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A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.

Introduction Patients treated with Immunocheckpoint Inhibitors (ICI) can develop adverse cardiovascular events, most frequently myocarditis, but also arrhythmias, conduction abnormalities, pericarditis, Takotsubo syndrome, ACS, heart failure, cardiac arrest. Myocarditis occurs early, within the first 3–4 administrations of therapy, and is fraught with a high mortality rate. Case Presentation 80–year–old patient with renal pelvic carcinoma who underwent nephroureterectomy and subsequent adrenalectomy. Twenty days after the first cycle of Pembrolizumab, the patient is admitted to cardiology for syncope and ECG finding of Left Posterior Fascicular Block (LPFB) and right bundle branch block (RBBB) with significant increase in troponin without any alterations in regional kinetics and normal ventricular function (EF). The patient also complains of widespread muscle pain and severe hyponatremia on blood tests. On ECG monitoring, alternation of RBBB with associated LPFB and Left Posterior Fascicular Block, left bundle branch block, first and second degree atrio–ventricular block (AV block) and on day II appearance of complete paroxysmal AV block controlled with temporary pacemaker implantation. On the 4th day, we documented changes in the segmental motion of the left ventricle (LV) and progressive gradual worsening of the EF. During the hospitalization the patient manifested episodes of general malaise with profuse sweating and marked hypotension with possible SIADH picture. In suspicion of acute myocarditis, peripheral myositis and possible Pembrolizumab SIADH, the patient was treated with high dose methylprednisolone (1000 mg / day) with little benefit. On the 6th day the patient was found in critical condition, severely suffering, hypotensive and oliguric, resigned herself. Conclusions Our case highlights how even a single dose of Pembrolizumab can trigger an acute inflammatory pattern affecting the myocardium with prevalent involvement of the conduction tissue even before the appearance of alterations in the kinetics and ventricular dysfunction. During ICI therapy cycles it is therefore important to monitor the ECG and troponin levels in order to be able to diagnose myocardial involvement early. In fact, although this complication is rare, it is burdened by a high mortality rate. The only treatment currently available involves the suspension of immunotherapy and the administration of high–dose methylprednisolone.

Introduction Tako–Tsubo Syndrome (“TTS”) is a cardiomyopathy characterized by an acute reversible left ventricular dysfunction, mainly triggered by emotional or physical stress. Several variants have been reported, including reverse TTS, characterized by hypokinesia of basal segments and hyperkinesis of the apical ones. TTS has a clinical presentation similar to acute coronary syndrome but without evidence of obstructive coronary artery disease. A surprising association between TTS and cancer arose out of recent studies. Case Presentation 74–year–old patient got to the emergency room of our hospital for the appearance, apparently in the health, in the absence of physical or emotional stress of oppressive chest pain. On the ECG, there was evidence of ST–segment elevation in inferior leads, for which urgent coronary angiography was performed. It did not show significant stenotic lesions nor evidence of elevated troponin values. The Echocardiogram showed hypokinesia of the basal segments and hyperkinesis of the mid–apical ones, with EF 40%. In the following days, the patient performed MRI–heart with detection of LGE of the intramyocardial type (non–ischemic pattern) in correspondence with the inferior wall in the medioventricular area. During hospitalization on routine chest x–ray, hypodiaphanous image was found in the left apex for which an HR CT scan of the chest was performed which a lesion in the left apical lung area with spiculated margins of a heteroplastic nature, associated with multiple bilateral lesions suggestive of secondaryism. Therefore, the patient was taken over by the Oncology service. Conclusions Such case confirms the association between TTS and occult cancer. In the absence of obvious physical or emotional stress that may explain the onset of TTS, it is important to research for any silent neoplastic pathology. The literature shows that the prevalence of malignant diseases is high in patients with TTS. Recent studies have pinpointed the activation of the sympathetic nervous system promotes cardiac inflammation by upregulating ICAM–1 and the expression of p53. Furthermore, inflammation can lead to the activation of p38 MAP Kinase, thus contributing to myocardial stunning. The specific role of inflammation as a cofactor of adrenaline–induced stunning deserves further investigation in the specific context of malignant tumors, which are frequently associated with an enhanced inflammatory state.

Patient Presentation A 52 y/o female with history of arterial hypertension, diabetes mellitus, Bentall‘s previous intervention, presented to emergency department complaining dyspnea and oppressive chest pain which arose during celebrations for Italy‘s victory at the European soccer championship. According to increase in cardiac troponin level and ECG findings of subendocardial ischemia she was admitted to our Coronary Care Unit for acute coronary syndrome suspicious. Management transthoracic echocardiography (TTE) showed reduced left ventricle ejection fraction (LVEF 37%) with apical and left ventricle medium segments akinesis associated with basal segments hyperkinesis with typical apical ballooning aspect. According to these findings, Takotsubo syndrome (TTS) suspicious overtook acute coronary syndrome. Despite low probability of coronary disease, she underwent coronary angiography which was normal. Eight days later, TTE showed completely recovery with normal LVEF. At the routine blood test we found not known hyperthyroidism without detectable antibodies; thyroid ultrasound showed some cystic lesion without any nodule. Thyroid scintigraphy was normal. Antithyroid medications were started and one month later complete normalization of thyroid hormones occurred. The patient was event–free after correction of the hyperthyroidism. Discussion “Happy heart syndrome” (HHS) is a TTS triggered by deep happiness and positive emotions. TTS is an usual form of acute cardiomyopathy characterized by reversible left ventricle apical ballooning which occurs in the absence of significant coronary artery disease. Although the exact cause of TTC remains unknown, several pathogenetic mechanisms have been suggested. Catecholamines seem to play a central role and we know that thyroid hormones interact with sympathetic nervous system so that hyperthyroidism is associated with hypersensitivity to catecholamines. Tako–Tsubo syndrome is usually triggered by negative stressors such as fright, grief, rage, other diseases. The role of positive emotions is not well known neither described. We assume that the mechanisms are similar but triggered by different emotions. HHS seems to be caused by pleasant emotional life events such as birthday party, son’s wedding and so many others. Both positive and negative life events could trigger TTS, nevertheless negative life events trigger TTS in almost 95% of the cases, so “broken hearts” are more frequent than “happy hearts”.

The case we present involves a 75 years–old woman with no cardiological past medical history, who presented to our attention complaining of sudden onset thoracic pain associated with dyspnea, dry cough, nausea and an episode of vomit. She called 911 rapidly coming to our Hospital. In the Emergency room an EKG showed ST segment depression in the inferior leads and in the blood test a remarkable increase in HS–Troponin level was evident. An echocardiogram showed mid and apical left ventricle segments hypokinesia with moderately reduced Ejection Fraction (45%); notably, right ventricle was increased in dimension with moderate tricuspid regurgitation and mild pulmonary hypertension. Because of this last find, D–dimer was checked and a pulmonary angio– CT was performed which excluded active pulmonary embolism. Next day she underwent coronary angiography which showed no coronary lesion able to explain the clinical and echocardiographic presentation; left ventriculography was also performed showing an increase in end–systolic volume with hypokinesia of the anterolateral, apical and diaphragmatic walls and an Ejection Fraction (EF) of 30%. These findings allowed us to make the diagnosis of Tako–Tsubo syndrome, also known as stress–induced cardiomyopathy. Few days later, a cardiac magnetic resonance (CMR) was performed showing whole apical and antero–lateral mid ventricular hypokinesia with compensatory hyperkinesia of basal segments; T2–weighted sequences were positive at the hypokinetic segments with no specific Late Gadolinium Enhanced (LGE) images. What’s more, an atrial septal defect type “ostium secundum” was clearly evident, causing a left–to–right shunt hemodynamically significant (Qp/Qs of about 2,8) with right atrial and right ventricle dilatation. Pulmonary artery and its main branches were dilated too. After these findings, lady underwent right heart cardiac catheterization that reported a Qp/Qs of 3,24 and a shunt flow of 8,78 L/min, with a cardiac index of 2,5 L/min/m2 and normal pulmonary vascular resistance (0,7 Wood Units). Because of these measures the patient was discharged from our Cardiology Unit and referred to the Interventional Cardiology centre of our city for the percutaneous closure of the hemodynamically significant atrial septal defect. This case is curious because it shows how things in Cardiology can be deeply and unpredictably connected.

Background Many kinds of arrhythmias may occur in patients with myocarditis at any stage of the disease. However, as compared to the other clinical presentations, arrhythmic myocarditis has been poorly described in literature. Case Report A 20–year–old girl, without CVRF or comorbidities, presented at the ED because of palpitations and epigastric pain irradiated to left arm. 12–lead ECG evinced elevated HR and aspecific repolarization abnormalities. Blood samples showed high cTn value and normal PCR value. Echocardiography showed a preserved LVEF, without abnormalities. Patient was hospitalized with a diagnosis of suspect acute myocarditis. Following hospital stay has been complicated by recurrent episodes of chest pain with concomitant increase of cTn that finally had presented a sinusoidal trend (peak 12830ng/L). At the same time, continuous ECG monitoring has been showing frequent but short term ventricular extrasystole activity, so B–blocker therapy was optimized. On ECG monitoring, appearance of short runs of asymptomatic mono– and polymorphic NSVT and after a few days appearance of polymorphic NSVT “torsade de pointes” like, symptomatic for presyncope. New changes in kinetics appear on the echocardiogram: hypokinesia of medio–apical segments of lateral, anterior wall septum. Therapy with metoprolol and lidocaine iv was started with subsequent stabilization of the rhythm. CMR presented data suggestive of myocarditis. Patient performed several BEM at different time and centers: diagnostic signs of myocarditis were not be found. Autoimmune and infectious disease screening, abdominal echography and a PET TC total body were been performed to research a potential etiology, without positive result. Patient has been discharged with wearable defibrillator and we waited for the ICD implantation in secondary prevention. Follow–up CMR showed a resolution of inflammation and no signs of fibrosis. Blood samples did not demonstrate a rise of cTn. After discharged, she has not had news onset of ventricular arrhythmias. Conclusion The mechanisms underlying the occurrence of ventricular arrhythmias during myocardial inflammation are less clear. Arrhythmias usually being self–limited with no recurrences that follow the acute phase. Management of acute life–threatening arrhythmias is generally supportive and there is a lack of evidence to support the use of specific antiarrhythmic agents. Wearable life vest has been presented as a possible therapeutic option.

Reverse–Tako–tsubo (r–TTC) is a rare variant of Tako–tsubo syndrome (TTC). TTC is characterized by transient and reversible left ventricular systolic dysfunction, for which an emotional or physical stressful trigger can usually be identified. Clinically, it mimics an acute myocardial infarction, with elevation of myocardial cytonecrosis enzymes and no obstractive coronary artery stenosis. On imaging, r–TTC is characterized by hypokinesia of the mid–basal regions associated with hyperkinesia of the apical region that resolves spontaneously. Case report: 78–year–old female affected by cerebral atrophy, leukoencephalopathy, cognitive impairment, behavior disorders. Reported episode of loss of consciousness lasting several minutes, associated with spontaneously resolving tremors and left hemisome hyposthenia. When she arrived in the emergency room, the haematological tests found high troponin values. On CT brain without contrast, no evidence of alterations of the encephalic tissues referable to acute lesions, but it showed of diffuse supratentorial leukoaraiosis and widening of the cerebrospinal fluid spaces on an atrophic basis. The neurological evaluation excludes the presence of a seizure. The electrocardiogram showed diffuse negative T waves and QTc 636 ms. The coronary angiography didn’t show significant coronary arteries stenosis and the ventriculography showed normal ventricular dimensions with total akinesia of the mid segments and normokinesia of the apical region with an ejection fraction of 50%. With these findings a diagnosis of mid left ventricular Tako–tsubo (r–TTC) was made. Transthoracic color Doppler echocardiography confirmed the alterations of the left ventricular kinetics observed by ventriculography. Conclusions compared to CTT, r–TTC is associated with a lower decline in global systolic function and, as reported in the literature, there is a greater connection to neurological insults as triggering factors, such as episodes of aneurysmal subarachnoid hemorrhage, brain surgery, ischemic stroke seizures and traumatic brain injury. The underlying mechanisms are still unknown, a crucial role in catecholamine–induced cardiotoxicity, coronary microvascular dysfunction or coronary vasospasm and/or estrogen deficiency is hypothesized.