Papers by Cleante Scarduelli
Clinical cardiology and cardiovascular interventions, Jan 7, 2022
Infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and the res... more Infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and the resulting syndrome, COVID-19, have been associated with inflammation and a prothrombotic state, with increases in fibrin, fibrinogen, fibrin degradation products and D-dimers. In some studies, elevations in these markers have been associated with worse clinical outcomes. Several studies have demonstrated a high prevalence of venous thromboembolism (VTE), and pulmonary embolism (PE), particularly in patients admitted to the intensive care unit (ICU), even in those receiving prophylactic anticoagulation. The high rate of thrombosis in COVID-19 is driven by at least two interrelated processes: a hypercoagulable state responsible for large-vessel thrombosis and thromboembolism and direct vascular and endothelial injury responsible for in situ microvascular thrombosis. The presence of PE and pulmonary thrombosis may explain why hypoxemia is out of proportion to impairment in lung compliance in some patients with COVID-19 pneumonia. Diagnosing PE in patients with COVID-19 pneumonia may be challenging, because the two pathologies share many signs and symptoms. It has been demonstrated that the administration of prophylactic anticoagulation within 24 h of admission in patients with COVID-19 was associated with decreased mortality when compared with no prophylactic anticoagulation. Given the antithrombotic, anti-inflammatory and possibly antiviral properties of heparins, it has been hypothesized that anticoagulation with heparin administered at doses higher than conventionally used for venous thromboprophylaxis may improve outcomes. In non-critically ill patients hospitalized with COVID-19, therapeutic-dose anticoagulants with heparin (most commonly, low-molecular-weight heparin) increased the probability of survival until hospital discharge with a reduced need for ICU-level organ support at 21 days as compared with usual-care thromboprophylaxis. In Critically ill patients with confirmed COVID-19, therapeutic-dose anticoagulation did not increase the probability of survival to hospital discharge or the number of days free of cardiovascular o respiratory organ support and had a 95% probability of being inferior to usual-care pharmacologic thromboprophylaxis. Currently, randomized trials evaluating the use of tissue plasminogen activator and Tenecteplase in patients with COVID-19 ARDS are underway.
Internal and Emergency Medicine, Mar 21, 2008
Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynam... more Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynamic variables that cannot be recorded from a peripheral vein. However, the method can involve complications. In cardiac surgery, CVCs are electively placed in the right internal jugular vein but there is little information on deep venous thrombosis (DVT) in catheterized veins (CVC-related DVT) or on secondary pulmonary embolism (PE). The impact of CVC-related DVT and PE in cardiac surgery and measures to prevent PE were assessed. We used ultrasonography (US) to check the point of insertion of CVC in 815 patients in the intensive cardiac rehabilitation unit after heart surgery. In this series, 386 patients (48%) had CVC-related DVT; those already receiving anticoagulant, and considered at low risk, continued that therapy, while those taking an antiplatelet agent (aspirin 100 mg daily) but deemed at high risk of PE from the US findings were given an anticoagulant instead. Only patients with CVC-related DVT at low risk of PE continued taking aspirin. At 3 months, there were no cases of PE among patients receiving an anticoagulant, but six on antiplatelet had non-fatal PE. The prevalence of PE in the whole series of 815 patients was 0.7%. CVC-related DVT is a frequent complication of heart surgery. Anticoagulant therapy started early does not prevent thrombus formation but probably prevents PE, whereas antiplatelet gives no such protection. Sonographic screening of the CVC removal in intensive care unit may be useful for avoiding PE after CVC-related DVT.
Background: Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism... more Background: Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE) due to inflammation, hypoxia, immobilization, and diffuse intravascular coagulation, despite standard thrombopropylaxis. Our retrospective study reports the incidence of pulmonary embolism (PE) in patients with COVID-19 and severe respiratory failure(SRF) treated with intermediate to full-dose enoxaparin. .Methods: This retrospective case series analysed data from patients with COVID-19 pneumonia and severe respiratory failure (SRF) admitted to our Respiratory Intensive Care Unit (RICU) between February 27 and April 20, 2020 for non-invasive positive-pressure ventilation. All patients received at least intermediate-dose enoxaparin (40 mg twice daily). If PE was suspected or diagnosed, patients were treated with full-dose enoxaparin (1 mg/kg twice daily). Computed tomography pulmonary angiography (CTPA) was used to detect PE in patients with elevated D-dimer levels (> 3000 ng/mL...
Rassegna di Patologia dell'Apparato Respiratorio, Jun 15, 2014
Life, 2022
In Winter 2020, Italy, and in particular the Lombardy region, was the first country in the Wester... more In Winter 2020, Italy, and in particular the Lombardy region, was the first country in the Western hemisphere to be hit by the COVID-19 pandemic. Plasma from individuals recovered from COVID-19 (COVID-19 convalescent plasma, CCP) was the first therapeutic tool adopted to counteract the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In this retrospective cohort study, we report the experience of the city hospital of Mantua, Lombardy region, on the compassionate use of CCP in patients hospitalized for severe COVID-19. Between April 2020 and April 2021, 405 consecutive COVID-19 patients received 657 CCP units with a median anti-SARS-CoV-2 neutralizing antibody (nAb) titer of 160 (interquartile range (IQR), 80–320). Their median age was 68 years (IQR, 56–78 years), and 62% were males. At enrollment, 55% of patients had an increased body mass index (BMI), and 25.6% had at least three comorbidities. The 28-day crude mortality rate was 12.6% (51/405). Young age (<68 years...
Introduzione. L’attivita pneumologica in regione Lombardia risulta molto ricca e variegata in ter... more Introduzione. L’attivita pneumologica in regione Lombardia risulta molto ricca e variegata in termini di appropriata capacita di network. Molti DRG pneumologici vengono prodotti da unita operative di Medicina Interna, Geriatria e Riabilitazioni.Scopo. AIPO Lombardia, insieme con Regione Lombardia, ha proposto un questionario real life che indagasse i volumi di attivita dedicati ai DRG respiratori.Metodi. Le unita ospedaliere e ambulatoriali di strutture semplici e complesse della Lombardia hanno ricevuto un questionario che invitava a rilevare l’attivita svolta in un periodo di 2 diverse settimane. L’indagine includeva 45 temi/argomenti con i seguenti aspetti: dati generali; numerosita del personale in servizio; casistica; numerosita delle diagnosi; procedure eseguite; peso assistenziale; numero prestazioni fisiopatologiche e di Pneumologia Interventistica.Risultati. Hanno risposto 56 strutture delle 71 interpellate (79%) fra cui Pneumologie, Riabilitazioni Respiratorie, Pneumologie...
Rassegna di Patologia dell'Apparato Respiratorio
Chronic Obstructive Pulmonary Disease (COPD) is inextricably linked with cardiovascular disease f... more Chronic Obstructive Pulmonary Disease (COPD) is inextricably linked with cardiovascular disease from diagnosis to death. About 30% of patients with COPD have ischemic heart disease, about 20% have heart failure and the large majority of them have significant cardiac arrhythmias. Cardiovascular diseases in patients with COPD are in large parte due to atherosclerosis. The pathogenesis of atherosclerosis is complex and multifactorial and some risk factors are shared with COPD. Persistent low-grade systemic inflammation, found in COPD patients, is believed to be one of the centrepiece events leading to plaque formation. Intra-thoracic pressure modifications induced by respiratory activity, in particular in patients with COPD, can profoundly alter cardiovascular function via complex, conflicting and often opposite processes. Patients with COPD and lung hyperinflation have an impaired left ventricular diastolic filling pattern which has an independent effect on exercise tolerance. Cardiov...
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo, 2003
Venous thromboembolism encompasses deep venous thrombosis (DVT) and pulmonary embolism (PE), whic... more Venous thromboembolism encompasses deep venous thrombosis (DVT) and pulmonary embolism (PE), which represent different manifestations of the same disease process. Recent epidemiological studies confirm that DVT is a major health problem and that survival after pulmonary embolism is much worse than previously thought. Our understanding of the risk factors and natural history of DVT has undergone considerable evolution in recent years, influencing the clinical management of this epidemic disease. Known risk factors for DVT have been focused on hospitalised patients so that they have about 100-fold higher risk of developing DVT compared with non hospitalised people. So it is crucial for every hospital to develop its own strategy for prevention, diagnosis, treatment and follow-up of patients with DVT. It is now recognised that DVT is a chronic disease, given the high percentage of recurrences after the initial event. The possible modality to decrease the morbidity and mortality followin...
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo, 1994
The complications of endotracheal intubation are particularly frequent in patients with obstructi... more The complications of endotracheal intubation are particularly frequent in patients with obstructive sleep apnoea syndrome (OSAS). We prospectively tested nasal ventilation in such patients admitted for acute respiratory failure. Six consecutive patients, aged 17-70 yrs, were selected for the study. All patients were confused or severely obtunded, Glasgow Coma Score (GCS) 10 (SD 2). With nasal bi-level positive airways pressure (BiPAP) all these patients improved clinical status and arterial blood gas values, avoiding intubation and invasive mechanical ventilation. The median pH increased from 7.26 (SD 0.06) to 7.36 (0.01) and to 7.43 (0.02) after, 1-3 and 24 h of nasal ventilation, respectively. Nasal ventilation lasted an average of 21 (3) h on the first day. All patients were discharged home after a median hospital stay of 28 (11) days.
Cardiologia (Rome, Italy), 1991
The aim of this study was to assess: frequency and type of cardiac arrhythmias in patients with s... more The aim of this study was to assess: frequency and type of cardiac arrhythmias in patients with severe stable chronic obstructive lung disease (COLD) and chronic respiratory failure (CRF); diurnal or nocturnal predominance of the detected arrhythmias; prospective relationships between arrhythmias and nocturnal hypoxemic-hypercapnic episodes. All patients were examined with careful and complete medical history, chest roentgenogram, standard electrocardiogram, mono and bidimensional echocardiogram, respiratory function tests, arterial blood gases at rest, 24-hour dynamic electrocardiographic recording and, simultaneously, transcutaneous nocturnal monitoring of respiratory gases (TCNM). We studied 14 men: all complained of exercise-induced dyspnoea for 8 +/- 6 years; 10 of them reported usual nocturnal snoring. Respiratory function tests provided the following values (expressed in percentage compared with theoretical ones): vital capacity 58.6 +/- 15, forced expiratory volume/s 36 +/- ...
Long-Term Oxygen Therapy, 2012
Scientific evidence for the therapeutic benefits of long-term oxygen therapy (LTOT) in patients w... more Scientific evidence for the therapeutic benefits of long-term oxygen therapy (LTOT) in patients with hypoxemia due to chronic obstructive pulmonary disease (COPD) is based on two landmark prospective randomized clinical studies published about thirty years ago [1–2].
Internal and Emergency Medicine, 2008
Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynam... more Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynamic variables that cannot be recorded from a peripheral vein. However, the method can involve complications. In cardiac surgery, CVCs are electively placed in the right internal jugular vein but there is little information on deep venous thrombosis (DVT) in catheterized veins (CVC-related DVT) or on secondary pulmonary embolism (PE). The impact of CVC-related DVT and PE in cardiac surgery and measures to prevent PE were assessed. We used ultrasonography (US) to check the point of insertion of CVC in 815 patients in the intensive cardiac rehabilitation unit after heart surgery. In this series, 386 patients (48%) had CVC-related DVT; those already receiving anticoagulant, and considered at low risk, continued that therapy, while those taking an antiplatelet agent (aspirin 100 mg daily) but deemed at high risk of PE from the US findings were given an anticoagulant instead. Only patients with CVC-related DVT at low risk of PE continued taking aspirin. At 3 months, there were no cases of PE among patients receiving an anticoagulant, but six on antiplatelet had non-fatal PE. The prevalence of PE in the whole series of 815 patients was 0.7%. CVC-related DVT is a frequent complication of heart surgery. Anticoagulant therapy started early does not prevent thrombus formation but probably prevents PE, whereas antiplatelet gives no such protection. Sonographic screening of the CVC removal in intensive care unit may be useful for avoiding PE after CVC-related DVT.
Internal and Emergency Medicine, 2009
We greatly appreciate the comments and questions raised by Squizzato and Al. to our study ‘‘Upper... more We greatly appreciate the comments and questions raised by Squizzato and Al. to our study ‘‘Upper extremities DVT and pulmonary embolism after cardiac surgery. A prospective-observational trial’’ [1]. We agree on some methodological weaknesses that may emerge from our paper, but our study was designed with the objective of evaluating the true incidence of catheterrelated deep venous thrombosis (DVT) in a population selected after cardiac surgery admitted to a cardiac rehabilitation, after the catheter had been removed. The primary focus of the scientific community has been mainly upon upper extremity DVT in the oncological population, which certainly presents relevantly different requirements for a prolonged placement of the catheter, medication used and biological characteristics. On the formation of thrombus, several authors [2–4] have made plausible hypotheses: the traumatic mechanical event generated by insertion and maintenance of the catheter in the vessel is the cornerstone element in the genesis of DVT, rather than the intervention of other types of immunological factors. Our experience has been that the mere removal of the catheter will, in most of cases, contribute to a rapid and complete resolution of DVT. ACCP guidelines [5] highlight the need for prevention of DVT, but only in CABG (coronary artery bypass graft), assuming that valvular surgery requiring anticoagulation therapy will be adequately protected from thromboembolic pulmonary disease; on the contrary, our research shows that anticoagulant therapy is able to prevent symptomatic pulmonary embolism, but not central venous catheter (CVC)-related DVT. We have no evidence to satisfy the question of Squizzato et Al. concerning the role of anti-PF4/heparin antibody in CVC-related DVT; in some critical thrombocytopenic patients, who are anti-PF4/heparin antibody positive, are indeed negative for thrombosis. The search for other thrombogenic cofactors, as for instance inflammatory mediators, is inevitably contaminated by the surgery itself, as a consequence, this will affect anything that involves the event itself as for example extracorporeal circulation, invasive mechanical ventilation and anti-inflammatory drugs. We believe that high incidence of thrombotic events in the upper extremities from CVC-related problems after cardiac surgery, mostly asymptomatic, is clinically relevant as are all other venous thrombosis because of the high fatality rate from pulmonary embolism, and the large number of cases not recognized before the patient’s demise. It is probably true that CVC-related DVT, diagnosed by ultrasound (US) screening, after previous removal of the CVC, could be an advantageous step in the clinical strategy. If there are no absolute contraindications, anticoagulation therapy can be administered for thrombosis if not already being given for surgical indications, with echocardiographic follow-up in the presence of any kind of pericardial effusion, including small ones. In our experience, treatment with warfarin administered for 3 months has resolved any thrombosis. While waiting for new evidence, anticoagulant prophylaxis still seems to be the only therapy that is useful for CVC-related thrombosis. We hope that the questions arising in our work may also be stimulating to future research concerning the scientific R. Frizzelli (&) O. Tortelli V. Di Comite R. Ghirardi C. Pinzi C. Scarduelli Multifunctional Rehabilitation, Bozzolo Hospital, Viale 25 Aprile n. 71, 46012 Bozzolo (MN), Italy e-mail: [email protected]
Respiratory Medicine, 1998
The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary... more The role of non-invasive nocturnal domiciliary ventilation (NNV) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnia is still discussed. The aims of this study were to evaluate the long-term survival, the clinical effectiveness and side-effects of NNV in these patients. Forty-nine stable hypercapnic COPD patients on long-term oxygen therapy (LTOT) were assigned to two groups: in Group 1, 28 patients performed NNV by pressure support modality in addition to LTOT; in Group 2, 21 patients continued their usual LTOT regimen. Treatment was assigned according to the compliance to NNV, after an in hospital period. Mortality rate, hospital stay (HS) and ICU admissions (IA) were recorded in the two groups. HS and IA were compared to those recorded in a similar period of follow-back. Lung and respiratory muscle function, dyspnoea, and exercise capacity (by 6-min walk test) were evaluated baseline and every 3-6 months up to 3 yr. Mean follow-up time was 35 f 7 months. Mortality rate was not different between the two groups: 16, 33, 46% and 13, 28, 50% at 1, 2 and 3 yr in Groups 1 and 2 respectively. Lung and respiratory muscle function did not significantly change over time. A significant increase in 6-min walk test (from 245 * 78 to 250 It 88, 291 & 75, 284 ZIZ 89 m after 1, 2 and 3 yr respectively, PcO.01) was observed only in patients undergoing NNV. In comparison to the follow back HS significantly decreased in both groups (from 37 & 29 to 15 & 12 and from 32 + 18 to 17 & 11 days/pt/yr in Groups 1 and 2 respectively, P<O.OOl) whereas IA significantly decreased only in patients performing also NNV (from 1.0 rt 0.7 to 0.2 f 0,3/pt/yr, P<O.OOOl). Addition of NNV by pressure support modality to LTOT does not improve long term survival but significantly reduces ICU admissions and improves exercise capacity in severe COPD with hypercapnia.
European Respiratory Journal, 2002
The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease... more The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients.
European Journal of Internal Medicine, 2009
Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease leadin... more Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease leading to worsening functional status and reduced survival for those patients who cannot undergo pulmonary endarterectomy (PEA). Pharmacotherapy with novel drugs for pulmonary hypertension may be useful in treating patients who are poor candidates for surgery, but there are still few clinical data on medical therapy for CTEPH. The aim of this prospective open-label, multicenter, study is to compare the efficacy of 1-year bosentan treatment to standard drugs in nonoperated patients with CTEPH. Patients and methods: Thirty-four nonoperated patients with CTEPH were enrolled. Functional assessment included 6 minute walk test (6MWT), Borg index, WHO classification, arterial blood gases and echocardiography systolic pulmonary artery pressure (sPAP). Seventeen patients received bosentan (62.5 mg bid for 4 weeks and then 125 mg bid); 17 patients were treated with standard therapy alone. Results: At admission sPAP was 76.18 +/− 5.96 mmHg in bosentan group and 71.48 +/− 3.71 mmHg in controls, p a O 2 64.68 +/− 2.25 mmHg in bosentan group, and 59.52 +/− 2.05 mmHg in controls, 6MWT 297.53 +/− 34.25 mt in bosentan group, and 268.47 +/− 36.54 mt in controls. After 12 months there were significant differences between the groups in the 6MWT (+ 57.24 +/− 22.21 m vs −73.13 +/− 21.23 m, p b 0.001), dyspnoea index (Borg score 4.29 +/− 0.49 vs 7.06 +/− 0.32, p b 0.001) and oxygenation (p a O 2 65.93 +/− 3.76 mmHg vs 48.48 +/ − 1.31 mmHg, p b 0.001). The sPAP was stable after 12 months of bosentan (76.18 +/− 5.96 mmHg vs 71.00 +/− 5.41 mmHg, p = 0.221) in contrast to controls (71.48 +/− 3.71 mmHg vs 80.44 +/− 4.70 mmHg, p = 0.029). Conclusion: The data of this open-label study in nonoperated CTEPH patients suggest an improvement in functional outcomes adding Bosentan to diuretics and oral anticoagulants. No improvement was observed using only standard drugs after 1-year.
CHEST Journal, 2014
PURPOSE: Our purpose is to describe clinical presentation and diagnostic approach in 5 patients p... more PURPOSE: Our purpose is to describe clinical presentation and diagnostic approach in 5 patients presenting with upper extremity deep vein thrombosis (UEDVT) central venous catheters (CVC)-related and pulmonary embolism after cardiac surgery METHODS: We report clinical caracteristics, diagnostic approach, management and evolution of 5 patients consecutively admitted to our Cardiopulmonary Rehabilitation Unit. RESULTS: Clinical caracteristics of the patients at diagnosis were (beginning from the left column) : 1-Name, 2-sex, 3-age, 4-type of surgery, 5-days after surgery. 6systolic pulm. pressure (mmHg), 7-PaO2(mmHg), 8-PaCO2(mmHg), 9-pH G.
Italian heart journal : official journal of the Italian Federation of Cardiology, 2004
BACKGROUND Cardiovascular complications are frequently observed in patients with chronic obstruct... more BACKGROUND Cardiovascular complications are frequently observed in patients with chronic obstructive pulmonary disease (COPD) admitted to respiratory intensive care units and may affect the prognosis. The aims of this study were to evaluate a) the prevalence of cardiovascular complications in patients with COPD exacerbation admitted to respiratory intensive care units, b) which parameters detected at admission were predictive of cardiovascular complications, and c) the prognostic role of cardiovascular complications. METHODS A series of 278 consecutive patients with COPD admitted to 11 Italian respiratory intensive care units between November 1997 and January 1998 has been retrospectively analyzed. All cardiovascular complications were recorded. RESULTS One hundred and ten patients (39.6%) developed cardiovascular complications: congestive heart failure 49 (17.6%), arrhythmias 40 (14.4%), shock 13 (4.7%), and hypotension 11 (4%). Multivariate analysis showed that the APACHE II score...
Coronavirus disease (COVID-19) may predispose patients to pulmonary embolism (PE), despite standa... more Coronavirus disease (COVID-19) may predispose patients to pulmonary embolism (PE), despite standard thromboprophylaxis. Our retrospective study aimed to report the prevalence of PE in patients with COVID-19 and severe respiratory failure (SRF) treated with intermediate- to full-dose enoxaparin. We analyzed data from patients with COVID-19 pneumonia and SRF admitted to our Respiratory Intensive Care Unit (RICU) from February 27 to April 20, 2020. All patients received at least intermediate-dose enoxaparin (40 mg twice daily). Computed tomography pulmonary angiography (CTPA) was used to detect PE. Ninety-two patients with COVID-19 pneumonia and SRF were admitted to our RICU. Twenty-two patients underwent CTPA (24 %), 11 of whom had PEs (12%). We hypothesize that the enoxaparin treatment may be responsible for the lower prevalence of PE as compared to previous reports of similar patients, even if our report had several limitations, mainly the small sample size.
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Papers by Cleante Scarduelli