and efficacy of transaxillary (TAX) TAVI in patients not eligible for the transfemoral route. Methods: This is a retrospective study of a single center. We analysed 262 patients treated with TAVI. In 17 patients (6.5%), the procedure was performed with the TAX approach. Procedural and hospital data, 30-day safety, and clinical efficacy were assessed and compared between the transfemoral and TAX groups. Results: In the TAX groups, we found a higher prevalence of men (p = 0.001), smokers (p = 0.033), and previous strokes (p = 0.02). The EUROSCORE II was higher in the TAX group (p = 0.014). The success rate of the device was 100%. TAX was associated with a longer procedure time (p = 0.001) and shorter median device time (p = 0.034) in minutes. Patients treated with TAX had a longer hospital stay (p = 0.005) and higher overall bleeding rate (p = 0.001). Peripheral neurological complications were more frequent with TAX (p = 0.001), which almost completely resolved by 30 days. Conclusions: TAX TAVI is safe and effective and should be considered as a second choice when transfemoral TAVI is not feasible due to severe comorbidities.
Background Transcatheter edge-to-edge repair (TEER) with the MitraClip system is an alternative procedure for the treatment of severe mitral regurgitation (MR) in high-risk patients who are not suitable for conventional surgery and is usually performed under general anaesthesia (GA). GA may be associated with potential haemodynamic complications. A new alternative approach is deep sedation (DS) with spontaneous breathing using a target-controlled infusion (TCI). The aim of this study is to compare TCI during DS with manual administration of total intravenous anaesthesia (TIVA) during GA in patients undergoing TEER evaluating the impact of these approaches on anaesthesia time, remifentanil dose administered, haemodynamic profile, vasopressor requirements, adverse events and postoperative hospital stay. Methods The study population included 90 consecutive patients treated with MitraClip (mean age 73.5 ± 9.54 years). 65 patients (72%) suffered from functional MR. Mean LVEF was 35 ± 13% and logistic EuroSCORE was 23 ± 19%. 24 patients received GA and TIVA; 66 patients underwent DS and TCI, consisting of administration of midazolam and fentanyl citrate as induction of anaesthesia followed by continuous infusion of remifentanil hydrochloride. Results Acute procedural success was 100%, with no major complications during the procedure. No statistical differences were found between the GA-TIVA and the DS-TCI group in terms of demographics and surgical risk profile. Anaesthesia time was significantly shorter in the DS-TCI group (71 ± 30 vs. 118 ± 35 minutes; p < 0.0001), as was procedure duration (54 ± 29 vs. 99 ± 74 minutes; p = 0.00007). In addition, there was a significant reduction in the remifentanil dose administered (249 µg vs. 2865 µg, p < 0.01), the incidence of hypotension (p = 0.08) and the need for vasopressors (29.6% vs. 63%, p = 0.03) in the DS-TCI group. There were no differences in days of hospital stay after the procedure (5.4 days vs. 5.8 days, p = 0.4). Conclusions DS with spontaneous breathing using TCI could be a valid alternative during TEER which can ensure stable anaesthetic conditions, less drug administration, higher haemodynamic stability and fewer side effects, with particular advantages in patients at high risk for general anaesthesia.
Background Chronic kidney disease (CKD) has been shown to impact negatively the prognosis of patients with heart failure, coronary artery or valvular heart disease and emerged as predictor of poor outcomes in mitraclip population. Purpose Aim of our study was to evaluate three-year echocardiographic outcomes in CKD patients with severe mitral regurgitation (MR) treated with mitraclip. Methods This in an observational study including patients treated with mitraclip in our institution, who completed three years of follow up. Patients population was divided into two groups according to basal creatinine clearance (CrCl): group A, including patients with normal/mild decline of renal function (CrCl > 60 ml/min) and group B, including patients with CKD (CrCl < 60 ml/min). Demographic and procedural characteristics were compared, as well as echocardiographic data, including grade of MR, left ventricular ejection fraction (LVEF), mean transmitral gradient and systolic pulmonary artery pressure (sPAP). Kaplan-Meier survival curves were obtained. Results The study population consists of 107 patients (mean age 71 ± 9 years, 69% male): 57 belonging to group A and 50 to group B. Patients of group B had higher values of LogEuroScore (22 ± 10 vs.15 ± 9 p = 0,0002), systemic hypertension (92% vs. 74%, p = 0,026), complicated diabetes (46% vs. 24% p = 0,034) and NYHA IV before the procedure (24% vs 9 %, p = 0,059). Additionally, patients of group B had lower baseline LVEF (35 ± 11 vs. 41 ± 13; p = 0,012). Procedural success was similar between the two groups without significant difference in degree of MR reduction after mitraclip implantation. Echocardiographic follow-up showed that in group B, the LVEF did not improve after the treatment (more than 50% had LVEF < 35% at 1,2 and 3 years) while in the group A it improved significantly (LVEF < 35% from 47,6% at discharge to 29%, 32% and 31% at 1, 2 and 3 years, respectively). In comparison to group A, in group B a progressive increase in residual MR grade was observed (moderate-to-severe MR from 2% at discharge to 14%, 15%, and 27% at 1, 2 and 3 years, respectively) as well as in the mean transmitral gradient (from 3,90 ±1,6 mmHg after the mitraclip implantation to 5,28 ± 1,7; 5,73 ± 1,75; 6,06 ±1,75 at 1, 2 and 3 years, respectively) and sPAP (from 47 ± 12 mmHg at discharge to 49 ± 21; 51 ± 20; 48 ± 22 at 1, 2 and 3 years, respectively). Kaplan Meier estimate of survival free from in-hospital readmission was 77% in group A and 61% in group B (Log-Rank 4.563, p = 0,033) and survival free from cardiovascular death was 95% and 81,5%, in group A and B, respectively (Log-Rank 4.806, p = 0,028). Conclusion Our results suggest that CKD patients have poorer outcomes after mitraclip implantation with worsening of some echocardiographic parameters, particularly for residual MR degree, mean transmitral gradient and sPAP, without improvement in LVEF at one, two and three years of follow-up.
Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. Normally there are two main coronary arteries, which stem from the sinuses of Valsalva and descend towards the cardiac apex. The most frequent anomalous origin of the coronary arteries associated with sudden cardiac death is the anomalous origin of a coronary artery from the contralateral sinus, particularly if the anomalous coronary artery has a course between the aorta and the pulmonary artery. The diagnosis of a coronary artery anomaly is insidious since patients are usually asymptomatic. Indeed, in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure, and myocardial infarction may occur. We want to describe the case of a 54 years old man who went to another hospital of our district with chest pain. The EKG showed an infero-lateral STEMI. The patient underwent systemic thrombolysis complicated by arrhythmic storm, treated with effective DC shock, then he was urgently transferred to our Hospital to perform a PCI rescue. The coronary angiography showed a critical stenosis of the right coronary artery, treated with the implantation of a zotarolimus-eluting coronary stent system. Surprisingly, an abnormal origin of the anterior interventricular artery and circumflex artery from seperated hosts in the right coronary sinus was detected. A computed tomography showed the separated origin of the right coronary artery and the left main from the right coronary sinus; moreover, the left main presented a retroaortic course between the bulb and the left atrium; the left anterior intraventricular artery run anterior to the aortic root. During hospitalization, a diagnosis of diabetes was made with consequent setting of adequate hypoglycemic therapy. Serial echocardiograms showed an improval in the ejection fraction (from 35–40% to 50%). The patient was discharged in well clinical conditions and 1 month later at the follow-up, during an outpatient visit, he was fully asymptomatic. The dynamic EKG according to Holter showed rare isolated ventricular beats; laboratory tests were normal. The anomalous origin of a coronary ostium from the contralateral sinus is the most frequently anomaly which is associated with sudden cardiac death, in particular when the left coronary artery origins from the right sinus. The rapid advancement of the imaging techniques, including CT, CMR, intravascular ultrasound, and optical coherence tomography, have provided us with a wealth of new information on this subject. Coronary artery CT offers the best performance in terms of spatial resolution, acquisition time, and image contrast but the use is limited due the dose of ionizing radiation and the use of contrast agents, in particular taking into account that most patients are young. CMR is capable of visualizing the origin of the coronary arteries non-invasively, without use of ionizing radiation and contrast agents. Currently however, due to spatial resolution, the capability of CMR to visualize smaller coronary branches is still a limiting factor preventing full assessment of coronary arteries using this modality. Developments and more widespread access to advanced cardiac imaging will undoubtedly lead to earlier diagnoses. The taxonomies of the anomalous origin of coronary arteries are inconsistent and complex and so we want to make our contribution to the register of cases of abnormal origin of coronary arteries for the risk of sudden cardiac death and ischaemic events related to.
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