Cardiology and Cardiovascular Medicine Unit
A little bit of history…
Today’s Cardiology and Cardiovascular Medicine Unit results from the union of the two historical Units of the Institute of Clinical Physiology founded by Prof. Luigi Donato in 1969 (since 2007 an integral part of the Fondazione Toscana G. Monasterio): the famous “Coronary Department”, the Coronary/Cardiology Unit directed in order by Attilio Maseri, Antonio L’Abbate, Daniele Rovai and the Electrophysiology, Cardiostimulation and Failure Unit then Cardiovascular Medicine directed, respectively, by Carlo Contini, Andrea Biagini and Michele Emdin.
The activity is carried out in the clinical, research and training spheres at the Monasterio facility in Pisa, as part of the overall activities of the Cardio-Thoracic Department, in close liaison with the units operating at the Massa facility (Cardiac Surgery Unit, Diagnostic and Interventional Cardiology Unit, Medical and Surgical Cardiac Pathologies Unit, Paediatric and Adult Congenital Cardiology Unit).
The Unit’s activity is unique and characterised by its clinical, scientific research, training and contribution to the system redesign of care processes not only at local health authority level, but also at association of local health districts and regional level, with the use of advanced digital health and telemedicine tools.
The patient is considered in his or her entirety, not only in relation to the disease problem that requires a diagnostic and therapeutic pathway, but as a person with the emotional suffering that the impaired health state entails.
The activity is carried out on the basis of intensity of care in the inpatient ward, with six beds in the ICU and two sub-intensive care units with twelve continuously monitored beds, for a total of 45 beds, shared with the Respiratory medicine unit, with continuity of care thanks to the activity of the Multi-specialist Outpatient Department and the Day-Service and Day-Hospital activity, which ensures the execution of diagnostic packages for every problem (hypertension, heart failure, cardiovascular risk, cardiomyopathies, ischemic heart disease, arrhythmic heart disease, atrial fibrillation/flutter, other arrhythmias, etc.).
The strategies and organisation of the unit, in its clinical, research and training functions, have always been the subject of discussion and sharing between Prof. Michele Emdin and Prof. Claudio Passino in the daily dialogue with all the members, with the Foundation’s General, Administrative and Health Management and with the Directors of the Departments and the other sister units.
The ethos is that of teamwork, with doctors, nurses, technicians, administrative and secretarial staff working as a team in the diagnostic and therapeutic pathway of each patient, thanks to the collaboration with the SITRA Unit (Dr Marco Vaselli, Inpatient Nursing Coordinators Dr Maila Lazzerini, Outpatient Specialist Imaging Unit Dr Michela Romano, Technical Coordinator Dr Micaela Papini).
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Clinical activity is patient-centred and geared towards the criteria of continuous cultural updating and appropriateness as well as clinical and translational research. The areas covered are:
- cardiovascular risk conditions, with screening and diagnostic work, especially in outpatient and day-service settings (dyslipidaemia, diabetes mellitus, arterial hypertension, genetically determined conditions predisposing to atherosclerotic disease, sudden death, cardiomyopathies), under the supervision of Dr Emilio Pasanisi, in collaboration with the Molecular Cardiology Unit, with the Lipoapheresis Unit for cases of familial dyslipidaemia
- overt cardiovascular pathology, with screening and diagnostic work, especially in outpatient, day-service and inpatient settings, under the supervision of Prof. Claudio Passino, for acute management, in collaboration with the 118 service of the AVNO and with the Emergency Department/Emergency Medicine Unit and the AOUP University Emergency Medicine Unit, in coordination with the Diagnostic and Interventional Cardiology Unit, the Interventional Electrophysiology Unit and the Respiratory Medicine Unit.
- ischaemic heart disease related to atherosclerotic and non-atherosclerotic macro- and microvascular coronary artery disease, the classification of which makes use of the most refined invasive and non-invasive tools (stress echo, nuclear cardiology, coronary angio-CT, stress CMR, OCT, FFR, IVUS),
- peripheral atherosclerotic disease, epiaortic vessels, renal arteries, arteries of the lower limbs with percutaneous transradial revascularisation integrated with coronary revascularisation, thanks to the special expertise of the Diagnostic and Interventional Cardiology Unit. In this context, there is extensive collaboration and discussion with internal medicine and the AVNO diabetologists.
- supraventricular and ventricular arrhythmogenic cardiomyopathies, with the possibility of performing endocavitary electrophysiological studies and ablation procedures using the most up-to-date methods, in conjunction with the overall diagnostic/therapeutic classification of the cardiomyopathy, and of the underlying clinical situation, to which two specific outpatient clinics have been dedicated:
- Cardiomyopathy* outpatient clinic, dedicated to the diagnosis and treatment of patients suffering from dilated, hypertrophic, arrhythmogenic cardiomyopathy and other rarer forms such as restrictive and non-compaction cardiomyopathies;
- Channelopathy outpatient clinic in collaboration with the Interventional Electrophysiology Unit.
- The identification and management of cardiac involvement in the context of hereditary myopathies takes place in collaboration with the Neurology Unit headed by Prof. Gabriele Siciliano in the AOUP.
- Particular attention has been paid to cardiac involvement from chemotherapy or radiotherapy treatments in the course of cancer with the establishment of a CardiOncology Outpatient Clinic, coordinated by Dr. Iacopo Fabiani.
- Modern Next Generation Sequencing equipment in the Molecular Cardiology Laboratory of the Laboratory Medicine Unit enables diagnostic definition of the disease genotype. The Unit has also promoted (JUST Project, supported by the Pisa Foundation) a Regional Registry of Juvenile Sudden Death in collaboration with the Forensic Medicine of the University of Pisa (Prof. Marco Di Paolo) and the University of Florence (Prof. Iacopo Olivotto and Elisabetta Cerbai).
- complex cardiovascular disease worthy of multispecialist classification at a Level III Center, for example:
- Diagnostic-therapeutic path, coordinated by Dr Chrysanthos Grigoratos, for myocarditis, myopericarditis in the aetiological characterisation phase, possibility for complementary virological, microbiological, and instrumental (with CMR and nuclear imaging) classification, in collaboration with the units involved and pathology, especially with an endomyocardial biopsy approach (collaboration with Diagnostic and Interventional Cardiology Unit and the AOUP Experimental Pathology Department), as well as multi-specialist aetiological classification (infectious and rheumatological/immunoallergological)
- dilated, hypertrophic, infiltrative cardiomyopathy in correlation with the internal medicine, haematology, nephrology, immunology, microbiology and rheumatology specialist units of the university hospital centre and with other regional and national reference centres.
Clinical classification benefits from close collaboration with the respiratory, metabolic, endocrinological, anaesthesiological, radiological and imaging departments present within the Monasterio:
- the management of patients with chronic liver disease with an indication for liver transplantation, and patients referred from the Liver Surgery and Liver Transplantation Unit of the AOUP are assessed from a cardiological point of view with the help of the Monasterio’s Diagnostic Imaging Unit for proper prognostic stratification
- management of heart failure:
- Unit that functions to coordinate the activities of dedicated Integrated Home Care in the Pisa area, in increasing collaboration with the General Practitioners Regional Association
- Refractory unit with classification in the Advanced Heart Failure Outpatient Clinic coordinated by Dr. Valentina Spini and Dr. Alessandro Valleggi (in line with the patient’s transition towards an intervention (TAVI, percutaneous mitral intervention, VAD implant or heart transplant, in collaboration with the Siena Centre), or palliative care with collaboration in the context of end-of-life with Integrated Home Care and Hospices (in collaboration with the Director, Dr Angela Gioia, Nordovest Local Healthcare Authority)
The excellence of our clinical activity
- has been met with recognition on a large scale (AGENAS, MES, ARS RT), in quantitative and qualitative terms
- it benefits from dedicated instrumental diagnostic clinics (in particular, Echocardiography and Stress Echocardiography, with an adjoining post-processing laboratory with Tomtech and Ecopac instruments), the Physiolab Laboratory (exercise test, cardiopulmonary test, polygraphic signal diagnosis, Holter ECG, autonomic dysfunction diagnosis, syncope diagnosis, central and obstructive apnoea diagnosis).
- it is based on multidisciplinary collaboration between cardiologists and radiologists: in particular, dr. Andrea Barison coordinates the group of cardiologists with cardiac magnetic resonance skills who carry out diagnostic activities and clinical and experimental research in the sector in collaboration with the Diagnostic Imaging Unit.
- it benefits from human resources and multidisciplinary methodologies that combine the activity of doctors with engineering, physics, IT, statistical, and epidemiological expertise and with cutting-edge diagnostic tools, contributing to and coordinating continuous innovation activities in the diagnosis and treatment process, in particular in the further development, validation and development of the computerised medical record.
Outpatients and Day Hospital activities
The outpatient clinic of the Monasterio Foundation is the place where specialist activities naturally meet and intersect for the management of patients with heart disease with and without comorbidities. Directed by Dr Roberta Poletti with the help of Dr Michela Romano (nursing coordinator), the clinic employs specialists from the Cardiology and Cardiovascular Medicine Unit, who, on a rotating basis, take care of patients in the inpatient wards and outpatient activities (clinical and instrumental).
Patients with known or suspected heart disease access the outpatient clinic following a referral from the general practitioner, or sent by specialists from the AOUP or the Nord Ovest Association of Healthcare Districts.
The most common access route is the cardiology visit. The patient can then be redirected to one of the specialist clinics (cardiomyopathies, cardiovascular medicine, channelopathies, structural heart disease, interventional cardiology, amyloidosis, arrhythmias, hypertension, cardiac surgery, GUCH) or to a general cardiology check-up. Often, the cardiology specialist is assisted by other specialists involved in the patient’s care, as occurs in the case of diabetics, those with hereditary dyslipidaemias or bronchial pathologies. The cardiology specialist can also schedule outpatient, day service, day hospital or “ordinary” hospitalisation based on the clinical indications.
The patient is again redirected to the outpatient check-up to round off the beneficial pathway at the Foundation.
Research and training
The Operational Unit of Cardiology and Cardiovascular Medicine also produces a great deal of scientific literature (more than one hundred peer-reviewed manuscripts in 2020, on topics ranging from the pathophysiology of ischaemic heart disease, cardiomyopathies and heart failure to diagnostic and therapeutic innovation) within the Foundation. It is an incubator of ideas, a nursery for young people from which the other units of the Foundation also benefit. It is the Operational Unit that ensures a formal relationship with the Scuola Superiore Sant’Anna, a strategic relationship for the Foundation in order to develop clinical and translational research strategies and higher education initiatives (it is currently referred to as tutorship by Pisan University postgraduates currently in the Foundation, Sant’Anna doctoral students, regardless of their position in terms of clinical activity).
Numerous Specialisation Schools of the University of Pisa have an agreement guaranteeing the attendance of trainee residents, bearing witness to a long tradition of clinical and research collaboration: in particular, the School of Specialisation in Internal Medicine (Prof. Agostino Virdis, and until recently Prof. Stefano Taddei), Emergency Medicine (Prof. Lorenzo Ghiadoni), and Anaesthesiology and Intensive Care (Prof. Francesco Furfori), Rheumatology (Prof. Marta Mosca), as well as the School of Specialisation in Cardiology of the University of Siena (Director Prof. Matteo Cameli). Dr Annamaria Del Franco, Dr Alberto Aimo, Ignazio Gueli, PhD students of the doctoral Course in Translational Medicine and among the Specialists trainees on rotation, including in particular Dr Chiara Borrelli and Chiara Arzilli of the School of Specialisation in Emergency Medicine (Director Prof. Lorenzo Ghiadoni), assist in the activity of the Operational Unit.
The research and teaching network into which the Cardiology and Cardiovascular Medicine Operational Unit is integrated includes the clinic *, the Scuola Universitaria Superiore Sant’Anna**, where every year some of the best students in Italy are admitted as medical students and doctoral students, the Scuola Normale Superiore, the University of Pisa, the National Research Council (Institute of Clinical Physiology), the Italian Institute of Technology – IIT- in Genoa, and international organisations, not only to other clinical and university institutions but also to industry.
With the students of the Scuola Sant’Anna in collaboration with the University of Pisa, an e-learning training project was developed and implemented that was very successful in terms of participation and popularity. There are numerous Higher Education Courses, and Level II Master’s Degrees to which the Operational Unit contributes directly through Professors Emdin and Passino, who also participate directly in the Doctoral Courses in Translational Medicine (Director Prof. Claudio Passino), and Health Science, Technology and Management (Director Prof. Michele Emdin).
The Fondazione Toscana Monasterio is also Site of the ‘BIOS’ Training Centre of the University Hospital of Parma for the American Heart Association (AHA). Emilio Pasanisi coordinates a pool of about 20 instructors (BLS and ACLS) engaged in training Monasterio personnel in collaboration with Dr Lorenza Pratali of the CNR-Regional Faculty AHA Institute of Clinical Physiology and with Dr Alberto Giannoni and Prof Claudio Passino, coordinators of SIMULABO (simulation laboratory of the Scuola Superiore Sant’Anna).
* Patient-centred hospital, small in size and mainly single-specialist (although open especially in the field of research in the oncology and neuroscience fields), with highly specialised medical skills in the fields of cardiology, respiratory medicine and cardiac surgery, diagnostic imaging and topics that make the Pisa and Massa facilities at the forefront in the country (it is worth mentioning as a peculiarity the digital clinical record developed by the doctors and medical staff with the Foundation’s IT staff (data repository since 1999), an ideal tool not only for assessing the individual patient but also the pathology, now extended outside the hospital; diagnostic imaging (nuclear medicine and cardiology, cyclotron, radiopharmacy, PET-CT, 1.5 and 3T MRI, conventional radiological and haemodynamic survey instruments, cardiac electrical mapping.
** Experimental research facilities of the CBS (Centre for Experimental Biology) at the site of the CNR campus in Pisa where experimental preparations (rodents and non-rodents, medium sized animals, rabbit, pig, guinea pig, sheep) can be safely managed and chronic/acute experimental models prepared to meet research requirements using imaging resources (micro) PET / SPECT, CT, US, Laser Doppler, photoacoustic imaging hyperpolarised imaging (DNP), repository of imaging reporters, chemistry laboratory for synthesis and characterisation of probes for different imaging modalities, radiochemistry facilities, radionuclide production (cyclotron 16 MeV), small and large acute/chronic animal studies (radiology, invasive cardiology, surgery), cell and tissue laboratories (histology, biochemistry), state-of-the-art genomics and proteomics laboratories.
Integration and contribution to the system redesign
The Cardiology and Cardiovascular Medicine Operational Unit contributes to the reorganisation of the Tuscan health system both at the level of the association of local health districts, on the cardiovascular risk diagnostic pathways, on the reorganisation of the network for acute heart attacks, that of the pathway of the patient with heart failure between hospitals and the territory, on the appropriateness criteria in the diagnostic pathway for ischaemic heart disease and other cardiovascular diseases. This contribution includes the drafting of consensus documents, participation in the drafting of regional, national and international guidelines, and a comparison of experiences in our association of local health districts and in the other associations of local health districts of the Tuscany Region, particularly regarding the heart failure pathway.
The topics include the advancement of knowledge in modern pathophysiology, diagnostics and therapy, the foundations of Precision Medicine characteristic of tomorrow’s medicine, with a few main strands:
- new biomarkers with diagnostic function, screening, risk stratification, evaluation of treatment efficacy
- study of the heart-brain axis, neuropharmacology and bioelectronic medicine in cardiovascular diseases
- advanced imaging integrated with multiparameter patient assessment
- medical genetics for the study of the relationship between genotype and phenotype
- diagnostic and theranostic nanotechnologies
Direttore U.O.C. Cardiologia e Medicina Cardiovascolare
Direttore Dipartimento Cardio-Toracico
Direttore UOSVD Ricerca Clinica
Coordinatore Attività Degenza
Responsabile UOSVD Attività ambulatoriale
e Ospedale diurno
DIR.MED. - CARDIOLOGIA
DIR.MED. - CARDIOLOGIA
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