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We report a case of left pericardial agenesis in a 61 year old man presenting palpitations, without syncope. Clinical picture was not specific on clinical field: atypical chest pain, systolic murmur 2/6 Levine on the second left interspace were found. ECG showed sinus rhythm, clockwise deviation of axis in the precordial leads and incomplete right bundle branch block. Frequent isolated polymorphic premature extrabeats. Holter ecg was perfomed: frequent polymorphic extrabeats (9834/24 ore) with some couplets and triplets, without sustained ventricular tachycardia episodes. Starting metoprololo 100 mg per day the arrhythmic burden decreases significantly. Chest X–ray showed marked levocardia and dilatation of pulmonary trunk. Levocardia increased with the patient on the left side. Levoposition of the heart, lung interposition between the diaphragm and the base of the heart and between the aorta and pulmonary artery Echocardiography showed a classic abnormal swinging motion of the heart in the chest, a paradoxical interventricular septal movement, apparent right–sided heart enlargement, with unusual bulging of the apex of the right ventricle. Magnetic resonance imaging (currently the gold standard for diagnosing) confirmed the absence of the left pericardium, and a left pericardial agenesia diagnosis was performed Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. We analyze the diagnostic problems and the prognostic doubts of this rare congenital anomaly.

Transcatheter left atrial appendage occlusion (LAAO) has emerged as a reliable tool to prevent thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation (AF) in the absence of mitral stenosis/valve prosthesis and contraindication to oral anticoagulation (OAC). Antiplatelet therapy (APT) is required after device implantation to prevent device–related thrombus (DRT). Previous studies provided conflicting results on the optimal APT regimen after LAAO. Thus, herein we aimed at assessing the comparative effectiveness and safety of distinct APT regimens. We conducted a real–world single–center observational study including consecutive AF patients that underwent LAAO at the University Hospital of Parma between October 2010 and June 2021. Clinical follow–up included all successfully implanted patients. Primary endpoint was net efficacy outcome, a composite of any ischemic or hemorrhagic event. Secondary endpoints were ischemic (any of the following: ischemic stroke, transient ischemic attack [TIA], DRT, systemic embolism) and hemorrhagic (major [≥3] bleedings according to Bleeding Academic Research Consortium [BARC] classification) complications alone. We enrolled a total of 130 patients (median age 77.0 [72.7;81.0] years; 78 [60.0%] men). History of hemorrhagic stroke in OAC (74 [56.9%]) was the main indication for LAAO. Technical procedure success was achieved in 123 (94.6%) patients. According to multidisciplinary team evaluation, immediately after LAAO, 39 (31.7%) patients received short (≤ 1 month)–dual APT (DAPT) consisting of cardioaspirin and clopidogrel, 35 (28.5%) long (>1, ≤12 months)–DAPT and 49 (39.8%) single APT (SAPT). At a median follow–up of 32 months, the incidence of primary endpoint was significantly lower in short–DAPT group (3 [7.7%] vs. 7 [20.0%] in long–DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of bleeding endpoint (0 [0.0] vs. 4 [11.4%] in long–DAPT vs. 9 [18.4%] in SAPT, p = 0.020) without differences in the incidence of ischemic endpoint (p = 0.916). Finally, comparison of the Kaplan–Meier curves showed that short–DAPT group had a higher primary endpoint–free survival (p = 0.015) compared to the others. In summary, our study highlighted that short (≤ 1 month)–DAPT regimen after LAAO is associated with better outcomes, mainly driven by reduction of major bleedings. Strong evidences arising from randomized trials are warranted to support these findings.

62–year–old male with multiple cardiovascular risk factors.Known pre–capillary porto–pulmonary hypertension treated with Macitentan 10 mg per day, in the context of serum–negative liver disease complicated by portal hypertension and congestive gastropathy.Persistent atrial fibrillation in AVK due to high thromboembolic risk (CHA2DS2VAsc 3).At the last echocardium–TT evidence of worsening of right ventricular systolic function (TAPSE from 20 to 16 mm) and estimated pulmonary hypertension (PAPS from 45 to 65 mmHg). Subsequent hospitalization for severe anemia (Hb 6.5 g/dl), with diagnosis of bleeding angiodysplasias.In consideration of high bleeding risk (HAS–BLED 3), left atrial appendage occlusion has been indicated.The patient underwent right cardiac catheterization, via right femoral vein, with confirmation of severe pulmonary pre–capillary hypertension (mean PAP 45 mmHg, PCWP 14 mmHg); during the same session, left atrial appendage was occluded percutaneously using a Watchman device. At discharge, combination therapy with Riociguat plus Macitentan and single antiplatelet therapy with Clopidogrel 75 mg per day were undertaken. Shortly thereafter, recurrence of gastro–enteric bleeding occurred; after cardiac evaluation, Clopidogrel was discontinued and anticoagulant therapy with Edoxaban 30 mg od was started.The choice of shifting from Clopidogrel to low dose NOAC was guided by the unclear evidence of efficacy and safety of single or dual antiplatelet therapy in a population of patients with both high thrombotic and bleeding risk, such as in this case.Given that NOACs can be considered as an alternative to Warfarin after Watchman implantation (class IIB), after the second recurrence of bleeding, we opted for long–term antithrombotic strategy using a direct oral anticoagulant at reduced dose, making bleeding risk more acceptable instead of the administration of full dosage of NOAC, matter of major importance in candidates for left appendage closure, in whom long–term anticoagulant therapy itself is contraindicated; on the other hand, aiming for a better protection against thromboembolic events compared to standard antiplatelet therapy.