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La gestione dei pazienti con nota o sospetta cardiopatia, che sono ricoverati o che devono essere sottoposti ad intervento chirurgico non cardiaco o ad una procedura invasiva, è molto complessa, sia per le comorbilità spesso presenti, sia per le molteplici terapie assunte, sia perché spesso sono portatori di dispositivi cardiaci impiantabili. Scopo di questo documento è di fornire indicazioni e standardizzare i comportamenti dei vari medici nella gestione dei pazienti cardiopatici o sospetti tali, al fine di (a) gestire le acuzie cardiologiche con timing e accuratezza adeguati, e (b) definire il rischio cardiologico nel singolo paziente con tempi ed indicazioni appropriate, permettendogli di affrontare la procedura chirurgica o invasiva con il rischio più basso correlato alla presenza della cardiopatia.

Tricuspid regurgitation is a frequent valvular heart disease, particularly in the elderly and in association with other left-sided heart diseases. It has an adverse prognostic impact, with progressively increasing mortality as the degree of regurgitation increases. Isolated or combined (with mitral and/or aortic) surgery remains the treatment of choice, provided operative risk is acceptable. Several transcatheter treatment techniques, currently in early clinical or preclinical study phase, could provide alternative treatment options for patients with high surgical risk.

Cardiovascular imaging is key for the assessment of patients with heart failure. Today, both cardiac magnetic resonance and cardiac computed tomography play an established role in the assessment of patients with suspected and confirmed heart failure syndromes. In particular, cardiac magnetic resonance is of paramount importance in identifying etiology of left ventricular dysfunction. It has an increasing role in prognostic stratification and in clinical decision-making around therapy. Key strengths include its ability to characterize myocardial tissue, unrestricted field of view, lack of radiation, as well as accuracy and reproducibility. Cardiac computed tomography has become an important tool in the management of patients with congestive heart failure. Advances in scanner technology have increased its spatial and temporal resolution to unprecedented levels while resulting in decreasing radiation doses. The primary diagnostic application is in differentiation of ischemic from nonischemic etiology of left ventricular dysfunction. Its role in tissue characterization shows promise and is increasingly being studied.

The number of patients affected by cardiovascular disease admitted to internal medicine and geriatric wards is expanding due to the increasing prevalence of cardiovascular disease in the ageing population. This contributes to a growing demand for cardiology consult visits, with requests for perioperative risk stratification for non-cardiac surgery or endoscopy, and general clinical management. This document was jointly drafted by the Cardiology and Anesthesiology departments, medical and surgical departments, and endoscopy services of the Azienda Ospedaliero-Universitaria "Ospedali Riuniti" in Trieste (Italy). It addresses critical issues such as antiplatelet and anticoagulant therapy in non-cardiac surgery, electric device management, and prophylaxis of bacterial endocarditis. It provides general guidelines and appropriateness criteria, prompted by the Joint Commission International and approved by the Hospital Guidelines Committee. It provides a basis for periodic educational meetings, and will be periodically updated. Periodic audits will monitor its application, and critical and controversial points, in order to promote quality of health care, organizational efficiency, and appropriateness.

Background The appropriate timing to administer antithrombotic therapies in ST-elevation myocardial infarction (STEMI) remains uncertain. This study aims to evaluate the role of antithrombotic therapy administration at first medical contact (FMC) compared with the administration in the Cathlab. Methods We conducted a "before-after" observational study enrolling STEMI undergoing primary percutaneous coronary intervention (PCI). Outcomes were evaluated during two successive periods, before (control group: aspirin only at FMC) and after (pretreated intervention group: heparin, aspirin plus ticagrelor at FMC) the introduction of a new regional pretreatment protocol. Results A total of 537 consecutive patients (300 in control vs. 237 in intervention group) were enrolled. The pretreated compared with no pretreated population showed better basal reperfusion, expressed as basal Thrombolysis in Myocardial Infarction (TIMI)-flow (p for trend p < 0.001). Pretreated population showed lower frequency of TIMI 0 (56.5% vs. 73.7%, odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.32-0.67, p < 0.001) and higher frequency of TIMI 2-3 (33.3% vs. 19.3% OR: 2.0, 95% CI: 1.38-2.00, p < 0.001) and TIMI 3 (14.3% vs. 9.7%, OR: 1.56, 95% CI: (0.92-2.65), p = 0.094). Pretreated compared with no pretreated population showed reduced infarct size expressed as Troponin Peak (20,286 (8726-75,027) versus 48,676 (17,229-113,900), p = 0.001), and higher left ventricular ejection fraction at discharge (53% (44-59) vs. 50% (44-56), p = 0.027). In-hospital BARC >= 2 bleeding were similar (2.1% vs. 2.0%, p = 0.929, in pretreated versus no pretreated population, respectively). Conclusion This study provides support for an early pretreatment strategy in STEMI patients and confirmed the importance of an efficient organization of STEMI networks which allow initiation of antithrombotic treatment at FMC.

Background Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularisation strategies. However, the potential predictors of outcomes on top of different revascularisation strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularisation strategies and the potential impact of medical therapy. Methods Using a propensity score approach, the impact of two treatment strategies was analysed –staged non-culprit revascularisation group vs culprit-lesion-only percutaneous coronary intervention (PCI) group -- on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularisation. Moreover, models were further adjusted for medication at discharge. Results Among 1,385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21–65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularisation group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24–0.82; p=0.01), lower CVD (HR, 0.34; 95% CI, 0.14–0.82; p=0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24–0.86; p=0.02). Use of renin-angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27–0.95; p=0.03), and both renin-angiotensin inhibitors (HR, 0.52; 95% CI, 0.32–0.86; p=0.01) and beta blockers (HR, 0.48; 95% CI, 0.29–0.79; p=0.01) were associated with lower all-cause death. Conclusions In a real-word STEMI population with multivessel disease, staged non-culprit revascularisation was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularisation and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularisation.

Arrhythmogenic right ventricular cardiomyopathy is a myocardial disease generally caused by desmosomal mutations and characterized by progressive replacement of cardiomyocites with fibro-adipose tissue. In the classic form of the disease right ventricle is predominantly affected. However, biventricular and left-dominant variants have been recently recognized, leading to the new nosological definition of arrhythmogenic cardiomyopathy. The condition affects mostly young adults and athletes and is clinically characterized by ventricular arrhythmias, heart failure and sudden cardiac death. The diagnosis is based on clinical-instrumental criteria, including family history, morpho-functional and electrocardiographic abnormalities, ventricular arrhythmias and genetic defects (Task Force Criteria, 2010). The main goal in the management of patients is the prevention of sudden cardiac death, where implantable cardioverter-defibrillator is the only effective therapeutic strategy. Many arrhythmic risk factors have been described. Recently, an on-line calculator has been proposed, but it needs further validation.

Right ventricular involvement in inferior myocardial infarction (MI) was historically associated with a poor prognosis. However, few studies addressed the impact of right ventricular (RV) dysfunction in the primary percutaneous intervention (pPCI) era. Our aim was to assess the prognostic significance of RV dysfunction in right coronary artery (RCA) related MI treated with pPCI. Methods: A total of 298 patients with a RCA related MI undergone pPCI between January 2011 and June 2015 were included. RV dysfunction was defined by a RV-FAC

BACKGROUND: Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated. METHODS: We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality. RESULTS: Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality. CONCLUSIONS: In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Aims: The case we report, shows a successful treatment of right ventricle endomyocardial fibrosis. Materials and Methods: Surgical therapy by endocardial decortication seems to be beneficial for many patients with advanced disease who are in functional-therapeutic class III or IV. The operative mortality rate is high, but successful surgery has a clear benefit on symptoms and seems to favourably affect survival as well.

Introduction: Acute coronary syndromes (ACS) have been classified according to the finding of ST-segment elevation on the presenting electrocardiogram, with different treatment strategies and practice guidelines. However, a comparative description of the clinical characteristics and outcomes of acute coronary syndrome elderly patients undergoing percutaneous coronary intervention during index admission has not been published so far. Methods: Retrospective cohort study of patients enrolled in the Elderly ACS-2 multicenter randomized trial. Main outcome measures were crude cumulative incidence and cause-specific hazard ratio (cHR) of cardiovascular death, noncardiovascular death, reinfarction, and stroke. Results: Of 1443 ACS patients aged >75 years (median age 80 years, interquartile range 77-84), 41% were classified as ST-elevation myocardial infarction (STEMI), and 59% had non-ST-elevation ACS (NSTEACS) (48% NSTEMI and 11% unstable angina). As compared with those with NSTEACS, STEMI patients had more favorable baseline risk factors, fewer prior cardiovascular events, and less severe coronary disease, but lower ejection fraction (45% vs 50%, P

Background: Alcoholic cardiomyopathy(ACM) is part of the non-ischaemic dilated cardiomyopathy(NI-DCM) spectrum. Little is known about cardiovascular magnetic resonance(CMR) features in ACM patients. The aim of this study is to describe CMR findings and their prognostic impact in ACM patients. Methods: Consecutive ACM patients evaluated in five referral CMR centres from January 2005 to December 2018 were enrolled. CMR findings and their prognostic value were compared to idiopathic NI-DCM(iNI-DCM) patients. The main outcome was a composite of death/heart transplantation/life-threatening arrhythmias. Results: Overall 114 patients (52 with ACM and 62 with iNI-DCM) were included. ACM patients were more often males compared to iNI-DCM (90% vs 64%, respectively, p ≤ 0.001) and were characterized by a more pronounced biventricular adverse remodelling than iNI-DCM, i.e. lower LVEF (31 ± 12% vs 38 ± 11% respectively, p = 0.001) and larger left ventricular end-diastolic volume (116 ± 40 ml/m2 vs 67 ± 20 ml/m2 respectively, p < 0.001). Similarly to iNI-DCM, late gadolinium enhancement (LGE), mainly midwall, was present in more than 40% of ACM patients but, conversely, it was not associated with adverse outcome(p = 0.15). LGE localization was prevalently septal (87%) in ACM vs lateral in iNI-DCM(p < 0.05). Over a median follow-up of 42 months [Interquartile Range 24–68], adverse outcomes were similar in both groups(p = 0.67). Conclusions: ACM represents a specific phenotype of NI-DCM, with severe morpho-functional features at the onset, but similar long-term outcomes compared to iNI-DCM. Despite the presence and pattern of distribution of LGE was comparable, ACM and iNI-DCM showed a different LGE localization, mostly septal in ACM and lateral in iNI-DCM, with different prognostic impact.

Aims: Lake Louise Criteria (LLC) are time-dependent and some acute myocarditis (AM) with preserved left ventricular ejection fraction (LVEF) could be missed, due to the limited accessibility of Cardiac Magnetic Resonance (CMR). We aimed to assess the potential value of cardiac strain measured by feature tracking (FT) imaging in this population. Methods and results: Eighty-three patients with clinically suspected AM and normal LVEF were divided into 39 “confirmed AM” (positive LLC) and 44 “suspected AM” (negative LLC). An age and gender-matched sample of 42 normal subjects underwent CMR. In all groups, FT-derived biventricular strains and STE- global longitudinal strain (GLS) were assessed, being regularly measurable. Strain values < 5th percentile of the control group were considered abnormal. “Suspected” and “confirmed” AM were similar, except for medium time of CMR evaluation (5.2 vs 1 months from presentation, respectively; p = 0.004). Compared to healthy controls, both “suspected” and “confirmed” AM showed significantly impaired strain values. LV-global circumferential strain (GCS), right ventricular GCS and LV-GLS were abnormal in 15.4% and 15.9%, 20.5% and 15.9%, 7.7% and 9.1% in “confirmed” and “suspected” AM, respectively. STE analysis confirmed the results on LV-GLS, however a weak correlation emerged between STE and CMR-FT LV-GLS (p = 0.08). Conclusions: Compared to STE, CMR-FT analysis provided a more comprehensive and complementary biventricular strain evaluation that resulted similar in “confirmed” and “suspected” AM with normal LVEF. Conversely, mostly biventricular GCS was significantly reduced in up to 20% of patients, compared to healthy controls.

Coronary access after transcatheter aortic valve replacement will become increasingly common as younger patients undergo the procedure. Neo-commissures in transcatheter aortic valve replacement can interfere with coronary ostia and affect coronary access. It has been showed that in the CoreValve

Purpose of Review: To analyze the current state of the art of functional mitral regurgitation (FMR) treatment. Recent Findings: The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. Summary: The COAPT trial provided a “proof of concept” that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.

PURPOSE: Patients with symptomatic heart failure (HF), reduced left ventricular ejection fraction (LVEF), and high-grade functional mitral regurgitation (MR) may benefit from percutaneous edge-to-edge mitral valve repair (PMVR). However, patient selection still remains a central issue. We sought to investigate the potential role of the global longitudinal strain- (GLS-) based left ventricular contractile reserve (LVCR) at dobutamine stress echocardiography (DSE) in this setting. METHODS: Thirty-three stable HF patients (MR grade ≥ 3+; median LVEF, 29%; median GLS, -8.3%) who were candidates for PMVR were prospectively enrolled. All patients underwent DSE to assess LVCR (LVEF increase ≥ 5%; GLS increase ≥ 2%; stroke volume [SV] increase ≥ 20% of the measured SV value). RESULTS: After DSE, a positive LVCRLVEF was detected in 21 patients (64%), positive LVCRGLS in 12 patients (36%), and positive LVCRSV in 14 patients (42%). LVCRGLS was associated with better symptom relief, MR improvement, and LV reverse remodeling in a short-term follow-up. A significant improvement of GLS during DSE (hazard ratio [HR], 0.549; 95% CI, 0.395-0.765; P < .001), along with history of HF hospitalization (HR, 1.48; 95% CI, 1.119-1.967; P = .006) and beta-blocker therapy (HR, 0.146; 95% CI, 0.046-0.462; P = .001), were independently associated with risk of death/heart transplantation/HF-related hospitalizations. CONCLUSIONS: LVCR, assessed by speckle-tracking DSE, is associated with better results after PMVR in the setting of advanced HF. Improvement of longitudinal function emerged, beyond the ejection fraction, as an independent predictor of outcomes and could improve the selection of best candidates for the percutaneous correction of functional MR.

This book describes the role of basic and advanced imaging techniques in the diagnosis of different types of cardiomyopathy, including dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and infiltrative/storage cardiomyopathies. While the main focus is on echocardiography, the applications of cardiac magnetic resonance imaging and computed tomography are also described. Throughout, a clinically oriented approach is employed: detailed attention is paid to differential diagnosis and numerous high-quality images depict the main features of the various types of cardiomyopathy. Consideration is also given to the genetics of cardiomyopathies, with analysis of genotype-phenotype relationships. Finally, the potential value of imaging in prognostic assessment and in guiding treatment is described.

A 60 year old man was admitted to the E.R. for recurrence of transitory ischemic attacks. In order to exclude the presence of embolic sources a transesophageal echocardiography was performed which demonstrated an echo-free structure posteriorly to the aortic root, connected with the interatrial septum (Fig. 1 — A; online video 1). A continuous systo-diastolic flow inside the structure was evident at Color Doppler (Fig. 1 — B, online video 2), whereas the Continuous Doppler showed a high velocity systo-diastolic signal (>2.5 m/s; Fig. 1 — C) directed from the interatrial septum toward the right atrium.

The prognostic relevance of direct contrast toxicity in patients treated with primary percutaneous coronary intervention remains unclear, owing to the confounding hemodynamic effect of acute left ventricular ejection fraction (LVEF) impairment on kidney function estimation. In the present study, 644 consecutive patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were prospectively enrolled. Contrast-induced nephropathy (CIN) was defined as an increase in serum creatinine >25% or a decrease in the estimated glomerular filtration rate (eGFR)

BACKGROUND: The impact of diabetes in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) is unclear. The benefit of abciximab in this subset of patients remains controversial. METHODS AND RESULTS: Three hundred and twenty-seven consecutive and unselected patients with acute AMI treated with primary PCI were included in our single-center retrospective registry, 103 diabetic (31%) and 224 nondiabetic (69%). Abciximab was given at the physician's discretion. Diabetic patients were older (mean age 68.5±11 vs. 65±12 years; P=0.009), had an increased prevalence of hypertension (73 vs. 54%; P=0.001), a decreased prevalence of smoking (31 vs. 45%; P=0.02), a longer duration of symptoms before hospital admission (190 vs. 143 min; P=0.031), and a higher number of stents implanted (1.4 vs. 1.2; P=0.04). Other clinical and angiographic characteristics were comparable in the two groups. Diabetic patients had a higher incidence of the combined end-point of death and reinfarction rate at 30 days (18 vs. 10%; P=0.04) compared to nondiabetic patients. Abciximab treatment was associated with a lower in-hospital (23.8 vs. 5%; P=0.005) and 30-day (23.8 vs. 6.6%; P=0.012) mortality, and a lower incidence of death and reinfarction at 30 days (33.3 vs. 9.8%; P=0.003) in diabetic patients. In nondiabetic patients, abciximab was not associated with improved outcome measures. Advanced Killip class (III and IV) and abciximab were found to be independently associated with 30-day death or myocardial infarction [respectively, odds ratio (OR) 6.075, 95% confidence interval (CI) 1.59-23.218, P=0.008 and OR 0.177, 95% CI 0.034-0.938, P=0.042] in the propensity score-matched populations of diabetic patients. Advanced Killip class and thrombolysis in myocardial infarction score index were found to be independently associated with 30-day death or myocardial infarction (respectively, OR 6.607, 95% CI 1.5-29.106, P=0.013 and OR 1.094 95% CI 1.042-1.148, P

Some patients diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) are eventually found to have cardiac sarcoidosis (CS). Accurate differentiation between these 2 conditions has implications for immunosuppressive therapy and familial screening. We sought to determine whether cardiac magnetic resonance imaging (MRI) could be used to identify the characteristic findings to accurately differentiate between CS and ARVC. Consecutive patients with a diagnostic MRI scan indicating CS and/or ARVC constituted the cohort. All patients diagnosed with CS had histologic confirmation of sarcoidosis, and all patients with ARVC met the diagnostic task force criteria. The cardiac MRI data were retrospectively analyzed to identify possible differentiating characteristics. Of the patients, 40 had CS and 21 had ARVC. Those with CS were older and had more left ventricular scar. The presence of mediastinal lymphadenopathy or left ventricular septal involvement was seen exclusively in the patients with CS (p

In recent years, outstanding progress has been made in the diagnosis and treatment of cardiomyopathies. Genetics is emerging as a primary point in the diagnosis and management of these diseases. However, molecular genetic analyses are not yet included in routine clinical practice, mainly because of their elevated costs and execution time. A patient-based and patient-oriented clinical approach, coupled with new imaging techniques such as cardiac magnetic resonance, can be of great help in selecting patients for molecular genetic analysis and is crucial for a better characterisation of these diseases. This article will specifically address clinical, magnetic resonance and genetic aspects of the diagnosis and management of cardiomyopathies.

Attempting a careful evaluation of the incidence of sudden death (SD) in congestive heart failure is inevitably a complex and imprecise task. In particular, this is due to the difficulties in defining and understanding the baseline mechanisms underlying SD. “Sudden” death is commonly regarded as a synonym of “cardiac arrest due to ventricular fibrillation,” which is in turn considered to be a merely arrhythmic phenomenon occurring during apparent wellbeing, and without any precipitating cause other than an extrasystole or a sustained ventricular tachycardia. Cardiac arrest may also be the terminal event during refractory pulmonary edema and/or cardiogenic shock in a patient with end-stage heart failure, a pulmonary embolism in a patient with severe biventricular dysfunction, bradyarrhythmia due to advanced atrioventricular (AV) block, electrical asystole, ventricular fibrillation secondary to myocardial ischemia or infarction, or secondary to a noncardiac event such as a cerebro vascular accident or a ruptured aortic aneurysm. Pratt et al.[1] analyzed a population of 834 patients with an automatic implantable cardioverter defibrillator (ICD) implanted for ventricular tachycardia or sustained ventricular tachycardia. During follow-up 109 patients died (17 died “suddenly”). Autopsy findings revealed a nonarrhythmic cause (pulmonary embolism, ruptured aortic aneurysm, stroke, acute myocardial infarction) in 7/17 patients. Postmortem analysis of the ICD memory revealed ventricular tachyarrhythmias preceding death in only 7/17 patients.